Luís Carpinteiro

Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation – Acute phase results from a prospective observational study

INTRODUCTION AND AIM Multi-site pacing is emerging as a new method for improving response to cardiac resynchronization therapy (CRT), but has been little studied, especially in patients with atrial fibrillation. We aimed to assess the effects of triple-site (Tri-V) vs. biventricular (Bi-V) pacing on hemodynamics and QRS duration. METHODS This was a prospective observational study of patients with permanent atrial fibrillation and ejection fraction <40% undergoing CRT implantation (n=40). One right ventricular (RV) lead was implanted in the apex and another in the right ventricular outflow tract (RVOT) septal wall. A left ventricular (LV) lead was implanted in a conventional venous epicardial position. Cardiac output (using the FloTrac™ Vigileo™ system), mean QRS and ejection fraction were calculated. RESULTS Mean cardiac output was 4.81±0.97 l/min with Tri-V, 4.68±0.94 l/min with RVOT septal and LV pacing, and 4.68±0.94 l/min with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV). Mean pre-implantation QRS was 170±25 ms, 123±18 ms with Tri-V, 141±25 ms with RVOT septal pacing and LV pacing and 145±19 with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV and pre-implantation). Mean ejection fraction was significantly higher with Tri-V (30±11%) vs. Bi-V pacing (28±12% with RVOT septal and LV pacing and 28±11 with RV apical and LV pacing) and pre-implantation (25±8%). CONCLUSION Tri-V pacing produced higher cardiac output and shorter QRS duration than Bi-V pacing. This may have a significant impact on the future of CRT.

Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation: follow-up results from a prospective observational study

Aims Cardiac Resynchronization Therapy (CRT) is associated with a particularly high non-response rate in patients with atrial fibrillation (AF). We aimed to assess the effectiveness of triple-site (Tri-V) pacing CRT in this population. Methods and results Prospective observational study of patients with permanent AF who underwent CRT implantation with an additional right ventricle lead in the outflow tract septal wall. After implantation, programming mode (Tri-V or biventricular pacing) was selected based on cardiac output determination. Patients were classified as responders if NYHA class was reduced by at least one level and echocardiographic ejection fraction (EF) increased ≥ 10%, and as super-responders if in NYHA class I and EF ≥ 50%. Forty patients (93% male, mean age 72 ± 10 years) were included. Thirty-three were programmed in Tri-V. The following results pertain to this subgroup. At baseline, 58% were in NYHA class III and 36% NYHA class II. At 1 year follow-up, Minnesota QoL score was reduced (36 ± 23 vs. 8 ± 6; P = 0.001) and the 6MWT distance improved (384 ± 120 m to 462 ± 87 m, P = 0.003). Mean EF increased (26% ± 8 vs. 39 ± 10; P < 0.001 at 6 months and 41 ± 10; P < 0.001 at 12 months). Responder rate was 59% at 6 months and 79% at 12 months. Super-responder rate was 9% at 6 months and 16% at 12 months. One year survival free from heart failure hospitalization was 87.9%. Conclusion Tri-V CRT yielded higher response and super-response rates than usually reported for CRT in patients with permanent AF using clinical and remodeling criteria.

Ripple mapping: Initial multicenter experience of an intuitive approach to overcoming the limitations of 3D activation mapping

Ripple mapping (RM) displays electrograms as moving bars over a three‐dimensional surface displaying bipolar voltage, and has shown in a single‐center series to be effective for atrial tachycardia (AT) mapping without annotation of local activation time or window‐of‐interest assignment. We tested the reproducibility of these findings in operators naïve to RM, using it for the first time in postablation AT.

SP061EFFICACY AND SAFETY OF PERCUTANEOUS LEFT ATRIAL APPENDAGE CLOSURE IN CHRONIC KIDNEY DISEASE PATIENTS WITH ATRIAL FIBRILLATION: RESULTS OF A 7-YEAR REGISTRY

© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Electroanatomical mapping of coronary artery anatomy to guide epicardial ventricular tachycardia ablation

Published on behalf of the European Society of Cardiology. All rights reserved.

Ablação epicárdica para prevenção da fibrilhação ventricular em doente com síndrome de Brugada

We present the case of a 60-year-old woman with Brugada syndrome, permanent type 1 electrocardiographic pattern, who had previously received an implantable cardioverter-defibrillator. She suffered frequent syncopal episodes and multiple appropriate shocks (around five per month) due to polymorphic ventricular tachycardia/ventricular fibrillation, refractory to quinidine therapy. Combined epicardial and endocardial electroanatomical mapping was performed with a view to substrate ablation. An area of abnormal fractionated electrograms, lasting up to 370 ms and up to 216 ms after the end of the surface QRS, was identified in the epicardium in the lower anterior part of the right ventricular outflow tract. Extensive epicardial ablation of this area, which eliminated the fractionated electrograms, led to the disappearance of the Brugada electrocardiographic pattern six weeks after ablation. Despite discontinuation of quinidine, no further ventricular arrhythmias occurred during follow-up, which is still of short duration.

Atrial fibrosis in atrial fibrillation pre-ablation assessed by CMR: impact in atrial size and function?

Atrial fibrillation (AF) is associated with different amounts of diffuse fibrosis, which has impact in the therapy response. CMR is able to assess myocardial fibrosis using late gadolinium enhancement (LGE) and chamber function.