Ana Andrés

Incidence and predictors of clinically relevant cardiac perforation associated with systematic implantation of active-fixation pacing and defibrillation leads: a single-centre experience with over 3800 implanted leads

Aims Active-fixation leads have been associated with higher incidence of cardiac perforation. Large series specifically evaluating this complication are lacking. We sought to evaluate the incidence and predictors of clinically relevant cardiac perforation in a consecutive series of patients implanted with active-fixation pacing and defibrillation leads. Methods and results We conducted a retrospective observational study including all consecutive patients implanted with an active-fixation pacing/defibrillation lead at our institution from July 2008 to July 2015. The incidence of clinically relevant cardiac perforation and cardiac tamponade was evaluated. Univariate and multivariate analyses were used to identify predictors of cardiac perforation. Acute and long-term management of these patients was also investigated. A total of 3822 active-fixation pacing (n = 3035) and defibrillation (n = 787) leads were implanted in 2200 patients. Seventeen patients (0.8%) had clinically relevant cardiac perforation (13 acute and 4 subacute perforations), and 13 (0.5%) had cardiac tamponade resolved with pericardiocentesis. None of the patients with cardiac perforation required surgical treatment. In multivariate analysis, an age >80 years (OR 3.84, 95% CI 1.14–12.87, P = 0.029), female sex (OR 3.14, 95% CI 1.07–9.22, P = 0.037), and an apical position of the right ventricular lead (OR 3.37, 95% CI 1.17–9.67, P = 0.024) were independent predictors of cardiac perforation. Conclusions Implantation of active-fixation leads is associated with a low incidence of clinically relevant cardiac perforation. Older and female patients have a higher risk of perforation as well as those patients receiving the ventricular lead in an apical position.

The use of multisite left ventricular pacing via quadripolar lead improves acute haemodynamics and mechanical dyssynchrony assessed by radial strain speckle tracking: initial results.

AIMS The objective of the present study was to evaluate the effect of multipoint pacing (MPP) on acute haemodynamics, cardiac contractility, and left ventricle (LV) dyssynchrony, in comparison with conventional cardiac resynchronization therapy (CRT). METHODS AND RESULTS An open-label, non-randomized, single-centre, prospective study was designed. Twenty-seven consecutive patients were included. Evaluation of pacing configurations was performed in a random order. Transthoracic echocardiography was used to obtain haemodynamic and dyssynchrony parameters. Left ventricular ejection fraction (LVEF) was significantly superior in MPP compared with baseline (38.4 ± 1.8% vs. 26.1 ± 2.2%; P < 0.001), and in conventional pacing configuration compared with baseline (33.2 ± 1.8% vs. 26.1 ± 2.2%; P = 0.007). Cardiac index (CI) was increased by 21.8 ± 5.4% and 34.7 ± 5.1% in conventional and MPP configurations, respectively (P = 0.19). Percentage of acute responders (CI increase ≥10%) was 62.9 and 85.2% in conventional and MPP, respectively (P < 0.001). LV dyssynchrony was defined by radial strain rate parameters. Baseline anteroseptal-to-posterior wall time delay was 168 ± 21 ms. It was reduced until 70.4 ± 29 ms in conventional and -6.6 ± 11 ms in MPP (conventional vs. baseline P = 0.04; MPP vs. conventional P = 0.05). Standard deviation of the time-to-peak radial strain of the 6 LV basal segments was 101 ± 9.7, 80.3 ± 9.2, and 66 ± 8.03 ms in baseline, conventional, and MPP configurations, respectively (MPP vs. basal P = 0.012). Finally, we observed a positive correlation (r = 0.69) between reduction in dyssynchrony and CI increase (P < 0.0001). CONCLUSION MPP showed a further reduction in LV dyssynchrony compared with conventional biventricular pacing. Moreover, MPP resulted in an additional improvement in LVEF and in CI, and this was translated into a higher number of acute responders to CRT.

The Role of Conventional and Right-Sided ECG Screening for Subcutaneous ICD in a Tetralogy of Fallot Population: ELECTROCARDIOGRAPHIC sICD SCREENING IN FALLOT POPULATION

Information regarding suitability for subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implant in tetralogy of Fallot (ToF) population is scarce and needs to be further explored. The aims of our study were: (1) to determine the proportion of patients with ToF eligible for S‐ICD, (2) to identify the optimal sensing vector in ToF patients, (3) to test specifically the eligibility for S‐ICD with right‐sided screening, and (4) to compare with the proportion of eligible patients in a nonselected ICD population.

Safety and Feasibility of a Minimally Fluoroscopic Approach for Ventricular Tachycardia Ablation in Patients With Structural Heart Disease Influence of the Ventricular Tachycardia Substrate

Background—We sought to evaluate the safety and feasibility of a minimally fluoroscopic approach using the CARTOUNIVU module during scar-related ventricular tachycardia (VT) ablation. Methods and Results—Consecutive patients with structural heart disease undergoing VT ablation using the CARTOUNIVU module were prospectively included and classified depending on their VT substrate: (1) ischemic VT (IVT) and (2) nonischemic VT and depending on the presence of an epicardial access. Radiation exposure parameters and major and minor procedure-related complications were registered. A near-zero fluoroscopy exposure was defined as those procedures with an effective dose ⩽1 mSv. A total of 44 VT ablation procedures were performed in 41 patients (22 IVT and 19 nonischemic VT). The use of the CARTOUNIVU module resulted in low levels of radiation exposure: median total fluoroscopy time and effective dose of 6.08 (1.51–12.36) minutes and 2.15 (0.58–8.22) mSv, respectively. Patients with IVT had lower radiation exposure than patients with nonischemic VT (total fluoroscopy time, 2.53 [1.22–11.22] versus 8.51 [5.55–17.34] minutes; P=0.016). Epicardial access was associated with significantly higher levels of radiation exposure. Complications occurred in 4.9% patients, none of them being related to the use of the image integration tool. A near-zero fluoroscopy ablation could be performed in 14 of 44 procedures (32%), 43% of IVT procedures, and 50% of procedures with endocardial access only. Conclusions—The use of the CARTOUNIVU module during scar-related VT ablation resulted in low levels of radiation exposure. A near-zero fluoroscopy approach can be achieved in up to half of the procedures, especially in IVT patients with endocardial ablation.

Initial Experience With a New Ablation Catheter Using Laser Energy for Electrical Pulmonary Vein Isolation

Life Support Organization Registry Report 2012. ASAIO J. 2013;59:202–10. 4. Haneya A, Philipp A, Diez C, Schopka S, Bein T, Zimmermann M, et al. A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest. Resuscitation. 2012;83:1331–7. 5. Ariza-Solé A, Sánchez-Salado JC, Lorente-Tordera V, González-Costello J, Miralles-Cassina A, Cequier-Fillat A. Asistencia ventricular con membrana de oxigenación extracorpórea: una nueva alternativa al rescate del shock cardiogénico refractario. Rev Esp Cardiol. 2013;66:501–3. 6. Kirklin JK, Naftel DC, Stevenson LW, Kormos RL, Pagani FD, Miller MA, et al. INTERMACS database for durable devices for circulatory support: first annual report. J Heart Lung Transplant. 2008;27:1065–72.

Value of the Electrocardiogram as a Predictor of Right Ventricular Dysfunction in Patients With Chronic Right Ventricular Volume Overload

INTRODUCTION AND OBJECTIVES Pulmonary regurgitation is a common complication in patients with repaired tetralogy of Fallot or congenital pulmonary stenosis. Electrocardiographic variables have been correlated with parameters used to evaluate right ventricular function. We aimed to analyze the diagnostic value of the width and fragmentation of the electrocardiogram in the identification of patients with right ventricular dysfunction and/or dilation. METHODS We selected 107 consecutive patients diagnosed with severe pulmonary insufficiency after repair of pulmonary stenosis or tetralogy of Fallot. The tests included electrocardiography, echocardiography, and magnetic resonance. Each electrocardiogram was analyzed manually to measure QRS duration. We defined QRS fragmentation as the presence of low-voltage waves in the terminal portion of the QRS complex in at least 2 contiguous leads. RESULTS We found a significant negative correlation between QRS width and right ventricular function, as well as a positive correlation with right ventricular volume. The receiver operating characteristic curve indicated a cut-off point for QRS width of 140ms, which showed good sensitivity for a diagnosis of right ventricular dilation (> 80%) and dysfunction (> 95%). In logistic regression models, a QRS duration > 140ms was found to be the only independent predictor of right ventricular dilation and dysfunction. CONCLUSIONS Electrocardiography is a rapid, widely available, and reproducible tool. QRS width constitutes an independent predictor of the presence of right ventricular dilation and dysfunction. This study is the first to provide a cutoff value for QRS width to screen for right ventricle involvement.

Conventional and right‐sided screening for subcutaneous ICD in a population with congenital heart disease at high risk of sudden cardiac death

Information regarding suitability for subcutaneous defibrillator (sICD) implantation in tetralogy of Fallot (ToF) and systemic right ventricle is scarce and needs to be further explored. The main objective of our study was to determine the proportion of patients with ToF and systemic right ventricle eligible for sICD with both, standard and right‐sided screening methods. Secondary objectives were: (i) to study sICD eligibility specifically in patients at high risk of sudden cardiac death, (ii) to identify independent predictors for sICD eligibility, and (iii) to compare the proportion of eligible patients in a nonselected ICD population.

Improvement in Hemodynamics and Contractility With Multipoint Left Ventricular Pacing in Cardiac Resynchronization Therapy

a remaining relatives. No additional mutation was found in any of the other screened genes. The Table shows the results of the family study in affected (II:4, III:4, III:6 and IV:1) and nonaffected individuals (no additional family members were available for the study). Gene sequencing yielded the presence of the heterozygous ACTC1 mutation, not present in the National Center for Biotechnology list of single nucleotide polymorphisms in the ACTC1 gene. Although hundreds of variants have been identified in sarcomeric and desmosomal genes, only a few polymorphisms and < 30 mutations causing any kind of cardiomyopathy have been described in the ACTC1 gene, suggesting that changes in the ACTC1 gene are poorly tolerated. Actin is essential for cell morphology, adhesion, and migration. This novel variant alters a preserved amino acid residue (I289) in the protein, replacing a nonpolar (isoleucine) with another polar and noncharged (threonine) aminoacid, thus causing moderate modifications in the physicochemical properties related to the hydrophobicity, charge, polarity, and mass of the protein (Grantham distance 89 [0-215]). The prediction of in silico (SIFT [Sorting Intolerant from Tolerant], Polyphen-2, and Pmut) analyses neither confirmed nor ruled out its pathogenity (inconclusive results with low confidence). The preserved I289 amino acid residue maps to subdomain 3, important for the stability and polymerization of the actin filaments and next to the myosin binding site, possibly disrupted by the presence of the ACTC1 mutation. Furthermore, our ACTC1 mutation cosegregated perfectly with the LVNC phenotype, with a 100% penetrance in the individuals available for the study. We acknowledge that a more thorough genetic study could have included many other genes. Nonetheless, we considered it finished in terms of cost-effectiveness for three reasons: a) our results were consistent with a previous study linking LVNC and septal defects due to ACTC1 mutation; b) the variant strongly cosegregated with the phenotype, and c) the molecular consequences of the variant were considered probably pathogenic. Further functional information obtained from animal models may be valuable to confirm the causal role of the ACTC1 mutation. In summary, we offer the phenotypical description of a family with LVNC caused by the highly penetrant, novel, heterozygous ACTC1 mutation. Remarkably, in the literature this is the third ACTC1 mutation causing LVNC, and associated ostium secundum atrioseptal defect in some affected family members. J, d y.

Essential ECG clues in patients with congenital heart disease and arrhythmias.

The prevalence of adults with congenital heart disease has dramatically increased during the last decades due to significant advances in the surgical correction of these conditions. As a result, patients survival has been prolonged and arrhythmias have become one of the principal causes of morbidity and mortality for these patients. The surface 12-lead ECG may play a critical role in the identification of the underlying heart disease of the patient, the recognition of the arrhythmia mechanism and may also help in the planification of the ablation procedure in this setting. Finally, important prognostic information can be also obtained from the ECG in these patients. The present review will offer an overview of the principal utilities of the surface ECG in the diagnosis and management of patients with CHD and arrhythmias.

Utility of high density multielectrode mapping during ablation of scar-related ventricular tachycardia

Multielectrode mapping catheters (MEMC) allow the performance of high resolution and density maps but the utility of these catheters in ventricular tachycardia (VT) ablation procedures has not been yet widely described. We sought to evaluate the utility of a MEMC during scar‐related VT ablation procedures.