Carmen Altaba

Pulmonary hemorrhage after cryoballoon ablation for pulmonary vein isolation in the treatment of atrial fibrillation.

Pulmonary vein isolation has evolved over the past years as an alternative for the treatment of symptomatic recurrences of atrial fibrillation refractory to antiarrhythmic drug treatment. Both radiofrequency energy and cryoballoon ablation have proven useful in this setting. We present the case of a 55-year-old male patient undergoing cryoballoon ablation complicated with pulmonary hemorrhage. The cause of this rare complication may be found in the damage of vascular venous structures near the ablation zone or, alternatively, in hemorrhagic damage of the pulmonary vein surrounding tissue (or less probably to direct injury of the lingular bronchus). The extremely low temperatures achieved in this case (which are often associated with deep balloon position inside the veins) are alarming and should alert the physician about the possibility of an excessively intrapulmonary vein deployment of the cryoablation balloon.

Nuevos predictores de evolución a bloqueo auriculoventricular en pacientes con bloqueo bifascicular

Introduccion y objetivos Los pacientes con bloqueo bifascicular (BBF) pueden evolucionar a bloqueo auriculoventricular (BAV) avanzado, especialmente en presencia de sincope o intervalo HV prolongado. Otras variables podrian ayudar a definir que pacientes se beneficiaran de un marcapasos (MP) profilactico. Metodos Desde 1998 hasta 2006, hemos estudiado prospectivamente a 263 pacientes consecutivos con BBF en un solo centro. Se analizaron variables clinicas, electrocardiograficas y electrofisiologicas predictoras de evolucion a BAV significativo (segundo y tercer grado). Se implantaron dispositivos de estimulacion siguiendo las guias de la Sociedad Europea de Cardiologia. Los MP fueron programados en modo VVI con frecuencia minima de 40 lat/min. Se definio necesidad de MP la presencia de BAV significativo o de estimulacion ventricular > 10%. Resultados Se incluyo a 249 pacientes (media de edad, 73,4 ± 9,3 anos; 82 mujeres). Tras una mediana de seguimiento de 4,5 (2,16-6,41) anos, se observo necesidad de MP en 102 pacientes, 45 por estimulacion > 10% y 57 por BAV significativo. Las variables que predijeron la necesidad de MP fueron presencia de sincope o presincope (hazard ratio [HR] = 2,06; intervalo de confianza [IC] del 95%, 1,03-4,12), anchura QRS > 140 ms (HR = 2,44; IC del 95%, 1,59-3,76), la insuficiencia renal (HR = 1,86; IC del 95%, 1,22-2,83) y un intervalo HV > 64 ms (HR = 6,6; IC del 95%, 4,04-10,80). La asociacion de los cuatro factores mostro una probabilidad de necesitar el MP del 95% al ano de seguimiento. Conclusiones La clinica sincopal/presincopal, el QRS > 140 ms, la insuficiencia renal y el intervalo HV > 64 ms son predictores independientes de evolucion a BAV en pacientes con BBF.

Long-term mortality predictors in patients with chronic bifascicular block.

AIMS To evaluate the long-term mortality rate and to determine independent mortality risk factors in patients with bifascicular block (BFB). Patients with BFB are known to have a higher mortality risk than the general population, not only related to progression to atrio-ventricular block but also due to the presence of malignant ventricular arrhythmias. Previous observational and epidemiological studies including a high proportion of patients with structural heart disease have shown an important cardiac mortality rate and may not reflect the real outcome of patients with BFB. METHODS AND RESULTS From March 1998 until December 2006, we prospectively studied 259 consecutive BFB patients, 213 (82%) of whom presenting with syncope/pre-syncope, undergoing electrophysiological study. After a median follow-up of 4.5 years (P25:2.16-P75:6.41), 53 patients (20.1%) died, 19 (7%) of whom due to cardiac aetiology. Independent total mortality predictors were age [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.01-1.09], NYHA class>or=II (HR 2.17, 95% CI 1.05-4.5), atrial fibrillation (HR 2.96, 95% CI 1.1-7.92), and renal dysfunction (HR 4.26, 95% CI 2.04-9.01). An NYHA class of >or=II (HR 5.45, 95% CI 2.01-14.82) and renal failure (HR 3.82, 95% CI 1.21-12.06) were independent predictors of cardiac mortality. No independent predictors of arrhythmic death were found. CONCLUSION Total mortality, especially of cardiac cause, is lower than previously described in BFB patients. Advanced NYHA class and renal failure are predictors of cardiac mortality.

Novel Predictors of Progression of Atrioventricular Block in Patients With Chronic Bifascicular Block

INTRODUCTION AND OBJECTIVES Patients with chronic bifascicular block (BFB) can progress to advanced atrioventricular block (AVB), especially when syncope or a prolonged HV interval is present. It is possible that other variables could help identify patients who would benefit from prophylactic pacemaker implantation. METHODS The study involved 263 consecutive BFB patients seen at a single center between 1998 and 2006. Clinical, electrocardiographic and electrophysiologic variables were analyzed to identify predictors of progression to significant AVB (i.e. second or third grade). Cardiac pacemakers were implanted in accordance with European Society of Cardiology guidelines. Pacemakers were programmed in the VVI mode with a minimum frequency of 40 beats/min. A pacemaker was required if there was significant AVB or a ventricular pacing percentage >10%. RESULTS In total, the study included 249 patients (mean age, 73.4+/-9.3 years, 82 female). After a median follow-up period of 4.5 years (2.16-6.41 years), a pacemaker was required by 102 patients: 45 had a ventricular pacing percentage >10% and 57 had significant AVB. Factors predictive of the need for a pacemaker were: the presence of syncope or presyncope (hazard ratio [HR]=2.06; 95% confidence interval [CI], 1.03-4.12), QRS width >140 ms (HR=2.44; 95% CI, 1.59-3.76), renal failure (HR=1.86; 95% CI, 1.22-2.83), and an HV interval >64 ms (HR=6.6; 95% CI, 4.04-10.80). The presence of all four risk factors was associated with a 95% probability of needing a pacemaker within 1 year of follow-up. CONCLUSIONS The presence of syncope or presyncope, a QRS width >140 ms, renal failure, and an HV interval >64 ms were independent predictors of progression to AVB in patients with BFB.

Incremental His-to-coronary sinus maneuver: a nonlocal electrogram-based technique to assess complete cavotricuspid isthmus block during typical flutter ablation.

Background—Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-Coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block. Methods and Results—Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-Coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-Coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2. Conclusions—The incremental His-to-Coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram–based criteria is not feasible because of inconclusive potentials in the CTI ablation line.Background— Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-Coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block. Methods and Results— Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-Coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-Coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2. Conclusions— The incremental His-to-Coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram–based criteria is not feasible because of inconclusive potentials in the CTI ablation line.

Incremental His-To-Coronary Sinus ManeuverClinical Perspective

Background—Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-Coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block. Methods and Results—Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-Coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-Coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2. Conclusions—The incremental His-to-Coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram–based criteria is not feasible because of inconclusive potentials in the CTI ablation line.Background— Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-Coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block. Methods and Results— Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-Coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-Coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2. Conclusions— The incremental His-to-Coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram–based criteria is not feasible because of inconclusive potentials in the CTI ablation line.

Incremental His-To-Coronary Sinus ManeuverClinical Perspective: A Nonlocal Electrogram–Based Technique to Assess Complete Cavotricuspid Isthmus Block During Typical Flutter Ablation

Background—Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-Coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block. Methods and Results—Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-Coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-Coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2. Conclusions—The incremental His-to-Coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram–based criteria is not feasible because of inconclusive potentials in the CTI ablation line.Background— Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-Coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block. Methods and Results— Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-Coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-Coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2. Conclusions— The incremental His-to-Coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram–based criteria is not feasible because of inconclusive potentials in the CTI ablation line.