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1.
Biomed Eng Online ; 18(1): 96, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31519192

RESUMO

BACKGROUND: Considering the clinical importance of the ventricular fibrillation and that the most used therapy to reverse it has a critical side effect on the cardiac tissue, it is desirable to optimize defibrillation parameters to increase its efficiency. In this study, we investigated the influence of stimuli duration on the relationship between pacing threshold and defibrillation probability. RESULTS: We found out that 0.5-ms-long pulses had a lower ratio of defibrillation probability to the pacing threshold, although the higher the pulse duration the lower is the electric field intensity required to defibrillate the hearts. CONCLUSION: The appropriate choice of defibrillatory shock parameters is able to increase the efficiency of the defibrillation improving the survival chances after the occurrence of a severe arrhythmia. The relationship between pulse duration and the probability of reversal of fibrillation shows that this parameter cannot be underestimated in defibrillator design since different pulse durations have different levels of safety.


Assuntos
Cardioversão Elétrica/métodos , Coração/fisiopatologia , Animais , Cardioversão Elétrica/efeitos adversos , Masculino , Miócitos Cardíacos/patologia , Probabilidade , Ratos , Ratos Wistar , Segurança , Fatores de Tempo
2.
J Cardiovasc Med (Hagerstown) ; 20(11): 745-751, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31483328

RESUMO

BACKGROUND: Atrial fibrillation induces reversible electrical and mechanical modifications (atrial remodeling). Atrial stunning is a mechanical dysfunction with preserved bioelectrical function, occurring after successful atrial fibrillation electrical cardioversion (ECV). Two-dimensional speckle tracking echocardiography is a new technology for evaluating atrial mechanical function. We assessed atrial mechanical function after ECV with serial two-dimensional speckle tracking echocardiography evaluations. The investigated outcome was left atrium mechanical recovery within 3 months. METHODS: A total of 36 patients [mean age 73 (7.9) years, 23 males] with persistent atrial fibrillation underwent conventional transthoracic and transesophageal echocardiography before ECV. Positive global atrial strain (GSA+) was assessed at 3 h, 1, 2, 3, 4 weeks and 3 months after ECV. Mechanical recovery was defined as the achievement of a GSA+ value of 21%. RESULTS: Independent predictors of GSA+ immediately after ECV (basal GSA+) were E/e' ratio and left atrial appendage anterograde flow velocity. During the follow-up, 25% of patients suffered atrial fibrillation recurrence. In 12/36 patients (33%) left atrium mechanical recovery was detected (mechanical recovery group), while in 15/36 (42%) recovery did not occur (no atrial mechanical recovery group). At univariate analysis, the variables associated with recovery, were basal GSA+ (P = 0.015) and maximal velocity left atrial appendage (P = 0.022). Female sex (P = 0.038), N-terminal pro-B type natriuretic peptide (P = 0.013), E/e' (P = 0.042) and the indexed left atrium volume (P = 0.019) were associated with the lack of left atrium mechanical recovery. CONCLUSION: In almost half of the patients, the left atrium did not resume mechanical activity within the 3 months after ECV, despite sinus rhythm recovery. The left atrium of these patients was larger, stiffer and their E/E' was higher, suggesting a higher endocavitary pressure compared with mechanical recovery patients. These findings might suggest an increased thromboembolic risk.


Assuntos
Fibrilação Atrial/terapia , Função do Átrio Esquerdo , Remodelamento Atrial , Ecocardiografia , Cardioversão Elétrica , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Cardioversão Elétrica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Recidiva , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
4.
J Cardiovasc Med (Hagerstown) ; 20(10): 676-681, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31343450

RESUMO

AIMS: The high rate of implantable cardioverter defibrillator (ICD) lead failures related to the Sprint Fidelis' and Riata's design have raised serious concerns about the reliability of ICD leads. The St. Jude Medical Durata family of leads replaced the preceding Riata line following increased rates of lead failure (1.17% per year). The aim of our study was to evaluate the long-term performance of the Durata lead. METHODS: Eight hundred and eighteen Durata ICD leads were implanted in 11 Italian centers. The incidence of lead failure, defined as a sudden rise in long-term pacing or defibrillation impedance and/or a sudden change in R-wave amplitude and capture thresholds, was assessed. The incidences of lead dislodgment and lead perforation were also evaluated. RESULTS: During a median follow-up of 1353 days (3.7 years; 25-75th interquartile range 806-1887 days) lead failure occurred in 16/818 leads (0.54%/year). The overall survival, free of lead failure, was 98.9% at 3 years, 98.2% at 4 years and 97.5% at 5 years. Lead dislodgment occurred in 12/818 leads with an incidence of 0.4%/year. No cases of cardiac perforation were reported. No major adverse events were reported except for two cases of inappropriate shocks as a consequence of failure or dislodgment. CONCLUSION: Our study suggests that the Durata lead does not engender a higher risk of failure. Overall survival, free from lead failure, was found to be higher than previously reported for the Riata lead.


Assuntos
Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Cardiopatias/terapia , Falha de Prótese , Idoso , Cardioversão Elétrica/efeitos adversos , Feminino , Cardiopatias/diagnóstico por imagem , Cardiopatias/fisiopatologia , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Fatores de Risco , Fatores de Tempo
5.
Circ Arrhythm Electrophysiol ; 12(6): e006951, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31159582

RESUMO

Background The treatment of heart failure with reduced ejection fraction has been the subject of numerous randomized controlled trials involving medications and cardiac implantable electronic device therapies. As newer effective pharmacological therapies suggest significant reductions in all-cause mortality, the role of additional device therapy in heart failure with reduced ejection fraction deserves further scrutiny. Methods A systematic review and network meta-analysis on the effect of medication and device therapies in heart failure with reduced ejection fraction on all-cause mortality was performed. Randomized controlled trials published between January 1980 and July 2017 were identified using Medline, EMBASE, and Cochrane Controlled Register of Trials databases. Pcnetmeta package in R was used to calculate treatment arm-based estimated rates, rate ratios, and probability ranks with 95% credible intervals. Results Combination therapy of ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) with ß-blockers (BBs) alone or in addition to implantable cardiac defibrillators or cardiac resynchronization therapy with defibrillators demonstrated a significant reduction of all-cause mortality when compared with placebo. By probability rank, implantable cardiac defibrillator+ACE inhibitor or ARB+BB+mineralocorticoid receptor antagonist, implantable cardiac defibrillator+ACE inhibitor or ARB+BB, and angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist combination therapies have the highest probability of being ranked the best treatment. There was no significant difference in the rate of mortality when comparing angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist to implantable cardiac defibrillator+optimal pharmacological combination therapy. Conclusions BB and renin-angiotensin system blockers alone or in combination with defibrillator device therapy have robust evidence for a reduction in mortality compared with placebo. The comparative efficacy of pharmacological therapy with angiotensin receptor-neprilysin inhibitors and device therapy deserves further investigation.


Assuntos
Terapia de Ressincronização Cardíaca , Fármacos Cardiovasculares/uso terapêutico , Cardioversão Elétrica , Insuficiência Cardíaca/terapia , Volume Sistólico/efeitos dos fármacos , Função Ventricular Esquerda/efeitos dos fármacos , Antagonistas Adrenérgicos beta/uso terapêutico , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/mortalidade , Dispositivos de Terapia de Ressincronização Cardíaca , Fármacos Cardiovasculares/efeitos adversos , Desfibriladores Implantáveis , Quimioterapia Combinada , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , Neprilisina/antagonistas & inibidores , Meta-Análise em Rede , Inibidores de Proteases/uso terapêutico , Resultado do Tratamento
6.
Circ Arrhythm Electrophysiol ; 12(6): e007430, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31159583
7.
Am J Emerg Med ; 37(8): 1539-1543, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31126668

RESUMO

Pre-excited, fast conducting atrial fibrillation (AF) is a serious life-threatening arrhythmia that requires urgent pharmacological or electrical cardioversion. When anti-arrhythmic medications fail to restore sinus rhythm, biphasic, direct current (DC) cardioversion is required. Appropriate synchronization of the DC shock with the QRS is crucial, however not easily achieved. Since the QRS-T complexes in pre-excited AF are severely distorted, the diagnosis of inaccurate synchronization may be overlooked. Here, we report a unique case where during electrical cardioversion of pre-excited AF with inappropriate synchronization on the T wave inadvertently resulted in ventricular fibrillation (VF), and review the literature.


Assuntos
Fibrilação Atrial/terapia , Cardioversão Elétrica/efeitos adversos , Fibrilação Ventricular/etiologia , Adulto , Eletrocardiografia , Humanos , Masculino , Adulto Jovem
8.
J Cardiovasc Magn Reson ; 21(1): 28, 2019 05 16.
Artigo em Inglês | MEDLINE | ID: mdl-31096987

RESUMO

BACKGROUND: Impaired left ventricular (LV) contraction and relaxation may further promote adverse remodeling and may increase the risk of ventricular arrhythmia (VA) in ischemic cardiomyopathy. We aimed to examine the association of cardiovascular magnetic resonance (CMR)-derived circumferential strain parameters for LV regional systolic function, LV diastolic function and mechanical dispersion with the risk of VA in patients with prior myocardial infarction and primary prevention implantable cardioverter defibrillator (ICD). METHODS: Patients with an ischemic cardiomyopathy who underwent CMR prior to primary prevention ICD implantation, were retrospectively identified. LV segmental circumferential strain curves were extracted from short-axis cine CMR. For LV regional strain analysis, the extent of moderately and severely impaired strain (percentage of LV segments with strain between - 10% and - 5% and > - 5%, respectively) were calculated. LV diastolic function was quantified by the early and late diastolic strain rate. Mechanical dispersion was defined as the standard deviation in delay time between each strain curve and the patient-specific reference curve. Cox proportional hazard ratios (HR) (95%CI) were calculated to assess the association between LV strain parameters and appropriate ICD therapy. RESULTS: A total of 121 patients (63 ± 11 years, 84% men, LV ejection fraction (LVEF) 27 ± 9%) were included. During a median (interquartile range) follow-up of 47 (27;69) months, 30 (25%) patients received appropriate ICD therapy. The late diastolic strain rate (HR 1.1 (1.0;1.2) per - 0.25 1/s, P = 0.043) and the extent of moderately impaired strain (HR 1.5 (1.0;2.2) per + 10%, P = 0.048) but not the extent of severely impaired strain (HR 0.9 (0.6;1.4) per + 10%, P = 0.685) were associated with appropriate ICD therapy, independent of LVEF, late gadolinium enhancement (LGE) scar border size and acute revascularization. Mechanical dispersion was not related to appropriate ICD therapy (HR 1.1 (0.8;1.6) per + 25 ms, P = 0.464). CONCLUSIONS: In an ischemic cardiomyopathy population referred for primary prevention ICD implantation, the extent of moderately impaired strain and late diastolic strain rate were associated with the risk of appropriate ICD therapy, independent of LVEF, scar border size and acute revascularization. These findings suggest that disturbed LV contraction and relaxation may contribute to an increased risk of VA after myocardial infarction.


Assuntos
Arritmias Cardíacas/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Imagem por Ressonância Magnética , Infarto do Miocárdio/fisiopatologia , Prevenção Primária/instrumentação , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda , Idoso , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia , Remodelação Ventricular
9.
Am J Ther ; 26(4): e469-e480, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30946044

RESUMO

BACKGROUND: The optimal management for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators (ICDs) offers a challenge with no set guidelines regarding which therapy offers a best safety and efficacy profile. STUDY QUESTION: Which therapeutic strategy, among antiarrhythmic drugs and catheter ablation (CA), offers the most effective and safe approach in patients with ICDs? DATA SOURCES: Randomized controlled trials (RCTs) comparing the efficacy and safety of antiarrhythmic drugs or CA against a placebo group. RCTs were identified from a comprehensive search in PubMed, Embase, and Cochrane library. STUDY DESIGN: Our outcomes of interest were reductions in appropriate ICD shocks, inappropriate ICD shocks, and overall mortality. We used the event rates in both groups, and then using a frequentist approach employing a graph theory methodology, we constructed a network meta-analysis model. RESULTS: Fourteen RCTs with 3815 participants and 6 different interventions treatments were included in our network meta-analysis. The most effective treatment for the prevention of recurrent ventricular tachycardia after ICD is amiodarone followed by CA. Amiodarone is most effective in the reduction of appropriate and inappropriate ICD shocks with an odds ratio (OR) of 0.29 [95% confidence interval (CI), 0.11-0.74] and 0.15 (95% CI, 0.04-0.60), respectively. CA was effective in the reduction of appropriate ICD shocks (OR, 0.41; 95% CI, 0.20-0.87), whereas sotalol was effective in the reduction of inappropriate ICD shocks (OR, 0.46; 95% CI, 0.22-0.95). There was no significant reduction in the overall mortality from any therapy. There was a trend of increased mortality associated with amiodarone therapy (OR, 2.40; 95% CI, 0.92-6.26). CONCLUSIONS: Amiodarone remains the most efficacious therapy for the reduction of appropriate and inappropriate shocks in patients with ICD. No therapy resulted in mortality reduction, but amiodarone showed a trend toward increased mortality.


Assuntos
Desfibriladores Implantáveis , Insuficiência Cardíaca/prevenção & controle , Prevenção Secundária/métodos , Taquicardia Ventricular/prevenção & controle , Antiarrítmicos/administração & dosagem , Antiarrítmicos/efeitos adversos , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/métodos , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Humanos , Meta-Análise em Rede , Recidiva , Taquicardia Ventricular/complicações , Taquicardia Ventricular/mortalidade , Resultado do Tratamento
10.
J Cardiovasc Med (Hagerstown) ; 20(6): 372-378, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30950985

RESUMO

BACKGROUND: Finding of intracardiac lead masses in patients with cardiac implantable electronic devices remains controversial, as such masses have been observed in cases of exclusively local infections whereas they have not been recognized in patients with positive cultures of intravascular lead fragments. In this study, we aim to describe the prevalence of intracardiac lead masses in true asymptomatic patients with cardiac implantable electronic devices, to identify their predictive factors and to define their prognostic impact at long-term follow-up. METHODS: Seventy-eight consecutive patients admitted over a 6-month period for elective generator replacement without clinical evidence of infection were evaluated by transthoracic and transesophageal echocardiography and prospectively followed at in-clinic follow-up visits. RESULTS: Lead masses were found in 10 patients (12.8%). These patients had more frequently right ventricular dysfunction at univariate analysis (OR 2.71, P = 0.010) and after baseline variables adjustment (hazard ratio 6.25, P = 0.012). At 5-year follow-up without any specific therapy, none of the patients suffered from any cardiac device infections, or developed clinical signs of infections. CONCLUSION: There is an evidence of clinical lead masses in asymptomatic patients with cardiac implantable electronic devices. The value of these findings is still debated for aetiological interpretation and for therapeutic strategy, but they are not necessarily associated with an infection.


Assuntos
Estimulação Cardíaca Artificial/efeitos adversos , Desfibriladores Implantáveis/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Cardiopatias/epidemiologia , Marca-Passo Artificial/efeitos adversos , Infecções Relacionadas à Prótese/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Remoção de Dispositivo , Ecocardiografia Transesofagiana , Feminino , Cardiopatias/diagnóstico por imagem , Cardiopatias/cirurgia , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/cirurgia , Fatores de Tempo
11.
Scand Cardiovasc J ; 53(2): 71-76, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30958708

RESUMO

OBJECTIVES: The study sought to assess the prognostic impact of recurrences of electrical storm (ES-R) on mortality, rehospitalization and major adverse cardiac events (MACE). BACKGROUND: Data on the prognostic impact of ES-R is rare. METHODS: All consecutive ES patients with an implantable cardioverter defibrillator (ICD) were included retrospectively from 2002 to 2016. Patients with ES-R were compared to patients without ES-R. The primary endpoint was all-cause mortality, secondary endpoints were in-hospital mortality, rehospitalization and MACE. RESULTS: A total of 87 consecutive ES patients with an ICD were included, of which 26% presented with ES-R at 2.5 years of follow-up. ES-R patients revealed lower LVEF compared to non-ES-R patients (91% vs. 61%; p = .081). There was a numerically higher rate of the primary endpoint of all-cause mortality at 2.5 years (50% vs. 32%; log-rank p = .137). Furthermore, ES-R was associated with increasing rates of rehospitalization (64% vs. 37%; p = .031; HR 1.985; 95% CI 1.025-3.845; log-rank p = .042), especially of acute heart failure (32% vs. 12%; p = .001; HR 3.262; 95% CI 1.180-9.023; log rank p = .023). MACE were higher in ES-R patients (55% vs. 35%; p = .113; log rank p = .141). ES patients with LVEF ≤35% were 12.4 times more likely to develop ES-R (HR 12.417; 95% CI 1.329-115.997; p = .027). CONCLUSION: At long-term follow-up of 2.5 years, ES-R was associated with numerically higher rates of long-term all-cause mortality and significantly higher rates of rehospitalization due to acute heart failure. LVEF ≤35% was associated with increased risk of ES-R. Condensed Abstract This study examined retrospectively the impact of recurrences of electrical storm (ES-R) on survival in 87 patients. ES-R was associated with numerically higher long-term all-cause mortality, whereas significantly higher rates of rehospitalization, respectively of acute heart failure were observed. Highlights ES-R is associated with numerically higher rates of all-cause mortality at long-term follow-up. ES-R is associated with significantly higher rates of rehospitalization and numerically higher rates of MACE at long-term follow-up, mainly due to acute heart failure. Patients with LVEF ≤35% were 12.4 times more likely to develop ES-R.


Assuntos
Cardioversão Elétrica , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Desfibriladores Implantáveis , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Recidiva , Retratamento , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/fisiopatologia , Função Ventricular Esquerda , Adulto Jovem
12.
BMJ Case Rep ; 12(4)2019 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-31015234

RESUMO

Splenic laceration and rupture are common phenomena among patients in a traumatic setting, especially in blunt trauma. Much more unusual, however, is splenic injury without a known insult. Several case reports and studies have been written about spontaneous splenic injury in patients with viral, haematological or malignant processes. Recently, we encountered a patient with a spontaneous splenic rupture and no preceding trauma apart from semielective cardioversion. Operative decision-making was complicated by the fact that he required systemic anticoagulation for atrial fibrillation. He eventually underwent splenectomy and made an uneventful recovery.


Assuntos
Flutter Atrial/diagnóstico , Cardioversão Elétrica/efeitos adversos , Ruptura Esplênica/etiologia , Idoso , Flutter Atrial/diagnóstico por imagem , Flutter Atrial/fisiopatologia , Flutter Atrial/terapia , Diagnóstico Diferencial , Ecocardiografia Transesofagiana/métodos , Hemoperitônio/diagnóstico por imagem , Humanos , Masculino , Baço/diagnóstico por imagem , Baço/lesões , Esplenectomia/métodos , Ruptura Esplênica/diagnóstico por imagem , Ruptura Esplênica/cirurgia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
13.
Int J Cardiovasc Imaging ; 35(9): 1587-1596, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30993507

RESUMO

Atrial fibrillation (AF) is the most common arrhythmia in humans. After successful cardioversion, there is a recurrence of 60% due to atrial remodeling, and it has been shown that the global peak atrial longitudinal strain (GPALS) is decreased in these subjects. The aim of this study was to evaluate the predictive value of GPALS for AF recurrence. A prospective cohort of patients with persistent (PnVAF) and long standing persistent non-valvular AF (LSPnVAF) which underwent electrical cardioversion was evaluated with standard echocardiographic variables and GPALS quantification. The primary endpoint was AF recurrence at 6 months. We included PnVAF (n = 50, aged 68.4 ± 10.2 years, female 46%, lasted AF 6 months) and LSPnVAF (n = 81, aged 66.5 ± 13.1 years, female 36%, lasted AF 18 months). At 6 months there were a 68% of recurrence of AF in PnVAF and 53% in LSPnVAF group. GPALS was lower in recurrence 7.8 ± 2.0% versus 21.2 ± 8.9% (p < 0.001) for PnVAF and 7.3 ± 2.7% versus 20.7 ± 7.6% (p < 0.001) in LSPnVAF. GPALS ≤ 10.75% discriminates recurrence at 6 months with a sensitivity of 85%, specificity 99%, PPV 85%, NPV 90%, LR + 8.5 and LR- 0.17. The independent predictors of recurrence in PnVAF were GPALS ≤ 10.75% HR 8.89 [(2.2-35.7), p < 0.01] meanwhile in LSPnVAF were age HR 1.039 [(1.007-1.071), p = 0.01], and GPALS ≤ 10.75% HR 28.1 [(7.2-109.1), p < 0.001]. In subjects with PnVAF and LSPnVAF with successful electrical cardioversion, GPALS ≤ 10.75% predicts arrhythmia recurrence at 6-month follow-up.


Assuntos
Fibrilação Atrial/terapia , Função do Átrio Esquerdo , Ecocardiografia Doppler de Pulso/métodos , Cardioversão Elétrica/efeitos adversos , Átrios do Coração/diagnóstico por imagem , Interpretação de Imagem Assistida por Computador/métodos , Contração Miocárdica , Idoso , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Fenômenos Biomecânicos , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recidiva , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
14.
Int J Cardiovasc Imaging ; 35(9): 1549-1555, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30941564

RESUMO

The transient left atrial appendage (LAA) dysfunction after electrical cardioversion (CV), which is called as LAA-stunning, was found to be an important etiology of thrombus formation. The aim of the present study was to investigate the risk factors of LAA-stunning. This study included 134 patients who underwent catheter ablation for non-paroxysmal, non-valvular, and symptomatic atrial fibrillation (AF). Internal-CV was performed, and LAA emptying fraction (LAA-EF) was assessed using LAA-angiogram before and just after CV. LAA-stunning (defined as 10% reduction of LAA-EF after CV) was observed in 45/134 patients (34%). Patients in LAA-stunning group had longer duration of AF prior to CV, higher brain natriuretic peptide (BNP), higher prevalence of patients taking calcium blocker, larger left atrial (LA) diameter, elevated E wave, and larger LA volume than those in non LAA-stunning group. Multivariate analysis showed that longer duration of AF prior to CV (p = 0.015, OR 1.033 for 1 month extend, 95% CI 1.006-1.073) and elevated BNP (p = 0.038, OR 1.041 for each 10 pg/mL increase, 95% CI 1.001-1.009) were associated with LAA-stunning. In addition, all patients were divided into four groups based on the combination between duration of AF prior to CV and BNP; group 1 (low BNP/short-lasting AF), group 2 (high BNP/short-lasting AF), group 3 (low BNP/long-lasting AF), and group 4 (high BNP/long-lasting AF). The rate of LAA-stunning was the highest in the group 4 (55.6%). Elevated BNP and long duration of AF were associated with LAA stunning after electrical cardioversion.


Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/terapia , Função do Átrio Esquerdo , Cardioversão Elétrica/efeitos adversos , Miocárdio Atordoado/etiologia , Idoso , Antiarrítmicos/administração & dosagem , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Biomarcadores/sangue , Bloqueadores dos Canais de Cálcio/administração & dosagem , Esquema de Medicação , Ecocardiografia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio Atordoado/diagnóstico por imagem , Miocárdio Atordoado/fisiopatologia , Peptídeo Natriurético Encefálico/sangue , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima
16.
N Engl J Med ; 380(16): 1499-1508, 2019 04 18.
Artigo em Inglês | MEDLINE | ID: mdl-30883054

RESUMO

BACKGROUND: Patients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously. METHODS: In a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than -10. RESULTS: The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, -2.9 percentage points; 95% confidence interval [CI], -8.2 to 2.2; P = 0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively. CONCLUSIONS: In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks. (Funded by the Netherlands Organization for Health Research and Development and others; RACE 7 ACWAS ClinicalTrials.gov number, NCT02248753.).


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Cardioversão Elétrica , Tempo para o Tratamento , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Antiarrítmicos/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Digoxina/uso terapêutico , Cardioversão Elétrica/efeitos adversos , Serviço Hospitalar de Emergência , Feminino , Frequência Cardíaca , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Recidiva , Resultado do Tratamento
17.
J Cardiovasc Med (Hagerstown) ; 20(4): 169-179, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30829875

RESUMO

AIMS: Atrial fibrillation incidence is increasing due to ageing population and electrical cardioversion (ECV) is overused because of atrial fibrillation recurrences. Study's aim was to evaluate value of novel three-dimensional echocardiographic-derived left atrial conduit (LAC) function quantification in predicting early atrial fibrillation recurrence after ECV. METHODS: We included 106 patients [74 (64-78) years] who underwent ECV for persistent nonvalvular atrial fibrillation. For all clinical data and simultaneous left atrial and left ventricular (LV) three-dimensional full-volume data sets were available before ECV. We computed LAC as: [(LV maximum - LV minimum) - (left atrial maximum - left atrial minimum) volume], expressed as % LV stroke volume. Atrial fibrillation recurrence was checked with Holter monitoring. RESULTS: One month after ECV 66 patients were in sinus rhythm and 40 experienced atrial fibrillation recurrence. Pre-ECV patients with atrial fibrillation recurrence showed higher LAC contribution to LV filling (P < 0.0001) and noninvasively estimated left atrial stiffness (P < 0.0001) compared with sinus rhythm patients. There were no other differences, neither in clinical characteristics nor in LV properties. At multivariate LAC (P < 0.001), left atrial stiffness (P = 0.002) and volume (P = 0.043) predicted early atrial fibrillation relapse, even when compared with other confounding factors. Receiver-operating characteristics area (ROC) analysis confirmed LAC as best atrial fibrillation recurrence predictor (0.84, P < 0.0001), cut-off value more than 54% exhibiting reasonable sensibility-specificity (76-75%). CONCLUSION: Atrial fibrillation makes LV filling dependent on reciprocation between left atrial reservoir/conduit phases. Our data suggest that LAC larger contribution to filling in persistent atrial fibrillation patients reflects left atrial and LV diastolic dysfunction, which skews atrio-ventricular interaction that leads to atrial fibrillation perpetuation, making LAC a powerful atrial fibrillation recurrence predictor after ECV.


Assuntos
Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Função do Átrio Esquerdo , Ecocardiografia Tridimensional , Cardioversão Elétrica , Átrios do Coração/diagnóstico por imagem , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/fisiopatologia , Cardioversão Elétrica/efeitos adversos , Eletrocardiografia Ambulatorial , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recidiva , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologia
18.
J Am Coll Cardiol ; 73(5): 589-597, 2019 02 12.
Artigo em Inglês | MEDLINE | ID: mdl-30732713

RESUMO

BACKGROUND: Arrhythmias, conduction abnormalities, and intracardiac thrombus are common in patients with cardiac amyloidosis (CA). Outcomes of direct-current cardioversion (DCCV) for atrial arrhythmias in patients with CA are unknown. OBJECTIVES: This study sought to examine DCCV procedural outcomes in patients with CA. METHODS: Patients with CA scheduled for DCCV for atrial arrhythmias from January 2000 through December 2012 were identified and matched 2:1 with control patients by age, sex, type of atrial arrhythmia, and date of DCCV. RESULTS: CA patients (n = 58, mean age 69 ± 9 years, 81% male) were included. CA patients had a significantly higher cardioversion cancellation rate (28% vs. 7%; p < 0.001) compared with control patients, mainly due to intracardiac thrombus identified on transesophageal echocardiogram (13 of 16 [81%] vs. 2 of 8 [25%]; p = 0.02); 4 of 13 of the CA patients (31%) with intracardiac thrombus on transesophageal echocardiogram received adequate anticoagulation ≥3 weeks and another 2 of 13 (15%) had arrhythmia duration <48 h. DCCV success rate (90% vs. 94%; p = 0.4) was not different. Procedural complications were more frequent in CA versus control patients (6 of 42 [14%] vs. 2 of 106 [2%]; p = 0.007); complications in CA included ventricular arrhythmias in 2 and severe bradyarrhythmias requiring pacemaker implantation in 2. The only complication in the control group was self-limited bradyarrhythmias. CONCLUSIONS: Patients with CA undergoing DCCV had a significantly high cancellation rate mainly due to a high incidence of intracardiac thrombus even among patients who received adequate anticoagulation. Although the success rate of restoring sinus rhythm was high, tachyarrhythmias and bradyarrhythmias complicating DCCV were significantly more frequent in CA patients compared with control patients.


Assuntos
Amiloidose , Fibrilação Atrial , Cardioversão Elétrica , Cardiopatias , Trombose , Idoso , Amiloidose/complicações , Amiloidose/diagnóstico , Fibrilação Atrial/etiologia , Fibrilação Atrial/terapia , Contraindicações de Procedimentos , Ecocardiografia Transesofagiana/métodos , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/métodos , Feminino , Cardiopatias/complicações , Cardiopatias/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Estudos Retrospectivos , Risco Ajustado , Trombose/diagnóstico por imagem , Trombose/etiologia
19.
Circulation ; 139(8): 1080-1093, 2019 02 19.
Artigo em Inglês | MEDLINE | ID: mdl-30779645

RESUMO

This in-depth review of sex differences in advanced heart failure therapy summarizes the existing literature on implantable cardioverter defibrillators, biventricular pacemakers, mechanical circulatory support, and transplantation with a focus on utilization, efficacy/clinical effectiveness, adverse events, and controversies. One will learn about the controversies regarding efficacy/clinical effectiveness of implantable cardioverter defibrillators and understand why these devices should be implanted in women even if there are sex differences in appropriate shocks. Individuals will learn about the sex differences with biventricular pacemakers with respect to ventricular remodeling and reduction in heart failure hospitalizations/mortality, as well as, possible mechanisms. We will demonstrate sex differences in heart transplantation and waitlist survival. Despite similar survival for women and men with left ventricular assist devices, there are sex differences in adverse events. These devices do successfully bridge women and men to transplant, yet women are less likely than men to have a left ventricular assist at time of listing and time of transplantation. Finally, one will learn about the concerns regarding poor outcome for men who receive female donor hearts and discover this may not be due to sex, but rather size. More research is needed to better understand sex differences and further improve advanced heart failure therapy for both women and men.


Assuntos
Terapia de Ressincronização Cardíaca , Cardioversão Elétrica , Circulação Extracorpórea , Disparidades em Assistência à Saúde , Insuficiência Cardíaca/terapia , Transplante de Coração , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/mortalidade , Dispositivos de Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Circulação Extracorpórea/efeitos adversos , Circulação Extracorpórea/mortalidade , Feminino , Disparidades nos Níveis de Saúde , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Transplante de Coração/mortalidade , Humanos , Masculino , Fatores de Risco , Fatores Sexuais , Resultado do Tratamento
20.
Int Heart J ; 60(2): 318-326, 2019 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-30745538

RESUMO

Implantable cardioverter-defibrillators (ICDs) improve survival in patients who are at risk of sudden death. However, inappropriate therapy is commonly given to ICD recipients, and this situation may be associated with an increased risk of death. This study aimed to construct a risk stratification scheme by using decision tree analysis in patients who received inappropriate ICD therapy.Mortality was calculated from a retrospective data analysis of a multicenter cohort involving 417 ICD recipients. Inappropriate therapy was defined as therapy for nonventricular arrhythmias, including sinus tachycardia, supraventricular tachycardia, atrial fibrillation/flutter, oversensing, and lead failure. Inappropriate therapy included antitachycardia pacing, cardioversion, and defibrillation. The prognostic factors were identified by a Cox proportional hazards regression analysis, and we constructed a decision tree.During an average follow-up of 5.2 years, 48 patients (12%) had all-cause death. A multivariate Cox hazard model revealed that the age (hazard ratio [HR] 1.06, P < 0.001), ln B-type natriuretic peptide (BNP) (HR 1.47, P = 0.02), nonsinus rhythm at implantation (HR 2.70, P < 0.05), and inappropriate therapy occurring during sedentary/awake conditions (HR 3.51, P = 0.001) correlated with an increased risk of mortality. An inappropriate therapy due to abnormal sensing (HR 0.16, P = 0.04) decreased the risk of mortality. Furthermore, a decision tree analysis stratified the patients well by using 4 covariates: BNP, activity at the time of inappropriate therapy, mechanism of inappropriate therapy, and baseline rhythm at ICD implantation (log-rank test, P < 0.0001).We identified the predictors of mortality in inappropriate ICD therapy recipients and constructed a risk stratification scheme by using decision tree analysis.


Assuntos
Arritmias Cardíacas , Morte Súbita Cardíaca , Desfibriladores Implantáveis/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Falha de Equipamento/estatística & dados numéricos , Idoso , Arritmias Cardíacas/classificação , Arritmias Cardíacas/complicações , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/terapia , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Árvores de Decisões , Desfibriladores Implantáveis/estatística & dados numéricos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/métodos , Análise de Falha de Equipamento/métodos , Feminino , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Análise de Sobrevida
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