Redo procedures after sinus node sparing hybrid ablation for inappropriate sinus tachycardia/postural orthostatic sinus tachycardia.

AIMS: A novel sinus node (SN) sparing hybrid ablation for inappropriate sinus node tachycardia (IST)/postural orthostatic tachycardia syndrome (POTS) has been demonstrated to be an effective and safe therapeutic option in patients with symptomatic drug-resistant IST/POTS. The aim of this study was to evaluate the long-term rate of redo procedures after hybrid IST ablation and procedural strategy, outcomes and safety of redo procedures. METHODS AND RESULTS: All consecutive patients from 2015 to 2023 were prospectively enrolled in the UZ Brussel monocentric IST/POTS registry. They were analysed if the following inclusion criteria were fulfilled: 1) diagnosis of IST or POTS, 2) symptomatic IST/POTS refractory or intolerant to drugs, and 3) hybrid SN sparing ablation performed. The primary endpoint was redo procedure. The primary safety endpoint was pacemaker (PM) implantation. A total of 220 patients undergone to hybrid IST ablation were included, 185 patients (84.1%) were treated for IST and 61 patients (27.7%) for POTS.After a follow-up of 73.3 ± 16.2 months, 34 patients (15.4%) underwent a redo. A total of 23 patients (67.6%) had a redo for IST recurrence and 11 patients (32.4%) for other arrhythmias. Pacemaker implantation was performed in 21 patients (9.5%). Nine patients (4.1%) had no redo procedure and experienced sick sinus syndrome requiring a PM. Twelve patients (5.4%) received a PM as a shared therapeutic choice combined with SN ablation procedure. CONCLUSION: In a large cohort of patients the long-term free survival from redo procedure after hybrid IST ablation was 84.6% with a low PM implantation rate.

Ivabradina en el tratamiento de la taquicardia sinusal inapropiada / Ivabradine as treatment of inappropriate sinus tachycardia

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Ivabradina como alternativa terapéutica en la taquicardia sinusal inapropiada / Ivabradine as a treatment option for inappropriate sinus tachycardia

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Reducción de la frecuencia cardiaca. Otras oportunidades terapéuticas / Heart rate reduction. Therapeutic alternatives

La frecuencia cardiaca es un factor de riesgo bien definido en estudios epidemiológicos. La frecuencia cardiaca basal se relaciona de forma directa con episodios isquémicos, muerte súbita, mortalidad cardiovascular y mortalidad por cualquier causa, tanto en pacientes con cardiopatía isquémica conocida como en la población normal. La reducción de la frecuencia cardiaca mediante entrenamiento físico o el empleo de bloqueadores beta, verapamilo, diltiazem o digoxina puede ser útil, pero presenta limitaciones relacionadas con contraindicaciones o intolerancia para lograr una dosis adecuada, generalmente por hipotensión o alteraciones de la conducción auriculoventricular. Ivabradina presenta un mecanismo de acción único y reduce la frecuencia cardiaca al bloquear los canales If del nódulo sinusal, sin efecto en el miocardio ni en los vasos sanguíneos. Esta opción abre nuevas oportunidades terapéuticas para el tratamiento de la isquemia miocárdica, la insuficiencia cardiaca, prevención secundaria, taquicardia sinusal inapropiada y quizá para reducir el riesgo asociado con taquicardia sinusal en la población sana. Los resultados de varios ensayos clínicos permitirán definir mejor las nuevas indicaciones de este tipo de fármacos (AU)

The heart rate has been clearly identified as a risk factor in epidemiological studies. There are direct relationships between the resting heart rate and the number of ischemic episodes, the incidence of sudden death, cardiovascular mortality and all cause mortality both in patients with known ischemic heart disease and in the general population. Heart rate reduction can be achieved by exercise training or by using beta-blockers, verapamil, diltiazem or digoxin. However, use of these drugs is limited by contraindications and by intolerance of effective doses, generally due to hypotension or atrioventricular conduction abnormalities. Ivabradine reduces the heart rate by a unique mechanism of action. It blocks If channels in the sinus node, without having any effect on the myocardium or blood vessels. Explotation of this alternative mechanism opens the way for new approaches to the treatment of myocardial ischemia and heart failure, to secondary prevention, and to the treatment of inappropriate sinus tachycardia, with the possibility that it may also reduce the risk associated with sinus tachycardia in the healthy population. The results of several ongoing clinical trials will provide the information needed to identify the most appropriate applications for this new class of drug (AU)

Arritmia por doble vía intranodal con descompensación hemodinámica grave en un retrasplante hepático / Dual atrioventricular nodal conduction and arrythmia with severe hemodynamic alterations during liver retransplantation

Presentamos el caso de un paciente que presentó una taquicardia por reentrada auriculo-ventricular, en relación con la presencia de una doble vía intranodal con importante repercusión hemodinámica durante un retrasplante hepático. Las alteraciones del ritmo y de la conducción cardiaca representan unas de las complicaciones potenciales durante el trasplante hepático. Así están descritas la aparición de taquiarritmias del tipo de fibrilación auricular, taquicardias supraventriculares, ventriculares y bradiarritmias. Estas arritmias ocurren especialmente durante la reperfusión del injerto. Los factores implicados se relacionan con la presencia de alteraciones iónicas graves, del equilibrio ácido base y de la hipotermia que acompañan a la reperfusión del nuevo órgano. Se revisan los posibles mecanismos etiopatogénicos implicados en la aparición de las alteraciones del ritmo en los pacientes con enfermedad hepática terminal

We report the case of a man who developed tachycardia caused by atrioventricular reentry related to dual nodal conduction during liver retransplantation. The hemodynamic alterations were severe. Arrhythmia and altered cardiac conduction are potential complications of liver transplantation. The development of tachyarrhythmias —atrial fibrillation as well as episodes of supraventricular and ventricular tachycardia and bradycardia— have been described. Such arrhythmias tend to occur particularly during reperfusion of the graft. Risk factors implicated are the severe ion imbalances, acidbase imbalance, and hypothermia that accompany the reperfusion of a new organ. A review of the possible pathogenic and etiological mechanisms that lead to arrhythmia in patients with end-stage liver disease is provided