Fernando Sérgio Oliva de Souza

Ventricular resynchronization through biventricular cardiac pacing for the treatment of refractory heart failure in dilated cardiomyopathy

OBJECTIVE The biventricular pacing (BVP) approach has good results in the treatment of congestive heart failure (CHF) in patients (pts) with disorders of intraventricular conduction. METHODS We have applied BVP to 28 pts, with left ventricular pacing using minitoracotomy in 3 pts and the transvenous approach via coronary sinus in 25 pts. The mean duration of the QRS complexes was 187 ms, in the presence of the left branch block in 22 pts, and right branch block + divisional hemiblock in 6 pts. All pts had been considerated candidates to cardiac transplantation, and were under optimized drug therapy. Sixteen pts were in Functional Class (NYHA) IV, and 12 in class III. The ejection fraction varied from 22 to 46% (average = 34%). The pacing mode employed was biventricular triple-chamber in 22 pts, and bi-ventricular dual-chamber in 6 pts (one with ICD). RESULTS The pts were followed up for a period that ranged from 10 days to 14 months (mean 5 months). All pts presented clinical improvement after implant, changing the NYHA Functional Class at the end of follow-up to Class I (9pts), Class II (10 pts) and Class III (6 pts). The initial mean ejection fraction have-raised to 37%. Two pts died suddenly. One patient died due to a pulmonary fungal infection. CONCLUSION Ventricular resynchronization through BVP, improved significantly the Functional Class and, therefore, the quality of life. Assessments of myocardial function acutely performed do not reflect the clinical improvement observed.

Aspectos técnicos do implante de eletrodo para estimulação ventricular esquerda através do seio coronariano, com a utilização de anatomia radiológica e eletrograma intracavitário, na terapia de ressincronização cardíaca

OBJECTIVE: To present the experience of 157 implantations using a simplified technique for coronary sinus catheterization, based on the atrial component of the intracavitary electrogram and radiological anatomy, showing the success rate and total time of radioscopy use. METHOD: From October 2001 to February 2005, 157 biventricular pacemaker implantations were performed in previously selected patients, using radiological anatomy and observation of the intracavitary electrogram, focusing on the atrial component. Here we show the success rate, complications and total time of radioscopy use. RESULTS: The implantation of the system employing left ventricular pacing via the coronary sinus was not possible in 11 patients. Difficulties in cannulation of the coronary ostium were felt in 20 patients and difficulties of lead advancement through the coronary sinus existed in 39 patients. The mean time of radioscopy use was 18.27 ± 15.46 minutes. CONCLUSION: The implantation technique, proposed by the author, using the atrial component morphology of the intracavitary electrogram and radiological anatomy proved to be safe and effective for the cannulation of the coronary sinus ostium requiring shorter radioscopy times.

Ablação por cateter de taquicardia por reentrada nodal com degeneração para fibrilação atrial: abordagem resolutiva de quatro casos clínicos

1. Cardiologista, médica assistente da Equipe Fernando Oliva do Instituto de Arritmias Cardíacas/Hospital Beneficência Portuguesa de São Paulo (BP), São Paulo, SP, Brasil. 2. Eletrofisiologista, diretor do Instituto de Arritmias Cardíacas/Hospital BP, São Paulo, SP, Brasil. 3. Eletrofisiologista e cardiologista do Hospital Ibiapaba/Centro Barbacenense de Assistência Médica e Social, Barbacena, MG, Brasil. 4. Eletrofisiologista do Instituto de Arritmias Cardíacas/Hospital BP, São Paulo, SP, Brasil. Correspondência: Vanessa Sepulveda de Matos Rua Maestro Cardim, 592 – salas 905/906 – Bela Vista São Paulo, SP, Brasil – CEP 01323-001 E-mail: vsdematos@yahoo.com.br Artigo submetido em 2/2017. Artigo publicado em 12/2017. RESUMO A fibrilação atrial é a arritmia mais comumente diagnosticada nos dias atuais. Estima-se que sua prevalência seja de 0,5-1% na população geral. O número de indicações de ablação para tentativa de manutenção do ritmo sinusal tem crescido a cada ano. Não obstante a também crescente experiência dos centros especializados, as complicações ine rentes ao procedimento ainda continuam altas, quando comparadas às da ablação convencional. Constatamos a ocorrência de desorganização elétrica atrial consequente a taquicardia por reentrada nodal em quatro pa cientes encaminhados inicialmente para ablação de fibrilação atrial. DESCRITORES: Taquicardia por Reentrada do Nó Atrioventricular; Taquicardia Supraventricular; Fibrilação Atrial. ABSTRACT Atrial fibrillation is the most common arrhythmia diagnosed today. It is estimated that its prevalence is around 0.5% to 1% in the general population. The number of indications for ablation procedure, as an attempt to maintain sinus rhythm, grows every year. Nevertheless, the growing experience of specialized centers, the inherent procedurecomplications are still high when compared to conventional ablation. We have noticed the occurrence of atrial electrical disorganization resulting from AV nodal reentry tachycardia in four patients initially referred for atrial fibrillation ablation.

Subcutaneous Implantable Cardioverter Defibrillator: EarlyExperience

Introduction The implantable cardioverter defibrillator had been increasing the survival of patients at high risk for sudden cardiac death. The subcutaneous implantable cardioverter defibrillator was developed to mitigate the complications inherent to lead placement into cardiovascular system. Objective To report the initial experience of 18 consecutive cases of subcutaneous implantable cardioverter defibrillator implantation showing the indications, potential pitfalls and perioperative complications. Methods Between September 2016 and March 2017, 18 patients with indication for primary and secondary prevention of sudden cardiac death, with no concomitant indication for artificial cardiac pacing, were included. Results The implantation of the subcutaneous implantable cardioverter defibrillator successfully performed in 18 patients. It was difficult to place the subcutaneous lead at the parasternal line in two patients. One patient returned a week after the procedure complaining about an increase in pain intensity at pulse generator pocket site, which was associated with edema, temperature rising and hyperemia. Two patients took antialgic medication for five days after surgery. A reintervention was necessary in one patient to replace the lead in order to correct inappropriate shocks caused by myopotential oversensing. Conclusion In our initial experience, although the subcutaneous implantable cardioverter defibrillator implantation is a less-invasive, simple-accomplishment procedure, it resulted in a bloodier surgery perhaps requiring an operative care different from the conventional. Inappropriate shock by oversensing is a reality in this system, which should be overcame in order not to become a limiting issue for its indication.

Implante de cardioversor-desfibrilador subcutâneo: relato de caso de paciente com taquicardia ventricular induzida por esforço

1. Doutor em Cirurgia, diretor responsável do Instituto de Arritmias Cardíacas do Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brasil. 2. Eletrofisiologista, médica assistente do Instituto de Arritmias Cardíacas do Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brasil. 3. Membro especialista em Eletrofisiologia e Estimulação Cardíaca Artificial, coordenador do Setor de Eletrofisiologia e Clínica Invasiva do Instituto de Arritmias Cardíacas do Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brasil. Correspondência: Fernando Sérgio Oliva de Souza Rua Maestro Cardim, 592 – salas 905-906 – Bela Vista São Paulo, SP, Brasil – CEP 01323-001 E-mail: fernandoritmo@uol.com.br Artigo submetido em 9/2016. Artigo publicado em 3/2017. Resumo As complicações relacionadas ao cardioversor-desfibrilador implantável em geral estão relacionadas a implante de cabo-eletrodo transvenoso, fratura do condutor ou ruptura do isolamento de silicone, além de infecções. Essas complicações podem ser evitadas com o implante do sistema de cardioversor-desfibrilador implantável totalmente subcutâneo. Relatamos o caso de um paciente de 60 anos de idade, assintomático, com antecedentes de morte súbita cardíaca na família, submetido ao primeiro implante de cardioversor-desfibrilador implantável subcutâneo no Brasil. Descritores: Cardioversores-Desfibriladores Implantáveis; Morte Súbita Cardíaca. AbstRAct Complications related to the use of implantable cardioverter-defibrillator are often related to transvenous lead implant, conductor fracture or insulation disruption in addition to infections. These complications may be avoided by implanting a totally subcutaneous implantable cardioverter-defibrillator system. We report the case of a 60-year old, asymptomatic patient with a family history of cardiac sudden death, undergoing the first subcutaneous implantable cardioverter-defibrillator implant in Brazil.

Technical aspects of coronary sinus catheterization based on the atrial component of the intracavitary electrogram and radiological anatomy during the implantation procedure of a biventricular pacemaker

OBJECTIVE To present a technical proposal based on the experience of 130 implantations using a simplified technique for coronary sinus catheterization, based on the atrial component of the intracavitary electrogram and radiological anatomy. METHODS From October, 2001 to October, 2004, 130 biventricular pacemaker implantations were performed, using radiological anatomy and observation of the intracavitary electrogram, focusing on the atrial component. RESULTS The implantation of the system using left ventricular pacing via coronary sinus was not possible in 8 patients. Difficulties on the cannulation of the coronary ostium were felt in 12 patients and difficulties of lead advancement through the coronary sinus were felt in 15 patients. The mean time of radioscopy utilization was 18.69 min. CONCLUSION The implantation technique, using the atrial component morphology of the intracavitary electrogram and radiological anatomy showed to be workless, safe and effective for the cannulation of the coronary sinus ostium requesting reduced time of radioscopy.