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2.
J Am Coll Cardiol ; 74(13): 1682-1692, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31558252

RESUMO

BACKGROUND: Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function. OBJECTIVES: The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. METHODS: In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion. RESULTS: A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. SECONDARY OUTCOMES: Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives. CONCLUSIONS: The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).

4.
Am J Med ; 132(5): 622-630, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30639554

RESUMO

BACKGROUND: Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression. METHODS: STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression. RESULTS: Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001). CONCLUSIONS: STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.


Assuntos
Angiografia Coronária , Doença das Coronárias , Oclusão Coronária , Eletrocardiografia , Revascularização Miocárdica , Infarto do Miocárdio com Supradesnível do Segmento ST , Idoso , Arizona/epidemiologia , Angiografia Coronária/métodos , Angiografia Coronária/estatística & dados numéricos , Doença das Coronárias/complicações , Doença das Coronárias/diagnóstico , Doença das Coronárias/epidemiologia , Doença das Coronárias/terapia , Oclusão Coronária/diagnóstico , Oclusão Coronária/epidemiologia , Oclusão Coronária/etiologia , Oclusão Coronária/terapia , Vasos Coronários/diagnóstico por imagem , Eletrocardiografia/métodos , Eletrocardiografia/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/métodos , Revascularização Miocárdica/estatística & dados numéricos , Seleção de Pacientes , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Índice de Gravidade de Doença
5.
Heart Rhythm ; 16(6): 873-878, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30590192

RESUMO

BACKGROUND: The presence of inferior vena cava filters (IVCFs) has been considered a relative contraindication to electrophysiology (EP) procedures that require transfemoral venous placement of multiple catheters and/or long sheaths. There are inadequate data related to complex EP procedures in this population. OBJECTIVE: The purpose of this study was to describe the experience of a single high-volume center with respect to complex EP procedures in patients with IVCFs. METHODS: Patients with IVCFs undergoing complex EP procedures between 2004 and 2018 were identified. Clinical characteristics, IVCF type, procedural findings, and complications were analyzed. RESULTS: Fifty complex ablation procedures were performed in 40 patients (mean age 63.8 ± 10.9 years; 68% men). The mean IVCF dwell time was 69.1 ± 19.1 months, and 48 patients (96%) were on chronic oral anticoagulation. Procedures included ablation of atrial fibrillation (n = 21), ventricular tachycardia (n = 20), supraventricular tachycardia (n = 3), cavotricuspid isthmus flutter (n = 3), supraventricular tachycardia and cavotricuspid isthmus flutter (n = 1), and transvenous lead extraction (n = 3). Twenty procedures included quadripolar catheters (mean 1.4 ± 0.75), and 33 procedures involved deflectable decapolar catheters (mean 1.7 ± 0.47). Long sheaths were used in 35 cases (mean 1.63 ± 0.49) and intracardiac echocardiography in 38. In 4 cases (involving 3 patients), the IVCF was occluded and could not be crossed. There were no procedural complications related to the IVCF. CONCLUSION: The substantial majority of IVCFs in patients presenting for complex EP procedures were patent and easily crossed under fluoroscopic guidance. The presence of an IVCF should not discourage operators from performing procedures that require transfemoral deployment of multiple catheters and/or sheaths.

6.
JACC Clin Electrophysiol ; 4(9): 1155-1162, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30236388

RESUMO

OBJECTIVES: This study sought to characterize septal substrate in patients with nonischemic left ventricular cardiomyopathy (NILVCM) undergoing ventricular tachycardia (VT) ablation. BACKGROUND: The interventricular septum is an important site of VT substrate in NILVCM. METHODS: The authors studied 95 patients with NILVCM and VT. Electroanatomic mapping using standard bipolar (<1.5 mV) and unipolar (<8.3 mV) low-voltage criteria identified septal scar location and size. Analysis of unipolar voltage was performed and scars quantified using graded unipolar cutoffs from 4 to 8.3 mV were correlated with delayed gadolinium-enhanced cardiac magnetic resonance (DE-CMR), performed in 57 patients. RESULTS: Detailed LV endocardial mapping (mean 262 ± 138 points) showed septal bipolar and unipolar voltage abnormalities (VAs) in 44 (46%) and 79 (83%) patients, most commonly with basal anteroseptal involvement. Of the 59 patients in whom the septum was targeted, bipolar and unipolar septal VAs were seen in 36 (61%) and 54 (92%). Of the 35 with CMR-defined septal scar, bipolar and unipolar septal VAs were seen in 18 (51%) and 31 (89%). In 12 patients without CMR septal scar, 6 (50%) had isolated unipolar septal VAs on electroanatomic mapping, a subset of whom the septum was targeted for ablation (44%). In the graded unipolar analysis, the optimal cutoff associated with magnetic resonance imaging septal scar was 4.8 mV (sensitivity 75%, specificity 70%; area under the curve: 0.75; 95% confidence interval: 0.60 to 0.90). CONCLUSIONS: Septal substrate by unipolar or bipolar voltage mapping in patients with NILVCM and VT is common. A unipolar voltage cutoff of 4.8 mV provides the best correlation with DE-CMR. A subset of patients with septal VT had normal DE-CMR or endocardial bipolar voltage with abnormal unipolar voltage.


Assuntos
Cardiomiopatias/fisiopatologia , Taquicardia Ventricular/fisiopatologia , Septo Interventricular/fisiopatologia , Idoso , Cardiomiopatias/diagnóstico por imagem , Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/cirurgia , Septo Interventricular/diagnóstico por imagem
7.
J Cardiovasc Electrophysiol ; 29(12): 1654-1663, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30106213

RESUMO

BACKGROUND: Catheter ablation of ventricular arrhythmias (VA) from the papillary muscles (PM) is challenging due to limited catheter stability and contact on the PMs with their anatomic complexity and mobility. OBJECTIVE: This study aimed to evaluate the effectiveness of cryoablation as an adjunctive therapy for PM VAs when radiofrequency (RF) ablation has failed. METHODS: We evaluated a retrospective series of patients who underwent cryoablation for PM VAs when RF ablation had failed. The decision to switch to cryoablation was at the operator's discretion when intracardiac echocardiography (ICE) suggested that cryoablation might be more effective in achieving catheter stability and energy delivery. RESULTS: Sixteen patients underwent cryoablation of PM VAs between 2014 and 2016 after RF ablation was unsuccessful. VAs originated from the anterolateral left ventricle (LV) PM (six patients), posterolateral LV PM (six patients), and right ventricle PM (four patients). VAs were predominantly frequent premature ventricular complexes (PVCs); however, patients with sustained ventricular tachycardia and PVC-triggered VF were also represented. Fifteen of the 16 patients were treated with cryoablation; in one patient, a procedural complication with retrograde aortic access precluded treatment. In all patients treated with cryoablation, contact and stability was confirmed with ICE to be superior to the RF catheter, and there was acute and long-term elimination of VAs. CONCLUSION: Cryoablation is a useful adjunctive therapy in ablation of PM VAs, providing excellent procedural outcomes even when RF ablation has failed. Cryoablation catheters are less maneuverable than RF ablation catheters and care is required to avoid complications.


Assuntos
Ablação por Cateter/métodos , Criocirurgia/métodos , Músculos Papilares/diagnóstico por imagem , Músculos Papilares/cirurgia , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Estudos Retrospectivos , Taquicardia Ventricular/fisiopatologia , Falha de Tratamento , Adulto Jovem
8.
Curr Cardiol Rev ; 14(2): 102-108, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29737257

RESUMO

BACKGROUND: Sudden Cardiac Death (SCD) remains a major public health concern, accounting for more than 50% of cardiac deaths. The majority of these deaths are related to ischemic heart disease, however increasingly recognized are non-ischemic causes such as cardiac channelopathies. Bradyarrhythmias and pulseless electrical activity comprise a larger proportion of out-ofhospital arrests than previously realized, particularly in patients with more advanced heart failure or noncardiac triggers such as pulmonary embolism. Patients surviving Sudden Cardiac Arrest (SCA) have a substantial risk of recurrence, particularly within 18 months post event. The timing of tachyarrhythmias complicating acute infarction has important implications regarding the likelihood of recurrence, with those occurring within 48 hours having a more favorable long-term outcome. In the absence of a clear reversible cause, implantable cardioverter defibrillators remain the mainstay in the secondary prevention of SCD. Post defibrillation electromechanical dissociation is common in patients with cardiomyopathy and can lead to SCD despite successful defibrillation of the primary tachyarrhythmia. Antiarrhythmic agents are highly effective in preventing recurrent arrhythmias in specific diseases such as the congenital long QT syndrome. CONCLUSION: Catheter ablation is used most commonly to prevent recurrent ICD therapies in patients with structural heart disease-related ventricular arrhythmias, however recent publications have shown substantial benefit in other entities such as idiopathic ventricular fibrillation.


Assuntos
Eletrofisiologia Cardíaca/métodos , Morte Súbita Cardíaca/patologia , Humanos
9.
Curr Treat Options Cardiovasc Med ; 20(2): 16, 2018 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-29478118

RESUMO

As we have witnessed in other arenas of catheter-based therapeutics, ventricular tachycardia (VT) ablation has become increasingly anatomical in its execution. Multi-modality imaging provides anatomical detail in substrate characterization, which is often complex in nonischemic cardiomyopathy patients. Patients with intramural, intraseptal, and epicardial substrates provide challenges in delivering effective ablation to the critical arrhythmia substrate due to the depth of origin or the presence of adjacent critical structures. Novel ablation techniques such as simultaneous unipolar or bipolar ablation can be useful to achieve greater lesion depth, though at the expense of increasing collateral damage. Disruptive technologies like stereotactic radioablation may provide a tailored approach to these complex patients while minimizing procedural risk. Substrate ablation is a cornerstone of the contemporary VT ablation procedure, and recent data suggest that it is as effective and more efficient that conventional activation guided ablation. A number of specific targets and techniques for substrate ablation have been described, and all have shown a fairly high success in achieving their acute procedural endpoint. Substrate ablation also provides a novel and reproducible procedural endpoint, which may add predictive value for VT recurrence beyond conventional programmed stimulation. Extrapolation of outcome data to nonischemic phenotypes requires caution given both the variability in substrate nonischemic distribution and the underrepresentation of these patients in previous trials.

10.
Europace ; 20(3): e30-e41, 2018 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-28402404

RESUMO

Aims: Limited data exist on the long-term outcome of patients (pts) with non-ischemic cardiomyopathy (NICM) and ventricular tachycardia (VT) refractory to conventional therapies undergoing surgical ablation (SA). We aimed to investigate the long-term survival and VT recurrence in NICM pts with VT refractory to radiofrequency catheter ablation (RFCA) who underwent SA. Methods and results: Consecutive pts with NICM and VT refractory to RFCA who underwent SA were included. VT substrate was characterized in the electrophysiology lab and targeted by RFCA. During SA, previous RFCA lesions/scars were identified and targeted with cryoablation (CA; 3 min/lesion; target -150 °C). Follow-up comprised office visits, ICD interrogations and the social security death index. Twenty consecutive patients with NICM who underwent SA (age 53 ± 16 years, 18 males, LVEF 41 ± 20%; dilated CM = 9, arrhythmogenic right ventricular CM = 3, hypertrophic CM = 2, valvular CM = 4, and mixed CM = 2) were studied. Percutaneous mapping/ablation in the electrophysiology lab was performed in 18 and 2 pts had primary SA. During surgery, 4.9 ± 4.0 CA lesions/pt were delivered to the endocardium (2) and epicardium (11) or both (7). VT-free survival was 72.5% at 1 year and over 43 ± 31 months (mos) (range 1-83mos), there was only one arrhythmia-related death. There was a significant reduction in ICD shocks in the 3-mos preceding SA vs. the entire follow-up period (6.6 ± 4.9 vs. 2.3 ± 4.3 shocks/pt, P = 0.001). Conclusion: In select pts with NICM and VT refractory to RFCA, SA guided by pre-operative electrophysiological mapping and ablation may be a therapeutic option.


Assuntos
Cardiomiopatias/complicações , Criocirurgia , Taquicardia Ventricular/cirurgia , Potenciais de Ação , Adulto , Idoso , Cardiomiopatias/mortalidade , Cardiomiopatias/fisiopatologia , Angiografia Coronária , Criocirurgia/efeitos adversos , Criocirurgia/mortalidade , Técnicas Eletrofisiológicas Cardíacas , Estudos de Viabilidade , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
11.
J Cardiovasc Electrophysiol ; 28(12): 1475-1478, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28940881

RESUMO

INTRODUCTION: Asymptomatic arrhythmias can have important therapeutic implications in certain patient populations, for example, atrial fibrillation in patients with prior ischemic stroke. We sought to compare the diagnostic yield of two commercially available monitoring systems with automated arrhythmia detection algorithms. METHODS: We queried a large, proprietary database containing rhythm data for patients receiving ambulatory EKG monitoring (BioTelemetry, Malvern, PA, USA). We compared all patients prescribed mobile cardiac outpatient telemetry (MCOT™, Braemar Manufacturing, LLC, Eagan, MN, USA) versus autotrigger looping event recorder (AT-LER) devices over a consecutive 8-month period. Data from both device types were analyzed for diagnostic yields in detecting asymptomatic (device-triggered) arrhythmias consisting of atrial fibrillation (of any detected duration), bradycardia (ventricular rate ≤ 40 bpm), ventricular pause (≥ 3 seconds), supraventricular tachycardia (≥ 6 consecutive supraventricular beats), and ventricular tachycardia (≥ 4 consecutive premature ventricular contractions). The mean time to first diagnosis of each arrhythmia for each device was determined. Physician-designated diagnostic codes for patients prescribed each device were also determined from the database. RESULTS: The MCOT™ device had significantly higher diagnostic yields of all evaluated asymptomatic arrhythmias than the AT-LER. The MCOT™ device also produced an earlier mean time to diagnosis for all evaluated asymptomatic arrhythmias. These findings were noted despite a shorter average prescription length for MCOT™ monitored patients. CONCLUSIONS: In patients with conventional diagnostic monitoring indications, MCOT™ had significantly higher diagnostic yields for five asymptomatic arrhythmias compared to the AT-LER.


Assuntos
Assistência Ambulatorial/métodos , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Doenças Assintomáticas , Eletrocardiografia Ambulatorial/métodos , Telemetria/métodos , Assistência Ambulatorial/tendências , Bases de Dados Factuais/tendências , Eletrocardiografia Ambulatorial/tendências , Feminino , Humanos , Masculino , Monitorização Ambulatorial/métodos , Monitorização Ambulatorial/tendências , Pacientes Ambulatoriais , Estudos Retrospectivos , Telemetria/tendências
12.
J Cardiovasc Electrophysiol ; 28(5): 504-514, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28233951

RESUMO

INTRODUCTION: In outflow tract ventricular arrhythmias (OT-VAs), an abrupt loss of the R wave in lead V2 compared to V1 and V3 (pattern break in V2-PBV2) suggests an origin close to the anterior interventricular sulcus (anatomically opposite to lead V2) and adjacent to proximal coronaries. We studied the outcome of catheter ablation of OT-VAs with a PBV2. METHODS AND RESULTS: Of 130 consecutive patients with idiopathic left bundle block morphology OT-VAs and transition ≤V4, 12 (9%) had PBV2. Outcomes in this group were compared to the remaining 118 patients. Patients with PBV2 were more likely to be younger (41 ± 18 vs. 50 ± 14 years, P = 0.0384) and women (11 [92%] vs. 70 [59%], P = 0.0302). The earliest activation was at the RVOT in seven, left coronary cusp (LCC) in one, anterior interventricular vein (AIV) in two and the epicardium in two. In five (42%) cases (earliest activation in the AIV in two, epicardium in two, and RVOT below the valve level in one), ablation was aborted due to proximity to the left anterior descending (LAD) coronary artery. After 36 ± 17 months and 1.3 ± 0.5 procedures, VAs elimination was achieved in 58% of patients with PBV2 compared to 89% of the reference population (P = 0.0125) with effective site in five of seven at the most anterior and leftward RVOT adjacent to the pulmonic valve (PV). CONCLUSIONS: OT-VAs with PBV2 demonstrate a unique ECG pattern and challenging catheter ablation. Proximity to LAD precludes ablation in about half. Long-term VA suppression could be achieved in only 58% of cases most commonly when the earliest site is at the anterior and leftward RVOT just under the PV.


Assuntos
Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/cirurgia , Ablação por Cateter , Eletrocardiografia , Ventrículos do Coração/cirurgia , Potenciais de Ação , Adulto , Bloqueio de Ramo/fisiopatologia , Ablação por Cateter/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas , Feminino , Frequência Cardíaca , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
14.
JACC Clin Electrophysiol ; 3(5): 503-511, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-29759607

RESUMO

OBJECTIVES: This study sought to examine long-term outcomes in patients with structural heart disease in whom amiodarone was reduced/discontinued after ventricular tachycardia (VT) ablation. BACKGROUND: VT in patients with structural heart disease increases morbidity and mortality. Amiodarone can decrease VT burden, but long-term use may result in organ toxicities and possibly increased mortality. Catheter ablation can also decrease VT burden. Whether amiodarone can be safely reduced/discontinued following ablation remains unknown. METHODS: We studied consecutive patients undergoing VT ablation from 2008 to 2011, typically followed by noninvasive programmed stimulation several days later. Patients were divided into 3 groups by amiodarone use: group A-amiodarone reduced/discontinued following ablation; group B-amiodarone not reduced; group C-not on amiodarone at time of ablation. Baseline characteristics and outcomes were compared between groups. RESULTS: Overall, 231 patients (90% male; mean age: 63.4 ± 12.9 years; 53.7% ischemic cardiomyopathy) were included (group A: 99 patients; group B: 29 patients; group C: 103 patients). Group B patients were older with more advanced heart failure. Group A patients less frequently had inducible VT at the end of ablation or noninvasive programmed stimulation. In follow-up, 1-year VT-free survival was similar between groups (p = 0.10). Mortality was highest in group B (p < 0.001). Higher amiodarone dose after ablation (hazard ratio: 1.23; 95% confidence interval: 1.03 to 1.47; p = 0.02) was independently associated with shorter time to death. CONCLUSIONS: After successful VT ablation, as confirmed by noninducibility at the end of ablation and noninvasive programmed stimulation, amiodarone may be safely reduced/discontinued without an unacceptable increase in VT recurrence. Reduction/discontinuation of amiodarone should be considered an important goal of VT ablation.


Assuntos
Amiodarona/administração & dosagem , Antiarrítmicos/administração & dosagem , Cardiomiopatias/complicações , Ablação por Cateter , Taquicardia Ventricular/cirurgia , Estudos de Casos e Controles , Substituição de Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taquicardia Ventricular/complicações , Taquicardia Ventricular/tratamento farmacológico
15.
Artigo em Inglês | MEDLINE | ID: mdl-27733494

RESUMO

BACKGROUND: Catheter ablation (CA) of ventricular tachycardia (VT) in patients with nonischemic dilated cardiomyopathy can be challenging because of the complexity of underlying substrates. We sought to determine the long-term outcomes of endocardial and adjuvant epicardial CA in nonischemic dilated cardiomyopathy. METHODS AND RESULTS: We examined 282 consecutive patients (aged 59±15 years, 80% males) with nonischemic dilated cardiomyopathy who underwent CA. Ablation was guided by activation/entrainment mapping for tolerated VT and pacemapping/targeting of abnormal electrograms for unmappable VT. Adjuvant epicardial ablation was performed for recurrent VT or persistent inducibility after endocardial-only ablation. Epicardial ablation was performed in 90 (32%) patients. Before ablation, patients failed a median of 2 antiarrhythmic drugs), including amiodarone, in 166 (59%) patients. The median follow-up after the last procedure was 48 (19-67) months. Overall, VT-free survival was 69% at 60-month follow-up. Transplant-free survival was 76% and 68% at 60- and 120-month follow-up, respectively. Among the 58 (21%) patients with VT recurrence, CA still resulted in a significant reduction of VT burden, with 31 (53%) patients having only isolated (1-3) VT episodes in 12 (4-35) months after the procedure. At the last follow-up, 128 (45%) patients were only on ß-blockers or no treatment, 41 (15%) were on sotalol or class I antiarrhythmic drugs, and 62 (22%) were on amiodarone. CONCLUSIONS: In patients with nonischemic dilated cardiomyopathy and VT, endocardial and adjuvant epicardial CA is effective in achieving long-term VT freedom in 69% of cases, with a substantial improvement in VT burden in many of the remaining patients.


Assuntos
Cardiomiopatia Dilatada/cirurgia , Ablação por Cateter/métodos , Taquicardia Ventricular/cirurgia , Antiarrítmicos/uso terapêutico , Cardiomiopatia Dilatada/fisiopatologia , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Taxa de Sobrevida , Taquicardia Ventricular/fisiopatologia , Resultado do Tratamento
16.
Artigo em Inglês | MEDLINE | ID: mdl-27784738

RESUMO

BACKGROUND: Transformation from persistent to paroxysmal atrial fibrillation (AF) after ablation suggests modification of the underlying substrate. We examined the nature of initial arrhythmia recurrence in patients with nonparoxysmal AF undergoing antral pulmonary vein isolation and nonpulmonary vein trigger ablation and correlated recurrence type with long-term ablation efficacy after the last procedure. METHODS AND RESULTS: Three hundred and seventeen consecutive patients with persistent (n=200) and long-standing persistent (n=117) AF undergoing first ablation were included. AF recurrence was defined as early (≤6 weeks) or late (>6 weeks after ablation) and paroxysmal (either spontaneous conversion or treated with cardioversion ≤7 days) or persistent (lasting >7 days). During median follow-up of 29.8 (interquartile range: 14.8-49.9) months, 221 patients had ≥1 recurrence. Initial recurrence was paroxysmal in 169 patients (76%) and persistent in 52 patients (24%). Patients experiencing paroxysmal (versus persistent) initial recurrence were more likely to achieve long-term freedom off antiarrhythmic drugs (hazard ratio, 2.2; 95% confidence interval, 1.5-3.2; P<0.0001), freedom on/off antiarrhythmic drugs (hazard ratio, 2.5; 95% confidence interval, 1.6-3.8; P<0.0001), and arrhythmia control (hazard ratio, 5.2; 95% confidence interval, 2.9-9.2; P<0.0001) after last ablation. CONCLUSIONS: In patients with persistent and long-standing persistent AF, limited ablation targeting pulmonary veins and documented nonpulmonary vein triggers improves the maintenance of sinus rhythm and reverses disease progression. Transformation to paroxysmal AF after initial ablation may be a step toward long-term freedom from recurrent arrhythmia.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Veias Pulmonares/cirurgia , Antiarrítmicos/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Terapia Combinada , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
17.
Artigo em Inglês | MEDLINE | ID: mdl-27516457

RESUMO

BACKGROUND: Catheter ablation (CA) of ventricular tachycardia (VT) in patients with cardiac sarcoidosis can be challenging because of the complex underlying substrate. We sought to determine the long-term outcome of CA of VT in patients with cardiac sarcoidosis. METHODS AND RESULTS: We enrolled 31 patients (age, 55±10 years) with diagnosis of cardiac sarcoidosis based on Heart Rhythm Society criteria and VT who underwent CA. In 23 (74%) patients, preprocedure cardiac magnetic resonance imaging and positron emission tomographic (PET) evaluation were performed. Preprocedure magnetic resonance imaging was positive for late gadolinium enhancement in 21 of 23 (91%) patients, whereas abnormal 18-fluorodeoxyglucose uptake was found in 15 of 23 (65%) cases. In 14 of 15 patients with positive PET at baseline, PET was repeated after 6.1±3.7-month follow-up. After a median follow-up of 2.5 (range, 0-10.5) years, 1 (3%) patient died and 4 (13%) underwent heart transplant. Overall VT-free survival was 55% at 2-year follow-up. Among the 16 (52%) patients with VT recurrences, CA resulted in a significant reduction of VT burden, with 8 (50%) having only isolated (1-3) VT episodes and only 1 patient with recurrent VT storm. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET at baseline, and lack of PET improvement over follow-up were associated with increased risk of recurrent VT. CONCLUSIONS: In patients with cardiac sarcoidosis and VT, CA is effective in achieving long-term freedom from VT or improvement in VT burden in the majority of patients. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET scan at baseline, or lack of improvement at repeat PET over follow-up predict worse arrhythmia-free survival.


Assuntos
Cardiomiopatias/etiologia , Cardiomiopatias/cirurgia , Ablação por Cateter/métodos , Sarcoidose/complicações , Sarcoidose/cirurgia , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/cirurgia , Cardiomiopatias/diagnóstico por imagem , Meios de Contraste , Diagnóstico por Imagem , Mapeamento Epicárdico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sarcoidose/diagnóstico por imagem , Taxa de Sobrevida , Resultado do Tratamento
18.
Heart Rhythm ; 13(11): 2174-2180, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27544746

RESUMO

BACKGROUND: Atrial arrhythmias may still occur in patients after durable pulmonary vein isolation (PVI). OBJECTIVE: The purpose of this study was to examine the incidence of patients undergoing ablation for recurrent arrhythmia despite chronic PVI and their clinical outcomes. METHODS: Patients undergoing repeat left atrial ablation procedures were selected from a prospective registry. From this population, we identified patients with chronic PVI. Clinical characteristics, ablation strategies, and outcomes were analyzed. RESULTS: Between January 2003 and December 2013, 1045 patients underwent 1298 repeat left atrial procedures. Of these, 900 patients had atrial fibrillation (AF) and 145 had atrial flutter (AFL)/atrial tachycardia (AT). Fifty-two patients (5.0%; 27 with AF and 25 with AFL/AT) had chronic PVI and were included in the study. Patients were followed for 19.7 ± 5.6 months. In patients with AF, 11 (41%) had a non-PV trigger identified. Ablation strategies included non-PV trigger ablation (n = 11), empiric trigger-site ablation (n = 3), provoked arrhythmia ablation (n = 9), complex fractionated atrial electrogram ablation (n = 2), and linear ablation (n = 2). During follow-up, 9 (33%) had no recurrence, 7 (26%) had rare AF (≤2 episodes during follow-up ≥1 year), and 11 (41%) had AF recurrence. In patients with AFL/AT, 12 (48%) had no recurrence, 4 (16%) had rare recurrence (≤2 episodes during follow-up ≥1 year), and 9 (36%) had recurrence. CONCLUSION: In patients with PVI undergoing a repeat procedure during the time period studied, only a small portion had chronic PVI. A strategy of targeting non-PV triggers for AF and linear/focal ablation for AFL/AT may achieve long-term arrhythmia control in the majority of patients.


Assuntos
Fibrilação Atrial , Flutter Atrial , Ablação por Cateter , Efeitos Adversos de Longa Duração , Veias Pulmonares/cirurgia , Reoperação , Idoso , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Flutter Atrial/diagnóstico , Flutter Atrial/epidemiologia , Flutter Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Técnicas Eletrofisiológicas Cardíacas/métodos , Feminino , Sistema de Condução Cardíaco/fisiopatologia , Humanos , Incidência , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/epidemiologia , Efeitos Adversos de Longa Duração/fisiopatologia , Efeitos Adversos de Longa Duração/cirurgia , Masculino , Pessoa de Meia-Idade , Pennsylvania , Recidiva , Reoperação/métodos , Reoperação/estatística & dados numéricos
19.
Artigo em Inglês | MEDLINE | ID: mdl-27412430

RESUMO

BACKGROUND: The posterior-superior process of the left ventricle (PSP-LV) is the most inferior and posterior aspect of the basal LV that extends posteriorly to the plane of the tricuspid valve. The PSP-LV is anatomically adjacent to the inferior and medial aspect of the right atrium (RA). We report a series of patients with ventricular arrhythmias (VAs) arising from the PSP-LV and describe a mapping and ablation approach from the RA guided by intracardiac echocardiography. METHODS AND RESULTS: Mapping and ablation of the PSP-LV with an RA approach under intracardiac echocardiography guidance were performed in 5 patients with VAs (aged 44±14 years, 2 males) who had failed ablation attempts from multiple endocardial and epicardial (1 patient) sites. Mapping of the PSP-LV from the adjacent inferomedial RA was performed at sites anatomically opposite to the earliest endocardial site of activation under direct intracardiac echocardiography visualization. From the RA side of the PSP-LV, a small atrial signal and a larger ventricular signal were recorded in each case, with an activation time of 32±7 ms pre-QRS (versus 16±5 ms pre-QRS in the LV endocardium; P=0.068). We were able to capture the LV from these sites. Cryoablation was performed in 2 patients, and radiofrequency was used in the remaining 3 cases. In all patients, ablation from the RA eliminated the arrhythmia. All patients remained free of recurrent VAs after a mean follow-up of 12 (7-16) months. There were no immediate or long-term complications. CONCLUSIONS: The PSP-LV can be a site of origin of VAs, which can be successfully eliminated from the adjacent RA under direct intracardiac echocardiographic visualization.


Assuntos
Ablação por Cateter/métodos , Átrios do Coração/cirurgia , Ventrículos do Coração/cirurgia , Taquicardia Ventricular/cirurgia , Adulto , Ecocardiografia , Eletrocardiografia , Mapeamento Epicárdico , Feminino , Átrios do Coração/fisiopatologia , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Taquicardia Ventricular/fisiopatologia , Resultado do Tratamento
20.
Heart Rhythm ; 13(2): 374-82, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26477712

RESUMO

BACKGROUND: The relevance of focal triggers in persistent atrial fibrillation (PerAF) and long-standing persistent atrial fibrillation (LSPAF) has not been previously investigated. OBJECTIVE: We prospectively evaluated the prevalence and distribution of AF triggers in patients referred for catheter ablation of PerAF and LSPAF. METHODS: We analyzed consecutive patients undergoing first time AF ablation who underwent a standardized trigger protocol including cardioversion of induced or spontaneous AF and infusion of up to 20 µg of isoproterenol for 15-20 minutes either before or after pulmonary vein (PV) isolation accomplished. Triggers were defined as AF/sustained atrial tachyarrhythmia or repetitive atrial premature depolarizations. RESULTS: A total of 2168 patients were included (mean age 57 ± 11 years; 1636 [75%] men), with 1531 patients having paroxysmal AF (PAF) (71%), 496 having PerAF (23%), and 141 having LSPAF (7%). PV triggers were found in 1398 patients with PAF (91%), 449 patients with PerAF (91%), and 129 patients with LSPAF (91%) (P = .856 for comparison across groups). Non-PV triggers were elicited in a total of 234 patients (11%), and the prevalence was similar across the different types of AF (PAF, 165 [11%]; PerAF, 54 [11%]; LSPAF, 15 [11%]; P = .996 for comparison across groups). CONCLUSION: PVs are the main AF trigger site in patients with PerAF and LSPAF, with an overall prevalence similar to that found in patients with PAF. These results support the current recommendations for PV isolation as the cornerstone of catheter ablation to eliminate AF triggers in PerAF and LSPAF.


Assuntos
Fibrilação Atrial , Complexos Atriais Prematuros/fisiopatologia , Ablação por Cateter/métodos , Taquicardia Atrial Ectópica/fisiopatologia , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/etiologia , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Complexos Atriais Prematuros/complicações , Complexos Atriais Prematuros/diagnóstico , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Veias Pulmonares/cirurgia , Taquicardia Atrial Ectópica/complicações , Taquicardia Atrial Ectópica/diagnóstico
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