Luis C. Sáenz

Esophageal Capsule Endoscopy After Radiofrequency Catheter Ablation for Atrial Fibrillation Documented Higher Risk of Luminal Esophageal Damage With General Anesthesia as Compared With Conscious Sedation

Background—Left atrioesophageal fistula is a rare but devastating complication that may occur after catheter ablation of atrial fibrillation. We used capsule endoscopy to assess esophageal injury after catheter ablation for atrial fibrillation in a population randomized to undergo general anesthesia or conscious sedation. Methods and Results—Fifty patients undergoing atrial fibrillation ablation for paroxysmal symptomatic atrial fibrillation refractory to antiarrhythmic drugs were enrolled and randomized, including those undergoing the procedure under general anesthesia (25 patients, group 1) and those receiving conscious sedation with fentanyl or midazolam (25 patients, group 2). All patients underwent esophageal temperature monitoring during the procedure. The day after ablation, all patients had capsule endoscopy to assess the presence of endoluminal tissue damage of the esophagus. We observed esophageal tissue damage in 12 (48%) patients of group 1 and 1 esophageal tissue damage in a single patient (4%) of group 2 (P<0.001). The maximal esophageal temperature was significantly higher in patients undergoing general anesthesia (group 1) versus patients undergoing conscious sedation (group 2) (40.6±1°C versus 39.6±0.8°C; P< 0.003). The time to peak temperature was 9±7 seconds in group 1 and 21±9 seconds in group 2, and this difference was statistically significant (P<0.001). No complication occurred during or after the administration of the pill cam or during the procedures. All esophageal lesions normalized at the 2-month repeat endoscopic examination. Conclusion—The use of general anesthesia increases the risk of esophageal damage detected by capsule endoscopy.

Ablation of Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy: Arrhythmia-Free Survival after Endo-Epicardial Substrate Based Mapping and Ablation

Background— In patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy, freedom from ventricular arrhythmias (VAs) after endocardial ablation is limited. We compared the long-term freedom from recurrent VAs by using endocardial-alone ablation versus endo-epicardial substrate-based ablation. Methods and Results— Forty-nine patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergoing ablation of ventricular tachycardia (VT) were divided into 2 groups: endocardial-alone ablation (group 1, n=23) and endo-epicardial ablation (group 2, n=26). All patients had an implantable cardioverter-defibrillator (ICD). Conventional and 3D mappings were used to determine the mechanism of induced VTs and to identify area of “scar” or “abnormal” myocardium. All critical sites responsible for VTs and points with “abnormal” potential were targeted for ablation from endocardium (group 1) or from both endocardium and epicardium (group 2). The procedural end point was noninducibility of sustained, monomorphic VT with isoproterenol. The presence of frequent premature ventricular contractions at the end of ablation was recorded. Patients were followed up by ECG, Holter, and ICD interrogation. After a follow-up of at least 3 years, freedom from VAs or ICD therapy was 52.2% (12/23) in group 1 and 84.6% (22/26) in group 2 (P=0.029), with 21.7% (5/23) and 69.2% (18/26) patients off antiarrhythmic drugs (P<0.001), respectively. Compared with patients with no premature ventricular contractions after ablation, patients with frequent premature ventricular contractions after ablation were more likely to have VA recurrence/ICD therapy [3/33 (9%) versus 12/16 (75%); log-rank P<0.001]. Conclusions— An endo-epicardial–based ablation strategy achieves higher long-term freedom from recurrent VAs off antiarrhythmic therapy in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy when compared with endocardial-alone ablation. The presence of ≥10 premature ventricular contractions per minute after ablation is associated with more VA recurrence.Background— In patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy, freedom from ventricular arrhythmias (VAs) after endocardial ablation is limited. We compared the long-term freedom from recurrent VAs by using endocardial-alone ablation versus endo-epicardial substrate-based ablation. Methods and Results— Forty-nine patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergoing ablation of ventricular tachycardia (VT) were divided into 2 groups: endocardial-alone ablation (group 1, n=23) and endo-epicardial ablation (group 2, n=26). All patients had an implantable cardioverter-defibrillator (ICD). Conventional and 3D mappings were used to determine the mechanism of induced VTs and to identify area of “scar” or “abnormal” myocardium. All critical sites responsible for VTs and points with “abnormal” potential were targeted for ablation from endocardium (group 1) or from both endocardium and epicardium (group 2). The procedural end point was noninducibility of sustained, monomorphic VT with isoproterenol. The presence of frequent premature ventricular contractions at the end of ablation was recorded. Patients were followed up by ECG, Holter, and ICD interrogation. After a follow-up of at least 3 years, freedom from VAs or ICD therapy was 52.2% (12/23) in group 1 and 84.6% (22/26) in group 2 ( P =0.029), with 21.7% (5/23) and 69.2% (18/26) patients off antiarrhythmic drugs ( P <0.001), respectively. Compared with patients with no premature ventricular contractions after ablation, patients with frequent premature ventricular contractions after ablation were more likely to have VA recurrence/ICD therapy [3/33 (9%) versus 12/16 (75%); log-rank P <0.001]. Conclusions— An endo-epicardial–based ablation strategy achieves higher long-term freedom from recurrent VAs off antiarrhythmic therapy in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy when compared with endocardial-alone ablation. The presence of ≥10 premature ventricular contractions per minute after ablation is associated with more VA recurrence.

Arrhythmias in Chagasic Cardiomyopathy

Chagas disease, a chronic parasitosis caused by the protozoa Trypanosoma cruzi, is an increasing worldwide problem because of the number of cases in endemic areas and the migration of infected individuals to more developed regions. Chagas disease affects the heart through cardiac parasympathetic neuronal depopulation, immune-mediated myocardial injury, parasite persistence in cardiac tissue with secondary antigenic stimulation, and coronary microvascular abnormalities causing myocardial ischemia. A lack of knowledge exists for risk stratification, management, and prevention of ventricular arrhythmias in patients with chagasic cardiomyopathy. Catheter ablation can be effective for the management of recurrent ventricular tachycardia.

Cardiac sympathetic denervation for intractable ventricular arrhythmias in Chagas disease

BACKGROUND Autonomic modulation is a valuable therapeutic option for the management of ventricular arrhythmias. Bilateral cardiac sympathetic denervation (BCSD) has shown promising results in the acute, intermediate, and long-term management of polymorphic and monomorphic ventricular tachycardia (VT) in patients with structural heart disease. Cardiomyopathy (CM) due to Chagas disease (CD), and associated VT, is thought to be in part due to autonomic neuronal destruction and dysfunction. OBJECTIVE The purpose of this study was to assess whether BCSD is a safe and effective treatment modality in patients with CD and VT storm or refractory VT. METHODS A retrospective analysis of data from patients with chagasic CM who underwent BCSD between 2009 and 2015 at 2 international centers was performed. RESULTS Of 75 patients who underwent BCSD for VT storm or refractory VT in the setting of CM, 7 (9.3%) patients had CD as the etiology of CM. All patients had monomorphic VT. Median follow-up was 7 months (range 1-46 months). All patients either underwent previous unsuccessful catheter ablation or were not candidates for ablation. The median number of implantable cardioverter-defibrillator (ICD) shocks 1 month before BCSD was 4 (range 2-30) and decreased to 0 (range 0-2) during available follow-up after BCSD. When antitachycardia pacing therapies were included in the analysis, the median number of ICD therapies (shocks + antitachycardia pacing) still decreased to 1 (range 0-3). CONCLUSION In patients with chagasic CM presenting with refractory monomorphic VT, early evidence suggests that BCSD reduces appropriate ICD therapy and may represent a valuable treatment option.

Ventricular Tachycardia in the Setting of Chagasic Cardiomyopathy: Use of Voltage Mapping to Characterize Endoepicardial Nonischemic Scar Distribution

Background: Chagasic cardiomyopathy (CC) is the most frequent nonischemic substrate causing left ventricular (LV) tachycardia in Latin America. Systematic characterization of the LV epicardial/endocardial scar distribution and density in CC has not been performed. Additionally, the usefulness of unipolar endocardial electroanatomic mapping to identify epicardial scar has not been assessed in this setting. Methods and Results: Nineteen patients with CC undergoing detailed epicardial and endocardial LV tachycardia mapping and ablation were included. A total of 8494 epicardial and 6331 endocardial voltage signals and 314 epicardial/endocardial matched pairs of points were analyzed. Basal lateral LV scar involvement was observed in 18 of 19 patients. Bipolar voltage mapping demonstrated larger epicardial than endocardial scar and core-dense (⩽0.5 mV) scar areas (28 [20–36] versus 19 [15–26] and 21 [2–49] versus 4 [0–7] cm2; P=0.049 and P=0.004, respectively). Bipolar epicardial and endocardial voltages within scar were low (0.4 [0.2–0.55] and 0.54 [0.33–0.87] mV, respectively) and confluent, indicating a dense/transmural scarring process in CC. The endocardial unipolar voltage value (with a newly proposed ⩽4-mV cutoff) predicted the presence and extent of epicardial bipolar scar (P<0.001). Conclusions: CC causes a unique ventricular tachycardia substrate concentrated to the basal lateral LV, with marked epicardial predominance. The scar pattern is particularly dense and transmural as compared with the more erratic/patchy scar patterns seen in other nonischemic cardiomyopathies. Endocardial unipolar voltage mapping serves to characterize epicardial scar in this setting.

Use of Intracardiac Echocardiography in Interventional Cardiology: Working With the Anatomy Rather Than Fighting It

The indications for catheter-based structural and electrophysiological procedures have recently expanded to more complex scenarios, in which an accurate definition of the variable individual cardiac anatomy is key to obtain optimal results. Intracardiac echocardiography (ICE) is a unique imaging modality able to provide high-resolution real-time visualization of cardiac structures, continuous monitoring of catheter location within the heart, and early recognition of procedural complications, such as pericardial effusion or thrombus formation. Additional benefits are excellent patient tolerance, reduction of fluoroscopy time, and lack of need for general anesthesia or a second operator. For these reasons, ICE has largely replaced transesophageal echocardiography as ideal imaging modality for guiding certain procedures, such as atrial septal defect closure and catheter ablation of cardiac arrhythmias, and has an emerging role in others, including mitral valvuloplasty, transcatheter aortic valve replacement, and left atrial appendage closure. In electrophysiology procedures, ICE allows integration of real-time images with electroanatomic maps; it has a role in assessment of arrhythmogenic substrate, and it is particularly useful for mapping structures that are not visualized by fluoroscopy, such as the interatrial or interventricular septum, papillary muscles, and intracavitary muscular ridges. Most recently, a three-dimensional (3D) volumetric ICE system has also been developed, with potential for greater anatomic information and a promising role in structural interventions. In this state-of-the-art review, we provide guidance on how to conduct a comprehensive ICE survey and summarize the main applications of ICE in a variety of structural and electrophysiology procedures.

Eficacia a largo plazo de la ablación con radiofrecuencia en la taquicardia auricular

Introduccion y objetivos La ablacion con radiofrecuencia ha demostrado ser altamente efectiva en el tratamiento de las taquicardias supraventriculares incluyendo fluter y taquicardia auricular, pero la informacion clinica disponible sobre esta ultima es limitada. El objetivo de este estudio fue evaluar la efectividad de la ablacion con radiofrecuencia en estos pacientes, asi como establecer criterios predictores de efectividad y recurrencia de la arritmia. Metodos Se analizo una serie consecutiva de 126 procedimientos de ablacion de taquicardia auricular en 117 pacientes. La mayoria fueron mujeres (69%), con una media de edad de 50 ± 19 anos. Resultados El 91% de los focos se localizaron en la auricula derecha. Se realizaron una media de seis aplicaciones por procedimiento, logrando el 74% de efectividad con el primer procedimiento y total del 80%. El unico predictor de efectividad fue el numero de focos, siendo menor en las taquicardias auriculares multifocales (p Conclusiones La ablacion es un procedimiento efectivo y seguro a corto y largo plazo para el tratamiento de los pacientes con taquicardia auricular. La efectividad esta determinada por el numero de focos, mientras que el unico predictor de las recurrencias fue una menor precocidad del electrograma auricular en el punto de aplicacion.

Role of intracardiac echocardiography for guiding ablation of tricuspid valve arrhythmias

Introduction Ventricular tachycardia and premature ventricular contractions (PVCs) arising from around the tricuspid valve (TV) annulus represent 8%–9% of idiopathic ventricular arrhythmias (VAs). Additionally, in some patients with nonischemic cardiomyopathy, the perivalvular region is a common source of VAs. Tada and colleagues showed that the outcomes of catheter ablation for TV arrhythmias are relatively modest. In our experience, the 3 main obstacles for ablation of these VAs are a prominent Eustachian ridge that sometimes interferes with advancing the catheter into the right ventricle (RV), the exaggerated annular mobility during the cardiac cycle that limits catheter stability, and the presence of the valve leaflets and chordae, which are often interposed between the tip of the catheter and the myocardial tissue. The same considerations apply for ablation of right-sided accessory pathways (APs) and explain why primary failure and recurrence rates are higher compared to ablation of left free-wall APs. In this report, we describe 5 cases that illustrate the utility of intracardiac echocardiography (ICE) to guide mapping and ablation of tricuspid annular arrhythmias. In all these cases an initial attempt of ablation had failed using the standard femoral approach.

Percutaneous Transhepatic Venous Access for Atrial Tachyarrhythmia Ablation in Patients with Single Ventricle and Interrupted Inferior Vena Cava

From the *Division of Cardiology, Department of Cardiac Electrophysiology, National Cardiovascular Institute INCOR, Lima, Peru, Division of Cardiology, Department of Cardiac Electrophysiology, University of Maryland Medical System, Baltimore, Maryland, Division of Cardiology, Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, and xInternational Arrhythmia Center, Cardiology Institute, Fundación Cardioinfantil, University of La Sabana, Bogota, Colombia.

CARDIOLOGÍA DEL ADULTO - PRESENTACIÓN DE CASOSAspergillus fumigatus en cardiodesfibrilador implantado cinco años antesAspergillus fumigatus in cardioverter defibrillator implanted five years ago

Fungal infections of cardiac devices infections are exceptional and the have only been a few reported cases reported for the Aspergillus species. Its diagnosis requires a high index of suspicion including complete removal of the device in order to document it. We describe a rare case of Aspergillus fumigatus infection five years after being implanted, complemented with a review of the literature and reviewing the main features of the largest reported series.