Washington Maciel

Atrial-oesophageal fistula following percutaneous radiofrequency catheter ablation of atrial fibrillation: the risk still persists

Aims Atrial‐oesophageal fistula is a serious complication related to ablation of atrial fibrillation. As its occurrence is rare, there is a great lack of information about their mechanisms, incidence, presentations, and treatment. The objective of this manuscript is to present a series of cases of atrial‐oesophageal fistula in Brazil, focusing on incidence, clinical presentation, and follow‐up. Methods and results This is a retrospective multicentre registry of atrial‐oesophageal fistula cases that occurred in eight Brazilian centres from 2003 to 2015. Ten cases (0.113%) of atrial‐oesophageal fistula were reported in 8863 ablation procedures in the period. Most of the subjects were male (70%) with age 59.6 ± 9.3 years. Eight centres were reference units in atrial fibrillation ablation with an experience over than 200 procedures at the time of fistula occurrence. Oesophageal temperature monitoring was performed in eight cases using coated sensors in six. The first atrial‐oesophageal fistula clinical manifestation was typically fever (in six patients), with a median onset time of 16.5 (12‐43) days after ablation. There was a delay of 7.8 ± 3.3 days between the first manifestation and the diagnosis in five patients. The treatment was surgical in six cases, clinical in three and stenting in one. Seven patients died (70%) and two developed permanent neurological sequelae. Conclusion Atrial‐oesophageal fistula remains a serious complication following AF ablation despite the incorporation of protective measures and increased technical experience of the groups. The high morbidity and mortality despite the treatment indicates the need to develop adequate preventive strategies.

Acompanhamento clínico de pacientes portadores de cardioversor-desfibrilador implantável

OBJECTIVE: To report appropriate (AT) and inappropriate (IT) ICD therapies in patients with ischemic and nonischemic heart disease, as well as early and late procedure-related complications. METHODS: One hundred and fifty-five patients (119 male and 36 female), mean age 47 years (21-88), who underwent ICD implantation between 1994 and March 2003 were analyzed. Patients were divided into the following groups: Group I--Post-AMI patients (n = 80); Group II--Patients with nonischemic heart disease and LV ejection fraction < 40% (n = 45), Chagas disease (n = 18), idiopathic dilated cardiomyopathy (n= 12), hypertensive disease (n = 8), hypertrophic cardiomyopathy (n = 4) and valvular heart disease (n = 3); Group III--Patients with arrhythmogenic right ventricular dysplasia (n = 13); and Group IV--Patients with channelopathies: Brugada Syndrome (n = 8) and idiopathic ventricular arrhythmias (n = 9). All patients underwent electrophysiological study (EPS) with induction of sustained ventricular arrhythmia ICD implantation. RESULTS: During the 26-month mean follow up, a high rate of appropriate ICD therapies (antitachycardia pacing and/or shock) was observed (46%) in the four groups, with no statistically significant difference. The four groups did not differ in either overall (8.4%) or arrhythmic mortality (1.3%). There was no correlation between appropriate ICD therapies and initial clinical presentation or inducible ventricular arrhythmia at EPS, and a 4% incidence of early and late procedure-related complications was found. CONCLUSION: The high incidence of appropriate ICD therapy and low rate of sudden death in the patients studied suggest that ICD is a valuable strategy in the management of ischemic and nonischemic patients previously selected by means of EPS.

Intra-His bundle block: clinical, electrocardiographic, and electrophysiologic characteristics

OBJECTIVE To assess the clinical, electrocardiographic, and electrophysiologic characteristics of patients (pt) with intra-His bundle block undergoing an electrophysiologic study (EPS). METHODS We analyzed the characteristics of 16 pt with second-degree atrioventricular block and symptoms of syncope or dyspnea, or both, undergoing conventional EPS. RESULTS Intra-His bundle block was documented in 16 pt during an EPS. In 15 (94%) pt, the atrioventricular block was recorded in sinus rhythm; 4 (25%) pt had intra-His Wenckebach phenomenon, which correlated with Mobitz I (MI) atrioventricular block on the electrocardiogram. Seven (44%) pt had 2:1 atrioventricular block, 2 of whom were asymptomatic (12.5%). One (6%) pt had intra- and infra-His bundle block. Clinically, 11 (68%) pt had syncope or presyncope, 3 (18%) had dyspnea on exertion, and 2 (12.5%) were asymptomatic. Eight (50%) pt had bundle-branch block as follows: 4 (25%) pt had left bundle-branch block, and 4 (25%) had right bundle-branch block. Left anterosuperior divisional block was observed in 3 pt (19%), 2 of whom with associated right bundle-branch block. CONCLUSION Intra-His bundle block was observed in 11% of the pt with second-degree atrioventricular block, syncope or presyncope, or both, it being the most frequent clinical presentation. Intra-His bundle block was more common in the elderly (> 60 years) and among females. The most frequent electrocardiographic presentations were second-degree Mobitz I or type 2:1 atrioventricular block.