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1.
Artigo em Inglês | MEDLINE | ID: mdl-32462550

RESUMO

PURPOSE: The prospective, multicenter SMART SF trial demonstrated the acute safety and effectiveness of the 56-hole porous tip irrigated contact force (CF) catheter for drug-refractory paroxysmal atrial fibrillation (PAF) ablation with a low primary adverse event rate (2.5%), leading to FDA approval of the catheter. Here, we are reporting the long-term effectiveness and safety results that have not yet been reported. METHODS: Ablations were performed using the 56-hole porous tip irrigated CF catheter guided by the 3D mapping system stability module. The primary effectiveness endpoint was freedom from atrial tachyarrhythmia (including atrial fibrillation, atrial tachycardia, and/or atrial flutter), based on electrocardiographic data at 12 months. Atrial tachyarrhythmia recurrence occurring 3 months post procedure, acute procedural failures such as lack of entrance block confirmation of all PVs, and undergoing repeat procedure for atrial fibrillation in the evaluation period (91 to 365 days post the initial ablation procedure) were considered to be effectiveness failures. RESULTS: Seventy-eight patients (age 64.8 ± 9.7 years; male 52.6%; Caucasian 96.2%) participated in the 12-month effectiveness evaluation. Mean follow-up time was 373.5 ± 45.4 days. The Kaplan-Meier estimate of freedom from 12-month atrial tachyarrhythmia was 74.9%. Two procedure-related pericardial effusion events were reported at 92 and 180 days post procedure. There were no pulmonary vein stenosis complications or deaths reported through the 12-month follow-up period. CONCLUSIONS: The SMART SF 12-month follow-up evaluation corroborates the early safety and effectiveness success previously reported for PAF ablation with STSF.

2.
J Cardiovasc Electrophysiol ; 31(5): 1175-1181, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32237003

RESUMO

BACKGROUND: There are limited data on cardiac implantable electronic device implantation (CIED) in patients with persistent left superior vena cava (PLSVC). OBJECTIVE: To describe the outcomes of implanting CIEDs with a focus on cardiac resynchronization therapy (CRT) in patients with PLSVC. METHODS: We identified all patients with a PLSVC that underwent CIED implantation from December 2008 until February 2019 at our institution by querying the electronic medical record (n = 34). We then identified controls in a 3:1 fashion (n = 102) by matching on device type (CRT vs non-CRT). Procedure success, complications, fluoroscopy and procedural time were recorded. Outcomes were compared using a two-way analysis of variance test and conditional regression modeling for continuous and categorical variables, respectively. RESULTS: A total of 34 patients with PLSVC underwent 38 procedures. Four patients underwent dual chamber system implantation followed by a subsequent upgrade to CRT. Thirteen patients underwent CRT implantation: one was implanted via the right subclavian while the rest were implanted via the PLSVC. Left ventricular (P = .06). Procedure and fluoroscopy times were significantly higher in the PLSVC as compared with the control group (97.7 vs 66.1 minute, P < .001 and 18.1 minute vs 8.7 minutes, P = .005, respectively). CONCLUSION: CIED implant in patients with PLSVC is feasible but technically more challenging and appears to be associated with higher risk of right ventricular lead dislodgment.

3.
J Cardiovasc Electrophysiol ; 31(6): 1270-1276, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32219901

RESUMO

BACKGROUND: Outcomes of catheter ablation for persistent atrial fibrillation (PeAF) are suboptimal. The convergent procedure (CP) may offer improved efficacy by combining endocardial and epicardial ablation. METHODS: We reviewed 113 consecutive patients undergoing the CP at our institution. The cohort was divided into two groups based on the presence (n = 92) or absence (n = 21) of continuous rhythm monitoring (CM) following the CP. Outcomes were reported in two ways. First, using a conventional definition of any atrial fibrillation/atrial tachycardia (AF/AT) recurrence lasting >30 seconds, after a 90 day blanking period. Second, by determining AF/AT burden at relevant time points in the group with CM. RESULTS: Across the entire cohort, 88% had either persistent or long-standing persistent AF, mean duration of AF diagnosis before the CP was 5.1 ± 4.6 years, 45% had undergone at least one prior AF ablation, 31% had impaired left ventricle ejection fraction and 62% met criteria for moderate or severe left atrial enlargement. Mean duration of follow-up after the CP was 501 ± 355 days. In the entire cohort, survival free from any AF/AT episode >30 seconds at 12 months after the blanking period was 53%. However, among those in the CM group who experienced recurrences, mean burden of AF/AT was generally very low (<5%) and remained stable over the duration of follow-up. Ten patients (9%) required elective cardioversion outside the 90 day blanking period, 11 patients (9.7%) underwent repeat ablation at a mean of 229 ± 178 days post-CP and 64% were off AADs at the last follow-up. Procedural complications decreased significantly following the transition from transdiaphragmatic to sub-xiphoid surgical access: 23% versus 3.8% (P = .005) CONCLUSIONS: In a large, consecutive series of patients with predominantly PeAF, the CP was capable of reducing AF burden to very low levels (generally <5%), which appeared durable over time. Complication rates associated with the CP decreased significantly with the transition from transdiaphragmatic to sub-xiphoid surgical access. Future trials will be necessary to determine which patients are most likely to benefit from the convergent approach.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31728875

RESUMO

PURPOSE: Sizing of the left atrial appendage (LAA) ostium prior to occlusion (LAAO) is routinely performed with transesophageal echocardiography (TEE). We sought to compare the utility of sizing via fluoroscopy to TEE for percutaneous LAAO. METHODS: We retrospectively evaluated all patients undergoing percutaneous LAAO at our institution from April 2015 through January 2018 (n = 195). We evaluated baseline characteristics, maximum measured ostium size (for both TEE and fluoroscopy), and differences in measured size to device size for both techniques. RESULTS: Of the total cohort, 185 (95%) had both intraoperative TEE and fluoroscopic images available for analysis and were included in the final analysis. The mean age was 74 years and 64% were male. Hypertension was present in 89%, diabetes in 30%, and stroke in 32% of patients. The mean ejection fraction was 51%. The most common LAA morphology was "wind sock" (52%). Measured ostial diameter on fluoroscopy was larger compared with TEE (2.04 ± 3.43 mm larger on fluoroscopy, p < 0.001). Ostium diameter on TEE was more closely correlated to the size of the device implanted compared with fluoroscopy (0.76 vs. 0.61, p = 0.001). CONCLUSIONS: Fluoroscopy results in larger estimated LAA ostium diameter compared with TEE. Despite this, TEE was more strongly correlated to operator choice in device sizing, which may reflect practice patterns. Because compression of the ostium on the device is necessary for long-term procedural success, under-sizing may lead to a higher rate of leaks. Prospective evaluation of the utility of routine fluoroscopic sizing compared with TEE is warranted.

5.
J Atr Fibrillation ; 12(1): 2153, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31687066

RESUMO

Background: Data suggests that same day discharge after implantation of trans-venous pacemakers is safe and feasible. We sought to determine whether same day discharge was feasible and safe following implantation of Medtronic MICRA leadless pacemakers. Methods: We retrospectively identified all patients undergoing MICRA placement at our institution between April 2014 to August 2018 (n=167). Patients were stratified into two groups: those discharged on the same day as their procedure (SD, n=25), and those observed for at least one night in the hospital (HD, n=142). The primary endpoint included a composite of major complications including: access site complications, new pericardial effusion, device dislodgement, and need for device revision up to approximately 45 days of follow up. Results: SD and HD had similar age (75±13 vs. 75±13 years, p=0.923), prevalence of male sex (49 vs. 44%, p=0.669), and frequency of high-grade heart block as an indication for pacing (38 vs. 32%, p=0.596). There were more Caucasians in the SD group (72 vs. 66%, p=0.038). The rate of the composite endpoint was statistically non-significantly higher in the HD group (3.5% vs. 0.0%, p=1.00). The rates of each individual components comprising the composite endpoint were similar between groups. Conclusions: Our data suggest that in appropriately selected patients, same day discharge can occur safely following Micra leadless pacemaker implantation.

6.
J Cardiovasc Electrophysiol ; 30(8): 1313-1318, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31045296

RESUMO

BACKGROUND: Implantation of the MICRA Leadless pacemaker requires the use of a 27 French introducer, blunt delivery system and device fixation to the myocardium via nitinol tines. While prior studies have proven its safety, it is unclear whether performing this procedure with uninterrupted anticoagulation exposes patients to increased risks. We sought to investigate the feasibility and safety of continuing therapeutic anticoagulation during the periprocedural period. METHODS: We evaluated all patients undergoing MICRA placement at our institution between April 2014 and August 2018 with complete follow-up data (n = 170). Patients were stratified into two groups: those on active anticoagulation (OAC, n = 26), defined as having an International normalized ratio >2.0 or having continued a direct oral anticoagulant, and those not anticoagulated (Off-OAC, n = 144). We evaluated for a composite outcome of all major complications, including access site complications and pericardial effusion. RESULTS: OAC and Off-OAC groups had similar mean age (74 ± 13 vs 75 ± 13 years; P = .914). The OAC group had a nonsignificantly lower prevalence of end-stage renal disease (8% vs 17%; P = .375) and aspirin use (27% vs 47%; P = .131). Those in the OAC group were more likely to be on warfarin than those in the Off-OAC group (81% vs 30%; P < .001). The rate of the composite endpoint was similar between the OAC and Off-OAC groups (3.8 % vs 1.4%, respectively; P = .761). Length of stay was similar between groups (1.3 ± 2.6 vs 2.3 ± 3.4 days; P = 0.108). CONCLUSION: Continuation of therapeutic anticoagulation during MICRA implantation appears to be feasible, safe and associated with shorter hospitalization among appropriately selected individuals.

7.
Interv Cardiol Clin ; 7(2): 267-283, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29526294

RESUMO

The epidemic of atrial fibrillation (AF) requires a comprehensive management strategy that uses the full force of available data and technology, including anticoagulation, ablative therapy, and left atrial appendage occlusion. Patient-centered care with an emphasis on shared decision-making is particularly relevant to the authors' understanding of the complexity of AF and has helped them tailor therapy in this ever-growing patient population.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/prevenção & controle , Cateterismo Cardíaco/instrumentação , Idoso , Anticoagulantes/uso terapêutico , Apêndice Atrial/fisiopatologia , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/terapia , Ablação por Cateter/métodos , Tomada de Decisões , Feminino , Humanos , Assistência Centrada no Paciente/normas , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
8.
Heart Rhythm ; 15(7): 1001-1008, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29458192

RESUMO

BACKGROUND: Recommendations regarding performance of magnetic resonance imaging (MRI) in non-MRI conditional pacemaker and defibrillator recipients are evolving. Previous studies have suggested low adverse event rates with MRI in nonconditional cardiac implantable electronic device (CIED) recipients, but low power limits optimal characterization of risk. OBJECTIVE: The purpose of this study was to perform a systematic review and meta-analysis to characterize the clinical risk associated with MRI in CIED recipients in order to improve power. METHODS: PubMed and CINAHL indexed articles from 1990 to 2017 were queried. A random effects model was used for meta-analysis of continuous variables. Safety outcomes were evaluated with descriptive statistics. RESULTS: Seventy studies of non-MRI conditional devices undergoing MRI were identified, allowing for analysis of 5099 patients who underwent a total of 5908 MRI studies. Heterogeneity in lead parameter changes was observed within studies, although smaller variances were noted between studies. All lead characteristics and battery voltages showed very small, clinically insignificant changes when assessed as a pooled cohort, although cases of clinically relevant outcomes were also noted (lead failure 3, implantable cardioverter-defibrillator shock 1, electrical reset 94). Electrical resets were found only in older devices. Defibrillator function was unchanged, and inappropriate shocks were avoided with pre-MRI programming changes. CONCLUSION: This review demonstrated low lead failure and clinical event rates in non-MRI conditional pacemaker and defibrillator recipients undergoing MRI. Observed changes were small and interstudy variance was low, suggesting that the composite event rates offer a reasonable estimate of true effect. The observed adverse events reinforce the need for ongoing vigilance and caution, particularly with older devices.


Assuntos
Arritmias Cardíacas/terapia , Desfibriladores Implantáveis , Imagem Cinética por Ressonância Magnética/normas , Marca-Passo Artificial , Arritmias Cardíacas/diagnóstico , Segurança de Equipamentos , Humanos
9.
Europace ; 20(FI_3): f392-f400, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29016769

RESUMO

Aims: THERMOCOOL SMARTTOUCH® SF Catheter is a new contact-force (CF)-sensing catheter with 56-hole porous tip designed for improved cooling and reduced fluid delivery compared with a standard 6-hole open-irrigated catheter. The SMART SF study examined the periprocedural safety, acute effectiveness, and procedural efficiency of the catheter for drug-refractory symptomatic paroxysmal atrial fibrillation (PAF) ablation. Methods and results: The prospective, open-label, non-randomized SMART-SF was conducted at 17 US sites. Circumferential pulmonary vein (PV) isolation was performed with confirmation of entrance block in all PVs. Stable ablation sites were identified using CARTO VISITAG™ Module. Primary adverse events (AEs; ≤1 week of index procedure), periprocedural AEs within 30 days of ablation procedure, acute effectiveness (confirmation of entrance block for targeted PVs), CF, and procedural parameters were assessed. Overall, 165 patients were enrolled (mean age, 62.7 years; male, 57.9%; white, 97%; left ventricular ejection fraction, 60.1 ± 7%; left atrium diameter, 38.8 ± 6 mm); 159 underwent radiofrequency ablation and comprised the safety cohort. Primary safety performance criteria were met: primary AE rate was 2.5% (4/159; cardiac tamponade [n = 2], thrombo-embolism [n = 1], transient ischaemic attack [n = 1]). All primary AEs resolved/improved within the 1-month follow-up period. Acute procedural effectiveness was attained in 96.2% (95% confidence interval: 92.0-98.6%) of patients. Procedure time, fluoroscopy time, and fluid delivered were observed in comparison to predecessor catheters. Conclusion: In the SMART-SF trial, the predetermined safety performance goal was met, demonstrating the safety and acute effectiveness of the THERMOCOOL SMARTTOUCH® SF Catheter for PAF ablation.


Assuntos
Fibrilação Atrial/cirurgia , Cateteres Cardíacos , Ablação por Cateter/instrumentação , Frequência Cardíaca , Veias Pulmonares/cirurgia , Irrigação Terapêutica/instrumentação , Potenciais de Ação/efeitos dos fármacos , Idoso , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Resistência a Medicamentos , Desenho de Equipamento , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Porosidade , Estudos Prospectivos , Veias Pulmonares/fisiopatologia , Fatores de Risco , Irrigação Terapêutica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
10.
Heart Rhythm ; 14(12): 1801-1806, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28713024

RESUMO

BACKGROUND: Early experience with leadless pacemakers has shown a low rate of complications. However, little is known about system revision in patients with these devices. OBJECTIVE: The purpose of this study was to describe the system revision experience with the Micra Transcatheter Pacing System (TPS). METHODS: Patients with implants from the Pre-market Micra Transcatheter Pacing Study and the Micra Transcatheter Pacing System Continued Access Study (N = 989) were analyzed and compared with 2667 patients with transvenous pacemakers (TVPs). Revisions included TPS retrieval/explant, repositioning, replacement, or electrical deactivation (with or without prior attempt at retrieval, generally followed by TVP implant) for any reason. Kaplan-Meier revision rates were calculated to account for varying follow-up duration and were compared using a Fine-Gray competing risk model. RESULTS: The actuarial rate for revision at 24 months postimplant was 1.4% for the TPS group (11 revisions in 10 patients), 75% (95% confidence interval 53%-87%; P < .001) lower than the 5.3% for the TVP group (123 revisions in 117 patients). TPS revisions occurred 5-430 days postimplant for elevated pacing thresholds, need for alternate therapy, pacemaker syndrome, and prosthetic valve endocarditis; none were due to device dislodgment or device-related infection. TPS was disabled and left in situ in 7 cases, 3 were retrieved percutaneously (range 9-406 days postimplant), and 1 was surgically removed during aortic valve surgery. CONCLUSION: The overall system revision rate for patients with TPS at 24 months was 1.4%, 75% lower than that for patients with TVPs. TPS was disabled and left in situ in 64% of revisions, and percutaneous retrieval was successful as late as 14 months postimplant.


Assuntos
Arritmias Cardíacas/terapia , Cateteres Cardíacos , Tomada de Decisões , Remoção de Dispositivo/instrumentação , Marca-Passo Artificial/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/mortalidade , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Miniaturização , Estudos Prospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
11.
Pacing Clin Electrophysiol ; 40(5): 467-475, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28224629

RESUMO

OBJECTIVES: This study compared risks associated with magnetic resonance imaging (MRI) in patients with non-MRI conditional and MRI conditional pacing and defibrillator systems with particular attention to clinically actionable outcomes. BACKGROUND: While recipients of new MRI conditional pacemaker and defibrillator systems may undergo MRI scanning with very low risk, safety and regulatory concerns persist regarding such scanning in recipients of non-MRI conditional systems. METHODS: Patients with any cardiac device who were referred for MRI were prospectively enrolled at a single center and underwent scanning at 1.5 Tesla. Pre- and postscan lead characteristic changes, system integrity, and symptoms were analyzed. A comparison was made between non-MRI conditional and MRI conditional devices. RESULTS: 105 patients were evaluated allowing for comparison of 97 scans with non-MRI conditional devices and 16 scans with MRI conditional devices. The cohort included those with pacemaker dependency, defibrillator, and cardiac resynchronization devices. Small, nonsignificant changes were observed in lead characteristics following scanning, and there was no significant difference when comparing non-MRI and MRI conditional devices. Lead parameter changes did not require lead revision or programming changes. No device reset, failures, or premature scan termination was observed. CONCLUSIONS: 1.5 T MRI scanning in patients with MRI conditional and non-MRI conditional cardiac devices was performed with similar, low clinical risk.


Assuntos
Desfibriladores Implantáveis/estatística & dados numéricos , Traumatismos por Eletricidade/epidemiologia , Falha de Equipamento/estatística & dados numéricos , Segurança de Equipamentos/estatística & dados numéricos , Imagem por Ressonância Magnética/instrumentação , Imagem por Ressonância Magnética/estatística & dados numéricos , Marca-Passo Artificial/estatística & dados numéricos , Idoso , Causalidade , Contraindicações , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Georgia/epidemiologia , Humanos , Masculino , Prevalência , Fatores de Risco
12.
J Cardiovasc Electrophysiol ; 25(8): 852-858, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24602038

RESUMO

INTRODUCTION: This report presents safety data on the use of a new open-irrigation radiofrequency ablation (RFA) catheter with a 56-hole porous tip in 742 patients enrolled in 2 US prospective, multicenter observational registry studies representing real-world use of the catheter. METHODS: This analysis is comprised of patients who underwent RFA of drug-refractory recurrent symptomatic paroxysmal atrial fibrillation (AF). Acute adverse events (AEs) were collected and categorized by seriousness, timing, and relatedness, with 7 days of follow-up data in one study and at least 120 days of data from a 1-year follow-up in the other. Acute serious adverse events (SAEs) that were identified as potentially related to the device and/or procedure were adjudicated by an independent safety committee. RESULTS: A total of 30 patients (4.0%) in the combined studies experienced an acute SAE related to the device and/or procedure, which was similar in the subset of patients age 65 and over (4.2%). These SAEs included 1.2% cardiac tamponade/perforation, 0.7% pericarditis, 0.5% pulmonary events, and 0.8% vascular access complications. No myocardial infarction, stroke, transient ischemic attack, or atrioesophageal fistulas within 7 days postprocedure were reported. In the study with extended follow-up, 1 pulmonary vein stenosis and 1 esophageal injury were seen beyond 7 days postprocedure (0.2% each). There were no device or procedure related deaths. CONCLUSION: Results from 2 large observational studies demonstrated that a new porous tip RFA catheter was safe for the treatment of drug refractory, recurrent, symptomatic paroxysmal AF, including treatment of older patients (≥65 years).


Assuntos
Fibrilação Atrial/cirurgia , Cateteres Cardíacos , Ablação por Cateter/instrumentação , Irrigação Terapêutica/instrumentação , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Sistema de Registros , Fatores de Risco , Irrigação Terapêutica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
13.
J Interv Card Electrophysiol ; 22(3): 205-10, 2008 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-18506606

RESUMO

INTRODUCTION: Magnetic resonance (MR) imaging of the left atrium (LA) can be integrated with electroanatomic mapping systems to guide catheter ablation of atrial fibrillation (AF). The usefulness of this technique is dependent on the accuracy of image integration. OBJECTIVE: The aim of this study is to determine the effect of heart rhythm at the time of pre-procedure MR imaging and heart rhythm at the time of ablation on integration error. METHODS: Fifty-two consecutive patients who underwent catheter ablation for AF were included. All patients underwent MR imaging of LA and pulmonary veins and image integration with real-time electroanatomic mapping. The rhythm at the time of MR imaging and on the day of ablation was recorded. CARTO-Merge software (Biosense-Webster) was used to calculate the average accuracy of integration of electroanatomic points with MR-derived reconstructions. RESULTS: There was no significant difference in integration error between patients who were in AF at the time of their MR vs. those who were in sinus rhythm at the time of their MR (1.76 +/- 0.26 vs. 1.88 +/- 0.31 mm, p = 0.15). There was also no significant difference in integration error between patients who were in concordant vs. discordant rhythms at the time of MR vs. day of ablation (1.81 +/- 0.23 vs. 1.89 +/- 0.32 mm, p = 0.40). There was a trend toward less integration error between patients who were in AF on the day of ablation vs. those in sinus rhythm (1.74 +/- 0.26 vs. 1.89 +/- 0.31 mm, p = 0.07). CONCLUSIONS: Image integration can be performed to direct catheter ablation of AF regardless of the rhythm at the time of imaging and ablation.


Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Mapeamento Potencial de Superfície Corporal/métodos , Ablação por Cateter/métodos , Espectroscopia de Ressonância Magnética/métodos , Técnica de Subtração , Cirurgia Assistida por Computador/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
14.
Am J Cardiol ; 101(2): 209-11, 2008 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-18178408

RESUMO

Patients with methadone-induced long-QT syndrome may experience Torsades de Pointes (TDP) or aborted sudden death requiring the placement of implantable cardioverter-defibrillators (ICDs). Outcomes after ICD implantation in these patients are unknown. Eight patients presenting with methadone-induced long-QT syndrome and episodes of symptomatic TDP were followed after having undergone ICD implantation. The study group included 5 women and 3 men (mean age 48.5 +/- 5 years) receiving methadone doses of 204 +/- 173 mg. All but 1 subject had preserved ventricular function (mean left ventricular ejection fraction 61 +/- 1.1%). All of the patients had prolonged QTc intervals (mean 613 +/- 71 ms) while taking methadone. After ICD implantation, 6 of the 8 patients continued treatment with methadone as a result of intractable dependence. Over a mean follow-up period of 27 months, 1 patient expired from unknown causes. Three of those patients had interrogation-proved ICD shocks for TDP. In conclusion, patients with methadone-induced long-QT syndrome and TDP are at high risk for recurrent arrhythmic events if methadone is continued. This small cohort of patients suggests that ICDs may be lifesaving in those subjects who continue taking methadone after initial episodes of TDP.


Assuntos
Desfibriladores Implantáveis , Síndrome do QT Longo/terapia , Metadona/efeitos adversos , Entorpecentes/efeitos adversos , Estudos de Coortes , Eletrocardiografia , Feminino , Humanos , Síndrome do QT Longo/induzido quimicamente , Síndrome do QT Longo/fisiopatologia , Masculino , Pessoa de Meia-Idade
15.
Circ Arrhythm Electrophysiol ; 1(1): 14-22, 2008 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19808389

RESUMO

BACKGROUND: Atrial tachycardia (AT) that develops after ablation of atrial fibrillation often poses a more difficult clinical situation than the index arrhythmia. This study details the use of an impedance-based electroanatomic mapping system (Ensite NavX) in concert with a specialized multielectrode mapping catheter for rapid, high-density atrial mapping. In this study, this activation mapping was combined with entrainment mapping to eliminate ATs developing late after atrial fibrillation ablation. METHODS AND RESULTS: All study patients developed AT after ablation for atrial fibrillation. The approach to AT ablation consisted of 4 steps: use of a 20-pole penta-array catheter to map the chamber rapidly during the rhythm of interest, analysis of the patterns of atrial activation to identify wave fronts of electric propagation, targeted entrainment at putative channels, and catheter ablation at these "isthmuses." All ablations were performed with irrigated radiofrequency ablation catheters. Forty-one ATs were identified in 17 patients (2.4+/-1.6 ATs per patient). Using the multielectrode catheter in conjunction with the Ensite NavX system, we created activation maps of 33 of 41 ATs (81%) (mean cycle length, 284+/-71 seconds) with a mean of 365+/-108 points per map and an average mapping time of 8+/-3 minutes. Of the 33 mapped ATs, 7 terminated either spontaneously or during entrainment maneuvers. Radiofrequency energy was used to attempt ablation of 26 ATs; 25 of 26 of the ATs (96%) were terminated successfully by ablation or catheter pressure. CONCLUSIONS: This study demonstrates a strategy for rapidly defining and eliminating the scar-related ATs typically encountered after ablation of atrial fibrillation.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas , Átrios do Coração/cirurgia , Taquicardia Supraventricular/cirurgia , Idoso , Fibrilação Atrial/fisiopatologia , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Desenho de Equipamento , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Taquicardia Supraventricular/etiologia , Taquicardia Supraventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
16.
Cardiol Rev ; 14(5): e16-20, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-16924159

RESUMO

We report the case of a double-chambered right ventricle in a 59-year-old man with previously undiagnosed Noonan syndrome. The patient presented with dyspnea on exertion and his transthoracic echocardiogram suggested a right ventricular outflow tract obstruction. Cardiac catheterization, cardiac magnetic resonance imaging, and transesophageal echocardiography revealed a hypertrophic muscle bundle dynamically obstructing right ventricular outflow. He was referred for operative repair of his double-chambered right ventricle and had successful patch expansion of his right ventricular outflow tract. In addition, he underwent a medical genetics evaluation that confirmed a new diagnosis of Noonan syndrome. To the best of our knowledge, this is the first report of a double-chambered right ventricle in an adult patient with Noonan syndrome.


Assuntos
Ventrículos do Coração/anormalidades , Síndrome de Noonan/complicações , Síndrome de Noonan/diagnóstico , Diagnóstico Diferencial , Dispneia/diagnóstico , Dispneia/etiologia , Dispneia/fisiopatologia , Ecocardiografia , Ecocardiografia Transesofagiana , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/diagnóstico , Humanos , Peptídeos e Proteínas de Sinalização Intracelular/genética , Masculino , Pessoa de Meia-Idade , Mutação , Síndrome de Noonan/genética , Síndrome de Noonan/fisiopatologia , Proteína Tirosina Fosfatase não Receptora Tipo 11 , Proteínas Tirosina Fosfatases/genética , Obstrução do Fluxo Ventricular Externo/complicações , Obstrução do Fluxo Ventricular Externo/diagnóstico , Obstrução do Fluxo Ventricular Externo/fisiopatologia
17.
Chest ; 123(4): 1082-9, 2003 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-12684297

RESUMO

STUDY OBJECTIVES: The single-breath diffusing capacity of the lung (DLCO) is a commonly performed pulmonary function test. The current American Thoracic Society (ATS) recommendations for reproducibility of DLCO measurements suggest that two measurements for the DLCO agree within 10% or 3 mL/min/mm Hg of the average value. The European Respiratory Society (ERS) recommends that two measurements should agree within 10%. The objectives of the present study were to examine whether the current reproducibility criteria were met in a general pulmonary function laboratory and to determine whether alternative criteria might be appropriate. DESIGN: Cross-sectional study. SETTING: University-based pulmonary function laboratory. PATIENTS OR PARTICIPANTS: Patients referred for spirometry, helium lung volumes, and DLCO measurement. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: In a sample of 6,193 patients referred for clinical testing, 98.3% had two DLCO values that fulfilled the current ATS criteria for reproducibility. The coefficient of variation (CV) and the percentage difference between two repeat measurements were inversely associated with the baseline DLCO and the FEV(1). As the baseline DLCO (percentage of predicted) or FEV(1) (percentage of predicted) decreased, there was an increase in the CV and the percentage difference. In contrast, the absolute difference between repeat measurements was relatively stable irrespective of the baseline DLCO or FEV(1) values. Other patient factors, such as gender and race, were not associated with measurement variability. Using an absolute difference of 2 to 2.5 mL/min/mm Hg between two DLCO measurements as alternative criteria for reproducibility, 91.5% and 95.8% of the patient sample fulfilled these criteria, respectively. CONCLUSIONS: Reproducibility of the DLCO measurement is generally much better than current standards allow. Future standards should consider an absolute difference rather than a percentage difference criterion for DLCO reproducibility.


Assuntos
Capacidade de Difusão Pulmonar , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Testes de Função Respiratória/normas , Estudos Retrospectivos , Espirometria
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