Victor Bazan

Nuevos predictores de evolución a bloqueo auriculoventricular en pacientes con bloqueo bifascicular

Introduccion y objetivos Los pacientes con bloqueo bifascicular (BBF) pueden evolucionar a bloqueo auriculoventricular (BAV) avanzado, especialmente en presencia de sincope o intervalo HV prolongado. Otras variables podrian ayudar a definir que pacientes se beneficiaran de un marcapasos (MP) profilactico. Metodos Desde 1998 hasta 2006, hemos estudiado prospectivamente a 263 pacientes consecutivos con BBF en un solo centro. Se analizaron variables clinicas, electrocardiograficas y electrofisiologicas predictoras de evolucion a BAV significativo (segundo y tercer grado). Se implantaron dispositivos de estimulacion siguiendo las guias de la Sociedad Europea de Cardiologia. Los MP fueron programados en modo VVI con frecuencia minima de 40 lat/min. Se definio necesidad de MP la presencia de BAV significativo o de estimulacion ventricular > 10%. Resultados Se incluyo a 249 pacientes (media de edad, 73,4 ± 9,3 anos; 82 mujeres). Tras una mediana de seguimiento de 4,5 (2,16-6,41) anos, se observo necesidad de MP en 102 pacientes, 45 por estimulacion > 10% y 57 por BAV significativo. Las variables que predijeron la necesidad de MP fueron presencia de sincope o presincope (hazard ratio [HR] = 2,06; intervalo de confianza [IC] del 95%, 1,03-4,12), anchura QRS > 140 ms (HR = 2,44; IC del 95%, 1,59-3,76), la insuficiencia renal (HR = 1,86; IC del 95%, 1,22-2,83) y un intervalo HV > 64 ms (HR = 6,6; IC del 95%, 4,04-10,80). La asociacion de los cuatro factores mostro una probabilidad de necesitar el MP del 95% al ano de seguimiento. Conclusiones La clinica sincopal/presincopal, el QRS > 140 ms, la insuficiencia renal y el intervalo HV > 64 ms son predictores independientes de evolucion a BAV en pacientes con BBF.

Long-term mortality predictors in patients with chronic bifascicular block.

AIMSnTo evaluate the long-term mortality rate and to determine independent mortality risk factors in patients with bifascicular block (BFB). Patients with BFB are known to have a higher mortality risk than the general population, not only related to progression to atrio-ventricular block but also due to the presence of malignant ventricular arrhythmias. Previous observational and epidemiological studies including a high proportion of patients with structural heart disease have shown an important cardiac mortality rate and may not reflect the real outcome of patients with BFB.nnnMETHODS AND RESULTSnFrom March 1998 until December 2006, we prospectively studied 259 consecutive BFB patients, 213 (82%) of whom presenting with syncope/pre-syncope, undergoing electrophysiological study. After a median follow-up of 4.5 years (P25:2.16-P75:6.41), 53 patients (20.1%) died, 19 (7%) of whom due to cardiac aetiology. Independent total mortality predictors were age [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.01-1.09], NYHA class>or=II (HR 2.17, 95% CI 1.05-4.5), atrial fibrillation (HR 2.96, 95% CI 1.1-7.92), and renal dysfunction (HR 4.26, 95% CI 2.04-9.01). An NYHA class of >or=II (HR 5.45, 95% CI 2.01-14.82) and renal failure (HR 3.82, 95% CI 1.21-12.06) were independent predictors of cardiac mortality. No independent predictors of arrhythmic death were found.nnnCONCLUSIONnTotal mortality, especially of cardiac cause, is lower than previously described in BFB patients. Advanced NYHA class and renal failure are predictors of cardiac mortality.

Entrainment from the para-Hisian region for differentiating atrioventricular node reentrant tachycardia from orthodromic atrioventricular reentrant tachycardia

AIMSnThe difference between the stimulus-atrial and ventriculo-atrial intervals (SA-VA) and between the post-pacing interval and the tachycardia cycle length (PPI-TCL) during entrainment from the right ventricular apex distinguishes atrioventricular node reentrant (AVNRT) from orthodromic atrioventricular reentrant tachycardia (AVRT). We hypothesized that these features still apply when entrainment is performed from the para-Hisian region.nnnMETHODS AND RESULTSnForty-seven supraventricular tachycardias (34 AVNRT/13 AVRT) were included. The SA-VA and PPI-TCL were obtained in all patients by using two right-sided diagnostic catheters. In 24 of them, these measurements were also performed upon His-bundle capture during entrainment. A paced QRS widening of >or=40 ms during entrainment, when compared with the tachycardia QRS width, identified absence of His-bundle capture, P < 0.001. A SA-VA >75 ms distinguished AVNRT from AVRT, P < 0.001 (sensitivity/specificity 97%/100%). A PPI-TCL >100 ms was diagnostic of AVNRT, P < 0.001 (sensitivity/specificity 97%/92%). Upon His-bundle capture, the SA-VA and PPI-TCL shortened in AVNRT (121 +/- 23 to 66 +/- 24 ms; 139 +/- 30 to 85 +/- 31 ms, respectively, P < 0.001) and no longer differentiated AVNRT from AVRT.nnnCONCLUSIONnPara-Hisian entrainment without His-bundle capture distinguishes AVNRT from AVRT with the advantage of using only two diagnostic catheters.

Taquicardia auricular de vena pulmonar: características clínicas, electrocardiográficas y electrofisiológicas diferenciales

Introduccion y objetivos Las venas pulmonares (VP) son un origen frecuente de taquicardias auriculares (TA) ocasionalmente dificil de reconocer en el ECG. Analizamos las caracteristicas diferenciales clinicas y electrofisiologicas, incluidas la duracion y la presencia de melladura en la onda P sinusal, asociadas a las TA-VP. Metodos Ochenta y siete pacientes sometidos a ablacion de TA fueron incluidos y agrupados: TA-VP (grupo 1, nxa0=xa025), TA-VP asociada a fibrilacion auricular (grupo 2, nxa0=xa018), otras TA izquierdas (grupo 3, nxa0=xa07) y TA derechas (grupo 4, nxa0=xa037). Resultados El grupo 1 presento edad media mas joven (44xa0±xa014 anos) que los grupos 2 a 4 (57xa0±xa09, 58xa0±xa012 y 53xa0±xa016 anos, respectivamente; p Conclusiones Una P sinusal prolongada y mellada en pacientes jovenes con TA rapidas y sin cardiopatia predice un origen en VP.

Novel Predictors of Progression of Atrioventricular Block in Patients With Chronic Bifascicular Block

INTRODUCTION AND OBJECTIVESnPatients with chronic bifascicular block (BFB) can progress to advanced atrioventricular block (AVB), especially when syncope or a prolonged HV interval is present. It is possible that other variables could help identify patients who would benefit from prophylactic pacemaker implantation.nnnMETHODSnThe study involved 263 consecutive BFB patients seen at a single center between 1998 and 2006. Clinical, electrocardiographic and electrophysiologic variables were analyzed to identify predictors of progression to significant AVB (i.e. second or third grade). Cardiac pacemakers were implanted in accordance with European Society of Cardiology guidelines. Pacemakers were programmed in the VVI mode with a minimum frequency of 40 beats/min. A pacemaker was required if there was significant AVB or a ventricular pacing percentage >10%.nnnRESULTSnIn total, the study included 249 patients (mean age, 73.4+/-9.3 years, 82 female). After a median follow-up period of 4.5 years (2.16-6.41 years), a pacemaker was required by 102 patients: 45 had a ventricular pacing percentage >10% and 57 had significant AVB. Factors predictive of the need for a pacemaker were: the presence of syncope or presyncope (hazard ratio [HR]=2.06; 95% confidence interval [CI], 1.03-4.12), QRS width >140 ms (HR=2.44; 95% CI, 1.59-3.76), renal failure (HR=1.86; 95% CI, 1.22-2.83), and an HV interval >64 ms (HR=6.6; 95% CI, 4.04-10.80). The presence of all four risk factors was associated with a 95% probability of needing a pacemaker within 1 year of follow-up.nnnCONCLUSIONSnThe presence of syncope or presyncope, a QRS width >140 ms, renal failure, and an HV interval >64 ms were independent predictors of progression to AVB in patients with BFB.

Secondary prevention strategies after an acute ST-segment elevation myocardial infarction in the AMI code era: beyond myocardial mechanical reperfusion

BackgroundThe AMI code is a regional network enhancing a rapid and widespread access to reperfusion therapy (giving priority to primary angioplasty) in patients with acute ST-segment elevation myocardial infarction (STEMI). We aimed to assess the long-term control of conventional cardiovascular risk factors after a STEMI among patients included in the AMI code registry.Design and methodsFour hundred and fifty-four patients were prospectively included between June-2009 and April-2013. Clinical characteristics were collected at baseline. The long-term control of cardiovascular risk factors and cardiovascular morbidity/mortality was assessed among the 6-months survivors.ResultsA total of 423 patients overcame the first 6xa0months after the STEMI episode, of whom 370 (87%) underwent reperfusion therapy (363, 98% of them, with primary angioplasty). At 1-year follow-up, only 263 (62%) had adequate blood pressure control, 123 (29%) had LDL-cholesterol within targeted levels, 126/210 (60%) smokers had withdrawn from their habit and 40/112 (36%) diabetic patients had adequate glycosylated hemoglobin levels. During a median follow-up of 20 (11–30) months, cumulative mortality of 6xa0month-survivors was 6.1%, with 9.9% of hospital cardiovascular readmissions. The lack of assessment of LDL and HDL-cholesterol were significantly associated with higher mortality and cardiovascular readmission rates.ConclusionsWhereas implementation of the AMI code resulted in a widespread access to rapid reperfusion therapy, its long-term therapeutic benefit may be partially counterbalanced by a manifestly suboptimal control of cardiovascular risk factors. Further efforts should be devoted to secondary prevention strategies after STEMI.

Diagnostic and Prognostic Value of Electrophysiologic Study in Patients With Nondocumented Palpitations

The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitations. However, in the setting of nondocumented palpitations the value of the electrophysiologic study (EPS) needs additional investigation. We investigated the utility of the EPS in patients with nondocumented palpitations. A total of 172 patients with normal electrocardiographic findings and nondocumented palpitations underwent an EPS. The clinical and electrophysiologic characteristics were assessed. The symptoms were long-lasting (>5 minutes) in 56%. Sudden onset was present in 99%, and termination was rapid in 65%. Neck palpitations were reported in 36%. The EPS findings were normal in 86 patients (50%); atrioventricular nodal reentrant tachycardia was induced in 43, orthodromic reentrant tachycardia in 9, and nonsustained atrial tachycardia/fibrillation (AT/AF) in 34. Long-lasting episodes, sudden termination, and neck palpitations predicted positive EPS findings and were associated with reentrant supraventricular tachycardia (p<0.001). The induction of AT/AF was associated with age >50 years and structural heart disease (p<0.001). After 53 ± 36 months of follow-up, 92% of patients with negative EPS findings were symptom free. Only 32% of patients with induced AT/AF remained free of symptoms (p<0.001). The recurrence of palpitations was more prevalent among patients with structural heart disease and aged >50 years (p<0.001). In conclusion, 50% of patients with nondocumented palpitations had positive EPS findings. A long duration, sudden termination, and neck palpitations, together with structural heart disease and age >50 years, predicted tachycardia inducibility and recurrence and could help in selecting patients suitable for EPS and ablation.

Insuficiencia cardiaca en un paciente con Wolff-Parkinson-White

angioplastia no era técnicamente factible, tras un intenso debate del equipo tratante y debido a los deseos de la paciente, se realizó la reducción quirúrgica de la masa tumoral como última opción terapéutica para paliar los sı́ntomas progresivos. Falleció 3 dı́as después tras múltiples complicaciones postoperatorias. Los angiosarcomas primarios de la arteria pulmonar son excepcionales, y sólo se han descrito unos pocos casos. La similitud de los sı́ntomas iniciales con el TEP agudo o crónico, y la incapacidad de las técnicas de imágenes para realizar un diagnóstico de certeza (aunque pueden ser útiles en el diagnóstico diferencial) causan demoras en el diagnóstico definitivo. Este sólo se consigue mediante la toma de muestra de tejido, o durante la autopsia (el 60% de los casos). La biopsia endomiocárdica percutánea es un procedimiento seguro, fácilmente realizable y con escasa morbimortalidad. Para aumentar el rédito diagnóstico,

Endocarditis trombótica no bacteriana sobre válvula aórtica en mujer joven

Full English text available at: www.revespcardiol.org A 40-year-old woman without heart disease suffered two embolic episodes in both legs due to a thrombus of the aortic valve. Transesophageal echocardiography performed after the first episode was considered normal, but a second study performed after the second embolism demonstrated a thrombus in the non-coronary leaflet that failed to resolve with the intravenous administration of heparin for two weeks. Surgical excision of the mass revealed a thrombus on an otherwise healthy aortic valve. The case is interesting because it is an exceptional cause of systemic embolism and the patient did not present a prothrombotic status in coagulation studies. The 3 years of follow-up was uneventful.

Impacto a largo plazo del tratamiento con presión positiva continua en la vía aérea superior sobre la incidencia de arritmias y la variabilidad de frecuencia cardiaca en pacientes con apnea del sueño

INTRODUCTIONnAutonomic dysfunction can alter heart rate variability and increase the incidence of arrhythmia. We analyzed the impact of continuous positive airway pressure (CPAP) on this pathophysiological phenomenon in patients with severe sleep apnea-hypopnea syndrome.nnnMETHODSnConsecutive patients with recently diagnosed severe sleep apnea-hypopnea syndrome were prospectively considered for inclusion. Incidence of arrhythmia and heart rate variability (recorded on a 24-hour Holter monitoring device) were analyzed before starting CPAP therapy and 1 year thereafter.nnnRESULTSnA total of 26 patients were included in the study. CPAP was administered for 6.6 ± 1.8 hours during Holter monitoring. After starting CPAP, we observed a marginally significant reduction in mean HR (80 ± 9 to 77 ± 11 bpm, p=.05). CPAP was associated with partial modulation (only during waking hours) of r-MSSD (p=.047) and HF (p=.025) parasympathetic parameters and LF (p=.049) sympathetic modulation parameters. None of these parameters returned completely to normal levels (p<.001). The number of unsustained episodes of atrial tachycardia diminished (p=.024), but no clear effect on other arrhythmias was observed.nnnCONCLUSIONSnCPAP therapy only partially improves heart rate variability, and exclusively during waking hours, and reduces incidence of atrial tachycardia, both of which can influence cardiovascular morbidity and mortality in sleep apnea-hypopnea syndrome patients.