Roberto Matía

Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study)

Background Catheter ablation (CA) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). No randomized studies have compared the two strategies in persistent AF. The present randomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistent AF. Methods and results Patients with persistent AF were randomly assigned to CA or ADT (excluding patients with long-standing persistent AF). Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting >24 h that occurred after a 3-month blanking period. Secondary endpoints were any atrial tachyarrhythmia lasting >30 s, hospitalization, and electrical cardioversion. In total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) in the ADT group were free of the primary endpoint (P = 0.002), implying an absolute risk difference of 26.6% (95% CI 10.0–43.3) in favour of CA. The proportion of patients free of any recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs. 29.2%; P < 0.001) and cardioversion was less frequent (34.7 vs. 50%, respectively; P = 0.018). Conclusion Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up. Clinical Trial Registration Information NCT00863213 (http://clinicaltrials.gov/ct2/show/NCT00863213).

Non-Antiarrhythmic Drugs to Prevent Atrial Fibrillation

Atrial fibrillation (AF) is the most frequent arrhythmia found in clinical practice. The majority of patients with AF are still candidates for antiarrhythmic drug treatment, not only for acute reversion to sinus rhythm but also for long-term treatment to prevent recurrences of AF. Currently available antiarrhythmic drugs, however, are unable to provide complete efficacy in all patients, and present problematic risks of proarrhythmia.The progressively increasing prevalence of AF supports the need to develop improved therapeutic approaches for the clinical management of arrhythmia. Accordingly, new treatment techniques aimed at suppressing the origin of the arrhythmogenic foci have been developed in the last decade. However, ablative treatments are only available for selected patients.Because of these factors, and also because primary prevention of AF should be our goal, the introduction of non-antiarrhythmic agents that could prevent both new-onset AF and recurrences of AF may eventually improve patient outcomes and reduce the incidence of this epidemic disease. The potential clinical value of these non-antiarrhythmic options is currently under active investigation.There is now clinical and experimental evidence that many drugs may have beneficial effects in preventing AF through several possible mechanisms. Non-antiarrhythmic drugs, such as ACE inhibitors and angiotensin receptor blockers, HMG-CoA reductase inhibitors (statins), corticosteroids, and N-3 polyunsaturated fatty acids may have a positive effect in patients with AF or in preventing AF in patients at risk.

Wireless Ultrasound‐Guided Axillary Vein Cannulation for the Implantation of Cardiovascular Implantable Electric Devices

Ultrasound guidance for vascular cannulation seems safer and more effective than an anatomical landmark approach, though it has not gained widespread support partly due to workflow interference of wired probes. A wireless ultrasound transducer (WUST) may overcome this issue. We report the effectiveness, time consumption, and safety of the first‐in‐human experience in axillary vein cannulation guided with a novel WUST for the implantation of cardiovascular implantable electric devices (CIEDs).

Device pacing diagnostics overestimate effective cardiac resynchronization therapy pacing results of the hOLter for Efficacy analysis of CRT (OLÉ CRT) study

BACKGROUND A high percentage of biventricular (BiV) or left ventricular (LV) pacing in cardiac resynchronization therapy (CRT) devices has been associated with superior clinical outcomes. However, the percent ventricular (%V) pacing reported by CRT devices simply indicates the number of paces the device has delivered and not the proportion of pacing that has captured the LV effectively. OBJECTIVE The purpose of this study was to determine whether a beat-by-beat evaluation of effective pacing would provide a more accurate evaluation of CRT delivery. METHODS An automatic electrogram (EGM)-based algorithm that classifies each LV pace as effective or ineffective based on detection of QS/QS-r morphology on the unipolar LV EGM during pacing was developed and validated. LV EGMs that were recorded by 24-hour Holter from 57 CRT patients were postprocessed. The percent effective CRT (%e-CRT) pacing was calculated by dividing the time spent in e-CRT pacing by the total time of the recording. RESULTS In this CRT cohort, the average %V pacing (94.8% ± 8%) significantly overestimated the %e-CRT pacing (87.5% ± 23%; P <.001). A significant minority of subjects (18%) had a discrepancy of at least 3 percentage points between %V pacing and %e-CRT pacing (mean 39% ± 41%). CONCLUSION Current device pacing diagnostics overestimate the amount of CRT pacing actually delivered. The new algorithm quantifies ineffective CRT pacing, which enables clinicians to identify patients with this issue and to address the reasons behind suboptimal CRT delivery.

Impact of previous cardiac surgery on long-term outcome of cavotricuspid isthmus-dependent atrial flutter ablation

AIMS The aim of this study was to determine the acute and long-term outcome of radiofrequency catheter ablation (RFCA) for cavotricuspid isthmus-dependent atrial flutter (CTI-AFL) in adults with and without previous cardiac surgery (PCS), and predictors of these outcomes. Structural alterations of the anatomical substrate of the CTI-AFL are observed in post-operative patients, and these may have an impact on the acute success of the ablation and in the long-term. METHODS AND RESULTS Clinical records of consecutive adults undergoing RFCA of CTI-AFL were analysed. Two main groups were considered: No PCS and PCS patients, who were further subdivided into acquired heart disease (AHD: ischaemic heart disease and valvular/mixed heart disease) and congenital heart disease [CHD: ostium secundum atrial septal defect (OS-ASD) and complex CHD]. Multivariate analysis identified clinical and procedural factors that predicted acute and long-term outcomes. A total of 666 patients (73% men, age 65 ± 12 years) were included: 307 of them with PCS. Ablation was successful in 647 patients (97%), 96% in the PCS group and 98% in the No PCS group (P = 0.13). Regression analysis showed that surgically corrected complex CHD was related to failure of the procedure [odds ratio 5.6; 95% confidence interval (CI) 1.6-18, P = 0.008]. After a follow-up of 45 ± 15 months, recurrences were observed in 90 patients (14%), more frequently in the PCS group: absolute risk of recurrence 18 vs. 10.5%, relative risk 1.71, 95% CI: 1.2-2.5, P = 0.006. Multivariate analysis indicated that the types of PCS [OS-ASD vs. No PCS: hazard ratio (HR) 2.57; 95% CI: 1.1-6.2, P = 0.03 and complex CHD vs. No PCS: HR 2.75; 95% CI: 1.41-5.48, P = 0.004], female gender (HR 1.55; 95% CI: 1.04-2.4, P = 0.048), and severe LV dysfunction (HR 1.36; 95% CI: 1.06-1.67, P = 0.04) were independent predictors of long-term recurrence. CONCLUSION Radiofrequency catheter ablation of CTI-AFL after surgical correction of AHD and CHD is associated with high acute success rates. The severity of the structural alterations of the underlying heart disease and consequently the type of surgical correction correlates with higher risk for recurrence.

An Automatic Algorithm Based on Morphological Stability During Fast Ventricular Arrhythmias Predicts Successful Antitachycardia Pacing in ICD Patients: A Multicenter Study.

Different types of ventricular arrhythmias (monomorphic ventricular tachycardia [VT], polymorphic VT, or ventricular fibrillation) can be detected by implantable cardiac defibrillators (ICDs) in fast VT zone. The efficacy of antitachycardia pacing (ATP) depends on the type of the treated arrhythmia. We hypothesized that an automatic algorithm based on morphological affinity of ICD far‐field electrograms during tachycardia can predict ATP success and the need of shock.

Narrow QRS Tachycardia in a Patient with Spongiform Cardiopathy and Preexcitation: What is the Mechanism?

A 19-year-old man diagnosed with spongiform cardiomyopathy and ventricular preexcitacion was referred to our hospital for electrophysiological (EP) testing after a syncopal episode. Baseline electrocardiogram (ECG) showed ventricular preexcitation consistent with the presence of a superior paraseptal, anteroseptal, accessory pathway (AP). After triple femoral vein puncture, a decapolar catheter was placed in the coronary sinus, a tetrapolar catheter in the His bundle region (with no clear His deflection recorded through the EP study), and a 4-mm-tip irrigated ablation catheter initially at the RV apex. Programmed atrial extrastimuli from the coronary sinus reproducibly induced nonsustained and sustained episodes of an irregular narrow QRS tachycardia with apparent atrioventricular dissociation in the surface ECG (Fig. 1). Intracardiac recording during ongoing tachycardia are also shown (Figs. 2 and 3). What is the involved mechanism?

Multiple accessory pathways in a patient with congenitally corrected transposition of the great arteries and severe malformation of the coronary sinus.

A 29-year-old patient diagnosed with (S,L,L) congenitally corrected transposition of great arteries (CCTGA) and pre-excitation is presented. We performed a coronary angiogram and it documented …

Atypical Response to Diagnostic Maneuvers in a Narrow QRS Tachycardia: What is the Mechanism?

A 69-year-old woman without known cardiopathy was referred to our unit for an electrophysiological (EP) study, due to a history of paroxysmal episodes of palpitations with sudden onset and termination. She was being treated with verapamil and flecainide, with mild clinical improvement. For the EP study, a decapolar catheter was placed in the coronary sinus (CS), a tetrapolar catheter at the right ventricular apex (RVA), and a 4-mm-tip ablation catheter at the bundle of His. Baseline electrocardiogram showed sinus rhythm, but programmed ventricular stimulation with extrastimuli performed to study retrograde conduction, triggered a narrow QRS tachycardia (Fig. 1A). This tachycardia was also easily triggered with overdrive atrial pacing using different S1-S1 intervals (Fig. 1B). Response of the tachycardia to single atrial extrastimuli with different coupling intervals is shown in Figure 2. To perform these maneuvers, the RVA tetrapolar catheter was placed in the His bundle region, in order to improve His signal visualization. No isoproterenol infusion was used during the procedure. What is the mechanism of the tachycardia?

An unusual device-related complication: multiple painful stones after explantation of a subcutaneous Holter system

The patient was a 67-year-old woman. She had a St Jude mechanical mitral prosthesis in 2000. The patient presented recurrent syncope and worsening of heart failure functional class to II–III NYHA and, had …