Jorge A. Salerno-Uriarte

Electroanatomic Analysis of Sinus Impulse Propagation in Normal Human Atria

Sinus Impulse Propagation in Normal Human Atria. Introduction: Better understanding of atrial propagation during sinus rhythm (SR) in normal hearts under the most normal physiologic conditions may be propaedeutic to pathophysiologic studies of complex atrial arrhythmias. In this study, qualitative and quantitative analyses of sinus impulse propagation in both atria were performed by electroanatomic mapping in patients with no organic heart disease who were undergoing an electrophysiologic procedure.

Atrial fibrillation in heart failure patients: Prevalence in daily practice and effect on the severity of symptoms. Data from the ALPHA study registry

Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials.

Superiority of Simulator-Based Training Compared With Conventional Training Methodologies in the Performance of Transseptal Catheterization

OBJECTIVES This study aims to compare the performance of electrophysiology fellows in transseptal catheterization (TSP-C) after conventional (Conv-T) or simulator training (Sim-T). BACKGROUND Current training for TSP-C, an increasingly used procedure, relies on performance on patients with supervision by an experienced operator. Virtual reality, a new training option, could improve post-training performance. METHODS Fellows inexperienced in TSP-C were enrolled and randomly assigned to Conv-T or Sim-T. The post-training performance of each fellow was evaluated and scored in 3 consecutive patient-based procedures by an experienced operator blinded to the fellows training assignment. RESULTS Fourteen fellows were randomized to Conv-T (n = 7) or to Sim-T (n = 7) and, after training, performed 42 TSP-Cs independently. Training time was significantly longer for Conv-T than for Sim-T (median 30 days vs. 4 days; p = 0.0175). The Conv-T fellows had significantly lower post-training performance scores (median 68 vs. 95; p = 0.0001) and a higher number of recurrent errors (median 3 vs. 0; p = 0.0006) when compared with Sim-T fellows. CONCLUSIONS The TSP-C training with virtual reality results in shorter training times and superior post-training performance.

Long-term outcome in diabetic heart failure patients treated with cardiac resynchronization therapy

Diabetes mellitus is an independent risk factor for increased morbidity and mortality in heart failure (HF) patients.

Atrial tachycardias in patients with congenital heart disease: a minimally invasive simplified approach in the use of three-dimensional electroanatomic mapping.

AIMS Atrial tachycardia (AT) is a common complication after repair of congenital heart disease (CHD). This two-centre prospective study evaluated the ability of three-dimensional electroanatomic mapping (EAM) to guide ablation of ATs in this particular population with a minimally invasive simplified approach. METHODS AND RESULTS Thirty-one consecutive patients (mean age 26 ± 17 years) with AT after repair of CHD were treated with a very limited number of intracavitary catheters and a specific setting of the Window of Interest (WoI) for the ablation of post-surgical ATs. A single-intracavitary catheter approach was performed in 22 patients, whereas an overall use of two intracavitary catheters in the other nine patients. Thirty-one patients exhibited 41 ATs. Seventy-six per cent of these were macro-reentrant ATs (MRATs), and 24% were focal ATs (FAT). The mid-diastolic isthmus (MDI) was located in the right atrial free wall (RAFW) in 82.8% of MRATs. Also in FATs, the RAFW was the most common site (77.8%) of the ectopic focus. Fifty-eight per cent of MRATs showed a double-loop reentry, with both loops sharing the same MDI in all cases. In 87% of cases, the abolition of the MRAT was obtained by applying radiofrequency energy to the MDI. Ninety per cent of FATs were successfully ablated. Mean conduction velocity and voltage amplitude had significantly lower values in successfully treated than in unsuccessfully treated MRATs. CONCLUSION Three-dimensional EAM, performed with a minimally invasive simplified approach and by using a specific parameter setting of the WoI, showed to be very effective to guide ablation of ATs in CHD patients.

Role of echocardiography in takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TTC) is characterized by transient and reversible left ventricular (LV) systolic dysfunction due to extended myocardial stunning. Despite a good long term prognosis, approximately one-third of patients with TTC experience life-threatening complications during the acute phase. Echocardiography is the first imaging modality for an early evaluation of LV systolic and diastolic function in patients with TTC. Moreover, echocardiography allows the detection of specific findings associated with TTC, such as LV outflow tract obstruction, mitral regurgitation, and right ventricular involvement, providing crucial information for clinical management and therapy and for monitoring myocardial function recovery during the follow-up.

Proportion of patients needing an implantable cardioverter defibrillator on the basis of current guidelines: impact on healthcare resources in Italy and the USA. Data from the ALPHA study registry

AIMS Implantable cardioverter defibrillators (ICD) improve survival in selected patients with left ventricular dysfunction or heart failure (HF). The objective is to estimate the number of ICD candidates and to assess the potential impact on public health expenditure in Italy and the USA. METHODS AND RESULTS Data from 3513 consecutive patients (ALPHA study registry) were screened. A model based on international guidelines inclusion criteria and epidemiological data was used to estimate the number of eligible patients. A comparison with current ICD implant rate was done to estimate the necessary incremental rate to treat eligible patients within 5 years. Up to 54% of HF patients are estimated to be eligible for ICD implantation. An implantation policy based on guidelines would significantly increase the ICD number to 2671 implants per million inhabitants in Italy and to 4261 in the USA. An annual increment of prophylactic ICD implants of 20% in the USA and 68% in Italy would be necessary to treat all indicated patients in a 5-year timeframe. CONCLUSION Implantable cardioverter defibrillator implantation policy based on current evidence may have significant impact on public health expenditure. Effective risk stratification may be useful in order to maximize benefit of ICD therapy and its cost-effectiveness in primary prevention.

Radiofrequency catheter ablation of concealed accessory pathways in two dogs with symptomatic atrioventricular reciprocating tachycardia

BACKGROUND Radiofrequency catheter ablation (RFCA) is widely used as a curative therapeutic strategy in human beings with paroxysmal supraventricular tachycardia (SVT), but rarely applied in animals. This report describes successful RFCA of atrioventricular accessory pathways (AP) in two dogs with episodic weakness caused by frequent paroxysms of supraventricular tachycardia. METHODS AND RESULTS Invasive electrophysiological studies (EPS) identified two APs in the 1st dog (right postero-septal, right posterior), and one in the 2nd dog (right posterior). Programmed electrical stimulation demonstrated that all APs had only retrograde unidirectional conduction, and played a role to maintain inducible atrioventricular reciprocating tachycardia (AVRT). The bypass tracts were successfully eliminated with RFCA, with consequent prevention of AVRT induction during post-ablation EPS. At 8months follow-up, the dogs were asymptomatic, and no reoccurrence of tachycardia was seen. CONCLUSION Concealed APs responsible for AVRT and accompanied symptoms may be safely eliminated using RFCA in dogs.

Iterative atrial tachycardia originating from the coronary sinus musculature.

Coronary Sinus Atrial Tachycardia. A case of iterative atrial tachycardia leading to dilated cardiomyopathy is reported. During electrophysiologic study, the tachycardia showed a markedly irregular cycle length associated with changes in atrial activation breakthrough as demonstrated by coronary sinus (CS) recordings and frequently degenerated into self‐terminating atrial fibrillation. Left atrial transseptal mapping demonstrated the earliest endocardial atrial activation close to the posterolateral mitral annulus, but this was invariably later than that recorded within the CS, where low‐energy radiofrequency applications eliminated the tachycardia. No acute vessel damage was observed at postablation CS angiography. In accordance with previously published experimental data, we hypothesized that the muscular sleeves surrounding the CS might be involved in the genesis of this tachycardia. During 6‐month follow‐up, the patient remained asymptomatic without tachycardia recurrences and with complete recovery of left ventricular function, confirming the reversible nature of the tachycardia‐induced cardiomyopathy.

Independent Impact of RV Involvement on In-Hospital Outcome of Patients With Takotsubo Syndrome

Takotsubo syndrome (TTS) is an acute clinical condition characterized by transient left ventricular dysfunction and reversible heart failure, the pathogenetic mechanism of which remains unclear. Although left ventricular apical ballooning is the most frequent morphological pattern, other variant