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2.
Circ Arrhythm Electrophysiol ; 13(1): e007611, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31922914

RESUMO

BACKGROUND: Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. METHODS: Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. RESULTS: Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20-76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93-847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9-162). No significant progression of voltage was observed (bipolar: 38 cm2 [interquartile range (IQR), 25-54] versus 53 cm2 [IQR, 25-65], P=0.09; unipolar: 116 cm2 [IQR, 61-209] versus 159 cm2 [IQR, 73-204], P=0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170-253] versus 263 mL [IQR, 204-294], P<0.001) for the entire study population. Larger scars at baseline but not changes over time were associated with a significant increase in RV volume (bipolar: Spearman ρ, 0.6965, P=0.006; unipolar: Spearman ρ, 0.5743, P=0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. CONCLUSIONS: In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.

3.
Heart Rhythm ; 16(9): 1421-1428, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31226487

RESUMO

BACKGROUND: The slow pathway region (SPR) is commonly targeted during ablation of atrioventricular nodal reentrant tachycardia. However, its role in idiopathic ventricular arrhythmias (IVAs) remains unknown. OBJECTIVE: The purpose of this study was to describe the electrocardiographic and electrophysiological characteristics of IVAs that were successfully ablated from the SPR. METHODS: Medical records of consecutive patients undergoing ablation of IVAs in the para-Hisian region between 2010 and 2018 were reviewed to identify subjects whose ventricular arrhythmias were targeted from the SPR. RESULTS: Among 63 patients with para-Hisian IVAs undergoing ablation, the SPR was targeted in 12 (20%; mean age 64 ± 7 years; 9 men). All patients presented with ventricular premature depolarizations manifesting left bundle branch block morphology with variable precordial transition (leads V2-V5) and a mean QRS duration of 131 ± 11 ms. In all cases, leads I and aVL had positive forces (R or Rs) and lead aVR had negative forces (QS or Qr). In the majority of cases, lead II had positive forces (R or Rs; n = 9 [75%]) and lead III had negative forces (rS or QS; n = 9 [75%]). Mean activation at the SPR was 31 ± 5 ms pre-QRS. All patients had initial ablation with radiofrequency, resulting in junctional rhythm in 9 (75%); 3 (25%) patients required additional cryoablation. Ablation was successful in 11 patients (92%). One patient required a permanent pacemaker for heart block but subsequently recovered intrinsic conduction. CONCLUSION: The SPR can be a source of IVAs, which can be safely and successfully ablated in most cases using radiofrequency energy. IVAs arising from this location manifest unique electrocardiographic features.

4.
J Electrocardiol ; 56: 29-33, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31247443

RESUMO

BACKGROUND: The mechanism of ST elevation on baseline electrocardiograms (ECG) unknown but it may be associated with abnormal myocardial substrate. This paper evaluates whether clinically unrecognized myocardial scar on cardiac magnetic resonance imaging (CMR) is associated with ST elevation at baseline. METHODS: The Multi-Ethnic Study of Atherosclerosis (MESA) study is a population-based cohort in the United States. Participants were aged 45 through 84 years and free of clinical cardiovascular disease at enrollment in 2000-2002. Our cohort included 1365 participants who underwent both ECG and contrast enhanced CMR in the 5th examination (2010-2012). Multivariable logistic regression examined the association of ST elevation and CMR defined regional myocardial scar after adjusting for cardiovascular risk factors. RESULTS: Of 1365 participants (58 ±9 years, 52% men), 105 (8%) had scar on CMR. Of these, the scar in 40 participants followed an ischemic pattern and in the other 65 participants followed a non-ischemic pattern. ST elevation at the 5th examination was present in 435 participants: 40 (0.9%) had ST elevations in inferior and 427 (98%) in lateral leads. 2/40 (5%) and 22/427 (5%) participants with inferior and lateral ST elevations, respectively, had evidence of scar. 15 (1.0%) had myocardial scar noted in the basal anterior region. In the fully adjusted models, ST elevation was associated with scar in basal anterior region (OR 18.2, p = 0.031). CONCLUSIONS: In a community population, ST elevation at baseline in the inferior or lateral leads was associated with myocardial scar in the basal inferior and anterior segments. The previously described association between ST elevation and increased mortality may be mediated by myocardial scar.

5.
F1000Res ; 82019.
Artigo em Inglês | MEDLINE | ID: mdl-30755794

RESUMO

Traditional chemotherapeutic agents and newer targeted therapies for cancer have the potential to cause cardiovascular toxicities. These toxicities can result in arrhythmias, heart failure, vascular toxicity, and even death. It is important for oncologists and cardiologists to understand the basic diagnostic and management strategies to employ when these toxicities occur. While anti-neoplastic therapy occasionally must be discontinued in this setting, it can often be maintained with caution and careful monitoring. In the second of this two-part review series, we focus on the management of cardiovascular toxicity from anthracyclines, HER2/ErbB2 inhibitors, immune checkpoint inhibitors, and vascular endothelial growth factor inhibitors.

6.
Trends Cardiovasc Med ; 29(5): 249-261, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30268648

RESUMO

Ventricular arrhythmias can present as asymptomatic premature ventricular complexes (PVCs) or non-sustained ventricular tachycardia (VT), symptomatic presentation of the former arrhythmias, or sustained VT with minimal symptoms to full hemodynamic collapse. The most important and feared consequence of VT is sudden cardiac death (SCD). Independent of SCD risk, frequent ventricular arrhythmias can cause substantial symptoms. Implantable cardioverter defibrillators (ICDs) are the foundation of managing patients at high risk for SCD due to their ability to automatically identify and defibrillate malignant ventricular arrhythmias. Unfortunately, defibrillation is associated with significant physical and emotional adverse effects. Other treatment options include antiarrhythmic drugs, which have substantial toxicities and limited efficacy, and catheter ablation. The techniques and strategies for VT ablation have advanced considerably in recent years leading to a rapid expansion of indications and use. In this review, we discuss current state of the art therapies for ventricular arrhythmias and highlight some of the most promising areas of ongoing development.


Assuntos
Antiarrítmicos/uso terapêutico , Ablação por Cateter , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Taquicardia Ventricular/terapia , Complexos Ventriculares Prematuros/terapia , Antiarrítmicos/efeitos adversos , Ablação por Cateter/efeitos adversos , Ablação por Cateter/mortalidade , Tomada de Decisão Clínica , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/mortalidade , Humanos , Seleção de Pacientes , Valor Preditivo dos Testes , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Resultado do Tratamento , Complexos Ventriculares Prematuros/diagnóstico , Complexos Ventriculares Prematuros/fisiopatologia
8.
J Interv Card Electrophysiol ; 53(1): 19-29, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30066291

RESUMO

PURPOSE: To evaluate whether catheter ablation is superior to conventional therapy for atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF). METHODS: Electronic databases were searched for randomized, controlled trials of AF ablation compared with conventional therapy in adults with AF and HFrEF. Odds ratio (OR), standard mean difference (SMD), and 95% confidence intervals (CIs) were measured using the Mantel-Haenszel method. RESULTS: There were seven trials including 856 patients (mean age 62 years, male 86%). All-cause mortality in patients who underwent ablation was 10% vs. 19% in those who received conventional treatment (four trials, 668 patients, 47% relative reduction, 9% absolute reduction; OR 0.46, 95% CI 0.29-0.72). Improvement in the left ventricular ejection fraction was significantly higher for patients undergoing ablation (+ 9 ± 10%) compared to conventional treatment (+ 2 ± 7%) (seven trials, 856 patients, SMD 0.68, 95% CI 0.28-1.08). Freedom from AF was higher in patients undergoing ablation (seven trials, 856 patients, 70% vs. 18%, respectively; 64% relative reduction, 52% absolute reduction; OR 0.03 95% CI 0.01-0.11). There was no significant difference in major complications between both strategies (OR 1.13, 95% CI 0.58-2.20). CONCLUSIONS: Catheter ablation for AF in patients with HFrEF decreases mortality and AF recurrence and improves left ventricular function, functional capacity, and quality of life, when compared to conventional management, without increasing complications.


Assuntos
Fibrilação Atrial/cirurgia , Baixo Débito Cardíaco/fisiopatologia , Ablação por Cateter/métodos , Tratamento Conservador/métodos , Insuficiência Cardíaca/cirurgia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Humanos , Masculino , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Medição de Risco , Volume Sistólico , Taxa de Sobrevida , Resultado do Tratamento
10.
F1000Res ; 7: 113, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29399333

RESUMO

The therapeutic options available to treat a wide range of malignancies are rapidly increasing. At the same time, the population being treated is aging with more cardiovascular risk factors, comorbid conditions, and associated poor cardiac reserve. Both traditional chemotherapeutic agents (for example, anthracyclines) and newer therapies (for example, targeted tyrosine kinase inhibitors and immune checkpoint inhibitors) have demonstrated profound cardiovascular toxicities. It is important to understand the mechanisms of these toxicities to establish strategies for the prevention and management of complications-arrhythmias, heart failure, and even death. In the first of this two-part review series, we focus on what is known and hypothesized about the mechanisms of cardiovascular toxicity from anthracyclines, HER2/ErbB2 inhibitors, immune checkpoint inhibitors, and vascular endothelial growth factor inhibitors.

12.
Case Rep Oncol ; 10(2): 452-454, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28626404

RESUMO

Epithelial ovarian cancer (OC) is a leading cause of death among females in the United States, due in part to challenges of diagnosis in the early stages of the disease. While efforts are underway to develop a high-quality screening test, it is equally important to consider whether high-risk populations are appropriate to screen. One such population may be females with hyperthyroidism, as epidemiologic studies have shown an association between this condition and OC. In this report, we present a case of a female with OC and Graves' disease to highlight the potential significance of this association.

13.
Pediatr Blood Cancer ; 64(11)2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28453898

RESUMO

BACKGROUND: Anthracycline use is limited by cardiotoxicity, including arrhythmias and left ventricular (LV) dysfunction. We aim to characterize the association between electrophysiological changes and LV dysfunction. METHODS: A retrospective chart review was conducted, including all 147 pediatric cancer survivors at our institution over 18 years of age and treated with an anthracycline. One hundred thirty-four patients who had at least one electrocardiogram (ECG) and echocardiogram were analyzed. The association between dysfunction and baseline characteristics, treatment history, and electrocardigraphic parameters were analyzed using multivariable logistic regression. Additionally, a longitudinal generalized estimating equation (GEE) model was used to examine the temporal association between repeated measure corrected QT (QTc) intervals and subsequent LV function. RESULTS: In our population, 24% of patients had LV dysfunction. The initial posttreatment QTc interval was longer in patients with LV dysfunction (438 ± 35 vs. 420 ± 20 msec, P = 0.002). In logistic regression analysis, QTc interval (P < 0.001) and cumulative radiation dose (P = 0.027) were associated with LV dysfunction. On ECGs performed prior to evidence of LV dysfunction, the QTc was longer than on ECGs preceding a normal echocardiogram (451 ± 32 msec vs. 423 ± 25 msec, P < 0.001). Mean time from QTc ≥ 450 msec to evidence of LV dysfunction was 1.8 ± 2.9 years. In the longitudinal GEE model, QTc prolongation was associated with subsequent decreased fractional shortening. CONCLUSIONS: Among adult survivors of pediatric cancer treated with anthracyclines, prolongation of the QTc interval was associated with subsequent LV dysfunction.


Assuntos
Antraciclinas/efeitos adversos , Neoplasias/complicações , Disfunção Ventricular Esquerda/induzido quimicamente , Adulto , Criança , Eletrocardiografia , Fenômenos Eletrofisiológicos , Feminino , Seguimentos , Humanos , Masculino , Neoplasias/tratamento farmacológico , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Sobreviventes
15.
Eur Heart J Cardiovasc Imaging ; 18(10): 1138-1144, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-28329137

RESUMO

Aims: Diabetes mellitus (DM) is associated with the development of cardiovascular disease (CVD). Morphological changes in the left atrium (LA) may appear before symptoms. We aimed to investigate the association between cardiac magnetic resonance imaging (CMR) measured LA structure and function and incident CVD in asymptomatic individuals with DM. Methods and results: Tissue tracking CMR was used to measure LA size and phasic function (emptying fractions and strain) on all 536 Multi-Ethnic Study of Atherosclerosis (MESA) participants with DM and available CMR at baseline in 2000-2002. At the time of enrolment, all participants were free of clinically recognized CVD, which was defined as MI, resuscitated cardiac arrest, angina, stroke, heart failure, and atrial fibrillation. Cox regression was used to assess the association of LA parameters with incident CVD adjusted for traditional cardiovascular risk factors, LV mass, NT Pro-BNP and maximum LA volume. Kaplan-Meier curves, adjusted for traditional risk factors, were generated for each LA measurement for the 25% of participants with the most abnormal values versus the remaining 75%. After a mean follow up of 11.4 ± 3.4 years, 141 individuals developed CVD. Individuals with incident CVD (mean age 66 years, 66% male vs. mean age 64 years, 50% male) had larger maximum and minimum LA volume index (LAVI) (32.1 vs. 26.8 mm3/m2; 19.4 vs. 14.2 mm3/m2 respectively, P < 0.001 for both), and lower total, passive, and active EF than those without CVD (P < 0.01 for all). In the fully adjusted model, there was a significant association of minimum LAVI, LA total EF, LA passive EF and LA active EF with incident CVD (HR 1.12 per mm3/m2, P < 0.001; HR 0.95 per %, P < 0.001; HR 0.97 per %, P = 0.021; HR 0.98 per %, P < 0.027, respectively). Conclusions: CMR measured LA minimum volume and LA function as measured by emptying fraction are predictive of CVD in a diabetic multi-ethnic population free of any clinically recognized CVD at baseline.


Assuntos
Doenças Cardiovasculares/diagnóstico por imagem , Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus/epidemiologia , Átrios do Coração/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aterosclerose/diagnóstico por imagem , Aterosclerose/etnologia , Função Atrial , Doenças Cardiovasculares/fisiopatologia , Estudos de Coortes , Comorbidade , Diabetes Mellitus/fisiopatologia , Grupos Étnicos/estatística & dados numéricos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico/fisiologia , Análise de Sobrevida
17.
Oncology ; 91(2): 61-8, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27256307

RESUMO

IMPORTANCE: Cardiotoxicity is an important limiting factor in the use of antineoplastic agents. The risk of arrhythmia and the electrophysiological effects of these agents are poorly characterized though increasing evidence suggests a high prevalence of complications. OBSERVATIONS: Patients with substantial cardiovascular risk factors are often excluded from clinical trials, while the aging population of patients actually receiving therapies may have an underlying arrhythmogenic substrate due to comorbidities. Risk stratification of patients before the selection of a therapeutic regimen is essential. Given the regular use of combination therapies, the potential for arrhythmia of each agent must be fully understood. Despite limited data and understanding in clinical practice, decisions on whether to initiate specific therapies in high-risk patients and how to manage the associated complications are made regularly. CONCLUSIONS AND RELEVANCE: This review describes the observed arrhythmias and proposed mechanisms for several major classes of antineoplastic agents. It also provides recommendations for risk stratification, monitoring, prophylaxis, and therapy, emphasizing the need for a collaborative relationship between oncologists and cardiologists and areas for future research.


Assuntos
Antineoplásicos/efeitos adversos , Arritmias Cardíacas/induzido quimicamente , Arritmias Cardíacas/fisiopatologia , Cardiotoxicidade/fisiopatologia , Antraciclinas/efeitos adversos , Antimetabólitos Antineoplásicos/efeitos adversos , Antineoplásicos Alquilantes/efeitos adversos , Trióxido de Arsênio , Arsenicais/efeitos adversos , Humanos , Óxidos/efeitos adversos , Inibidores de Proteínas Quinases/efeitos adversos , Medição de Risco , Taxoides/efeitos adversos
18.
Curr Oncol Rep ; 16(8): 396, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24992733

RESUMO

As antineoplastic treatment options expand at an increasing rate, both traditional and novel agents continue to be limited by their cardiotoxic effects. While functional decline becomes clinically apparent at late states of toxicity, little is known about early stages during which treatment or prevention may still be an option. Several imaging modalities,including echocardiography, multiple gated acquisition, and cardiac magnetic resonance imaging have the ability to identify cardiac effects before they produce clinical symptoms.Here we discuss the current and future role of cardiac imaging in the assessment of cardiotoxicity of antineoplastic agents. effects on cardiac tissue, resulting in myocardial cellular damage,and ultimately lead to a wide range of effects including electrophysiological abnormalities, symptomatic heart failure(HF), and even death. This represents a limiting factor in the therapy of several otherwise treatable neoplasms [2].The cardiotoxicity of antineoplastic agents raises several important questions regarding the actual prevalence of cardiac toxicity, the ability to effectively treat or prevent such effects with pharmaceutical interventions, and the availability of a means for early diagnosis. Here, we focus on the latter, specifically examining current and potential future imaging strategies to detect the cardiac effects of chemotherapeutic agents.


Assuntos
Antineoplásicos/efeitos adversos , Técnicas de Imagem Cardíaca , Cardiopatias/induzido quimicamente , Cardiotoxicidade/diagnóstico , Cardiopatias/diagnóstico , Humanos , Neoplasias/tratamento farmacológico
19.
J Neurodev Disord ; 3(4): 388-404, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22101809

RESUMO

Growing evidence supports the notion that dynamic gene expression, subject to epigenetic control, organizes multiple influences to enable a child to learn to listen and to talk. Here, we review neurobiological and genetic influences on spoken language development in the context of results of a longitudinal trial of cochlear implantation of young children with severe to profound sensorineural hearing loss in the Childhood Development after Cochlear Implantation study. We specifically examine the results of cochlear implantation in participants who were congenitally deaf (N = 116). Prior to intervention, these participants were subject to naturally imposed constraints in sensory (acoustic-phonologic) inputs during critical phases of development when spoken language skills are typically achieved rapidly. Their candidacy for a cochlear implant was prompted by delays (n = 20) or an essential absence of spoken language acquisition (n = 96). Observations thus present an opportunity to evaluate the impact of factors that influence the emergence of spoken language, particularly in the context of hearing restoration in sensitive periods for language acquisition. Outcomes demonstrate considerable variation in spoken language learning, although significant advantages exist for the congenitally deaf children implanted prior to 18 months of age. While age at implantation carries high predictive value in forecasting performance on measures of spoken language, several factors show significant association, particularly those related to parent-child interactions. Importantly, the significance of environmental variables in their predictive value for language development varies with age at implantation. These observations are considered in the context of an epigenetic model in which dynamic genomic expression can modulate aspects of auditory learning, offering insights into factors that can influence a child's acquisition of spoken language after cochlear implantation. Increased understanding of these interactions could lead to targeted interventions that interact with the epigenome to influence language outcomes with intervention, particularly in periods in which development is subject to time-sensitive experience.

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