Ferran Rosés-Noguer

Intra-atrial re-entrant tachycardia in congenital heart disease: types and relation of isthmus to atrial voltage

BackgroundnIntra-atrial re-entrant tachycardia (IART) is a frequent and severe complication in patients with congenital heart disease (CHD). Cavotricuspid isthmus (CTI)-related IART is the most frequent mechanism. However, due to fibrosis and surgical scars, non-CTI-related IART is also frequent.nnnObjectivenThe main objective of this study was to describe the types of IART and circuit locations and to define a cut-off value for unhealthy tissue in the atria.nnnMethods and resultsnThis observational study included all consecutive patients with CHD who underwent a first ablation procedure for IART from January 2009 to December 2015 (94 patients, 39.4% female, age: 36.55u2009±u200914.9u2009years, 40.4% with highly complex cardiac disease). During the study, 114 IARTs were ablated (1.21u2009±u20090.41 IARTs per patient). Cavotricuspid isthmus-related IART was the only arrhythmia in 51% (nu2009=u200948) of patients, non-CTI-related IART was the only mechanism in 27.7% (nu2009=u200926), and 21.3% of patients (nu2009=u200920) presented both types of IART. In cases of non-CTI-related IART, the most frequent location of IART isthmus was the lateral or posterolateral wall of the venous atria, and a voltage cut-off value for unhealthy tissue in the atria of 0.5u2009mV identified 95.4% of IART isthmus locations.nnnConclusionnIn our population with a high proportion of complex CHD, CTI-related IART was the most frequent mechanism, although non-CTI-related IART was present in 49% of patients (alone or with concomitant CTI-related IART). A cut-off voltage of 0.5u2009mV could identify 95.4% of the substrates in non-CTI-related IART.

Current Situation of the Treatment of Arrhythmias in Children in Spain. Finding a Place of its Own

Ferran Rosés-Noguer* and Ángel Moya-Mitjans a Servei de Cardiologia Pediàtrica, Hospital Universitari Vall d’Hebron, Barcelona, Spain b Paediatric Cardiology Department, Royal Brompton Hospital, NHS Fundation Trust, London, United Kingdom Unitat d’Arı́tmies, Servei de Cardiologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain d Instituto de Medicina y Cardiologı́a, Unitat d’Arı́tmies, Hospital Universitari Dexeus, Barcelona, Spain

Acute Myocarditis with Infarct-like Presentation in a Pediatric Population: Role of Cardiovascular Magnetic Resonance

Chest pain is a typical symptom of acute myocarditis in adolescents. It may be indistinguishable from myocardial ischemia so it is called “infarct-like pattern.” Cardiovascular magnetic resonance has an important role as a non-invasive diagnostic tool. The aim of our study is to provide a description of an acute myocarditis series with infarct-like pattern and to evaluate the cardiovascular magnetic resonance role in a pediatric population. We included all pediatric patients (0–16xa0years) admitted to our hospital (May 2007–May 2016) with clinical diagnosis of acute myocarditis and infarct-like presentation (chest pain, EKG alterations, and released cardiac biomarkers). Diagnosis was confirmed with cardiovascular magnetic resonance using Lake Louise criteria. Seven patients (five males, two females) with a median age of 14xa0years (12.5–15.2) were included. All patients showed ST-segment changes and released cardiac biomarkers. Three patients had left ventricular hypertrophy and two presented mild systolic left ventricular dysfunction. All patients had at least two positive Lake Louise criteria. Late gadolinium enhancement was positive in all of them. With a median follow-up of 23xa0months (8–47), all of them are alive, with no cardiac symptoms and normal ventricular function. Infarct-like pattern is a typical presentation of acute myocarditis in adolescents. CMR should be performed in this population and may be considered as a first-line diagnostic tool. Its high sensitivity in infarct-like acute myocarditis may allow us to avoid endomyocardial biopsy. Unlike what was described in adults, late gadolinium enhancement does not imply worse outcome in our series.

Predictors of Acute Failure Ablation of Intra‐atrial Re‐entrant Tachycardia in Patients With Congenital Heart Disease: Cardiac Disease, Atypical Flutter, and Previous Atrial Fibrillation

Background Intra‐atrial re‐entrant tachycardia (IART) in patients with congenital heart disease (CHD) increases morbidity and mortality. Radiofrequency catheter ablation has evolved as the first‐line treatment. The aim of this study was to analyze the acute success and to identify predictors of failed IART radiofrequency catheter ablation in CHD. Methods and Results The observational study included all consecutive patients with CHD who underwent a first ablation procedure for IART at a single center from January 2009 to December 2015 (94 patients, 39.4% female, age: 36.55±14.9 years). In the first procedure, 114 IART were ablated (acute success: 74.6%; 1.21±0.41 IART per patient) with an acute success of 74.5%. Cavotricuspid isthmus–related IART was the only arrhythmia in 51%; non–cavotricuspid isthmus–related IART was the only mechanism in 27.7% and 21.3% of the patients had both types of IART. Predictors of acute radiofrequency catheter ablation failure were as follows: nonrelated cavotricuspid isthmus IART (odds ratio 7.3; confidence interval [CI], 1.9–17.9; P=0.04), previous atrial fibrillation (odds ratio 6.1; CI, 1.3–18.4; P=0.02), transposition of great arteries (odds ratio, 4.9; CI, 1.4–17.2; P=0.01) and systemic ventricle dilation (odds ratio 4.8; CI, 1.1–21.7; P=0.04) with an area under the receiver operating characteristic curve of 0.83±0.056 (CI, 0.74–0.93, P=0.001). After a mean follow‐up longer than 3.5 years, 78.3% of the patients were in sinus rhythm (33.1% of the patients required more than 1 radiofrequency catheter ablation procedure). Conclusions Although ablation in CHD is a challenging procedure, acute success of 75% can be achieved in moderate–highly complex CHD patients in a referral center. Predictors of failed ablation are IART different from cavotricuspid isthmus, previous atrial fibrillation, and markers of complex CHD (transposition of great arteries, systemic ventricle dilation).

Long-Term Follow-Up After Ablation of Intra-Atrial Re-Entrant Tachycardia in Patients With Congenital Heart Disease: Types and Predictors of Recurrence

OBJECTIVESnThe aim of this study was to analyze the long-term outcomes after intra-atrial re-entrant tachycardia (IART) ablation in congenital heart disease (CHD).nnnBACKGROUNDnIART increases morbidity and mortality in CHD patients. Radiofrequency catheter ablation has evolved into the first-line treatment of this complication.nnnMETHODSnThis was a prospective, single-center study of all consecutive CHD patients who underwent first ablation for IART from January 2009 to December 2015 (nxa0= 94, 39.4% female, age 36.55 ± 14.9 years, follow-up 44.45 ± 22.7 months).nnnRESULTSnDuring the study period, 130 procedures were performed (nxa0= 94, 1.21 ± 0.41 IART/patient). In the first procedure, 114 IART were ablated (short-term success 74.66%). Forty-nine percent of the patients whose IART was ablated had non-cavotricuspid isthmus (CTI)-related IART (alone or with concomitant CTI IART). After the first ablation, 54.3% maintained sinus rhythm (SR), 23.9% presented with recurrence of the ablated IART, 14.2% developed new IART, and 7.6% presented with atrial fibrillation (AF). After the second radiofrequency catheter ablation, 78.3% were in SR, 8.7% presented with AF, and 23.0% presented with IART (50% new IART). Multivariate predictors of recurrences were non-CTI IART (hazard ratio [HR]: 5.06; 95% confidence interval [CI]: 1.6 to 15.9; pxa0= 0.006), PR interval >200 ms (HR: 4.02; 95% CI: 1.9 to 11.3; pxa0= 0.009), AF induction (HR: 3.11; 95% CI: 1.1 to 9.1; pxa0= 0.04). and previous AF (HR: 3.08; 95% CI: 1.1 to 9.3; pxa0= 0.04). A risk score according multivariate model identified 3 levels of recurrence risk: 5.8%, 20%, and 58.5% (area under the receiver-operating characteristic curve 0.8 ± 0.03; pxa0< 0.0001).nnnCONCLUSIONSnAblation of IART in CHD is a challenging procedure, but after ablation in experienced centers, SR can be maintained in 78.3%. Predictors of recurrences are non-CTI-related IART, long PR interval, and previous or induced AF. Axa0risk score based on these factors can be useful for recurrence prediction.

Mechanisms of Intra-Atrial Re-Entrant Tachycardias in Congenital Heart Disease: Types and Predictors

Intra-atrial re-entrant tachycardia (IART) is a severe complication in patients with congenital heart disease (CHD). Cavotricuspid isthmus (CTI)-related IART is the most frequent mechanism. However, due to fibrosis and surgical scars, non-CTI-related IART is frequent. The main objective of this study was to describe the types of IART, circuit locations, and to analyze predictors of CTI versus non-CTI-related IART. This is an observational study that includes all consecutive patients with CHD who underwent a first IART ablation in a single referral tertiary hospital from January 2009 to December 2015 (94 patients; 39.4% women; age: 36.55 ± 14.9 years, 40.4% with highly complex cardiac disease). During the study, 114 IARTs were ablated (1.21 ± 0.41 IARTs per patient). CTI-related IART was the only arrhythmia in 51% (nu202f=u202f48) of patients; non-CTI-related IART was the only mechanism in 27.7% (nu202f=u202f26), and 21.3% of patients (nu202f=u202f20) presented the two types of IART. Severe dilation of the systemic ventricle, absence of severe dilation of the venous atrium, highly complex cardiac defects, and nontypical electrocardiography (ECG) were related to non-CTI-related IART in univariate analysis. In multivariate analysis, nontypical ECG (odds ratio 3.64; 1.01 to 4.9; pu202f=u202f0.049) and grade III CHD complexity (odds ratio 9.43; 1.44 to 11.7; pu202f=u202f0.001) were predictors of non-CTI-related IART. In conclusion, in our population with a high proportion of complex CHD, CTI-related IART was the most frequent mechanism, although non-CTI-related IART was present in 49% (alone or with concomitant CTI-related IART). High-grade CHD complexity and nontypical ECG were strongly related to non-CTI IART.