Mid-term outcomes after catheter ablation in patients with congenital heart disease.

INTRODUCTION: Cardiac arrhythmias are a major concern in patients with CHD. The purpose of this study was to evaluate the long-term outcomes in patients with CHD submitted to catheter ablation. MATERIALS AND METHODS: Observational retrospective study of patients with CHD referred for catheter ablation from January 2016 to December 2021 in a tertiary referral centre. Acute procedural endpoints and long-term outcomes were assessed. RESULTS: A total of 44 ablation procedures were performed in 36 CHD patients (55% male, mean age 43 ±3 years). Fifty-four arrhythmias were ablated: 23 cavotricuspid isthmus atrial flutters, 10 atrial re-entrant tachycardias, eight focal atrial tachycardias, eight atrial fibrillations, three atrioventricular re-entrant tachycardias, and two ventricular tachycardias. During a median follow-up time of 37 months (interquartile range 12-51), freedom from arrhythmia recurrence was achieved in 93%, with 1.2 procedures per patient (18% with anti-arrhythmic drugs). There were no adverse events related to catheter ablation. No predictors of recurrence were identified. CONCLUSION: In patients with CHD, catheter ablation presents a high mid-term efficacy while maintaining a safe profile.

Digoxin in Patients With Advanced Heart Failure and Sinus Rhythm Submitted to Cardiac Resynchronization Therapy-Is There Any Benefit?

ABSTRACT: Digoxin (DG) use in patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm remains controversial. We aimed to assess the prognostic effect of DG in patients in sinus rhythm submitted to cardiac resynchronization therapy (CRT). Retrospective study including 297 consecutive patients in sinus rhythm, with advanced HFrEF submitted to CRT. Patients were divided into 2 groups: with DG and without DG (NDG). During a mean follow-up of 4.9 ± 3.4 years, we evaluated the effect of DG on the composite end point defined as cardiovascular hospitalization, progression to heart transplantation, and all-cause mortality. Previous to CRT, 104 patients (35%) chronically underwent DG and 193 patients (65%) underwent NDG treatment. The 2 groups did not differ significantly regarding HF functional class, HF etiology, QRS, and baseline left ventricular ejection fraction. The proportion of responders to CRT was similar in both groups (54% in DG vs. 56% in NDG; P = 0.78). During the long-term follow-up period, the primary end point occurred in a higher proportion in DG patients (67 vs. 48%; P = 0.002). After adjustment for potential confounders, DG use remained as an independent predictor of the composite end point of CV hospitalization, heart transplantation, and all-cause mortality [hazards ratio = 1.58; confidence interval, 95 (1.01-2.46); P = 0.045]. In conclusion, in patients in sinus rhythm with HFrEF submitted to CRT, DG use was associated with CV hospitalization, progression to heart transplant, and all-cause mortality.

Unsafe Drug Use and Arrhythmic Events in Brugada Patients with ICD: Results of a Long-Term Follow-Up.

PURPOSE: Brugada syndrome is a hereditary disease linked with an increased risk of sudden death that may require an implantable cardioverter-defibrillator (ICD) in order to halt the arrhythmic events. The aim of this study was to identify possible triggers for appropriate ICD therapies in patients with Brugada syndrome, focusing on their past and current therapeutic profiles. METHODS: Thirty patients with high-risk Brugada syndrome, with ICD implanted at the Coimbra Hospital and University Center, were enrolled. Patients were questioned about their Brugada syndrome history, previous cardiac events, comorbidities, present and past medications, and physical activity. Patients were followed up during 5.8 ± 5.3 years. The ICD was interrogated, and arrhythmic events and device therapies were recorded. The cohort who received appropriate ICD therapies was compared with the remaining patients to determine the potential link between clinical variables and potentially fatal arrhythmic events. RESULTS: More than half of the patients (53.3%) took at least one non-recommended drug, and 16.7% received appropriate ICD therapies, with a long-term rate of 4.0%/year. There was a tendency for more appropriate ICD therapies in patients who took unsafe drugs (85.7 versus 45.5%, p = 0.062), and the mean time between unsafe drug intake and appropriate ICD therapies was 3.8 ± 7.5 days. CONCLUSIONS: This study revealed that the medical community is still unaware of the pharmacological restrictions imposed by Brugada syndrome. Patients who took non-recommended drugs seem to have a higher risk of ventricular arrhythmic events.

Who still remains at risk of arrhythmic death at time of implantable cardioverter-defibrillator generator replacement?

BACKGROUND: Implantable cardioverter-defibrillator (ICD) is associated with reduction in arrhythmic mortality. However, at the time of generator replacement (GR) some patients had not experienced therapies and had a different clinical profile. Therefore, the risk-benefit ratio of ICD may have changed. Our aim was to determine the proportion of patients with ICD implanted in primary prevention that maintain guideline-derived indications at the time of GR and assess predictors of therapies in the postreplacement period. We evaluate the long-term benefit of ICD after GR in nonischemic cardiomyopathy (NICM) versus ischemic cardiomyopathy (ICM). METHODS: We included 141 patients undergoing GR from 11/2009 to 7/2015. Patients were divided into: G1 - guideline congruent indication for ICD at the time of GR (left ventricular ejection fraction [LVEF] ≤ 35% or appropriate therapies) and G2 - guideline incongruent indication (patients without appropriate therapies and LVEF >35%). We also compared ICD benefit between ICM and NICM patients. RESULTS: Maintenance of guideline-driven indications for ICD (G1) was present in 68% of patients and 32% had recovery of LVEF and no ICD therapies at the time of GR (G2). After GR, G2 patients showed a lower rate of appropriate therapies (3% vs 33%, P < 0.01). LVEF ≤ 35% was the only independent predictor of appropriate therapies (OR 12.0, P < 0.01). In multivariate analysis, etiology of heart failure did not predict the arrhythmic risk. CONCLUSION: At the time of GR, a significant proportion of patients no longer met guideline indications for ICD and their need for therapies is reduced. The etiology of heart failure did not predict freedom from therapies.

Circulating endothelial progenitor cells as a predictor of response to cardiac resynchronization therapy: the missing piece of the puzzle?

BACKGROUND: It would be important to better identify heart failure (HF) patients most likely to respond to cardiac resynchronization therapy (CRT). Because endothelial progenitor cells (EPCs) play a crucial role in the maintenance of vascular endothelium integrity, we hypothesize that patients who have higher circulating EPCs levels have greater neovascularization potential and are more prone to be responders to CRT. METHODS: Prospective study of 30 consecutive patients, scheduled for CRT. Echocardiographic evaluation was performed before implant and 6 months after. Responders to CRT were defined as patients who were still alive, have not been hospitalized for HF management, and demonstrated ≥15% reduction in left ventricular end-systolic volume (LVESV) at the 6-month follow-up. EPCs were quantified before CRT, from peripheral blood, by flow cytometry using five different conjugated antibodies: anti-CD34, anti-KDR, anti-CD133, anti-CD45, and anti-CXCR4. We quantified five different populations of angiogenic cells: CD133(+) /CD34(+) cells, CD133(+) /KDR(+) cells, CD133(+) /CD34(+) /KDR(+) cells, CD45(dim) CD34(+) /KDR(+) cells, and CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells. RESULTS: The proportion of responders to CRT at the 6-month follow-up was 46.7%. Responders to CRT presented higher baseline EPCs levels than nonresponders (0.0003 ± 0.0006% vs 0.0001 ± 0.0002%, P = 0.04, for CD34(+) /CD133(+) /KDR(+) and 0.0006 ± 0.0005% vs 0.0003 ± 0.0003%, P = 0.009, for CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells). In addition, baseline levels of CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells were positively correlated with the reduction of LVESV verified 6 months after CRT (r = 0.497, P = 0.008). CONCLUSIONS: High circulating EPCs levels may identify the subset of HF patients who are more likely to undergo reverse remodeling and benefit from CRT. Addition of EPCs levels assessment to current selection criteria may improve the ability to predict CRT response.

Impact of the COVID-19 lockdown in urgent pacemaker implantations: A cross-sectional study.

AIMS: The COVID-19 pandemic resulted in a decrease in patients' follow-up and interventions with cardiovascular disease. In Portugal, the consequences on emergent pacemaker implantation rates are largely unknown. We sought to analyze the impact of the COVID-19 pandemic on emergent pacemaker implantation rate and patient profile. METHODS: We retrospectively reviewed the clinical profile of the 180 patients who had pacemakers implanted in our hospital in an emergent setting from March 18, 2020, to May 17, 2020 ("lockdown") and May 19 to July 17, 2020 ("postlockdown"). This data was then directly compared to the homologous periods from the year before. RESULTS: Urgent pacemaker implantation rates during "lockdown" was lower than its homologous period (-23.7%), and cases in "postlockdown" were significantly increased (+106.9% vs. "lockdown"; +13.2% vs. May-July 2019).When comparing "lockdown" and "postlockdown," there was a tendency for a higher number of temporary pacemaker use (p = .076). Patients during "lockdown" were 7.57 times more likely to present with hypotension/shock (odds ratio 7.57; p = .013). We also noted a higher tendency for hypotension on presentation during "lockdown" (p = .054) in comparison to 2019. In comparison to its homologous 2019 period, "postlockdown" saw more patients presenting with bradycardia (p = .026). No patients were admitted to the emergency department during "lockdown" for anomalies detected on ambulatory tests. CONCLUSION: Our data show that the COVID-19 pandemic had a real impact on urgent pacemaker implantation. Patients with bradyarrhythmias are at particular risk for severe complications and should seek medical care regardless of the pandemic.

Improvement in circulating endothelial progenitor cells pool after cardiac resynchronization therapy: increasing the list of benefits.

BACKGROUND: Recent studies suggest that circulating endothelial progenitor cells (EPCs) may influence the response to cardiac resynchronization therapy (CRT). The aim of this study was to evaluate the effect of CRT on EPC levels and to assess the impact of EPCs on long-term clinical outcomes. POPULATION AND METHODS: Prospective study of 50 patients submitted to CRT. Two populations of circulating EPCs were quantified previously to CRT implantation: CD34+KDR+ and CD133+KDR+ cells. EPC levels were reassessed 6 months after CRT. Endpoints during the long-term follow-up were all-cause mortality, heart transplantation, and hospitalization for heart failure (HF) management. RESULTS: The proportion of non-responders to CRT was 42% and tended to be higher in patients with an ischemic vs non-ischemic etiology (64% vs 35%, p = 0.098). Patients with ischemic cardiomyopathy (ICM) showed significantly lower CD34+KDR+ EPC levels when compared to non-ischemic dilated cardiomyopathy patients (DCM) (0.0010 ± 0.0007 vs 0.0030 ± 0.0024 cells/100 leukocytes, p = 0.032). There were no significant differences in baseline EPC levels between survivors and non-survivors nor between patients who were rehospitalized for HF management during follow-up or not. At 6-month follow-up, circulating EPC levels were significantly higher than baseline levels (0.0024 ± 0.0023 vs 0.0047 ± 0.0041 CD34+KDR+ cells/100 leukocytes, p = 0.010 and 0.0007 ± 0.0004 vs 0.0016 vs 0.0013 CD133+/KDR+ cells/100 leukocytes, p = 0.007). CONCLUSIONS: Patients with ICM showed significantly lower levels of circulating EPCs when compared to their counterparts. CRT seems to improve the pool of endogenously circulating EPCs and reduced baseline EPC levels seem not to influence long-term outcomes after CRT.

Identification of 'super-responders' to cardiac resynchronization therapy: the importance of symptom duration and left ventricular geometry.

AIMS: Some patients show such an important clinical improvement and reverse remodelling after cardiac resynchronization therapy (CRT) that anatomy and function approach normal. These patients have been called 'super-responders'. The aim of our study was to identify predictors of becoming a super-responder after CRT. METHODS AND RESULTS: Eighty-seven consecutive patients who underwent CRT were prospectively studied. Before CRT and 6 months after, clinical and echocardiographic evaluation was performed. Patients with a decrease in New York Heart Association functional class >or=1, a two-fold or more increase of left ventricular ejection fraction (LVEF) or a final LVEF >45%, and a decrease in LV end-systolic volume >15% were classified as super-responders. There were 12% super-responders. At baseline, there were no significant differences between super-responders and the other patients, except for the fact that super-responders had significantly smaller mitral regurgitation and LV end-diastolic diameter (LVEDD) and a shorter duration of heart failure symptoms. Mitral regurgitation jet area, LVEDD, and duration of heart failure symptoms were correlated with this super-response. Moreover, an evolution of symptoms for <12 months was an independent predictor of super-response to CRT. CONCLUSION: Patients in earlier phases of the cardiomyopathy, with a less altered ventricular geometry, seem to have a greater probability of becoming super-responders.

Which echocardiographic definition should be used to define response to cardiac resynchronization therapy?

INTRODUCTION: The definition of response to cardiac resynchronization therapy (CRT) remains controversial, with different criteria being used to define a positive response. The PROSPECT trial recently demonstrated that echocardiography is not sufficiently accurate to identify responders to CRT. However, it is possible that the definition used in this study was not the most appropriate. OBJECTIVE: To compare different echocardiographic definitions of response to CRT with peak oxygen consumption (VO2), in an attempt to identify the best echocardiographic definition. METHODS: Thirty consecutive patients who underwent echocardiography and cardiopulmonary exercise testing (CPET) before and 6 months after CRT were studied. An improvement of > or =1 NYHA class defined clinical responders; a > or =15% decrease in left ventricular end-systolic volume (LVESV) defined remodeling responders; a > or =25% improvement in left ventricular ejection fraction (LVEF) identified responders according to LVEF; a >25% improvement in left ventricular dP/dt defined responders according to dP/dt; and a ?10% improvement in peak VO2 defined CPET responders. RESULTS: There were 47% responders according to the reverse remodeling definition, 60% according to LVEF and 67% according to dP/dt; 77% were clinical responders and 40% CPET responders. The only baseline characteristic that differed between CPET responders and non-responders was the sphericity index (57 +/- 12% vs. 72 +/- 16%, p = 0.019), which showed an inverse correlation with CPET response (r = -0.455, p = 0.011). LVEF response showed the best agreement with CPET response (83% positive and 56% negative concordance). Clinical and echocardiographic responses were often discordant: 48% of clinical responders were non-responders according to reverse remodeling, 35% according to LVEF and 39% according to dP/dt. However, of clinical responders who did not respond on echocardiographic criteria, a positive NYHA response paralleled the CPET definition in 35% of cases. CONCLUSION: The best agreement between echocardiographic definitions of response and CPET was achieved with LVEF. In 35% of cases of discrepancy between clinical and echocardiographic responses, the clinical response paralleled CPET, which implies a benefit of CRT undetected by echocardiography and not a placebo effect.

Pacemaker implantation in familial amyloid polyneuropathy: when and for whom?

BACKGROUND: Despite the important role of cardiac pacing in preventing syncope and sudden cardiac death in familial amyloid polyneuropathy (FAP), we lack clear guidelines as to the ideal timing and indications for permanent pacemaker implantation. PURPOSE: The purpose of this study was to evaluate the ideal timing for pacemaker implantation in FAP patients submitted to liver transplantation. METHODS: Retrospective study of 258 FAP patients submitted to liver transplantation between 1992 and 2012. Comparison of three groups: (A) patients without pacemaker (N = 122); (B) patients submitted to pacemaker implantation after liver transplantation, with documented conduction disorders (N = 73); and (C) patients submitted to "prophylactic" pacemaker implantation before transplantation, (N = 73). Patients were followed up for 12.2 ± 6.7 years. RESULTS: The majority of patients (57%) were referred for pacemaker implantation, which occurred before liver transplantation in 50% of cases. Patients who required pacemaker after transplantation presented significantly higher Machado-Joseph Score during pre-transplant evaluation than those who did not require pacemaker (24 ± 10 vs 20 ± 10, p = .025), and also exhibited higher levels of hepatic cytolysis enzymes and hyperbilirubinemia. The most common indication for permanent pacemaker was first degree atrioventricular block, with a mean time between transplantation and pacemaker implantation of 8.7 ± 4.2 years. During long-term follow-up, all-cause mortality was 27% and was lowest in the group submitted to pacemaker implantation only after liver transplantation (p = 0.002). CONCLUSION: The majority of FAP patients submitted to liver transplantation will need a pacemaker at some time of follow-up. However, it seems that there is no benefit in "prophylactic" cardiac pacing before liver transplantation.

Transvenous removal of cardiac implantable electronic device leads.

INTRODUCTION AND OBJECTIVE: The number and complexity of cardiac implantable electronic devices (CIEDs) have increased, as has the number of related complications, often leading to removal of the implanted system. The aim of this study was to characterize transvenous explantation/extraction of CIED leads in a reference center. METHODS: This was a descriptive observational study of patients consecutively admitted from January 2009 to May 2014 for transvenous lead extraction. RESULTS: The sample consisted of 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. The main indication for lead extraction was CIED infection. The mean time from first implantation to lead removal was 5.6±4.89 years. Blood cultures were positive in 32.8% of cases and 29% of patients had vegetations on echocardiography. A total of 228 cardiac leads were removed, of which 58.8% were ventricular, 32.4% atrial and 8.8% coronary sinus. Complete clinical success was achieved in 97.2% of cases, while procedural success was complete in 93.4% and partial in 5.3%. The complications reported were three cases of significant pocket hematoma, one of subclavian vein thrombosis and three of cardiac tamponade, effectively treated by pericardiocentesis. CONCLUSIONS: Transvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure.

Cardiac resynchronization therapy is effective even in elderly patients with comorbidities.

PURPOSE: The purpose of this study was to compare the effects of cardiac resynchronization therapy (CRT) in elderly patients (> or =65 years) with younger patients and to assess the impact of comorbidities in CRT remodeling response. METHODS: This is a prospective study of 87 consecutive patients scheduled for CRT who underwent clinical and echocardiographic evaluation before and 6 months after CRT. A reduction in left ventricular end-systolic volume (LVESV) > or =15% after CRT defined remodeling responders, and a reduction of at least one New York Heart Association class defined clinical responders. Multivariate analysis was used to identify independent predictors of non-response to CRT in terms of reverse remodeling. RESULTS: The mean age was 62 +/- 11 years, with 36 elderly patients (41%). The baseline QRS duration was 145 +/- 32 ms. After CRT, there were significant and similar improvements of left ventricular (LV) ejection fraction, LVESV, LV dP/dt, and mitral regurgitation jet area (JA) between elderly (> or =65 years) and younger (<65 years) patients. The number of clinical and remodeling responders was comparable, and we found no significant differences in unplanned cardiac hospitalizations at 6 months between groups. Independent predictors of lack of remodeling response to CRT were QRS duration <120 ms, LV diastolic diameter >74 mm, and JA >10 cm(2) before CRT, but not comorbidities. CONCLUSION: This work suggests that being elderly is not an impediment to CRT success even in the presence of comorbidities.

Cirurgia de Felder: análise de 35 casos / Felder's surgery: analysis of 35 cases

Foram analisados, retrospectivamente, 35 pacientes do Hospital das Clínicas da Faculdade de Medicina de Ribeiräo Preto, de janeiro de 1973 a dezembro de 1986, portadores de doença varicosa, que foram submetidos a tratamento cirúrgico, segundo a técnica descrita por Felder. Desses pacientes 28 (80%) eram do sexo feminino e todos referiam profissäo que exige posiçäo ortostática prolongada. A faixa etária de maior incidência foi de 40-50 anos. Trinta e três pacientes tinham ou tiveram úlcera flebopática na evoluçäo da doença primária e dois apresentavam dermite de estase. Houve completa cicatrizaçäo da úlcera e nenhuma recidiva em 29 (82,8%) pacientes após 11,9 meses de seguimento médio. Quatro (11,4%) pacientes apresentaram recidiva da úlcera venosa, sendo que em dois deles recidivaram também as varizes de dois (5,7%) tiveram recidiva isolada de varizes. Estes resultados nos autorizam a prosseguir utilizando-se a cirurgia de Felder no tratamento cirúrgico da úlcera venosa e/ou dermite de estase grave

Ecobiometria fetal: padröes e índices que permitem a avaliaçäo do desenvolvimento fetal intra-útero / Fetal echobiometry: pattenrs and indices which permit the evaluation of intrauterine fetal development

Durante o segundo e terceiro trimestres da gestacao na populacao que atendemos, para fetos normais, obtivemos os padroes de variacao dos ­ndices ecograficos: circunferência craniana (CC); circunferência abdominal (CA); fêmur (F) CA x 100; diametro biparietal (DBP); diametro fronto-occipital (DFO) x 100 e FIDBP x 100. Esses ­ndices sao importantes para avaliarmos o desenvolvimento fetal intra-uterino normal e diagnosticarmos seus desvios, algumas vezes at, sem sabermos precisamente a idade gestacional. Lembramos, no entanto, ser boa pratica obstetrica conhecermos a idade gestacional desde o primeiro trimestre da gravidez, o que nos levar a diagnosticos precisos.