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.

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...

Prevalência familiar da Síndrome de Brugada / Family prevalence of Brugada Syndrome

Objetivo: Avaliar os familiares de primeiro grau de oito pacientes com diagnóstico confirmado da doença estimando a prevalência familiar na série de casos estudados, e identificando aqueles portadores assintomáticos o que propiciaria uma terapia específica antes do aparecimento de eventos graves como síncope e/ou morte súblita. Métodos: Os familiares de primeiro grau foram avaliados clínica e eletrocardiograficamente. Aqueles sem alterações definitivas da síndrome foram submetidos a teste provocativo com ajmalina ou procainamida, na tentativa de desmascaras possíveis formas ocultas da doença, esultando em mais 41 indivíduos incluídos no estudo. Resultados: São apresentadas tabelas com a relação de todos os estudados, sendo destacados aqueles com diagnóstico final da doença. São disponibilizados ainda os mapas genéticos onde os homens são representados por quadrados e as mulheres por círculos (escuros com SB e claros sem doença). O diagnóstico foi firmado em mais 12 pacientes com uma prevalência média de 39,5 por cento, chegando até a 55 por cento na família mais afetada pela doença....

Objective: To assess the immediate relatives of eight patients with confirmed diagnoses of this disease,estimating the prevalence of this syndrome in the families studied and identifying asymptomatic bearersin order to provide specific treatment before the appearance of serious events such as syncope and / or sudden death.Methods: The immediate family members were assessed clinically and through electrocardiographs. Thosewith no definitive alterations indicating the syndrome underwent an ajmaline challenge or procainamide test, in an attempt to discover possible hidden forms of the disease, resulting in a further 41 individuals being included in the study. Results: Tables are presented of all family members studied, highlighting those with final diagnosesof Brugada syndrome, as well as genetic maps, representing men by squares and women by circles (dark: with Brugada syndrome / light without Brugada syndrome). Diagnoses were confirmed for twelve other patients, with an average prevalence of 39.5%, reaching 55% in the family most severely affected by this disease. Conclusion: The extremely high prevalence of this disease in the families studied, associated with the clinical and social implications imposed by the conditionof people suffering from this syndrome, justifies an active survey of all family members in order to define treatment strategies before the appearance of symptoms that are often serious or even fatal.

Clinical follow-up of patients with implantable cardioverter-defibrillator.

OBJECTIVE: To report appropriate (AT) and inappropriate (IT) ICD therapies in patients with ischemic and nonischemic heart disease, as well as early and late procedure-related complications. METHODS: One hundred and fifty-five patients (119 male and 36 female), mean age 47 years (21-88), who underwent ICD implantation between 1994 and March 2003 were analyzed. Patients were divided into the following groups: Group I--Post-AMI patients (n = 80); Group II--Patients with nonischemic heart disease and LV ejection fraction < 40% (n = 45), Chagas disease (n = 18), idiopathic dilated cardiomyopathy (n= 12), hypertensive disease (n = 8), hypertrophic cardiomyopathy (n = 4) and valvular heart disease (n = 3); Group III--Patients with arrhythmogenic right ventricular dysplasia (n = 13); and Group IV--Patients with channelopathies: Brugada Syndrome (n = 8) and idiopathic ventricular arrhythmias (n = 9). All patients underwent electrophysiological study (EPS) with induction of sustained ventricular arrhythmia ICD implantation. RESULTS: During the 26-month mean follow up, a high rate of appropriate ICD therapies (antitachycardia pacing and/or shock) was observed (46%) in the four groups, with no statistically significant difference. The four groups did not differ in either overall (8.4%) or arrhythmic mortality (1.3%). There was no correlation between appropriate ICD therapies and initial clinical presentation or inducible ventricular arrhythmia at EPS, and a 4% incidence of early and late procedure-related complications was found. CONCLUSION: The high incidence of appropriate ICD therapy and low rate of sudden death in the patients studied suggest that ICD is a valuable strategy in the management of ischemic and nonischemic patients previously selected by means of EPS.

Prognostic criteria of success and recurrence in circumferential ablation for the treatment of atrial fibrillation.

OBJECTIVES: To analyze the success of circumferential ablation of atrial fibrillation and to investigate possible clinical and electroanatomic predictors of recurrence of cardiac arrhythmia. METHODS: 104 consecutive patients free of structural heart disease and refractory to at least two antiarrhythmic drugs, and undergoing circumferential ablation for the treatment of paroxysmal/persistent atrial fibrillation were analyzed. Seventy two patients were males and the mean age of the group was 58.6 + 10.9 years. The procedure consisted of a single transseptal puncture and three-dimension mapping using the CARTO system to acquire points in the left atrium and pulmonary veins. Radiofrequency applications were performed encircling the pulmonary vein ostea, up to a > or = 80% reduction of the atrial potential amplitude. One additional line was created in the mitral isthmus and another in the cavotricuspid isthmus. Total left atrium volume, area ablated around the pulmonary veins, and completeness of the ablation line (complete or incomplete line) were analyzed. A line was considered complete when the distance between two contiguous radiofrequency application points was lower than 10mm. RESULTS: In a mean 18-month follow-up, 87 patients were in sinus rhythm (84%), and 17 patients presented recurrence (16%). In the multivariate analysis, only the left atrial volume (p<0.0001) and complete ablation (p<0.05) were independent predictors of recurrence. CONCLUSION: The results suggest that the left atrial volume and the presence of complete ablation are predictive of recurrence of atrial fibrillation.

Critérios prognósticos de sucesso e recorrência na ablação circunferencial para tratamento da fibrilação atrial / Prognostic criteria of success and recurrence in circumferential ablation for the treatment of atrial fibrillation

OBJETIVOS: Analisar o sucesso da ablação circunferencial da fibrilação atrial e investigar possíveis preditores, clínicos e eletroanatômicos, de recorrência da arritmia. MÉTODOS: Foram analisados 104 pacientes consecutivos, submetidos à ablação circunferencial para tratamento de fibrilação atrial paroxística/persistente, sem cardiopatia estrutural e refratários a pelo menos duas drogas antiarrítmicas. Eram do sexo masculino 72 pacientes e a idade média do grupo foi de 58,6 + 10,9 anos. O procedimento consistiu em punção transeptal única e mapeamento tridimensional, com o sistema CARTO® para a aquisição de pontos no átrio esquerdo e veias pulmonares. As aplicações de radiofreqüência foram realizadas ao redor dos óstios das veias pulmonares, até a redução > 80 por cento da amplitude dos potenciais atriais. Uma linha adicional foi criada no istmo mitral e outra no istmo cavotricuspídeo. Foram analisadas: volume total do átrio esquerdo, área ablacionada ao redor das veias pulmonares e a presença ou não de falhas na linha de ablação (linha completa ou incompleta). Foi considerada linha completa quando a distância entre dois pontos contíguos de aplicação de radiofreqüência foi inferior a 10 mm. RESULTADOS: Em acompanhamento médio de 18 meses, 87 pacientes estavam em ritmo sinusal (84 por cento) e 17 pacientes apresentaram recidiva (16 por cento). Na análise multivariada, somente o volume atrial esquerdo (p < 0,0001) e a ablação completa (p <0 ,05) foram preditores independentes de recorrência. CONCLUSÃO: Os resultados sugerem que o volume atrial esquerdo e a presença de ablação completa são preditores de recorrência da fibrilação atrial.

OBJECTIVES: To analyze the success of circumferential ablation on atrial fibrillation and investigate possible clinical and electro-anatomical predictors of the recurrence of cardiac arrhythmia. METHODS: Analysis was done of 104 consecutive patients, free of structural heart disease and refractory to at least 2 antiarrhythmic drugs, submitted to circumferential ablation for treatment of paroxysmal/persistent atrial fibrillation. Were males 72 of the patients and the average age of the group was 58.6 + 10.9. The procedure consisted in a single transeptal puncture and three-dimensional mapping using the CARTO® system. Images of the left atrium and pulmonary veins were reconstructed. Radiofrequency applications were performed around the pulmonary vein ostia, up to a > 80 percent reduction in atrial potential amplitude. An additional mitral isthmus line was created, as well as one in the cavo-tricuspid isthmus. Total left-atrial volume, area ablated around the pulmonary veins, and the presence or absence of flaws in the ablation line (complete or incomplete line) were analyzed. A line was considered complete when the distance between two contiguous radiofrequency application points was less than 10 mm. RESULTS: After an average follow-up period of 18 months, 87 patients were in sinus rhythm (84 percent), while 17 patients presented recidivism (16 percent). In the multivariate analysis only left-atrial volume (p < 0.0001) and complete ablation (p < 0.05) were independent predictors of success. CONCLUSION: These data suggest that the left-atrial volume and the presence of complete ablation are predictors of recurrence.

Acompanhamento clínico de pacientes portadores de cardioversor-desfibrilador implantável / Clinical follow-up of patients with implantable cardioverter-defibrillator

OBJETIVO: Relatar o perfil de terapias apropriadas (TA) e inapropriadas (TI) do cardioversores-desfibriladores implantáveis (CDI) em portadores de cardiopatia isquêmica e não-isquêmica e as complicações precoces e tardias do procedimento. MÉTODOS: Foram analisados 155 pacientes (119 homens e 36 mulheres), idade média de 47 (21-88) anos, submetidos ao implante de CDI. Foram divididos em grupos I - pacientes pós-infarto agudo do miocárdio (IAM) (n = 80), grupo II - cardiopatia não-isquêmica e fração de ejeção de ventrículo esquerdo (FEVE) < 40 por cento (n = 45): chagásicos (n = 18), portadores de cardiopatia dilatada idiopática (n = 12), hipertensiva (n = 8), hipertrófica (n = 4) e valvar (n = 3); grupo III - displasia arritmogênica do ventrículo direito (n = 13) e grupo IV- canalopatias: síndrome de Brugada (n = 8) e arritmias ventriculares primárias (n = 9). Os pacientes eram submetidos a estudo eletrofisiológico (EEF) antes do implante. RESULTADOS: No seguimento médio de 26 meses foi observado um alto índice (46 por cento) de TA (terapias antitaquicardia e/ou choques) do CDI nos 4 grupos, sem diferença estatística. Os 4 grupos não diferiram na mortalidade total (8,4 por cento) ou arrítmica (1,3 por cento). Não houve correlação entre as TA do CDI e a apresentação clínica dos pacientes ou arritmia ventricular indutível, com 4 por cento de complicações precoces e tardias do procedimento. CONCLUSÃO: A alta incidência de TA do CDI e a baixa incidência de morte súbita sugerem que o CDI é uma estratégia terapêutica valiosa no manejo de pacientes isquêmicos e não isquêmicos selecionados previamente com EEF.

OBJECTIVE: To report appropriate (AT) and inappropriate (IT) ICD therapies in patients with ischemic and nonischemic heart disease, as well as early and late procedure-related complications. METHODS: One hundred and fifty-five patients (119 male and 36 female), mean age 47 years (21-88), who underwent ICD implantation between 1994 and March 2003 were analyzed. Patients were divided into the following groups: Group I - Post-AMI patients (n = 80); Group II - Patients with nonischemic heart disease and LV ejection fraction < 40 percent (n = 45), Chagas disease (n = 18), idiopathic dilated cardiomyopathy (n= 12), hypertensive disease (n = 8), hypertrophic cardiomyopathy (n = 4) and valvular heart disease (n = 3); Group III - Patients with arrhythmogenic right ventricular dysplasia (n = 13); and Group IV - Patients with channelopathies: Brugada Syndrome (n = 8) and idiopathic ventricular arrhythmias (n = 9). All patients underwent electrophysiological study (EPS) with induction of sustained ventricular arrhythmia ICD implantation. RESULTS: During the 26-month mean follow up, a high rate of appropriate ICD therapies (antitachycardia pacing and/or shock) was observed (46 percent) in the four groups, with no statistically significant difference. The four groups did not differ in either overall (8.4 percent) or arrhythmic mortality (1.3 percent). There was no correlation between appropriate ICD therapies and initial clinical presentation or inducible ventricular arrhythmia at EPS, and a 4 percent incidence of early and late procedure-related complications was found. CONCLUSION: The high incidence of appropriate ICD therapy and low rate of sudden death in the patients studied suggest that ICD is a valuable strategy in the management of ischemic and nonischemic patients previously selected by means of EPS.