Atrial Fibrillation in Heart Failure Patients with Preserved or Reduced Ejection Fraction. Prognostic significance of Rhythm control strategy with Catheter Ablation.

INTRODUCTION: Atrial fibrillation (AF) and heart failure (HF) often coexist with an increase in morbidity and mortality. AF catheter ablation (CA) has proved to be a safe and efficient option for HF patients, but long-term evolution and prognosis remain uncertain. The aim is to assess the efficacy and safety of CA in HF patients with AF, and analyze HF long-term evolution. METHODS: We prospectively analyzed consecutive patients with AF and congestive HF or left ventricular ejection fraction (EF) less than 45%, who underwent CA of AF between 2011 and 2016. We excluded patients who did not complete one year of follow-up. RESULTS: Seventy-nine patients were included. Mean age was 62.1 years, 72.4% were men, 67.2% had hypertension and 8.6% were diabetics. Mean EF was 49%, left atrial area was 26.5 cm2 and mean CHA2DS2-VASc score was 2. 70.6% were on NYHA FC II-III.The recurrence rate of AF was 60%, and after a second CA the rate decreased to 27.8%. Only persistent AF prior to the procedure was identified as independent predictor of recurrence. There was a significant NYHA FC improvement in the sinus rhythm (SR) group vs those with recurrence (63.6% vs 36.4%; p=0.047). None of the patients in SR were hospitalized, whereas six with recurrence were hospitalized due to HF (0% vs. 18.2%; p = 0.07). The rate of complications was 9.1%. CONCLUSIONS: Catheter ablation of atrial fibrillation in heart failure presents an adequate success rate, improving symptoms and reducing rehospitalizations due to heart failure.

Non-fluoroscopic catheter ablation of arrhythmias with origin at the summit of the left ventricle.

BACKGROUND: Catheter ablation of ventricular arrhythmias (VAs) arising from the left ventricular Summit (LVS) is challenging and requires high-dose fluoroscopy to limit vascular damage of the coronary arteries. Ionizing radiation can increase the incidence of malignancies to both patient and operator. This study describes outcomes of catheter ablation of LVS VAs using intracardiac echo-facilitated 3D electroanatomical mapping (ICE-3D) to avoid fluoroscopy. METHODS: Twenty-six patients (47 ± 17 years old; 52% males; median ejection fraction 55 ± 13%) with premature ventricular contractions or ventricular tachycardia underwent catheter ablation. VAs were localized using ICE-3D with arrhythmia foci being mapped at the LVS. Focal ablation was performed using a 3.5-mm open-irrigated, contact force sensing radiofrequency catheter. RESULTS: Acute success and recurrence rates were 84% and 24%, respectively. Holter burden was significantly reduced (24 ± 15% to 1.5 ± 2%; P = 0.01) after ablation. The use of zero fluoroscopy was achieved in 100% of cases. No major complications were observed. CONCLUSIONS: Zero fluoroscopy catheter ablation of LVS VAs using ICE-3D mapping is feasible and effective.

Anatomical Connections Between the Papillary Muscles and the Ventricular Myocardium: Correlation With QRS Variability of Ventricular Arrhythmias.

BACKGROUND: Papillary muscles (PM) ventricular arrhythmias (VAs) exhibit QRS variability, attributed to anisotropy. ECG inconsistencies such as late precordial transition (TZ) and discordant QRS axis may not be solely explained by anisotropic conduction. We sought to determine the presence of anatomic connections of the PM and correlate them with ECG inconsistencies and ablation results. METHODS: Patients with prior PM VAs catheter ablation (N=33/66 PMs) were prospectively evaluated with cardiac resonance for the presence of muscular connection (PMCs) away from the PM base. Specific ECG characteristics including early (consistent TZ) and late (inconsistent-ITZ) TZ or inconsistent (IQA) or consistent QA QRS axis were correlated with PMCs. RESULTS: Thirty-five PMs exhibited clinical VAs (N=29 posteromedial PM and N=6 anterolateral PM). PM VAs with ITZ and IQA were observed in 11 and 9 PMs, respectively. In total, 41 PMs (62%) exhibited 90 PMCs. Arrhythmogenic PMs (N=35) exhibited higher number of PMCs (72 versus 18; P=0.01). Patients with ITZ and IQA exhibited 100% prevalence of PMCs. Those with consistent TZ and consistent QA showed 40% and 26% prevalence of PMCs, respectively. ITZ and IQA predicted the presence of PMCs with 59% of 28% sensitivity; and 100% of 100% specificity, respectively. Type-specific PMCs were more prevalent in patients with ECG inconsistencies. Those PMs are exhibiting clinical recurrence after ablation presented higher prevalence of PMCs (91% versus 60%; P=0.04). CONCLUSIONS: PMCs are highly prevalent in patients with PM VAs. A direct correlation exists between PM VAs ECG inconsistencies and type-specific PMCs. Patients with ITZ or IQA exhibited PMC 100% prevalence. Recurrence was higher among patients with PMCs.

Impact of a hybrid decision support system to improve the adherence to implantable cardioverter defibrillator therapy guidelines for primary prevention of sudden cardiac death.

OBJECTIVES: Despite the well-documented benefit of implantable cardioverter defibrillator (ICD) in patients with severe left ventricular dysfunction, there is a large number of patients who had not been offered this therapy. The aim of this study is to evaluate the utility of a hybrid decision support system (hCDSS) to improve the adherence to indicate ICD therapy in our institution. METHODS: We conducted a retrospective, observational and single-center study. An hCDSS focused on patients with severe deterioration of the left ventricular function was implemented, creating a mandatory field containing the value of left ejection fraction and three options to choose: >35%, ≤ 35% or unknown. When the option ≤ 35% is checked, an email is automatically sent to the electrophysiology section where the staff can contact the treating physician to discuss the indication of ICD therapy. We measured the number of ICDs implanted before the alert (month 1-21), immediate post and late post alert (month 22-27 and 28-48 months respectively) RESULTS: The rate of ICD implantation increased from 1.76% per month in the pre-intervention period to 4.48% after the intervention (p < 0.001). This increase in the rate of ICD implantation remained stable between the immediate and late post-intervention period (4.6 vs. 4.4; p = .8) CONCLUSION: The implementation of a hybrid decision support system was associated with improved adherence to clinical guidelines for prevention of sudden cardiac death, as evidenced by a rapid and sustained increase in the number of ICD implants in patients with severe left ventricular dysfunction.

Proyecto de mejora de calidad para reducir errores de prescripción en pacientes internados por patologías cardiovasculares / Quality Improvement Project to Reduce Prescription Errors in Patients Hospitalized due to Cardiovascular Diseases

Introducción: Los errores de prescripción son un problema frecuente que amenaza la seguridad de los pacientes internados, especialmente en áreas de cuidados críticos. Objetivo: Evaluar la efectividad de un proyecto de mejora de la calidad para reducir errores de prescripción en pacientes internados por patologías de origen cardiovascular. Material y métodos: Se implementó un proyecto de mejora de la calidad destinado a reducir errores de prescripción intrahos-pitalaria. Los tres componentes principales del proyecto fueron: supervisión obligatoria de las indicaciones, utilización de un software que ordena las indicaciones por sistemas biológicos e implementación de una norma de formato universal de prescripción de medicamentos, que incluyó un diccionario de abreviaturas y de diluciones normalizadas. Con anterioridad a la implementación de estos cambios se midió la cantidad de errores de prescripción semanales, estratificados por área de internación. Se analizó el impacto del proyecto dividiendo las muestras en cuatro períodos consecutivos de 9 semanas cada uno (un período preintervención y tres posintervención) y se comparó luego la cantidad de errores detectados en cada uno de ellos. En cada período se evaluaron de manera aleatoria las indicaciones de 180 pacientes. Resultados: Se analizaron en total 720 prescripciones. La implementación del proyecto de mejora logró reducir la cantidad de errores de manera rápida y sostenida en el tiempo (mediana preintervención de 85, RIC 70-95 y mediana final de 26, RIC 21-37; p = 0,0004). Conclusión: El proyecto de mejora de la calidad implementado permitió reducir significativamente la cantidad de errores de prescripción en pacientes internados por patologías cardiovasculares.

Predictores de recurrencia y resultados en la ablación de la fibrilación auricular paroxística / Predictors of Recurrence and Outcomes in Catheter Ablation of Paroxysmal Atrial Fibrillation

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Fibrilación auricular paroxística: crioablación versus ablación por radiofrecuencia / Paroxysmal Atrial Fibrillation: Cryoballoon versus Radiofrequency Catheter Ablation

Introducción: En la ablación de la fibrilación auricular paroxística por radiofrecuencia o crioablación existe poca información acerca de la superioridad de una técnica sobre la otra. Objetivo: Comparar los resultados agudos y a largo plazo de las técnicas de ablación de la fibrilación auricular paroxística por catéter irrigado y mediante crioablación con balón de segunda generación. Material y métodos: Estudio retrospectivo, observacional, unicéntrico, en el que se evaluaron 159 pacientes consecutivos con fibrilación auricular paroxística, a los cuales se les realizó aislamiento de venas pulmonares mediante radiofrecuencia o crioablación. Se examinaron las características de los pacientes y del procedimiento, así como el éxito inmediato y en el seguimiento a 12 meses. Resultados: Sobre un total de 159 pacientes, 89 procedimientos se realizaron con crioablación y 70 mediante radiofrecuencia. El seguimiento promedio fue de 12 meses. No se encontraron diferencias significativas en las características de la población. La tasa de éxito inmediato fue del 97,8% con crioablación versus 97,1% con radiofrecuencia (p = 0,8). La tasa libre de fibrilación auricular a los 12 meses luego de un único procedimiento fue del 77,5% mediante crioablación versus 71,4% con radiofrecuencia (p = 0,33). La crioablación con balón se asoció con menor duración del procedimiento respecto de la radiofrecuencia (60,19 ± 15 minutos frente a 75,8 ± 31 minutos, respectivamente; p < 0,00001), con menor tiempo en la aurícula izquierda (45 ± 14 minutos frente a 58 ± 26 minutos; p < 0,00001). Los tiempos de fluoroscopia fueron significativamente mayores para el grupo crioablación (18 ± 3,76 minutos vs. 13 ± 2,23 minutos para radiofrecuencia; p < 0,0001). La tasa de complicaciones crioablación vs. radiofrecuencia fue similar (p = 0,76). Conclusión: La crioablación con balón, en comparación con radiofrecuencia mediante catéter irrigado, se asoció con menor tiempo del procedimiento, similar tasa de complicaciones y tasa libre de fibrilación auricular a los 12 meses luego de un único procedimiento.

High-sensitivity troponin and right ventricular function in acute pulmonary embolism.

INTRODUCTION: Right ventricular (RV) dysfunction has proved to be an important predictor of morbidity and mortality in patients with pulmonary embolism (PE). Tricuspid annular plane systolic excursion (TAPSE) is one of the parameters that have been validated as predictor of outcomes. The aim of our study was to evaluate the performance (sensitivity and specificity) of high-sensitivity cardiac troponin T (hs-cTnT) to predict RV dysfunction defined as TAPSE <16 mm. METHODS: We conducted a single-center retrospective analysis of 40 patients prospectively included. Median age was 66 years (59-76) and PESI score was 81 (67-100). RESULTS: Right ventricular dysfunction was present in 30% of the patients and was associated with higher median troponin values (33.5 ng/L vs 16 ng/L; P= .03). A logarithmic relation was observed between hs-cTnT and lower TAPSE values (r(2)= 0.36; P< .0001). The area under the ROC curve of hs-cTnT to predict RV dysfunction was 0.77 (0.63-0.92). CONCLUSION: hs-cTnT is a biomarker with good performance to identify RV dysfunction in PE.

Infrared and Raman spectroscopic studies of tris-[3-(trimethoxysilyl)propyl] isocyanurate, its sol-gel process, and coating on aluminum and copper.

Tris-[3-(trimethoxysilyl)propyl] isocyanurate (TTPI) has been used as a precursor to prepare a sol using ethanol as the solvent under acidic conditions. The sol-gel was applied for the surface treatment of aluminum and copper. Infrared and Raman spectra have been recorded for pure TTPI and the TTPI sol, xerogel and TTPI sol-gel coated metals. From the vibrational spectra, TTPI is likely to have the C1 point group. Vibrational assignments are suggested based on group frequencies, the expected reactions in the sol-gel process and the vibrational studies of some related molecules. From the experimental infrared spectra of xerogels annealed at different temperatures and from the thermal-gravimetric analysis, it is found that the TTPI xerogel decomposes at around 450°C with silica being the major decomposition product. A cyclic voltammetric study of the metal electrodes coated with different concentrations of TTPI ranging from 5% to 42% (v/v) has shown that the films with high concentrations of sol would provide better corrosion protection for aluminum and copper.

Infrared and Raman spectra of (3,3,3-trifluoropropyl)trimethoxysilane, its sol and xerogel.

Organic modified silica sol was prepared by using (3,3,3-trifluoropropyl)trimethoxysilane (TFPTMS) as a precursor in ethanol solution under acidic condition. Infrared and Raman spectra were recorded for the silane coupling agent (SCA), TFPTMS sol and xerogel. Vibrational assignments have been suggested based on the spectral relative intensity, results from the vibrational study of trimethoxypropylsilane (TMPS), similar trifluorocompounds and group frequencies. Low temperature IR spectra revealed the presence of two conformers in TFPTMS. Only one conformer could be identified in the TFPTMS sol and xerogel. Thermal investigation of TFPTMS xerogel with infrared spectroscopic method indicated that the organic part remained essentially unchanged at or below 350 °C but decomposed at or around 450 °C, in agreement with the result from thermal gravimetric analysis (TGA). After the decomposition of the organic branch, the remaining part of the xerogel was composed of silica.

Vibrational spectra of metals treated with allyltrimethoxysilane sol-gel and self-assembled monolayer of allytrichlorosilane.

A sol-gel has been prepared by using allyltrimethoxysilane (ATMS) as precursor, ethanol as homogenizer as well as solvent, and hydrochloric acid as catalyst. The sol-gel was employed for the coating treatment of aluminum. Self-assembled monolayer (SAM) with allyltrichlorosilane (ATCS) is another method used for the metal surface treatment in the present work. The treated metal surfaces were characterized with reflection adsorption infrared spectra (RAIR). Detailed interpretation and vibrational assignment have been given to the collected IR spectra of the sol-gel, xerogel and surface films of ATMS and the SAM of ATCS on aluminum as well as pure silanes. A series of investigation of the UV exposure and temperature effects has been carried out. Results from the investigation indicate that the UV radiation exposure or the high temperature thermal treatment will induce a chemical process on the organosilica coated surfaces.

Spectroscopic studies of trimetoxypropylsilane and bis(trimethoxysilyl)ethane sol-gel coatings on aluminum and copper.

Trimethoxypropylsilane (TMPS) and bis(trimethoxysilyl)ethane (BTMSE) were used as surface modifiers of metal vie the sol-gel process and dip coating. In addition to the single coating of Al, Cu and Sn, double treatments of Al were also conducted by combining coatings with these sol-gels in different sequences. Reflection and absorption infrared spectroscopy (RAIR) was employed to characterize and to trace the proceeding of the sol-gel process of the films. It was found that the silanol condensation occurs in the coating films on Al and the covalent linkage exists between the TMPS film and copper surface. From the assigned vibration modes, two conformers were identified in pure TMPS, TMPS sol-gel and coated film. A series of dip coating experiments with different concentrations of TMPS sol-gel was conducted, and the results from the collected RAIR spectra of the coated samples suggested that the coated Cu consistently has a better RAIR spectrum than that of the coated Al. The TMPS sol-gel appeared to have a better affinity to Cu than to Al. The temperature effect and the aging effect in the coating films were studied. X-ray photoelectronic spectroscopy (XPS) was employed to characterize the coated film, and the XPS data confirm the formation of the siloxane film from the silane coupling agents (SCA). Electrochemical impedance spectra (EIS) have been collected for bare Al and Cu, BTMSE sol-gel coated Al, and TMPS sol-gel coated Cu in 0.15M NaCl solution. The corresponding electronic circuit parameters have been determined to match the experimental EIS data.