RESUMO
BACKGROUND: Abdominal aortic aneurysm (AAA) is an asymptomatic condition characterized by progressive dilatation of the aorta. The purpose of this study is to identify important 2D-TTE aortic indices associated with AAA as predictive tools for undiagnosed AAA. METHODS: In this retrospective study, we evaluated the size of the ascending aorta in patients without known valvular diseases or hemodynamic compromise as predictive tool for undiagnosed AAA. We studied the tubular ascending aorta of 170 patients by 2-dimensional transthoracic echocardiography (2D-TTE). Patients were further divided into two groups, 70 patients with AAA and 100 patients without AAA with normal imaging results. RESULTS: Dilatation of tubular ascending aorta was measured in patients with AAA compared to the group with absent AAA (37.5 ± 4.8 mm vs. 31.2 ± 3.6 mm, p < 0.001, respectively) and confirmed by computed tomographic (CT) (35.6 ± 5.1 mm vs. 30.8 ± 3.7 mm, p < 0.001, respectively). An increase in tubular ascending aorta size was associated with the presence of AAA by both 2D-TTE and CT (r = 0.40, p < 0.001 and r = 0.37, p < 0.001, respectively). The tubular ascending aorta (D diameter) size of ≥33 mm or ≥ 19 mm/m2 presented with 2-4 times more risk of AAA presence (OR 4.68, CI 2.18-10.25, p = 0.001 or OR 2.63, CI 1.21-5.62, p = 0.02, respectively). In addition, multiple logistic regression analysis identified tubular ascending aorta (OR 1.46, p < 0.001), age (OR 1.09, p = 0.013), gender (OR 0.12, p = 0.002), and LVESD (OR 1.24, p = 0.009) as independent risk factors of AAA presence. CONCLUSIONS: An increased tubular ascending aortic diameter, measured by 2D-TTE, is associated with the presence of AAA. Routine 2D-TTE screening for silent AAA by means of ascending aorta analysis, may appear useful especially in older patients with a dilated tubular ascending aorta (≥33 mm).
Assuntos
Aneurisma da Aorta Abdominal/complicações , Dilatação Patológica/complicações , Ecocardiografia/métodos , Idoso , Idoso de 80 Anos ou mais , Aorta/diagnóstico por imagem , Dilatação , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios XRESUMO
AIMS: Many tachy-brady syndrome (TBS) patients, are implanted a permanent pacemaker (PPM) to allow continuation of anti-arrhythmic drug (AAD) therapy to maintain sinus rhythm. Many of these PPM's are implanted as a preventive measure, in absence of symptomatic bradycardia. Our primary aim was to evaluate pacing use among these patients and find predictors for PPM use. Our secondary aim was to appreciate the portion of these patients who progress to permanent atrial fibrillation (AF). METHODS: Retrospective study of TBS patients implanted a PPM as preventive measure, dividing cases into defined categories regarding highest percent atrial and ventricular pacing documented in PPM clinic visits during 3 year follow-up (F/U) period. Patients' baseline characteristics and AAD therapy were compared between cases with a major (>90%) pacing use and cases with <90% pacing use to find predictors for pacing use. Multivariable logistic regression was applied to identify independent variables associated with major pacing use. RESULTS: Our study included 119 TBS patients. Most (86.5%) TBS patients had a moderate (>50%) pacing use and 58% had a major pacing use. Significant association was found between pre-implant severe sinus bradycardia (<40 bpm), first degree atrioventricular block and amiodarone treatment to major pacing use on univariate analysis and severe sinus bradycardia was significantly associated with major pacing on multivariate analysis as well. Only minority (16.8%) of TBS patients progressed to permanent AF during the study F/U period. CONCLUSION: Our study reveals most TBS patients succeed to maintain sinus rhythm using an AAD with a significant pacing use, suggesting preventive PPM implantation might be advantageous in these cases. Pre-implant severe sinus bradycardia (<40 bpm) is a possible predictor for major pacing use in this population.
Assuntos
Fibrilação Atrial/terapia , Bradicardia/terapia , Estimulação Cardíaca Artificial/estatística & dados numéricos , Síndrome do Nó Sinusal/terapia , Idoso , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/etiologia , Bradicardia/tratamento farmacológico , Bradicardia/etiologia , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Síndrome do Nó Sinusal/complicações , Síndrome do Nó Sinusal/tratamento farmacológicoRESUMO
BACKGROUND: Diabetes mellitus (DM) is a common and increasingly prevalent condition in patients with atrial fibrillation (AFib). The left atrium appendage (LAA), a small outpouch from the LA, is the most common location for thrombus formation in patients with AFib. HYPOTHESIS: In this study, we examined LAA remodeling differences between diabetic and nondiabetic patients with AFib. METHODS: This retrospective study analyzed data from 242 subjects subdivided into two subgroups of 122 with DM (diabetic group) and 120 without DM (nondiabetic group). The study group underwent real-time 3-dimensional transesophageal echocardiography (RT3DTEE) for AFib ablation, cardioversion, or LAA device closure. The LAA dimensions were measured using the "Yosefy rotational 3DTEE method." RESULTS: The RT3DTEE analysis revealed that diabetic patients display larger LAA diameters, D1-lengh (2.09 ± 0.50 vs 1.88 ± 0.54 cm, P = .003), D2-width (1.70 ± 0.48 vs 1.55 ± 0.55 cm, P = .024), D3-depth (2.21 ± 0.75 vs 1.99 ± 0.65 cm, P = .017), larger orifice areas (2.8 ± 1.35 and 2.3 ± 1.49 cm2 , P = .004), and diminished orifice flow velocity (37.3 ± 17.6 and 43.7 ± 19.5 cm/sec, P = .008). CONCLUSIONS: Adverse LAA remodeling in DM patients with AFib is characterized by significantly LAA orifice enlargement and reduced orifice flow velocity. Analysis of LAA geometry and hemodynamics may have clinical implications in thrombotic risk assessment and treatment of DM patients with AFib.
Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/fisiopatologia , Remodelamento Atrial/fisiologia , Cardiomiopatias Diabéticas/fisiopatologia , Idoso , Apêndice Atrial/diagnóstico por imagem , Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Cardiomiopatias Diabéticas/diagnóstico por imagem , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Cardioversão Elétrica , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Implantação de Prótese , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
INTRODUCTION: Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation. METHODS AND RESULTS: Data were derived from a prospective Israeli ICD Registry. Two groups of patients were compared, those who died and those who were alive 1 year after ICD implantation. Factors associated with 1-year mortality were identified on a derivation cohort. A risk score was established and validated. A total of 2617 patients have completed 1 year of follow-up after ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Age greater than 75 years (hazard ratio [HR], 2.7; 95% confidence interval [95% CI], 1.6 to 4.4), atrial fibrillation (AF; HR, 1.9; 95% CI, 1.12 to 3.17), chronic lung disease (HR, 2.0; 95% CI, 1.1 to 3.76), anemia (HR, 2.3; 95% CI, 1.3 to 3.93) and chronic renal failure (CRF; HR, 3.4; 95% CI, 1.74 to 6.6) were independent risk factors for 1-year mortality. We propose a simple AAACC ("triple A double C") score for prediction of 1-year mortality after ICD implantation: Age greater than 75 years (3 points(pts)), anemia (2 pts), AF (1 pt), CRF (3 pts) and chronic lung disease (1 pt). Mortality risk increased with rising number of points (from 1% with 0 pts to 12.5% with >4 pts). The risk score was evaluated with receiver operating characteristic curve and the area under the curve of the validation curve is 0.71 (95% CI, 0.66 to 0.76). CONCLUSIONS: Age greater than 75, AF, chronic lung disease, anemia, and CRF were independent risk factors for 1-year mortality. AAACC risk score identifies patients at high risk of death during 1 year after ICD implantation.
Assuntos
Fibrilação Atrial/mortalidade , Fibrilação Atrial/terapia , Desfibriladores Implantáveis/tendências , Cardioversão Elétrica/mortalidade , Cardioversão Elétrica/tendências , Sistema de Registros , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Análise de Dados , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Feminino , Seguimentos , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de RiscoRESUMO
BACKGROUND: Multiform fascicular tachycardia (FT) was recently described as a ventricular tachycardia (VT) that has a reentrant mechanism using multiple fascicular branches and produces alternate fascicular VT forms. Ablating the respective fascicle may cause a change in the reentrant circuit resulting in a change in morphology. Ablation of the septal fascicle is crucial for successful treatment. OBJECTIVES: To describe four cases of FT in which ablation induced a change in QRS morphologies and aggravated clinical course. METHODS: Four out of 57 consecutive FT cases at three institutions were retrospectively analyzed and found to involve multiform FT. These cases underwent electrophysiological study, fascicular potential mapping, and electroanatomical mapping. All patients initially had FT with right bundle branch block (RBBB) and superior axis morphology. RESULTS: Radiofrequency catheter ablation (RFCA) targeting the distal left posterior fascicle (LPF) resulted in a second VT with an RBBB-inferior axis morphology that sometimes became faster and/or incessant and/or verapamil-refractory in characteristics. RFCA in the upper septum abolished the second VT with no complications and uneventful long-term follow-up. CONCLUSIONS: The change in FT morphology during ablation may be associated with a change in clinical course when shifting from one route to another and may aggravate symptoms. Targeting of the proximal conduction system (such as bifurcation, LPF, left anterior fascicle, high septal/auxiliary pathway) may serve to solve this problem.
Assuntos
Fascículo Atrioventricular , Bloqueio de Ramo , Ablação por Cateter/métodos , Técnicas Eletrofisiológicas Cardíacas/métodos , Taquicardia Ventricular , Adulto , Fascículo Atrioventricular/fisiopatologia , Fascículo Atrioventricular/cirurgia , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/fisiopatologia , Bloqueio de Ramo/cirurgia , Eletrocardiografia/métodos , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/prevenção & controle , Tempo , Resultado do TratamentoRESUMO
PURPOSE: Multisite cardiac resynchronization therapy (MSCRT) with dual-vein left ventricular (LV) pacing has theoretical advantages over conventional CRT in faster and more physiological LV activation. We aimed to define indications, feasibility, safety, acute, and long-term results of MSCRT. METHODS: All patients implanted with MSCRT during 2008-2014 in a single center were reviewed and analyzed. RESULTS: Thirty-nine patients (90% CRT-defibrillators, 64 ± 9 years, 85% male, 74% ischemic etiology) were included. Four groups of indications were recognized: (1) significant tricuspid regurgitation (TR) in patients planned for device implantation without right ventricular lead (n = 3). Follow-up (f/u) of 4 ± 3 years showed major symptomatic improvement in all, with stable LV size and function and deferral of valve surgery; (2) severe heart failure with reduced ejection fraction (HFrEF) and refractory ventricular tachycardia (VT) (n = 4). Except for 1 early death for acute renal failure, all others showed no VT episodes and HF improvement (f/u 4.5 ± 0.5 years); (3) severe HFrEF and wide QRS (≥ 150 ms) or failure of biventricular pacing to narrow QRS during implantation (n = 5). One patient had periprocedural mortality. The others had major clinical improvement; (4) severe HF and narrow QRS/RBBB (n = 27). 23/24 patients with available f/u of 3 ± 1.7 years improved clinically and 57% had EF improvement. In 3 patients, LV1 was disabled and one had LV2 dislodgement. CONCLUSIONS: MSCRT is feasible, safe, and valuable in selected patients with a need to avoid RV lead during device implantation, refractory VT with no other solution, severe HFrEF with wide QRS or CRT non-responsiveness, and severe HF without LBBB. Randomized controlled studies are required.
Assuntos
Terapia de Ressincronização Cardíaca/métodos , Ecocardiografia Transesofagiana/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapia , Sistema de Registros , Idoso , Estimulação Cardíaca Artificial/métodos , Estimulação Cardíaca Artificial/mortalidade , Terapia de Ressincronização Cardíaca/mortalidade , Estudos de Viabilidade , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial , Seleção de Pacientes , Recuperação de Função Fisiológica , Recidiva , Estudos Retrospectivos , Medição de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
AIMS: Cardiac resynchronization therapy (CRT) with a defibrillator (CRT-D) has downsides of high cost and inappropriate shocks compared to CRT without a defibrillator (CRT-P). Recent data suggest that the survival benefit of implantable cardioverter defibrillator (ICD) therapy is attenuated in the older age group. We hypothesized that, among octogenarians eligible for cardiac resynchronization therapy, CRT-P confers similar morbidity and mortality benefits as CRT-D. METHODS AND RESULTS: We compared morbidity and mortality outcomes between consecutive octogenarian patients eligible for CRT therapy who underwent CRT-P implantation at Barzilai MC (n = 142) vs. those implanted with CRT-D for primary prevention indication who were prospectively enrolled in the Israeli ICD Registry (n = 104). Among the 246 study patients, mean age was 84 ± 3 years, 74% were males, and 66% had ischaemic cardiomyopathy. Kaplan-Meier survival analysis showed that at 5 years of follow-up the rate of all-cause mortality was 43% in CRT-P vs. 57% in the CRT-D group [log-rank P = 0.13; adjusted hazard ratio (HR) = 0.79, 95% CI 0.46-1.35, P = 0.37]. Kaplan-Meier analysis also showed no significant difference in the rates of the combined endpoint of heart failure or death (46 vs. 60%, respectively, log-rank P = 0.36; adjusted HR was 0.85, 95% CI 0.51-1.44, P = 0.55). A Cox proportional hazard with competing risk model showed that re-hospitalizations for cardiac cause were not different for the two groups (adjusted HR 1.35, 95% CI 0.7-2.6, P = 0.37). CONCLUSION: Our data suggest that, in octogenarians with systolic heart failure, CRT-P therapy is associated with similar morbidity and mortality outcomes as CRT-D therapy.
Assuntos
Dispositivos de Terapia de Ressincronização Cardíaca , Terapia de Ressincronização Cardíaca/mortalidade , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Insuficiência Cardíaca/terapia , Prevenção Primária/instrumentação , Fatores Etários , Idoso de 80 Anos ou mais , Terapia de Ressincronização Cardíaca/efeitos adversos , Causas de Morte , Distribuição de Qui-Quadrado , Cardioversão Elétrica/efeitos adversos , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Israel , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Readmissão do Paciente , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Not all echo laboratories have the capability of measuring direct online 3D images, but do have the capability of turning 3D images into 2D ones "online" for bedside measurements. Thus, we hypothesized that a simple and rapid rotation of the sagittal view (green box, x-plane) that shows all needed left atrial appendage (LAA) number of lobes, orifice area, maximal and minimal diameters and depth parameters on the 3D transesophageal echocardiography (3DTEE) image and LAA measurements after turning the images into 2D (Rotational 3DTEE/"Yosefy Rotation") is as accurate as the direct measurement on real-time-3D image (RT3DTEE). METHODS: We prospectively studied 41 consecutive patients who underwent a routine TEE exam, using QLAB 10 Application on EPIQ7 and IE33 3D-Echo machine (BORTHEL Phillips) between 01/2013 and 12/2015. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between RT3DTEE and Rotational 3DTEE versus CT. RESULTS: Rotational 3DTEE measurements of LAA were not statistically different from RT3DTEE and from CT regarding: number of lobes (1.6 ± 0.7, 1.6 ± 0.6, and 1.4 ± 0.6, respectively, p = NS for all); internal area of orifice (3.1 ± 0.6, 3.0 ± 0.7, and 3.3 ± 1.5 cm(2), respectively, p = NS for all); maximal LAA diameter (24.8 ± 4.5, 24.6 ± 5.0, and 24.9 ± 5.8 mm, respectively, p = NS for all); minimal LAA diameter (16.4 ± 3.4, 16.7 ± 3.3, and 17.0 ± 4.4 mm, respectively, p = NS for all), and LAA depth (20.0 ± 2.1, 19.8 ± 2.2, and 21.7 ± 6.9 mm, respectively, p = NS for all). CONCLUSION: Rotational 3DTEE method for assessing LAA is a simple, rapid and feasible method that has accuracy similar to that of RT3DTEE and CT. Thus, rotational 3DTEE ("Yosefy rotation") may facilitate LAA closure procedure by choosing the appropriate device size.
Assuntos
Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/diagnóstico , Função do Átrio Esquerdo/fisiologia , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Apêndice Atrial/fisiopatologia , Fibrilação Atrial/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
INTRODUCTION: Recent efforts to increase CRT response by multiSPOT pacing (MSP) from multiple bipols on the same left ventricular lead are still inconclusive. AIM: The Left Ventricular (LV) MultiSPOTpacing for CRT (iSPOT) study compared the acute hemodynamic response of MSP pacing by using 3 electrodes on a quadripolar lead compared with conventional biventricular pacing (BiV). METHODS: Patients with left bundle branch block (LBBB) underwent an acute hemodynamic study to determine the %change in LV+dP/dtmax from baseline atrial pacing compared to the following configurations: BiV pacing with the LV lead in a one of lateral veins, while pacing from the distal, mid, or proximal electrode and all 3 electrodes together (i.e. MSP). All measurements were repeated 4 times at 5 different atrioventricular delays. We also measured QRS-width and individual Q-LV durations. RESULTS: Protocol was completed in 24 patients, all with LBBB (QRS width 171±20 ms) and 58% ischemic aetiology. The percentage change in LV+dP/dtmax for MSP pacing was 31.0±3.3% (Mean±SE), which was not significantly superior to any BiV pacing configuration: 28.9±3.2% (LV-distal), 28.3±2.7% (LV-mid), and 29.5±3.0% (LV-prox), respectively. Correlation between LV+dP/dtmax and either QRS-width or Q-LV ratio was poor. CONCLUSIONS: In patients with LBBB MultiSPOT LV pacing demonstrated comparable improvement in contractility to best conventional BiV pacing. Optimization of atrioventricular delay is important for the best performance for both BiV and MultiSPOT pacing configurations. TRIAL REGISTRATION: ClinicalTrials.gov NTC01883141.
Assuntos
Bloqueio de Ramo/terapia , Estimulação Cardíaca Artificial/métodos , Insuficiência Cardíaca/terapia , Hemodinâmica , Função Ventricular Esquerda , Idoso , Bloqueio de Ramo/fisiopatologia , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
AIMS: Currently, two-dimensional transesophageal echocardiography (2DTEE) at a cut-plane angulation of 135° is the recommended method to size maximal left atrial appendage (LAA) orifice diameter before introducing a percutaneous LAA closure device. We compared real time three-dimensional TEE (RT3DTEE) and 2DTEE for measuring LAA dimensions versus computed tomography (CT) as gold standard. METHODS AND RESULTS: We prospectively studied 30 consecutive patients who underwent a routine TEE examination, using QLAB 10.0 Application on EPIQ7 iE33 3D echo machine between December 2012 and December 2013. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between 135 2DTEE and RT3DTEE. Results were compared with CT measurements. Using RT3DTEE, larger LAA diameters were measured versus 2DTEE (23.5 ± 3.9 vs. 24.5 ± 4.7 mm). In seven patients (23.3%), the measurements in 135° 2DTEE were smaller than the cut-plane angulation with maximal orifice diameter. RT3DTEE measurements of LAA were not different from CT regarding number of lobes, area of orifice, and maximal diameter. LAA volume could not be measured directly using RT3DTEE. No difference was found between LAA depth using RT3DTEE (19.5 ± 2.3 mm) vs. CT (19.6 ± 2.3, P = NS) and 2DTEE (19.4 ± 2.2 mm) vs. CT (P = NS). However, RT3DTEE (24.5 ± 4.7 mm) vs. CT (24.6 ± 5, P = NS) was more accurate in measuring maximal LAA diameter compared to 2DTEE (23.5 ± 3.9 mm) vs. CT (P < 0.01). CONCLUSION: RT3DTEE method is more accurate than 2DTEE for assessment of maximal LAA orifice diameter. Bedsides, RT3DTEE LAA measurements are not statistically different from CT. Thus, RT3DTEE may facilitate LAA closure procedure by choosing the appropriate device size.
Assuntos
Apêndice Atrial/diagnóstico por imagem , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
AIMS: We compare our experience with available circular multi-electrode catheters for atrial fibrillation (AF) ablation: PVAC(®), a phased radiofrequency system, and nMARQ™, an irrigated tip-CARTO-based technology. METHODS AND RESULTS: Prospective observational study of 175 consecutive patients with follow-up duration of at least 5 months who underwent pulmonary vein isolation (PVI) for symptomatic AF using PVAC(®) (n = 93, age 61.4 ± 9.8 years; 60% male, 13% persistent AF) vs. nMARQ™ (n = 82, age 63.2 ± 10.6 years; 67% male, 24% persistent AF). Procedure and radiation times were 94 ± 27 and 33 ± 13 min for PVAC(®) and 81 ± 18 and 30 ± 8.5 for nMARQ™ (P = 0.0008 and P = 0.18), respectively. The number of applications and the total burning time (min) were 20 ± 7 and 19 ± 6.7 for PVAC(®) and 16 ± 5.6 and 11 ± 4 for nMARQ™ (P < 0.0001 for both), respectively. In two nMARQ™ patients with small atria and pulmonary veins (PVs) and in two PVAC(®) patients with large PVs, the procedure failed; switching to the alternative technology was successful. Acute success rate was 97% for PVAC(®) and 95% for nMARQ™. There was one tamponade in nMARQ™ group and non-significant different minor complications for both techniques. One-year freedom from AF was 79 and 80.7% with PVAC(®) vs. nMARQ™, after one PVI, and 88 vs. 87.7% after two PVIs. CONCLUSION: Both technologies have short procedure and fluoroscopy times, comparable complication rates, and comparable acute and 1-year success rates. The number of applications and total procedure and burning times were shorter with nMARQ™. nMARQ™ was more suitable for larger atria and PVs. Thus, a patient-based pre-ablation anatomy definition is probably warranted for appropriate selection of technology type.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/instrumentação , Eletrodos Implantados , Átrios do Coração/cirurgia , Veias Pulmonares/cirurgia , Idoso , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Fluoroscopia , Seguimentos , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do TratamentoRESUMO
PURPOSE: Previous data showed that pain sensation was common during pulmonary vein isolation (PVI) using an 8-mm radiofrequency (RF) ablation catheter. Pain was more common in the left pulmonary veins (PVs). We characterized the location of pain during PVI using circular multi-electrode ablation catheters. METHODS: Included are all consecutive patients with atrial fibrillation (AF) who underwent PVI using the phased RF PVAC® catheter (Medtronic) or the irrigated nMARQ™ catheter (Biosense Webster) under conscious sedation between July 2011 and March 2015. Site of pain reaction was marked for each patient. RESULTS: A total of 251 patients (141 PVAC®, 110 nMARQ™) were studied; 214 (85 %) had at least one lesion associated with pain. Gender (r = 0.084, p = 0.186), type of AF (r = 0.048, p = 0.452), age (r = 0.078, p = 0.216), and repeat procedure (r = 0.018, p = 0.78) were not correlated with pain. There was no association between site of pain and catheter type; only 33% of the painful PVs were also the largest ones (p = 0.5, kappa = 0.03, R = -0.083). One-year freedom from AF was similar for patients with and without painful PVs (p = 0.6). The distribution of pain was as follows: 126 (59%) left superior PV (LSPV), 28 (13%) left inferior, 28 (13%) all PVs, 12 (5.6%) right superior, 12 (5.6%) right inferior, 18 (8.4%) left common, and 2 (0.9%) right common PV. CONCLUSIONS: PVI using multi-electrode catheters more commonly caused pain sensation in LSPV. There was no influence of catheter type or PV size on pain localization. Our findings, which are similar to those using an 8-mm ablation catheter, imply that location of pain is not catheter dependent but rather a reflection of autonomic physiology.
Assuntos
Fibrilação Atrial/epidemiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/instrumentação , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/epidemiologia , Veias Pulmonares/cirurgia , Fibrilação Atrial/diagnóstico , Ablação por Cateter/métodos , Ablação por Cateter/estatística & dados numéricos , Causalidade , Sedação Consciente , Eletrodos/estatística & dados numéricos , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Sistema de Condução Cardíaco/cirurgia , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/classificação , Prevalência , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Randomized clinical trials have shown conflicting data on the benefit of implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with more advanced heart failure (HF) symptoms. Using the Israeli ICD Registry data, we sought to examine the effect of HF functional class on the outcome of patients who receive device therapy in a real-world setting. METHODS: The association between HF functional class (categorized as baseline New York Heart Association [NYHA] functional class I and II in [61%] vs class III and IV in [39%]) and clinical outcomes was assessed among 913 patients who received an ICD (n = 514) or a cardiac resynchronization therapy with a defibrillator (CRT-D; n = 399) device and were prospectively followed in the Israeli ICD Registry between July 2011 and June 2013. RESULTS: The risk associated with advanced HF functional class was significantly different in ICD and CRT-D recipients. In the former group, patients with NYHA classes III and IV experienced >3-fold increased risk of HF or death (hazard ratio [HR] = 3.28; P < 0.001), whereas among CRT-D recipients the risk was similar between patients with NYHA III/IV and those with less advanced HF symptoms (HR = 0.97 [95% confidence interval (CI) 0.54-1.78]; P = 0.42; P value for NYHA functional class by device type interaction = 0.002). The risk for ventricular arrhythmia (VA) was significantly lower among patients with more advanced NYHA functional class, regardless of device type (overall HR = 0.52; 95% CI 0.33-0.91; P = 0.04). CONCLUSION: Our findings suggest that patients with less advanced HF symptoms experience a greater risk for VA and the development of HF is attenuated in CRT-D recipients with more advanced NYHA functional class.
Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Prevenção Primária , Idoso , Feminino , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Resultado do TratamentoRESUMO
INTRODUCTION: Pulmonary vein isolation (PVI) using the irrigated multi-electrode ablation system (nMARQ™) remains challenging in complex atrial anatomy cases and when CARTOMERGE™ technology is not available, due to absence of a leading guide-wire. OBJECTIVES: Our objective was to assess feasibility and safety of PVI using nMARQ™ catheter with intra-procedural contrast injections through the deflectable sheath compared to nMARQ™ alone. METHODS: This is a prospective non-randomized observational study of 78 consecutive patients who underwent PVI only with nMARQ™. The first group (n=37, 64±10.5 years, 62% male, 13.5% persistent AF) underwent the procedure with the guidance of signal mapping, fluoroscopy, and electro-anatomical mapping (EAM) alone. Since 12/2013 an automatic closed-loop contrast media injector was added to improve catheter location (n=41, 62.5±11 years, 71% male, 34% persistent AF). RESULTS: Total procedure time was 78±19 and 85.5±18.5 minutes, and mean fluoroscopy time was 30±9 and 29.5±8.7 minutes for the first and second groups, respectively (NS); acute success rate was 97% and 97.5%, with a mean of 14.7±5 and 17.6±5.4 RF applications, respectively (p=0.02); and mean total burning time of 10.3±3.6 and 12±4 minutes, respectively (p=0.08). Mean contrast used was 60±18 mL versus 203±65 mL, with no effect on renal function or major complications. One year freedom from AF was 77% and 83%, respectively (p=0.5). CONCLUSIONS: Addition of contrast injections to standard nMARQ™ procedure is feasible and safe. It has no benefit in routine use but further studies may confirm its potential added value to EAM in catheter localization by newly trained operators and in selective cases of large/common PV anatomy.
RESUMO
Atrial fibrillation is the most common arrhythmia and its incidence and prevalence are growing steadily. It causes increased morbidity and mortality, while keeping patients in sinus rhythm was proven to decrease mortality rate. Nevertheless, antiarrhythmic drugs are limited in efficacy and have life-threatening adverse effects, thus neutralizing their benefits. Over the last years, ablation of pulmonary vein antrum has proven to be efficient in treating patients with atrial fibrillation. It has a success rate of 60-93% and overall complication rate of 6%. Recently, new ablation technologies entered the market and there has been improved understanding of the pathogenesis of atrial fibrillation. These improvements have led to better results and lower complication rates for atrial fibrillation ablation as a treatment option. In addition, new data was published regarding ablation treatment in the relatively healthy" elderly population. In the recent European Society of Cardiology (ESC) guidelines, ablation treatment for atrial fibrillation was graded as Class IA for patients who failed one antiarrhythmic drug and as Class IIA for patients who preferred ablation as their first treatment option. The field of atrial fibrillation ablation is evolving rapidly. The novel ablation catheters (the circular ones: PVAC and nMARQ, and the CryoCath balloon catheter) provide better tools for treating atrial fibrillation by reducing procedure time, making it possible to avoid general anesthesia and they are safer for use even in low-volume centers. These developments may enlarge the population that could be treated with ablation. It seems that we are in the middle of a process of change in the concept of treating atrial fibrillation.
Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Ablação por Cateter/métodos , Idoso , Antiarrítmicos/efeitos adversos , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/instrumentação , Humanos , Incidência , PrevalênciaRESUMO
Atrial fibrillation (AF) is the most common sustained arrhythmia in Western countries (prevalence 1-2%). Patients with AF have a 5-fold increased risk of stroke, and 15%-20% of all strokes are attributable to AF. Moreover, mortality, morbidity and economic burden from stroke complicating AF are particularly high. Thus, preventing stroke and thromboembolism is the cornerstone in AF management, with the vitamin K antagonist (VKA) - warfarin as the leading drug for many years. Although warfarin is effective in stroke reduction, only 55% of eligible patients with AF received it, 28% of patients discontinue it by 1-year, rates of major bleeding are higher that 20% and patients remain in the therapeutic range (INR 2-3) only 58% of the time. Warfarin underuse results from its pharmacological properties including: genetic variability in metabolism, multiple drug and food interactions, unpredictable anticoagulant effects, narrow therapeutic window, and the resulting need for inconvenient monitoring. The combination of aspirin and clopidogrel was found to be less effective than warfarin. Hence, new treatments were recently evaluated for AF-related stroke and thromboembolic prevention including: direct thrombin inhibitors (dabigatran etexilate), oral selective factor Xa inhibitors (rivaroxaban and apixaban), and percutaneous left atrial appendage closure. Some of these drugs have demonstrated promising results in clinical studies, they are convenient to use and do not require monitoring. The downsides are lack of antidotes or specific blood assays to monitor the anticoagulant effect and the need for invasive procedure for installation. Herein, we review the new treatments and the available clinical evidence for their use in AF.
Assuntos
Fibrilação Atrial/complicações , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/prevenção & controle , Anticoagulantes/efeitos adversos , Anticoagulantes/farmacologia , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Monitoramento de Medicamentos/métodos , Hemorragia/induzido quimicamente , Humanos , Coeficiente Internacional Normatizado , Acidente Vascular Cerebral/etiologia , Tromboembolia/etiologia , Varfarina/efeitos adversos , Varfarina/farmacologia , Varfarina/uso terapêuticoRESUMO
BACKGROUND: As the lowest natural site on earth (-415 meters), the Dead Sea is unique for its high pressure and oxygen tension in addition to the unparalleled combination of natural resources. Furthermore, its balneotherapeutic resorts have been reported to be beneficial for patients with various chronic diseases. OBJECTIVES: To evaluate the safety, quality of life (QoL), exercise capacity, heart failure, and arrhythmia parameters in patients with systolic congestive heart failure (SCHF) and implantable cardioverter defibrillator (ICD) following descent and stay at the Dead Sea. METHODS: The study group comprised patients with SCHF, New York Heart Association functional class II-III after ICD implantation. The following parameters were tested at sea level one week prior to the descent, during a 4 day stay at the Dead Sea, and one week after return: blood pressure, 02 saturation, ejection fraction (echocardiography), weight, B-type natriuretic peptide (BNP), arrhythmias, heart rate, heart rate variability (HRV), and QoL assessed by the Minnesota Living with Heart Failure questionnaire. RESULTS: We evaluated 19 patients, age 65.3 +/- 9.6 years, of whom 16 (84%) were males and 18 (95%) had ICD-cardiac resynchronization therapy. The trip to and from and the stay at the Dead Sea were uneventful and well tolerated. The QoL score improved by 11 points, and the 6 minute walk increased by 63 meters (P < 0.001). BNP levels increased slightly with no statistical significance. The HRV decreased (P = 0.018). There were no significant changes in blood pressure, weight, 02 saturation or ejection fraction. CONCLUSIONS: Descent to, ascent from, and stay at a Dead Sea resort are safe and might be beneficial in some aspects for patients with SCHF and an ICD.
Assuntos
Desfibriladores Implantáveis , Exposição Ambiental , Estâncias para Tratamento de Saúde , Insuficiência Cardíaca Sistólica/reabilitação , Frequência Cardíaca/fisiologia , Qualidade de Vida , Adulto , Idoso , Idoso de 80 Anos ou mais , Altitude , Pressão Atmosférica , Ecocardiografia , Teste de Esforço , Feminino , Seguimentos , Insuficiência Cardíaca Sistólica/fisiopatologia , Insuficiência Cardíaca Sistólica/psicologia , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Oceanos e Mares , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
AIMS: The Secura ICD and Consulta CRT-D are the first defibrillators to have automatic right atrial (RA), right ventricular (RV), and left ventricular (LV) capture management (CM). Complete CM was evaluated in an implantable cardioverter defibrillator (ICD) population. METHODS AND RESULTS: Two prospective clinical studies were conducted in 28 centres in Europe and Israel. Automatic CM data were compared with manual threshold measurements, the CM applicability was determined, and adjustments to pacing outputs were analysed. In total, 160 patients [age 64.6 +/- 10.4 years, 77% male, 80 ICD and 80 cardiac resynchronization therapy defibrillator (CRT-D)] were included. The differences between automatic and manual measurements were =0.25 V in 97% (RA CM) and 96% (RV CM) and were all within the safety margin. Fully automatic CM measurements were available within 1 week prior to the 3-month visit in 90% (RA), 99% (RV), and 97% (LV) of the patients. Results indicated increased output (threshold >2.5 V) due to raised RA threshold in seven (4.4%), high RV threshold in nine (5.6%), and high LV threshold in three patients (3.8%). All high threshold detections and all automatic modulations of pacing output were adjudicated appropriate. CONCLUSION: Complete CM adjusts pacing output appropriately, permitting a reduction in office visits while it may maximize device longevity. The study was registered at ClinicalTrials.gov identifiers: NCT00526227 and NCT00526162.