Ermengol Vallès

Simple predictors for new onset atrial fibrillation

BACKGROUNDnPredicting atrial fibrillation is a tremendous challenge. Only few studies have included 24h-Holter monitoring characteristics to predict new onset AF (NOAF).nnnOBJECTIVESnOur aim is to define simple predictors for NOAF.nnnMETHODSnThe study population included 468 patients undergoing Holter for any cause. After excluding 169 patients for history of AF prior to or during the Holter monitoring period, 299 patients were assessed for incidence of NOAF.nnnRESULTSnAge at inclusion was 62.5±18years (53.5% male). After a median follow up of 39.1 [IQI 36.6-40] months, the incidence of NOAF was 10.4%. With univariate analysis, age, hypertension, diabetes, renal impairment, heart failure/cardiomyopathy, left ventricle ejection fraction ≤50%, left atrium diameter ≥40mm, CHA2DS2 VASc ≥4, premature atrial complexes (PAC) ≥0.2%, and PR interval were associated with NOAF. With multivariate analysis, age (HR 1075; p=0.001 per year), presence of heart failure/cardiomyopathy (HR 6,16; p<0.001), PAC≥0.2% (HR 3,32; p=0.003) and PR interval (HR 1.011; p=0.006 per millisecond) were independent predictors for NOAF. Those predictors were used to create a risk calculator for NOAF, which was validated in an independent cohort of 200 consecutive patients with similar baseline characteristics. This new tool resulted in good discrimination capacity calculated by the C index for NOAF prediction: Area under curve (AUC) (95% CI) 0.794 (0.714-0.875) at 2years and 0.794 (0.713-0.875) at 3years.nnnCONCLUSIONSnSimple clinical, ECG and Holter monitoring parameters are able to predict NOAF in a broad population and may help guide more rigorous monitoring for atrial fibrillation.

Diagnostic and Prognostic Value of Electrophysiologic Study in Patients With Nondocumented Palpitations

The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitations. However, in the setting of nondocumented palpitations the value of the electrophysiologic study (EPS) needs additional investigation. We investigated the utility of the EPS in patients with nondocumented palpitations. A total of 172 patients with normal electrocardiographic findings and nondocumented palpitations underwent an EPS. The clinical and electrophysiologic characteristics were assessed. The symptoms were long-lasting (>5 minutes) in 56%. Sudden onset was present in 99%, and termination was rapid in 65%. Neck palpitations were reported in 36%. The EPS findings were normal in 86 patients (50%); atrioventricular nodal reentrant tachycardia was induced in 43, orthodromic reentrant tachycardia in 9, and nonsustained atrial tachycardia/fibrillation (AT/AF) in 34. Long-lasting episodes, sudden termination, and neck palpitations predicted positive EPS findings and were associated with reentrant supraventricular tachycardia (p<0.001). The induction of AT/AF was associated with age >50 years and structural heart disease (p<0.001). After 53 ± 36 months of follow-up, 92% of patients with negative EPS findings were symptom free. Only 32% of patients with induced AT/AF remained free of symptoms (p<0.001). The recurrence of palpitations was more prevalent among patients with structural heart disease and aged >50 years (p<0.001). In conclusion, 50% of patients with nondocumented palpitations had positive EPS findings. A long duration, sudden termination, and neck palpitations, together with structural heart disease and age >50 years, predicted tachycardia inducibility and recurrence and could help in selecting patients suitable for EPS and ablation.

Impacto a largo plazo del tratamiento con presión positiva continua en la vía aérea superior sobre la incidencia de arritmias y la variabilidad de frecuencia cardiaca en pacientes con apnea del sueño

INTRODUCTIONnAutonomic dysfunction can alter heart rate variability and increase the incidence of arrhythmia. We analyzed the impact of continuous positive airway pressure (CPAP) on this pathophysiological phenomenon in patients with severe sleep apnea-hypopnea syndrome.nnnMETHODSnConsecutive patients with recently diagnosed severe sleep apnea-hypopnea syndrome were prospectively considered for inclusion. Incidence of arrhythmia and heart rate variability (recorded on a 24-hour Holter monitoring device) were analyzed before starting CPAP therapy and 1 year thereafter.nnnRESULTSnA total of 26 patients were included in the study. CPAP was administered for 6.6 ± 1.8 hours during Holter monitoring. After starting CPAP, we observed a marginally significant reduction in mean HR (80 ± 9 to 77 ± 11 bpm, p=.05). CPAP was associated with partial modulation (only during waking hours) of r-MSSD (p=.047) and HF (p=.025) parasympathetic parameters and LF (p=.049) sympathetic modulation parameters. None of these parameters returned completely to normal levels (p<.001). The number of unsustained episodes of atrial tachycardia diminished (p=.024), but no clear effect on other arrhythmias was observed.nnnCONCLUSIONSnCPAP therapy only partially improves heart rate variability, and exclusively during waking hours, and reduces incidence of atrial tachycardia, both of which can influence cardiovascular morbidity and mortality in sleep apnea-hypopnea syndrome patients.

Incremental pacing maneuver for atrial flutter recurrence reduction after ablation: Vallès: Yield of incremental pacing after flutter ablation

BACKGROUNDnA < 20 ms increase in the interval between cavo-tricuspid isthmus (CTI) double potentials during incremental pacing (IP) is a highly specific marker differentiating functional from complete CTI block during typical flutter (AFL) ablation. Long-term effects of IP remain unclear. We aimed to assess the impact of IP in reducing AFL recurrences after CTI ablation.nnnMETHODSnOne hundred and thirty-four patients (age 67 ± 13 years, 78% males) undergoing successful CTI ablation were included and divided into 2 groups: Group 1 (n = 68), in which ablation was performed before the IP maneuver was incorporated, with CTI block confirmed by at least 1 non-local and 1 local electrogram-based previously established criteria; and Group 2 (n = 66), in which IP maneuver was used to confirm complete CTI block.nnnRESULTSnNo intergroup differences were noted in baseline characteristics, ablation settings and fluoroscopy/radiofrequency times. Long-term AFL recurrences were observed in 14 out of 134 patients (10.4%), and were more common in Group 1 (19%, vs 1.5% among Group 2 patients, p < 0,001). Despite a longer follow-up period among the former group (1603 ± 734 vs. 964 ± 289 days, respectively), the adjusted AFL recurrence rate was still higher among Group 1 patients (4.3%/year vs. 0.6%/year, p < 0,001). Cox-regression analysis confirmed inclusion in Group 1 as the only predictor of AFL recurrences (HR = 8.2, CI 1.04-64.7, p = 0.046).nnnCONCLUSIONSnThe addition of the IP maneuver for the diagnosis of complete CTI block reduces AFL long-term recurrences after ablation.

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.nnMethods 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.nnConclusions— 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.

Burning the Gap: Electrical and Anatomical Basis of the Incremental Pacing Maneuver for Cavotricuspid Isthmus Block Assessment.

The incremental pacing (IP) maneuver is a highly specific technique that improves the ability to confirm complete CTI conduction block during typical atrial flutter (AFL) ablation, and reduces long‐term AFL recurrences. The purpose of this study is to assess the performance of new catheters equipped with additional high precision bipoles (AHPB) to allow the visualization of the cavotricuspid isthmus (CTI) conduction gap and to compare them with the IP maneuver.

Long-term Outcome of Cryoballoon Ablation of Atrial Fibrillation in a Low-volume Center

Cryoballoon ablation (CBA) accounted for 19% of all ablation procedures for atrial fibrillation (AF) in Spain in 2012. Little information is available on the long-term outcomes of CBA. No data have been reported from low-volume centers, but such information is important because almost 80% of Spanish catheterization laboratories perform fewer than 50 AF ablations per year. We prospectively analyzed the outcomes of CBA as the first-line technique in a low-volume center. From November 2010 through June 2013, 63 patients were included (12 of whom were women; mean [standard deviation] age, 55 [10] years). Of these patients, 48 (76%) had recurrent paroxysmal AF, and 15 had short-lasting persistent AF (< 6 months). The mean left atrial diameter was 41 (4) mm, and 9 patients (14%) had structural heart disease; 11 patients (18%) had a score 2 on the CHA2DS2–VASc scale. Oral anticoagulants were administered for at least 1 month prior to CBA and were continued for 1 month after the ablation procedure. After the first month, the decision to continue or stop anticoagulant therapy was based on the score on the CHA2DS2–VASc scale. Antiarrhythmic agents were continued for 3 months after the procedure (6 months in persistent AF). Cryoballoon ablation was initially performed through double transseptal puncture, although single puncture techniques were used once the intraluminal circular catheter became available. The last 19 procedures were performed with the Advance Cryoballoon (Medtronic Inc.), which was the device that achieved the most homogeneous application to the whole circumference of the opening of the pulmonary vein. At least 2 applications were made per vein, with continuous phrenic pacing of the right pulmonary veins during ablation to monitor for the appearance of phrenic paralysis. Procedure and fluoroscopy times were 168 (22) minutes and 30 (12) minutes, respectively. These times decreased significantly after the first 30 procedures (the procedure time was 189 [18] minutes for the first 30 procedures and 147 [34] minutes for subsequent procedures, while the fluoroscopy time was 35 [7] minutes for the first 30 procedures and 23 [5] minutes for subsequent procedures; P<.001). Electrical isolation was achieved in 224 of the 231 pulmonary veins identified (97%). The vessel most frequently left without isolation was the right inferior vein (4 procedures), in all cases because phrenic paralysis was detected in the superior right pulmonary vein during the application. Six patients had a common chamber (4 left, 2 right). During the 12 (8) months of follow-up, recurrence of AF was reported in 20 patients (32%), with a rate of sustained sinus rhythm after 1 and 2 years of 69% and 51%, respectively. With antiarrhythmic agents, these rates increased to 94% and 86%, respectively (Figure). Symptomatic arrhythmic episodes persisted in 5 patients, AF was documented in 3 patients, and 2 patients had atrial flutter. All these patients underwent a further ablation procedure, this time with radiofrequency. On multivariate analysis, the only independent predictor of recurrence of AF after CBA was time in AF prior to the procedure (hazard ratio [HR] = 1.17; 95% confidence interval [CI], 1.035-1.32; P = .012). The number of pulmonary veins isolated was a protective factor (HR = 0.19; 95% CI, 0.072-0.509; P = .001) (Table). Of the 4 patients without application to the right inferior pulmonary vein, 2 experienced recurrence. Twelve complications were reported (19% of procedures). These were mainly phrenic paralysis in right pulmonary veins during the procedure (7 cases, 11%). These events were always transient, although resolution occurred late in 2 patients (9 and 12 months). After controlling the application times (240-180 seconds) and temperature (limited to 55 8C), no phrenic paralyses were reported in the last 28 ablations, with no impact on the efficacy of the procedure (P = .01). In addition, there was 1 transient ischemic attack due to air embolism, 1 asymptomatic thalamic stroke, and 2 minor episodes of hemoptysis. Finally, there was 1 case of atrioesophageal fistula, attributed to application (with the Rev Esp Cardiol. 2014;67(7):577–584

Long-term outcome of transitory "reversible" complete atrio-ventricular block unrelated to myocardial ischemia.

fraction: comorbidities drive myocardial dysfunction and remodeling through coronarymicrovascular endothelial inflammation. J AmColl Cardiol 2013;62:263–71. [15] Sekhri V, Sanal S, DeLorenzo LJ, Aronow WS, Maguire GP. Cardiac sarcoidosis: a comprehensive review. Arch Med Sci 2011;7(4):546–54. [16] Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;119(14):e391–479. [17] Baughman RP, Teirstein AS, Judson MA, et al. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 2001;164:1885–9. [18] Quarta G, Holdright DR, Plant GT, et al. Cardiovascular magnetic resonance in cardiac sarcoidosis with MR conditional pacemaker in situ. J Cardiovasc Magn Reson 2011;13:26. [19] Fang L, Beale A, Ellims AH, et al. Associations between fibrocytes and postcontrast myocardial T1 times in hypertrophic cardiomyopathy. J Am Heart Assoc 2013;2(5): e000270.

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.nnMethods 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.nnConclusions— 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.nnMethods 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.nnConclusions— 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.