Influence of PACE score and conduction disturbances in the incidence of early new onset atrial fibrillation after typical atrial flutter ablation.

PURPOSE: Patients undergoing cavotricuspid isthmus (CTI) ablation for typical flutter (AFL) have a high incidence of new onset atrial fibrillation (AF). We aimed to analyze the influence of PACE score to predict new onset AF in this subset of patients to stratify thromboembolic risk. METHODS: Between 2017 and 2019, patients undergoing CTI ablation for AFL and without history of AF were prospectively included. All patients were monitored continuously by implantable loop recorder and followed by remote monitoring. RESULTS: Overall 48 patients were included. New onset AF rate at 12 months was 56.3%. We observed two very strong independent predictors for new onset AF: a PACE score ≥ 30 (HR:6.9; 95% CI:1.71-27.91; p = 0.007) and an HV interval ≥ 55 (HR:11.86; 95% CI:2.57-54.8; p = 0.002). CONCLUSIONS: The incidence of newly diagnosed AF is high in patients with AFL after CTI ablation, and can occur early. A high PACE score and/or long HV interval predict even higher risk, and may be useful in the decision for empiric long-term anticoagulation.

Merged two-way mapping technique: an alternative 3D electroanatomical mapping approach to guide challenging ablation procedures of accessory pathways with bidirectional conduction properties.

BACKGROUND: Catheter ablation of accessory pathways (AP) with bidirectional conduction may be challenging due to issues related to anatomical course or location. OBJECTIVE: We describe an alternative electro-anatomical mapping technique which aims at depicting the entire anatomic course of the AP from the atrial toward the ventricular insertion in order to guide catheter ablation. METHODS: Twenty consecutive patients with confirmed bidirectional AP conduction and at least one previous ablation procedure or para-Hisian location were included. 3-D electro-anatomical mapping was used to depict the merged 10-ms isochrone area of maximum early activation of both the ventricular and atrial signals during sinus rhythm and ventricular pacing/orthodromic tachycardia, respectively. Catheter ablation was performed within the depicted earliest isochrone area. RESULTS: Acute bidirectional AP conduction block was achieved in all patients 4.2 ± 1.7 s after the first radiofrequency energy pulse was delivered, without reconnection during a 30 ± 10 min post-ablation observation time. No procedural complications were seen. After a mean follow-up period of 9 ± 7 months (range 3 to 16), no recurrences were documented. CONCLUSION: This merged two-way mapping technique is a safe, efficient, and effective technique for ablation of APs with bidirectional conduction.

Mapping potentials adjacent to the cavo-tricuspid isthmus ablation line during incremental pacing: A feasible and highly accurate maneuver to confirm complete CTI conduction block.

BACKGROUND: The diagnostic accuracy of incremental atrial pacing (IP) to determine complete cavo-tricuspid isthmus (CTI) block during typical atrial flutter (AFL) ablation is limited by both an extensive/nonlinear ablation and/or the presence of intra-atrial conduction delay elsewhere in the right atrium. We examined the diagnostic performance of an IP variant based on the assessment of the atrial potentials adjacent to the ablation line which aims at overcoming both limitations. METHODS: From a prospective population of 108 consecutive patients, 15 were excluded due to observation of inconclusive CTI ablation potentials precluding for a straight comparison between the IP maneuver and its variant. In the remaining 93, IP was performed from the low lateral right atrium and the coronary sinus ostium, with the ablation catheter positioned both at the CTI line and adjacent (<5 mm) to its septal and lateral aspect. The IP variant consisted of measuring the interval between the two atrial electrograms situated on the same side of the ablation line, opposite to the pacing site, a ≤10 ms increase indicating complete CTI block. RESULTS: The IP maneuver and its variant were consistent with complete CTI block in 82/93 (88%) and 87/93 (93%) patients, respectively. Four patients had AFL recurrence during follow-up: 2/4 and 4/4 had been adequately classified as incomplete block by the IP maneuver and its variant, respectively. Twenty-three patients (24%) had significant intra-atrial conduction delay elsewhere in the right atrium. The IP maneuver and its variant were suggestive of an incomplete CTI block in 11/23 and 4/23 in this setting (P = .028), with the later best predicting subsequent AFL relapses (2/12 vs 2/4, P = .01). CONCLUSIONS: The IP variant, which was designed to overcome the limitations of the conventional IP maneuver, accurately distinguishes complete from incomplete CTI block and helps to predict AFL recurrences after ablation.

Patrón de «De Winter» en el electrocardiograma: hay que correr / The «De Winter» pattern on the electrocardiogram: It is time to run

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Double factor single shot to diminish complications in cryoballoon ablation procedures for atrial fibrillation.

PURPOSE: Cryoballoon ablation (CBA) has become a standard treatment for recurrent atrial fibrillation (AF). There is need for improved CBA protocols. We aimed to demonstrate that a new protocol including minimum temperature (minT) reached could reduce procedure times and complications. METHODS: A new double factor protocol (DFP), based on the performance of one single shot per vein with variable duration, and conditional bonus shot, determined by time-to-effect (TTE) and minT, was compared with the conventional protocol (CP), with at least two shots per vein. Procedure parameters, complications, and efficacy were compared. RESULTS: We prospectively included 88 consecutive patients treated with the DFP. These were compared to the previous consecutive 69 patients treated with CP. All procedures were performed with 28-mm second-generation balloon. Acute pulmonary vein (PV) isolation was similar (98.6% vs. 98.9% in CP vs. DFP, p = 0.687). Procedure and ablation times favored DFP over CP (120 vs. 134 min, p = 0.003; and 1051 vs. 1475 s, p < 0.001; respectively). A composite of major and minor complications was significantly reduced in the DFP compared to the CP (18.8% vs. 6.8%, p = 0.02; respectively). Within a follow-up of 18 months, freedom from AF was 79.7% in CP and 78.4% in DFP (Log-rank 0.501). Paroxysmal AF and absence of PV potentials predicted better arrhythmia outcomes (HR 2.14 for paroxysmal vs. persistent, p = 0.031; and HR 1.61 for absence vs. presence of PV potentials, p = 0.01). CONCLUSIONS: The novel DFP results in reduced complication rates and procedure times, with similar success rates compared with a conventional strategy.

Respuesta al ECG de julio de 2018 / Response to ECG, July 2018

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ECG de julio de 2018 / ECG, July 2018

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Artritis reumatoide con fibrosis auricular grave y múltiples arritmias auriculares: ¿miocarditis auricular crónica? / Rheumatoid arthritis with severe atrial fibrosis and multiple atrial arrhythmias: chronic atrial myocarditis?

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Cambios en las propiedades de conducción de las vías accesorias: de preexcitación intermitente a fibrilación auricular preexcitada de riesgo / Changes in conduction properties of accessory pathways: from intermittent pre-excitation to rapid pre-excited ventricular response to atrial fibrillation

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Simple predictors for new onset atrial fibrillation.

BACKGROUND: Predicting atrial fibrillation is a tremendous challenge. Only few studies have included 24h-Holter monitoring characteristics to predict new onset AF (NOAF). OBJECTIVES: Our aim is to define simple predictors for NOAF. METHODS: The study population included 468 patients undergoing Holter for any cause. After excluding 169 patients for history of AF prior to or during the Holter monitoring period, 299 patients were assessed for incidence of NOAF. RESULTS: Age at inclusion was 62.5±18years (53.5% male). After a median follow up of 39.1 [IQI 36.6-40] months, the incidence of NOAF was 10.4%. With univariate analysis, age, hypertension, diabetes, renal impairment, heart failure/cardiomyopathy, left ventricle ejection fraction ≤50%, left atrium diameter ≥40mm, CHA2DS2 VASc ≥4, premature atrial complexes (PAC) ≥0.2%, and PR interval were associated with NOAF. With multivariate analysis, age (HR 1075; p=0.001 per year), presence of heart failure/cardiomyopathy (HR 6,16; p<0.001), PAC≥0.2% (HR 3,32; p=0.003) and PR interval (HR 1.011; p=0.006 per millisecond) were independent predictors for NOAF. Those predictors were used to create a risk calculator for NOAF, which was validated in an independent cohort of 200 consecutive patients with similar baseline characteristics. This new tool resulted in good discrimination capacity calculated by the C index for NOAF prediction: Area under curve (AUC) (95% CI) 0.794 (0.714-0.875) at 2years and 0.794 (0.713-0.875) at 3years. CONCLUSIONS: Simple clinical, ECG and Holter monitoring parameters are able to predict NOAF in a broad population and may help guide more rigorous monitoring for atrial fibrillation.

Burning the Gap: Electrical and Anatomical Basis of the Incremental Pacing Maneuver for Cavotricuspid Isthmus Block Assessment.

INTRODUCTION: The incremental pacing (IP) maneuver is a highly specific technique that improves the ability to confirm complete CTI conduction block during typical atrial flutter (AFL) ablation, and reduces long-term AFL recurrences. The purpose of this study is to assess the performance of new catheters equipped with additional high precision bipoles (AHPB) to allow the visualization of the cavotricuspid isthmus (CTI) conduction gap and to compare them with the IP maneuver. METHODS AND RESULTS: Twenty consecutive patients undergoing catheter ablation of the CTI for AFL were included. The IP maneuver confirmed functional versus complete CTI block. Local electrogram analysis using AHPB was then used to assess the presence or absence of gaps across the CTI line. Mean age was 67 years and 80% were male. At the end of the procedure CTI block was achieved in all patients. A transient stage of functional CTI block was observed in 40%. In all cases a continuous fragmented electrogram was present between the double potentials in the CTI in the AHPB channels. In contrast, no electrogram was observed between the CTI double potentials in any of the 20 patients once complete block was confirmed by the IP maneuver. When both techniques were compared a significant association and correlation were observed (chi-square <0.01, Spearman's rho = 1, P < 0.01). CONCLUSION: Catheters equipped with AHPB can aid in the assessment of complete CTI block during AFL ablation procedures by detecting conduction gaps that correlate with incomplete functional block diagnosed by the IP maneuver.

Risk of pacemaker implantation after uneventful successful cavotricuspid isthmus radiofrequency ablation in patients with common atrial flutter.

INTRODUCTION: Little is known about the risk of pacemaker implantation after common atrial flutter ablation in the long-term. METHODS: We retrospectively reviewed the electrophysiology laboratory database at two Spanish University Hospitals from 1998 to 2012 to identify patients who had undergone successful ablation for cavotricuspid dependent atrial flutter. Cox regression analysis was used to examine the risk of pacemaker implantation. RESULTS: A total of 298 patients were considered eligible for inclusion. The mean age of the enrolled patients was 65.7±11. During 57.7±42.8 months, 30 patients (10.1%) underwent pacemaker implantation. In the stepwise multivariate models only heart rate at the time of the ablation (OR: 0.96; 95% CI: 0.93-0.98; p<0.0001) and intraventricular conduction disturbances in the baseline ECG (OR: 3.87; 95% CI: 1.54-9.70; p=0.004) were independents predictors of the need of pacemaker implantation. A heart rate of ≤65 bpm was identified as the optimal cut-off value to predict the need of pacemaker implantation in the follow-up (sensitivity: 79%, specificity: 74%) by ROC curve analyses. CONCLUSION: This is the first study of an association between the slow conducting common atrial flutter and subsequent risk of pacemaker implantation. In light of these findings, assessing it prior to ablation can be helpful for the risk stratification of sinus node disease or atrioventricular conduction disease requiring a pacemaker implantation in patients with persistent atrial flutter.

Terapia con desfibrilador automático implantable en la miocardiopatía hipertrófica: utilidad en prevención primaria y secundaria / Implantable cardioverter-defibrillator therapy for hypertrophic cardiomyopathy: usefulness in primary and secondary prevention

Introducción y objetivos: La miocardiopatía hipertrófica es una causa frecuente de muerte súbita. Las guías de práctica clínica recomiendan implantar un desfibrilador como prevención primaria para pacientes con uno o más factores de riesgo, y como prevención secundaria para pacientes con antecedentes de muerte súbita recuperada o arritmias ventriculares sostenidas. El objetivo de este trabajo es analizar el seguimiento de los pacientes a quienes se implantó un desfibrilador siguiendo las guías actuales en centros que no son de referencia para esta afección. Métodos: Estudio observacional retrospectivo de todos los pacientes a quienes se implantó un desfibrilador entre enero de 1996 y diciembre de 2012 en tres centros de la provincia de Barcelona. Resultados: Se incluyó a 69 pacientes (media de edad, 44,8 ± 17 años; el 79,3% varones), 48 en prevención primaria y 21 en prevención secundaria. La media de factores de riesgo era 1,8 por paciente en el grupo de prevención primaria y 0,5 en el grupo de prevención secundaria (p = 0,029). La mediana de seguimiento fue de 40,5 meses. La tasa de terapias apropiadas fue de 32,7/100 pacientes-año en prevención secundaria y 1,7/100 pacientes-año en prevención primaria (p < 0,001). La mortalidad total fue del 10,1%. Sufrió complicaciones relacionadas con el implante el 8,7% de los pacientes, y en el 13% hubo descargas inapropiadas del desfibrilador. Conclusiones: En los pacientes portadores de desfibrilador como prevención primaria, la tasa de terapias apropiadas es excesivamente baja, lo que indica que los criterios actuales de estratificación de riesgo tienen bajo poder predictivo (AU)

Introduction and objectives: Hypertrophic cardiomyopathy is a frequent cause of sudden death. Clinical practice guidelines indicate defibrillator implantation for primary prevention in patients with 1 or more risk factors and for secondary prevention in patients with a history of aborted sudden death or sustained ventricular arrhythmias. The aim of the present study was to analyze the follow-up of patients who received an implantable defibrillator following the current guidelines in nonreferral centers for this disease. Methods: This retrospective observational study included all patients who underwent defibrillator implantation between January 1996 and December 2012 in 3 centers in the province of Barcelona. Results: The study included 69 patients (mean age [standard deviation], 44.8 [17] years; 79.3% men), 48 in primary prevention and 21 in secondary prevention. The mean number of risk factors per patient was 1.8 in the primary prevention group and 0.5 in the secondary prevention group (P = .029). The median follow-up duration was 40.5 months. The appropriate therapy rate was 32.7/100 patient-years in secondary prevention and 1.7/100 patient-years in primary prevention (P < .001). Overall mortality was 10.1%. Implant-related complications were experienced by 8.7% of patients, and 13% had inappropriate defibrillator discharges. Conclusions: In patients with a defibrillator for primary prevention, the appropriate therapy rate is extremely low, indicating the low predictive power of the current risk stratification criteria (AU)

Temas de actualidad en arritmias y estimulación cardiaca / Update in cardiac arrhythmias and pacing

En este trabajo se comentan los principales avances en arritmias y estimulación cardiaca aparecidos entre 2013 y 2014 seleccionados como más relevantes. Se revisan especialmente las publicaciones referidas al tratamiento intervencionista de la fibrilación auricular y de las arritmias ventriculares, y los avances en estimulación cardiaca y desfibrilador automático implantable, con mención especial al paciente mayor (AU)

This article discusses the main advances in cardiac arrhythmias and pacing published between 2013 and2014. Special attention is given to the interventional treatment of atrial fibrillation and ventricular arrhythmias, and on advances in cardiac pacing and implantable cardioverter defibrillators, with particular reference to the elderly patient (AU)