Luiz Roberto Leite

Luminal Esophageal Temperature Monitoring With a Deflectable Esophageal Temperature Probe and Intracardiac Echocardiography May Reduce Esophageal Injury During Atrial Fibrillation Ablation Procedures Results of a Pilot Study

Background— Luminal esophageal temperature (LET) monitoring is one strategy to minimize esophageal injury during atrial fibrillation ablation procedures. However, esophageal ulceration and fistulas have been reported despite adequate LET monitoring. The objective of this study was to assess a novel approach to LET monitoring with a deflectable LET probe on the rate of esophageal injury in patients undergoing atrial fibrillation ablation. Methods and Results— Forty-five consecutive patients undergoing an atrial fibrillation ablation procedure followed by esophageal endoscopy were included in this prospective observational pilot study. LET monitoring was performed with a 7F deflectable ablation catheter that was positioned as close as possible to the site of left atrial ablation using the deflectable component of the catheter guided by visualization of its position on intracardiac echocardiography. Ablation in the posterior left atrial was limited to 25 W and terminated when the LET increased 2°C from baseline. Endoscopy was performed 1 to 2 days after the procedure. All patients had at least 1 LET elevation >2°C necessitating cessation of ablation. Deflection of the LET probe was needed to accurately measure LET in 5% of patients when ablating near the left pulmonary veins, whereas deflection of the LET probe was necessary in 88% of patients when ablating near the right pulmonary veins. The average maximum increase in LET was 2.5±1.5°C. No patients had esophageal thermal injury on follow-up endoscopy. Conclusions— A strategy of optimal LET probe placement using a deflectable LET probe and intracardiac echocardiography guidance, combined with cessation of radiofrequency ablation with a 2°C rise in LET, may reduce esophageal thermal injury during left atrial ablation procedures.

Nonsurgical transthoracic epicardial ablation for the treatment of a resistant posteroseptal accessory pathway

A case of Wolff‐Parkinson‐White syndrome successfully treated by transcutaneous epicardial radiofrequency ablation is described in a patient with a posteroseptal accessory pathway who had failed prior attempts of conventional endocardial and coronary venous system approaches. Simultaneous endocardial and pericardial space mapping was performed and only ablation from the pericardial space was successful, suggesting an epicardial course of the accessory pathway. (PACE 2004; 27:259–261)

Catecholaminergic polymorphic ventricular tachycardia. An important diagnosis in children with syncope and normal heart

Syncope in children is primarily related to vagal hyperreactivity, but ventricular tachycardia (VT) way rarely be seen. Catecholaminergic polymorphic VT is a rare entity that can occur in children without heart disease and with a normal QT interval, which may cause syncope and sudden cardiac death. In this report, we describe the clinical features, treatment, and clinical follow-up of three children with syncope associated with physical effort or emotion and catecholaminergic polymorphic VT. Symptoms were controlled with beta-blockers, but one patient died suddenly in the fourth year of follow-up. Despite the rare occurrence, catecholaminergic polymorphic VT is an important cause of syncope and sudden death in children with no identified heart disease and normal QT interval.

Comparison of a shortened isosorbide dinitrate-potentiated head-up tilt testing with the conventional protocol: Tolerance and diagnostic accuracy

Background: The head‐up tilt test (HUT) is widely used to investigate unexplained syncope; however, in clinical practice, it is long and sometimes not well tolerated.

Life-Threatening Cardiac Manifestations of Pheochromocytoma

Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands, usually with benign manifestations, whose typical clinical presentation includes the triad of headache, palpitations and diaphoresis. However, a wide range of signs and symptoms may be present. In the cardiovascular system, the most common signs are labile hypertension and sinus tachycardia. Systolic heart failure and ST-segment deviations mimicking myocardial infarction have also been reported, as well as QT interval prolongation and, rarely, ventricular tachycardia. We describe a challenging diagnosis of pheochromocytoma with many cardiovascular manifestations, which could have been missed due to the absence of typical symptoms.

Sudden Cardiac Arrest in General Anesthesia as the First Manifestation of Anomalous Origin of the Left Coronary Artery

BACKGROUND AND OBJECTIVES This case report describes a rare and potentially fatal condition associated with anesthesia administration. Our aim was to discuss the causes of sudden cardiac arrest during the perioperative period in apparently healthy patients and the pathophysiology of anomalous origin of the coronary arteries as a cause of sudden cardiac arrest. CASE REPORT Female patient, 44 years old, with no previous symptoms of heart disease or arrhythmias, had a sudden cardiac arrest during general anesthesia in two different situations. In the first episode, the patient presented signs of acute abdomen, but remained hemodynamically stable. Following induction of anesthesia, the patient exhibited bradycardia and hypotension refractory to volume replacement and vasopressors. The condition progressed to asystole. The patient was successfully resuscitated and discharged from the hospital in good condition. In the second episode, one year after the first, the patient was in good clinical condition to undergo an elective surgery. After induction of anesthesia, the patient developed ventricular tachycardia followed by asystole, which was promptly reversed. After extensive investigation, an anomalous origin of the left coronary artery was identified. CONCLUSIONS Our report is illustrative as it emphasizes that a thorough diagnostic investigation should be done in cases of sudden cardiac arrest during the perioperative period, even in patients that appear to be healthy.

Índice de resistividade renal como preditor da revascularização renal para hipertensão renovascular

BACKGROUND Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95%CI for OR 6.1 to 1,621.2). CONCLUSION Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.FUNDAMENTO: A estenose arterial renal (EAR) e uma causa potencialmente reversivel de hipertensao arterial sistemica (HAS) e nefropatia isquemica. Apesar da revascularizacao bem sucedida, nem todos os pacientes (pt) apresentam melhora clinica e alguns podem piorar. OBJETIVO: O presente estudo se destina a avaliar o valor do indice de resistividade renal (IR) como preditor dos efeitos da revascularizacao renal. METODOS: Entre janeiro de 1998 e fevereiro de 2001, 2.933 pacientes foram submetidos ao duplex ultrassom renal. 106 desses pacientes apresentaram EAR significativa e foram submetidos a angiografia e revascularizacao renal. A pressao arterial (PA) foi medida antes e depois da intervencao, em intervalos de ate 2 anos e as medicacoes prescritas foram registradas. Antes da revascularizacao, o IR foi medido em 3 locais do rim, sendo obtida uma media dessas medicoes. RESULTADOS: Dos 106 pacientes, 81 tiveram IR 80. A EAR foi corrigida somente por angioplastia (PTA) em 25 pts, PTA + stent em 56 pts e cirurgicamente em 25 pts. Dos pacientes que se beneficiaram da revascularizacao renal; 57 dos 81 pacientes com IR 80. Usando um modelo de regressao logistica multipla, o IR esteve significativamente associado a evolucao da PA (p = 0,001), ajustado de acordo com os efeitos da idade, sexo, PAS, PAD, duracao da hipertensao, o tipo de revascularizacao, numero de farmacos em uso, nivel de creatinina, presenca de diabete melito, hipercolesterolemia, volume sistolico, doenca arterial periferica e coronariana e tamanho renal (OR 99,6-95%CI para OR 6,1-1.621,2). CONCLUSAO: A resistividade intrarrenal arterial, medida por duplex ultrassom, desempenha um papel importante na predicao dos efeitos pos revascularizacao renal para EAR.

Renal resistance index predicting outcome of renal revascularization for renovascular hypertension

BACKGROUND Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95%CI for OR 6.1 to 1,621.2). CONCLUSION Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.FUNDAMENTO: A estenose arterial renal (EAR) e uma causa potencialmente reversivel de hipertensao arterial sistemica (HAS) e nefropatia isquemica. Apesar da revascularizacao bem sucedida, nem todos os pacientes (pt) apresentam melhora clinica e alguns podem piorar. OBJETIVO: O presente estudo se destina a avaliar o valor do indice de resistividade renal (IR) como preditor dos efeitos da revascularizacao renal. METODOS: Entre janeiro de 1998 e fevereiro de 2001, 2.933 pacientes foram submetidos ao duplex ultrassom renal. 106 desses pacientes apresentaram EAR significativa e foram submetidos a angiografia e revascularizacao renal. A pressao arterial (PA) foi medida antes e depois da intervencao, em intervalos de ate 2 anos e as medicacoes prescritas foram registradas. Antes da revascularizacao, o IR foi medido em 3 locais do rim, sendo obtida uma media dessas medicoes. RESULTADOS: Dos 106 pacientes, 81 tiveram IR 80. A EAR foi corrigida somente por angioplastia (PTA) em 25 pts, PTA + stent em 56 pts e cirurgicamente em 25 pts. Dos pacientes que se beneficiaram da revascularizacao renal; 57 dos 81 pacientes com IR 80. Usando um modelo de regressao logistica multipla, o IR esteve significativamente associado a evolucao da PA (p = 0,001), ajustado de acordo com os efeitos da idade, sexo, PAS, PAD, duracao da hipertensao, o tipo de revascularizacao, numero de farmacos em uso, nivel de creatinina, presenca de diabete melito, hipercolesterolemia, volume sistolico, doenca arterial periferica e coronariana e tamanho renal (OR 99,6-95%CI para OR 6,1-1.621,2). CONCLUSAO: A resistividade intrarrenal arterial, medida por duplex ultrassom, desempenha um papel importante na predicao dos efeitos pos revascularizacao renal para EAR.

Epicardial mapping of sustained ventricular tachycardia in nonischemic heart disease

BACKGROUND The complexity of reentrant circuits related to ventricular tachycardias decreases the success rate of radiofrequency ablation procedures. OBJECTIVE To evaluate whether the epicardial mapping with multiple electrodes carried out simultaneously with the endocardial mapping helps in ablation procedures of sustained ventricular tachycardia (VT) in patients with nonischemic heart disease. METHODS Twenty-six patients with recurrent sustained VT, of which 22 (84.6%) presenting chronic chagasic cardiomyopathy, 2 (7.7%) with idiopathic dilated cardiomyopathy and 2 with right ventricular arrhythmogenic dysplasia (RVAD), were submitted to epicardial mapping with two or three microcatheters, with 8 electrodes each, simultaneously to the conventional endocardial mapping. A catheter with a 4-mm tip was used for the ablation by radiofrequency (RF) carried out during the induced VT. RESULTS Of the 33 induced VT, 25 were mapped and 20 had their origin defined. Eleven had epicardial and 9 had endocardial origin. The programmed ventricular stimulation did not induce sustained VT in 11 (42.0%) of the 26 patients after the ablation. Events such as VT recurrence and death occurred in 10.0% of the patients submitted to successful ablation and in 59.0% of the unsuccessful cases, during a mean ambulatory follow-up of 357 ± 208 days. CONCLUSION Subepicardial circuits are frequent in patients with nonischemic heart disease. The epicardial mapping with multiple catheters carried out simultaneously with the endocardial mapping contributes to the identification of these circuits in a same procedure.BACKGROUND: The complexity of reentrant circuits related to ventricular tachycardias decreases the success rate of radiofrequency ablation procedures. OBJECTIVE: To evaluate whether the epicardial mapping with multiple electrodes carried out simultaneously with the endocardial mapping helps in ablation procedures of sustained ventricular tachycardia (VT) in patients with nonischemic heart disease. METHODS: Twenty-six patients with recurrent sustained VT, of which 22 (84.6%) presenting chronic chagasic cardiomyopathy, 2 (7.7%) with idiopathic dilated cardiomyopathy and 2 with right ventricular arrhythmogenic dysplasia (RVAD), were submitted to epicardial mapping with two or three microcatheters, with 8 electrodes each, simultaneously to the conventional endocardial mapping. A catheter with a 4-mm tip was used for the ablation by radiofrequency (RF) carried out during the induced VT. RESULTS: Of the 33 induced VT, 25 were mapped and 20 had their origin defined. Eleven had epicardial and 9 had endocardial origin. The programmed ventricular stimulation did not induce sustained VT in 11 (42.0%) of the 26 patients after the ablation. Events such as VT recurrence and death occurred in 10.0% of the patients submitted to successful ablation and in 59.0% of the unsuccessful cases, during a mean ambulatory follow-up of 357 ± 208 days. CONCLUSION: Subepicardial circuits are frequent in patients with nonischemic heart disease. The epicardial mapping with multiple catheters carried out simultaneously with the endocardial mapping contributes to the identification of these circuits in a same procedure.

Catecholaminergic polymorphic ventricular tachycardia: a current overview.

Catecholaminergic polymorphic ventricular tachycardia occurs in healthy children and young adults causing syncope and sudden cardiac death. This is a familial disease, which affect de novo mutation in 50% of the cases. At least two causative genes have been described to be localized in the chromosome 1; mutation of the ryanodine receptor gene and calsequestrin gene. The classical clinical presentation is syncope triggered by exercise and emotion in children and adolescents with no structural heart disease. Polymorphic ventricular tachycardia during treadmill testing, or after isoproterenol infusion, is the most common feature. Therapeutic options include, beta-blockers, calcium-channel blockers and, an implantable cardioverter defibrillator is indicated in high-risk patients. Risk stratification of this disease is very challenging, since some risk factors proved to be useful in some series but not in others. However, family history of sudden cardiac death and symptoms initiated in very young children are important predictors.