RESUMO
Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert "think tank" reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.
RESUMO
BACKGROUND: Together with pulmonary veins, many extrapulmonary vein areas may be the source of initiation and maintenance of atrial fibrillation. The left atrial appendage (LAA) is an underestimated site of initiation of atrial fibrillation. Here, we report the prevalence of triggers from the LAA and the best strategy for successful ablation. METHODS AND RESULTS: Nine hundred eighty-seven consecutive patients (29% paroxysmal, 71% nonparoxysmal) undergoing redo catheter ablation for atrial fibrillation were enrolled. Two hundred sixty-six patients (27%) showed firing from the LAA and became the study population. In 86 of 987 patients (8.7%; 5 paroxysmal, 81 nonparoxysmal), the LAA was found to be the only source of arrhythmia with no pulmonary veins or other extrapulmonary vein site reconnection. Ablation was performed either with focal lesion (n=56; group 2) or to achieve LAA isolation by placement of the circular catheter at the ostium of the LAA guided by intracardiac echocardiography (167 patients; group 3). In the remaining patients, LAA firing was not ablated (n=43; group 1). At the 12+/-3-month follow-up, 32 patients (74%) in group 1 had recurrence compared with 38 (68%) in group 2 and 25 (15%) in group 3 (P<0.001). CONCLUSIONS: The LAA appears to be responsible for arrhythmias in 27% of patients presenting for repeat procedures. Isolation of the LAA could achieve freedom from atrial fibrillation in patients presenting for a repeat procedure when arrhythmias initiating from this structure are demonstrated.
Assuntos
Apêndice Atrial/fisiopatologia , Apêndice Atrial/cirurgia , Fibrilação Atrial , Ablação por Cateter , Idoso , Fibrilação Atrial/etiologia , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Catheter ablation of atrial fibrillation is associated with the potential risk of periprocedural stroke, which can range between 1% and 5%. We developed a prospective database to evaluate the prevalence of stroke over time and to assess whether the periprocedural anticoagulation strategy and use of open irrigation ablation catheter have resulted in a reduction of this complication. METHODS AND RESULTS: We collected data from 9 centers performing the same ablation procedure with the same anticoagulation protocol. We divided the patients into 3 groups: ablation with an 8-mm catheter off warfarin (group 1), ablation with an open irrigated catheter off warfarin (group 2), and ablation with an open irrigated catheter on warfarin (group 3). Outcome data on stroke/transient ischemic attack and bleeding complications during and early after the procedures were collected. Of 6454 consecutive patients in the study, 2488 were in group 1, 1348 were in group 2, and 2618 were in group 3. Periprocedural stroke/transient ischemic attack occurred in 27 patients (1.1%) in group 1 and 12 patients (0.9%) in group 2. Despite a higher prevalence of nonparoxysmal atrial fibrillation and more patients with CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score >2, no stroke/transient ischemic attack was reported in group 3. Complications among groups 1, 2, and 3, including major bleeding (10 [0.4%], 11 [0.8%], and 10 [0.4%], respectively; P>0.05) and pericardial effusion (11 [0.4%], 11 [0.8%], and 12 [0.5%]; P>0.05), were equally distributed. CONCLUSIONS: The combination of an open irrigation ablation catheter and periprocedural therapeutic anticoagulation with warfarin may reduce the risk of periprocedural stroke without increasing the risk of pericardial effusion or other bleeding complications.
Assuntos
Fibrilação Atrial/sangue , Perda Sanguínea Cirúrgica/prevenção & controle , Cateterismo Cardíaco/efeitos adversos , Ablação por Cateter/efeitos adversos , Coeficiente Internacional Normatizado , Acidente Vascular Cerebral/sangue , Idoso , Anticoagulantes/uso terapêutico , Fibrilação Atrial/terapia , Gerenciamento Clínico , Feminino , Seguimentos , Hemorragia/sangue , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Complicações Intraoperatórias/sangue , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/efeitos adversos , Estudos Prospectivos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controleRESUMO
INTRODUCTION: Popping, char and perforation are complications that can occur following catheter ablation. We measured the amount of grams (g) applied to the endocardium during ablation using a sensor incorporated in the long sheath of a robotic system. We evaluated the relationship between lesion formation, pressure, and the development of complications. METHODS: Using a robotic navigation system, lesions were placed in the left atrium (LA) at six settings, using a constant duration (40 seconds) and flow rate of either 17 cc/min or 30 cc/min with an open irrigated catheter (OIC). Evidence of complications was noted and lesion location recorded for later analysis at necropsy. RESULTS: Lesions using 30 Watts (W) were more likely to be transmural at higher (>40 g) than lower (<30 g) pressures (75% vs 25%, P < 0.001). Significantly higher number of lesions using >40 g of pressure demonstrated "popping" and crater formation as compared with lesions with 20-30 g of pressure (41% vs 15%, P = 0.008). A majority of lesions placed using higher power (45 W) with higher pressures (>40 g) were associated with char and crater formation (66.7%). No lesions using 10 g of pressure were transmural, regardless of the power. Lesions placed with a power setting less than 35 W were more likely to result in "relative" sparing of the endocardial surface than lesions at a power setting higher than 35 W (62% vs 33.3%, P = 0.02) regardless of the pressure. CONCLUSIONS: When using an OIC, lower power settings (Assuntos
Ablação por Cateter/efeitos adversos
, Endocárdio/lesões
, Traumatismos Cardíacos/etiologia
, Robótica
, Cirurgia Assistida por Computador
, Animais
, Ablação por Cateter/instrumentação
, Cães
, Endocárdio/diagnóstico por imagem
, Desenho de Equipamento
, Feminino
, Traumatismos Cardíacos/diagnóstico por imagem
, Traumatismos Cardíacos/prevenção & controle
, Masculino
, Teste de Materiais
, Pressão
, Medição de Risco
, Estresse Mecânico
, Ultrassonografia
RESUMO
INTRODUCTION: Evaluation of luminal temperature during left atrial ablation is used clinically; however, luminal temperature does not necessarily reflect temperature within the esophageal wall and poses a risk of atrioesophageal fistula. This animal study evaluates luminal esophageal temperature and its relation to the temperature of the external esophageal tissue during left atrial lesions using the 8 mm solid tip and the open irrigated tip catheters (OIC). METHODS AND RESULTS: A thermocouple was secured to the external surface of the esophagus at the level of the left atrium of the dogs. Luminal esophageal temperature was measured using a standard temperature probe. In four randomized dogs, lesions were placed using an 8 mm solid tip ablation catheter. In six randomized dogs, lesions were placed using the 3.5 mm OIC. The average peak esophageal tissue temperature when using the OIC was significantly higher than that of the 8 mm tip catheter (88.6 degrees C +/- 15.0 degrees C vs. 62.3 degrees C +/- 12.5 degrees C, P < 0.05). Both OIC and 8 mm tip catheter had significantly higher peak tissue temperatures than luminal temperatures (OIC: 88.6 degrees C +/- 15.0 degrees C vs 39.7 degrees C +/- 0.82 degrees C, P < 0.05) (8 mm: 62.3 degrees C +/- 12.5 degrees C vs 39.0 +/- 0.5 degrees C, P < 0.05). Both catheters achieved peak temperatures faster in the tissue as compared to the lumen of the esophagus, although the tissue temperature peaked significantly faster for the OIC (OIC: 25 seconds vs 90 seconds, P < 0.05) (8 mm: 63 seconds vs 105 seconds, P < 0.05). CONCLUSION: Despite the significant difference in actual tissue temperatures, no significant difference was observed in luminal temperatures between the OIC and 8 mm tip catheter.
Assuntos
Fibrilação Atrial/cirurgia , Temperatura Corporal/fisiologia , Ablação por Cateter/métodos , Esôfago/fisiopatologia , Monitorização Intraoperatória/métodos , Irrigação Terapêutica/instrumentação , Animais , Fibrilação Atrial/fisiopatologia , Modelos Animais de Doenças , Cães , Seguimentos , Reprodutibilidade dos Testes , TermômetrosRESUMO
AIMS: Catheter ablation is an effective treatment for atrial fibrillation (AF). The outcome of AF ablation in septuagenarians is not clear. Our aim was to evaluate success rate, outcome, and complication rate of AF ablation in septuagenarians. METHODS AND RESULTS: We collected data from 174 consecutive patients over 75 years of age who underwent AF ablation from 2001 to 2006. AF was paroxysmal in 55%. High-risk CHADS score (>or=2) was present in 65% of the population. Over a mean follow-up of 20 +/- 14 months, 127 (73%) maintained sinus rhythm (SR) with a single procedure, whereas 47 patients had recurrence of AF. Twenty of them had a second ablation, successful in 16 (80%). Major acute complications included one CVA and one hemothorax (2/194 [1.0%]). During the follow-up, three patients had a CVA within the first 6 weeks after ablation. Warfarin was discontinued in 138 out 143 patients (96%) who maintained SR without AADs with no embolic event occurring over a mean follow-up of 16 +/- 12 months. CONCLUSION: AF ablation is a safe and effective treatment for AF in septuagenarians.
Assuntos
Fibrilação Atrial/epidemiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/métodos , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Itália/epidemiologia , Masculino , Fatores de Risco , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Elimination of vagal inputs into the left atrium (LA) may be necessary for successful catheter ablation of atrial fibrillation (AF). These vagal inputs are clustered in autonomic ganglia (AG) that are close to the pulmonary vein antrum (PVA) borders, but whether standard intracardiac echocardiography (ICE)-guided PVA isolation (PVAI) affects these inputs is unknown. OBJECTIVE: The purpose of this study was to assess whether standard ICE-guided PVAI affects vagal responses induced by endocardial AG stimulation in the LA. METHODS: Twenty consecutive patients undergoing first-time PVAI (group 1) and 20 consecutive patients undergoing repeat PVAI for AF recurrence (group 2) were enrolled in the study. Before ablation, electrical stimulation (20 Hz, pulse duration 10 ms, voltage range 12-20 V) was performed through an 8-mm-tip ablation catheter. Based on prior data, regions around all four PVA borders were carefully mapped and stimulated to localize AG inputs. A positive stimulated vagal response was defined as atrioventricular (AV) block, asystole, or increase in mean RR interval by >50%. Locations of positive vagal responses were recorded wth biplane fluoroscopy and CARTO. All patients then underwent standard ICE-guided PVAI by an operator blinded to the locations of vagal responses. Stimulation of the AG locations was then repeated postablation. RESULTS: Patients (age 54 +/- 11 years, 30% female, ejection fraction 54% +/- 7%) had a history of paroxysmal (75%) and persistent (25%) AF. In group 1, vagal responses were induced in all 20 patients around a mean of 3.8 +/- 0.4 PVAs per patient. The most common response was asystole (53%), mean RR slowing >50% (28%), and AV block (20%). Postablation, vagal responses could no longer be induced in all 20 patients. A diminished response was induced (RR slowing <50%) in 2/20 patients around one PVA each. In group 2, vagal responses were not induced in any of the 20 repeat patients. Stimulation capture postablation was confirmed because transient, nonsustained (<30 seconds) AF or atrial flutter was induced in all 40 patients with stimulation, whether vagal responses were induced or not. CONCLUSIONS: Standard ICE-guided PVAI eliminates vagal responses induced by AG stimulation. Responses are not seen in patients presenting for repeat PVAI, despite clinical recurrence of AF.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Veias Pulmonares/cirurgia , Cirurgia Assistida por Computador/métodos , Adulto , Idoso , Fibrilação Atrial/diagnóstico por imagem , Função Atrial , Terapia Combinada , Ecocardiografia/métodos , Estimulação Elétrica , Feminino , Seguimentos , Sistema de Condução Cardíaco/diagnóstico por imagem , Sistema de Condução Cardíaco/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Sistema Nervoso Parassimpático/fisiopatologia , Veias Pulmonares/diagnóstico por imagem , Resultado do TratamentoRESUMO
BACKGROUND: Ablation of atrial fibrillation is generally considered safe and effective. However, atrial-esophageal fistulas have recently been reported as a rare but fatal complication. OBJECTIVE: To describe 9 patients with atrial-esophageal fistulas after ablation for atrial fibrillation. DESIGN: Retrospective case series. SETTING: Institutions where cardiologists performed atrial fibrillation ablation procedures. PATIENTS: 9 patients with atrial-esophageal fistulas after atrial fibrillation ablation. MEASUREMENTS: Demographic characteristics, mortality, presenting signs and symptoms, and days to presentation. RESULTS: Patients presented a mean of 12.3 days (range, 10 to 16 days) after their procedures. Nonspecific symptoms included fever, leukocytosis, and neurologic abnormalities. All patients died. Only 4 patients received correct diagnoses before death, although all patients presented to a physician. In 3 patients, surgical repair was attempted. LIMITATIONS: Few physicians reported cases, and only approximate numbers of procedures performed by the physicians are known. Thus, the authors could not estimate the incidence of atrial-esophageal fistulas after ablation. CONCLUSIONS: Formation of atrial-esophageal fistulas is a rare but potentially devastating complication of atrial fibrillation ablation. This disorder may have an indolent presentation and may mimic other disease states, such as stroke or sepsis.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Fístula Esofágica/etiologia , Fístula/etiologia , Átrios do Coração , Fístula Esofágica/diagnóstico por imagem , Fístula/diagnóstico por imagem , Átrios do Coração/diagnóstico por imagem , Humanos , Imageamento Tridimensional , Masculino , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Left atrioesophageal fistula is a devastating complication of atrial fibrillation ablation. There is no standard approach for avoiding this complication, which is caused by thermal injury during ablation. The objectives of this study were to evaluate the course of the esophagus and the temperature within the esophagus during pulmonary vein antrum isolation (PVAI) and correlate these data with esophagus tissue damage. METHODS AND RESULTS: Eight-one patients presenting for PVAI underwent esophagus evaluation that included temperature probe placement. Esophagus course was obtained with computed tomography, 3D imaging (NAVX), or intracardiac echocardiography. For each lesion, the power, catheter and esophagus temperature, location, and presence of microbubbles were recorded. Lesion location and esophagus course were defined with 6 predetermined left atrial anatomic segments. Endoscopy evaluated tissue changes during and after PVAI. Of 81 patients, the esophagus coursed near the right pulmonary veins in 23 (28.4%), left pulmonary veins in 31 (38.3%), and mid-posterior wall in 27 (33%). Esophagus temperature was significantly higher during left atrial lesions along its course than with lesions elsewhere (38.9+/-1.4 degrees C, 36.8+/-0.5 degrees C, P<0.01). Lesions that generated microbubbles had higher esophagus temperatures than those without (39.3+/-1.5 degrees C, 38.5+/-0.9 degrees C, P<0.01). Power was not predictive of esophagus temperatures. Distance between the esophagus and left atrium was 4.4+/-1.2 mm. CONCLUSIONS: Lesions near the course of the esophagus that generated microbubbles significantly increased esophagus temperature compared with lesions that did not. Power did not correlate with esophagus temperatures. Esophagus variability makes the avoidance of lesions along its course difficult. Rather than avoiding posterior lesions, emphasis could be placed on better esophagus monitoring for creation of safer lesions.
Assuntos
Fibrilação Atrial/cirurgia , Temperatura Corporal , Ablação por Cateter/efeitos adversos , Esôfago/patologia , Veias Pulmonares/cirurgia , Adulto , Idoso , Esôfago/fisiopatologia , Feminino , Átrios do Coração , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Multiple morphologies, hemodynamic instability, or noninducibility may limit ventricular tachycardia (VT) ablation in patients with arrhythmogenic right ventricular dysplasia (ARVD). Substrate-based mapping and ablation may overcome these limitations. We report the results and success of substrate-based VT ablation in ARVD. METHODS AND RESULTS: Twenty-two patients with ARVD were studied. Traditional mapping for VT was limited because of multiple/changing VT morphologies (n=14), nonsustained VT (n=10), or hemodynamic intolerance (n=5). Sinus rhythm CARTO mapping was performed to define areas of "scar" (<0.5 mV) and "abnormal" myocardium (0.5 to 1.5 mV). Ablation was performed in "abnormal" regions, targeting sites with good pace maps compared with the induced VT(s). Linear lesions were created in these areas to (1) connect the scar/abnormal region to a valve continuity or other scar or (2) encircle the scar/abnormal region. Eighteen patients had implanted cardioverter defibrillators, 15 had implanted cardioverter defibrillator therapies, and 7 had sustained VT (6 with syncope). VTs (3+/-2 per patient) were induced (cycle length, 339+/-94 ms), and scar was identified in all patients. Scar areas were related to the tricuspid annulus, proximal right ventricular outflow tract, and anterior/inferior-apical walls. Lesions connected abnormal regions to the annulus (n=12) or other scars (n=4) and/or encircled abnormal regions (n=13). Per patient, a mean of 38+/-22 radiofrequency lesions was applied. Short-term success was achieved in 18 patients (82%). VT recurred in 23%, 27%, and 47% of patients after 1, 2, and 3 years' follow-up, respectively. CONCLUSIONS: Substrate-based ablation of VT in ARVD can achieve a good short-term success rate. However, recurrences become increasingly common during long-term follow-up.
Assuntos
Displasia Arritmogênica Ventricular Direita/terapia , Ablação por Cateter/métodos , Técnicas Eletrofisiológicas Cardíacas/métodos , Taquicardia Ventricular/terapia , Adulto , Displasia Arritmogênica Ventricular Direita/patologia , Feminino , Seguimentos , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Taquicardia Ventricular/patologia , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to assess the incidence of atrial flutter (AFL) after pulmonary vein antrum isolation (PVAI) in patients with previous cardiac surgery (PCS) in comparison to patients without PCS and to assess the need for AFL ablation in both groups. BACKGROUND: Atrial fibrillation (AF) and AFL often co-exist. Pulmonary vein antrum isolation may be sufficient to control both arrhythmias. However, in patients with PCS, atrial incisions, cannulations, and scar areas may cause AFL recurrence despite elimination of pulmonary vein triggers. METHODS: Data from 1,345 patients who had PVAI were analyzed. Patients with a history of AFL ablation and patients who had concomitant AFL ablation during PVAI were excluded from analysis. Sixty-three patients constituted the PCS group (Group 1, age 57 +/- 13 years, 12 female) and 1,062 patients constituted the non-PCS group (Group 2, age 55 +/- 12 years, 212 female). Patients in Group 1 had larger left atria, higher incidence of AFL pre-PVAI, and lower ejection fraction. RESULTS: There was no significant difference in post-PVAI AF recurrence between Groups 1 and 2, but AFL incidence after PVAI was higher in Group 1 (33% vs. 4%, p < 0.0001). Ablation of AFL in Group 1 patients resulted in an 86% acute success rate and 11% recurrence over a mean follow-up of 357 +/- 201 days. CONCLUSIONS: In patients with PCS, post-PVAI AF recurrence is similar to patients without PCS. However, history of PCS is associated with a higher recurrence of AFL after PVAI. In a significant number of patients with PCS, AFL ablation is required to achieve a cure.
Assuntos
Fibrilação Atrial/cirurgia , Flutter Atrial/cirurgia , Ablação por Cateter , Complicações Pós-Operatórias/cirurgia , Veias Pulmonares/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Flutter Atrial/diagnóstico , Eletrocardiografia Ambulatorial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Reoperação , Estudos Retrospectivos , Fatores de Risco , Prevenção Secundária , Resultado do TratamentoRESUMO
OBJECTIVES: The aims of this study were to demonstrate the safety and the feasibility of the robotic catheter remote control system (CCS) in endocardial navigation in all cardiac chambers, as well as facilitation of the transseptal puncture. BACKGROUND: CCS has been developed to facilitate control and precise positioning of catheters within the cardiovascular system. METHODS: CCS consists of a remote catheter manipulator, a set up joint, a physician workstation, and a steerable guide catheter (SGC) and sheath. A conventional 4-mm tip catheter was inserted through the SGC to perform mapping of five predefined targets in each cardiac chamber. Seven mongrel dogs were used in this study. Intracardiac echocardiography and three-dimensional (3-D) electroanatomical mapping were integrated with CCS to facilitate catheter manipulation and to guide transseptal puncture. The time to complete the transseptal puncture and the time to complete access to the predefined targets in each cardiac chamber were measured. Gross and microscopic examinations of the accessed and ablation sites were performed to evaluate safety. RESULTS: Transseptal puncture was performed successfully in all animals with a mean time of 7 +/- 3 minutes. Procedure times to access the five targets in the right atrium, right ventricle, left atrium, and left ventricle were 5.6 +/- 1.7, 4.6 +/- 1.5, 13.5 +/- 11.0, 7.0 +/- 2.9 minutes, respectively. There were no intracardiac damages associated with catheter manipulation noted in the excised hearts. CONCLUSIONS: Endocardial catheter navigation and mapping using the robotic catheter remote control is safe and feasible. Moreover, the CCS could be used to perform transseptal puncture and left atrial instrumentation.
Assuntos
Cateterismo Cardíaco/instrumentação , Ablação por Cateter/instrumentação , Punções/instrumentação , Robótica/instrumentação , Cirurgia Assistida por Computador/instrumentação , Telemedicina/instrumentação , Animais , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/métodos , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Cães , Endocárdio/diagnóstico por imagem , Endocárdio/cirurgia , Desenho de Equipamento , Análise de Falha de Equipamento , Segurança de Equipamentos , Estudos de Viabilidade , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/etiologia , Septos Cardíacos/diagnóstico por imagem , Septos Cardíacos/cirurgia , Projetos Piloto , Punções/efeitos adversos , Punções/métodos , Robótica/métodos , Cirurgia Assistida por Computador/métodos , Telemedicina/métodos , UltrassonografiaRESUMO
BACKGROUND: Although pulmonary vein (PV) antrum isolation is effective in curing atrial fibrillation (AF) in a variety of heart diseases, results in patients with hypertrophic obstructive cardiomyopathy (HOCM) have not been reported. OBJECTIVES: The purpose of this study was to report the results and outcome of PV antrum isolation in patients with AF and HOCM. METHODS: Data from patients with AF and HOCM who underwent PV antrum isolation between February 2002 and May 2004 were analyzed retrospectively. An intracardiac echocardiographic-guided ablation technique with an 8-mm-tip catheter was used in all patients. Patients were followed in the outpatient clinic at 3, 6, and 12 months after ablation. RESULTS: Twenty-seven patients with AF and HOCM (mean age 55 +/- 10 years) underwent PV antrum isolation. Mean AF duration was 5.4 +/- 3.6 years. AF was paroxysmal in 14 (52%), persistent in 9 (33%), and permanent in 4 (15%). During a mean follow-up of 341 +/- 237 days, 13 patients (48%) had AF recurrence. Of these patients, five maintained sinus rhythm (SR) with antiarrhythmic drugs, one patient remained in persistent AF, and seven patients underwent a second PV antrum isolation. After the second PV antrum isolation, five patients remained in SR, giving a final success rate of 70% (19/27). Two patients had recurrence after second PV antrum isolation; one maintained SR with antiarrhythmic drugs and one remained in persistent AF. CONCLUSION: Compared with previously reported results in patients with lone AF, AF recurrence after the first PV antrum isolation is higher in patients with HOCM. However, after repeated ablation procedures, long-term cure can be achieved in a sizable number of patients. PV antrum isolation is a feasible therapeutic option in patients with AF and HOCM.
Assuntos
Fibrilação Atrial/cirurgia , Cardiomiopatia Hipertrófica/cirurgia , Ablação por Cateter/métodos , Veias Pulmonares/cirurgia , Fibrilação Atrial/complicações , Cardiomiopatia Hipertrófica/complicações , Ecocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: The goal of this study was to determine if parasympathetic nerves in the anterior fat pad (FP) can be stimulated at the time of coronary artery bypass surgery (CABG), and if dissection of this FP decreases the incidence of postoperative atrial fibrillation (AF). BACKGROUND: The human anterior epicardial FP contains parasympathetic ganglia and is often dissected during CABG. Changes in parasympathetic tone influence the incidence of AF. METHODS: Fifty-five patients undergoing CABG were randomized to anterior FP preservation (group A) or dissection (group B). Nerve stimulation was applied to the FP before and after surgery. Sinus cycle length (CL) was measured during stimulation. The incidence of postoperative AF was recorded. RESULTS: Of the 55 patients enrolled, 26 patients were randomized to group A, and 29 patients were randomized to group B. In all of the 55 patients, the FP was identified before initiating cardiopulmonary bypass by CL prolongation with stimulation (865.5 +/- 147.9 ms vs. 957.9 +/- 155.1 ms, baseline vs. stimulation, p < 0.001). In group A, stimulation at the conclusion of surgery increased sinus CL (801.8 +/- 166.4 ms vs. 890.9 +/- 178.2 ms, baseline vs. stimulation, p < 0.001). In group B, repeat stimulation failed to increase sinus CL (853.6 +/- 201.6 ms vs. 841.4 +/- 198.4 ms, baseline vs. stimulation, p = NS). The incidence of postoperative AF in group A (7%) was significantly less than that in group B (37%) (p < 0.01). CONCLUSIONS: This is the first study demonstrating that direct stimulation of the human anterior epicardial FP slows sinus CL. This parasympathetic effect is eliminated with FP dissection. Preservation of the human anterior epicardial FP during CABG decreases incidence of postoperative AF.
Assuntos
Tecido Adiposo/inervação , Tecido Adiposo/fisiologia , Fibrilação Atrial/prevenção & controle , Nó Atrioventricular/inervação , Nó Atrioventricular/fisiologia , Ponte de Artéria Coronária/métodos , Fibrilação Atrial/etiologia , Estimulação Elétrica/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Parassimpatectomia/métodos , Complicações Pós-Operatórias/prevenção & controle , Resultado do TratamentoRESUMO
Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert "think tank" reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community, but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.
Assuntos
Doenças Cardiovasculares/diagnóstico , Segurança do Paciente/normas , Proteção Radiológica/normas , Radiografia/normas , Cintilografia/normas , Adulto , Cardiologia/normas , Doenças Cardiovasculares/terapia , Educação , Humanos , Relações Interprofissionais , Cultura Organizacional , Indicadores de Qualidade em Assistência à Saúde , Proteção Radiológica/métodos , Radiometria , Estados UnidosRESUMO
Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert "think tank" reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community, but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.
Assuntos
Doenças Cardiovasculares/diagnóstico , Segurança do Paciente/normas , Proteção Radiológica/normas , Radiografia/normas , Cintilografia/normas , Adulto , Cardiologia/normas , Doenças Cardiovasculares/terapia , Educação , Humanos , Relações Interprofissionais , Cultura Organizacional , Indicadores de Qualidade em Assistência à Saúde , Proteção Radiológica/métodos , Radiometria , Estados UnidosRESUMO
BACKGROUND: Obstructive sleep apnea (OSA) may be associated with pulmonary vein antrum isolation (PVAI) failure. The aim of the present study was to investigate if treatment with continuous positive airway pressure (CPAP) improved PVAI success rates. METHODS AND RESULTS: From January 2004 to December 2007, 3000 consecutive patients underwent PVAI. Patients were screened for OSA and CPAP use. Six hundred forty (21.3%) patients had OSA. Patients with OSA had more procedural failures (P=0.024) and hematomas (P<0.001). Eight percent of the non-OSA paroxysmal atrial fibrillation patients had nonpulmonary vein antrum triggers (non-PV triggers) and posterior wall firing versus 20% of the OSA group (P<0.001). Nineteen percent of the non-OSA nonparoxysmal atrial fibrillation population had non-PV triggers versus 31% in the OSA group (P=0.001). At the end of the follow-up period (32±14 months), 79% of the non-CPAP and 68% of the CPAP group were free of atrial fibrillation (P=0.003). Not using CPAP in addition to having non-PV triggers strongly predicted procedural failure (hazard ratio, 8.81; P<0.001). CONCLUSIONS: OSA was an independent predictor for PVAI failure. Treatment with CPAP improved PVAI success rates. Patients not treated with CPAP in addition to having higher prevalence of non-PV triggers were 8 times more likely to fail the procedure.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Pressão Positiva Contínua nas Vias Aéreas/métodos , Sistema de Condução Cardíaco/cirurgia , Veias Pulmonares/cirurgia , Apneia Obstrutiva do Sono/terapia , Fibrilação Atrial/complicações , Fibrilação Atrial/fisiopatologia , Feminino , Seguimentos , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Although catheter-based radiofrequency ablation is no longer experimental, it is not yet the first-line treatment for most patients. The authors describe how this procedure works, its indications, benefits, and limitations, and important points to communicate to potential candidates for this procedure.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter , Fibrilação Atrial/tratamento farmacológico , Ablação por Cateter/efeitos adversos , Ablação por Cateter/economia , Análise Custo-Benefício , Humanos , Educação de Pacientes como Assunto , Qualidade de VidaRESUMO
BACKGROUND: The proximity of the phrenic nerve (PN) to cardiac tissue relevant to arrhythmias may increase the risk of PN injury. Strategies for preventing PN injury in the pericardial space are limited. OBJECTIVE: The purpose of this study was to compare methods for separating the PN from the epicardial surface in order to prevent PN injury. METHODS: Eight patients referred for epicardial ablation of arrhythmias were enrolled in the study. All patients required ablation near the PN. Endocardial and epicardial access was obtained in all patients. A three-dimensional mapping system was used to guide mapping and ablation. All patients underwent epicardial catheter ablation. Pacing via the ablation catheter identified the location of the PN. In order to prevent PN injury, four new strategies were tested in each patient. We sought to increase the distance between the epicardium and the PN by (1) placing a large-diameter balloon between the nerve and the myocardium, (2) introducing saline in steps of 20 ml until PN capture was lost or blood pressure dropped below 60 mmHg, (3) introducing air until PN capture was lost or blood pressure dropped below 60 mmHg, or (4) introducing a combination of saline and air until PN capture was lost or blood pressure dropped below 60 mmHg. RESULTS: At each step, epicardial pacing was performed to assess for PN stimulation. The combination of air and saline resulted in the greatest decrease of PN stimulation. Saline only failed in all cases. Air only and balloon placement were infrequently successful. CONCLUSION: Controlled and progressive inflation of air and saline together with careful monitoring of hemodynamic parameters appears to be the best strategy for preventing PN injury during epicardial ablation. Placement of a large balloon in the appropriate location can be difficult.