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1.
Am Heart J ; 221: 29-38, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31901798

RESUMO

BACKGROUND: In patients with paroxysmal atrial fibrillation (PAF), 10%-15% of patients require repeat procedures after second-generation cryoballoon pulmonary vein isolation (CB-PVI). We sought to explore the mechanisms of recurrences after cryoballoon ablation. METHODS: The data of 122 PAF patients who underwent second procedures for recurrent arrhythmias 7.0 (4.0-12.0) months after the CB-PVI were analyzed. During second procedures, non-PV AF foci were explored with isoproterenol, adenosine, and repetitive cardioversions. RESULTS: In total, 378/487 (77.6%) PVs remained isolated, and reconnections were not observed in any PVs in 59 (48.4%) patients. PV reconnections were associated with recurrences in 38 (31.1%) patients, of whom 33 (86.8%) had reconnections of at least 1 upper PV. In 6 (4.9%) patients, non-PV AF foci were identified in the upper PV antra where cryoballoons cannot isolate but within the circumferential radiofrequency PVI line. Non-PV AF foci were identified in the superior vena cava, right atrial body, left atrial body, and atrial septum in 28 (23.0%), 18 (14.7%), 4 (3.3%), and 5 (4.1%) patients, respectively. Twelve (9.8%) patients had multiple non-PV AF foci. Four (3.3%), 3 (2.4%), and 8 (6.5%) patients underwent second procedures for atrioventricular nodal reentrant tachycardia, atrial flutter, and atrial tachycardias. During 16.0 (8.0-24.0) months of follow-up, freedom from any atrial arrhythmia at 1 year and 2 years after the second procedure was 79.2% and 60.6%. Nineteen (15.5%) patients had antiarrhythmic drug therapy at the last follow-up. CONCLUSIONS: Our study suggested that improvement in the upper PV PVI durability, eliminating arrhythmogenic superior vena cavae and coexisting atrial arrhythmias, and bonus cryoballoon applications at PV antra might improve the single procedure outcome in cryoballoon ablation.


Assuntos
Fibrilação Atrial/cirurgia , Flutter Atrial/fisiopatologia , Criocirurgia/métodos , Átrios do Coração/cirurgia , Veias Pulmonares/cirurgia , Taquicardia Supraventricular/fisiopatologia , Idoso , Fibrilação Atrial/fisiopatologia , Flutter Atrial/cirurgia , Septo Interatrial/fisiopatologia , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Veias Pulmonares/fisiopatologia , Recidiva , Reoperação , Taquicardia Supraventricular/cirurgia , Veia Cava Superior/fisiopatologia
3.
J Cardiovasc Med (Hagerstown) ; 20(10): 660-666, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31361652

RESUMO

AIMS: Blood stasis is the main cause of left atrial thrombosis (LAT) in atrial tachyarrhythmias. The high-velocity flow inside the left atrium, due to mitral valve regurgitation, may prevent clot formation but the topic has never been investigated in large-scale studies. The aim of our study was to evaluate whether the presence and degree of mitral regurgitation have a protective role against LAT risk. METHODS: A total of 1302 consecutive adult patients with paroxysmal or persistent atrial fibrillation or flutter undergoing cardioversion, submitted to transesophageal echocardiography, were retrospectively enrolled in the study. The study population was divided into three groups according to the mitral regurgitation degree: absent, mild-to-moderate and severe. RESULTS: Among 1302 patients enrolled in the study, patients without mitral regurgitation were 248 (19%), those with mild-to-moderate 970 (75%), whereas 84 had severe mitral regurgitation (6%). LAT incidence was significantly lower in patients with severe mitral regurgitation compared with those with mild-to-moderate (mitral regurgitation) (2.4 vs. 8.9%, P < 0.05), and similar to subjects without mitral regurgitation (2.4%). CONCLUSION: Despite patients with severe regurgitation having clinical and echo characteristics predisposing to LAT (higher age, heart failure, higher atrial size, lower ventricular function) thrombosis prevalence was significantly lower than for those with mild-to-moderate mitral regurgitation. The percentage of LAT in severe mitral regurgitation cases was very low and similar to that of cases without regurgitation which were characterized by lower age, normal left ventricular function or other risk factors, reinforcing the hypothesis of a protecting role against atrial thrombosis of mitral regurgitation.


Assuntos
Fibrilação Atrial/fisiopatologia , Flutter Atrial/fisiopatologia , Hemodinâmica , Insuficiência da Valva Mitral/fisiopatologia , Valva Mitral/fisiopatologia , Trombose/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Flutter Atrial/diagnóstico , Flutter Atrial/epidemiologia , Ecocardiografia Transesofagiana , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/epidemiologia , Prevalência , Fatores de Proteção , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Trombose/diagnóstico , Trombose/epidemiologia , Trombose/fisiopatologia
4.
Clin Cardiol ; 42(7): 678-683, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31056764

RESUMO

INTRODUCTION: A common approach to patients, who developed atrial flutter secondary to treatment with class 1C anti-arrhythmic drugs for atrial fibrillation (AF) (1C flutter), is a hybrid approach: ablation of the Cavo-Tricuspid isthmus (CTI) and continuation 1C medical treatment to prevent recurrence of AF. We aim to explore the clinical outcome of patients treated in this approach. METHODS AND RESULTS: Two hundred and four consecutive patients who underwent ablation for typical AFL at a tertiary medical center between 2010 and 2016 were enrolled and followed up. The clinical outcome of patient treated by the hybrid approach (treatment group; n = 67) was compared to patient without history of AF (control group; n = 137). The primary endpoint was time to occurrence of AF. Twenty-eight (41.8%) patients in treatment group had AF occurrence in 1 year, including 9 (13.4%) patients who needed to escalate anti-arrhythmic drug treatment to class III, and 11 (16.4%) patients who underwent AF ablation. In comparison, only 21 (15.3%) patients in control group had occurrence during the first year after ablation. The median time from ablations till AF occur was 106 ± 481 days in treatment group, and 403 ± 668 days in control group (P < .01). CONCLUSIONS: There is a relatively high rate of AF recurrence in patients treated with the hybrid approach during the first year after CTI ablation. An alternative approach should be considered in this selected population.


Assuntos
Antiarrítmicos/uso terapêutico , Flutter Atrial/tratamento farmacológico , Ablação por Cateter/métodos , Idoso , Flutter Atrial/fisiopatologia , Flutter Atrial/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Recidiva , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
5.
Scand Cardiovasc J ; 53(3): 133-140, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31032647

RESUMO

Objectives. Left atrial flutter has been reported in up to 10% of patients following pulmonary vein isolation or cardiac surgery. Left atrial flutter is typically highly symptomatic, responds poorly to medical antiarrhythmic treatment, and is often treated by catheter ablation. We aimed to investigate midterm freedom from recurrent arrhythmia after catheter ablation for left atrial flutter. Design. In the National Danish Ablation Registry, we identified consecutive patients, who had undergone catheter ablation for left atrial flutter between 1 January 2014 and 1 April 2017 at our centre. Results. A total of 53 patients (median age 68 years (IQR 60-71) 37 (70%) male) were included. Forty-two patients had prior left atrial catheter ablation procedures (79%), one patient prior ablation for classic atrial flutter (2%), four patients had prior surgery for congenital heart disease (8%), and six patients (11%) had no previous cardiac intervention. Acute procedural success, defined as non-inducibility of any atrial arrhythmia, was achieved in 45 of 53 patients (85%). During midterm follow-up (mean 20 ± 12 months), 26 patients experienced an episode of recurrent atrial arrhythmia. Median EHRA-score was 3 (range 2-4) before catheter ablation and reduced to median 1 (range 1-3) evaluated at follow-up visits after three and twelve months (both p < .001, Wilcoxon rank test). Conclusion. Left atrial flutter is preceded by catheter ablation or cardiac surgery in 89% of patients. Acute procedural success is achieved in majority of patients and ablation reduces symptoms effectively. During midterm follow-up, almost half the patients experience recurrent atrial arrhythmia.


Assuntos
Flutter Atrial/cirurgia , Ablação por Cateter , Idoso , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Dinamarca , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
6.
Orv Hetil ; 160(14): 540-548, 2019 Apr.
Artigo em Húngaro | MEDLINE | ID: mdl-30931601

RESUMO

INTRODUCTION: Levels of cardiac necroenzymes, high-sensitive troponin (hsTnT) and creatine kinase muscle-brain (CKMB) increase as a result of a myocardial damage following catheter ablation. AIM: To analyze the mid-term alteration of hsTnT and CKMB levels following radiofrequency ablation (RFCA) for atrial fibrillation (AF), atrial flutter (AFlu), AV-nodal reentry tachycardia (AVNRT) and electrophysiological studies (EPS) without ablation. METHOD: Patients undergoing RFCA for various indications and EPS were consecutively enrolled in our prospective study. Concentrations of hsTnT and CKMB were measured from serial blood samples directly before and after the procedure, 4 and 20 hours later and at 3 months follow-up. RESULTS: Forty-seven patients (10 EPS, 12 AVNRT, 13 AFlu, 12 AF) with mean age of 55 ± 13 were included. hsTnT levels increased significantly in all groups after the procedures, while CKMB changed only in the AF group. hsTnT exceeded the reference value in all patients with ablation and in 80% of patients with EPS 4 hours post-ablation. Peak average hsTnT levels for EPS, AVNRT, AFlu were 24 ± 11, 260 ± 218 and 541 ± 233 ng/L, respectively. The highest hsTnT level was measured in the AF group (799 ± 433 ng/L). We found a positive correlation between hsTnT levels and ablation time after RFCA. CONCLUSIONS: The hsTnT levels significantly change after EPS and RFCA, in all patients who underwent ablation, and in 80% of those with EPS had hsTnT positivity in the early post-procedural phase. hsTnT levels depended significantly on the type of the subgroups and correlated with the ablation time. Awareness of those observations is essential to correctly interpret elevated hsTnT levels following RFCA. Orv Hetil. 2019; 160(14): 540-548.


Assuntos
Arritmias Cardíacas/cirurgia , Ablação por Cateter/efeitos adversos , Infarto do Miocárdio/complicações , Adulto , Idoso , Arritmias Cardíacas/sangue , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Flutter Atrial/fisiopatologia , Flutter Atrial/cirurgia , Biomarcadores/sangue , Ablação por Cateter/métodos , Creatina Quinase Mitocondrial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ablação por Radiofrequência , Resultado do Tratamento , Troponina/sangue
7.
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
8.
Circ Arrhythm Electrophysiol ; 12(3): e006955, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30866664

RESUMO

Background Although entrainment mapping is an established approach to atypical atrial flutter ablation, postpacing intervals shorter than tachycardia cycle length (difference between postpacing interval and tachycardia cycle length [dPPI] <0 ms) remain of unknown significance. We sought to compare anatomic and electrophysiological properties of sites with dPPI <0, dPPI=0-30, and dPPI >30 ms. Methods We studied 24 noncavotricuspid isthmus-dependent macroreentrant atypical atrial flutter in 19 consecutive patients. Ultra high-density electroanatomic activation maps were acquired with a 64-electrode basket catheter. Entrainment mapping was performed at multiple candidate sites. Ablation was performed at the narrowest accessible slow-conducting critical isthmuses. Results Of 102 entrainment mapping sites, dPPI <30 was observed at 72 sites on complete maps of 24 atypical atrial flutter. Compared with dPPI=0-30 sites (N=45), dPPI<0 sites (N=27) were more commonly located within isthmuses <15 mm wide (67% versus 6.7%, P<0.00001; odds ratio, 28.0; 95% CI, 6.8-115.7), more frequently located within 5 mm of the leading wavefront (93% versus 64%, P=0.008), exhibited slower local conduction velocity (0.49±0.43 versus 0.93±0.57 m/s, P=0.0005), lower voltages (0.48±0.79 versus 0.92±0.97 mV, P=0.04), and more frequently fractionated electrograms (67% versus 24%, P=0.0004). High rates of arrhythmia termination or cycle length increase >15 ms by ablation were observed in both dPPI groups (94% versus 86%, P=0.53). Compared with all dPPI <30, dPPI >30 sites (N=30) were less commonly observed within isthmuses (3.3%, P<0.001) or within 5 mm of the leading wavefront (30%, P<0.0001); conduction velocity (1.0±0.7 m/s, P=0.002) and voltage (1.1±1.4 mV, P=0.049) were higher compared with dPPI<0 but similar to dPPI=0-30 sites. Conclusions In atypical atrial flutter, sites with dPPI <0 are markers of limited width critical isthmuses with slower conduction velocity, whereas sites with dPPI=0-30 ms are often not in close proximity to the reentry circuit. Virtual electrode simultaneous down and upstream (antidromic) capture of a confined isthmus of slow conduction can explain a dPPI <0. Identifying these sites may improve selective and efficient ablation strategies compared with the standard 30-ms threshold.


Assuntos
Potenciais de Ação , Flutter Atrial/diagnóstico , Estimulação Cardíaca Artificial/métodos , Técnicas Eletrofisiológicas Cardíacas , Átrios do Coração/fisiopatologia , Frequência Cardíaca , Idoso , Idoso de 80 Anos ou mais , Flutter Atrial/fisiopatologia , Flutter Atrial/cirurgia , Ablação por Cateter , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Átrios do Coração/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Fatores de Tempo
10.
Am J Health Syst Pharm ; 76(4): 214-220, 2019 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-30715182

RESUMO

Purpose: The study was designed to characterize "on-label" use of i.v. diltiazem in patients with acute atrial fibrillation or flutter (AFF). Methods: An IRB-approved, single-center, retrospective, observational design was used. Eligible patients had acute AFF with heart rate >120 bpm and received i.v. diltiazem from June 1, 2012, to June 30, 2014. The primary outcome was frequency of on-label use of i.v. diltiazem, defined as use of at least one FDA-approved weight-based bolus dose followed by an infusion, if appropriate, in the absence of contraindications. Results: A total of 300 patients were screened; 97 patients were included for analysis. I.V. diltiazem was used on-label in only 14 patients (14%). Of the 96 patients who received an initial diltiazem bolus injection, the median dose was significantly higher in patients for whom the diltiazem dose was on-label, as follows: 17.5 mg (interquartile range [IQR]), 10-20 mg vs. 10.0 mg (IQR, 10-20 mg), p < 0.02). Twenty-nine patients (35%) in the off-label group had a therapeutic response to diltiazem alone compared with 8 patients (57%) in the on-label group (p = 0.11). More patients treated with off-label diltiazem bolus injection required additional rate control medications (41% vs. 7%, p < 0.04). Conclusion: In most patients, i.v. diltiazem was not used in accordance with FDA labeling. For most, i.v. diltiazem doses were lower than recommended and many of these patients required additional rate control medications to achieve a therapeutic response.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Flutter Atrial/tratamento farmacológico , Fármacos Cardiovasculares/administração & dosagem , Diltiazem/administração & dosagem , Frequência Cardíaca/efeitos dos fármacos , Doença Aguda , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Relação Dose-Resposta a Droga , Feminino , Frequência Cardíaca/fisiologia , Humanos , Infusões Intravenosas , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
Circ Arrhythm Electrophysiol ; 12(1): e006933, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30606034

RESUMO

BACKGROUND: The mitral isthmus is the critical element of perimitral reentrant tachycardias. Prolongation in transisthmus conduction time and differential pacing techniques are commonly used to determine block. However, these may not distinguish block from slow conduction or conduction via epicardial bridging connections. The aim of this study was to examine these standard criteria for mitral line block with endocardial and epicardial activation mapping. METHODS: In 56 patients, posterior mitral line was performed using radiofrequency ablation. Conduction block was defined as transisthmus time (≥100 ms) and reversal of coronary sinus activation during pacing from the left atrial appendage. These results were compared with high-resolution activation mapping (Rhythmia) of the endocardium and epicardium via the coronary sinus. RESULTS: Mitral block determined by pacing was achieved in 51 out of 56 (91%) patients. In 11 out of 51 (21.6%), activation mapping demonstrated residual endocardial (3/11; 27.2%) or epicardial (8/11; 72.7%) connections. Epicardial bridging connections were distant from the line (2.4±1.6 cm), inserting laterally at the proximal-middle coronary sinus and septally at the left atrial ridge. Patients with residual conduction were prone to complex circuits involving the epicardium (7/11; 63.6%). Mitral line block was achieved in 75% by targeting these insertion site(s). The transisthmus conduction time had limited predictive value for distinguishing block from pseudoblock. CONCLUSIONS: Standard criteria for posterior mitral line block may not distinguish block from pseudoblock. In particular, epicardial bridging connections can result in prolonged transisthmus conduction time and reversal in coronary sinus activation to falsely suggest block. These connections are a frequent cause for complex circuits, and their insertion site(s) can be targeted for ablation.


Assuntos
Fibrilação Atrial/cirurgia , Flutter Atrial/cirurgia , Seio Coronário/cirurgia , Frequência Cardíaca , Valva Mitral/cirurgia , Veias Pulmonares/cirurgia , Ablação por Radiofrequência/métodos , Potenciais de Ação , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Estimulação Cardíaca Artificial , Seio Coronário/fisiopatologia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/fisiopatologia , Estudos Prospectivos , Veias Pulmonares/fisiopatologia , Ablação por Radiofrequência/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
13.
J Cardiovasc Electrophysiol ; 30(1): 16-24, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30230088

RESUMO

INTRODUCTION: It has not been previously investigated whether the recurrence mechanism after cryoballoon ablation (CBA) of paroxysmal atrial fibrillation (AF) is similar to that of radiofrequency catheter ablation (RFCA). We aimed to evaluate the differences of recurrence characteristics between RFCA and CBA after the index procedure. METHODS: A total of 210 patients were enrolled in the study, and 69 patients underwent pulmonary vein (PV) isolation using a 28-mm second-generation CBA. The control group comprising 140 patients underwent PV isolation using an open-irrigated radiofrequency ablation catheter. A total of 69 patients in the CBA group and 69 patients in the RFCA group were investigated after propensity score matching. Recurrence patterns of AF were studied in the repeated procedure. RESULTS: During the index procedure, there was no difference in PV or non-PV triggers between the two groups. Nineteen (27.5%) patients in the CBA group and 19 (27.5%) patients in the RFCA group had recurrence after a follow-up of 11.3 ± 7 months. The Kaplan-Meier curve did not reveal significant difference in recurrence (log-rank, P = 0.364) between the two groups. In the second procedure, the CBA group had more non-PV triggers (63.6%, P = 0.009) and left atrial (LA) flutters (54.5%, P = 0.027) compared with the RFCA group (12.5% and 12.5%, respectively). The PV reconnection rates were similar between both groups. CONCLUSIONS: There was no difference in AF recurrence after catheter ablation between CBA and RFCA, but significant increases of non-PV triggers and LA flutter during the second procedure suggest the importance of the atrial substrate in maintaining AF during the second procedure after previous CBA.


Assuntos
Fibrilação Atrial/cirurgia , Flutter Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Criocirurgia/efeitos adversos , Veias Pulmonares/cirurgia , Potenciais de Ação , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/etiologia , Flutter Atrial/fisiopatologia , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Veias Pulmonares/fisiopatologia , Recidiva , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
14.
J Cardiovasc Med (Hagerstown) ; 20(1): 16-22, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30394961

RESUMO

AIMS: Electrical cardioversion is still the preferred method to restore sinus rhythm in patients with atrial fibrillation. The main disadvantage is that electrical cardioversion requires deep sedation, generally administered by anaesthesiologists, for safety concern. An exclusively cardiologic management of deep sedation should have the advantage to reduce resources and time consumed. METHODS: All consecutive patients admitted to our division with persistent atrial fibrillation or atrial flutter to undergo elective electrical cardioversion from June 2002 to December 2016 were included. The sedation protocol was managed only by cardiologists and involved the administration of a 5-mg bolus of midazolam, followed by increasing doses of propofol to achieve the desired sedation level. Exclusion criteria were strictly observed. Complications were recorded. A retrospective analysis on a deidentified database has been performed. RESULTS: A total of 1188 electrical cardioversions were scheduled in our centre. A total of 1195 patients were scheduled in our centre, of whom 1188 met inclusion criteria. Electrical cardioversion was performed in 1073 cases (90.3%). Electrical cardioversion was successful in restoring sinus rhythm in 1030 (96.0%) patients. Immediate recurrence of atrial fibrillation occurred in 89 patients (8.3%). 99/1073 (9.22%) patients underwent trans-oesophagel echocardiography before cardioversion. Deep sedation, according to our protocol, was effective in 100% of cases. Midazolam was administered at a dosage of 5 mg to all patients, while propofol was administered at a dosage ranging from 20 to 80 mg (25.1 ±â€Š11.0 mg SD). No anaesthesia-related complications were observed, neither significant respiratory depression requiring intubation nor anaesthesiologist support. CONCLUSION: The exclusively cardiological procedure of deep sedation seems to be safe and effective.


Assuntos
Anestésicos Combinados/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Fibrilação Atrial/terapia , Flutter Atrial/terapia , Cardiologistas , Sedação Profunda/métodos , Cardioversão Elétrica , Midazolam/administração & dosagem , Propofol/administração & dosagem , Idoso , Anestésicos Combinados/efeitos adversos , Anestésicos Intravenosos/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Bases de Dados Factuais , Sedação Profunda/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Feminino , Humanos , Masculino , Midazolam/efeitos adversos , Pessoa de Meia-Idade , Propofol/efeitos adversos , Recidiva , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Fluxo de Trabalho
15.
Pacing Clin Electrophysiol ; 42(4): 470-473, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30430590

RESUMO

Escape mapping is a novel technique that can be used to locate sites of persistent conduction and achieve exit block during an atrial fibrillation ablation. This method allows for mapping solely with the ablation catheter in the left atrium by annotating to a catheter in the coronary sinus. We illustrate the utility escape mapping during an atrial fibrillation ablation where entrance block is achieved without exit block. We further expand upon this technique by describing the first reported case of escape mapping being used to achieve bidirectional block during an atrial flutter ablation.


Assuntos
Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Flutter Atrial/fisiopatologia , Flutter Atrial/cirurgia , Ablação por Cateter/métodos , Mapeamento Epicárdico , Sistema de Condução Cardíaco/fisiopatologia , Idoso , Seio Coronário/fisiopatologia , Seio Coronário/cirurgia , Ecocardiografia , Eletrocardiografia , Humanos , Masculino
16.
J Cardiovasc Electrophysiol ; 30(1): 78-88, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203499

RESUMO

INTRODUCTION: Fluoroscopy use during catheter ablation procedures increases the cumulative lifetime radiation exposure of patients and operators, potentially leading to a higher risk of cancer and radiation-related injuries. Nonfluoroscopic ablation (NFA) has been described for supraventricular tachycardia, typical atrial flutter, paroxysmal atrial fibrillation (AF), and outflow-tract ventricular tachycardia (VT). Complete transition to NFA of more complex arrhythmias, including persistent AF, left atrial (LA) flutter, and structural VT, has not been previously described. We describe the transition to completely NFA of complex arrhythmias, including LA flutter and structural VT. The techniques, challenges, limitations, and results are described. METHODS AND RESULTS: Complex ablation procedures were performed using intracardiac echocardiography (ICE) and a three-dimensional mapping system without fluoroscopy or lead protection. Eighty consecutive patients underwent NFA (mean age, 60.1 ± 9.9 years, 70 with LA arrhythmias, 10 with VT). All cases were performed without the need for rescue fluoroscopy. There was an initial increase in procedural time for ablation of LA arrhythmias upon transitioning to NFA. However, after excluding the first 20 NFA cases to allow for operator learning, the transition to NFA was not associated with an increase in mean procedural time (229 ± 38 vs 225 ± 32 minutes; P = 0.002 for noninferiority). All procedures were completed successfully with no complications. CONCLUSIONS: NFA of most complex arrhythmias (persistent AF, LA flutter, and structural VT) is feasible, with a modest learning curve and no increase in procedural times.


Assuntos
Fibrilação Atrial/cirurgia , Flutter Atrial/cirurgia , Ablação por Cateter/métodos , Ecocardiografia , Fenômenos Eletromagnéticos , Taquicardia Ventricular/cirurgia , Ultrassonografia de Intervenção/métodos , Idoso , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico por imagem , Flutter Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Fluxo de Trabalho
17.
Comput Biol Med ; 104: 319-328, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30558815

RESUMO

Atrial Flutter (AFL) termination by ablating the path responsible for the arrhythmia maintenance is an extended practice. However, the difficulty associated with the identification of the circuit in the case of atypical AFL motivates the development of diagnostic techniques. We propose body surface phase map analysis as a noninvasive tool to identify AFL circuits. Sixty seven lead body surface recordings were acquired in 9 patients during AFL (i.e. 3 typical, 6 atypical). Computed body surface phase maps from simulations of 5 reentrant behaviors in a realistic atrial structure were also used. Surface representation of the macro-reentrant activity was analyzed by tracking the singularity points (SPs) in surface phase maps obtained from band-pass filtered body surface potential maps. Spatial distribution of SPs showed significant differences between typical and atypical AFL. Whereas for typical AFL patients 70.78 ±â€¯16.17% of the maps presented two SPs simultaneously in the areas defined around the midaxialliary lines, this condition was only satisfied in 5.15 ±â€¯10.99% (p < 0.05) maps corresponding to atypical AFL patients. Simulations confirmed these results. Surface phase maps highlights the reentrant mechanism maintaining the arrhythmia and appear as a promising tool for the noninvasive characterization of the circuit maintaining AFL. The potential of the technique as a diagnosis tool needs to be evaluated in larger populations and, if it is confirmed, may help in planning ablation procedures.


Assuntos
Flutter Atrial/fisiopatologia , Mapeamento Potencial de Superfície Corporal , Modelos Cardiovasculares , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade
18.
J Cardiovasc Pharmacol Ther ; 24(1): 3-10, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29940780

RESUMO

Dofetilide is a class III antiarrhythmic agent approved by the Food and Drug Administration for the conversion of atrial fibrillation and atrial flutter and maintenance of sinus rhythm in symptomatic patients with persistent arrhythmia. Drug trials showed neutral mortality in post-myocardial infarction patients and those with heart failure. This is a review of postmarket data, including real-world efficacy and safety in a variety of populations. Dofetilide has been used off-label with success in patients with paroxysmal atrial fibrillation and atrial flutter, as well as atrial tachycardia and ventricular tachycardia. The real-world acute conversion rate of atrial fibrillation and atrial flutter is higher than that reported in clinical trials. Dofetilide has an acceptable safety profile when initiated (or reloaded) under hospital monitoring and dosed according to creatinine clearance. Dofetilide is well tolerated and a good choice for patients with acceptable renal function and a normal QT interval, especially if atrioventricular nodal blockade needs to be avoided.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Flutter Atrial/tratamento farmacológico , Sistema de Condução Cardíaco/efeitos dos fármacos , Frequência Cardíaca/efeitos dos fármacos , Fenetilaminas/uso terapêutico , Bloqueadores dos Canais de Potássio/uso terapêutico , Sulfonamidas/uso terapêutico , Antiarrítmicos/efeitos adversos , Antiarrítmicos/farmacocinética , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/mortalidade , Flutter Atrial/fisiopatologia , Tomada de Decisão Clínica , Sistema de Condução Cardíaco/fisiopatologia , Humanos , Seleção de Pacientes , Fenetilaminas/efeitos adversos , Fenetilaminas/farmacocinética , Bloqueadores dos Canais de Potássio/efeitos adversos , Bloqueadores dos Canais de Potássio/farmacocinética , Fatores de Risco , Sulfonamidas/efeitos adversos , Sulfonamidas/farmacocinética , Resultado do Tratamento
19.
Scand Cardiovasc J ; 52(5): 268-274, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30445881

RESUMO

AIM: 3D Rotational angiography (3DRA) allows for detailed reconstruction of atrial anatomy and is often used to facilitate pulmonary vein isolation. This study aimed to reappraise the anatomy of the right atrium (RA) using 3DRA, specifically looking at Koch's triangle and the cavotricuspid isthmus (CTI) in atrio-ventricular reentrant tachycardia (AVNRT) and atrial flutter (AFl) ablation. METHODS AND RESULTS: 3DRA was performed in 97 patients: AVNRT = 51 and AFl = 46. Dimensions of Koch's triangle and CTI were highly variable between individuals but were not different in both ablation groups. RA volume was significantly larger in AFl patients (p = .004) while indexed RA volume to the body surface area (RAVI) was lightly different (p = .024). In univariate Cox analysis, age (p = .003), RAVI (p < .001) and previous ablation of AFl (p = .003) were predictors of AF occurrence . In multivariate Cox analysis, RAVI was the only independent predictor of AF occurrence. RAVI >80 ml/m2 was a strong predictor for AF during follow-up. CONCLUSION: 3DRA allows for detailed per-procedural evaluation of RA anatomy and revealed a great variability in Koch's triangle and CTI dimensions and morphology. RA enlargement as measured by RAVI was an independent predictor for AF occurrence during follow-up.


Assuntos
Flutter Atrial/diagnóstico por imagem , Flutter Atrial/cirurgia , Ablação por Cateter , Angiografia Coronária/métodos , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Imageamento Tridimensional/métodos , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico por imagem , Taquicardia por Reentrada no Nó Atrioventricular/cirurgia , Adulto , Idoso , Flutter Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recidiva , Estudos Retrospectivos , Fatores de Risco , Taquicardia por Reentrada no Nó Atrioventricular/fisiopatologia , Resultado do Tratamento
20.
Conf Proc IEEE Eng Med Biol Soc ; 2018: 490-493, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30440441

RESUMO

Atrial tachycardia and atrial flutter are frequent arrhythmia that occur spontaneously and after ablation of atrial fibrillation. Depolarization waves that differ significantly from sinus rhythm propagate across the atria with high frequency (typically 140 to 220 beats per minute). A detailed and personalized analysis of the spread of depolarization is imperative for a successful ablation therapy. Thus, catheters with several electrodes are employed to measure multichannel electrograms inside the atria. Here we propose a new concept for spatio-temporal analysis of multichannel electrograms during atrial tachycardia and atrial flutter. It is based on the calculation of simultaneously active areas. The method allows to identify atrial tachycardia and to automatically distinguish between subtypes of focal activity, micro-reentry and macro-reentry.


Assuntos
Fibrilação Atrial/diagnóstico , Flutter Atrial/diagnóstico , Técnicas Eletrofisiológicas Cardíacas , Taquicardia Supraventricular/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/fisiopatologia , Átrios do Coração/fisiopatologia , Humanos , Análise Espaço-Temporal , Taquicardia Supraventricular/fisiopatologia
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