Remodelado eléctrico reverso en pacientes tratados con terapia de resincronización cardíaca / Reverse electrical remodeling in patients under cardiac resynchronization therapy

RESUMEN Introducción : La terapia de resincronización cardíaca (TRC) se indica en pacientes que habitualmente presentan remodelado cardíaco generado por dilatación y disincronía contráctil. La TRC contribuye al remodelado reverso, relacionado con menor mortalidad y hospitalizaciones por insuficiencia cardíaca (IC). Se han observado además mejoras en la conducción intraventricular, con reducción del tiempo de activación. La cuantificación del remodelado eléctrico reverso se ha subutilizado como parámetro de respuesta, con escasos reportes sobre su asociación con la respuesta clínica-estructural. Objetivo : Analizar el remodelado eléctrico reverso intraventricular como parámetro de respuesta a la TRC. Métodos: Se incluyeron pacientes con más de 6 meses de implante. Se obtuvo un ECG con estimulación desactivada (QRS intrínseco, QRSi, post TRC), y por ecocardiograma transtorácico se definió la fracción de eyección ventricular izquierda (FEVI), el diámetro de fin de diástole del ventrículo izquierdo (DFDVI) y la presencia de insuficiencia mitral. Se clasificó a los pacientes según la respuesta clínica-estructural. El remodelado eléctrico se caracterizó con la comparación de la duración del QRS pre y post TRC y la valoración de los cambios del QRS (ΔQRSi) entre grupos. Resultados : Se incluyeron 23 pacientes. Un 39% presentó disminución >10 mseg del QRSi. Observamos un QRSi de -9,3 ± 20,7 mseg en respondedores, y 11,25 ± 18,9 mseg en no respondedores (p = 0,027), más acentuada en los hiper respondedores (ΔQRSi: -14,44 ± 17,40 mseg, p = 0,026). Las mujeres con QRS ≥150 mseg pre TRC exhibieron disminución significativa del QRSi (p = 0,0195). Conclusiones : El remodelado eléctrico reverso se comprobó en 39% de los pacientes que recibieron TRC. Observamos una relación significativa del QRSi con la respuesta clínica-estructural, mayor en hiper respondedores. Mujeres con QRS ancho pre-TRC exhiben remodelado eléctrico reverso más acentuado. Este es un parámetro de fácil acceso e interpretación durante los controles ambulatorios.

ABSTRACT Introduction : Cardiac resynchronization therapy (CRT) is indicated in patients who often present cardiac remodeling due to dilatation and contractile dyssynchrony. CRT contributes to reverse remodeling which is associated with reduced mortality and heart failure (HF) hospitalizations. Improvements in intraventricular conduction with decreased ventricular activation time have also been observed. The quantification of reverse electrical remodeling has been underused as a parameter of response, and there are few reports on its association with the clinical-structural response. Objective : To analyze intraventricular reverse electrical remodeling as a parameter of response to CRT in living individuals. Methods : We included patients implanted at least 6 months ago. A deactivated stimulation ECG (post-CRT intrinsic QRS) was obtained, and by means of transthoracic echocardiography (TTE), the left ventricular ejection fraction (LVEF), the left ventricular end-diastolic diameter (LVEDD) and the presence of mitral regurgitation were defined. Patients were classified according to their clinical-structural response. Electrical remodeling was characterized by comparing pre- and post-CRT QRS duration and assessing QRS changes (ΔiQRS) between groups. Results : A total of 23 patients were included, 39% of which showed a >10 ms decrease in iQRS. We observed a iQRS of -9.3±20.7 ms in responders, and of 11.25±18.9 ms in non-responders (p=0.027), more marked in hyper-responders (ΔiQRS: -14.44±17.40 ms, p=0.026). Women with pre-CRT QRS ≥150 ms showed a significant decrease in iQRS (p=0.0195). Conclusion : Reverse electrical remodeling was found in 39% of the patients under CRT. We noted a significant relationship between iQRS and clinical-structural response, higher in hyper-responders. Women with wider pre-CRT QRS showed more marked reverse electrical remodeling. This parameter is accessible and easy to read in outpatient visits.

Use of instant messaging in electrophysiological clinical practice in Latin America: a LAHRS survey.

AIMS: Instant messaging (IM) platforms are a prominent component of telemedicine and a practical tool for sharing clinical data and counselling. Purpose of the survey was to inquire about the use of IM, the platforms used, frequency, recipients, and contents in Latin America region. METHODS AND RESULTS: An online survey was sent to medical community via newsletter and social media channels. The survey consisted in 22 questions, in Spanish and Portuguese, collected on SurveyMonkey. A total of 125 responders from 13 Latin-American countries (79% male, mean age 46.1 ± 9.7 years) completed the survey. Most of the responders declared that they send (88.8%) and receive (97.6%) clinical data through IM apps. Most senders declare that they anonymize clinical data before sending (71.0 ± 38.3%), but that the data received is anonymized only in 51.4 ± 33.5%. The most common tests shared with other physicians were 12-lead electrocardiograms (99.2%), followed by Holter recordings (68.0%) and tracings from electrophysiological studies (63.2%). The majority (55.2%) said that are unaware of legal data protection rules in their countries. CONCLUSIONS: IM apps are used by medical professionals worldwide to share and discuss clinical data and are preferred to many other methods of data sharing and are often used to share many different types of clinical data. They are perceived as a fast and easy way of communication, but medical professionals should be aware of the appropriate use of IM to prevent legal and privacy issues.

Current status of pediatric electrophysiology in Latin America: a LAHRS survey.

PURPOSE: Over the last years, pediatric electrophysiology (EP) has evolved as a consolidated subspecialty of pediatric cardiology. In the USA, Canada, and Europe, there is a clear picture of the status of pediatric EP, but the situation in Latin America is largely unknown. METHODS: A descriptive cross-sectional observational study was performed. A survey was conducted by the Latin American Heart Rhythm Society in Spanish and Portuguese to assess the status of development of pediatric EP across Latin American countries. RESULTS: There are physicians practicing pediatric EP in 11 Latin American countries. The scope of the practices includes clinical and non-invasive EP as well as performing invasive EP procedures. All the current pediatric EP interventions are performed in most of Latin American countries. CONCLUSIONS: Pediatric electrophysiology is present as a subspecialty in half of the countries in Latin America, and all the current electrophysiology procedures and therapeutic technologies are available in most Latin American countries.

Current practice in transvenous lead extraction in Latin America: Latin American Heart Rhythm Association survey.

BACKGROUND: Transvenous lead extraction (TLE) is standard of care for the management of patients with cardiac implantable electronic device infection or lead-related complications. Currently, objective data on TLE in Latin America is lacking. OBJECTIVE: To describe the current practice standards in Latin American centers performing TLE. METHODS: An online survey was sent through the mailing list of the Latin American Heart Rhythm Society. Online reminders were sent through the mailing list; duplicate answers were discarded. The survey was available for 1 month, after which no more answers were accepted. RESULTS: A total of 48 answers were received, from 44 different institutions (39.6% from Colombia, 27.1% from Brazil), with most respondents (82%) being electrophysiologists. Twenty-nine institutions (66%) performed <10 lead extractions/year, with 7 (16%) institutions not performing lead extraction. Although most institutions in which lead extraction is performed reported using several tools, mechanical rotating sheaths were cited as the main tool (66%) and only 13% reported the use of laser sheaths. Management of infected leads was performed according to current guidelines. CONCLUSION: This survey is the first attempt to provide information on TLE procedures in Latin America and could provide useful information for future prospective registries. According to our results, the number of centers performing high volume lead extraction in Latin America is smaller than that reported in other continents, with most interventions performed using mechanical tools. Future prospective registries assessing acute and long-term success are needed.

Uso de la ivrabadina para el tratamiento de la taquicardia ectópica de la unión congénita / Use of ivabradine for the treatment of congenital junctional ectopic tachycardia

Resumen La taquicardia ectópica de la unión en su variante congénita es una taquiarritmia pediátrica poco frecuente, que por su naturaleza incesante y su refractariedad a los agentes farmacológicos tradicio nales lleva asociada una alta morbimortalidad. Se presentan los casos clínicos de dos pacientes pediátricos con diagnóstico de taquicardia ectópica de la unión congénita, que mostraron respuesta inadecuada a las alternativas de tratamiento habituales y que, en consecuencia, desarrollaron miocardiopatía dilatada y disfunción ventricular secundaria a la taquicardia sostenida. En ambos se utilizó ivabradina como alternativa farmacológica innovadora pare el control de ésta con excelente respuesta clínica.

Abstract The congenial form of junctional ectopic tachycardia is a rare variant of pediatric tachyarrhythmia that due to its incessant nature and its refractoriness to the traditionally used antiarrhythmic agents has a high morbimortality The clinical cases of two patients with a diagnosis of congenital junctional ectopic tachycardia with inadequate response to the regular pharmacological options, who developed dilated cardiomyopathy and ventricular dysfunc tion secondary to sustained tachycardia, are presented. In both ivrabadine, a new innovative option was used with excellent clinical response.

[Use of ivabradine for the treatment of congenital junctional ectopic tachycardia]. / Uso de la ivrabadina para el tratamiento de la taquicardia ectópica de la unión congénita.

The congenial form of junctional ectopic tachycardia is a rare variant of pediatric tachyarrhythmia that due to its incessant nature and its refractoriness to the traditionally used antiarrhythmic agents has a high morbimortality The clinical cases of two patients with a diagnosis of congenital junctional ectopic tachycardia with inadequate response to the regular pharmacological options, who developed dilated cardiomyopathy and ventricular dysfunction secondary to sustained tachycardia, are presented. In both ivrabadine, a new innovative option was used with excellent clinical response.

La taquicardia ectópica de la unión en su variante congénita es una taquiarritmia pediátrica poco frecuente, que por su naturaleza incesante y su refractariedad a los agentes farmacológicos tradicionales lleva asociada una alta morbimortalidad. Se presentan los casos clínicos de dos pacientes pediátricos con diagnóstico de taquicardia ectópica de la unión congénita, que mostraron respuesta inadecuada a las alternativas de tratamiento habituales y que, en consecuencia, desarrollaron miocardiopatía dilatada y disfunción ventricular secundaria a la taquicardia sostenida. En ambos se utilizó ivabradina como alternativa farmacológica innovadora pare el control de ésta con excelente respuesta clínica.

Comparison of cost-effectiveness of implantable cardioverter defibrillator therapy in patients for primary prevention in Latin America: an analysis using the Improve SCA study.

OBJECTIVE: The mortality benefit of implantable cardioverter defibrillators (ICDs) for primary prevention (PP) of sudden cardiac arrest (SCA) has been well-established, but ICD therapy remains globally underutilized. The results of the Improve SCA study showed a 49% relative risk reduction in all-cause mortality among ICD patients with 1.5 primary prevention (1.5PP) characteristics (patients with one or more risk factors, p < 0.0001). We evaluated the cost-effectiveness of ICD compared to no ICD therapy among patients with 1.5PP characteristics in three Latin American countries and analyzed the factors involved in cost-effectiveness. METHODS: We used a published Markov model that compares costs and outcomes of ICD to no ICD therapy from local payers' perspective and included country-specific and disease-specific inputs from the Improve SCA study and current literature. We used WHO-recommended willingness-to-pay (WTP) thresholds to assess cost-effectiveness and compared model outcomes between countries. RESULTS: Incremental costs per QALY (quality-adjusted life year) saved by ICD compared to no ICD therapy are Colombian Pesos COP$46,729,026 in Colombia, Mexican Pesos MXN$246,016 in Mexico, and Uruguayan Pesos UYU$1,213,614 in Uruguay in the base case scenario; all three figures are between 1-3-times GDP per capita for each country. One-way and probabilistic sensitivity analyses confirm the base case scenario results. Non-cardiac accumulated deaths are lower in Mexico, resulting in a comparatively increased cost-effective ICD therapy. LIMITATIONS: The Improve SCA study was not randomized, so clinical results could be biased; however, measures were taken to reduce this bias. Costs and benefits were modelled beyond the timeline of direct observation in the Improve SCA study. CONCLUSIONS: ICD therapy is cost-effective in Mexico and Uruguay and potentially cost-effective in Colombia for a 1.5PP population. Variability in ICER estimates by country can be explained by differences in non-cardiac deaths and cost inputs.

Prevalencia de síntomas depresivos en pacientes hospitalizados por síndrome coronario agudo y factores asociados / Frequency of depression symptoms in patients hospitalized for acute coronary syndrome and search for predisposing associated factors / Frequência dos sintomas de depressão em pacientes internados por síndrome coronariana aguda e pesquisa de fatores associados

Resumen: Introducción: la depresión se relaciona con la enfermedad cardiovascular. Es una complicación posible luego de un síndrome coronario agudo (SCA) y afecta su pronóstico. Objetivos: 1) Evaluar la prevalencia de síntomas de depresión en pacientes ingresados por un SCA con elevación y sin elevación del segemento ST, de riesgo alto y moderado, estudiados con angiografía coronaria. 2) Identificar asociaciones entre la presencia de estos síntomas y variables socio-demográficas. Método: estudio observacional, descriptivo-analítico, transversal, en pacientes que ingresaron en una institución privada de Montevideo con diagnóstico de SCA. La presencia de depresión se evaluó con el inventario de depresión de Beck (BDI-II). Resultados: se incluyeron 111 pacientes, de 63,0±11,9 años y 56,8% hombres. El puntaje en el BDI-II fue de 7,3±3,3. Según este, 23 pacientes (20,7%) presentaron síntomas de depresión media (SDM) y ninguno en grados mayores. Los pacientes con SDM eran más añosos que quienes no la presentaron (67,5±9,4 vs. 62,0±12,3 años, p=0,048), con menor proporción de secundaria completa (39,1% vs. 64,8%, p=0,026) y con residencia fuera de Montevideo más frecuente (34,8% vs. 11,4%, p=0,012) (OR=1,5; IC95%: 1,0-2,3), única variable que fue significativa en el análisis multivariado (p=0,011). Hubo diferencias no significativas en cuanto a sexo y sedentarismo. El 36,9% de los pacientes conocía el significado y el pronóstico de su enfermedad y 27,0% las medidas de rehabilitación, sin diferencias significativas entre subgrupos con y sin SDM. Conclusiones: en esta serie la prevalencia de SDM fue de 20,7%, menor a la esperada. La residencia fuera de Montevideo se asoció de forma independiente con los SDM. El conocimiento por parte de los pacientes de su enfermedad y de las medidas de rehabilitación, fue bajo.

Summary: Introduction: depression is related to cardiovascular disease. It is a complication after an acute coronary event and affects its prognosis. Objectives: 1) To assess the presence of depression symptoms in patients admitted for an acute coronary syndrome with and without persistent ST elevation of moderate or high risk treated with coronary catheterization. 2) To identify associations between the presence of these symptoms and sociodemographic variables. Method: observational, descriptive-analytic, cross-sectional study in patients admitted to a mutual fund in Montevideo because an acute coronary syndrome. The presence of depression was evaluated with Beck-II´s scale (BDI-II). Results: 111 patients were included, aged 63.0 ± 11.9 and 56.8% men. The BDI-II score was 7.3 ± 3.3. According to this, 23 patients (20.7%) presented medium depression symptoms but none greater degrees. Patients with medium depression symptoms were older than those who did not have (67.5 ± 9.4 vs. 62.0 ± 12.3 years, p = 0.048), have lower proportion of complete secondary education (39.1% vs. 64.8%, p = 0.026) and more frequently reside outside Montevideo (34.8% vs. 11.4%, p = 0.012) (OR = 1.5 CI95% 1.0-2.3), the only variable that remained significant in the multivariate analysis (p=0.011). There were no significant differences in terms of gender and sedentary lifestyle. 36.9% of the patients knew the meaning and prognostic value of their disease and 27.0% the measures for rehabilitation, without significant differences between subgroups: with or without medium depression symptoms. Conclusions: in this series the prevalence of medium depression symptoms was 20.7%, lower than expected. Residence outside Montevideo was independently associated with medium depression symptoms. Patients' knowledge of their disease and of rehabilitation measures was low.

Resumo: Introdução: a depressão está relacionada a doenças cardiovasculares. É uma complicação após uma síndrome coronariana aguda e afeta seu prognóstico. Objetivos: 1) Avaliar a presença de sintomas de depressão em pacientes admitidos por síndrome coronariana aguda com e sem elevação persistente do ST de risco moderado ou alto tratados com cateterismo coronariano. 2) Identificar associações entre a presença desses sintomas e variáveis sócio-demográficas. Método: estudo observacional, descritivo-analítico, transversal, em pacientes admitidos em um fundo mútuo em Montevidéu por causa de uma síndrome coronariana aguda. A presença de depressão foi avaliada com a escala de Beck (BDI-II). Resultados: 111 pacientes foram incluídos, com idade entre 63,0 ± 11,9 anos e 56,8% homens. O escore do BDI-II foi de 7,3 ± 3,3. De acordo com isso, 23 pacientes (20,7%) apresentaram sintomas de depressão média, mas nenhum grau maior. Os pacientes com sintomas de depressão média eram mais velhos do que aqueles que não tinham (67,5 ± 9,4 vs. 62,0 ± 12,3 anos, p = 0,048), tinham menor proporção de ensino médio completo (39,1% vs. 64,8%, p = 0,026) e residiam com maior frequência fora de Montevidéu (34,8% vs. 11,4%, p = 0,012) (OR = 1,5 IC95% 1,0-2,3), a única variável que permaneceu significativa na análise multivariada (p = 0,011). Não houve diferenças significativas em termos de gênero e estilo de vida sedentário. 36,9% dos pacientes conheciam o significado e o prognóstico de sua doença e 27,0% as medidas de reabilitação, sem diferenças significativas entre os subgrupos: com ou sem sintomas de depressão média. Conclusões: nesta série, a prevalência de sintomas de depressão média foi de 20,7%, abaixo do esperado. A residência fora de Montevidéu foi associada independentemente ao sintomas de depressão média. O conhecimento dos pacientes sobre sua doença e medidas de reabilitação foi baixo.

Deporte: modificaciones fisiológicas y evaluación para la prevención de la muerte súbita (Parte II). Corazón del deportista / Sport: physiological modifications and evaluation for the prevention of sudden death (Part II). Athlete`s heart / Esporte: modificações fisiológicas e avaliação para prevenção de morte súbita (Parte II). Coração do esportista

Resumen: La práctica de deporte regular ha demostrado ser beneficiosa para la salud y prolongar la vida, tanto en personas sanas como en aquellas con patología cardiovascular (CV), a cualquier edad. También es verdad que aumenta el riesgo de morir en forma súbita. Recientemente, ha surgido evidencia de que el exceso puede ser nocivo y se está investigando. En los deportistas hay adaptaciones del aparato CV que pueden confundirse con anormalidades; por otra parte, existen patologías CV que progresan más rápido con el ejercicio y en las personas con alteraciones asintomáticas, el ejercicio puede desencadenar eventos adversos. La valoración predeportiva ha demostrado prevenir la muerte súbita. Para no efectuar diagnósticos erróneos que afecten la vida de los deportistas, es necesario conocer las adaptaciones clínicas, electrocardiográficas y anatómicas que se consideran normales y usar pautas precisas internacionales. En esta segunda entrega se valoran los aspectos relacionados al corazón del deportista, profundizando en el diagnóstico diferencial entre adaptación fisiológica y patología.

Summary: The practice of regular sports has proven to be beneficial for health, and prolong life, both in healthy people and in those with cardiovascular disease, at any age. It is also true that it increases the risk of dying suddenly. Evidence has recently emerged that excess could be harmful and is being investigated. In athletes there are adaptations of the cardiovascular apparatus, which can be confused with abnormalities; on the other hand, there are cardiovascular pathologies that progress faster with exercise, and in people with asymptomatic disorders, exercise can trigger adverse events. Pre-sport assessment has been shown to prevent sudden death. In order not to make erroneous diagnoses that affect the lives of athletes, it is necessary to know the clinical, electrocardiographic and anatomical adaptations that are considered normal and to use precise international guidelines. In this second installment, the aspects related to the athlete's heart will be evaluated, delving into the differential diagnosis between physiological adaptation and pathology.

Resumo: A prática de esportes regulares tem se mostrado benéfica para a saúde e prolonga a vida, em pessoas saudáveis e com doenças cardiovasculares, em qualquer idade. Também é verdade que aumenta o risco de morrer repentinamente. Recentemente, surgiram evidências de que o excesso pode ser prejudicial e estão sendo investigadas. Nos atletas há adaptações do aparelho cardiovascular que podem ser confundidas com anormalidades; por outro lado, existem patologias cardiovasculares que progridem mais rapidamente com o exercício e em pessoas com distúrbios assintomáticos, o exercício pode desencadear eventos adversos. A avaliação pré-esporte demonstrou prevenir a morte súbita. Para não se fazer diagnósticos errôneos que afetam a vida dos atletas é necessário conhecer as adaptações clínicas, eletrocardiográficas e anatômicas consideradas normais e utilizar diretrizes internacionais precisas. Nesta segunda edição, serão avaliados os aspectos relacionados ao coração do atleta, aprofundando-se no diagnóstico diferencial entre adaptação fisiológica e patologia.

Deporte: modificaciones fisiológicas y evaluación para la prevención de la muerte súbita. (Parte I) / Sport: physiological modifications and evaluation for the prevention of sudden death. (Part I) / Esporte: modificações fisiológicas e avaliação para prevenção de morte súbita. (Parte I)

Resumen: La práctica de deporte en forma regular ha demostrado ser beneficiosa para la salud y prolongar la vida en personas sanas, con patología cardiovascular (CV) y a cualquier edad. También es verdad que aumenta el riesgo de morir de forma súbita. Recientemente, ha surgido evidencia de que el exceso puede ser nocivo, y se continúa investigando. En los deportistas hay adaptaciones del aparato CV que pueden confundirse con anormalidades. También existen patologías CV que progresan más rápido con el ejercicio y anormalidades asintomáticas en las que el ejercicio puede desencadenar eventos adversos. La valoración predeportiva ha demostrado prevenir la muerte súbita (MS). Para no efectuar diagnósticos erróneos que afecten la vida de los deportistas, es necesario conocer las adaptaciones clínicas, electrocardiográficas y anatómicas que se consideran normales y usar pautas internacionales. Se presenta una revisión que será publicada en dos partes. En la primera, tratamos el beneficio del deporte y las incertidumbres existentes en relación con el exceso de su práctica, así como al riesgo de MS, su fisiopatología y las ventajas de la valoración predeportiva. En la segunda entrega se abordarán los cambios clínicos, eléctricos y anatómicos adaptativos a la práctica del deporte y cómo identificarlos para una correcta habilitación.

Summary: The practice of regular sport has proven to be beneficial for health and prolong life, in healthy people, with cardiovascular pathology and at any age. It is also true that the risk of dying suddenly increases. Recently there has been evidence that the excess could be harmful and so research continues. In athletes there are adaptations of cardiovascular system that can be confused with abnormalities. There are also cardiovascular pathologies that progress faster with exercise and people with asymptomatic disorders in which exercise can trigger adverse events. Pre-sport assessment has been shown to prevent sudden death. In order to avoid erroneous diagnoses that affect athlete's life, it is necessary to know the clinical, electrocardiographic and anatomical adaptations that are considered normal and to use international guidelines. A review is presented, which will be published in two parts. In the first one, the benefit of sport and uncertainties in relation to its excess are discussed, as well as the risk of sudden death, its pathophysiology and the advantage of pre-sport assessment. In the second part, the adaptive clinical, electrical and anatomical changes will be addressed and differentiated, for a correct qualification.

Resumo: A prática do esporte regular provou ser benéfica para a saúde e prolongar a vida, em pessoas saudáveis, com patologia cardiovascular e em qualquer idade. Também é verdade que aumenta o risco de morte súbita. Recentemente, houve evidências de que o excesso poderia ser prejudicial e está sendo investigado. Nos atletas, há adaptações do sistema cardiovascular que podem ser confundidas com anormalidades. Existem também patologias que progridem mais rapidamente com o exercício e pessoas com distúrbios assintomáticos nas quais o exercício pode desencadear eventos adversos. A avaliação pré-esportiva demonstrou prevenir a morte súbita. Para não fazer diagnósticos errôneos que afetam a vida dos atletas, é necessário conhecer as adaptações clínicas, eletrocardiográficas e anatômicas consideradas normais e utilizar diretrizes internacionais. Se realiza uma revisão dividido em duas partes. Na primeira, é discutido o benefício do esporte e as incertezas em relação ao seu excesso, o risco de morte súbita, sua fisiopatologia e a vantagem da avaliação pré-esportiva. No segundo, será abordado as mudanças clínicas, elétricas e anatômicas adaptativas ao esporte e que devem ser distinguidas para uma correta habilitação.

Muerte súbita de causa cardíaca en pediatría. Análisis de 95 casos en los últimos 20 años / Sudden death of cardiac etiology in pediatrics. Analysis of 95 cases in the last 20 years / Morte súbita de etiologia cardíaca em pediatria. Análises de 95 casos nos últimos 20 anos

Resumen: Introducción: acerca del tema muerte súbita de origen cardíaco en niños y adolescentes es mucho lo que se describe en la literatura mundial, pero son pocos los datos publicados en nuestro país. Más de la mitad de los casos de muerte súbita en este grupo etario responden a una etiología cardíaca. Objetivo: analizar los eventos de muerte súbita en edad pediátrica a partir de casos de muerte súbita (incluidas las frustras o abortadas) referidos por los colegas intervinientes en su evaluación de manera correlativa, según fueron sucediendo en el tiempo, tratando de investigar en ellos y en sus familiares cercanos la existencia de patologías cardíacas responsables de dicho evento. Evaluar mecanismos de prevención. Resultados: se estudiaron 95 casos, el 68% de sexo masculino, con edades entre 6 meses y 18 años. En el 65% de los casos se encontró una etiología cardíaca responsable. De ellos, en dos tercios se trató de una patología estructural cardíaca y en el tercio restante de una canalopatía o arritmia. Hubo antecedentes familiares de muerte súbita en el 50% de los casos. En el 35% de éstos se encontró una etiología potencialmente causante de muerte súbita. Conclusiones: la muerte súbita en edad pediátrica es un hecho real. Desconocemos su incidencia en nuestro país. La etiología cardíaca tuvo un papel preponderante en los casos estudiados. Por lo tanto, debemos poder detectar las situaciones de riesgo de un evento de muerte súbita previo a su aparición, y, si este ocurriera, tener previstos los mecanismos necesarios para revertirla.

Summary: Introduction: much has been described in the global literature about Sudden Cardiac Death, but few reliable data is available in Uruguay. More than half of the cases of sudden death in this age group arise from a cardiac etiology. Objective: to analyze sudden death in pediatric populations by studying sudden death cases (including frustrated or aborted deaths) referred to by colleagues involved in their assessment, as they happened over time. We studied the existence of cardiac pathologies in patients and their close relatives and evaluated prevention mechanisms. Results: 95 cases were studied, 68% males, aged between 6 months and 18 years. In 65% of the cases, we were able to find a cardiac etiology responsible for the event, in two thirds of the cases it was a structural cardiac pathology, and in the remaining third it was a canalopathy or arrhythmia. There was a family history of sudden death in 50% of cases. Of these cases, 35% showed a potential etiology that caused the sudden death. Conclusions: sudden death in children is a real fact. We do not know its incidence in Uruguay. Cardiac etiology played a significant role in the cases studied. Therefore, we should be able to detect situations of risk of a sudden death event prior to its appearance and if it occurred, we should be able to prevent the necessary mechanisms to reverse it.

Resumo: Introdução: muito tem sido descrito na literatura internacional sobre morte súbita cardíaca, mas poucos dados confiáveis estão disponíveis no Uruguai. Mais da metade dos casos de morte súbita nessa faixa etária vem duma etiologia cardíaca. Objetivo: analisar eventos de morte súbita durante a idade pediátrica, estudando casos de morte súbita (incluindo mortes frustradas ou abortadas) referidos pelos colegas envolvidos em sua avaliação, assim tal como ocorreram ao longo do tempo. Estudamos a existência de patologias cardíacas em pacientes e familiares próximos e avaliamos os mecanismos de prevenção. Resultados: foram estudados 95 casos, 68% do sexo masculino, com idade entre 6 meses e 18 anos. Em 65% dos casos, conseguimos encontrar uma etiologia cardíaca responsável pelo evento, e em dois terços dos casos era uma patologia cardíaca estrutural e no terço restante era uma canalopatia ou arritmia. Em 50% dos casos existia história familiar de morte súbita. Desses casos, 35% mostraram uma etiologia potencial que causou a morte súbita. Conclusões: a morte súbita em crianças é um fato real. Não sabemos sua incidência em Uruguai. A etiologia cardíaca teve um papel importante nos casos estudados. Portanto, devemos ser capazes de detectar situações de risco de morte súbita antes de que ocorra e, se ocorrer, devemos prever os mecanismos necessários para revertê-lo.

Alcohol consumption and cardiovascular health: A nationwide survey of Uruguayan cardiologists.

BACKGROUND AND AIMS: Heavy alcohol use is a risk factor for disease and mortality; however, epidemiological findings have demonstrated protective effects of a light-to-moderate intake of alcohol on cardiovascular health. There are many misconceptions regarding appropriate levels of alcohol intake and the risks and benefits of consumption. We sought to examine physician attitudes and recommendations regarding alcohol intake in a cohort of Uruguayan cardiologists. METHODS: A cross-sectional survey of 25 questions was distributed through the Uruguayan Society of Cardiology to attending cardiologists and advanced cardiology trainees. RESULTS: There were 298 respondents; 237 were attending cardiologists and 61 were advanced cardiology trainees. In total, 34% of cardiologists viewed moderate alcohol intake to be beneficial for cardiovascular health, 27% believed only wine offered such benefits, 36% viewed any intake to be harmful, and 3% had other opinions. More than half (57%) self-reported their perceived knowledge to come from academic sources. Regarding knowledge of guidelines, only 42% were aware of the concept of 'standard drink' (SD). Cardiologists were not comfortable (on a Likert scale) converting SD into other metric units (1.92 ± 2.77). Cardiologists were not satisfied with their knowledge of drinking guidelines (2.42 ± 2.63); however, men were more comfortable than women (p = 0.003). Cardiologists were generally comfortable in counseling patients regarding safe limits of consumption (5.46 ± 3.08, on a 0-10 scale). CONCLUSIONS: Uruguayan cardiologists were not satisfied with their knowledge of drinking guidelines or understanding of the alcohol metric units. This study suggests a necessity to optimize educational resources for physicians.

Molecular autopsy in a cohort of infants died suddenly at rest.

Sudden infant death syndrome is the leading cause of death during the first year of life. A large part of cases remains without a conclusive cause of death after complete autopsy. In these situations, cardiac arrhythmia of genetic origin is suspected as the most plausible cause of death. Our aim was to ascertain whether genetic variants associated with sudden cardiac death might be the cause of death in a cohort of infants died suddenly. We analyzed 108 genes associated with sudden cardiac death in 44 post-mortem samples of infants less than 1 year old of age who died at rest. Definite cause of death was not conclusive in any case after a complete autopsy. Genetic analysis identified at least one rare variant in 90.90% of samples. A total of 121 rare genetic variants were identified. Of them, 33.05% were novel and 39.66% were located in genes encoding ion channels or associated proteins. A comprehensive genetic analysis in infants who died suddenly enables the unraveling of potentially causative cardiac variants in 2045% of cases. Molecular autopsy should be included in forensic protocols when no conclusive cause of death is identified. Large part genetic variants remain of uncertain significance, reinforcing the crucial role of genetic interpretation before clinical translation but also in early identification of relatives at risk.

[Acute effect of yerba mate (Ilex paraguariensis) consumption on heart rhythm in patients referred for Holter study]. / Efecto agudo del consumo de yerba mate (Ilex paraguariensis) sobre el ritmo cardíaco en pacientes derivados para estudio Holter.

INTRODUCTION: The consumption of yerba mate (YM) (Ilex paraguariensis) is common in South America and is now used all over the world. It contains many bioactive substances that can be beneficial. There is also the opinion that it may have harmful effects on heart rhythm, but no studies have been found on this. OBJECTIVE: The aim of this study was to evaluate the acute effect of YM on heart rhythm in patients referred for a Holter study. METHOD: A before and after pseudo-experimental clinical study was conducted by performing a Holter on 50 habitual users of YM, and another one after 24 without YM consumption. The use of other products that could interfere was also controlled. RESULTS: The mean age of the subjects was 55±15 years, and 52% were women. At least one vascular risk factor was found in 78%, with 44% structural heart disease, and 90% taking cardiovascular medication. The heart rate (HR) with and without YM was similar. Only the minimum hourly HR was lower when taking YM (61±10 vs. 63±9, P=.021). There was no significant difference in the incidence of sustained or non-sustained arrhythmias, or in ventricular extrasystoles. The total number of supra-ventricular premature beats was higher without YM (952±3,538 vs. 1,294±5,201, P=.014) and also the maximum hourly (86±302 vs. 107±360, P=.032). There was no difference in HR variability. CONCLUSIONS: In cardiology patients, usual users of YM, habitual consumption was not associated with significant changes in HR or an increase in the incidence of arrhythmias. There was less ectopic supraventricular activity.

Resultados del estudio electrofisiológico y ablación en niños de hasta 13 años con técnica mínimamente invasiva

El estudio electrofisiológico (EEF) y la ablación en niños son eficaces y están internacionalmente bien pautados. Clásicamente se utilizan tres a cinco accesos vasculares y catéteres endovasculares (CEVs). Propusimos un protocolo simplificado para reducir la cantidad y con ello las complicaciones. Quisimos evaluar los resultados obtenidos. Material y método: realizamos un estudio descriptivo, prospectivo, longitudinal, de 120 pacientes consecutivos de hasta 13 años, sin cardiopatía estructural. El protocolo se basa en utilizar un registro esofágico (RIE) cuando es de utilidad, tener la imagen radiológica en pantalla de la posición del His e ir moviendo un CEV a la posición necesaria cada momento. Resultados: la edad osciló entre 7 meses y 13 años (media=9,5 años) y 72 (62%) eran varones. En 101 (84%) se intentó una ablación y en 19 (16%) EEF. El 70% de las ablaciones fueron por una vía accesoria, 25% por una reentrada nodal y 5% otras causas. El tiempo total de procedimiento fue 104 ± 55 minutos. En 58 niños se intentó RIE y en 57 se logró. El 42% de las ablaciones se hicieron con un solo acceso y 94% con uno o dos CEVs. En seis casos complejos se requirieron tres CEVs y en ninguno, cuatro. Hubo 15 que requirieron más de dos accesos. La ablación fue efectiva en 94%, y seguidos 51±22 meses hubo 6 (6%) recurrencias. Un paciente hizo una pericarditis, no hubo complicaciones vasculares, eléctricas ni otras. Conclusiones: con este protocolo se obtuvieron resultados similares a las series convencionales, con un número muy bajo de accesos, catéteres y complicaciones.

Summary: The electrophysiology study (EPS) and ablation procedure in children are effective and internationally well-defined techniques. They typically use 3 to 5 vascular accesses and endovascular catheters (EVC). We proposed a simplified protocol to reduce these numbers and thus, reduce complications. The study aimed to evaluate the results obtained. Method: we performed a descriptive, prospective, longitudinal study over 120 consecutive patients up to 13 years of age, with no structural heart disease. The protocol consists in using an esophageal record (IER) when it is useful, having the radiological image of its position on the screen and in continuing to move an EVC to the required position at each time. Results: age ranged between 7 months and 13 years (mean = 9.5) and 72 (62%) children were male. In 101 (84%) an ablation was attempted and in 19 (16%) EPS. 70% of the ablations were done for accessory pathways, 25% for nodal reentry tachycardia and 5% others causes. The total time of the procedure was 104 ± 55 minutes. In 58 children an IAR was attempted and in 57 it was achieved. In 42% of cases the ablation was made with 1 single access and 94% with 1 or 2 EVCs. In 6 complex cases 3 EVCs were required and 4 in none. There were 15 cases that required >2 accesses. The ablation was effective in 94%. During 51 ± 22 months of follow-up there were 6 (6%) recurrences. One patient had pericarditis, there were no vascular, electrical, or other complications. Conclusions: with this protocol the results are similar to the conventional series, using a very low number of accesses, catheters and complications rate.

O estudo eletrofisiológico (EPS) e a ablação em crianças são procedimentos eficazes e internacionalmente bem estabelecidos. Tipicamente utilizam-se 3 a 5 acessos vasculares e cateteres endovasculares (CEVs). Propusemos um protocolo simplificado para reduzir a quantidade e com isso as complicações com o fim de avaliar os resultados obtidos. Métodos: realizou-se um estudo longitudinal descritivo, prospectivo, de 120 pacientes consecutivos com até 13 anos de idade, sem cardiopatia estrutural. O protocolo consiste na utilizacao dum registro esofágico (EIR) quando resultar útil, uma imagem radiológica na tela que mostra posição de His e a movimentacao do CEV para a posição necessária a cada momento. Resultados: a idade variou de 7 meses a 13 anos (média = 9,5 anos). 72 (62%) dos pacientes eram do sexo masculino. 101 (84%) pacientes receberam uma ablação e 19 (16%) o FES. 70% das ablações foram por via acessória, 25% por reentrada nodal e 5% por outras causas. O tempo total do procedimento foi de 104 ± 55 minutos. O RIE se tentou em 58 crianças e se conseguiu em 57. 42% das ablações foram feitas com 1 acesso único e 94% com 1 ou 2 CEVs. Em 6 casos complexos, foram necessários 3 CEVs e em nenhum caso foram necessários 4. 15 casos necessitaram de mais de 2 acessos. A ablação foi eficaz em 94% dos casos e, após do seguimento de 51 ± 22 meses, houve 6 (6%) recorrências. Um paciente apresentou pericardite, más sem complicações vasculares, elétricas ou de outro tipo. Conclusões: obtivemos resultados semelhantes com este protocolo para as séries convencionais, com um número muito baixo de acessos, cateteres ou complicações.

Efecto agudo del consumo de yerba mate (Ilex paraguariensis) sobre el ritmo cardíaco en pacientes derivados para estudio Holter / Acute effect of yerba mate (Ilex paraguariensis) consumption on heart rhythm in patients referred for Holter study

Resumen Introducción: El consumo de yerba mate (YM) (Ilex paraguariensis) es común en Sudamérica y se extiende a todo el mundo. Contiene muchas sustancias bioactivas que pueden ser beneficiosas. También existe la opinión de que puede tener efectos nocivos sobre el ritmo cardíaco, pero no encontramos investigaciones al respecto. Objetivo: Nuestro objetivo fue evaluar el efecto agudo de YM sobre el ritmo, en pacientes enviados para realizar un Holter. Método: Realizamos un estudio clínico seudoexperimental, de tipo antes y después. Tomamos 50 pacientes consumidores habituales de YM y se les realizó un Holter tomando YM y otro luego de 24 sin consumir. También se controló el uso de otros productos que pudieran interferir. Resultados: El 52% fueron mujeres y la edad, de 55 ± 15 años. El 78% tenía al menos un factor de riesgo vascular, el 44% cardiopatía estructural y el 90% tomaba medicación cardiovascular. La frecuencia cardíaca (FC) con y sin YM fue similar. Solo la FC mínima horaria fue menor tomando YM (61 ± 10 vs. 63 ± 9, p = 0.021). No hubo diferencia significativa en la incidencia de arritmias sostenidas, no sostenidas ni en la extrasistolia ventricular. El total de extrasístoles supraventriculares fue mayor sin YM (952 ± 3,538 vs. 1,294 ± 5,201, p = 0.014) y la cantidad máxima horaria también (86 ± 302 vs. 107 ± 360, p = 0.032). No hubo diferencia en la variabilidad de la FC. Conclusiones: En pacientes cardiológicos tomadores de YM, su consumo de la forma habitual no se asoció con cambios importantes de la FC ni con un aumento en la incidencia de arritmias. Hubo menos actividad ectópica supraventricular.

Abstract Introduction: The consumption of yerba mate (YM) (Ilex paraguariensis) is common in South America and is now used all over the world. It contains many bioactive substances that can be beneficial. There is also the opinion that it may have harmful effects on heart rhythm, but no studies have been found on this. Objective: The aim of this study was to evaluate the acute effect of YM on heart rhythm in patients referred for a Holter study. Method: A before and after pseudo-experimental clinical study was conducted by performing a Holter on 50 habitual users of YM, and another one after 24 without YM consumption. The use of other products that could interfere was also controlled. Results: The mean age of the subjects was 55 ± 15 years, and 52% were women. At least one vascular risk factor was found in 78%, with 44% structural heart disease, and 90% taking cardio- vascular medication. The heart rate (HR) with and without YM was similar. Only the minimum hourly HR was lower when taking YM (61 ± 10 vs. 63 ± 9, P = .021). There was no significant diffe- rence in the incidence of sustained or non-sustained arrhythmias, or in ventricular extrasystoles. The total number of supra-ventricular premature beats was higher without YM (952 ± 3,538 vs. 1,294 ± 5,201, P = .014) and also the maximum hourly (86 ± 302 vs. 107 ± 360, P = .032). There was no difference in HR variability. Conclusions: In cardiology patients, usual users of YM, habitual consumption was not associated with significant changes in HR or an increase in the incidence of arrhythmias. There was less ectopic supraventricular activity.

Erratum to '2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing' [Journal of Arrhythmia 32/1 (2016) 1-28].

[This corrects the article DOI: 10.1016/j.joa.2015.12.001.].