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3.
Europace ; 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32142113

RESUMO

AIMS: Study sex-differences in efficacy and safety of atrial fibrillation (AF) ablation. METHODS AND RESULTS: We assessed first AF ablation outcomes on continuous anticoagulation in 633 patients [209 (33%) women and 424 (67%) men] in a pre-specified subgroup analysis of the AXAFA-AFNET 5 trial. We compared the primary outcome (death, stroke or transient ischaemic attack, or major bleeding) and secondary outcomes [change in quality of life (QoL) and cognitive function] 3 months after ablation. Women were older (66 vs. 63 years, P < 0.001), more often symptomatic, had lower QoL and a longer history of AF. No sex differences in ablation procedure were found. Women stayed in hospital longer than men (2.1 ± 2.3 vs. 1.6 ± 1.3 days, P = 0.004). The primary outcome occurred in 19 (9.1%) women and 26 (6.1%) men, P = 0.19. Women experienced more bleeding events requiring medical attention (5.7% vs. 2.1%, P = 0.03), while rates of tamponade (1.0% vs. 1.2%) or intracranial haemorrhage (0.5% vs. 0%) did not differ. Improvement in QoL after ablation was similar between the sexes [12-item Short Form Health Survey (SF-12) physical 5.1% and 5.9%, P = 0.26; and SF-12 mental 3.7% and 1.6%, P = 0.17]. At baseline, mild cognitive impairment according to the Montreal Cognitive Assessment (MoCA) was present in 65 (32%) women and 123 (30%) men and declined to 23% for both sexes at end of follow-up. CONCLUSION: Women and men experience similar improvement in QoL and MoCA score after AF ablation on continuous anticoagulation. Longer hospital stay, a trend towards more nuisance bleeds, and a lower overall QoL in women were the main differences observed.

4.
Europace ; 2020 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-32101605

RESUMO

AIMS: Ventricular tachycardia (VT) substrate-based ablation has become a standard procedure. Electroanatomical mapping (EAM) detects scar tissue heterogeneity and define conduction channels (CCs) that are the ablation target. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is able to depict CCs and increase ablation success. Most patients undergoing VT ablation have an implantable cardioverter-defibrillator (ICD) that can cause image artefacts in LGE-CMR. Recently wideband (WB) LGE-CMR sequence has demonstrated to decrease these artefacts. The aim of this study is to analyse accuracy of WB-LGE-CMR in identifying the CC entrances. METHODS AND RESULTS: Thirteen consecutive ICD-patients who underwent VT ablation after WB-LGE-CMR were included. Number and location of CC entrances in three-dimensional EAM and in WB-LGE-CMR reconstruction were compared. Concordance was compared with a historical cohort matched by cardiomyopathy, scar location, and age (26 patients) with LGE-CMR prior to ICD and VT ablation. In WB-CMR group, 101 and 93 CC entrances were identified in EAM and WB-LGE-CMR, respectively. In historical cohort, 179 CC entrances were identified in both EAM and LGE-CMR. The EAM/CMR concordance was 85.1% and 92.2% in the WB and historical group, respectively (P = 0.66). There were no differences in false-positive rate (CC entrances detected in CMR and absent in EAM: 7.5% vs 7.8% in WB vs. conventional CMR, P = 0.92) nor in false-negative rate (CC entrances present in EAM not detected in CMR: 14.9% vs.7.8% in WB vs. conventional CMR, P = 0.23). Epicardial CCs was predictor of poor CMR/EAM concordance (OR 2.15, P = 0.031). CONCLUSION: Use of WB-LGE-CMR sequence in ICD-patients allows adequate VT substrate characterization to guide VT ablation with similar accuracy than conventional LGE-CMR in patients without an ICD.

5.
Int J Cardiol ; 2020 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-32081470

RESUMO

AIMS: Pacing/cardiac resynchronization therapy (CRT) implant training currently lacks a common system to objectively assess trainee ability to perform required tasks at predetermined performance levels. The purpose of this study was to primarily examine construct validity and reliability, secondarily discriminative validity of novel intraoperative performance metrics, developed for a reference approach to training novice CRT implanters. METHODS: Fifteen novice and eleven experienced CRT implanters performed a 3-lead implant procedure on a virtual reality simulator. Performances were video-recorded, then independently scored using predefined metrics endorsed by an international panel of experts. First, Novice and Experienced group scores were compared for steps completed and errors made. Secondly, each group was split in two around the median score of the group and subgroup scores were compared. RESULTS: The mean number of scored metrics per performance was 108 and the inter-rater reliability for scoring was 0.947. Compared with novices, experienced implanters completed more procedural Steps correctly (mean 87% vs. 73%, p = 0.001), made fewer procedural Errors (6.3 vs. 11.2, p = 0.005), Critical Errors (1.8 vs. 4.4, p = 0.004), and total errors (8.1 vs. 15.6, p = 0.002). Furthermore, the differences between the two Novice subgroups were 25% for steps completed correctly and 94% for total errors made (p < 0.001); the differences between the two Experienced subgroups were respectively 16% and 191% (p < 0.001). CONCLUSIONS: The procedure metrics used in this study reliably distinguish novice and experienced CRT implanters' performances. The metrics further differentiated performance levels within a group with similar experience. These performance metrics will underpin quality-assured novice implanter training.

6.
Artigo em Inglês | MEDLINE | ID: mdl-31944978

RESUMO

Two-dimensional representation of 3D anatomical structures is a simple and intuitive way for analysing patient information across populations and image modalities. While cardiac ventricles, especially the left ventricle, have an established standard representation (bull's eye plot), the 2D depiction of the left atrium (LA) remains challenging due to its sub-structural complexity including the pulmonary veins (PV) and the left atrial appendage (LAA). Quasi-conformal flattening techniques, successfully applied to cardiac ventricles, require additional constraints in the case of the LA to place the PV and LAA in the same geometrical 2D location for different cases. Some registration-based methods have been proposed but surface registration is time-consuming and prone to errors when the geometries are very different. We propose a novel atrial flattening methodology where a 2D map of the LA is obtained quickly and without errors related to registration. The LA is divided into 5 regions which are then mapped to their analogue two-dimensional regions. 67 human left atria from magnetic resonance images (MRI) were studied to derive a population-based template representing the averaged relative locations of the PVs and LAA. The clinical application of our methodology is illustrated on different use cases including the integration of MRI and electroanatomical data.

7.
Artigo em Inglês | MEDLINE | ID: mdl-31967367

RESUMO

BACKGROUND: Micra transcatheter pacemaker system (TPS) usually achieves low implant pacing threshold (IPT). However, IPT may increase in some patients during follow-up. AIM: To apply implant parameters in predicting long-term occurrence of very high pacing threshold (VHPT) in patients with Micra-TPS. METHODS: A cohort of 110 consecutive patients implanted with a Micra-TPS from 2014 to 2018 was evaluated at discharge and at 1, 12, 24, 36, and 48 months follow-up. VHPT was defined as greater than 2 V/0.24 ms. VHPT predictors were identified. RESULTS: Micra-TPS was implanted successfully in 108 patients (98.2%). During a mean follow-up of 24 ± 16 months, 18 patients (16.7%) died of causes nonpacemaker-related, and 4 (3.8%) developed VHPT. Patients with VHPT had higher IPT and lower implant impedance than patients with non-VHPT: 1 ± 0.31 vs 0.55 ± 0.29 V/0.24 ms (P = .003) and 580 ± 59 vs 837 ± 232 Ω (P = .03), respectively. IPT and impedance had excellent discriminative power to predict VHPT (area under the curve: 0.85 ± 0.07 and 0.91 ± 0.05, respectively). Negative predictive value (NPV) of IPT ≤ 0.5 V/0.24 ms was 100%; positive predictive value (PPV) was 8% throughout follow-up. Implant impedance ≤ 600 Ω had NPV of 99% throughout follow-up, whereas PPV varied: 16%, 21%, 16%, and 28% at 1, 12, 24, and 36 months, respectively. Sequential combination of IPT greater than 0.5 V/0.24 ms and impedance ≤ 600 Ω improved PPV to 25%, 35%, 27%, and 44%, respectively, whereas NPV remained 99% throughout follow-up. CONCLUSION: Despite favorable long-term electrical performance of Micra-TPS, a small percent of patients developed VHPT during follow-up. A sequential combination of IPT and impedance could allow the implanter to identify patients who will develop VHPT during long-term follow-up.

8.
J Cardiovasc Electrophysiol ; 31(3): 638-646, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31957087

RESUMO

INTRODUCTION: Ablation with second-generation cryoballoon technology evolves as an effective and safe alternative to radiofrequency for atrial fibrillation ablation procedures. Nevertheless, the optimal freezing strategy remains unknown. Our objective was to identify the procedural cryoablation parameters predicting successful peri-pulmonary vein (PV) lesions by directly analyzing Postablation gaps in late-gadolinium-enhanced cardiac magnetic resonance (LGE-CMR). METHODS AND RESULTS: Forty-nine consecutive patients (196 PVs) undergoing ablation with second-generation cryoballoon at our center were included. The number and duration of cryoballoon application to achieve PV isolation were left to operator discretion. Gap number and length were quantified in all patients with a LGE-CMR performed 3 months postablation. Application time (420 ± 217 seconds), number of applications (2.1 ± 1.2), application time after electrical isolation (311 ± 194 seconds) and minimum temperature (-45.8 ± 6.5°C) were similar in the 4 PVs. Gaps were observed in 148 PVs (76%), averaging 1.3 ± 1 gaps per vein. Gaps were longer and more frequent in the right PVs (91% vs 59% in left PVs, P < .001). Neither the number, total duration of applications, nor postisolation application time predicted relative length or number of gaps. CONCLUSIONS: After successful PV isolation was achieved in patients undergoing cryoablation, increasing the number of applications, the total application time or application time postisolation did not result in a reduction in the number or the relative length of gaps.

9.
JACC Clin Electrophysiol ; 6(1): 94-106, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31709982

RESUMO

OBJECTIVES: This study reports on the performance of a leadless ventricular pacemaker with automated, enhanced accelerometer-based algorithms that provide atrioventricular (AV) synchronous pacing. BACKGROUND: Despite many advantages, leadless pacemakers are currently only capable of single-chamber ventricular pacing. METHODS: The prospective MARVEL 2 (Micra Atrial tRacking using a Ventricular accELerometer 2) study assessed the performance of an automated, enhanced accelerometer-based algorithm downloaded to the Micra leadless pacemaker for up to 5 h in patients with AV block. The primary efficacy objective was to demonstrate the superiority of the algorithm to provide AV synchronous (VDD) pacing versus VVI-50 pacing in patients with sinus rhythm and complete AV block. The primary safety objective was to demonstrate that the algorithm did not result in pauses or heart rates of >100 beats/min. RESULTS: Overall, 75 patients from 12 centers were enrolled; an accelerometer-based algorithm was downloaded to their leadless pacemakers. Among the 40 patients with sinus rhythm and complete AV block included in the primary efficacy objective analysis, the proportion of patients with ≥70% AV synchrony at rest was significantly greater with VDD pacing than with VVI pacing (95% vs. 0%; p < 0.001). The mean percentage of AV synchrony increased from 26.8% (median: 26.9%) during VVI pacing to 89.2% (median: 94.3%) during VDD pacing. There were no pauses or episodes of oversensing-induced tachycardia reported during VDD pacing in all 75 patients. CONCLUSIONS: Accelerometer-based atrial sensing with an automated, enhanced algorithm significantly improved AV synchrony in patients with sinus rhythm and AV block who were implanted with a leadless ventricular pacemaker. (Micra Atrial Tracking Using a Ventricular Accelerometer 2 [MARVEL 2]; NCT03752151).

10.
J Electrocardiol ; 58: 113-118, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31816563

RESUMO

AIMS: One third of ischemic strokes are of unknown etiology. Interatrial block (IAB) is a marker of atrial electromechanical dysfunction that may predispose to the development of atrial fibrillation (AF). We hypothesized that IAB, especially in its advanced form, could be a marker of covert AF in patients with embolic stroke of undetermined source (ESUS). METHODS: We reviewed a single center cohort of ESUS patients with no prior history of AF. According to P-wave analysis of baseline ECG we distinguished 3 groups: normal P-wave duration (P-wave < 120 ms), partial IAB (P-IAB, P-wave ≥ 120 ms) and A-IAB (A-IAB, P-wave ≥ 120 ms with biphasic morphology in inferior leads). Follow-up was done 1, 6 and 12 months after discharge; then every 6 months. AF episodes, frequent premature atrial contractions (PACs) (>1%) and atrial tachyarrhythmias (runs of >3 consecutive PACs) were detected on 24 h Holter. The primary endpoint was new-onset AF detection on follow-up by any means. RESULTS: A high prevalence of both P-IAB (n = 30, 40%) and A-IAB (n = 23, 31%) was found in 75 ESUS patients. After a 521 day mean follow-up, 14 patients (19%) were diagnosed of AF. A-IAB independently predicted AF diagnosis (p =0.042) on follow-up. 24 h Holter analysis showed greater frequency of PACs and atrial tachyarrhythmia episodes in patients with IAB (p = 0.0275). CONCLUSIONS: In this hypothesis-generating study, A-IAB in the setting of ESUS is an independent risk predictor of covert AF. Although additional randomized clinical trials are warranted, A-IAB identifies ESUS patients with advanced atrial disease that could potentially benefit from early oral anticoagulation in secondary prevention.

11.
Am Heart J ; 220: 213-223, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31864099

RESUMO

BACKGROUND: Cardiogenic syncope in Brugada syndrome (BrS) increases the risk of major events. Nevertheless, clinical differentiation between cardiogenic and vasovagal syncope can be challenging. We characterized the long-term incidence of major events in a large cohort of BrS patients who presented with syncope. METHODS: From a total of 474 patients, syncope was the initial manifestation in 135 (28.5%) individuals (43.9 ±â€¯13.9 years, 71.1% male). The syncope was classified prospectively as cardiogenic, vasovagal, or undefined if unclear characteristics were present. Clinical, electrocardiographic, genetic, and electrophysiologic features were analyzed. Cardiogenic syncope, sustained ventricular arrhythmias, and sudden death were considered major events in follow-up. RESULTS: In 66 patients (48.9%), the syncope was cardiogenic; in 51 (37.8%), vasovagal and in 18 (13.3%); undefined. The electrophysiology study (EPS) inducibility was more frequent in patients with cardiogenic syncope and absent in all patients with undefined syncope (28 [53.8%] vs 5 [12.2%] vs 0 [0%]; P < .01). During follow-up (7.7 ±â€¯5.6 years), only patients with cardiogenic syncope presented major events (16 [11.9%]). Among patients with inducible EPS, 7 (21.2%) presented major events (P = .04). The negative predictive value of the EPS for major events was 92.4%. The incidence rate of major events was 2.6% person-year. Parameters associated with major events included cardiogenic syncope (hazard ratio [HR] 6.3; 95% CI 1.1-10.4; P = .05), spontaneous type 1 electrocardiogram (HR 3.7; 95% CI 1.3-10.5; P = .01), and inducible EPS (HR 2.8; 95% CI 1.1-8.8; P = .05). CONCLUSIONS: An accurate syncope classification is crucial in BrS patients for risk stratification. In patients with syncope of unclear characteristics, the EPS may be helpful to prevent unnecessary implantable cardioverter defibrillators.

12.
Europace ; 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31821484

RESUMO

AIMS: Cryoballoon (CB) ablation has emerged as a reliable modality to isolate pulmonary veins (PVs) in atrial fibrillation. Ablation lesions and the long-term effects of energy delivery can be assessed by delayed-enhancement cardiac magnetic resonance (DE-CMR). The aim of the study was to compare the number, extension, and localization of gaps in CB and radiofrequency (RF) techniques in pulmonary vein isolation (PVI). METHODS AND RESULTS: Consecutive patients submitted to PVI with CB in whom DE-CMR images were available (n = 30) were matched (1:1) to patients who underwent PVI with RF (n = 30), considering age, sex, hypertension, and diabetes. Delayed-enhancement cardiac magnetic resonance was obtained at 3 months post-procedure, and images were processed to assess the mean number of gaps around PV ostia, their localization, and the normalized gap length (NGL), calculated as the difference between total gap length and total PV perimeter. Patients were followed up for 12 months. The CB and RF procedures did not differ in the mean number of gaps per patient (4.40 vs. 5.13 gaps, respectively; P = 0.21) nor NGL (0.35 vs. 0.32, P = 0.59). For both techniques, a higher mean number of gaps were detected in right vs. left PVs (3.18 vs. 1.58, respectively; P = 0.01). The incidence of recurrences did not differ between techniques (odds ratio 1.87, 95% confidence interval 0.66-4.97; P = 0.29). CONCLUSION: Location and extension of ablation gaps in PVI did not differ between CB and RF groups in DE-CMR image analysis.

14.
Eur Heart J ; 40(46): 3793-3799c, 2019 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-31755940

RESUMO

Recent innovations have the potential to improve rhythm control therapy in patients with atrial fibrillation (AF). Controlled trials provide new evidence on the effectiveness and safety of rhythm control therapy, particularly in patients with AF and heart failure. This review summarizes evidence supporting the use of rhythm control therapy in patients with AF for different outcomes, discusses implications for indications, and highlights remaining clinical gaps in evidence. Rhythm control therapy improves symptoms and quality of life in patients with symptomatic AF and can be safely delivered in elderly patients with comorbidities (mean age 70 years, 3-7% complications at 1 year). Atrial fibrillation ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, but recurrent AF remains common, highlighting the need for better patient selection (precision medicine). Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Atrial fibrillation ablation appears to improve left ventricular function in a subset of patients with AF and heart failure. Data on the prognostic effect of rhythm control therapy are heterogeneous without a clear signal for either benefit or harm. Rhythm control therapy has acceptable safety and improves quality of life in patients with symptomatic AF, including in elderly populations with stroke risk factors. There is a clinical need to better stratify patients for rhythm control therapy. Further studies are needed to determine whether rhythm control therapy, and particularly AF ablation, improves left ventricular function and reduces AF-related complications.

15.
Artigo em Inglês | MEDLINE | ID: mdl-31748945

RESUMO

The use of cardiovascular magnetic resonance imaging left atrial late gadolinium enhancement (LA LGE) is increasing for fibrosis evaluation though the use is still limited to specialized centres due to complex image acquisition and lack of consensus on image analyses. Analysis of LA LGE with image intensity ratio (IIR) (pixel intensity of atrial wall normalized by blood pool intensity) provides an objective method to obtain quantitative data on atrial fibrosis. A threshold between healthy myocardium and fibrosis of 1.2 has previously been established in 3T scans. The aim of the study was to reaffirm this threshold in 1.5T scans. LA LGE was performed using a 1.5T magnetic resonance scanner on: 11 lone-AF patients, 11 age-matched healthy volunteers (aged 27-44) and 11 elderly patients without known history of AF but varying degrees of comorbidities. Mean values of IIR for all healthy volunteers +2SD were set as upper limit of normality and was reproduced to 1.21 and the original IIR-threshold of 1.20 was maintained. The degree of fibrosis in lone-AF patients [median 9.0% (IQR 3.9-12.0)] was higher than in healthy volunteers [2.8% (1.3-8.3)] and even higher in elderly non-AF [20.1% (10.2-35.8), p = 0.001]. The previously established IIR-threshold of 1.2 was reaffirmed in 1.5T LA LGE scans. Patients with lone AF presented with increased degrees of atrial fibrosis compared to healthy volunteers in the same age-range. Elderly patients with no history of AF showed significantly higher degrees of fibrosis compared to both groups with younger individuals.

16.
Curr Cardiol Rep ; 21(10): 127, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31520271

RESUMO

PURPOSE OF REVIEW: The goal of this paper is to review present knowledge regarding preventive and antitachycardia pacing algorithms, aimed to reduce atrial fibrillation (AF) burden in patients when pacing is indicated. RECENT FINDINGS: Reactive antitachycardia pacing (ATP), the new generation of ATP, is significantly associated with a reduced risk of AF. In patients with indication for pacing and history of AF, pacemakers endowed with atrial preventive pacing and atrial ATP combined with managed ventricular pacing proved superior to standard dual-chamber pacing. Managed ventricular pacing is an algorithm that minimizes unnecessary right ventricular pacing. Progression to persistent AF is prevented by ventricular pacing minimization in patients with normal PR interval. The synergistic effect of pacemakers that combine atrial preventive pacing with reactive ATP and with algorithms that minimize ventricular pacing can reduce AF incidence and decrease the combined endpoint of permanent AF, hospital admissions, and mortality.

17.
Sci Rep ; 9(1): 11443, 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31391506

RESUMO

Obstructive sleep apnea syndrome (OSA) promotes aortic dilatation, increased stiffness and accelerated atherosclerosis, but the mechanisms of vascular remodelling are not known. We aimed to assess vascular remodelling, its mechanisms, and the effect of mesenchymal stem cells (MSC) infusions in a clinically relevant rat model of chronic OSA involving recurrent airway obstructions leading thoracic pressure swings and intermittent hypoxia/hypercapnia (OSA-rats). Another group of rats were placed in the same setup without air obstructions (Sham-rats) and were considered controls. Our study demonstrates that chronic, non-invasive repetitive airway obstructions mimicking OSA promote remarkable structural changes of the descending thoracic aorta such as eccentric aortic hypertrophy due to an increased wall thickness and lumen diameter, an increase in the number of elastin fibers which, in contrast, get ruptured, but no changes in tunica media fibrosis. As putative molecular mechanisms of the OSA-induced vascular changes we identified an increase in reactive oxygen species and renin-angiotensin system markers and an imbalance in oxide nitric synthesis. Our results also indicate that MSC infusion blunts the OSA-related vascular changes, most probably due to their anti-inflammatory properties.

18.
Europace ; 21(10): 1459-1467, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31377792

RESUMO

Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.

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