RESUMEN
BACKGROUND: Patients commonly present for atrial fibrillation (AF) ablation while taking antiarrhythmic (AA) medications. It is unknown if AA use at the time of ablation affects procedural outcome. This study compares the AF ablation outcomes of patients who underwent ablation while on AA medications to those who were not on AA medications. METHODS AND RESULTS: A total of 180 consecutive patients who underwent their first catheter ablation of AF were identified from the Johns Hopkins Hospital AF registry and divided into 2 cohorts: those On AA at the time of ablation (127 patients, mean follow-up 24.6 months) and those Off AA at the time of ablation (53 patients, mean follow-up 20.3 months). Follow-up was performed to identify recurrent AF. There was no statistically significant difference in the percentage of patients without a recurrence of symptomatic AF (single procedure success rate) in the On and Off AA groups at 6 months postablation (53.5% vs 50.1%, P = 0.75), or by the end of follow-up (37.8% vs 41.5%, P = 0.64). For those patients who had symptomatic AF recurrence, the average time to recurrence was 6.2 ± 9.0 months in the On AA group and 4.2 ± 7.2 months in the Off AA group (P = 0.27). CONCLUSIONS: There was no statistically significant difference in the rate of symptomatic AF recurrence between the On AA and Off AA groups in this study. The use of AA medications at the time of ablation does not appear to affect procedural outcomes in this population.
Asunto(s)
Antiarrítmicos/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Distribución de Chi-Cuadrado , Terapia Combinada , Técnicas Electrofisiológicas Cardíacas , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Estadísticas no Paramétricas , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: The reported complication rate of catheter ablation of atrial fibrillation (AF) varies. OBJECTIVE: Our goal was to assess temporal trends and the effect of both institutional and individual operators' experience on the incidence of complications. METHODS: All patients undergoing AF ablation at Johns Hopkins Hospital between February 2001 and December 2010 were prospectively enrolled in a database. Major complications were defined as those that were life-threatening, resulted in permanent harm, required intervention, or significantly prolonged hospitalization. RESULTS: Fifty-six major complications occurred in 1190 procedures (4.7%). The majority of complications were vascular (18; 1.5%), followed by pericardial tamponade (13; 1.1%) and cerebrovascular accident (12; 1.1%). No cases of death or atrioesophageal fistula occurred. The overall complication rate decreased from 11.1% in 2002 to 1.6% in 2010 (P <.05). On univariate analysis, demographic and clinical factors associated with the increased risk of complications were CHADS(2) score of ≥2 (hazard ratio [HR] = 2.5; 95% confidence interval [CI] = 1.4-4.4; P = .002), female gender (HR = 2.0; 95% CI = 1.2-3.5; P = .014), and age (HR = 1.03; 95% CI = 1.0-1.1; P = .042). Gender and CHADS(2) score of ≥2 remained independent predictors of complication on multivariable analysis. CONCLUSION: The complication rate of catheter ablation of AF decreased with increased institutional experience. Female gender and CHADS(2) score of ≥2 are significant independent risk factors for complications and should be considered when referring patients for AF ablation.
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Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Baltimore/epidemiología , Taponamiento Cardíaco/epidemiología , Taponamiento Cardíaco/etiología , Competencia Clínica , Femenino , Humanos , Enfermedad Iatrogénica , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiologíaRESUMEN
PURPOSE: Esophageal injury is a potential complication with radiofrequency ablation in the posterior wall of the left atrium (LA). The "box isolation" method isolates the posterior LA wall including the pulmonary veins without ablation on the posterior LA wall. This study compares the acute and long-term efficacy of the box isolation method with conventional circumferential pulmonary vein isolation (PVI) for catheter ablation of AF. METHODS: Twenty-nine patients (age 60 ± 9 years, 62% male, 79% paroxysmal) with drug refractory AF underwent catheter ablation. Sixteen of the 29 patients (55%) underwent box isolation. Recurrence of AF was detected by checking the daily recorded rhythm strip on a portable home ECG monitor, irrespective of the symptoms. Mean follow-up duration was 10 ± 2 months. RESULTS: Complete isolation of the posterior LA using box isolation lesions was achieved in three of 16 (19%) patients. The other 13 patients underwent creation of additional lesions until all PVs were isolated. Of the 16 patients who underwent box isolation, four patients (25%) had complete success, six patients (38%) had improvement, and the remaining six patients (37%) had failure. Of the 13 patients who underwent the standard PV isolation, two patients (15%) had complete success, eight patients (62%) had improvement, and the remaining three patients (23%) had failure (p = 0.44). CONCLUSION: In this pilot study, the efficacy of box isolation is similar to the circumferential PVI for catheter ablation of AF. Few patients achieved PVI with box method alone. Based on these results, we do not recommend the box isolation strategy.
Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Atrios Cardíacos/cirugía , Interpretación de Imagen Asistida por Computador , Venas Pulmonares/cirugía , Centros Médicos Académicos , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Baltimore , Ablación por Catéter/efectos adversos , Distribución de Chi-Cuadrado , Electrocardiografía/métodos , Electroencefalografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Estudios Prospectivos , Calidad de Vida , Medición de Riesgo , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Catheter ablation is a widely accepted treatment for drug refractory atrial fibrillation (AF). The purpose of our study was to examine secular trends in the demographic profile of patients undergoing AF ablation. METHODS AND RESULTS: Data for 792 patients who underwent catheter ablation for AF at Johns Hopkins Hospital between years 2001 and 2009 were systematically reviewed. There has been a steady increase in total number of procedures and repeat procedures. The majority of patients undergoing AF ablation at our institution are men (76.6%). Females accounted for 36.0% of patients in 2001 versus 19.6% in 2009. A total of 93.3% of patients undergoing AF ablation were Caucasian. The mean age of patients has increased over time (52 years in 2001 to 60 years in 2009, P = 0.015) and the number of antiarrhythmic drugs (AADs) used prior to first ablation has decreased (2.3 to 1.2, P = 0.009). In addition, the mean duration of AF prior to first referral has decreased (7.8 years in 2001 vs 4.2 years in 2009). CONCLUSION: There is a significant gender and racial disparity in patients undergoing AF ablation favoring Caucasian men that warrants further investigation. We also observed a significant increase in age of patients, decrease in number of AADs, and increase in number of repeat procedures. These results are important when interpreting outcomes of AF ablation and designing future trials.
Asunto(s)
Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Ablación por Catéter/tendencias , Hospitalización/tendencias , Adulto , Anciano , Fibrilación Atrial/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Incidence of sudden cardiac death (SCD) in end-stage renal disease (ESRD) remains high. Limited data is available about whether implantable cardioverter-defibrillators (ICDs) can prevent arrhythmic death in patients with chronic kidney disease (CKD). The purpose of this retrospective study was to determine the impact of CKD on all-cause and sudden cardiac death in ICD recipients. We evaluated 441 consecutive patients who underwent ICD implantation at our center between 1994 and 2002. We found that mortality rate was higher in patients with eGFR <60 mL/min and those with ESRD on hemodialysis (43%, n = 69/162 and 54%, n = 12/22, resp.) than in patients with eGFR >/=60 mL/min (23%, n = 58/257; P < .0005). The SCD rate was also higher in the patients with ESRD (50%) than in CKD patients not on dialysis (10.2%; P < .0005). Mortality rate for single-chamber ICDs was 56.8% in comparison with dual-chamber ICDs (38.1%) and for biventricular ICDs (5.0%) (P < .0005).
RESUMEN
AIMS: To assess the utility of transoesophageal echocardiography (TEE) parameters such as spontaneous echo contrast (SEC), left atrial (LA) appendage velocities, and aortic plaque in predicting periprocedural cerebrovascular accidents (CVAs) in patients undergoing catheter ablation of atrial fibrillation (AF). METHODS AND RESULTS: Five hundred and seventy-nine consecutive patients underwent catheter ablation of AF with pre-procedural TEE, 94% of whom also received pre-procedural warfarin and enoxaparin bridging. Of the 579 patients, 10 patients (cases) who developed periprocedural CVA (1.7%) and 40 randomly selected patients who did not develop CVA (controls) were included (50 study patients, age 58 ± 11 years, 82% male, 54% persistent AF). Periprocedural CVA was defined as a new neurological deficit that occurred anytime between the start of the procedure and 30 days after AF ablation. Demographic, clinical, and TEE variables of cases and controls were compared using standard statistical analyses. Patients with CVA more often had coronary artery disease [odds ratio (OR) 6.0, P = 0.03], previous history of CVA (OR 8.2, P = 0.02), and CHADS(2) score ≥ 2 (OR 5.4, P = 0.03) than patients without CVA. There was no difference in any of the TEE parameters (SEC, LA appendage velocity and area, patent foramen ovale, atrial septal aneurysm, valve abnormality, and aortic plaque). When these TEE parameters were adjusted for coronary artery disease, prior CVA and CHADS(2) ≥ 2, none emerged as an independent predictor of CVA. CONCLUSION: Transoesophageal echocardiographic variables (other than LA thrombus) were not associated with the occurrence of periprocedural CVA in our patients undergoing catheter ablation of AF who generally received pre-procedural anticoagulation. Despite serving as markers of a thrombogenic milieu, the presence of SEC, low LA appendage velocities, and aortic plaque may not increase the risk of periprocedural CVA after AF ablation.
Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Ecocardiografía Transesofágica , Complicaciones Posoperatorias/diagnóstico por imagen , Accidente Cerebrovascular/diagnóstico por imagen , Anciano , Anticoagulantes/uso terapéutico , Estudios de Casos y Controles , Enoxaparina/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Resultado del Tratamiento , Warfarina/uso terapéuticoRESUMEN
INTRODUCTION: Early recurrence of atrial tachyarrhythmias is commonly noted after catheter ablation of atrial fibrillation (AF). The long-term outcomes of patients who require cardioversion for persistent AF after AF ablation is not known. This study reports the outcomes of patients who underwent cardioversion for persistent AF or atrial flutter following an AF ablation procedure. METHODS: The patient population comprised 55 patients (mean age 58 +/- 10 years, 35% paroxysmal) who underwent catheter ablation of AF and subsequently required electrical cardioversion for persistent AF (45 patients) or atrial flutter (10 patients). Cardioversion was defined as early (within 90 days of the ablation procedure) or late (between 90 and 180 days following ablation). RESULTS: The mean follow-up duration was 15 +/- 8 months. Forty-six of the 55 patients (84%) patients experienced recurrence during follow-up. The average time to recurrence after cardioversion was 37 days. Of the 55 patients, 8 (15%) patients had a complete success, 11 (20%) patients had a partial success and 36 patients (65%) had a failed outcome. Seven of the 43 patients (16%) who underwent early cardioversion had a complete success as opposed to one of 12 patients (8%) who underwent late cardioversion (P = 0.49). CONCLUSIONS: This study shows that >80% of patients who undergo cardioversion for persistent AF or atrial flutter after AF ablation have recurrence. The timing of cardioversion did not affect the outcome. These findings allow clinicians to provide realistic expectations to patients regarding the long-term outcome and/or requirement for a second ablation procedure.
Asunto(s)
Fibrilación Atrial/epidemiología , Fibrilación Atrial/prevención & control , Ablación por Catéter/estadística & datos numéricos , Cardioversión Eléctrica/estadística & datos numéricos , Femenino , Humanos , Incidencia , Estudios Longitudinales , Masculino , Maryland/epidemiología , Persona de Mediana Edad , Prevención Secundaria , Resultado del TratamientoRESUMEN
BACKGROUND: Obesity and obstructive sleep apnea (OSA) have a strong association with atrial fibrillation (AF). The purpose of this study was to prospectively determine the effects of obesity, assessed by the body mass index (BMI) and OSA on the efficacy of catheter ablation of AF. METHODS: The patient population consisted of 109 patients (mean age: 60 +/- 10 years, 79% male, 67% paroxysmal, mean BMI 28 +/- 5 kg/m(2)) who underwent catheter ablation of AF. Based on BMI, patients were classified as normal (<25 kg/m(2)), overweight (>or=25 and <30 kg/m(2)), or obese (>or=30 kg/m(2)). OSA was assessed by the Berlin questionnaire. Clinical success was defined as at least 90% reduction in AF burden after 3-month blanking period. Mean duration of follow-up was 11 +/- 4 months. RESULTS: Of the 75 patients with clinical success, 25 (33%) had normal BMI, 29 (39%) were overweight, and 21 (28%) were obese. Among the 34 patients with failed outcome, 5 (15%) had normal BMI, 14 (41%) were overweight, and 15 (44%) were obese (P = 0.04). Twenty-eight of the 48 patients with OSA (58%) had clinical success as opposed to 47 of the 61 patients (77%) without OSA (P = 0.036). On multivariate analysis, only BMI emerged as an independent predictor of procedural failure ((OR 1.11, CI: 1.00-1.21, P = 0.03). CONCLUSIONS: The results of this prospective study show that obesity, a modifiable risk factor, is an independent predictor of procedural failure after catheter ablation of AF. Whether treating obesity may improve the results of catheter ablation of AF warrants further investigation.
Asunto(s)
Fibrilación Atrial/complicaciones , Fibrilación Atrial/cirugía , Ablación por Catéter , Obesidad/complicaciones , Apnea Obstructiva del Sueño/complicaciones , Anciano , Índice de Masa Corporal , Ablación por Catéter/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
BACKGROUND: Cerebrovascular accident (CVA) is a serious complication of catheter ablation of atrial fibrillation (AF). The incidence and clinical predictors of periprocedural CVA in patients undergoing AF ablation are not fully understood. METHODS: This study included 721 cases (age 57 +/- 11 years; 23% female; 345 persistent AF) in 579 consecutive patients referred for AF ablation. Periprocedural CVA was defined as onset of a new neurologic deficit that occurred anytime between the start of the procedure and 30 days after the AF ablation, and was confirmed by a neurologist. Cranial imaging with CT and/or MRI was performed in each case. Patients were anticoagulated with warfarin for at least 4 weeks pre- and immediately postprocedure and were bridged with enoxaparin. Transesophageal echocardiography was performed within 24 hours prior to ablation in all cases. RESULTS: Periprocedural CVA occurred in 10 of 721 cases (1.4%). The risk of periprocedural CVA did not vary significantly during the course of the study. Among these 10 patients (age 62 +/- 11 years; 1 female; 5 persistent AF), 6 manifested neurological deficits within 24 hours, 3 after 24-48 hours, and 1 patient had a CVA 6 days following AF ablation despite a therapeutic INR level. All CVAs were ischemic. Five patients had residual deficits after 30 days. Four of 43 patients (9.3%) with a prior history of CVA had periprocedural CVA. Periprocedural CVA occurred in 0.3%, 1.0%, and 4.7% of patients with CHADS(2) scores of 0, 1, and > or = 2 (P < 0.001). In 2 separate multivariate analyses, a CHADS(2) score > or = 2 (OR 7.1, P = 0.02) and history of CVA (OR 9.5, P < 0.01) remained independent predictors of periprocedural CVA. CONCLUSIONS: Despite periprocedural anticoagulation and transesophageal echocardiography, we found a 1.4% incidence of periprocedural CVA in AF ablation patients. A CHADS(2) score > or = 2 and a history of CVA are independent predictors of CVA after AF ablation. The CVA risk is low in patients with CHADS(2) score of 0.
Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Accidente Cerebrovascular/epidemiología , Adulto , Anciano , Comorbilidad , Femenino , Humanos , Incidencia , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Medición de Riesgo/métodos , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Transseptal catheterization (TSC) is performed during catheter ablation involving the lefthand side of the heart. TSC causes a transient iatrogenic atrial septal defect that can predispose patients to migraine episodes. However, isolated migraine aura episodes in patients undergoing TSC have not been described. METHODS: Five hundred seventy-one procedures involving TSC were performed over a 3-year duration. Of these, 3 patients presented with visual symptoms in the first month after the procedure. One patient underwent a TSC during catheter ablation of left-sided accessory pathway and 2 patients underwent TSC during catheter ablation of atrial fibrillation. RESULTS: The incidence of migraine aura in this patient population was 0.5%. In the first week after the procedure, all 3 patients experienced transient reversible visual symptoms of scintillating scotoma consistent with migraine aura. None of the patients had an associated headache. The workup for stroke or transient ischemic attack was negative. All the patients recovered completely within 1 hour of symptom onset and did not have any sequelae. CONCLUSION: This study reports for the first time the incidence and outcomes of isolated migraine aura in patients undergoing electrophysiology procedures involving TSC. For post-TSC patients who present with atypical neurologic symptoms, especially "scintillating scotoma," once transient ischemic attack or other neurologic event has been ruled out, an aura associated with the TSC should be entertained as a possible diagnosis. Electrophysiologists who perform TSC, need to be aware of this phenomenon and can reassure the patients of the transient and benign nature.
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Arritmias Cardíacas/epidemiología , Arritmias Cardíacas/cirugía , Ablación por Catéter/estadística & datos numéricos , Tabiques Cardíacos/cirugía , Migraña con Aura/epidemiología , Punciones/estadística & datos numéricos , Adulto , Comorbilidad , Femenino , Humanos , Incidencia , Masculino , Maryland/epidemiología , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo , Factores de RiesgoRESUMEN
INTRODUCTION: Preprocedural factors may be helpful in selecting patients with atrial fibrillation (AF) for treatment with catheter ablation and in making an assumption regarding their prognosis. The aims of this study were to investigate whether left atrial (LA) volume and pulmonary venous (PV) anatomy, evaluated by computed tomography (CT) prior to ablation, will predict AF recurrence following catheter ablation. METHODS AND RESULTS: We included 146 patients (mean age 57 +/- 11 years, 83% male) with symptomatic AF (55% paroxysmal, 18% persistent, 27% long-standing persistent). All patients underwent CT scanning prior to catheter ablation to evaluate LA volume and PV anatomy. Circumferential PV isolation was performed guided by Cartomerge electroanatomical mapping. The outcome was defined as complete success, improvement, or failure. After a mean follow-up of 19 +/-7 months, complete success was achieved in 59 patients (40%), and 38 patients (26%) demonstrated improvement. LA volume was found to be an independent predictor of AF recurrence with an adjusted OR of 1.14 for every 10-mL increase in volume (95% CI 1.00-1.29, P = 0.047). PV variations were equally distributed among the different outcomes of the ablation procedure, and therefore univariate analysis did not identify PV anatomy as a predictor of outcome. CONCLUSION: LA volume is an independent predictor of AF recurrence after catheter ablation. Additionally, PV anatomy did not have any effect on the outcome. These findings suggest that an assessment of LA volume may be incorporated into the preprocedural evaluation of patients being considered for AF ablation.
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Aortografía/métodos , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Flebografía/métodos , Venas Pulmonares/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Femenino , Atrios Cardíacos , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/métodos , Pronóstico , Reproducibilidad de los Resultados , Medición de Riesgo/métodos , Factores de Riesgo , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
AIMS: Obstructive sleep apnoea (OSA) is a risk factor for atrial fibrillation (AF) recurrence after catheter ablation. The purpose of this study is to determine whether OSA assessed by the simple tool, the Berlin Questionnaire (BQ), is useful in predicting the efficacy of catheter ablation of AF. METHODS AND RESULTS: The patient population consisted of 210 consecutive patients [mean age 58 +/- 10 years, 167 (80%) male, 119 (57%) paroxysmal] who underwent catheter ablation of AF and completed the BQ. Clinical success was defined as at least 90% reduction in AF burden after 3-month blanking period. Mean duration of follow-up was 25 +/- 12 months. One hundred and one of the 118 (85%) patients at low risk for OSA had clinical success as opposed to 64 of the 92 (70%) patients at high risk for OSA on BQ (P = 0.005). On multivariate analysis, only high-risk for OSA on BQ emerged as an independent predictor of procedural failure (OR 4.53, CI: 1.21-16.87, P = 0.02). CONCLUSION: High risk of OSA on BQ predicts procedural failure after catheter ablation of AF. We recommend the use of BQ for risk-stratifying patients for OSA prior to AF ablation procedures and to identify patients for formal sleep study assessment.
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Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Ablación por Catéter/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/métodos , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/epidemiología , Encuestas y Cuestionarios , Adulto , Fibrilación Atrial/diagnóstico , Comorbilidad , Femenino , Alemania/epidemiología , Humanos , Incidencia , Masculino , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Reproducibilidad de los Resultados , Medición de Riesgo/métodos , Factores de Riesgo , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
BACKGROUND: Aggressive anticoagulation with heparin to maintain an activated clotting time (ACT) >300 s is required during catheter ablation of atrial fibrillation (AF) to reduce the risk of systemic thromboembolism. The purpose of this study is to describe the incidence and outcome of protamine reactions and analyze the risk factors in patients undergoing catheter ablation of AF. METHODS: The patient population included 242 consecutive patients (193 men, age 57.6 +/- 10.8 years) with drug refractory AF who underwent catheter ablation and received protamine immediately following catheter ablation to reverse the effects of heparin. Fifty eight of these patients had prior exposure to protamine. RESULTS: Three of the 242 patients in our study developed an adverse reaction to protamine (1.2%). Although each of the three protamine reaction presented in a dramatic fashion with profound hypotension, all three patients responded to medical treatment and did not experience clinical sequelae. Age, gender, type of AF, number of ablations, prior exposure, diabetes mellitus, and ejection fraction did not predict the occurrence of these reactions. CONCLUSION: This study reports, for the first time, the incidence and outcomes of protamine reaction in patients undergoing catheter ablation of AF. The results of this study reveal that protamine reactions present in a dramatic fashion often with profound hypotension. Although the incidence of protamine reactions in this setting is low (1.2%), they do occur. Electrophysiologists who use protamine need to be aware of this reaction and the appropriate therapeutic interventions.
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Ablación por Catéter/estadística & datos numéricos , Hemorragia/epidemiología , Hemorragia/prevención & control , Antagonistas de Heparina , Hipotensión/epidemiología , Protaminas , Anciano , Comorbilidad , Femenino , Humanos , Hipotensión/diagnóstico , Incidencia , Masculino , Maryland/epidemiología , Persona de Mediana Edad , Medición de Riesgo , Resultado del TratamientoRESUMEN
INTRODUCTION: For patients undergoing catheter ablation of atrial fibrillation (AF), left atrial size is a predictor of recurrence of AF during follow-up. For this reason, major clinical trials have used a left atrial diameter (LAD) of more than 5.0 or 5.5 cm, assessed by echocardiography, as an exclusion criterion for patients deemed candidates for ablation of AF. However, whether LAD accurately reflects true left atrial size has not been systematically investigated. Therefore, the purpose of this study was to test the hypothesis that LAD, measured by echocardiography, accurately correlates to left atrial volume measured by computed tomography (CT). METHODS AND RESULTS: We included 50 patients (mean age 56 +/- 12 years, five female) with symptomatic AF (40% paroxysmal, 60% persistent), referred for catheter ablation. In each patient, transthoracic echocardiography was performed. Additionally, all patients underwent CT using a 64-slice CT scanner. Left atrial volume was calculated by manually tracing left atrial area on each CT cross-sectional image. Patients had a mean LAD measured by echocardiography of 4.5 +/- 0.7 cm, ranging from 2.9 to 5.7 cm. Left atrial volume measured by CT ranged from 67 mL to 270 mL with a mean value of 146 +/- 49 mL. A poor correlation was noted between LAD and left atrial volume, r = 0.49 (P < 0.001). CONCLUSION: LAD measured by echocardiography correlates poorly with left atrial volume measured by CT in patients with AF. As a result, selecting patients with AF for treatment with catheter ablation should not be based on an echocardiographic-derived LAD alone.
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Ecocardiografía , Corazón/anatomía & histología , Corazón/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano , Femenino , Atrios Cardíacos/diagnóstico por imagen , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Transesophageal echocardiography (TEE) is commonly used prior to catheter ablation of atrial fibrillation (AF) in order to exclude left atrial (LA) thrombus. However, the incidence and predictors of LA thrombus detected with TEE have not been systematically examined in this setting. METHODS: This study included 732 cases (mean age 57 +/- 11 years; 23% female; 353 persistent AF) in 585 consecutive patients referred for catheter ablation of AF. Patients were anticoagulated for at least 4 weeks prior to the procedure and then bridged with enoxaparin. TEE was performed in all cases within 24 hours prior to ablation. RESULTS: Preprocedural TEE revealed LA thrombus in 12 of 732 cases (1.6%), all located in the LA appendage. Among these 12 patients, 9 had persistent AF and 3 had paroxysmal AF. All patients with thrombus had an LA size >or= 4.5 cm. LA thrombus was present in 0.3%, 1.4%, and 5.3% of patients with CHADS(2) scores of 0, 1, and >or= 2, respectively. In multivariate analysis, a CHADS(2) score >or= 2 and larger LA diameter remained significant predictors of LA thrombus. CONCLUSIONS: Despite oral anticoagulation treatment, there is a small but significant incidence of LA thrombus by TEE prior to AF ablation. A CHADS(2) score >or= 2 and larger LA diameter are independent predictors of LA thrombus in this patient population, while type of AF or rhythm at the time of TEE is not. The risk of LA thrombus is low in patients with a CHADS(2) score of 0 and in patients with an LA diameter < 4.5 cm.
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Fibrilación Atrial/cirugía , Cateterismo Cardíaco , Ablación por Catéter , Trombosis/etiología , Administración Oral , Anciano , Anticoagulantes/administración & dosificación , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico por imagen , Ecocardiografía Transesofágica , Enoxaparina/administración & dosificación , Femenino , Atrios Cardíacos/diagnóstico por imagen , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Trombosis/diagnóstico por imagen , Trombosis/epidemiología , Trombosis/prevención & control , Factores de Tiempo , Resultado del Tratamiento , Warfarina/administración & dosificaciónRESUMEN
The success of catheter ablation of atrial fibrillation (AF) is highly dependent on a preprocedural assessment of the size and shape of the left atrium. The most precise method to determine left atrial (LA) volume using computed tomography requires manually tracing the LA area of each cross-sectional image. This is a labor-intensive and time-consuming technique. The purpose of this study was to compare LA volume derived using the "gold-standard" multiple-slice technique with LA volume estimated using 3 orthogonal LA dimensions in patients with AF. The patient population was composed of 100 patients referred for catheter ablation of AF (87 men, mean age 57 +/- 12 years). AF was paroxysmal in 49 patients and persistent in 51. Each patient underwent computed tomography before catheter ablation, and LA volume was measured using the 2 methods. The mean LA volume measured using the multiple-slice technique was 136 +/- 46 ml. According to the simpler estimation approach, the mean LA volume was 112 +/- 41 ml. A close correlation was noted between atrial volumes determined using the 2 methods (r = 0.91, p <0.001). There was a mean underestimation of LA volume by the estimation technique of 17 +/- 13%. In conclusion, the results of this study reveal that LA volume determined using an estimation approach correlates closely with true LA volume as determined using the gold-standard multiple-slice approach. This estimation approach underestimates true LA volume by approximately 20%.
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Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/patología , Función del Atrio Izquierdo , Atrios Cardíacos/patología , Tomografía Computarizada por Rayos X , Fibrilación Atrial/fisiopatología , Ablación por Catéter , Femenino , Atrios Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Estadística como Asunto , Factores de TiempoRESUMEN
Sarcopenia is an inevitable age-related degenerative process chiefly characterized by decreased synthesis of muscle proteins and impaired mitochondrial function, leading to progressive loss of muscle mass. Here, we sought to probe whether long-term administration of oral amino acids (AAs) can increase protein and adenosine triphosphate (ATP) content in the gastrocnemius muscle of aged rats, enhancing functional performance. To this end, 6- and 24-month-old male Fisher 344 rats were divided into 3 groups: group A (6-month-old rats) and group B (24-month-old rats) were used as adult and senescent control group, respectively, while group C (24-month-old rats) was used as senescent treated group and underwent 1-month oral treatment with a mixture of mainly essential AAs. Untreated senescent animals exhibited a 30% reduction in total and fractional protein content, as well as a 50% reduction in ATP content and production, compared with adult control rats (p <0.001). Long-term supplementation with mixed AAs significantly improved protein and high-energy phosphate content, as well as the rate of mitochondrial ATP production, conforming their values to those of adult control animals (p <0.001). The improved availability of protein and high-energy substrates in the gastrocnemius muscle of treated aged rats paralleled a significant enhancement in functional performance assessed by swim test, with dramatic elongation of maximal exertion times compared with untreated senescent rats (p <0.001). In line with these findings, we observed that, after 6 hours of rest following exhaustive swimming, the recovery in mitochondrial ATP content was approximately 70% in adult control rats, approximately 60% in senescent control rats, and normalized in treated rats as compared with animals of the same age unexposed to maximal exertion (p <0.001). In conclusion, nutritional supplementation with oral AAs improved protein and energy profiles in the gastrocnemius of treated rats, enhancing functional performance and accelerating high-energy phosphate recovery after exhaustive exertion.
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Músculo Esquelético/metabolismo , Condicionamiento Físico Animal/fisiología , Adenosina Trifosfato/metabolismo , Administración Oral , Envejecimiento/patología , Envejecimiento/fisiología , Animales , Suplementos Dietéticos , Metabolismo Energético , Masculino , Mitocondrias Musculares/metabolismo , Proteínas Musculares/metabolismo , Ratas , Ratas Endogámicas F344RESUMEN
We have previously demonstrated that the transcription factor STAT1 plays a critical role in promoting apoptotic cell death, whereas the related STAT3 family member may antagonize STAT1 and protect cardiac myocytes from ischemia/reperfusion (I/R) injury. More recently we demonstrated that long-term nutritional supplementation with mixed amino acids (AAs) can enhance myocyte survival by preserving mitochondrial functional capacity during I/R injury. We therefore investigated whether short-term nutritional supplementation with the same AA mixture has any effects on STAT1 or STAT3 activation in the Langendorff perfused rat heart exposed to I/R injury. In Sprague-Dawley rats given a single oral dose of a mixture of mainly essential l-AA (1 g/kg), and exposed, after 6 hours, to 35 minutes of ischemia, followed by 120 minutes of reperfusion, AA supplementation prolonged STAT3 activation/phosphorylation, while STAT1 activation was reduced. Enhanced STAT3 phosphorylation paralleled a reduction in expression of Fas, a known STAT1 target gene and proapoptotic marker that is upregulated after I/R. Moreover, abrogation of STAT3 activation by means of the JAK inhibitor AG490, reduced, but did not abolish, the cardioprotective effects of AA supplementation after I/R. These results show that modulation of the functional balance between STAT3 and STAT1, with preferential activation of prosurvival STAT3 over the proapoptotic STAT1, represents a mechanism by means of which short-term oral supplementation with mixed AAs protects the heart from I/R injury.
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Aminoácidos/administración & dosificación , Suplementos Dietéticos , Miocardio/metabolismo , Daño por Reperfusión/metabolismo , Factor de Transcripción STAT1/metabolismo , Factor de Transcripción STAT2/metabolismo , Animales , Apoptosis/fisiología , Inhibidores Enzimáticos/farmacología , Técnicas In Vitro , Masculino , Miocitos Cardíacos/fisiología , Fosforilación , Ratas , Ratas Sprague-Dawley , Tirfostinos/farmacologíaRESUMEN
INTRODUCTION: Pulmonary vein (PV) isolation by catheter ablation is an increasingly used strategy to treat atrial fibrillation (AF). Complication rates from AF ablation reported in different case series vary widely. We conducted a retrospective analysis of 641 consecutive ablation procedures to assess complication rates, temporal trends, and clinical predictors of adverse outcomes. METHODS: All patients (n = 517) undergoing catheter ablation for AF at Johns Hopkins Hospital between February, 2001 and June, 2007 were prospectively enrolled in a database. Data from 641 consecutive procedures were analyzed and complications considered if they occurred within 30 days of ablation. Major complications were defined as those that required intervention, resulted in long-term disability, or prolonged hospitalization. RESULTS: Thirty-two major complications occurred in 641 procedures (5%). Among the patients with major complications, seven had cerebrovascular accident (CVA), eight had tamponade, one had PV occlusion with hemoptysis, and 11 had vascular injury requiring surgical repair and/or transfusion. No periprocedural deaths occurred, and no instances of esophageal injury were seen. Complication rates were higher during the first 100 cases (9.0%) than during the subsequent 541 (4.3%). Major adverse clinical events were associated with age > 70 years (P = 0.007; odds ratio 3.7, 95% confidence interval 1.4-9.6) and female gender (P = 0.014; odds ratio 3.0, 95% confidence interval 1.3-7.2). No other clinical or procedural predictors of complication were identified. CONCLUSIONS: Complication rates from AF ablation remain significant, despite improved techniques and increased awareness of procedural risks. Both advanced age and female gender predict major adverse events, suggesting careful consideration of the risk/benefit profile in these patients prior to ablation.
Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Complicaciones Posoperatorias/epidemiología , Ecocardiografía Transesofágica , Electrocardiografía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
We describe the case of an 86-year-old woman who presented with unstable angina. She was given heparin and eptifibatide, and she underwent percutaneous coronary intervention (PCI). Shortly thereafter, she developed acute profound thrombocytopenia (6,000 platelets/mm3), which resolved after the discontinuation of heparin and eptifibatide. Four months later, she presented again with unstable angina and underwent PCI. Soon after the procedure, she again developed acute profound thrombocytopenia (2,000 platelets/mm3). To our knowledge, acute profound thrombocytopenia due to eptifibatide treatment in the same patient at two different times has not been reported before.