Cardioneuroablación como tratamiento del síncope reflejo: reporte de un caso

Resumen: El síncope mediado neuralmente es un trastorno causado por un reflejo autónomo anormalmente amplificado que involucra componentes tanto simpáticos como parasimpáticos. Es la causa más frecuente de síncope en personas jóvenes y su tratamiento sigue siendo un desafío, ya que no se ha demostrado que alguna terapia farmacológica prevenga por completo su recurrencia. En los últimos años ha surgido una técnica denominada cardioneuroablación, que consiste en la ablación por radiofrecuencia de los plexos ganglionares (PG) parasimpáticos, con buenos resultados a corto y largo plazo en la prevención de síncope recurrente, según los diferentes grupos de investigación. Presentamos el primer caso en Chile de un hombre joven con síncopes mediados neuralmente recurrentes que fue tratado con esta técnica en el Hospital Regional de Concepción.

Abstract: Cardioneuroablation is a novel method that can be used to treat reflex syncope. Although the experience with this technique is relatively limited it provides a more physiological way to treat this condition. The first case in Chile is herein reported along with a discussion of the subject.

[Features, management and prognosis of Chilean patients with non valvular atrial fibrillation: GARFIELD AF registry]. / Características basales, manejo de terapias antitrombóticas y pronóstico de pacientes chilenos con FA no valvular. Lecciones del Registro GARFIELD AF en Chile.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with high rates of death, ischemic stroke and systemic embolism (SE). There is scarce information about clinical characteristics and use of anti-thrombotic therapies in Chilean patients with non-valvular AF. AIM: To describe the characteristics and 1-year outcomes of patients with recently diagnosed AF recruited in Chile into the prospective global GARFIELD-AF registry. MATERIAL AND METHODS: Between 2011-2016, we prospectively registered information of 971 patients recruited at 15 centers, 85% of them from the public system and 15% from the private sector. Demographics, clinical characteristics and use of antithrombotic therapies were recorded for all patients. Adverse clinical outcomes were analyzed in 711 patients with 1-year follow-up. RESULTS: The mean age was 71.5 years (66-79), 50% were men. Mean CHAD2S2 Vasc and HAS BLED scores for stroke risk were 3.3 (2.0-4.0) and 1.5 (1.0-2.0) respectively. Oral anticoagulants were prescribed in 82% of patients. Seventy percent received Vitamin K antagonists, 10% novel direct anticoagulants or antiplatelet therapy and only 8% did not receive any antithrombotic therapy. Mean time in optimal therapeutic range (an international normalized ratio of 2 to 3), was achieved in only 40.7% (23.0-54.8) of patients receiving Vitamin K antagonists. One year rates of death, stroke/systemic embolism and bleeding were 4.75 (3.36-6.71), 2.40 (1.47-3.92) and 1.64% (0.91-2.97) per 100 person-years. Ischemic stroke occurred in 1.8% and hemorrhagic stroke in 0.8% of patients at 1-year of follow up. CONCLUSIONS: Although the use of vitamin K antagonists at baseline was high, the mean time in optimal therapeutic range was low. Mortality and stroke rates are higher than those reported in other contemporary registries.

Características basales, manejo de terapias antitrombóticas y pronóstico de pacientes chilenos con FA no valvular. Lecciones del Registro GARFIELD AF en Chile / Features, management and prognosis of Chilean patients with non valvular atrial fibrillation: GARFIELD AF registry

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with high rates of death, ischemic stroke and systemic embolism (SE). There is scarce information about clinical characteristics and use of anti-thrombotic therapies in Chilean patients with non-valvular AF. Aim: To describe the characteristics and 1-year outcomes of patients with recently diagnosed AF recruited in Chile into the prospective global GARFIELD-AF registry. Material and Methods: Between 2011-2016, we prospectively registered information of 971 patients recruited at 15 centers, 85% of them from the public system and 15% from the private sector. Demographics, clinical characteristics and use of antithrombotic therapies were recorded for all patients. Adverse clinical outcomes were analyzed in 711 patients with 1-year follow-up. Results: The mean age was 71.5 years (66-79), 50% were men. Mean CHAD2S2 Vasc and HAS BLED scores for stroke risk were 3.3 (2.0-4.0) and 1.5 (1.0-2.0) respectively. Oral anticoagulants were prescribed in 82% of patients. Seventy percent received Vitamin K antagonists, 10% novel direct anticoagulants or antiplatelet therapy and only 8% did not receive any antithrombotic therapy. Mean time in optimal therapeutic range (an international normalized ratio of 2 to 3), was achieved in only 40.7% (23.0-54.8) of patients receiving Vitamin K antagonists. One year rates of death, stroke/systemic embolism and bleeding were 4.75 (3.36-6.71), 2.40 (1.47-3.92) and 1.64% (0.91-2.97) per 100 person-years. Ischemic stroke occurred in 1.8% and hemorrhagic stroke in 0.8% of patients at 1-year of follow up. Conclusions: Although the use of vitamin K antagonists at baseline was high, the mean time in optimal therapeutic range was low. Mortality and stroke rates are higher than those reported in other contemporary registries.

Predictors of arrhythmia recurrence in patients with lone atrial fibrillation.

AIMS: The need for antiarrhythmic drugs (AAD) after a first episode of atrial fibrillation (AF) is determined by the probability of recurrence. The aim of this study was to asses the probability of relapse and the predictors of recurrence in patients with idiopathic AF. METHODS AND RESULTS: A cohort of 98 consecutive patients younger than 65 years admitted at the emergency room because of an episode of symptomatic idiopathic (lone) AF was included in this study. On admission, a complete medical history was taken, and an echocardiogram and 24-h Holter monitoring were performed. Patients were seen at 3 and 6 months after the index episode. There were 35 (35.7%) patients with a new-onset AF episode and 63 (64.3%) with a recurrent AF episode. A majority of them were male (71%), with a mean age of 48+/-11 years. Patients with new-onset AF episodes did not receive AAD. At 6 month follow-up, 57% of all patients suffered at least one symptomatic AF relapse. Patients with AF relapses belong more often to the recurrent group vs. new-onset group of AF (65.1 vs. 34.9%, respectively, P = 0.03); they had larger LA diameter indexed for body surface area (BSA) (22.6+/-3.7 vs. 19.8+/-3.2 mm/m(2), P = 0.001), larger left ventricular end-systolic diameter (18.4+/-3.1 vs. 17.2+/-2.5 mm/m(2), P = 0.05) and a tendency towards a higher proportion of atrial tachycardia runs on Holter (66.7 vs. 50%, P = 0.09). Logistic regression analysis showed that the presence of previous episodes of AF (OR: 3.2; 95% CI; 1.0-8.0, P = 0.04) and a larger anteroposterior LA diameter (OR: 1.3; 95% CI; 1.1-1.6, P = 0.001) were independent predictors of AF recurrences at 6 months. CONCLUSIONS: The recurrence rate in lone AF patients is high. The presence of previous episodes and a mildly enlarged anteroposterior LA diameter increase the probability of relapse of lone AF.

Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein ablation.

AIMS: The success rate of circumferential pulmonary vein ablation (CPVA) to treat atrial fibrillation (AF) ranges from 60 to 90%, depending on the series. The objective of the study was to identify predictors of AF recurrence after a standardized CPVA procedure. METHODS AND RESULTS: A series of 148 consecutive patients undergoing CPVA for symptomatic paroxysmal (60.8%), persistent (23.6%), or permanent (15.5%) AF refractory to antiarrhythmic drugs were included in the study. CPVA with the creation of supplementary block lines along the posterior wall and mitral isthmus was performed and a minimum of 6 months follow-up completed in all patients. Structural heart disease was present in 19.6% and hypertension in 33.8% of patients. After 13.1 +/- 8.4 months follow-up, 73.6% of patients were free of AF recurrences after a mean of 1.18 +/- 0.45 procedures/patient (one procedure in 85.2%, two procedures in 14.8%, and three procedures in 2.7%). Univariable analysis showed that the risk of AF recurrence increases with age (HR 1.03; 95% CI 1.00-1.06, P = 0.031), with the presence of previous hypertension (HR 2.7; 95% CI 1.43-5.07, P = 0.002), and if AF is permanent (HR 2.23; 95% CI 1.08-4.59, P = 0.042). In addition, larger anteroposterior left atrial diameter (LAD) (HR 1.11; 95% CI 1.05-1.18, P = 0.001) and larger left ventricular end-systolic diameter (HR 1.07; 95% CI 1.00-1.15, P = 0.029) prior to the procedure were associated with AF recurrence after CPVA. Cox regression analysis showed that hypertension (OR = 2.8; 95% CI 1.5-5.4; P = 0.002) and LAD (OR = 1.1; 95% CI 1.05-1.19, P < 0.001) were independent predictors of AF recurrence. The mean predicted proportion of patients with AF recurrence after CPVA of the multivariable model showed a linear relationship with the increase in LAD prior to the procedure. The presence of hypertension further increased the mean predicted proportion of patients with AF recurrence at each LAD. CONCLUSION: Hypertension and LAD are independent pre-procedural predictors of AF recurrence after CPVA to treat AF. These data may help in patient selection for AF ablation.