Moisés Rodríguez-Mañero

Monomorphic ventricular tachycardia in patients with Brugada syndrome: A multicenter retrospective study

BACKGROUNDnIsolated cases of monomorphic ventricular tachycardia (MVT) in patients with Brugada syndrome (BrS) have been reported.nnnOBJECTIVEnWe aimed to describe the incidence and characteristics of MVT in a cohort of patients with BrS who had received an implantable cardioverter-defibrillator (ICD).nnnMETHODSnData from 834 patients with BrS implanted with an ICD in 15 tertiary hospitals between 1993 and 2014 were included.nnnRESULTSnThe mean age of enrolled patients was 45.3 ± 13.9 years; 200 patients (24%) were women. During a mean follow-up of 69.4 ± 54.3 months, 114 patients (13.7%) experienced at least 1 appropriate ICD intervention, with MVT recorded in 35 patients (4.2%) (sensitive to antitachycardia pacing in 15 [42.8%]). Only QRS width was an independent predictor of MVT in the overall population. Specifically, 6 (17.1%) patients presented with right ventricular outflow tract tachycardia (successfully ablated from the endocardium in 4 and epicardial and endocardial ablation in 1), 2 patients with MVT arising from the left ventricle (1 successfully ablated in the supra lateral mitral annulus), and 2 (5.7%) patients with bundle branch reentry ventricular tachycardia. Significant structural heart disease was ruled out by echocardiography and/or cardiac magnetic resonance imaging.nnnCONCLUSIONnIn this retrospective study, 4.2% of patients with BrS implanted with an ICD presented with MVT confirmed as arising from the right ventricular outflow tract tachycardia in 6, patients with MVT arising from the left ventricle in 2, and patients with bundle branch reentry ventricular tachycardia in 2. Endocardial and/or epicardial ablation was successful in 80% of these cases. These data imply that the occurrence of MVT should not rule out the possibility of BrS. This finding may also be relevant for ICD model selection and programming.

Retrograde coronary venous ethanol infusion for ablation of refractory ventricular tachycardia

Background—Radiofrequency ablation (RFA) of ventricular tachycardia (VT) can fail because of inaccessibility to the VT substrate. Transarterial coronary ethanol ablation can be effective but entails arterial instrumentation risk. We hypothesized that retrograde coronary venous ethanol ablation can be an alternative bail-out approach to failed VT RFA. Methods and Results—Out of 334 consecutive patients undergoing VT/premature ventricular contraction ablation, 7 patients underwent retrograde coronary venous ethanol ablation. Six out of 7 patients had failed RFA attempts (including epicardial in 3). Coronary venogram-guided venous mapping was performed using a 4F quadripolar catheter or an alligator-clip–connected angioplasty wire. Targeted veins included those with early presystolic potentials and pace-maps matching VT/premature ventricular contraction. An angioplasty balloon (1.5–2×6 mm) was used to deliver 1 to 4 cc of 98% ethanol into a septal branch of the anterior interventricular vein in 5 patients with left ventricular summit VT, a septal branch of the middle cardiac vein, and a posterolateral coronary vein (n=1 each). The clinical VT was successfully ablated acutely in all patients. There were no complications of retrograde coronary venous ethanol ablation, but 1 patient developed pericardial and pleural effusion attributed to pericardial instrumentation. On follow-up of 590±722 days, VT recurred in 4 out of 7 patients, 3 of whom were successfully reablated with RFA. Conclusions—Retrograde coronary venous ethanol ablation is safe and feasible as a bail-out approach to failed VT RFA, particularly those originating from the left ventricular summit.

Anticoagulation prescription in atrial fibrillation

Aims: We seek to assess the factors associated with the anticoagulation prescription in a cohort of patients with atrial fibrillation (AF) collected from out-patient clinics. Methods: A total of 1524 patients with a history of AF were collected from out-patients clinics. CHADS2, CHA2DS2-VASc and HAS-BLED scores were calculated in every patient. Variables associated with anticoagulant treatment prescription were analyzed in univariant and multivariant models. Results: Most patients received either anticoagulant (62%) or antiplatelet treatment (37%). Anticoagulation rates increased among higher CHADS2 and CHA2DS2-VASc score values. A logistic regression model was performed to assess the variables associated with the prescription of anticoagulant treatment; the variables with stronger association were the presence of arrhythmia at the current visit (odds ratio (OR) 33, 95% CI 27 – 40, p < 0.001) and lack of concomitant antiplatelet treatment (OR 0.17, 95% CI 0.14 – 0.21, p < 0.001). Conclusions: Although prognosis of patients with AF is mainly determined by the long-term thrombotic risk, the prescription of antithrombotic therapy depends more on the bleeding risk and the immediate thrombotic risk perception.

Left Atrial Appendage Remodeling after Lariat Left Atrial Appendage Ligation

Background—Left atrial appendage (LAA) ligation with the Lariat device is being used for stroke prevention in atrial fibrillation. Residual leaks into the LAA are commonly reported after the procedure. Little is known about the anatomic LAA remodeling after Lariat ligation. Methods and Results—In an exploratory study, we evaluated LAA 3-dimensional geometry via computed tomographic scan in 31 consecutive patients before Lariat closure and after a minimum of 30 days post procedure. Thirteen patients were classified as unfavorable cases based on anatomic criteria. Our population had an average age of 70±12 years, a mean CHADS2 (congestive heart failure, hypertension, age>75, diabetes mellitus, history of stroke) score of 3.2±1.2, a mean CHADS2VASC (CHADS2 in addition to female sex, ages 65–75, as well as double impact of age >75, vascular disease) of 4.2±1.5, and a mean HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding predisposition/history, labile international normalized ratio, elderly, drugs/alcohol) bleeding score of 4.0±1.1. Successful suture deployment was achieved in all cases, but 3 patients had intraprocedural residual flow into the LAA (leak). On follow-up, 10 patients (32%) had recanalized residual LAA cavities, which were morphologically similar to the original LAA, albeit significantly smaller in volume (22.5±13.3% of the original volume). Recanalization was not associated with age, sex, comorbid conditions, stroke or bleeding risk scores, follow-up interval, baseline LAA volume, or morphology. Unfavorable cases had anatomic outcomes comparable with those of the anatomically favorable population. No patients have exhibited thromboembolism after 842±338 days post ligation. Conclusions—Incomplete LAA ligation after Lariat is common. However, the remodeled LAA cavity is dramatically reduced. Diminished cavity size and tightening of the LAA orifice may play a role in the reduction of thrombus formation.

The Human Left Atrial Venous Circulation as a Vascular Route for Atrial Pharmacological Therapies: Effects of Ethanol Infusion

OBJECTIVESnThis study catalogued the human venous left atrium (LA) circulation system and the ablative effects of ethanol in different branches.nnnBACKGROUNDnVascular routes to target the LA could have significant therapeutic potential. Beyond the vein of Marshall (VOM), the fluoroscopic LA venous anatomy has not been described.nnnMETHODSnPatients undergoing ethanol infusion in the VOM as adjunctive therapy to atrial fibrillation (AF) catheter ablation were included in this study. Balloon occlusion venograms of the VOM and other LA veins were obtained in 218xa0patients.nnnRESULTSnSequentially from the coronary sinus (CS) ostium, LA veins included: 1) proximal septal vein draining the inferior septum; 2) inferior LA vein in the annular inferior LA; 3) VOM; 4) LA appendage vein; and 4) anterior LA vein. Additionally, venous sinuses not connected to the CS included roof veins and posterior wall veins, which drained into the right and left atria, respectively. Venous connections between LA veins through capillaries and with pulmonary veins were abundant. Extracardiac collateral vessels were present in 38 patients (17.4%). Ethanol infusion in LA veins led to tissue ablation in their corresponding regions.nnnCONCLUSIONSnThe atrial venous anatomy is amenable to selective cannulation. Consistent anatomical patterns arexa0present.xa0Targeting atrial tissues through atrial veins can be used for therapeutic purposes.

Strategies for phrenic nerve preservation during ablation of inappropriate sinus tachycardia

BACKGROUNDnRadiofrequency (RF) ablation can alleviate drug-refractory inappropriate sinus tachycardia (IST). However, phrenic nerve (PN) injury and other complications limit its use.nnnOBJECTIVEnThe purpose of this study was to characterize the maneuvers used to avoid PN injury and the long-term clinical outcomes.nnnMETHODSnThe study consisted of a retrospective analysis of consecutive patients who underwent ablation for IST.nnnRESULTSnRF ablation was performed on 13 consecutive female patients with drug-refractory IST. Eleven patients exhibited PN capture at desired ablation sites. In 1 patient, PN capture was not continuous throughout the respiratory cycle and ventilation holding sufficed to avoid PN injury. In 10 patients, pericardial access (PA) and balloon insertion was required. Initially (n = 4) a posterior PA was used, which was replaced by an anterior PA in the subsequent 6 cases. PA to optimal balloon positioning time was significantly lower in anterior vs posterior PA (16.3 ± 6 minutes vs 58 ± 21.3 minutes, P = .01), as was fluoroscopy time (15.66 ± 16.72 min vs 35.9 ± 1.8 min, P = .03). RF ablation successfully reduced sinus rate to <90 bpm in 13 of 13 patients. Procedure times and total RF times were not significantly different in anterior vs posterior PA. Major complications occurred in 2 patients, including unremitting pericardial bleeding requiring open-chested repair in 1 patient and sinus pauses mandating pacemaker implantation in the other patient. Long-term symptom control after follow-up of 811 ± 42 days was successful in 84.6%.nnnCONCLUSIONnVentilation holding and/or pericardial balloon insertion are frequently warranted in IST ablation. Anterior PA appears to facilitate the procedure over posterior PA.

The cost effectiveness of LAA exclusion

Left atrial appendage (LAA) exclusion strategies are increasingly utilized for stroke prevention in lieu of oral anticoagulants. Reductions in bleeding risk and long-term compliance issues bundled with comparable stroke prevention benefits have made these interventions increasingly attractive. Unfortunately, healthcare funding remains limited. Comparative cost economic analyses are therefore critical in optimizing resource allocation. In this review we seek to discourse the cost economics analysis of LAA exclusion over available therapeutic alternatives (warfarin and the new oral anticoagulants (NOACs)).u2003.

Vagal stimulation to suppress alternans: Are we saving lives or simply masking surrogate markers?

Multiple studies have demonstrated that the functional modulation of the heart exerted by the autonomic nervous system (ANS) can prove maladaptive in the context of heart failure (HF), and it is evident that increased sympathetic and reduced parasympathetic tone play an important pathophysiological role in the progression of HF irrespective of its etiology. In light of its implications in the pathogenesis of HF, there has been growing interest in the potential of ANSmodulation as HF therapy. Theoretically, it is conceivable that enhancing parasympathetic tone to counteract the adverse effects of excessive adrenergic activity could ameliorate or even reverse the course of this progressive disease. Parasympathetic modulation of the heart is carried by the right and left vagus nerves, originating in the medulla and connecting with postganglionic neurons in ganglionated plexi located in the epicardium. The anatomical accessibility of the cervical vagus nerves and their response to electrical impulses provide a unique opportunity to interfere with ANS responses to disease. In 1967 Braunwald et al demonstrated that vagal nerve stimulation (VNS) could reproducibly attenuate angina symptoms and improve exercise capacity in 2 patients after myocardial infarction. Schwartz et al studied the effect of VNS in a series of 8 patients with advanced HF. They demonstrated a significant improvement in left ventricular end-systolic volume and functional class. A nonrandomized study of 32 patients with HF with reduced left ventricular ejection fraction (LVEF) reported that VNS favorably influenced quality of life, exercise capacity, and left ventricular remodeling. However, larger randomized studies have failed to systematically replicate these effects. A sham-controlled trial (NECTAR-HF) showed no benefit of VNS in LVEF or left ventricular remodeling. The ANTHEM-HF trial randomly assigned 31 and 29 patients to left and right cervical VNS, respectively. In contrast to NECTAR-HF, modest but

Ablation of Inappropriate Sinus Tachycardia: A Systematic Review of the Literature

OBJECTIVESnThe goal of this study was to describe short- and long-term outcomes in all patients referred for inappropriate sinus tachycardia ablation, along with the potential complications of the intervention.nnnBACKGROUNDnSinus node (SN) ablation/modification has been proposed for patients refractory to pharmacological therapy. However, available data derive from limited series.nnnMETHODSnThe electronic databases MEDLINE, Embase, CINAHL, Cochrane, and Scopus were systematically searched (January 1, 1995-December 31, 2015). Studies were screened according to predefined inclusion and exclusion criteria.nnnRESULTSnA total of 153 patients were included. Their mean age was 35.18 ± 10.02 years, and 139 (90.8%) were female. All patients had failed to respond to maximum tolerated doses of pharmacological therapy (3.5 ± 2.4 drugs). Mean baseline heart rates averaged 101.3 ± 16.4 beats/min according to electrocardiography and 104.5 ± 13.5 beats/min according to 24-h Holter monitoring. Two electrophysiological strategies were used, SN ablation and SN modification, with the latter being used more. Procedural acute success (using variably defined pre-determined endpoints) was 88.9%. Consistently, all groups reported high-output pacing from the ablation catheter to confirm absence of phrenic nerve stimulation before radiofrequency delivery. Need of pericardial access varied between 0% and 76.9%. Thirteen patients (8.5%) experienced severe procedural complications, and 15 patients (9.8%) required implantation of a pacemaker. At a mean follow-up interval of 28.1 ± 12.6 months, 86.4% of patients demonstrated successful outcomes. The symptomatic recurrence rate was 19.6%, and 29.8% of patients continued to receive antiarrhythmic drug therapy after procedural intervention.nnnCONCLUSIONSnInappropriate sinus tachycardia ablation/modification achieves acute success in the vast majority ofxa0patients. Complications are fairly common and diverse. However, symptomatic relief decreases substantially overxa0longer follow-up periods, with a corresponding high recurrence rate.

Case reportPermanent junctional reciprocating tachycardia in a patient with an atypically located accessory pathway in the left lateral mitral annulusTaquicardia juncional permanente reciprocante numa doente com via acessória de localização atípica no anel mitral lateral esquerdo

Permanent junctional reciprocating tachycardia (PJRT) is an uncommon form of atrioventricular reentrant tachycardia due to an accessory pathway characterized by slow and decremental retrograde conduction. The majority of accessory pathways in PJRT are located in the posteroseptal zone. Few cases of atypical location have been described. We report a case of PJRT in a 72-year-old woman in whom the accessory pathway was located in the left lateral region and treated by radiofrequency catheter ablation.