Analysis of Three-Dimensional Scar Architecture and Conducting Channels by High-Resolution Contrast-Enhanced Cardiac Magnetic Resonance Imaging in Chagas Heart Disease.

BACKGROUND: We aimed to describe the morphology of the border zone of viable myocardium surrounded by scarring in patients with Chagas heart disease and study their association with clinical events. METHODS: Adult patients with Chagas heart disease (n=22; 55% females; 65.5 years, SD 10.1) were included. Patients underwent high-resolution contrast-enhanced cardiac magnetic resonance using myocardial delayed enhancement with postprocessing analysis to identify the core scar area and border zone channels number, mass, and length. The association between border zone channel parameters and the combined end-point (cardiovascular mortality or internal cardiac defibrillator implantation) was tested by multivariable Cox proportional hazard regression analyses. The significance level was set at 0.05. Data are presented as the mean (standard deviation [SD]) or median (interquartile range). RESULTS: A total of 44 border zone channels (1[1-3] per patient) were identified. The border zone channel mass per patient was 1.25 (0.48-4.39) g, and the extension in layers of the border zone channels per patient was 2.4 (1.0-4.25). Most border zone channels were identified in the midwall location. Six patients presented the studied end-point during a mean follow-up of 4.9 years (SD 1.6). Border zone channel extension in layers was associated with the studied end-point independent from left ventricular ejection fraction or fibrosis mass (HR=2.03; 95% CI 1.15-3.60). CONCLUSIONS: High-resolution contrast-enhanced cardiac magnetic resonance can identify border zone channels in patients with Chagas heart disease. Moreover, border zone channel extension was independently associated with clinical events.

Analysis of Three-Dimensional Scar Architecture and Conducting Channels by High-Resolution Contrast-Enhanced Cardiac Magnetic Resonance Imaging in Chagas Heart Disease

ABSTRACT Background: We aimed to describe the morphology of the border zone of viable myocardium surrounded by scarring in patients with Chagas heart disease and study their association with clinical events. Methods: Adult patients with Chagas heart disease (n=22; 55% females; 65.5 years, SD 10.1) were included. Patients underwent high-resolution contrast-enhanced cardiac magnetic resonance using myocardial delayed enhancement with postprocessing analysis to identify the core scar area and border zone channels number, mass, and length. The association between border zone channel parameters and the combined end-point (cardiovascular mortality or internal cardiac defibrillator implantation) was tested by multivariable Cox proportional hazard regression analyses. The significance level was set at 0.05. Data are presented as the mean (standard deviation [SD]) or median (interquartile range). Results: A total of 44 border zone channels (1[1-3] per patient) were identified. The border zone channel mass per patient was 1.25 (0.48-4.39) g, and the extension in layers of the border zone channels per patient was 2.4 (1.0-4.25). Most border zone channels were identified in the midwall location. Six patients presented the studied end-point during a mean follow-up of 4.9 years (SD 1.6). Border zone channel extension in layers was associated with the studied end-point independent from left ventricular ejection fraction or fibrosis mass (HR=2.03; 95% CI 1.15-3.60). Conclusions: High-resolution contrast-enhanced cardiac magnetic resonance can identify border zone channels in patients with Chagas heart disease. Moreover, border zone channel extension was independently associated with clinical events.

Fibrose Cardíaca e Mudanças Evolutivas na Função Ventricular Esquerda em Pacientes com Cardiopatia Chagásica Crônica / Cardiac Fibrosis and Changes in Left Ventricle Function in Patients with Chronic Chagas Heart Disease

Resumo Fundamento A cardiopatia chagásica (CC) é uma condição de progressão lenta, cujo principal achado histopatológico é fibrose. Objetivos Avaliar se a fibrose cardíaca aumenta ao longo do tempo e se correlaciona com aumento no tamanho do ventrículo esquerdo (CE) e redução na fração de ejeção (FE) na CC crônica. Métodos Estudo retrospectivo que incluiu 20 indivíduos (50% homens; 60±10 anos) com CC crônica que se submeteram a dois exames de ressonância magnética cardíaca (RMC) com realce tardio com gadolínio em um intervalo mínimo de quatro anos entre os exames. Volume, FE e massa de fibrose do ventrículo esquerdo (VE) foram determinados por RMC. Associações da massa de fibrose na primeira RMC com alterações no volume do VE e FE ventricular esquerda na segunda RMC foram testadas por análise de regressão logística. Valores p<0,05 foram considerados significativos. Resultados Os pacientes foram classificados em: A (n=13; alterações típicas de CC no eletrocardiograma e função sistólica global e segmentar do VE normal) e B1 (n=7; alteração na motilidade da parede do VE e FE ≥45%). O tempo médio entre os dois estudos de RMC foi de 5,4±0,5 anos. Fibrose do VE (em % massa do VE) aumentou de 12,6±7.9% para 18,0±14,1% entre os exames de RMC (p=0,02). A massa de fibrose cardíaca no basal associou-se com uma diminuição > cinco unidades absolutas na FE ventricular esquerda da primeira para a segunda RMC (OR 1,48; IC95% 1,03-2,13; p=0,03). A massa de fibrose do VE foi maior e aumentou entre os dois estudos de RMC no grupo de pacientes que apresentaram diminuição na FE entre os testes. Conclusões Mesmo pacientes em estágios iniciais da CC apresentam um aumento na fibrose do miocárdio ao longo do tempo, e a presença de fibrose do VE no basal está associada a uma diminuição da função sistólica do VE.

Abstract Background Chagas heart disease (CHD) is a slow progressing condition with fibrosis as the main histopathological finding. Objectives To study if cardiac fibrosis increases over time and correlates with increase in left ventricular (LV) size and reduction of ejection fraction (EF) in chronic CHD. Methods Retrospective study that included 20 individuals (50% men; 60±10 years) with chronic CHD who underwent two cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement with a minimum interval of four years between tests. LV volume, EF, and fibrosis mass were determined by cardiac MRI. Associations of fibrosis mass at the first cardiac MRI and changes in LV volume and EF at the second cardiac MRI were tested using logistic regression analysis. P values <0.05 were considered significant. Results Patients were classified as follows: A (n=13; changes typical of CHD in the electrocardiogram and normal global and segmental LV systolic function) and B1 (n=7; LV wall motion abnormality and EF≥45%). Mean time between cardiac MRI studies was 5.4±0.5 years. LV fibrosis (in %LV mass) increased from 12.6±7.9% to 18.0±14.1% between MRI studies (p=0.02). Cardiac fibrosis mass at baseline was associated with decrease in >5 absolute units in LV EF from the first to the second MRI (OR 1.48, 95% CI 1.03-2.13, p=0.03). LV fibrosis mass was larger and increased between MRI studies in the group that presented decrease in LV EF between the tests. Conclusions Even patients at an initial stage of CHD show an increase in myocardial fibrosis over time, and the presence of LV fibrosis at baseline is associated with a decrease in LV systolic function.

Cardiac Fibrosis and Changes in Left Ventricle Function in Patients with Chronic Chagas Heart Disease. / Fibrose Cardíaca e Mudanças Evolutivas na Função Ventricular Esquerda em Pacientes com Cardiopatia Chagásica Crônica.

BACKGROUND: Chagas heart disease (CHD) is a slow progressing condition with fibrosis as the main histopathological finding. OBJECTIVES: To study if cardiac fibrosis increases over time and correlates with increase in left ventricular (LV) size and reduction of ejection fraction (EF) in chronic CHD. METHODS: Retrospective study that included 20 individuals (50% men; 60±10 years) with chronic CHD who underwent two cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement with a minimum interval of four years between tests. LV volume, EF, and fibrosis mass were determined by cardiac MRI. Associations of fibrosis mass at the first cardiac MRI and changes in LV volume and EF at the second cardiac MRI were tested using logistic regression analysis. P values <0.05 were considered significant. RESULTS: Patients were classified as follows: A (n=13; changes typical of CHD in the electrocardiogram and normal global and segmental LV systolic function) and B1 (n=7; LV wall motion abnormality and EF≥45%). Mean time between cardiac MRI studies was 5.4±0.5 years. LV fibrosis (in %LV mass) increased from 12.6±7.9% to 18.0±14.1% between MRI studies (p=0.02). Cardiac fibrosis mass at baseline was associated with decrease in >5 absolute units in LV EF from the first to the second MRI (OR 1.48, 95% CI 1.03-2.13, p=0.03). LV fibrosis mass was larger and increased between MRI studies in the group that presented decrease in LV EF between the tests. CONCLUSIONS: Even patients at an initial stage of CHD show an increase in myocardial fibrosis over time, and the presence of LV fibrosis at baseline is associated with a decrease in LV systolic function.

FUNDAMENTO: A cardiopatia chagásica (CC) é uma condição de progressão lenta, cujo principal achado histopatológico é fibrose. OBJETIVOS: Avaliar se a fibrose cardíaca aumenta ao longo do tempo e se correlaciona com aumento no tamanho do ventrículo esquerdo (CE) e redução na fração de ejeção (FE) na CC crônica. MÉTODOS: Estudo retrospectivo que incluiu 20 indivíduos (50% homens; 60±10 anos) com CC crônica que se submeteram a dois exames de ressonância magnética cardíaca (RMC) com realce tardio com gadolínio em um intervalo mínimo de quatro anos entre os exames. Volume, FE e massa de fibrose do ventrículo esquerdo (VE) foram determinados por RMC. Associações da massa de fibrose na primeira RMC com alterações no volume do VE e FE ventricular esquerda na segunda RMC foram testadas por análise de regressão logística. Valores p<0,05 foram considerados significativos. RESULTADOS: Os pacientes foram classificados em: A (n=13; alterações típicas de CC no eletrocardiograma e função sistólica global e segmentar do VE normal) e B1 (n=7; alteração na motilidade da parede do VE e FE ≥45%). O tempo médio entre os dois estudos de RMC foi de 5,4±0,5 anos. Fibrose do VE (em % massa do VE) aumentou de 12,6±7.9% para 18,0±14,1% entre os exames de RMC (p=0,02). A massa de fibrose cardíaca no basal associou-se com uma diminuição > cinco unidades absolutas na FE ventricular esquerda da primeira para a segunda RMC (OR 1,48; IC95% 1,03-2,13; p=0,03). A massa de fibrose do VE foi maior e aumentou entre os dois estudos de RMC no grupo de pacientes que apresentaram diminuição na FE entre os testes. CONCLUSÕES: Mesmo pacientes em estágios iniciais da CC apresentam um aumento na fibrose do miocárdio ao longo do tempo, e a presença de fibrose do VE no basal está associada a uma diminuição da função sistólica do VE.

Atrial-oesophageal fistula following percutaneous radiofrequency catheter ablation of atrial fibrillation: the risk still persists.

Aims: Atrial-oesophageal fistula is a serious complication related to ablation of atrial fibrillation. As its occurrence is rare, there is a great lack of information about their mechanisms, incidence, presentations, and treatment. The objective of this manuscript is to present a series of cases of atrial-oesophageal fistula in Brazil, focusing on incidence, clinical presentation, and follow-up. Methods and results: This is a retrospective multicentre registry of atrial-oesophageal fistula cases that occurred in eight Brazilian centres from 2003 to 2015. Ten cases (0.113%) of atrial-oesophageal fistula were reported in 8863 ablation procedures in the period. Most of the subjects were male (70%) with age 59.6 ± 9.3 years. Eight centres were reference units in atrial fibrillation ablation with an experience over than 200 procedures at the time of fistula occurrence. Oesophageal temperature monitoring was performed in eight cases using coated sensors in six. The first atrial-oesophageal fistula clinical manifestation was typically fever (in six patients), with a median onset time of 16.5 (12­43) days after ablation. There was a delay of 7.8 ± 3.3 days between the first manifestation and the diagnosis in five patients. The treatment was surgical in six cases, clinical in three and stenting in one. Seven patients died (70%) and two developed permanent neurological sequelae. Conclusion: Atrial-oesophageal fistula remains a serious complication following AF ablation despite the incorporation of protective measures and increased technical experience of the groups. The high morbidity and mortality despite the treatment indicates the need to develop adequate preventive strategies.

Radioterapia em paciente com neoplasia pulmonar e marcapasso ipsilateral / Radiotherapy in a patient with pulmonary neoplasia and ipsilateral pacemaker

Durante anos, o tratamento com radioterapia de portadores de dispositivos eletrônicos implantáveisfoi considerado perigoso. Se a zona a ser irradiada envolvesse o lado em que o dispositivo estivesse localizado, aestratégia envolvia inclusive mudanças no local do implante. Passaram-se os anos e tanto os dispositivos como aradioterapia evoluíram, e o que antes era regra para a segurança do binômio marcapasso-radioterapia hoje pode serexceção. Relatamos o caso de um paciente portador de neoplasia maligna de lobo superior de pulmão direito, emposição ipsilateral ao marcapasso implantado previamente...

For years treatment with radiotherapy in patients with implantable electronic devices was considered dangerous. If the area to be irradiated involved the side where the device was located, the strategy involved including changes at the implant site. The years have gone by, the devices have evolved, radiotherapy has evolved,and what used to be the safety rule for the pacemaker-radiotherapy binomial may be the exception today. We report the case of a patient with malignant neoplasia of the upper lobe of the right lung, ipsilateral to a previously implanted pacemaker...

Terapia de ressincronização cardíaca após implante por cateter debioprótese valvar aórtica / Cardiac resynchronization therapy after transcatheter aortic valve implantation

O tratamento da estenose aórtica com implante por cateter de bioprótese valvar aórtica é sabidamente eficaz. Contudo, os distúrbios de condução são complicações frequentes e associam-se a elevada taxa de implante de marcapasso definitivo. Questões referentes ao melhor modo de estimulação, ao papel do cardiodesfibrilador na profilaxia de morte súbita e ao prognóstico ainda não apresentam consenso. Relata-se, portanto, um caso de paciente que, após o implante valvar, evoluiu com bloqueio completo de ramo esquerdo agudo e bradiarritmia, insuficiência cardíaca refratária ao tratamento medicamentoso, com fração de ejeção gravemente comprometida e intolerância ao betabloqueador por bradiarritmia. Optou-se, então, pela terapia de ressincronização ao invésdo marcapasso convencional, com boa resposta clínica. A associação com cardiodesfibrilador foi descartada paraprofilaxia de morte súbita após o estudo eletrofisiológico, o qual não evidenciou instabilidade elétrica ventricular...

Treatment of aortic stenosis with valve of transcatheter implant is known to be effective. However, conduction disorders are common complications and are associated with a high permanent pacemaker implantation rate. Questions regarding the best pacing mode, the role of the defibrillator in sudden death prevention and prognosis, do not have consensus yet. We report, therefore, the case of a patient who developed complete blockage of acute left bundle branch and bradyarrhythmia, heart failure refractory to drug therapy, poor ejection fraction and intolerance to betablocker due bradyarrhythmias after valve implant. Thus, we chose resynchronizationtherapy instead of conventional pacemakers and obtained a good clinical response. The association with adefibrillator was ruled out for sudden death prevention after the electrophysiological study, which did not show ventricular electrical instability...

Atrial fibrillation in decompensated heart failure: associated factors and in-hospital outcome.

BACKGROUND: Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil. OBJECTIVES: To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay. METHODS: Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used. RESULTS: The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001). CONCLUSIONS: Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality.

Atrial Fibrillation in Decompensated Heart Failure: Associated Factors and In-Hospital Outcome / Fibrilação Atrial em Insuficiência Cardíaca Descompensada: Fatores Associados e Evolução Hospitalar

Background: Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil. Objectives: To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay. Methods: Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used. Results: The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001). Conclusions: Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality. .

Fundamento: Estudos sobre fibrilação atrial (FA) na insuficiência cardíaca descompensada (ICD) são muito escassos no Brasil. Objetivos: Determinar a prevalência, os tipos e os fatores associados à FA em pacientes hospitalizados por ICD; analisar perfil de risco embólico e taxa de anticoagulação; e avaliar o impacto da FA na mortalidade hospitalar e no tempo de internação. Métodos: Estudo seccional de casos incidentes, retrospectivo, observacional. Analisaram-se 659 internações consecutivas por ICD entre 01/01/2006 a 31/12/2011. Risco embólico foi avaliado pelo acrônimo CHADSVASc. Na análise univariada, foram utilizados o qui-quadrado, teste t de Student ou Mann Whitney. Na análise multivariada, utilizou-se a regressão logística. Resultados: A prevalência de FA foi de 40%, predominando o tipo permanente (73,5%). No modelo multivariado, a FA se associou à idade avançada (p < 0,0001), etiologia não isquêmica (p = 0,02), disfunção ventricular direita (VD) (p = 0,03), menor pressão arterial sistólica (PAS) (p = 0,02), maior fração de ejeção (FE) (p < 0,0001) e aumento atrial esquerdo (AE) (p < 0,0001). A mediana do CHADSVASc foi quatro e 90% tinham escore ≥ 2. A taxa de anticoagulação foi de 52,8% na admissão e 66,8% na alta, sendo menor em escores mais elevados. O grupo com FA apresentou maior mortalidade hospitalar (11,0% versus 8,1%, p = 0,21) e internação mais prolongada (20,5 ± 16 versus 16,3 ± 12, p = 0,001). Conclusões: A FA é frequente na ICD, predominando o tipo permanente. Associa-se com idade avançada, etiologia não isquêmica, disfunção de VD, menor PAS, maior FE e aumento AE. O perfil de risco embólico é elevado e a anticoagulação é subutilizada. ...

Devemos suspender os agentes antiagregantes plaquetários para procedimentos de dispositivos cardíacos implantáveis? / Should we discontinue antiplatelet agents in implantable cardiac devices procedures?

A cardiopatia isquêmica está comumente associada a arritmias ventriculares malignas, sendo ocardiodesfibriladorimplantável indicado para pacientes selecionados. Essa população faz uso de agentesantiagregantes plaquetários como terapia única ou com duas medicações combinadas. Embora fundamentaispara o tratamento da coronariopatia, os antiagregantes plaquetários aumentam o risco de sangramento nessespacientes, em especial ao se tratar de intervenção cirúrgica. Os autores relatam o caso de paciente portador dedesfibrilador cardíaco implantável e cardiopatia isquêmica, que precisou suspender o uso de antiagregantesplaquetários em decorrência de indicação cirúrgica de troca da unidade geradora por desgaste de bateria. Apóssuspensão da dupla antiagregação, o paciente apresentou choque apropriado decorrente de fibrilação ventricularsecundária a trombose aguda intrastent.

Ischemic heart disease is commonly associated with malignant ventricular arrhythmias and theimplantable cardiac defibrillator is indicated for selected patients. This population uses single or dual antiplatelettherapy. Although they are essential for the treatment of coronary artery disease, anti-platelet agents increase therisk of bleeding in these patients, especially in surgical interventions. The authors report the case of a patient withimplantable cardiac defibrillator and ischemic heart disease, who had to discontinue the use of antiplatelet agentsdue to the indication for device replacement surgery. After discontinuation of dual antiplatelet therapy, the patienthad appropriate shock resulting from ventricular fibrillation secondary to acute in-stent thrombosis.

Taquicardia ventricular curável em paciente com miocardiopatia isquêmica / Curable Ventricular tachycardia in a patient with ischemic myocardiopathy

Em pacientes com atraso na condução pelo sistema His-Purkinje, macrorreentradas através dos ramos esquerdo e direito podem produzir taquicardias ventricularessustentadas, sendo denominadas taquicardias ventriculares por reentrada entre os ramos ou taquicardiasventriculares ramo a ramo. O diagnóstico desse tipo de arritmia é muito importante já que geralmente nãoresponde a tratamento farmacológico, tem alta recorrência, pode causar palpitações, síncope, morte súbita oumúltiplas terapias em pacientes portadores de desfibriladorcardíaco implantável. O diagnóstico de taquicardia ventricular (TV) ramo a ramo é extremamente importante,haja vista que pode ser curada com ablação por cateter.

Acometimento do ventrículo esquerdo na displasia arritmogênica do ventrículo direito: estudo ecocardiográfico de três casos / Ventricle involvement in arrhythmogenic right ventricular cardiomyopathy: ecocardiographic study of three cases

A Displasia Arritmogênica do Ventrículo Direito (DAVD) é uma rara cardiomiopatia genética, caracterizada por infiltração fibrogordurosa, associada a alto risco de morte súbita (MS). A prevenção de MS permite-nos observar estágios mais avançados da doença, como o acometimento do ventrículo esquerdo (VE). O objetivo deste estudo é relatar três casos, nos quais, além das alterações do ventrículo direito (VD), foi observado acometimento do VE, com afinamento, hiperrefringência e hipocinesia acentuada das paredes inferior e ínferolateral documentadas ao ecocardiograma. Portanto, o estudo ecocardiográfico do paciente com DAVD deve incluir avaliação cuidadosa do VE, com especial atenção aos segmentos da parede inferior e ínferolateral.

Arrythmogenic right ventricular dysplasia (ARVD) is a rare genetically mediated cardiomyopathy characterized as fibrofatty infi ltration, associated to high risk of sudden death (SD). Prevention of SD has allowed us to study advanced stages of this disease, like left ventricle (LV) involvement. The aim of this paper is to report three cases of patients with the disease, where, besides alteration of right ventricle, it was observed left ventricle involvement like thinning, brightness and hypokinesia of inferior and infero lateral walls, showed by echocardiography. So, echocardiography of ARVD patients must include carefully attention to the LV, especially when it comes to inferior and infero lateral walls.

Síndrome de wolff-parkinson-white e outras vias acessórias atrioventriculares em 1465 pacientes submetidos à ablação por radiofrequência / Wolff-parkinson-white syndrome and other atrioventricular accessory pathways in 1465 patients undergoing radio-frequency ablation

Vários estudos foram realizados analisando dados clínicos e eletrofisiológicos de pacientes com vias acessórias, todavia a sua maioria é proveniente de ensaios estrangeiros, que se basearam em um número relativamente pequeno de pacientes. Descrever o número e a localização das vias acessórias em pacientes brasileiros submetidos à ablação por radiofrequência. Foram analisados, retrospectivamente, 1465 pacientes consecutivos portadores de vias acessórias que foram submetidos...

Atrial fibrillation ablation in Brazil: results of the registry of the Brazilian Society of Cardiac Arrhythmias.

BACKGROUND: Aiming to define the profile of curative atrial fibrillation (AF) ablation in Brazil, the Brazilian Cardiac Arrhythmia Society [Sociedade Brasileira de Arritmias Cardíacas] (SOBRAC) created the Brazilian Registry of AF Ablation [Registro Brasileiro de Ablação da FA]. OBJECTIVE: To describe the results of this registry. METHODS: A questionnaire was sent to SOBRAC members asking about data on patients submitted to AF ablation between September 2005 and November, 2006. RESULTS: A total of 29 groups from 13 states completed the forms. Of these, 22 (76%) had performed AF ablations. Between 1998 and 2001, 7 groups (32%) initiated AF ablations and between 2002 and 2006, 15 groups began to perform them (68%). From 1998 to 2006, 2,374 patients were submitted to ablation, 755 (32%) of them during the registry period. Most (70%) were males and 89% presented with paroxysmal or persistent AF. Ancillary imaging methods (intracardiac echocardiography and electroanatomic mapping) were used by 9 groups (41%). During an average five-month follow-up period, total success was 82% and success without use of antiarrhythmic agents was 57%. Nevertheless, 35% of the patients required two or more procedures. There were 111 complications (14.7%) and 2 deaths (0.26%). CONCLUSION: Curative AF ablation has been increasing significantly in our country, with success rates comparable to international indexes, but often more than one procedure is necessary. Despite promising results, AF ablation still results in significant morbidity. Supplementary imaging methods have been used more and more in an effort to increase efficacy and safety of the procedure. These findings should be considered by public and private funding agencies.

Ablação da fibrilação atrial no Brasil: resultados do registro da Sociedade Brasileira de Arritmias Cardíacas / Atrial fibrillation ablation in Brazil: results of the registry of the Brazilian Society of Cardiac Arrhythmias

FUNDAMENTO: Buscando delinear o perfil da ablação curativa de fibrilação atrial (FA) no Brasil, a Sociedade Brasileira de Arritmias Cardíacas (SOBRAC) idealizou o Registro Brasileiro de Ablação da FA. OBJETIVO: Descrever os resultados desse registro. MÉTODOS: Foi enviado um formulário aos sócios da SOBRAC, inquirindo sobre os dados de pacientes submetidos a ablação de FA entre setembro de 2005 e novembro de 2006. RESULTADOS: No total, 29 grupos, de 13 Estados, responderam ao formulário. Desses, 22 (76 por cento) realizaram ablações de FA. Entre 1998 e 2001, 7 grupos (32 por cento) iniciaram ablações de FA e entre 2002 e 2006, 15 grupos (68 por cento). De 1998 a 2006, 2.374 pacientes foram submetidos a ablação, sendo 755 (32 por cento) no período do registro. A maioria (70 por cento) era do sexo masculino e 89 por cento apresentavam FA paroxística ou persistente. Métodos auxiliares de imagem (ecocardiografia intracardíaca e mapeamento eletroanatômico) foram utilizados por 9 grupos (41 por cento). Durante seguimento médio de cinco meses, o sucesso total foi de 82 por cento e o sucesso sem uso de antiarrítmicos foi de 57 por cento. Contudo, 35 por cento dos pacientes necessitaram de dois ou mais procedimentos. Houve 111 complicações (14,7 por cento) e 2 óbitos (0,26 por cento). CONCLUSÃO: A ablação curativa de FA vem crescendo significativamente em nosso País, com taxas de sucesso comparáveis às internacionais, mas comumente há necessidade de mais de um procedimento. Apesar dos resultados promissores, a ablação de FA ainda acarreta morbidade significativa. Métodos auxiliares de imagem têm sido cada vez mais utilizados, visando a aumentar a eficácia e a segurança do procedimento. Esses achados devem ser considerados pelos órgãos pagadores públicos e privados.

BACKGROUND: Aiming to define the profile of curative atrial fibrillation (AF) ablation in Brazil, the Brazilian Cardiac Arrhythmia Society [Sociedade Brasileira de Arritmias Cardíacas] (SOBRAC) created the Brazilian Registry of AF Ablation [Registro Brasileiro de Ablação da FA]. OBJECTIVE: To describe the results of this registry. METHODS: A questionnaire was sent to SOBRAC members asking about data on patients submitted to AF ablation between September 2005 and November, 2006. RESULTS: A total of 29 groups from 13 states completed the forms. Of these, 22 (76 percent) had performed AF ablations. Between 1998 and 2001, 7 groups (32 percent) initiated AF ablations and between 2002 and 2006, 15 groups began to perform them (68 percent). From 1998 to 2006, 2,374 patients were submitted to ablation, 755 (32 percent) of them during the registry period. Most (70 percent) were males and 89 percent presented with paroxysmal or persistent AF. Ancillary imaging methods (intracardiac echocardiography and electroanatomic mapping) were used by 9 groups (41 percent). During an average five-month follow-up period, total success was 82 percent and success without use of antiarrhythmic agents was 57 percent. Nevertheless, 35 percent of the patients required two or more procedures. There were 111 complications (14.7 percent) and 2 deaths (0.26 percent). CONCLUSION: Curative AF ablation has been increasing significantly in our country, with success rates comparable to international indexes, but often more than one procedure is necessary. Despite promising results, AF ablation still results in significant morbidity. Supplementary imaging methods have been used more and more in an effort to increase efficacy and safety of the procedure. These findings should be considered by public and private funding agencies.

Estudo prospectivo das repercussões de baixas doses de remifentanil na função sinoatrial e na condução e refratariedade cardíaca / Prospective study on the repercussions of low doses of remifentanil on sinoatrial function and in cardiac conduction and refractory period

JUSTIFICATIVA E OBJETIVOS: O remifentanil é um opióide com início e término de ação rápidos, cujo uso em procedimentos de curta duração vem se propagando nos últimos anos. Entre os efeitos colaterais descritos, há relatos de bradicardia e assistolia. O objetivo deste estudo foi avaliar os efeitos desse fármaco na condução e refratariedade cardíaca, em humanos. MÉTODO: Estudo prospectivo de 16 pacientes, entre 18 e 65 anos, de ambos os sexos, ASA I a III, submetidos a estudo eletrofisiológico intracardíaco eletivo. Foram excluídos os pacientes com doença do nódulo sinoatrial e os portadores de bloqueios cardíacos graves. No laboratório de eletrofisiologia, os pacientes foram inicialmente sedados com midazolam (0,03 mg.kg-1), após 5 minutos (M0) avaliou-se o grau de sedação de intensidade de dor, pressões arteriais sistólica e diastólica, freqüências cardíaca e respiratória e saturação de oxigênio. O eletrofisiologista avaliou as variáveis de condução cardíaca (duração do QRS, intervalos AA, AH, HV e PA), o tempo de recuperação do nódulo sinoatrial e as variáveis de refratariedade cardíaca (período refratário do átrio direito, período refratário do ventrículo direito e período refratário do nódulo atrioventricular). Após as medidas iniciais o remifentanil foi introduzido (bolus de 0,5 μg.kg-1 + infusão de 0,05 μg.kg-1.min-1) e após 20 minutos as mesmas variáveis foram reavaliadas (M1). RESULTADOS: Observou-se diminuição das pressões sistólica e diastólica (p = 0,0001) entre M0 e M1, sem diferença estatística significativa da freqüência respiratória ou da saturação de oxigênio. Houve aumento do intervalo átrio-His (p = 0,006) e do tempo de recuperação do nódulo sinoatrial (p = 0,0004), do período refratário do átrio direito (p = 0,001) e do período refratário do nódulo atrioventricular (p = 0,0001), porém não houve diminuição da freqüência cardíaca basal entre M0 e M1. CONCLUSÕES: O remifentanil alterou as variáveis eletrofisiológicas cardíacas,...

BACKGROUND AND OBJECTIVES: Remifentanil is an opiod with fast onset of action and short acting, and its use in short-duration procedures has increased in the last few years. Bradycardia and asystole are among the side effects reported. The objective of this study was to evaluate the effects of this drug in cardiac conduction and refractory period in human beings. METHODS: A prospective study with 16 patients, ages 18 to 65, both genders, ASA I to III, undergoing elective intracardiac electrophysiological study, was undertaken. Patients with disorders of the sinoatrial node and those with severe cardiac blocks were excluded. In the laboratory of electrophysiology, patients were sedated with midazolam (0.03 mg.kg-1) after 5 minutes the degree of sedation and degree of pain, systolic and diastolic blood pressure, heart rate and respiratory rate, and oxygen saturation were evaluated. The electrophysiologist evaluated cardiac conduction (duration of the QRS complex, and AA, AH, HV, and PA intervals), duration of sinoatrial node recovery, and cardiac refractory period (refractory period of the right atrium, right ventricle, and atrioventricular node). After the initial measurements, remifentanil was administered (bolus of 0.5 μg.kg-1 + infusion of 0.05 μg.kg-1.min-1) and, after 20 minutes, the same parameters were evaluated. RESULTS: There was a reduction in systolic and diastolic blood pressure (p = 0.0001) between M0 and M1, and significant differences in respiratory rate and oxygen saturation, which were not statistically significant. The atrium-His interval (p = 0.006), recovery time of the sinoatrial node (p = 0.0004), refractory period of the right atrium (p = 0.001), and refractory period of the sinoatrial node (p = 0.0001) were all increased; however, there were no differences in heart rate between M0 and M1. CONCLUSIONS: Remifentanil changes cardiac electrophysiological parameters and, in doses higher than the ones used in this study,...

JUSTIFICATIVA Y OBJETIVOS: El remifentanil es un opioide con inicio y fin de acción rápidos, cuyo uso en procedimientos de corta duración se ha venido propagando en los últimos años. Entre los efectos colaterales descritos, hay relatos de bradicardia y asistolia. El objetivo de este estudio fue evaluar los efectos de este fármaco en la conducción y refractariedad cardíaca, en humanos. MÉTODO: Estudio prospectivo de 16 pacientes, entre 18 y 65 años, de ambos sexos, ASA I a III, que se sometieron a estudio electrofisiológico intra cardiaco electivo. Se excluyeron pacientes con enfermedades del nódulo sino-atrial y los portadores de bloqueos cardíacos graves. En el laboratorio de electrofisiologia, los pacientes fueron inicialmente sedados con midazolam (0,03 mg.kg-1), 5 minutos después (M0) se evaluó el grado de sedación e intensidad de dolor, presiones arteriales sistólica y diastólica, frecuencias cardíaca y respiratoria y saturación de oxígeno. El electrofisiologista evaluó las variables de conducción cardíaca (duración del QRS, intervalos AA, AH, HV y PA), el tiempo de recuperación del nódulo sino-atrial y las variables de refractariedad cardíaca (período refractario del atrio derecho, período refractario del ventrículo derecho y período refractario del nódulo atrio ventricular). Después de las medidas iniciales el remifentanil fue introducido (bolo de 0,5 μg.kg-1 + infusión de 0,05 μg.kg-1.min-1) y después de 20 minutos las mismas variables fueron evaluadas nuevamente (M1). RESULTADOS: Se observó disminución de las presiones sistólica y diastólica (p = 0.0001) entre M0 y M1, sin diferencia estadística significativa de la frecuencia respiratoria o de la saturación de oxígeno. Hubo aumento del intervalo atrio-His (p = 0,006) y del tiempo de recuperación del nódulo sino-atrial (p = 0,0004), del período refractario del atrio derecho (p = 0,001) y del período refractario del nódulo atrio ventricular (p = 0,0001), pero no hubo disminución...