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1.
JACC Clin Electrophysiol ; 4(12): 1541-1552, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30573117

RESUMO

OBJECTIVES: This study aimed: 1) to determine the voltage correlation between sinus rhythm (SR) and atrial fibrillation (AF)/atrial flutter (AFL) using multielectrode fast automated mapping; 2) to identify a bipolar voltage cutoff for scar and/or low voltage areas (LVAs); and 3) to examine the reproducibility of voltage mapping in AF. BACKGROUND: It is unclear if bipolar voltage cutoffs should be adjusted depending on the rhythm and/or area being mapped. METHODS: High-density mapping was performed first in SR and afterward in induced AF/AFL. In some patients, 2 maps were performed during AF. Maps were combined to create a new one. Points of <1 mm difference were analyzed. Correlation was explored with scatterplots and agreement analysis was assessed with Bland-Altman plots. The generalized additive model was also applied. RESULTS: A total of 2,002 paired-points were obtained. A cutoff of 0.35 mV in AFL predicted a sinus voltage of 0.5 mV (95% confidence interval [CI]: 0.12 to 2.02) and of 0.24 mV in AF (95% CI: 0.11 to 2.18; specificity [SP]: 0.94 and 0.96; sensitivity [SE]: 0.85 and 0.75, respectively). When generalized additive models were used, a cutoff of 0.38 mV was used for AFL for predicting a minimum value of 0.5 mV in SR (95% CI: 0.5 to 1.6; SP: 0.94, SE: 0.88) and of 0.31 mV for AF (95% CI: 0.5 to 1.2; SP: 0.95, SE: 0.82). With regard to AF maps, there was no change in the classification of any left atrial region other than the roof. CONCLUSIONS: It is possible to establish new cutoffs for AFL and/or AF with acceptable validity in predicting a sinus voltage of <0.5 mV. Multielectrode fast automated mapping in AFL and/or AF seems to be reliable and reproducible when classifying LVAs. These observations have clinical implications for left atrial voltage distribution and in procedures in which scar distribution is used to guide pulmonary vein isolation and/or re-isolation.


Assuntos
Fibrilação Atrial/diagnóstico , Técnicas Eletrofisiológicas Cardíacas/métodos , Técnicas Eletrofisiológicas Cardíacas/normas , Idoso , Flutter Atrial/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes
2.
Sensors (Basel) ; 18(5)2018 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-29724033

RESUMO

The intracardiac electrical activation maps are commonly used as a guide in the ablation of cardiac arrhythmias. The use of catheters with force sensors has been proposed in order to know if the electrode is in contact with the tissue during the registration of intracardiac electrograms (EGM). Although threshold criteria on force signals are often used to determine the catheter contact, this may be a limited criterion due to the complexity of the heart dynamics and cardiac vorticity. The present paper is devoted to determining the criteria and force signal profiles that guarantee the contact of the electrode with the tissue. In this study, we analyzed 1391 force signals and their associated EGM recorded during 2 and 8 s, respectively, in 17 patients (82 ± 60 points per patient). We aimed to establish a contact pattern by first visually examining and classifying the signals, according to their likely-contact joint profile and following the suggestions from experts in the doubtful cases. First, we used Principal Component Analysis to scrutinize the force signal dynamics by analyzing the main eigen-directions, first globally and then grouped according to the certainty of their tissue-catheter contact. Second, we used two different linear classifiers (Fisher discriminant and support vector machines) to identify the most relevant components of the previous signal models. We obtained three main types of eigenvectors, namely, pulsatile relevant, non-pulsatile relevant, and irrelevant components. The classifiers reached a moderate to sufficient discrimination capacity (areas under the curve between 0.84 and 0.95 depending on the contact certainty and on the classifier), which allowed us to analyze the relevant properties in the force signals. We conclude that the catheter-tissue contact profiles in force recordings are complex and do not depend only on the signal intensity being above a threshold at a single time instant, but also on time pulsatility and trends. These findings pave the way towards a subsystem which can be included in current intracardiac navigation systems assisted by force contact sensors, and it can provide the clinician with an estimate of the reliability on the tissue-catheter contact in the point-by-point EGM acquisition procedure.


Assuntos
Arritmias Cardíacas/terapia , Ablação por Cateter/métodos , Técnicas Eletrofisiológicas Cardíacas/normas , Humanos , Reprodutibilidade dos Testes
3.
J Cardiovasc Electrophysiol ; 29(7): 990-997, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29660191

RESUMO

INTRODUCTION: The unipolar electrogram (UEG) provides local measures of cardiac activation and repolarization and is an important translational link between patient and laboratory. A simple theoretical model of the UEG was previously proposed and tested in silico. METHOD AND RESULTS: The aim of this study was to use epicardial sock-mapping data to validate the simple model's predictions of unipolar electrogram morphology in the in vivo human heart. The simple model conceptualizes the UEG as the difference between a local cardiac action potential and a position-independent component representing remote activity, which is defined as the average of all action potentials. UEGs were recorded in 18 patients using a multielectrode sock containing 240 electrodes and activation (AT) and repolarization time (RT) were measured using standard definitions. For each cardiac site, a simulated local action potential was generated by adjusting a stylized action potential to fit AT and RT measured in vivo. The correlation coefficient (cc) measuring the morphological similarity between 13,637 recorded and simulated UEGs was cc  =  0.89 (0.72-0.95), median (Q1 -Q3 ), for the entire UEG, cc  =  0.90 (0.76-0.95) for QRS complexes, and cc  =  0.83 (0.58-0.92) for T-waves. QRS and T-wave areas from recorded and simulated UEGs showed cc> 0.89 and cc> 0.84, respectively, indicating good agreement between voltage isochrones maps. Simulated UEGs accurately reproduced the interaction between AT and QRS morphology and between RT and T-wave morphology observed in vivo. CONCLUSIONS: Human in vivo whole heart data support the validity of the simple model, which provides a framework for improving the understanding of the UEG and its clinical utility.


Assuntos
Eletrocardiografia/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Sistema de Condução Cardíaco/fisiologia , Modelos Cardiovasculares , Eletrocardiografia/instrumentação , Eletrocardiografia/métodos , Eletrodos/normas , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Técnicas Eletrofisiológicas Cardíacas/métodos , Humanos , Reprodutibilidade dos Testes
4.
J Cardiothorac Vasc Anesth ; 32(4): 1892-1910, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29422281

RESUMO

As the complexity and duration of cardiac ablation procedures increase, there is a growing demand for anesthesiologist involvement in the electrophysiology suites for sedation and anesthesia provision, hemodynamic and neuromonitoring, and procedural guidance through transesophageal echocardiography. To deliver high-quality perioperative care, it is important that the anesthesiologist is intimately familiar with the evolving techniques and technologies, the anesthetic options and ventilation strategies, and the anticipated postprocedural complications.


Assuntos
Anestesia/métodos , Anestesiologistas , Ablação por Cateter/métodos , Cuidados Intraoperatórios/métodos , Anestesia/normas , Anestesiologistas/normas , Ablação por Cateter/normas , Técnicas Eletrofisiológicas Cardíacas/métodos , Técnicas Eletrofisiológicas Cardíacas/normas , Humanos , Cuidados Intraoperatórios/normas
6.
Europace ; 19(12): 1909-1922, 2017 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29126278
9.
J Interv Card Electrophysiol ; 49(1): 3-9, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28168447

RESUMO

PURPOSE: Bedside vascular ultrasound machines are increasingly available. They are used to facilitate safer vascular access across a number of different specialties. In the electrophysiology laboratory however, where patients are frequently anticoagulated and require the insertion of multiple venous sheaths, anatomical landmark techniques predominate. Despite the high number of vascular complications associated with electrophysiological procedures and the increasing evidence to support its use in electrophysiology, ultrasound remains underutilised. A new standard of care is required. A comprehensive technical report, providing a detailed explanation of this important technique, will provide other electrophysiology centres with the knowledge and justification for adopting ultrasound guidance as their standard practice. METHOD: We review the increasing body of evidence which demonstrates that routine ultrasound usage can substantially improve the safety of femoral venous access in the electrophysiology laboratory. We offer a comprehensive technical report to guide operators through the process of ultrasound-guided venous access, with a specific focus on the electrophysiology laboratory. Additionally, we detail a novel technique which utilises real-time colour Doppler ultrasound to accurately identify needle tip location during venous puncture. CONCLUSIONS: The use of vascular ultrasound to guide femoral venous cannulation is rapid, inexpensive and easily learnt. Ultrasound is readily available and offers the potential to significantly reduce vascular complications in the unique setting of the electrophysiology laboratory. Ultrasound guidance to achieve femoral venous access should be the new standard of care in electrophysiology.


Assuntos
Cateteres Venosos Centrais/normas , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Técnicas Eletrofisiológicas Cardíacas/normas , Veia Femoral/diagnóstico por imagem , Guias de Prática Clínica como Assunto , Ultrassonografia de Intervenção/instrumentação , Ultrassonografia de Intervenção/normas , Técnicas Eletrofisiológicas Cardíacas/métodos , Humanos , Laboratórios/normas , Ultrassonografia de Intervenção/métodos , Reino Unido
10.
J Cardiovasc Electrophysiol ; 28(1): 109-114, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27653802

RESUMO

BACKGROUND: Contact-force (CF) sensing catheters are increasingly used in electrophysiological procedures due to their efficacy and safety profile. As data about the accuracy of fiberoptic CF technology are scarce, we sought to quantify it using in vitro experiments. METHODS AND RESULTS: A force sensor was built with a flexible membrane to allow exact reference force measurements for each set of experiments. A TactiCath Quartz (TCQ) ablation catheter was brought in contact with the force sensor membrane in order to compare the TCQ force measurements to sensor reference force measurements. Measurements were performed at different tip angles (0°/perpendicular contact, 45°, 90°/parallel contact), with fluid irrigation, different degrees of catheter deflection, and using a sheath. The accuracy of the TCQ force measurements was 0.9 ± 0.9 g (0°), 0.8 ± 0.8 g (45°) and 1.2 ± 1.3 g (90°), 0.8 ± 0.7 g (irrigation), 0.8 ± 0.8 g (deflection), and 0.8 ± 0.9 g (sheath); this was not significantly different among all experimental conditions. The precision was ≤3.8%. CONCLUSION: CF measurements using a fiberoptic sensing technology show a high level of accuracy and precision, without being significantly influenced by tip angle, fluid irrigation, catheter deflection or use of a sheath.


Assuntos
Cateterismo Cardíaco/instrumentação , Cateteres Cardíacos , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Tecnologia de Fibra Óptica/instrumentação , Transdutores de Pressão , Calibragem , Cateterismo Cardíaco/normas , Cateteres Cardíacos/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Desenho de Equipamento , Tecnologia de Fibra Óptica/normas , Teste de Materiais , Padrões de Referência , Reprodutibilidade dos Testes , Irrigação Terapêutica , Transdutores de Pressão/normas
11.
Int J Cardiol ; 225: 4-8, 2016 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-27694034

RESUMO

BACKGROUND: The atrioventricular (AV) dissociation, which is frequently used in differential diagnosis of wide QRS complex tachycardia (WQCT), is the most specific finding of ventricular tachycardia (VT) with lower sensitivity. Herein, we aimed to show the importance of Lewis lead ECG records to detect 'visible p waves' during WQCT. METHOD: A total of 21 consecutive patients who underwent electrophysiologic study (EPS) were included in the study. During EPS, by using a quadripolar diagnostic catheter directed to the right ventricular apex, a fixed stimulus was given and the ventriculoatrial (VA) Wenkebach point was found, and a VT was simulated by a RV apical stimulus at 300ms. The standard and Lewis lead ECG records were taken during this procedure. RESULT: We detected 'visible p waves' in 7 (33.3%) and 14 (66.7%) patients in the standard and Lewis lead ECG groups, respectively. In terms of the 'visible p waves', there was a statistically significant difference between groups (p=0.022). The sensitivity of standard and Lewis lead ECG in determination of the visible p waves was 33.3% and 66.7%, respectively. CONCLUSION: The Lewis lead ECG can be more informative about AV dissociation than the standard 12 lead ECG. As a result, we could suggest the assessment of the Lewis lead ECG recording in addition to the standard 12 lead ECG in differential diagnosis of VT in patients with WQCT.


Assuntos
Eletrocardiografia/normas , Bloqueio Cardíaco/diagnóstico , Bloqueio Cardíaco/fisiopatologia , Frequência Cardíaca/fisiologia , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Adulto , Idoso , Eletrocardiografia/instrumentação , Eletrodos/normas , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Técnicas Eletrofisiológicas Cardíacas/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
12.
J Interv Card Electrophysiol ; 47(1): 19-27, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27565971

RESUMO

Development of new medical technology is a crucial part of the advancement of medicine and our ability to better treat patients and their diseases. This process of development is long and arduous and requires a significant investment of human, financial and material capital. However, technology development can be rewarded richly by its impact on patient outcomes and successful sale of the product. One of the major regulatory hurdles to technology development is the Food and Drug Administration (FDA) approval process, which is necessary before a technology can be marketed and sold in the USA. Many businesses, medical providers and consumers believe that the FDA approval process is the only hurdle prior to use of the technology in day-to-day care. In order for the technology to be adopted into clinical use, reimbursement for both the device as well as the associated work performed by physicians and medical staff must be in place. Work and coverage decisions require Current Procedural Terminology (CPT) code development and Relative Value Scale Update Committee (RUC) valuation determination. Understanding these processes is crucial to the timely availability of new technology to patients and providers. Continued and better partnerships between physicians, industry, regulatory bodies and payers will facilitate bringing technology to market sooner and ensure appropriate utilization.


Assuntos
Aprovação de Equipamentos/normas , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Técnicas Eletrofisiológicas Cardíacas/normas , Vigilância de Produtos Comercializados/normas , Avaliação da Tecnologia Biomédica/normas , United States Food and Drug Administration/normas , Biotecnologia/instrumentação , Biotecnologia/normas , Aprovação de Equipamentos/legislação & jurisprudência , Guias como Assunto , Marketing de Serviços de Saúde/normas , Avaliação da Tecnologia Biomédica/legislação & jurisprudência , Estados Unidos
13.
J Am Heart Assoc ; 5(6)2016 06 17.
Artigo em Inglês | MEDLINE | ID: mdl-27317349

RESUMO

BACKGROUND: Drug safety precautions recommend monitoring of the corrected QT interval. To determine which QT correction formula to use in an automated QT-monitoring algorithm in our electronic medical record, we studied rate correction performance of different QT correction formulae and their impact on risk assessment for mortality. METHODS AND RESULTS: All electrocardiograms (ECGs) in patients >18 years with sinus rhythm, normal QRS duration and rate <90 beats per minute (bpm) in the University Hospitals of Leuven (Leuven, Belgium) during a 2-month period were included. QT correction was performed with Bazett, Fridericia, Framingham, Hodges, and Rautaharju formulae. In total, 6609 patients were included (age, 59.8±16.2 years; 53.6% male and heart rate 68.8±10.6 bpm). Optimal rate correction was observed using Fridericia and Framingham; Bazett performed worst. A healthy subset showed 99% upper limits of normal for Bazett above current clinical standards: men 472 ms (95% CI, 464-478 ms) and women 482 ms (95% CI 474-490 ms). Multivariate Cox regression, including age, heart rate, and prolonged QTc, identified Framingham (hazard ratio [HR], 7.31; 95% CI, 4.10-13.05) and Fridericia (HR, 5.95; 95% CI, 3.34-10.60) as significantly better predictors of 30-day all-cause mortality than Bazett (HR, 4.49; 95% CI, 2.31-8.74). In a point-prevalence study with haloperidol, the number of patients classified to be at risk for possibly harmful QT prolongation could be reduced by 50% using optimal QT rate correction. CONCLUSIONS: Fridericia and Framingham correction formulae showed the best rate correction and significantly improved prediction of 30-day and 1-year mortality. With current clinical standards, Bazett overestimated the number of patients with potential dangerous QTc prolongation, which could lead to unnecessary safety measurements as withholding the patient of first-choice medication.


Assuntos
Arritmias Cardíacas/diagnóstico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Arritmias Cardíacas/induzido quimicamente , Arritmias Cardíacas/fisiopatologia , Eletrocardiografia/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Feminino , Frequência Cardíaca/fisiologia , Humanos , Síndrome do QT Longo/induzido quimicamente , Síndrome do QT Longo/diagnóstico , Síndrome do QT Longo/fisiopatologia , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Medição de Risco
14.
J Cardiovasc Electrophysiol ; 27 Suppl 1: S17-22, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26969218

RESUMO

INTRODUCTION: Circular mapping catheters (CMC) are an essential tool in most atrial fibrillation ablation procedures. The Vdrive™ with V-Loop™ system enables a physician to remotely manipulate a CMC during electrophysiology studies. Our aim was to compare the clinical performance of the system to conventional CMC navigation according to efficiency and safety endpoints. METHODS AND RESULTS: A total of 120 patients scheduled to undergo a CMC study followed by pulmonary vein isolation (PVI) were included. Treatment allocation was randomized 2:1, remote navigation:manual navigation. The primary effectiveness endpoint was assessed based on both successful navigation to the targeted pulmonary vein (PV) and successful recording of PV electrograms. All PVs were treated independently within and between patients. The primary safety endpoint was assessed based on the occurrence of major adverse events (MAEs) through seven days after the study procedure. Primary effectiveness endpoints were achieved in 295/302 PVs in the Vdrive arm (97.7%) and 167/167 PVs in the manual arm (100%). Effectiveness analysis indicates Vdrive non-inferiority (pnon-inferiority = 0.0405; δ = -0.05) per the Cochran-Mantel-Haenszel test adjusted for PV correlation. Five MAEs related to the ablation procedure occurred (three in the Vdrive arm-3.9%; two in the manual arm-2.33%). No device-related MAEs were observed; safety analysis indicates Vdrive non-inferiority (pnon-inferiority = 0.0441; δ = 0.07) per the normal Z test. CONCLUSION: Remote navigation of a CMC is equivalent to manual in PVI in terms of safety and effectiveness. This allows for single-operator procedures in conjunction with a magnetically guided ablation catheter.


Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Ablação por Cateter/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Fenômenos Magnéticos , Procedimentos Cirúrgicos Robóticos/normas , Idoso , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/métodos , Técnicas Eletrofisiológicas Cardíacas/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/métodos
15.
J Interv Card Electrophysiol ; 47(1): 5-10, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26936264

RESUMO

The evolving healthcare environment demands optimally measured quality of care. Performance measures are increasingly being used for quality improvement, public reporting, and reimbursement determinations. The National Quality Forum has created rigorous criteria for the evaluation of potential performance measures across medical fields. The Heart Rhythm Society has championed the development of four separate electrophysiology (EP)-specific performance measures: implantable cardioverter defibrillator complication rate, cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation, infection within 180 days of a cardiac implantable electronic device implantation, replacement, or revision, and in-person evaluation following a cardiac implantable electronic device implantation. National registries serve a key role in developing performance measures and facilitating quality improvement, particularly as they provide improved granularity and accuracy of data compared with administrative claims data. All performance measures demand continued reassessment as technology and performance gaps change and as unintended consequences may arise.


Assuntos
Cardiologia/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Política de Saúde/tendências , Guias de Prática Clínica como Assunto , Garantia da Qualidade dos Cuidados de Saúde/métodos , Garantia da Qualidade dos Cuidados de Saúde/normas , Internacionalidade , Estados Unidos
16.
J Interv Card Electrophysiol ; 47(1): 11-18, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27020440

RESUMO

The Food and Drug Administration (FDA) is a large regulatory agency that monitors everything from food, tobacco, and veterinary medicine to pharmaceutical drugs and medical devices. The Mission statement of the CDRH, one of the Centers of the FDA, in its most succinct form is to protect and promote public health. This is accomplished through timely and continued access to safe, effective, and high quality medical devices. This paper aims to review the overarching principles of the Agency's review process for cardiac devices as well as highlight some of the newer programs that FDA has engaged in to facilitate innovation, device development, research, and timely market approval.


Assuntos
Aprovação de Equipamentos/normas , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Técnicas Eletrofisiológicas Cardíacas/normas , Vigilância de Produtos Comercializados/normas , Avaliação da Tecnologia Biomédica/normas , United States Food and Drug Administration/normas , Aprovação de Equipamentos/legislação & jurisprudência , Guias como Assunto , Avaliação da Tecnologia Biomédica/legislação & jurisprudência , Estados Unidos
19.
Congenit Heart Dis ; 11(1): 19-25, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26450752

RESUMO

A program to collect and analyze cardiac catheterization, electrophysiologic studies and cardiac operations in children was initiated in 1982. The purpose was to help centers compare their experience and outcomes with a group of centers to determine areas where their performance might improve. Cardiac centers became members of the Pediatric Cardiac Care Consortium and submitted demographic data and copies of procedure reports regularly to a central office. Data were extracted from the reports, coded by trained coders and entered into a computer database. Annually, the data were analyzed to compare the experience of an individual center with that of the entire group of centers. The annual data were adjusted for severity on the basis of eight factors selected after discussion with participants in the Consortium. Adjustment was by multivariate analysis. Reports were prepared for each center and distributed at an annual meeting. The data were used by centers to review operations where the mortality rate exceeded +2 standard deviations of the group. With discussion, the center staff often initiated changes to improve outcome. The outcome could then be monitored by the annual reports. Our data were also utilized in the creation of the Risk Adjustment for Surgery for Congenital Heart Disease (RACHS)-1 categories of disease severity. The mortality rates of our centers were comparable with the combined hospital discharge data from New York, Massachusetts, and California. From 1982 through 2007, the mortality rates of our centers dropped for each RACHS-1 category, falling to less than 1% for categories 1 and 2 for the last 5-year period. During the 25 years, we received data from 52 centers about 137 654 patients who underwent 117 756 cardiac operations.


Assuntos
Cardiologia/normas , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/terapia , Pediatria/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Sistema de Registros/normas , Adolescente , Fatores Etários , Cateterismo Cardíaco/normas , Procedimentos Cirúrgicos Cardíacos/normas , Criança , Pré-Escolar , Mineração de Dados , Técnicas Eletrofisiológicas Cardíacas/normas , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/fisiopatologia , Humanos , Lactente , Recém-Nascido , Análise Multivariada , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
20.
Heart Rhythm ; 13(4): e222-37, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26409096

RESUMO

OBJECTIVE: To review the literature systematically to determine whether noninvasive or invasive risk stratification, such as with an electrophysiological study of patients with asymptomatic pre-excitation, reduces the risk of arrhythmic events and improves patient outcomes. METHODS: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (all January 1, 1970, through August 31, 2014) were searched for randomized controlled trials and cohort studies examining noninvasive or invasive risk stratification in patients with asymptomatic pre-excitation. Studies were rejected for low-quality design or the lack of an outcome, population, intervention, or comparator of interest or if they were written in a language other than English. RESULTS: Of 778 citations found, 9 studies met all the eligibility criteria and were included in this paper. Of the 9 studies, 1 had a dual design-a randomized controlled trial of ablation versus no ablation in 76 patients and an uncontrolled prospective cohort of 148 additional patients-and 8 were uncontrolled prospective cohort studies (n=1,594). In studies reporting a mean age, the range was 32 to 50 years, and in studies reporting a median age, the range was 19 to 36 years. The majority of patients were male (range, 50% to 74%), and <10% had structural heart disease. In the randomized controlled trial component of the dual-design study, the 5-year Kaplan-Meier estimates of the incidence of arrhythmic events were 7% among patients who underwent ablation and 77% among patients who did not undergo ablation (relative risk reduction: 0.08; 95% confidence interval: 0.02 to 0.33; p<0.001). In the observational cohorts of asymptomatic patients who did not undergo catheter ablation (n=883, with follow-up ranging from 8 to 96 months), regular supraventricular tachycardia or benign atrial fibrillation (shortest RR interval >250 ms) developed in 0% to 16%, malignant atrial fibrillation (shortest RR interval ≤250 ms) in 0% to 9%, and ventricular fibrillation in 0% to 2%, most of whom were children in the last case. CONCLUSIONS: The existing evidence suggests risk stratification with an electrophysiological study of patients with asymptomatic pre-excitation may be beneficial, along with consideration of accessory-pathway ablation in those deemed to be at high risk of future arrhythmias. Given the limitations of the existing data, well-designed and well-conducted studies are needed.


Assuntos
American Heart Association , Terapia de Ressincronização Cardíaca/normas , Cardiologia/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Guias de Prática Clínica como Assunto , Medição de Risco , Taquicardia Supraventricular , Adulto , Saúde Global , Humanos , Morbidade/tendências , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/epidemiologia , Taquicardia Supraventricular/terapia , Estados Unidos
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