David Keane

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.

Cardiac MR imaging of nonischemic cardiomyopathies: imaging protocols and spectra of appearances.

Cardiac MR is an excellent noninvasive imaging technique for the detection and assessment of the morphology, function, and myocardial contrast-enhancement characteristics of the nonischemic cardiomyopathies.

Friedreich’s Ataxia: a review from a cardiology perspective

BackgroundNeuromuscular disorders are not among the common causes of cardiomyopathy in the general population; however, cardiomyopathy is known to occur in several neuromuscular disorders including Friedreich’s Ataxia (FA). In patients with neuromuscular disorders, concomitant cardiac involvement contributes significantly to morbidity and mortality and often leads to premature death.MethodsAn extensive literature search of Medline and Pubmed was conducted to include all published reports on cardiac involvement in FA. Secondary articles were identified from key paper reference listings.ConclusionHypertrophic cardiomyopathy is a cardinal feature of FA; therefore all FA patients should be screened for cardiomyopathy. A cardiac examination, ECG and ECHO are advised at diagnosis, and also on the development of any cardiac symptoms. Treatment is determined by the presence of symptoms, the presence of left ventricular outflow gradient and the sudden death risk. Institution of aggressive medical therapy early in the course of the disease may help improve quality of life and provide survival benefit.

Practical tips and tricks for assessing prosthetic valves and detecting paravalvular regurgitation using cardiac CT

Paravalvular leaks are an uncommon but serious complication of prosthetic valves. Transthoracic echocardiography is used in the assessment of prosthetic valves but can be limited by acoustic shadowing from the prosthesis and poor acoustic windowing. Small case series have previously shown cardiac CT to have promising results in detecting paravalvular leaks. We assessed 32 valves in our institution on cardiac CT using echocardiography results as standard and developed methods for improved evaluation of prosthetic valves. These include optimizing prescan drug therapy for heart rate control, optimum window and center adjustments, and carefully selected image planes to best demonstrate the valve ring and valve annulus. Recognition of surgical material is also important to recognize. In this review, we provide a detailed description of these techniques with imaging examples of prosthetic valve evaluation using cardiac CT.

Post mortem study of the depth and circumferential location of sympathetic nerves in human renal arteries--implications for renal denervation catheter design.

The aims of this study were to examine human renal arteries and to accurately characterize their sympathetic innervation and location using CD‐56 immunohistochemistry stains to highlight Neural Cell Adhesion Molecules (N‐CAM).

Clinical outcome when left atrial posterior wall box isolation is included as a catheter ablation strategy in patients with persistent atrial fibrillation.

PurposeIsolation of the pulmonary veins alone (PVI) is associated with a 50 to 70xa0% success rate in paroxysmal atrial fibrillation (AF) but is significantly lower for persistent AF. We sought to evaluate patient outcomes in terms of safety and efficacy when posterior left atrial box isolation is included as a catheter ablation strategy in patients with mainly persistent AF.MethodsWe performed an audit of 100 patients undergoing left atrial (LA) box isolation. Recurrence of arrhythmia was detected by evaluating symptoms and continuous 24xa0h ECG monitoring at 2, 6 and 12xa0months post procedure.ResultsSeventy-two patients had persistent AF prior to procedure. Average duration of AF was 5.4u2009±u20095.2xa0years. All patients underwent circumferential PVI plus linear posterior LA lines to complete box isolation. At a mean follow-up of 12.5u2009±u20094.2xa0months, 75 patients were free from atrial fibrillation, 50.6xa0% of these were taking no antiarrhythmic medication. Twenty-five patients had recurrence of AF, 84xa0% of whom had previous persistent AF. The average time to recurrence post procedure was 5.9u2009±u20094.4xa0months. Thirteen patients underwent repeat procedures for recurrent AF. There were no adverse events relating to the procedure.ConclusionThese results suggest that the strategy of left atrial box isolation is safe and effective, worthy of further evaluation in a multicentre registry.

Screening for atrial fibrillation in general practice : a national, cross-sectional study of an innovative technology

BACKGROUNDnTo test the use of three lead monitoring as a screening tool for atrial fibrillation (AF) in general practice. AF is responsible for up to a quarter of all strokes and is often asymptomatic until a stroke occurs.nnnMETHODSn26 randomly selected general practices identified 80 randomly selected patients aged 70 or older from their database and excluded those known to have AF, those with clinical issues or who had not attended for three years. Up to 40 eligible patients/practice were invited to attend for screening. A 2min three-lead ECG was recorded and collected centrally for expert cardiology assessment. Risk factor data was gathered.nnnOUTCOMESn(i) point prevalence of AF, (ii) proportion of ECG tracings which were adequate for interpretation, (iii) uptake rate by patients and (iv) acceptability of the screening process to patients and staff (reported separately).nnnRESULTSnOf 1447 current patients, 1003 were eligible for inclusion, 639 (64%) agreed to take part in screening and 566 (56%) completed screening. The point prevalence rate for AF was 10.3%-2.1% new cases (12 of 566 who were screened) and 9.5% existing cases (137 of 1447 eligible patients). Only four of 570 (0.7%) screening visits did not record a usable ECG and 11 (2.6%) three lead ECGs required a clarifying 12 lead ECG.nnnCONCLUSIONSnThree lead screening for AF is feasible, effective and offers an alternative to pulse taking or 12 lead ECGs. The availability of this technology may facilitate more effective screening, leading to reduced stroke incidence.

Investigation of cardiomyopathy using cardiac magnetic resonance imaging part 2: Rare phenotypes

Cardiac magnetic resonance imaging (CMRI) has emerged as a useful tertiary imaging tool in the investigation of patients suspected of many different types of cardiomyopathies. CMRI images are now of a sufficiently robust quality to enable high spatial and temporal resolution image acquisition. This has led to CMRI becoming an effective non-invasive imaging tool for many cardiomyopathies. In this two-part review we outline the typical sequences used to image cardiomyopathy and present the imaging spectrum of cardiomyopathy. Partu2005Iu2005focused on the current classification of cardiomyopathy, the basic CMRI sequences used in evaluating cardiomyopathy and the imaging spectrum of common phenotypes. Part II illustrates the imaging spectrum of the more rare phenotypes.

Renal Sympathetic Denervation: MDCT Evaluation of the Renal Arteries

OBJECTIVEnPercutaneous transluminal renal sympathetic denervation is a new treatment of refractory systemic hypertension. The purpose of this study was to assess the clinical utility of MDCT to evaluate the anatomic configuration of the renal arteries in the context of renal sympathetic denervation.nnnMATERIALS AND METHODSnTwo readers retrospectively evaluated the MDCT renal artery scans of 90 patients (mean age, 70 ± 13 years; range, 32-98 years). Analysis included the number of renal arteries on each side, ostial shape and size, angle off the aorta, branching pattern, degree of tortuosity, and distance to adjacent vascular structures.nnnRESULTSnSixty-five patients had one, 23 had two, and two had three renal arteries on one side. One hundred forty-six arteries were funnel-shaped (72 left and 74 right; mean ostial diameter, 0.9 ± 0.2 cm tapering to 0.6 ± 0.1 cm). The mean tortuosity index was 1.1 (range, 1 [no tortuosity] to 3.1). Compared with the left renal artery, the right renal artery was longer (4.0 ± 0.9 cm vs 5.0 ± 1.2 cm, p ≤ 0.001), originated at a more acute angle on axial (67° vs 98°, p < 0.05) and coronal images (57° ± 16° vs 65° ± 14°, p < 0.05), was significantly closer to the superior mesenteric artery (1.0 ± 0.7 cm vs 1.6 ± 1.2 cm, p < 0.001), and came in closer contact with venous structures (0.0 ± 0.1 vs 0.2 ± 0.9, p < 0.05).nnnCONCLUSIONnOur findings suggest MDCT of the renal arteries is an informative investigation in patients undergoing renal sympathetic denervation, providing data on the number and size of renal branches, ostial shape, and proximity to adjacent venous structures.

Pulmonary fibrosis in systemic sclerosis: association with myocardial fibrosis.

Purpose To evaluate the relationship between pulmonary and myocardial fibrosis in patients with systemic sclerosis (SS). Materials and Methods Eighteen patients with SS prospectively underwent cardiac magnetic resonance imaging (CMR) and high-resolution computed tomography (HRCT) of the chest. Cardiac biomarkers (N-terminal pro B-type natriuretic peptide) and quality-of-life measures (SF-36 and SS health assessment questionnaires) were assessed. Two readers blinded to other test results evaluated the CMRs in consensus for functional left and right ventricular parameters and for myocardial late enhancement. HRCT images were reviewed at 5 levels and scored for total disease extent, extent of reticulation, proportion of ground-glass opacities (GGO), and coarseness of reticulation. Results Right ventricular ejection fraction correlated significantly with the percentage of late enhancement of the myocardium (R=0.63, P<0.01), extent of pulmonary fibrosis (R=0.57, P<0.01), and extent of GGO (R=0.53, P<0.05). Significant correlations were also found between the percentage of late enhancement of the myocardium and the extent of overall pulmonary fibrosis (R=0.59, P<0.05) and the extent of the ground-glass subcomponent (R=0.58, P<0.05). N-terminal pro B-type natriuretic peptide correlated significantly with the number of myocardial segments with late enhancement (R=0.64, P<0.05). Stepwise multiple linear regression revealed the extent of pulmonary GGO to be the only independent predictor of the percentage of myocardial enhancement (R2=0.61, P<0.0001). Conclusion In patients with SS with pulmonary fibrosis on HRCT images, CMR may be a useful test to detect early-stage myocardial fibrosis.