Epicardial adipose tissue volume assessed by cardiac CT as a predictor of atrial fibrillation recurrence following catheter ablation.

INTRODUCTION: In patients with atrial fibrillation (AF), up to one third have recurrence after a first catheter ablation (CA). Epicardial adipose tissue (EAT) has been considered to be closely related to AF, with a potential role in its recurrence. We aimed to evaluate the association between the volume of EAT measured by cardiac computed tomography (CT) and AF recurrence after CA. METHODS: Consecutive AF patients underwent a standardized cardiac CT protocol for quantification of EAT, thoracic adipose volume (TAV) and left atrium (LA) volume before CA. An appropriate cut-off of EAT was determined and risk recurrence was estimated. RESULTS: 305 patients (63.6 % male, mean age 57.5 years, 28.2 % persistent AF) were followed for 24 months; 23 % had AF recurrence at 2-year mark, which was associated with higher EAT (p = 0.037) and LAV (p < 0.001). Persistent AF was associated with higher EAT volumes (p = 0.010), TAV (p = 0.003) and LA volumes (p < 0.001). EAT was predictive of AF recurrence (p = 0.044). After determining a cut-off of 92 cm3, survival analysis revealed that EAT volumes > 92 cm3 showed higher recurrence rates at earlier time points after the index ablation procedure (p = 0.006), with a HR of 1.95 (p = 0.008) of AF recurrence at 2-year. After multivariate adjustment, EAT > 92 cm3 remained predictive of AF recurrence (p = 0.028). CONCLUSION: The volume of EAT measured by cardiac CT can predict recurrence of AF after ablation, with a volume above 92 cm3 yielding almost twice the risk of arrhythmia recurrence in the first two years following CA. Higher EAT and TAV are also associated with persistent AF.

Evaluation of left atrial strain imaging and integrated backscatter as predictors of recurrence in patients with paroxysmal, persistent, and long-standing persistent atrial fibrillation undergoing catheter ablation.

BACKGROUND: Impaired left atrial (LA) strain predicts atrial fibrillation (AF) recurrence after catheter ablation (CA), but currently there is no cut-off to guide patient selection for CA. Integrated backscatter (IBS) is a promising tool for noninvasive quantification of myocardial fibrosis. The aim of this study was to compare LA strain and IBS between paroxysmal, persistent, and long-standing persistent AF and evaluate their association with AF recurrence after CA. METHODS: Analysis of consecutive patients with symptomatic paroxysmal and persistent AF who underwent CA. LA phasic strain, strain rate and IBS were assessed by two-dimensional speckle-tracking at baseline. RESULTS: We analyzed 78 patients, 31% with persistent AF (46% long-standing AF), 65% male, mean age 59 ± 14 years, who underwent CA and were followed-up for 12 months. AF recurrence occurred in 22 (28%) patients. LA phasic strain parameters were significantly impaired in patients with AF recurrence and were independent predictors of AF recurrence in a multivariable analysis. LA reservoir strain (LASr) < 18% predicted AF recurrence with 86% sensitivity and 71% specificity, with a higher predictive power compared to LA volume index (LAVI). LASr < 22% in paroxysmal AF and LASr < 12% in persistent AF correlated with AF recurrence. Increased IBS was a predictor of AF recurrence in patients with paroxysmal AF. CONCLUSION: LA phasic strain parameters were predictors of AF recurrence after CA, independently of LAVI and AF subtype. LASr < 18% showed a higher predictive power compared to LAVI. Further studies are needed to investigate the role of IBS as a predictor of AF recurrence.

A simplified single transseptal puncture approach using high-density 3D voltage mapping for atrial fibrillation ablation: acute complications and long-term results.

Background: An ablation catheter and a circular mapping catheter requiring a double transeptal puncture (TSP) for left atrial access have been conventionally used for atrial fibrillation (AF) ablation. Recently, different operators have combined a single transseptal puncture technique with 3D high-density mapping catheters for pulmonary vein isolation (PVI). Objective: This study aims to compare two strategies, single vs. double TSP, regarding the duration of the procedure, radiation time, complication rates, and outcomes. Methods: Retrospective analysis of a large cohort of consecutive patients that underwent first PVI with radiofrequency energy (RF), using a point-by-point strategy, with a 3D mapping system, either with single or double TSP, according to the operator's choice. Results: 285 patients with a mean age of 59.5 ± 11.6 years (36.5% female, 67.7% paroxysmal AF) underwent a point-by-point catheter ablation with RF between July 2015 and March 2020. The mean CHA2DS2-VASc score was 1.7 ± 1.3. Single TSP was performed in 115 (40.3%) patients and double TSP in 170 (59.6%). The operator's experience (≥5 years of AF ablation procedures) was equally distributed among the two groups. The average procedure time (133 ± 31.7 min vs. 123 ± 35.5 min, for single and double TSP, respectively) did reach a statistical difference between both groups (p = 0.008), but there was a substantial advantage regarding fluoroscopy time (13 ± 6.3 min vs. 19 ± 9.1 min, for single and double TSP, respectively; p < 0.001). Acute major complications present similar rates in both groups (2.6% vs. 2.3%, p = 0.799). At the 2-year follow-up, both groups had a similar sinus rhythm maintenance rate (76.5% vs. 78.8%, p = 0.646). Conclusion: A simplified single-TSP technique using high-density multi-electrode 3D mapping is a safe and highly successful option for AF ablation. This approach yields a substantial reduction in fluoroscopy time, with the potential to avoid acute complications, compared to a conventional double-TSP strategy.

The atrial fibrillation burden during the blanking period is predictive of time to recurrence after catheter ablation.

Objective: This study aimed to assess whether atrial fibrillation (AF) occurrence or its corresponding daily mean burden (in minutes/day) during the mid to late blanking period after pulmonary vein isolation (PVI), predicts AF recurrence. Methods: Analysis of consecutive first PVI ablation patients undergoing prolonged electrocardiogram (ECG) monitoring during the second and third months after PVI. The clinical variables, total AF burden, and their relationship with time to recurrence were studied. Results: 477 patients with a mean age of 56.9 (SD = 12.3) years (63.7 % male; 71.7 % paroxysmal AF), from which 317 (66.5 %) had an external event recorder between 30 and 90 days after ablation. Median follow-up of 16.0 (P 25:12.0: P 75:33.0) months, 177 (37 %) patients had an AF recurrence, with 106 (22.2 %) having the first episode after 12 months of follow-up. In the group of patients with an event recorder, 80 (25.2 %) had AF documented during the blanking period. Multivariable analysis showed that AF during the blanking period was associated with a 4-fold higher risk of recurrence (HR: 3.98; 95 %CI: 2.95-5.37), and, compared to patients in sinus rhythm, those with an AF burden ≥ 23 min/day had an approximately 7-fold higher risk of recurrence (HR estimate: 6.79; 95 %CI: 4.56-10.10). Conclusions: The probability of experiencing AF recurrence can be predicted by atrial tachyarrhythmia episodes during the second and third months after PVI. Atrial arrhythmias burden > 23 min/day has a high predictive ability for recurrence.

Long-term outcomes of non-contact multi-electrode balloon catheter mapping-guided ablation of ventricular arrhythmias originating from the outflow tract.

INTRODUCTION: The outflow tract (OT) regions of the ventricles are a common location of origin for idiopathic ventricular arrhythmias (VA). Non-contact mapping (NCM) with a multi-electrode balloon catheter Ensite-Array enables three-dimensional reconstruction of the geometry of the cardiac chambers and accurate mapping of the propagation map, based on a single beat analysis, facilitating the ablation and contributing procedure success. OBJECTIVE: Assessment of the feasibility and long-term outcomes following NCM-guided OT VA ablation. METHODS: Single center retrospective analysis of patients admitted for symptomatic OT VA ablation. Demographic and clinical characteristics of patients, procedure data and long-term outcomes were assessed. RESULTS: Fifty-eight patients (79.3% female, age 43.9±17.6 years) were considered, 89.7% without structural heart disease. In 85.7% of the cases left ventricle ejection fraction (LVEF) was preserved (LVEF≥50%), 8.6% had mild systolic dysfunction (LVEF 40%-49%) and 5.7% had moderate systolic dysfunction (LVEF 30%-39%). Twenty-four-hour Holter recording documented sustained VA episodes in 12.1% of the patients, non-sustained VA in 31.0%, and >10 000 premature ventricular complex (PVC)/24 h in 56.9%, with an ECG suggesting right ventricular OT origin in 84.5%. There was total elimination of PVC in 87.9% cases and a significant reduction in 3.4%. During a mean follow-up of 5.5 years, 87.9% patients remained asymptomatic without medication, 12.1% underwent re-ablation due to symptomatic PVC recurrence, and two cases underwent a third successful intervention. CONCLUSION: Non-contact mapping-guided multi-electrode balloon catheter VA ablation is a highly effective and safe procedure, with a low rate of long-term recurrence.

Teorias e concepcoes de prestacao de servicos basicos

A prioridade para os cuidados de saude primarios esta inscrito nos documentos de politica do MISAU desde a independencia. A prestacao de servicos foi desde cedo concebido para chegar ao nivel da comunidade. O Servico Nacional de Saude desenvolveu-se ate ao distrito articulando com a comunidade atraves do seu Agente Polivalente Elementar escolhido que treinava sem o incorporar no sistema. Este sistema de saude sofreu com a guerra civil com perda estimada de 1/3 das infra-estruturas. De acordo com o projeto de apoio aos servicos de saude; em Nampula (1999) existe uma rede sanitaria composta por 156 unidades que incluem: 1 hospital central; 1 hospital psiquiatrico; 1 hospital geral; 4 hospitais rurais; 40 centros de saude e 109 postos de saude. A grande questao e que as distancias do local onde vivem as familias a estes servicos; no meio rural; sao longas (problema de acessibilidade).