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1.
Herzschrittmacherther Elektrophysiol ; 32(1): 21-26, 2021 Mar.
Artigo em Alemão | MEDLINE | ID: mdl-33533995

RESUMO

The advances in imaging and 3D mapping systems in the last decade allowed a better correlation of ventricular premature contractions (PVCs) with anatomical structures. With regard to PVCs, interpretation of the 12-lead ECG is still crucial for the management of patients and the planning of therapies. Although there is an armamentarium of indices and algorithms to exactly pinpoint the origin of a PVC in advance, a thorough understanding of cardiac anatomy and impulse propagation, together with an awareness of the surface ECGs limitations, provides a sufficiently close approximation. PVCs from the diaphragmatic part of the ventricular cavae exhibit a superiorly directed axis, whereas PVCs from superior parts of the heart show an inferior axis. A right bundle branch block morphology or positive concordance of the precordial leads yields a high probability of left ventricular origin of a PVC. A left bundle branch block morphology is indicative of a right ventricular or septal origin of a PVC. Using the transition zone, one can estimate the origin of a PVC with regard to anterior or posterior regions of the heart: A late precordial transition is indicative of a right ventricular origin, an early precordial transition suggests a left ventricular focus. An absent transition in the sense of negative concordance is indicative for an apical origin. The intertwined course of the ventricular outflow tracts makes PVC localization more difficult. Here, shape and height of the R­wave in V1-V3 help to narrow the origin down. PVCs from structures like the papillary muscles, the moderator band or infundibular bands are challenging to interpret and evidence of the limitations of the surface ECG. Based on the information gained by the aforementioned approach, a prediction of prognosis and possible treatment success is possible.


Assuntos
Ablação por Cateter , Taquicardia Ventricular , Complexos Ventriculares Prematuros , Bloqueio de Ramo , Eletrocardiografia , Ventrículos do Coração/diagnóstico por imagem , Humanos , Taquicardia Ventricular/cirurgia , Complexos Ventriculares Prematuros/diagnóstico , Complexos Ventriculares Prematuros/cirurgia
2.
Ann Thorac Surg ; 111(4): e295-e296, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33419566

RESUMO

Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown to decrease VT recurrence and defibrillator shocks in patients with ischemic and nonischemic cardiomyopathy. Here and in the accompanying Video, we demonstrate the technique for minimally invasive CSD, highlight important technical points, and report surgical outcomes. CSD is accomplished through bilateral resection of the inferior one-third to one-half of the stellate ganglion en bloc with T2-T4 sympathectomy. Despite the high potential for perioperative risk, most patients do not have serious complications. We find that surgical CSD can be performed safely in an attempt to liberate patients from refractory VT.


Assuntos
Ganglionectomia/métodos , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca/fisiologia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Taquicardia Ventricular/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taquicardia Ventricular/fisiopatologia , Vértebras Torácicas
5.
Cancer Radiother ; 24(6-7): 534-546, 2020 Oct.
Artigo em Francês | MEDLINE | ID: mdl-32792297

RESUMO

Myocardial scar-related ventricular tachycardia is a serious and potentially life-threatening arrhythmia. The prevention of sudden rhythmic death and ventricular tachycardia recurrence relies on implantable cardioverter defibrillator (ICD), anti-arrhythmic drugs and more recently on radiofrequency catheter ablation. Nevertheless, these approaches have their own risk of adverse events and complications, with a recurrence rate up to 50 % at 2 years. Stereotactic body radiotherapy, delivered in a single dose of 25Gy, has emerged as a new therapeutic tool in the management of highly refractory ventricular tachycardia. In 2017, the very first prospective 5-patient cohort suffering from recurrent ventricular tachycardia on structural heart disease (40 % of ischemic cardiomyopathy) who benefited from cardiac stereotactic body radiotherapy was published. After stereotactic body radiotherapy, the authors observed a strong ventricular tachycardia burden reduction at 12 months, with no major side effects. Since then, around 100 cases have been described in the literature, particularly in the prospective ENCORE-VT study, with positive short- and medium-term outcomes in terms of safety and ventricular tachycardia burden reduction. Recently, another American prospective 5-patient series, published in March 2020, mitigated these results since all patients presented a ventricular tachycardia recurrence at 12 months despite an initial reduction in ventricular tachycardia burden. This article describes the use of stereotactic body radiotherapy in refractory VT, the rationale of the technique, its implementation, preliminary results and potential acute and long-term consequences.


Assuntos
Radiocirurgia , Taquicardia Ventricular/radioterapia , Ablação por Cateter , Humanos , Recidiva , Taquicardia Ventricular/cirurgia
7.
Circ Arrhythm Electrophysiol ; 13(8): e008307, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32657137

RESUMO

BACKGROUND: In patients with an ischemic cardiomyopathy (ICM), the combination of late potential (LP) abolition and postprocedural ventricular tachycardia (VT) noninducibility is known to be the desirable end point for a successful long-term outcome after VT ablation. We investigated whether LP abolition and VT noninducibilty have a similar impact on the outcomes of patients with non-ICMs (NICM) undergoing VT ablation. METHODS: A total of 403 patients with NICM (523 procedures) who underwent a VT ablation from 2010 to 2016 were included. The procedure end points were the LP abolition (if the LPs were absent, other ablation strategies were undertaken) and the VT noninducibilty. RESULTS: The underlying structural heart disease consisted of dilated cardiomyopathy (DCM, 49%), arrhythmogenic right ventricular dysplasia (ARVD, 17%), postmyocarditis (14%), valvular heart disease (8%), congenital heart disease (2%), hypertrophic cardiomyopathy (2%), and others (5%). The epicardial access was performed in 57% of the patients. At baseline, the LPs were present in 60% of the patients and a VT was either inducible or sustained/incessant in 85% of the cases. At the end of the procedure, the LP abolition was achieved in 79% of the cases and VT noninducibility in 80%. After a multivariable analysis, the combination of LP abolition and VT noninducibilty was independently associated with free survival from VT (hazard ratio, 0.45 [95% CI, 0.29-0.69], P=0.0002) and cardiac death (hazard ratio, 0.38 [95% CI, 0.18-0.74], P=0.005). The benefit of the LP abolition on preventing the VT recurrence in patients with ARVD and postmyocarditis appeared superior to that observed for those with DCM. CONCLUSIONS: In patients with NICM undergoing VT ablation, the strategy of LP abolition and VT noninducibilty were associated with better outcomes in terms of long-term VT recurrences and cardiac survival. Graphic Abstract: A graphic abstract is available for this article.


Assuntos
Potenciais de Ação , Cardiomiopatias/complicações , Ablação por Cateter , Frequência Cardíaca , Taquicardia Ventricular/cirurgia , Adulto , Idoso , Cardiomiopatias/diagnóstico , Cardiomiopatias/fisiopatologia , Ablação por Cateter/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Medição de Risco , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
10.
Circ Arrhythm Electrophysiol ; 13(7): e008262, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32538133

RESUMO

BACKGROUND: To facilitate ablation of ventricular tachycardia (VT), an automated localization system to identify the site of origin of left ventricular activation in real time using the 12-lead ECG was developed. The objective of this study was to prospectively assess its accuracy. METHODS: The automated site of origin localization system consists of 3 steps: (1) localization of ventricular segment based on population templates, (2) population-based localization within a segment, and (3) patient-specific site localization. Localization error was assessed by the distance between the known reference site and the estimated site. RESULTS: In 19 patients undergoing 21 catheter ablation procedures of scar-related VT, site of origin localization accuracy was estimated using 552 left ventricular endocardial pacing sites pooled together and 25 VT-exit sites identified by contact mapping. For the 25 VT-exit sites, localization error of the population-based localization steps was within 10 mm. Patient-specific site localization achieved accuracy of within 3.5 mm after including up to 11 pacing (training) sites. Using 3 remotes (67.8±17.0 mm from the reference VT-exit site), and then 5 close pacing sites, resulted in localization error of 7.2±4.1 mm for the 25 identified VT-exit sites. In 2 emulated clinical procedure with 2 induced VTs, the site of origin localization system achieved accuracy within 4 mm. CONCLUSIONS: In this prospective validation study, the automated localization system achieved estimated accuracy within 10 mm and could thus provide clinical utility.


Assuntos
Potenciais de Ação , Eletrocardiografia , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca , Taquicardia Ventricular/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Automação , Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Feminino , Sistema de Condução Cardíaco/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Processamento de Sinais Assistido por Computador , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/cirurgia , Fatores de Tempo
11.
12.
Circ Arrhythm Electrophysiol ; 13(7): e007425, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32496820

RESUMO

BACKGROUND: Electrophysiological procedures such as epicardial ventricular tachycardia ablation and Lariat left atrial appendage ligation that involve the epicardial space are typically associated with significant postoperative pain due to mechanical irritation and associated inflammation. There is an unmet need for an effective pain management strategy in this group of patients. We studied how this impacts patient comfort and duration of hospitalization and other associated comorbidities related to pericardial access. METHODS: This is a multicenter retrospective study including 104 patients who underwent epicardial ventricular tachycardia ablation and Lariat left atrial appendage exclusion. We compared 53 patients who received postprocedural intrapericardial liposomal bupivacaine (LB)+oral colchicine (LB group) and 51 patients who received colchicine alone (non-LB group) between January 2015 and March 2018. RESULTS: LB was associated with significant lowering of median pain scale at 6 hours (1.0 [0-2.0] versus 8.0 [6.0-8.0], P<0.001), 12 hours (1.0 [1.0-2.0] versus 6.0 [5.0-6.0], P<0.001), and up to 48 hours postprocedure. Incidence of acute severe pericarditis delayed pericardial effusion and gastrointestinal adverse effects were similar in both groups. Median length of stay was significantly lower in LB group (2.0 versus 3.0; adjusted linear coefficient -1 [CI -1.3 to -0.6], P<0.001). Subgroup analysis demonstrated similar favorable outcomes in both Lariat and epicardial ventricular tachycardia ablation groups. CONCLUSIONS: Addition of intrapericardial postprocedural LB to oral colchicine in patients undergoing epicardial access during ventricular tachycardia ablation or Lariat procedure is associated with significantly decreased numeric pain score up to 48 hours compared with colchicine alone. It is also associated with significantly shorter length of hospital stay without an increase in the risk of adverse events.


Assuntos
Anestésicos Locais/administração & dosagem , Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Bupivacaína/administração & dosagem , Procedimentos Cirúrgicos Cardíacos , Ablação por Cateter , Dor Pós-Operatória/prevenção & controle , Pericárdio/cirurgia , Taquicardia Ventricular/cirurgia , Idoso , Anestésicos Locais/efeitos adversos , Apêndice Atrial/fisiopatologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Bupivacaína/efeitos adversos , Ablação por Cateter/efeitos adversos , Colchicina/administração & dosagem , Feminino , Humanos , Tempo de Internação , Ligadura , Lipossomos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Pericárdio/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
13.
Medicine (Baltimore) ; 99(21): e19970, 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32481260

RESUMO

INTRODUCTION: The RF ablation of ventricular tachycardia (VT) or atrial flutter (AFl) can be unsuccessful due to lack of lesion transmurality. Bipolar ablation (BA) is more successful than unipolar ablation (UA). The purpose of our study was to investigate the long-term effect of BA ablation in patients after failed UA. METHODS: Patients with septal VT (5) or AFL (2) after 2 to 5 unsuccessful UA were prospectively analysed after BA. All patients presented with heart failure or had ICD interventions. RESULTS: BA was successful in 5 patients (1 failure each in the AFL and VT group). The follow-up duration was 10 to 26 months. In AFL group, BA was successful in 1 patient, unidirectional cavotricuspid block in was achieved in the other patient. All patients were asymptomatic for 12 months, but 1 had atrial fibrillation and the other had AFL reablation 19 months after BA. In VT group, all patients had several forms of septal VT. BA was successful in 4 patients. In 2 patients with high septal VT BA resulted in complete atrioventricular block. During follow-up, 1 patient had VT recurrence 26 months after BA and died after an unsuccessful reablation. Three patients had VT recurrences of different morphologies, which required reablation (UA in 2 and alcohol septal ablation in the other patient). CONCLUSION: BA was successful in patients with AFL and septal VT resistant to standard ablation. Relapses of clinical arrhythmia are rare; however, long-term follow-up is complicated by recurrences of different arrhythmias related to complex arrhythmogenic substrate.


Assuntos
Ablação por Cateter/métodos , Taquicardia Ventricular/cirurgia , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Irrigação Terapêutica , Fatores de Tempo , Resultado do Tratamento
14.
Circ Arrhythm Electrophysiol ; 13(6): e008625, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32372657

RESUMO

BACKGROUND: The optimal method to identify the arrhythmogenic substrate of scar-related ventricular tachycardia (VT) is unknown. Sites of activation slowing during sinus rhythm (SR) often colocalize with the VT circuit. However, the utility and limitations of such approach for guiding ablation are unknown. METHODS: We conducted a multicenter study in patients with infarct-related VT. The left ventricular (LV) was mapped during activation from 3 directions: SR (or atrial pacing), right ventricular, and LV pacing at 600 ms. Ablation was applied selectively to the cumulative area of slow activation, defined as the sum of all regions with activation times of ≥40 ms per 10 mm. Hemodynamically tolerated VTs were mapped with activation or entrainment. The primary outcome was a composite of appropriate implanted cardioverter-defibrillator therapies and cardiovascular death. RESULTS: In 85 patients, the LV was mapped during activation from 2.4±0.6 directions. The direction of LV activation influenced the location and magnitude of activation slowing. The spatial overlap of activation slowing between SR and right ventricular pacing was 84.2±7.1%, between SR and LV pacing was 61.4±8.8%, and between right ventricular and LV pacing was 71.3±9.6% (P<0.05 between all comparisons). Mapping during SR identified only 66.2±8.2% of the entire area of activation slowing and 58% critical isthmus sites. Activation from other directions by right ventricular and LV stimulation unmasked an additional 33% of slowly conducting zones and 25% critical isthmus sites. The area of maximal activation slowing often corresponded to the site where the wavefront first interacted with the infarct. During a follow-up period of 3.6 years, the primary end point occurred in 14 out of 85 (16.5%) patients. CONCLUSIONS: The spatial distribution of activation slowing is dependent on the direction of LV activation with the area of maximal slowing corresponding to the site where the wavefront first interacts with the infarct. This data may have implications for VT substrate mapping strategies.


Assuntos
Ablação por Cateter , Taquicardia Ventricular/cirurgia , Potenciais de Ação , Idoso , Ablação por Cateter/efeitos adversos , Ablação por Cateter/mortalidade , Técnicas Eletrofisiológicas Cardíacas , Europa (Continente) , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , República da Coreia , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
J Card Surg ; 35(7): 1708-1710, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32436599

RESUMO

BACKGROUND: Recurrent ventricular tachycardia (VT) can occur after left ventricular assist device (LVAD) implantation. In this case, medical treatment might be insufficient. We report a case of a left-sided thoracoscopic sympathectomy as a feasible treatment escalation in intractable VT. CASE REPORT: A 72-year-old patient underwent an internal cardioverter defibrillator (ICD) implantation as primary prophylaxis for VTs in the setting of staged heart failure therapy. Afterwards, due to a progressive dilative cardiomyopathy he underwent a minimal-invasive LVAD implantation (HeartWare, Medtronic). After an uneventful minimal-invasive LVAD-implantation the patient was discharged to a rehabilitation program. However, after 7 weeks he developed recurrent VTs which were successfully terminated by ICD shocks deliveries leading to severe discomfort and frequent hospitalizations. Eventually, the patient was admitted with an electrical VT storm. Successful endocardial catheter ablation of all inducible VTs were performed combined with multiple rearrangements of his oral antiarrhythmic medication. However, all these treatments could not suppress further occurrence of VTs. After an interdisciplinary discussion the patient agreed to a left-sided video-assisted thoracoscopic sympathectomy. After a follow up of 150 days the patient was free from VTs apart from one short event. CONCLUSION: We believe video-assisted thoracoscopic sympathectomy might be a surgical treatment option in patients with intractable recurrent VTs after catheter ablation of VT reentrant substrate even after minimal-invasive LVAD implantation.


Assuntos
Insuficiência Cardíaca/cirurgia , Ventrículos do Coração/cirurgia , Coração Auxiliar/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Implantação de Prótese/efeitos adversos , Simpatectomia/métodos , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/cirurgia , Cirurgia Torácica Vídeoassistida/métodos , Idoso , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Insuficiência da Valva Mitral/complicações , Recidiva , Resultado do Tratamento
19.
AJR Am J Roentgenol ; 215(2): 374-381, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32374663

RESUMO

OBJECTIVE. Patients with cardiac implantable electronic devices (CIEDs) require cardiac MRI (CMRI) for a variety of reasons. The purpose of this study is to review and evaluate the value and safety of CMRI for patients with in situ CIEDs. CONCLUSION. Late gadolinium enhancement CMRI is the reference standard for assessing myocardial viability in patients with ventricular tachycardia before ablation of arrhythmogenic substrates. The use of late gadolinium enhancement CMRI for patients with CIEDs is safe as long as an imaging protocol is in place and precaution measures are taken.


Assuntos
Técnicas de Imagem Cardíaca , Meios de Contraste , Desfibriladores Implantáveis , Gadolínio , Coração/diagnóstico por imagem , Imagem por Ressonância Magnética/efeitos adversos , Marca-Passo Artificial , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/cirurgia , Idoso , Técnicas de Imagem Cardíaca/métodos , Feminino , Humanos
20.
Eur J Med Res ; 25(1): 4, 2020 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-32183887

RESUMO

BACKGROUND: Catheter ablation of non-reentrant, commonly termed "idiopathic" ventricular arrhythmias (VA) is highly effective in patients without structural heart disease (SHD). Meanwhile, the outcome of catheter ablation of these arrhythmias in patients with SHD remains unclear. This study sought to characterize the outcome of patients with and without SHD undergoing catheter ablation of non-reentrant VA. METHODS: In this single-centre study the acute and long-term outcome of 266 consecutive patients undergoing catheter ablation of non-reentrant VA was investigated. In 41.0% of patients a SHD was present (n = 109, 80.7% male, age 59.1 ± 14.7 years), 59.0% had no SHD (n = 157; 44.0% male, age 49.9 ± 16.5 years). RESULTS: Acute procedural success (absence of spontaneous or provoked VA at the end of procedure and within 48 h after the procedure) was achieved in 89.9% of patients with SHD vs. 94.3% without SHD (p = 0.238). During a mean follow-up of 34.7 ± 15.1 months a repeat catheter ablation was performed in 19.6% of patients with SHD vs. 13.0% without SHD (p = 0.179). Patients with dilated cardiomyopathy (DCM) were the most likely to require a repeat ablation procedure (32.0% of patients with DCM vs. 13.0% without SHD; p = 0.022). Periprocedural complications occurred in 5.5% of patients with SHD vs. 5.7% without SHD (p > 0.999). All complications were managed without sequelae. CONCLUSIONS: The outcome of catheter ablation of non-reentrant VA in patients with SHD appears good and is comparable to patients without SHD. A slightly higher rate of repeat ablations was observed in patients with DCM.


Assuntos
Cardiomiopatia Dilatada/cirurgia , Ablação por Cateter , Cardiopatias/cirurgia , Taquicardia Ventricular/cirurgia , Adulto , Cardiomiopatia Dilatada/etiologia , Ablação por Cateter/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taquicardia Ventricular/etiologia , Resultado do Tratamento
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