Alberto Giniger

Results of Cryoenergy and Radiofrequency-Based Catheter Ablation for Treating Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle, Guided by Intracardiac Echocardiography and Image Integration

Background—Catheter radiofrequency ablation of ventricular arrhythmias (VAs) arising from the left ventricle’s papillary muscles has been associated with inconsistent results. The use of cryoenergy versus radiofrequency has not been compared yet. This study compares outcomes and complications of catheter ablation of VA from the papillary muscles of the left ventricle with either cryoenergy or radiofrequency. Methods and Results—Twenty-one patients (40±12 years old; 47% males; median ejection fraction 59±7.3%) with drug refractory premature ventricular contractions or ventricular tachycardia underwent catheter cryoablation or radiofrequency ablation. VAs were localized using 3-dimensional mapping, multidetector computed tomography, and intracardiac echocardiography, with arrhythmia foci being mapped at either the anterolateral papillary muscle or posteromedial papillary muscles of the left ventricle. Focal ablation was performed using an 8-mm cryoablation catheter or a 4-mm open-irrigated radiofrequency catheter, via transmitral approach. Acute success rate was 100% for cryoenergy (n=12) and 78% for radiofrequency (n=9; P=0.08). Catheter stability was achieved in all patients (100%) treated with cryoenergy, and only in 2 (25%) patients treated with radiofrequency (P=0.001). Incidence of multiple VA morphologies was observed in 7 patients treated with radiofrequency (77.7%), whereas none was observed in those treated with cryoenergy (P=0.001). VA recurrence at 6 months follow-up was 0% for cryoablation and 44% for radiofrequency (P=0.03). Conclusions—Cryoablation was associated with higher success rates and lower recurrence rates than radiofrequency catheter ablation, better catheter stability, and lesser incidence of polymorphic arrhythmias.

Three-dimensional esophagus reconstruction and monitoring during ablation of atrial fibrillation: Combination of two imaging techniques

OBJECTIVE The purpose of the study was to determine the accuracy of a novel three-dimensional (3D) imaging integration technique of the esophagus combining multislice computed tomography (CT) scan of the esophagus into the three-dimensional (3D) electroanatomic map just before pulmonary vein (PV) isolation. METHODS We included 94 consecutive patients with symptomatic atrial fibrillation (AF) who underwent ablation. All patients had a CT performed prior procedure that was integrated to the 3D reconstruction electromechanical map of the atrium and the esophagus (Verismo(TM), EnSite® NavX version 7.0 J, St. Jude Medical Inc.). During the procedure, a quadripolar electrophysiology catheter placed in the esophagus was used for mapping and to monitor esophagus position. Integrated (fusion) images were used to determinate the esophagus position compared to the left atrium posterior wall and its relationship with PV ostiums. We compared esophagus position by CT and fusion images. RESULTS Procedural success was 97.9% with no fatal complications. Esophagus locations were as follows: left 57%, right 7%, oblique course 11% and central 25%. Agreements in esophageal position between CT and fusion imaging techniques were 83.3% and 64% for patients with a recent (≤48 h) and non-recent CT assessment (>48 h), respectively. Throughout the procedure, esophagus stability was 88.8% (lateral displacement<15 mm). Ablative strategy was modified in 51% of the cases due to awareness of esophagus location. CONCLUSION Guidance of AF ablation with 3D fusion images was safe and effective. CT images of the esophagus, especially if acquired within 48 h before ablation, ensure appropriate intraprocedural localization of the esophagus.

Flecainide or Propafenone vs Vernakalant for Conversion of Recent-Onset Atrial Fibrillation

To the Editor: Several studies have demonstrated the efficacy of flecainide and propafenone for conversion of recent-onset atrial fibrillation (AF) to sinus rhythm. Randomized controlled studies demonstrated conversion to sinus rhythm within 8 hours in about 70% of patients treated with either agent. A single oral dose of flecainide or propafenone is widely used for conversion of recent-onset AF in hemodynamically stable patients without structural heart disease. The European guidelines consider flecainide or propafenone class IA agents for this application. Vernakalant is a novel, rapidly acting intravenous drug with proven effectiveness and safety compared with placebo and amiodarone in randomized clinical trials. Our study compared the time for conversion of recent-onset AF in patients treated with vernakalant vs flecainide or propafenone. Hemodynamically stable patients (n 1⁄4 51) with recentonset AF without structural heart disease were prospectively and consecutively included. Patients received single oral doses of flecainide 300 mg (n 1⁄4 15) or propafenone 600 mg (n 1⁄4 19), or intravenous vernakalant (n 1⁄4 17) at standard doses. Baseline characteristics were similar in all groups. Median time to conversion to sinus rhythm was 161 minutes (interquartile range [IQR], 125-312 minutes) in the flecainide group, 166 minutes (IQR, 120-300 minutes) in the propafenone group, and 9 minutes (IQR, 6-18 minutes) in the vernakalant group (P 1⁄4 0.0001 vs flecainide or propafenone). Median hospital stay was shorter in the vernakalant group, 238 minutes (IQR, 190-278 minutes), vs flecainide, 402 minutes (IQR, 337-741 minutes; P 1⁄4 0.001), or propafenone, 416 minutes (IQR, 337-741 minutes; P 1⁄4 0.001). We conclude that conversion of AF to sinus rhythm is faster with vernakalant than with flecainide or propafenone

Implant of Cardiac Resynchronization Therapy Device in Patients with High Percentage of Right Ventricular Pacing and Refractory Heart Failure

Background: Implant of a cardiac resynchronization therapy device in patients with pacemaker or implantable cardioverter defibrillator who develop heart failure with left ventricular dysfunction is controversial. Objective: The aim of this study was to evaluate the outcome of these patients after upgrading to cardiac resynchronization therapy. Methods: Patients undergoing therapy upgrade between 2011 and 2015 were evaluated. Results: A total of 21 patients were included with mean age of 70.7±10.8 years. Mean QRS duration was 180.9±23.2 ms and left ventricular ejection fraction was 26.8 ± 7.7%. The frequency of right ventricular pacing was 90.5±19.3%. Ten patients were in functional class II and 11 in FC III. The implant was successful in 18 patients (85.7%). Left ventricular ejection fraction was 33.9±10.4% one year after upgrading (p=0.028). Among the total number of patients, 13 improved their functional class in at least one category and only 4 were rehospitalized due to heart failure (p=0.048). The rate of complications was 14.28%. Conclusions: Therapy upgrade improved symptoms and reduced hospitalizations due to heart failure.

Predictors of Recurrence and Outcomes in Catheter Ablation of Paroxysmal Atrial Fibrillation

Introduccion: El aislamiento de las venas pulmonares es actualmente la terapeutica de eleccion en pacientes con fibrilacion auricular paroxistica, sintomatica y refractaria al tratamiento antiarritmico. Diferentes grupos abocados al tratamiento de la fibrilacion auricular paroxistica han publicado su experiencia y se conocen varios predictores de recurrencia. Sin embargo, hasta el presente no se ha reportado en nuestro medio una experiencia similar. Objetivos: Primario: Analizar los predictores de recurrencia posaislamiento de venas pulmonares con radiofrecuencia. Secundario: Evaluar la tasa de exito y las complicaciones asociadas con el procedimiento. Material y metodos: Analisis prospectivo, observacional, unicentrico, realizado entre mayo de 2009 y agosto de 2015 de 1.000 casos consecutivos de ablacion de fibrilacion auricular paroxistica con radiofrecuencia y mapeo electroanatomico. Para el analisis del seguimiento se utilizaron 507 aislamientos de venas pulmonares con al menos un ano de seguimiento, excluyendo las reablaciones y los pacientes que no cumplieron con todas las visitas de seguimiento. Resultados: En un analisis multivariado utilizando regresion de Cox se observo que la mayor frecuencia de episodios de fibrilacion auricular previos a la ablacion [HR 1,354 (1,059-1,732); p = 0,016] y la recurrencia temprana (0-3 meses) [HR 4,006 (2,703-5,937); p < 0,0001] fueron los predictores mas significativos de recurrencia a los 12 meses. La tasa de mantenimiento de ritmo sinusal al ano sin tratamiento antiarritmico fue del 77,5% para fibrilacion auricular paroxistica, con una recurrencia del 22,5%. Las complicaciones fueron taponamiento cardiaco con pericardiocentesis en 16 pacientes (1,6%), complicaciones vasculares en 21 (2,1%), ataque isquemico transitorio en 2 (0,2%), paralisis del nervio frenico en 1 (0,1%), pericarditis en 5 (0,5%) y hemotorax en 1 (0,1%). Conclusiones: La mayor frecuencia de episodios de fibrilacion auricular previos al aislamiento de venas pulmonares y la recurrencia temprana favorecen la recurrencia al ano. El aislamiento de venas pulmonares es un metodo seguro y eficaz para el control del ritmo en pacientes con fibrilacion auricular paroxistica, sintomatica y refractaria al tratamiento antiarritmico, con una tasa baja de complicaciones.

Coronary artery vasospasm during catheter cryoablation of left ventricular summit nonsustained ventricular tachycardia

Santiago Rivera, MD,* Maria de la Paz Ricapito, MD, Josefina Parodi, MD, Pablo Spaletra, Gaston Albina, MD, Alberto Giniger, MD, Fernando Scazzuso, MD From the Division of Cardiac Electrophysiology, Department of Cardiology, Cardiovascular Institute of Buenos Aires (ICBA), Buenos Aires, Argentina, Division of Cardiac Imaging, Department of Cardiology, Cardiovascular Institute of Buenos Aires (ICBA), Buenos Aires, Argentina, and Division of Interventional Cardiology, Department of Cardiology, Cardiovascular Institute of Buenos Aires (ICBA), Buenos Aires, Argentina.

Epicardial Cryoablation of Ventricular Tachycardia in Chagas Disease: Emergency Hybrid Treatment

Las taquicardias ventriculares asociadas a cardiopatia estructural de origen no isquemico presentan escaras de mayor area en el epicardio, comparadas con el area endocardica 1 . A su vez, la densidad de canales de conduccion lenta dentro de la escara a nivel del epicardio es mayor que en el endocardio 2 . La ablacion combinada (epicardica y endocardica) de taquicardia ventricular (TV) logra mayor tasa de exito y menores recurrencias 3 , sin embargo evitar lesiones de las arterias coronarias durante la ablacion epicardica representa un gran desafio. A continuacion presentamos un caso de enfermedad de Chagas y tormenta electrica, donde se fusiono el mapa de voltaje epicardico y endocardico del ventriculo izquierdo con una angiotomografia cardiaca multicorte (ATCMC), con el fin de visualizar en forma directa la relacion de la escara y las arterias coronarias. Se utilizo un tratamiento hibrido con radiofrecuencia y crioenergia, con el fin de minimizar riesgos.

LONG-TERM INCIDENCE OF ATRIAL FIBRILLATION AFTER LONE PERSISTENT ATRIAL FLUTTER RADIOFREQUENCY ABLATION

Asrac Caeor: 16. Arrhhmias: AF/SVTreseaio Numer: 1239-274Auhors: Fernando Adrian Scazzuso, Santiago Rivera, Gaston Albina, Ruben Laino, Luis Gomez, Alberto Giniger, Instituto Cardiovascular de Buenos Aires(ICBA), Buenos Aires, ArgentinaBackground: Curre uielies esalishe cavoricusi ishmus (CTI) alaio as class I hera or recurre AFL. Neverheless a hih roorio o aies wih ical loe ersise Arial Fluer (AFL) have recurre eisoes o Arial Firillaio (AF). The aim o his su was o evaluae he resece o AF i aies uerwe CTI alaio wihou rior ocumee AF.Methods: 179 aies eliile or CTI alaio were iclue. rior hisor AF was assesse i 61 aies a eclue. CTI alaio was erorme i 118 remaii aies as escrie reviousl. aies ha mohl cliical ollow-u a 12-lea elecrocarioram or a miimum o ear. Ever 2 mohs a 48 Holer moior was erorme o eermie AF iciece aer CTI alaio aer a ear. Arial irillaio iaosis was eermie as a eisoe o more ha 30 secos. Aiarrhhmic rus were iscoiue aer roceure a aicoaulaio oe moh aer.Results: A oal o 118 aies (77.09% male; Ae 66 +/- 8 ears) were aalze. Biirecioal loc a he CTI was achieve i all a ies. A aie resee AF uri simulaio maeuvers or aer isoroereol amiisraio. Aer a ear AF was oserve i 85 aies (72%) uri he ollow u. Boh rous variales were aalze. Arial irillaio reicors aer CTI alaio were: Heresio ( = 0.003). Le arium area >23.3 cm2.Conclusions: CTI alaio i aies wih loe arial luer (AF) is o curaive as mos o he aies will evelo AF wihi a ear. Le arial area was he sro reicor or arial irillaio evelome i aies uerwe AFL alaio. Heresio ma e he ricial cause o LA elareme. os roceural aicoaulaio srae mus e revise ace o hese resuls a iall, i woul e wise o erorm oh CTI a LA alaio i aies resei wih loe AFL a le arium elareme. Furher rials ma hel o eie he eei o his sraey.

MAPEO ELECTROANATOMICO Y AISLAMIENTO DE VENA CAVA SUPERIOR EN UN PACIENTE CON FIBRILACION AURICULAR

Electroanatomic reconstruction of both atriums with En Site (Nav X) system during pulmonary veins isolation in a 47 years old patient with paroxistic atrial fibrillation. The polygraph shows the electrical activity registered by the circular catheter positioned in the superior vena cava, 3cm away from its origin. Superior Vena Cava disconnection is observed while catheter radiofrequency ablation is performed.