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1.
Diabetes ; 2020 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-32732305

RESUMO

Compared with standard glycemic control, intensive glycemic control caused increased mortality in the ACCORD trial. Preliminary data from several studies suggests that intensive glycemic control is associated with QT prolongation, which may lead to ventricular arrhythmias as a possible explanation of this increased mortality. We sought to assess the effects of intensive glycemic control and intensive blood pressure control on the risk of incident QT prolongation. Cox proportional hazards models were used to compare the risk of incident QT prolongation (>460 ms in women or >450 ms in men) in the intensive versus standard glycemic control arms. Over a combined 48,634 person-years of follow-up (mean 4.9), 634 participants (6.4%) developed a prolonged QTc. Participants in the intensive glycemic control arm did not have an increased risk of QT prolongation. Similarly, a strategy of intensive blood pressure control did not result in a significant change in risk of prolonged QTc. Sensitivity analyses using alternative QT correction formulas (Hodges, Bazett) yielded overall similar findings. In conclusion, the increased mortality observed in the intensive glycemic control arm in the ACCORD trial is not likely to be explained by QT prolongation leading to lethal ventricular arrhythmias.

2.
Ann Noninvasive Electrocardiol ; 23(2): e12467, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28660734

RESUMO

BACKGROUND: Although abnormalities of the QT interval are associated with atrial fibrillation (AF), it is unclear whether ventricular depolarization (QRS duration) or repolarization (JT interval) is a more important marker of AF risk. METHODS: This analysis included 4,181 (95% white; 59% women) participants from the Cardiovascular Health Study (CHS) who were free of baseline AF and major intraventricular delay. A linear scale was used to compute heart rate adjusted QT (QTa), QRS (QRSa ), and JT (JTa ) intervals. Prolonged QTa , QRSa , and JTa were defined by values greater than the sex-specific 95th percentile for each measurement. AF events were ascertained during the annual study electrocardiograms and from hospitalization discharge data. Cox regression was used to compute hazard ratios (HR) and 95% confidence intervals (CI) for the associations of prolonged QTa , QRSa , and JTa with AF, separately. RESULTS: Over a mean follow-up of 12.1 years, a total of 1,236 (30%) AF events were detected. An increased risk of AF (HR = 1.50. 95% CI = 1.20, 1.88) was observed with prolonged QTa . When we examined the association between individual components of the QTa interval and AF, the risk of AF was limited to prolonged JTa (HR = 1.31, 95% CI = 1.04, 1.65) and not prolonged QRSa (HR = 1.00, 95% CI = 0.77, 1.30). Similar results were obtained per 1-SD increase in QTa (HR = 1.07, 95% CI = 1.01, 1.13), QRSa (HR = 0.99, 95% CI = 0.94, 1.06), and JTa (HR = 1.07, 95% CI = 1.01, 1.13). CONCLUSIONS: The JT interval is a more important marker of AF risk in the QT interval among persons who do not have ventricular conduction delays.


Assuntos
Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/epidemiologia , Eletrocardiografia/métodos , Sistema de Condução Cardíaco/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/fisiopatologia , Estudos de Coortes , Intervalos de Confiança , Feminino , Humanos , Incidência , Masculino , Modelos de Riscos Proporcionais , Estudos Prospectivos , Medição de Risco , Taxa de Sobrevida
3.
J Cardiovasc Electrophysiol ; 29(1): 17-21, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28877379

RESUMO

INTRODUCTION: Left atrial appendage (LAA) closure with the WATCHMAN device, according to FDA labelling, is recommended in patients with a maximal LAA ostial width between 17 and 31 mm. The safety and efficacy of LAA closure in patients with a maximal LAA ostial width < 17 mm has not been evaluated. The goal of this study was to determine the acute and short-term safety and efficacy of LAA closure with the WATCHMAN device in patients with a maximal LAA ostial width < 17 mm. METHODS AND RESULTS: Thirty-two consecutive patients with a maximal LAA ostial width < 17 mm as determined by a screening transesophageal echocardiogram (TEE) underwent LAA closure with the WATCHMAN device between March 2015 and November 2016 at five medical centers, and were included in this study. Mean age, body mass index (BMI), and CHA2 DS2 -VASC score were 70.8 ± 8.6 years, 29.3 ± 6.5 kg/m2 , and 3.9 ±1.2, respectively. At the screening TEE, mean maximal LAA ostial width and depth were 15.6 ± 0.6 mm (range 14-16) and 23.2 ± 4.5 mm (range 13-31), respectively. Successful LAA closure with the WATCHMAN device was achieved in 31 of 32 patients (97%), with no major complications. TEE performed 45 days after LAA closure demonstrated no peridevice leak > 5 mm and no device related thrombi. Warfarin was discontinued in all 31 patients 45 days after LAA closure. CONCLUSIONS: LAA closure with the WATCHMAN device can be successfully and safely achieved in patients with a maximal LAA ostial width < 17 mm.


Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/terapia , Cateterismo Cardíaco/instrumentação , Potenciais de Ação , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Função do Átrio Esquerdo , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Bases de Dados Factuais , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Desenho de Equipamento , Frequência Cardíaca , Humanos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
5.
JACC Clin Electrophysiol ; 3(12): 1356-1365, 2017 12 11.
Artigo em Inglês | MEDLINE | ID: mdl-29759664

RESUMO

OBJECTIVES: This study sought to assess long-term left atrial appendage (LAA) closure efficacy of the Atriclip applied via totally thoracoscopic (TT) approach with computed tomographic angiography. BACKGROUND: LAA closure is associated with a low risk for atrial fibrillation-related embolic stroke. The Atriclip exclusion device allows epicardial LAA closure, avoiding the need for post-operative oral anticoagulation. Previous data with Atriclip during open chest procedures show a high efficacy rate of closure >95%. METHODS: Three-dimensional volumetric 2-phase computed tomographic angiography ≥90 days post-implantation was independently assessed by chest radiology for complete LAA closure on all consented subjects identified retrospectively as having had a TT-placed Atriclip at Vanderbilt University Medical Center from June 13, 2011, to October 6, 2015. RESULTS: Complete LAA closure (defined by complete exclusion of the LAA with no exposed trabeculations, and clip within 1 cm from the left circumflex artery) was found in 61 of 65 subjects (93.9%). Four cases had incomplete closure (6.2%). Two clips were placed too distally, leaving a large stump with exposed trabeculae. Two clips failed to address a secondary LAA lobe. No major complications were associated with TT placement of the Atriclip. Follow-up over 183 patient-years revealed 1 stroke in a patient with complete LAA closure and no thrombus (hypertensive cerebrovascular accident). CONCLUSIONS: Angiographic LAA closure efficacy with a TT-placed Atriclip is high (93.9%). The clinical significance of a remnant stump is unknown. Confirmation of complete LAA occlusion should be made before cessation of systemic anticoagulation.


Assuntos
Apêndice Atrial/cirurgia , Embolia Intracraniana/patologia , Toracoscopia/métodos , Idoso , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/complicações , Procedimentos Cirúrgicos Cardíacos/métodos , Angiografia por Tomografia Computadorizada/métodos , Ecocardiografia Transesofagiana , Feminino , Humanos , Embolia Intracraniana/etiologia , Embolia Intracraniana/prevenção & controle , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos Retrospectivos , Instrumentos Cirúrgicos , Oclusão Terapêutica/instrumentação , Trombose/etiologia , Resultado do Tratamento , Técnicas de Fechamento de Ferimentos/instrumentação
6.
Ann Noninvasive Electrocardiol ; 22(3): 1-5, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28019050

RESUMO

BACKGROUND: Although left ventricular hypertrophy (LVH) detected by electrocardiography (ECG-LVH) and echocardiography (echo-LVH) independently predict cardiovascular disease events, it is unclear if ECG-LVH and echo-LVH independently predict atrial fibrillation (AF). METHODS: This analysis included 4,904 participants (40% male; 85% white) from the Cardiovascular Health Study who were free of baseline AF and major intraventricular conduction delays. ECG-LVH was defined by Minnesota Code Classification from baseline ECG data. Echo-LVH was defined by sex-specific left ventricular mass values >95th sex-specific percentiles. Incident AF events were identified during the annual study ECGs and from hospitalization discharge data. Cox regression was used to compute hazard ratios (HR) and 95% confidence intervals (CI) for the association of ECG-LVH and echo-LVH with incident AF, separately. RESULTS: ECG-LVH was detected in 224 (4.6%) participants and echo-LVH was present in 231 (4.7%) participants. Over a median follow-up of 11.9 years, a total of 1,430 AF events were detected. In a multivariable Cox model adjusted for age, sex, race, education, income, smoking, systolic blood pressure, diabetes, body mass index, total cholesterol, high-density lipoprotein cholesterol, aspirin, antihypertensive medications, and cardiovascular disease, ECG-LVH (HR = 1.50; 95% CI = 1.18, 1.90) and echo-LVH (HR = 1.39; 95% CI = 1.09, 1.78) were independently associated with AF. When ECG-LVH (HR = 1.47, 95% CI = 1.16, 1.87) and echo-LVH (HR = 1.36, 1.07, 1.75) were included in the same model, both were predictive of incident AF. CONCLUSION: The association of ECG-LVH with AF is not dependent on left ventricular mass detected by echocardiography, suggesting that abnormalities in cardiac electrophysiology provide a distinct profile in the prediction of AF.


Assuntos
Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Eletrocardiografia/métodos , Hipertrofia Ventricular Esquerda/complicações , Hipertrofia Ventricular Esquerda/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/patologia , Humanos , Masculino , Tamanho do Órgão , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco
7.
Am J Cardiol ; 119(3): 466-472, 2017 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-27889043

RESUMO

Reports on the association between the PR-interval and atrial fibrillation (AF) are conflicting. We hypothesized that inconsistencies stem from that fact that the PR-interval represents a composite of several distinct components. We examined the associations of the PR-interval and its components (P-wave onset to P-wave peak duration, P-wave peak to P-wave end duration, and PR-segment) with incident AF in 14,924 participants (mean age 54 ± 5.8 years; 26% black; 55% women) from the Atherosclerosis Risk In Communities study. The PR-interval and its components were automatically measured at baseline (1987 to 1989) from standard 12-lead electrocardiograms. PR-interval >200 ms was considered prolonged and values above the ninety-fifth percentile defined abnormal PR-interval components. AF was ascertained during follow-up through December 31, 2010. Over a median follow-up of 21.2 years, 1,985 participants (13%) developed AF. Prolonged PR-interval was associated with an increased risk of AF (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.02 to 1.40). However, PR-interval components showed varying levels of association with AF (P-wave onset to P-wave peak duration: HR 1.57, 95% CI 1.31 to 1.88; P-wave peak to P-wave end duration: HR 1.20, 95% CI 0.99 to 1.46; and PR-segment: HR 1.05, 95% CI 0.85 to 1.29). In addition, the components of the PR-interval had weak-to-moderate correlation with each other (correlation r ranged from -0.44 to 0.06). In conclusion, our findings suggest the PR-interval represents a composite of distinct components that are not uniformly associated with AF. Without considering the contribution of each component, inconsistent associations between the PR-interval and AF are inevitable.


Assuntos
Fibrilação Atrial/epidemiologia , Síndrome de Brugada/epidemiologia , Eletrocardiografia , Afro-Americanos/estatística & dados numéricos , Síndrome de Brugada/fisiopatologia , Doença do Sistema de Condução Cardíaco , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Vida Independente , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco , Estados Unidos/epidemiologia
8.
J Arrhythm ; 32(1): 51-6, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26949431

RESUMO

BACKGROUND: Atrial fibrillation (AF) is associated with cardiac fibrosis, which can now be measured noninvasively using T1-mapping with cardiac magnetic resonance imaging (CMRI). This study aimed to assess the impact of AF on ventricular T1 at the time of CMRI. METHODS: Subjects with AF scheduled for AF ablation underwent CMRI with standard electrocardiography gating and breath-hold protocols on a 1.5 T scanner with post-contrast ventricular T1 recorded from 6 regions of interest at the mid-ventricle. Baseline demographic, clinical, and imaging characteristics were examined using univariate and multivariable linear regression modeling for an association with myocardial T1. RESULTS: One hundred fifty-seven patients were studied (32% women; median age, 61 years [interquartile range {IQR}, 55-67], 50% persistent AF [episodes>7 days or requiring electrical or pharmacologic cardioversion], 30% in AF at the time of the CMRI). The median global T1 was 404 ms (IQR, 381-428). AF at the time of CMRI was associated with a 4.4% shorter T1 (p=0.000) compared to sinus rhythm when adjusted for age, sex, persistent AF, body mass index, congestive heart failure, and renal dysfunction (estimated glomerular filtration rate<60). A post-hoc multivariate model adjusted for heart rate suggested that heart rate elevation (p=0.009) contributes to the reduction in T1 observed in patients with AF at the time of CMRI. No association between ventricular T1 and AF recurrence after ablation was demonstrated. CONCLUSION: AF at the time of CMRI was associated with lower post-contrast ventricular T1 compared with sinus rhythm. This effect was at least partly due to elevated heart rate. T1 was not associated with the recurrence of AF after ablation.

9.
J Cardiovasc Electrophysiol ; 27(4): 428-34, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26725742

RESUMO

INTRODUCTION: Totally thoracoscopic (TT) epicardial ablation combined with endocardial catheter ablation is an emerging treatment for persistent AF. The effects of timing of the TT and endocardial portion on AT/AF recurrence are not known. METHODS: We retrospectively analyzed patients undergoing TT staged versus simultaneous hybrid AF ablation at our institution. Arrhythmia-free outcome was compared using time to recurrence (AF or AT greater than 30 seconds after a 3-month blanking period from endocardial ablation) at 12 months. All subjects had continuous ILR or PM monitoring. RESULTS: Eighty-three patients (52 same-day, 31 staged) underwent TT hybrid AF ablation. Recurrence was observed in 23 (29%) patients at a median time of 147 days (IQR 91,238). In univariate analysis, a staged approach significantly increased the likelihood of detecting incomplete PVI (OR 6 [95% CI 2-17] P = 0.001). However, only longstanding persistent AF (LSP-AF) status predicted recurrence (HR 4 [95% CI 1.4-12] P = 0.01). Neither a staged approach (HR 1.0 [95% CI 0.4-2.4] P = 0.9), nor detection of incomplete PVI (HR 0.9 [95% CI 0.4-2.3] P = 0.8) predicted time to first AF/AT recurrence. CONCLUSIONS: Staged hybrid ablation of AF significantly increases the likelihood of discovering incomplete PVI at the time of endocardial mapping versus a same-day procedure. However, the staged approach did not improve time to first AT/AF recurrence.


Assuntos
Fibrilação Atrial/epidemiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Ablação por Cateter/estatística & dados numéricos , Toracoscopia/métodos , Toracoscopia/estatística & dados numéricos , Idoso , Fibrilação Atrial/diagnóstico , Doença Crônica , Terapia Combinada/métodos , Terapia Combinada/estatística & dados numéricos , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Recidiva , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Tennessee/epidemiologia , Resultado do Tratamento
10.
J Cardiovasc Electrophysiol ; 26(10): 1111-6, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26222980

RESUMO

INTRODUCTION: Cardiac implantable electronic device (CIED) infections are potentially preventable complications associated with high morbidity, mortality, and cost. A recently developed bio-absorbable antibacterial envelope (TYRX™-A) might prevent CIED infections in high-risk subjects. However, data regarding safety and efficacy have not been published. METHODS AND RESULTS: In a single-center retrospective cohort study, we compared the prevalence of CIED infections among subjects with ≥2 risk factors treated with the TYRX™-A envelope (N = 135), the nonabsorbable TYRX™ envelope (N = 353), and controls who did not receive an envelope (N = 636). Infection was ascertained by individual chart review. The mean (95% confidence interval) number of risk factors was 3.08 (2.84-3.32) for TYRX™-A, 3.20 (3.07-3.34) for TYRX™, and 3.09 (2.99-3.20) for controls, P = 0.3. After a minimum 300 days follow-up, the prevalence of CIED infection was 0 (0%) for TYRX™-A, 1 (0.3%) for TYRX™, and 20 (3.1%) for controls (P = 1 for TYRX™-A vs. TYRX™, P = 0.03 for TYRX™-A vs. controls, and P = 0.002 for TYRX™ vs. controls). In a propensity score-matched cohort of 316 recipients of either envelope and 316 controls, the prevalence of infection was 0 (0%) and 9 (2.8%), respectively, P = 0.004. When limited to 122 TYRX™-A recipients and 122 propensity-matched controls, the prevalence of CIED infections was 0 (0%) and 5 (4.1%), respectively, P = 0.024. CONCLUSIONS: Among high-risk subjects, the TYRX™-A bio-absorbable envelope was associated with a very low prevalence of CIED related infections that was comparable to that seen with the nonabsorbable envelope.


Assuntos
Antibacterianos/administração & dosagem , Desfibriladores Implantáveis/estatística & dados numéricos , Implantes de Medicamento/administração & dosagem , Marca-Passo Artificial/estatística & dados numéricos , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/prevenção & controle , Implantes Absorvíveis/estatística & dados numéricos , Idoso , Causalidade , Estudos de Coortes , Preparações de Ação Retardada/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Infecções Relacionadas à Prótese/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Taxa de Sobrevida , Tennessee/epidemiologia , Resultado do Tratamento
11.
Circ Arrhythm Electrophysiol ; 8(2): 296-302, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25684755

RESUMO

BACKGROUND: Common single nucleotide polymorphisms (SNPs) at chromosomes 4q25 (rs2200733, rs10033464 near PITX2), 1q21 (rs13376333 in KCNN3), and 16q22 (rs7193343 in ZFHX3) have consistently been associated with the risk of atrial fibrillation (AF). Single-center studies have shown that 4q25 risk alleles predict recurrence of AF after catheter ablation of AF. Here, we performed a meta-analysis to test the hypothesis that these 4 AF susceptibility SNPs modulate response to AF ablation. METHODS AND RESULTS: Patients underwent de novo AF ablation between 2008 and 2012 at Vanderbilt University, the Heart Center Leipzig, and Massachusetts General Hospital. The primary outcome was 12-month recurrence, defined as an episode of AF, atrial flutter, or atrial tachycardia lasting >30 seconds after a 3-month blanking period. Multivariable analysis of the individual cohorts using a Cox proportional hazards model was performed. Summary statistics from the 3 centers were analyzed using fixed effects meta-analysis. A total of 991 patients were included (Vanderbilt University, 245; Heart Center Leipzig, 659; and Massachusetts General Hospital, 87). The overall single procedure 12-month recurrence rate was 42%. The overall risk allele frequency for these SNPs ranged from 12% to 35%. Using a dominant genetic model, the 4q25 SNP, rs2200733, predicted a 1.4-fold increased risk of recurrence (adjusted hazard ratio,1.3 [95% confidence intervals, 1.1-1.6]; P=0.011). The remaining SNPs, rs10033464 (4q25), rs13376333 (1q21), and rs7193343 (16q22) were not significantly associated with recurrence. CONCLUSIONS: Among the 3 genetic loci most strongly associated with AF, the chromosome 4q25 SNP rs2200733 is significantly associated with recurrence of atrial arrhythmias after catheter ablation for AF.


Assuntos
Fibrilação Atrial/genética , Fibrilação Atrial/cirurgia , Flutter Atrial/genética , Ablação por Cateter , Cromossomos Humanos Par 4 , Polimorfismo de Nucleotídeo Único , Taquicardia Supraventricular/genética , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Boston , Ablação por Cateter/efeitos adversos , Distribuição de Qui-Quadrado , Cromossomos Humanos Par 1 , Cromossomos Humanos Par 16 , Feminino , Frequência do Gene , Estudos de Associação Genética , Predisposição Genética para Doença , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Fenótipo , Modelos de Riscos Proporcionais , Recidiva , Fatores de Risco , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/fisiopatologia , Tennessee , Fatores de Tempo , Resultado do Tratamento
12.
J Cardiovasc Electrophysiol ; 25(6): 617-21, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24446764

RESUMO

INTRODUCTION: Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a "hybrid" technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique. METHODS AND RESULTS: Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism. CONCLUSIONS: Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.


Assuntos
Angioplastia a Laser/métodos , Desfibriladores Implantáveis , Remoção de Dispositivo/métodos , Falha de Equipamento , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Toracotomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Desfibriladores Implantáveis/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
13.
J Cardiovasc Electrophysiol ; 25(1): 36-42, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24028661

RESUMO

INTRODUCTION: The FDA has issued class I advisories for Medtronic Sprint Fidelis(®) and St. Jude Medical Riata(TM) ICD lead families. Transvenous Riata(TM) ICD lead extraction is typically considered higher risk than Fidelis(®) extraction, based on longer duration from implant, presence of externalized conductors and lack of silicone backfill in the SVC and RV coils. However, published data comparing procedural outcomes between these leads are limited. METHODS: Records were reviewed for all patients undergoing transvenous extraction of Sprint Fidelis(®) or Riata(TM) ICD leads at the Vanderbilt Heart and Vascular Institute from July 2006 to April 2013 to ascertain indication for extraction, procedural details, complications, and 30-day mortality. RESULTS: There were significant differences between those undergoing extraction of a Sprint Fidelis(®) (n = 145) or Riata(TM) lead (n = 47). In the Riata(TM) group, device-related endocarditis was a more common indication for extraction, the mean duration of implant was longer, and larger excimer laser sheaths were required. Lead malfunction was a more common indication in the Fidelis(®) group. There were no statistically significant differences in median procedure duration, procedural success (97.9% vs 95.7%, P = 0.41), median length of hospital stay (1 day vs 1 day, P = 0.23), procedural complication rate (5.5% vs 10.6%, P = 0.23) or 30-day mortality (2.1% vs 2.1%, P = 0.98). Analyses excluding patients with device infection revealed similar results. CONCLUSION: Despite differences in baseline characteristics, this study indicates that Medtronic Sprint Fidelis(®) and St. Jude Riata(TM) ICD leads have similar procedural outcomes with transvenous lead extraction.


Assuntos
Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/mortalidade , Remoção de Dispositivo/métodos , Eletrodos Implantados/efeitos adversos , Desfibriladores Implantáveis/microbiologia , Eletrodos Implantados/microbiologia , Endocardite/diagnóstico , Endocardite/mortalidade , Endocardite/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Estudos Retrospectivos , Resultado do Tratamento
14.
J Cardiovasc Electrophysiol ; 24(9): 1047-50, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23577693

RESUMO

St. Jude Riata family ICD leads are subject to an FDA class I recall due to insulation failure, cable extrusions, and a high rate of electrical failures. We present multiple cases of large intravascular thrombus formation adherent to externalized conductor cables on Riata leads. Our observations highlight a previously unknown risk of large or calcified thrombus formation involving externalized conductors. We suggest that these leads should be screened for thrombi prior to potential lead extraction to determine the safest approach. Serial echocardiography may help detect progressive thrombus formation. The role of systemic anticoagulation for prevention or treatment of these thrombi remains unclear.


Assuntos
Desfibriladores Implantáveis/efeitos adversos , Eletrodos Implantados/efeitos adversos , Falha de Equipamento , Cardiopatias/diagnóstico , Trombose/diagnóstico , Idoso , Feminino , Cardiopatias/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Trombose/etiologia
15.
J Interv Card Electrophysiol ; 37(3): 241-7, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23625091

RESUMO

PURPOSE: Left atrial catheter ablation for patients with atrial fibrillation (AF) requires periprocedural anticoagulation to minimize thromboembolic complications. High rates of major bleeding complications using dabigatran etexilate for periprocedural anticoagulation have been reported, raising concerns regarding its safety during left atrial catheter ablation. We sought to evaluate the safety and efficacy of a dabigatran use strategy versus warfarin, at a single high-volume AF ablation center. METHODS: We performed a retrospective analysis on consecutive patients undergoing left atrial ablation at Vanderbilt Medical Center from January 2011 through August 2012 with a minimum follow-up of 3 months. Patient cohorts were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation and those undergoing ablation on dose-adjusted warfarin, with or without low-molecular-weight heparin bridging. Dabigatran was held 24-30 h pre-procedure and restarted 4-6 h after hemostasis was achieved. We evaluated all thromboembolic and bleeding complications at 3 months post-ablation. RESULTS: A total of 254 patients underwent left atrial catheter ablation for atrial fibrillation or left atrial flutter. Periprocedural anticoagulation utilized dabigatran in 122 patients and warfarin in 135 patients. Three late thromboembolic complications occurred in the dabigatran group (2.5 %), compared with one (0.7 %) in the warfarin group (p = 0.28). The dabigatran group had similar minor bleeding (2.5 vs. 7.4 %, p = 0.07), major bleeding (1.6 vs. 0.7 %, p = 0.51), and composite of bleeding and thromboembolic complications (6.6 vs. 8.9 %, p = 0.49) when compared to warfarin. There were no acute thromboembolic complications in either group (<24 h post-ablation). CONCLUSIONS: In patients undergoing left atrial catheter ablation for AF or left atrial flutter, use of periprocedural dabigatran etexilate provides a safe and effective anticoagulation strategy compared to warfarin. A prospective randomized study is warranted.


Assuntos
Fibrilação Atrial/cirurgia , Flutter Atrial/cirurgia , Benzimidazóis/administração & dosagem , Ablação por Cateter/estatística & dados numéricos , Embolia/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Varfarina/administração & dosagem , beta-Alanina/análogos & derivados , Adulto , Anticoagulantes/administração & dosagem , Fibrilação Atrial/epidemiologia , Comorbidade , Dabigatrana , Embolia/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Pré-Medicação , Estudos Retrospectivos , Medição de Risco , Acidente Vascular Cerebral/epidemiologia , Tennessee/epidemiologia , Resultado do Tratamento , beta-Alanina/administração & dosagem
16.
Am J Cardiol ; 111(3): 368-73, 2013 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-23168290

RESUMO

Obese patients with atrial fibrillation (AF) are frequently treated with AF ablation. We sought to examine whether a body mass index (BMI) threshold exists beyond which the odds of experiencing a complication from AF ablation increases. All patients enrolled in the Vanderbilt AF Registry who underwent catheter-based AF ablation from May 1999 to February 2012 were included. Major complications were recorded. Morbid obesity was defined as a BMI >40 kg/m(2) and examined in multivariable analysis. A total of 35 complications (6.8%) occurred in 512 ablations. Morbidly obese patients experienced a greater rate of complications (6 of 42, 14.3%) than the nonmorbidly obese (29 of 470, 6.2%; p = 0.046). Using a discrete BMI cutoff, the odds of complications increased 3.1-fold in those with morbid obesity (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.1 to 8.4, p = 0.03) and 2.1-fold for female gender (OR 2.1, 95% CI 1.04 to 4.38, p = 0.04). With BMI as a continuous variable, the odds of complications increased by 5% per 1 unit increase in BMI (OR 1.05, 95% CI 1.0 to 1.11, p = 0.05), and the increase for female gender was 2.2-fold (OR 2.2, 95% CI 1.1 to 4.6, p = 0.03). In conclusion, morbid obesity represents a BMI threshold above which the odds of complications with AF ablation increase significantly. The increase in complications appears to be driven primarily by events in women, suggesting that morbidly obese women are a special population when considering AF ablation.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/epidemiologia , Medição de Risco , Fibrilação Atrial/complicações , Índice de Massa Corporal , Intervalos de Confiança , Eletrocardiografia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Taxa de Sobrevida/tendências , Tennessee/epidemiologia , Resultado do Tratamento
19.
Circ Arrhythm Electrophysiol ; 3(5): 505-10, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20858860

RESUMO

BACKGROUND: Postoperative atrial fibrillation remains a common cause of morbidity. Although epicardial drug delivery can increase efficacy and reduce side effects, it is impractical for postoperative atrial fibrillation because pericardial bleeding/effusion and drainage cause rapid drug elimination. Fibrin glue sprayed on the epicardium is vigorously adherent, allowing an admixed drug to remain in contact with the heart. The purpose of the present study was to evaluate a novel corticosteroid-fibrin glue mixture applied to the atrial epicardium at the time of surgery for prevention of postoperative atrial tachyarrhythmias. METHODS AND RESULTS: Talc was instilled into the pericardium in 15 dogs to simulate postoperative inflammation. Pacemakers were implanted to monitor arrhythmias. A mixture of triamcinolone and fibrin glue (Tisseel) was sprayed onto the atria of the treatment animals (n=9), whereas control animals (n=6) received Tisseel or nothing. After 1 week, pacemaker interrogation quantified postoperative atrial tachyarrhythmias (atrial rate >200 bpm) burden. Excised hearts underwent histological examination and tensile strength testing. postoperative atrial tachyarrhythmias occurred in 100% of control animals but only 33% of treatment animals (P=0.027). The median time (25th percentile, 75th percentile) in tachycardia was 5.5 hours (2.7, 12.6) per day in the control group, compared with 0 hours (0, 0.2) in the treatment group (P=0.001). Severe inflammation was present in 6 of 6 control animals and 1 of 9 treatment animals (P=0.001). The tensile strength of a healing left atriotomy was not significantly different between groups. Steroid levels at the time the animals were killed were very low (median of 0.22 µg/dL [0.18, 0.23]). CONCLUSIONS: A mixture of triamcinolone and fibrin glue sprayed onto the atria reduced postoperative atrial tachyarrhythmias and reduced inflammatory cell infiltration. There was no change in the tensile strength of a healing atriotomy and plasma steroid levels were low. Clinical trials of this approach are warranted.


Assuntos
Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Adesivo Tecidual de Fibrina/administração & dosagem , Glucocorticoides/administração & dosagem , Adesivos Teciduais/administração & dosagem , Triancinolona/administração & dosagem , Animais , Fibrilação Atrial/etiologia , Modelos Animais de Doenças , Cães , Combinação de Medicamentos , Masculino , Pericárdio , Complicações Pós-Operatórias , Resultado do Tratamento
20.
Heart Rhythm ; 2(2): 134-40, 2005 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-15851285

RESUMO

OBJECTIVES: The purpose of this study was to test for a genetic component to risk for acquired long QT syndrome (LQTS). BACKGROUND: Many drugs prolong the QT interval, and some patients develop excessive QT prolongation and occasionally torsades de pointes-the acquired LQTS. Similarities between the acquired and congenital forms of the long QT syndrome suggest genetic factors modulate susceptibility. METHODS: Intravenous quinidine was administered to 14 relatives of patients who safely tolerated chronic therapy with a QT-prolonging drug (control relatives) and 12 relatives of patients who developed acquired LQTS, and ECG intervals between groups were compared. RESULTS: Baseline QT and heart-rate corrected QT (QTc) were similar (QT/QTc: 394 +/- 28/410 +/- 20 ms vs 395 +/- 24/418 +/- 20 ms; control vs acquired LQTS) and prolonged equally in the two groups. The interval from the peak to the end of the T wave, an index of transmural dispersion of repolarization, prolonged significantly with quinidine in acquired LQTS relatives (63 +/- 17 to 83 +/- 18 ms, P = .017) but not in control relatives (66 +/- 19 to 71 +/- 18 ms, P = 0.648). In addition, the baseline peak to end of the T wave as a fraction of the QT interval was similar in both groups but was longer in acquired LQTS relatives after quinidine (16.3 +/- 3.5% and 19.5 +/- 3.9% in control and acquired LQTS relatives, respectively, P = .042). CONCLUSIONS: First-degree relatives of patients with acquired long QT syndrome have greater drug-induced prolongation of terminal repolarization compared to control relatives, supporting a genetic predisposition to acquired long QT syndrome.


Assuntos
Antiarrítmicos , Predisposição Genética para Doença/genética , Síndrome do QT Longo/genética , Quinidina , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
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