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1.
Heart Rhythm ; 2020 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-32348845

RESUMO

BACKGROUND: Radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) arising from the inaccessible basal region of the left ventricular summit (LVS) is challenging due to proximity to coronary vessels, epicardial fat, and poor radiofrequency (RF) delivery within the distal coronary venous system. OBJECTIVE: The purpose of this study was to describe the outcomes of an anatomic approach to inaccessible LVS-VAs using bipolar radiofrequency (Bi-RFCA) delivered from the anatomically adjacent left pulmonic cusp (LPC) to the opposite left ventricular outflow tract (LVOT). METHODS: Patients from 3 centers who had undergone Bi-RFCA for inaccessible LVS-VAs refractory to conventional RFCA using an anatomic approach targeting the adjacent LPC (reversed U approach) with catheter tip pointing inferiorly within the LPC and LVOT were reviewed. RESULTS: Seven patients (age 59 ± 12 years; 3 women) underwent Bi-RF from the LPC to the LVOT for LVS-VAs after ≥1 failed conventional RFCA. Bi-RFCA (power 36 ± 7 W; duration 333 ± 107 seconds) resulted in VA suppression in 5 of 7 patients. In 2 cases, Bi-RFCA was successfully performed using dextrose 5% in water. No complications occurred. After mean follow-up of 14 ± 6 months, no recurrent VT was documented in 2 of 2 patients with baseline VT. Mean 84% reduction in premature ventricular contraction (PVC) burden (31% ± 13% vs 4% ± 5% PVCs per day; P = .0027) was documented in the other patients. CONCLUSION: In patients with LVS-VAs arising from the inaccessible region and refractory to conventional RFCA, an anatomic approach using Bi-RFCA from the LPC and opposite LVOT is an effective alternative approach.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32144677

RESUMO

PURPOSE: Cerebral thromboembolic events are well-known complications of pulmonary vein isolation (PVI) and can manifest as stroke or silent cerebral embolic lesions. The aim of this study was to compare the incidence of cerebral embolic lesions (including silent cerebral embolism and stroke) after AF ablation in patients on vitamin K antagonists versus patients on non-vitamin K-dependent oral anticoagulants, and to identify corresponding clinical and procedural risk factors. METHODS: A total of 421 patients undergoing PVI were prospectively included into the study. Of these, 43.7% were on VKA and 56.3% on NOAC treatment (dabigatran, rivaroxaban, apixaban, and edoxaban). In the NOAC group, 38% of patients had an interruption of anticoagulation for 24-36 h. All patients underwent pre- and postprocedural cerebral magnetic resonance imaging. RESULTS: Periprocedural cerebral lesions occurred in 13.1% overall. Of these, three (0.7%) resulted in symptomatic cerebrovascular accidents and 52 (12.4%) in silent cerebral embolic lesions. Incidence of cerebral lesions was significantly higher in patients on NOAC compared with VKA (16% vs. 9.2%, respectively, p = 0.04), and in patients who had intraprocedural cardioversions compared with no cardivoersions (19.5% vs. 10.4%, respectively, p = 0.03). In multivariate analysis, both parameters were found to be independent risk factors for cerebral embolism. No significant difference between interrupted and uninterrupted NOAC administration could be detected. CONCLUSIONS: In patients undergoing AF ablation, we identified the use of NOAC and intraprocedural cardioversion as independent risk factors for the occurrence of periprocedural cerebral embolic lesions.

3.
Clin Res Cardiol ; 2020 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-32002633

RESUMO

BACKGROUND: Supraventricular tachycardias induced by dual antegrade conduction via the atrioventricular (AV) node are rare but often misdiagnosed with severe consequences for the affected patients. As long-term follow-up in these patients was not available so far, this study investigates outcomes in patients with dual antegrade conduction in the AV node. METHODS AND RESULTS: In this multicentre observational study, patients from six European centres were studied. Catheter ablation was performed in 17 patients (52 ± 16 years) with dual antegrade conduction via both AV nodal pathways between 2012 and 2018. Patients with the final diagnosis of a manifest dual AV nodal non-re-entrant tachycardia had a mean delay of the correct diagnosis of over 1 year (range 2-31 months). Two patients received prescription of non-indicated oral anticoagulation, two further patients suffered from inappropriate shocks of an implantable cardioverter defibrillator. In 12 patients, a co-existence of dual antegrade and re-entry conduction in the AV node was present. Mean fast pathway conduction time was 138 ± 61 ms and mean slow pathway conduction time was 593 ± 134 ms. Successful radiofrequency catheter ablation was performed in all patients. Post-procedurally oral anticoagulation was discontinued, without detection of cerebrovascular events or atrial fibrillation during a long-term follow-up of median 17 months (range 6-72 months). CONCLUSION: This first multicentre study investigating patients with supraventricular tachycardia and dual antegrade conduction in the AV node demonstrates that catheter ablation is safe and effective while long-term patient outcome is good. Autonomic tone dependent changes in ante- vs. retrograde conduction via slow and/or fast pathway can challenge the diagnosis and therapy in some patients.

4.
Europace ; 22(4): 576-583, 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-31985789

RESUMO

AIMS: Atrial fibrillation (AF) is the most prevalent arrhythmia in western countries. It is associated with increased mortality and morbidity and responsible for hospitalization rates of 10-40% per patient per year. Studies from the UK and the USA have shown that AF is responsible for ∼1% of the total healthcare expenditures in these countries. The only potentially curative treatment is pulmonary vein isolation (PVI). Published health economic data on the impact of PVI mainly consist of simulations of expenditures with assumed efficacy taken from ablation studies. Real expenditure data are missing as well as pre-ablation period data and long-term data. METHODS AND RESULTS: We analyse true healthcare expenditures based on inpatient and outpatient data from the Upper Austrian Health Insurance Fund social security system of patients undergoing PVI during 2005 to 2015. We identified 1135 patients undergoing PVI with 268 having multiple procedures. Days of hospitalization and days of sick leave started to rise in the year before ablation. PVI was able to lower both parameters to the level of 1 year before ablation. Comparing four quarters before and after a single-index ablation, a highly significant reduction in inpatient healthcare expenditures was documented. There was a significant, but numerically small increase in outpatient expenditures, resulting in a significant reduction in overall healthcare expenditures. CONCLUSION: Analysing a cohort of the Upper Austrian Health Insurance Fund undergoing PVI, we found significant cost-saving effects on post-interventional healthcare expenditures and a reduction in days of sick leave.

5.
Eur Heart J ; 2019 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-31298266

RESUMO

AIMS: The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints. METHODS AND RESULTS: Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P < 0.00001), and greater improvement in quality of life (Minnesota Living with Heart Failure Questionnaire score) (WMD: -9.1, P = 0.007). CONCLUSION: Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.

6.
JACC Clin Electrophysiol ; 5(7): 778-786, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31320006

RESUMO

OBJECTIVES: This study sought to evaluate the safety and short-term performance of a novel catheter for very high power-short duration (vHPSD) ablation in the treatment of paroxysmal atrial fibrillation. BACKGROUND: The vHPSD catheter is a novel contact force-sensing catheter optimized for temperature-controlled radiofrequency ablation with microelectrodes and 6 thermocouples for real-time temperature monitoring; the associated vHPSD algorithm modulates power to maintain target temperature during 90 W, 4 s lesions. METHODS: QDOT-FAST (Clinical Study for Safety and Acute Performance Evaluation of the THERMOCOOL SMARTTOUCH SF-5D System Used With Fast Ablation Mode in Treatment of Patients With Paroxysmal Atrial Fibrillation) is a prospective, multicenter, single-arm study enrolling patients with symptomatic paroxysmal atrial fibrillation indicated for catheter-based pulmonary vein isolation. Primary endpoints were short-term effectiveness (confirmation of entrance block in all targeted pulmonary veins after adenosine/isoproterenol challenge) and short-term safety (primary adverse events). Participants were screened for silent cerebral lesions by magnetic resonance imaging. Patients were followed for 3 months post-ablation. RESULTS: A total of 52 patients underwent ablation and completed follow-up. Pulmonary vein isolation was achieved in all patients using the study catheter alone, with total procedure and fluoroscopy times of 105.2 ± 24.7 min and 6.6 ± 8.2 min, respectively. Most patients (n = 49; 94.2%) were in sinus rhythm at 3 months. Two primary adverse events were reported: 1 pseudoaneurysm; and 1 asymptomatic thromboembolism. There were no deaths, stroke, atrioesophageal fistula, pulmonary vein stenosis, or unanticipated adverse device effects. Six patients had identified silent cerebral lesions-all classified as asymptomatic without clinical or neurologic deficits. CONCLUSIONS: This first-in-human study of a novel catheter with optimized temperature control demonstrated the clinical feasibility and safety of vHPSD ablation. Procedure and fluoroscopy times were substantially lower than historical standard ablation with point-by-point catheters. (Clinical Study for Safety and Acute Performance Evaluation of the THERMOCOOL SMARTTOUCH SF-5D System Used With Fast Ablation Mode in Treatment of Patients With Paroxysmal Atrial Fibrillation [QDOT-FAST]; NCT03459196).

7.
JAMA Netw Open ; 2(5): e194934, 2019 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-31150082

RESUMO

Importance: Postoperative atrial fibrillation (POAF) is a well-known complication after cardiac surgery. Renin-angiotensin system inhibitors (RASIs) have been suggested as an upstream therapy for selected patients with AF; however, evidence in the surgical setting is limited. Objective: To evaluate the role of preoperative RASIs in prevention of POAF and adverse events for patients undergoing cardiac surgery. Data Sources: The PubMed database and the Cochrane Library from inception until December 31, 2018, were searched by using the keywords renin-angiotensin system inhibitors OR angiotensin-converting enzyme inhibitors OR angiotensin receptor blocker OR aldosterone antagonist AND cardiac surgery. ClinicalTrials.gov was searched from inception until December 31, 2018, by using the keywords postoperative atrial fibrillation. Study Selection: Randomized clinical trials (RCTs) and observational studies comparing the association between preoperative RASI treatment vs no preoperative RASI treatment (control group) and the incidence of POAF were identified. Eleven unique studies met the selection criteria. Data Extraction and Synthesis: Pooled analysis was performed using a random-effects model. Sensitivity and subgroup analyses of RCTs were performed to test the stability of the overall effect. Metaregression was conducted to explore potential risk of bias. Main Outcomes and Measures: The primary outcome was POAF, and the secondary outcomes included rates of stroke and mortality and duration of hospitalization. Results: Eleven unique studies involving 27 885 unique patients (74.4% male; median age, 65 years [range, 58.5-74.5 years]) were included. Compared with the control group, the RASI group did not have a significantly reduced risk of POAF (odds ratio [OR], 1.04; 95% CI, 0.91-1.19; P = .55; z = 0.60), stroke (OR, 0.86; 95% CI, 0.62-1.19; P = .37; z = 0.90; without significant heterogeneity, P = .11), death (OR, 1.07; 95% CI, 0.85-1.35; P = .56; z = 0.59; without significant heterogeneity, P = .12), composite adverse cardiac events (OR, 1.04; 95% CI, 0.91-1.18; P = .58; z = 0.56), or a reduced hospital stay (weighted mean difference, -0.04; 95% CI, -1.05 to 0.98; P = .94; z = 0.07) using a random-effects model. Pooled analysis focusing on RCTs showed consistent results. The primary overall effect was maintained in sensitivity and subgroup analyses. Metaregression showed that male sex was significantly associated with POAF (τ2 = 0.0065; z = 3.47; Q = 12.047; P < .001) and that use of ß-blockers was associated with a significantly reduced risk in developing POAF (τ2 = 0.018; z = -2.24; Q = 5.0091; P = .03). Conclusions and Relevance: The findings from this study suggest that preoperative RASI treatment does not offer additional benefit in reducing the risk of POAF, stroke, death, and hospitalization in the setting of cardiac surgery. The results provide no support for conventional use of RASIs for the possible prevention of POAF and adverse events in patients undergoing cardiac surgery; further randomized data, particularly among those patients with heart failure, are needed.


Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Fibrilação Atrial/epidemiologia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios/métodos , Resultado do Tratamento
8.
BMC Cardiovasc Disord ; 19(1): 58, 2019 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-30871479

RESUMO

BACKGROUND: Atrial fibrillation (AF) without other stroke risk factors is assumed to have a low annual stroke risk comparable to patients without AF. Therefore, current clinical guidelines do not recommend oral anticoagulation for stroke prevention of AF in patients without stroke risk factors. We analyzed brain magnetic resonance imaging (MRI) imaging to estimate the rate of clinically inapparent ("silent") ischemic brain lesions in these patients. METHODS: We pooled individual patient-level data from three prospective studies comprising stroke-free patients with symptomatic AF. All study patients underwent brain MRI within 24-48 h before planned left atrial catheter ablation. MRIs were analyzed by a neuroradiologist blinded to clinical data. RESULTS: In total, 175 patients (median age 60 (IQR 54-67) years, 32% female, median CHA2DS2-VASc = 1 (IQR 0-2), 33% persistent AF) were included. In AF patients without or with at least one stroke risk factor, at least one silent ischemic brain lesion was observed in 4 (8%) out of 48 and 10 (8%) out of 127 patients, respectively (p > 0.99). Presence of silent ischemic brain lesions was related to age (p = 0.03) but not to AF pattern (p = 0.77). At least one cerebral microbleed was detected in 5 (13%) out of 30 AF patients without stroke risk factors and 25 (25%) out of 108 AF patients with stroke risk factors (p = 0.2). Presence of cerebral microbleeds was related to male sex (p = 0.04) or peripheral artery occlusive disease (p = 0.03). CONCLUSION: In patients with symptomatic AF scheduled for ablation, brain MRI detected silent ischemic brain lesions in approximately one in 12 patients, and microbleeds in one in 5 patients. The prevalence of silent ischemic brain lesions did not differ in AF patients with or without further stroke risk factors.


Assuntos
Fibrilação Atrial/cirurgia , Isquemia Encefálica/diagnóstico por imagem , Ablação por Cateter , Imagem de Difusão por Ressonância Magnética , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Doenças Assintomáticas , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Isquemia Encefálica/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/epidemiologia , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento
10.
Wien Klin Wochenschr ; 130(Suppl 1): 1-8, 2018 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-29372411

RESUMO

In summary, uninterrupted oral antikoagulation can be recommended, with different recommendation classes and levels of evidence, for both, VKA and NOAC therapy, in the framework of PVI. Even with low CHA2DS2 VASc scores, OAK is indicated 3-4 weeks before and 8 weeks after the procedure. Periinterventional bridging with heparins should be avoided due to increased bleeding events.The present Consensus provides recommendations on the current state of knowledge and has been prepared exclusively by members of the Rhythmology Working Group of the Austrian Cardiological Society who have great practical experience in catheter ablation and peri-interventional OAK in patients with atrial fibrillation. Publication of new randomized and controlled studies on the subject are expected in the coming months, so that there will certainly be changes in the recommendations. The Rhythmology Working Group of the Austrian Cardiological Society will strive to keep this S1 guideline regularly up to date. We hope that this consensus is used to increase the safety for patients undergoing PVI and to provide physicians with a homogeneous approach in Austria.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/cirurgia , Ablação por Cateter , Administração Oral , Anticoagulantes/efeitos adversos , Áustria , Esquema de Medicação , Humanos , Veias Pulmonares/cirurgia , Acidente Vascular Cerebral/prevenção & controle , Vitamina K/antagonistas & inibidores
11.
Europace ; 20(2): 263-270, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-28069838

RESUMO

Aims: Cardiac arrhythmias following acute myocardial infarction (AMI) can be associated with major adverse cardiovascular events. Data on the "real incidence" of post-MI arrhythmias are limited. We aimed to determine the rate and burden of cardiac arrhythmias by the use of insertable cardiac monitors (ICM) in patients with preserved left ventricular ejection fraction (LVEF) after AMI. Methods and results: In this prospective observational study, patients with LVEF ≥40% who underwent PCI within 7 days following AMI were enrolled to receive an ICM. Primary outcome was the incidence of new-onset atrial fibrillation (AF) measured by the ICM during a follow-up of 2 years; results: Of 165 consecutive patients with AMI, 50 (30.3%) eligible patients were recruited (mean age 57.8 ± 8.3, 88% male). During follow-up, AF was the most frequently detected arrhythmia. Twenty-nine (58%, 95% CI: 42-70%) patients developed new-onset AF, with a cumulative rate of all detected arrhythmias of 65%. Median time to the first detected AF episode was 4.8 months and the peak cumulative AF burden was detected between 3 and 6 months. Twenty-seven (93%) out of 29 patients with AF were asymptomatic. Cox regression analysis found that baseline troponin level (hazard ratio [HR] for 1 ng/mL increment: 1.03, 95% CI: 1.01-1.06, P = 0.01) and CHA2DS2-VASc score of 4 (HR: 11.42, 95% CI: 1.01-129.06, P = 0.04) were independent risk factors of new-onset AF post-AMI. Conclusion: AF is a frequent but largely underestimated cardiac arrhythmia after AMI. More rigorous monitoring strategies resulting in crucial medical interventions (e.g. implementation of oral anti-coagulation) are needed. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT02492243.


Assuntos
Fibrilação Atrial/diagnóstico , Eletrocardiografia Ambulatorial , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Volume Sistólico , Função Ventricular Esquerda , Idoso , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Eletrocardiografia Ambulatorial/instrumentação , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Fatores de Tempo
12.
Eur J Intern Med ; 48: 64-68, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28978409

RESUMO

BACKGROUND: Subcutaneous implantable cardioverter-defibrillators (S-ICD) are an innovative and less invasive alternative to transvenous ICD (TV-ICD) in selected patients. We aimed to investigate the underlying diseases and the specific indications for implanting S-ICD in clinical practice, as well as the prevalence of shock delivery and complications. METHODS AND RESULTS: From December 2012, data of 236 patients (30,5% female; age 48,6±16,8years) were gathered from 12 centres in Austria. Follow-up data over a period of 1,7±1,1years were available for 231 patients (in total 359,2 patient-years). Predominant underlying diseases were ischemic cardiomyopathy (iCMP; 32,0%), idiopathic ventricular fibrillation (22,6%) and dilated cardiomyopathy (dCMP; 17,3%). The most frequent indications for implantation were sudden cardiac death survival (27,4%), primary prevention for iCMP (23,9%) and for dCMP (12,8%), and previous explantation of TV-ICD (12,4%). Appropriate shocks were documented in 16 patients (6,9%), iCMP being the predominant underlying disease. Arrhythmia conversion was successful in all patients, efficacy of the first shock was 96%. Inappropriate shock rate was 5,2%, predominantly caused by oversensing of T wave or artefacts. A device upgrade to an ICD system with pacing function was necessary in <1%. Clinical complications needing surgical revision occurred in 8 patients (3,5%). CONCLUSIONS: S-ICD were mostly implanted for primary prevention, one fourth of our cases were sudden death survivors. Clinical and functional complication rate was relatively low. In conclusion, S-ICD is a safe and efficient alternative in a larger population of ICD candidates, when no cardiac pacing is needed. EC-number: C-136-17.


Assuntos
Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Falha de Equipamento/estatística & dados numéricos , Fibrilação Ventricular/terapia , Adulto , Idoso , Áustria/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevenção Primária , Sistema de Registros , Estudos Retrospectivos , Prevenção Secundária , Resultado do Tratamento , Fibrilação Ventricular/etiologia
13.
J Clin Hypertens (Greenwich) ; 19(4): 361-368, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28266770

RESUMO

Renal denervation (RDN) has been proposed as a novel interventional antihypertensive technique. However, existing evidence was mainly from patients with severe resistant hypertension. The authors aimed to evaluate the efficacy of RDN in patients with resistant hypertension with mildly elevated blood pressure (BP). Studies of RDN in patients with mild resistant hypertension (systolic office BP 140-160 mm Hg despite treatment with three antihypertensive drugs including one diuretic, or mean systolic BP by 24-hour ambulatory BP measurement [ABPM] 135-150 mm Hg) were included. Two observational and one randomized cohort were identified (109 patients in the RDN group and 36 patients in the control group). Overall, the mean age of patients was 62±10 years, and 69.7% were male. Before-after comparison showed that RDN significantly reduced ABPM as compared with the baseline systolic ABPM, from 146.3±13 mm Hg at baseline to 134.6±14.7 mm Hg at 6-month follow-up and diastolic ABPM from 80.8±9.4 mm Hg at baseline to 75.5±9.8 mm Hg at 6-month follow up (both P<.001). This significant effect was not observed in the control group. Between-group comparison showed a greater change in ABPM in the RDN group as compared with that in the control group (change in systolic ABPM: -11.7±9.9 mm Hg in RDN vs -3.5±9.6 mm Hg in controls [P<.001]; change in diastolic ABPM: -5.3±6.3 mm Hg in RDN vs -2.1±5.5 mm Hg in control [P=.007]). RDN was also associated with a significantly decreased office systolic/diastolic BP and reduced number of antihypertensive medications. No severe adverse events were found during follow-up. RDN seems feasible to treat patients with mild resistant hypertension.


Assuntos
Ablação por Cateter/métodos , Hipertensão/cirurgia , Rim/inervação , Simpatectomia/métodos , Idoso , Monitorização Ambulatorial da Pressão Arterial/métodos , Feminino , Humanos , Rim/cirurgia , Masculino , Pessoa de Meia-Idade
14.
Arrhythm Electrophysiol Rev ; 6(4): 217-221, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29326838

RESUMO

To improve the single-procedural success and long-term outcomes of catheter ablation techniques for AF, there is a need for durable, contiguous and transmural lesions encircling the pulmonary veins (PV). Measurement of contact force (CF) between the catheter tip and the target tissue can optimise ablation procedures. A new approach to obtain single-procedure durable PV isolation (PVI) using the latest CF technology combined with the CARTO VISITAG™ Module with Ablation Index (Biosense Webster) has been shown in small studies to almost eliminate recurrence of paroxysmal AF at 1-year follow up and to make PVI procedures more reproducible. The use of a standardised workflow is expected to increase the reproducibility of results and to increase the efficiency of PVI procedures.

15.
JAMA Pediatr ; 170(12): 1156-1163, 2016 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-27749951

RESUMO

Importance: The timing and selection of patients with Kawasaki disease for corticosteroid use to prevent coronary artery complications remain controversial. Objective: To evaluate the effect of corticosteroid therapy in KD. Data Sources: Databases of Medline, The Cochrane Library, and the Clinicaltrials.gov website until July 2015. We used the key words ["Kawasaki disease"] and ["steroid" OR "corticosteroid"] to retrieve potentially relevant studies in the databases of Medline, the Cochrane Library, and the Clinicaltrials.gov website until July 2015. Both English and non-English literature was identified. Titles and abstracts were reviewed by 2 authors (S.C. and Y.D.) to determine suitability for inclusion. Relevant articles were reassessed by reviewing the full text. Discrepancies in study inclusion were resolved by consensus (M.G.K.). Study Selection: Clinical studies that compared corticosteroids plus intravenous immunoglobulin (IVIG) therapy with IVIG therapy alone in treating patients with KD. Studies either using corticosteroids as initial therapy or as rescue therapy were included. Data Extraction and Synthesis: Investigators independently extracted the data information. Data were quantitatively synthesized using random-effects analysis. Main Outcomes and Measures: Rate of coronary artery abnormalities. Results: Sixteen comparative studies characterizing 2746 patients were analyzed. The duration of illness before corticosteroids therapy was significantly shorter in the initial corticosteroids subset than in the rescue corticosteroids subset. The rate of coronary artery abnormalities was significantly lower in adjunctive corticosteroids therapy than in IVIG therapy (odds ratio [OR], 0.424; 95% CI, 0.270-0.665). Meta-regression based on known variables demonstrated that the overall efficacy was negatively correlated with the duration of illness before corticosteroid therapy (P < .001). Subgroup analysis, including studies using corticosteroids plus IVIG as initial therapy, showed a more advantageous effect than IVIG alone regarding coronary artery abnormality prevention (OR, 0.320; 95% CI, 0.183-0.560), whereas this benefit was not found in a subgroup of studies using corticosteroids as rescue therapy. Further analysis found that patients predicted at baseline to be at high risk of IVIG resistance seemed to obtain the greatest benefit from adjunctive corticosteroid therapy regarding coronary artery abnormality prevention (OR, 0.240; 95% CI, 0.123-0.467). The fever duration was significantly reduced in the corticosteroids group. The favorable effects of corticosteroids were conferred without an increased risk of adverse events. Conclusions and Relevance: This study highlights the importance of timing to prevent coronary artery complication in treating KD. High-risk patients with KD benefit greatly from a timely and potent adjunctive corticosteroid therapy strategy.


Assuntos
Corticosteroides/uso terapêutico , Doença da Artéria Coronariana/prevenção & controle , Síndrome de Linfonodos Mucocutâneos/tratamento farmacológico , Quimioterapia Adjuvante , Criança , Pré-Escolar , Ensaios Clínicos como Assunto , Quimioterapia Combinada , Feminino , Febre/prevenção & controle , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Lactente , Recém-Nascido , Masculino , Fatores de Risco , Tempo para o Tratamento , Resultado do Tratamento
16.
Heart Rhythm ; 12(6): 1162-8, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25728754

RESUMO

BACKGROUND: Periprocedural anticoagulation management with uninterrupted warfarin and a "therapeutic" international normalized ratio is the best approach for reducing both thromboembolic and bleeding complications in the setting of catheter ablation for atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to evaluate the safety and feasibility of uninterrupted apixaban in this setting. METHODS: This was a prospective multicenter registry of AF patients undergoing radiofrequency catheter ablation at 4 institutions in United States and Europe with uninterrupted apixaban. These patients were compared with an equal number of patients, matched for age, gender, and type of AF, undergoing AF ablation on uninterrupted warfarin. The apixaban group was comprised of consecutive patients who had taken their last dose of apixaban the morning of the procedure. A subset of 29 patients in the apixaban group underwent diffusion magnetic resonance imaging (dMRI) to detect silent cerebral ischemia. RESULTS: A total of 400 patients (200 patients in each group) were included in the study. The average age was 65.9 ± 9.9 years, 286 (71.5%) were male, and 334 (83.5%) had nonparoxysmal AF. There were no statistical differences with regard to major complications (1% vs 0.5%, P = 1), minor complications (3.5% vs 2.5%, P = .56), or total bleeding complications (4.5% vs 3%, P = .43) between the apixaban and warfarin groups. There were no symptomatic thromboembolic complications. All dMRIs were negative for "new" silent cerebral ischemia in the apixaban group. CONCLUSION: Uninterrupted apixaban administration in patients undergoing AF ablation seems to be feasible and effective in preventing clinical and silent thromboembolic events without increasing the risk of major bleeding.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Inibidores do Fator Xa/administração & dosagem , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Idoso , Anticoagulantes/administração & dosagem , Imagem de Difusão por Ressonância Magnética , Estudos de Viabilidade , Feminino , Humanos , Masculino , Hemorragia Pós-Operatória/prevenção & controle , Estudos Prospectivos , Segurança , Varfarina/administração & dosagem
17.
Pacing Clin Electrophysiol ; 38(2): 201-8, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25469738

RESUMO

BACKGROUND: Sufficient electrode-tissue contact is crucial for adequate lesion formation in radiofrequency catheter ablation (RFCA). OBJECTIVE: We assessed the impact of direct catheter force measurement on acute procedural parameters and outcome of RFCA for paroxysmal and persistent atrial fibrillation (AF). METHODS: Ninety-nine consecutive patients (70% men) with paroxysmal (63.6%) or persistent AF underwent left atrial RFCA using a 3.5-mm open-irrigated-tip (OIT) catheter with contact force measurement capabilities (group 1). For comparison a case-matched cohort with standard OIT catheters was used (99 patients; group 2). Case matching included gender, type of AF, number or RFCA procedures, and type of procedure. RESULTS: Procedural data showed a significant decline in radiofrequency ablation time from 52 ± 20 to 44 ± 16 minutes (P = 0.003) with a remarkable mean reduction in overall procedure time of 34 minutes (P = 0.0001; 225.8 ± 53.1 vs 191.9 ± 53.3 minutes). In parallel, the total fluoroscopy time could be significantly reduced from 28.5 ± 11.0 to 19.9 ± 9.3 minutes (P = 0.0001) as well as fluoroscopy dose from 74.1 ± 58.0 to 56.7 ± 38.9 Gy/cm(2) (P = 0.016). Periprocedural complications were similar in both groups. CONCLUSIONS: The use of contact force sensing technology is able to significantly reduce ablation, procedure, and fluoroscopy times as well as dose in RFCA of AF in a mixed case-matched group of paroxysmal and persistent AF. Energy delivery is substantially reduced by avoiding radiofrequency ablation in positions with insufficient surface contact. Additionally 12-month outcome data showed increased efficacy. Such time saving and equally safe technology may have a relevant impact on laboratory management and increased cost effectiveness.


Assuntos
Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/cirurgia , Ablação por Cateter/instrumentação , Duração da Cirurgia , Cirurgia Assistida por Computador/instrumentação , Ablação por Cateter/métodos , Desenho de Equipamento , Análise de Falha de Equipamento , Retroalimentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estresse Mecânico , Cirurgia Assistida por Computador/métodos , Tato , Resultado do Tratamento
18.
Europace ; 15(9): 1292-7, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23612730

RESUMO

AIMS: Currently, fluoroscopy-based catheter visualization is the standard modality in invasive electrophysiological procedures. Recently a new technology for non-fluoroscopic visualization of diagnostic (since 2010) and ablation catheters (since May 2012) has been introduced. The MediGuide™-Technology (MediGuide) projects catheter tips on prerecorded cine loops in a high time resolution. METHODS AND RESULTS: We report on MediGuide-based supraventricular tachycardia (SVT) cases [atrioventricular nodal reentry tachycardia (AVNRT), atrioventricular reentry tachycardia (AVRT), Wolff-Parkinson-White syndrome (WPW), ectopic atrial tachycardia (EAT) and typical atrial flutter) from two European centres. In all patients, diagnostic and/or ablation catheters with a special sensor were used to perform the ablation procedures. All procedural data such as acute success, duration of the procedure, fluoroscopy time, and dose and patients' characteristics were analyzed and compared with conventionally ablated patients (n = 1865). Procedure-related complications during the hospital stay were recorded. A total of 24 consecutive patients were analyzed: no significant difference to the control group was seen in the baseline characteristics. The MediGuide patients were predominantly male (66%), aged 58 ± 14 years and were ablated for 6 AVNRT (25%), 4 AVRT/WPW (17%), 1 EAT (4%), and 13 typical atrial flutter (54%). The acute success rate was 100% (98% in the control group, n.s.). The median fluoroscopy time was 0.5 ± 1.4 min (10.2 ± 9.6 in the control group, P < 0.001), the median fluoroscopy dose was 187 ± 554 cGy cm(2) (996 ± 2593 cGy cm(2), P < 0.05). Mean procedure time was 70 ± 25 min (60 ± 36 min, n.s.). No complications during the hospital stay were recorded. CONCLUSION: In several different forms of supraventricular tachycardias the MediGuide-Technology contributed to a dramatic reduction in irradiation exposure. With a median fluoroscopy time of 30 s all SVT cases were effectively performed with no complications; the fluoroscopy burden can be significantly reduced not only for the patient but also for the nurses and the physicians performing the case. The overall procedure times are not prolonged due to the use of MediGuide Technology compared with a control group of >1800 patients undergoing conventional ablation procedures.


Assuntos
Ablação por Cateter/estatística & dados numéricos , Sistema de Registros , Cirurgia Assistida por Computador/métodos , Cirurgia Assistida por Computador/estatística & dados numéricos , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/terapia , Áustria/epidemiologia , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Prevalência , Estudos Retrospectivos , Fatores de Risco , Taquicardia Supraventricular/epidemiologia , Resultado do Tratamento
19.
Europace ; 15(3): 325-31, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23097222

RESUMO

AIMS: Left atrial radiofrequency ablation has been shown to carry a risk of asymptomatic cerebral lesions. No data exist in patients under continued oral anticoagulation during the ablation procedure. The aim of this study was to quantify the amount of silent cerebral lesions assessed by pre-procedural and post-procedural magnetic resonance imaging (MRI) in patients under therapeutic international normalized ratio (INR) and to identify clinical or procedural parameters that correlate with cerebral embolism. METHODS AND RESULTS: A total of 131 consecutive patients undergoing catheter ablation for paroxysmal (n = 80, 61.1%) or persistent (n = 51, 38.9%) atrial fibrillation were included in the study. Pulmonary vein antrum isolation (PVI), roofline, mitral isthmus line, and complex fractionated atrial electrogram (CFAE) ablation using 3.5 mm open-irrigated tip catheters were performed, as needed. All patients underwent pre-procedural and post-procedural cerebral MRI. Post-procedural MRI revealed new embolic lesions in 16 patients (12.2%), all of them asymptomatic. Clinical parameters showing a significant correlation with cerebral embolism in univariate analysis were age (P = 0.027), persistent atrial fibrillation (vs. paroxysmal; P = 0.039), and spontaneous echo contrast in transesophageal echocardiography (P = 0.029). Significant procedural parameters were electric cardioversion (P = 0.041), PVI only (P = 0.008), and ablation of complex atrial electrograms (P = 0.005). Independent risk factors in multivariate analysis were age (P = 0.009), spontaneous echo contrast (P = 0.029) and CFAE ablation (P = 0.006). CONCLUSION: Radiofrequency ablation in patients under continued oral therapeutic anticoagulation is associated with a substantial risk of silent embolism detected by cerebral MRI. Therefore, continuation of oral anticoagulation is not able to prevent cerebral embolism. A variety of different clinical and procedural factors seem to contribute to the risk of cerebral lesions.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Embolia Intracraniana/etiologia , Veias Pulmonares/cirurgia , Administração Oral , Fatores Etários , Idoso , Doenças Assintomáticas , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Áustria , Coagulação Sanguínea/efeitos dos fármacos , Distribuição de Qui-Quadrado , Esquema de Medicação , Ecocardiografia Transesofagiana , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Coeficiente Internacional Normatizado , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/prevenção & controle , Modelos Logísticos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Estudos Prospectivos , Veias Pulmonares/fisiopatologia , Medição de Risco , Fatores de Risco , Resultado do Tratamento
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