RESUMEN

BACKGROUND: In current practice, the ablation target of atypical atrioventricular nodal re-entrant tachycardia (AVNRT) is the earliest atrial activation site in the coronary sinus (CS) or conventional slow pathway region. OBJECTIVES: The purposes of this study were to map the site of earliest retrograde atrial activation using electroanatomic three-dimensional mapping during atypical AVNRT and to evaluate successful ablation sites. METHODS: A total of 42 patients with a total of 49 AVNRTs (slow/fast: 30; fast/slow: 15; slow/slow: 4) underwent electrophysiological study and ablation. Among them there were 14 patients (10 women; 60 ± 19 years of age) in whom 19 atypical AVNRT (fast/slow: 15; slow/slow: 4) were induced. RESULTS: The intracardiac electrocardiograms or three-dimensional mapping of the exit site during tachycardia revealed that 7 patients had exit sites solely inside the CS (left inferior extension [LIE]), 3 solely in the right postero-septal tricuspid annulus (TA; right inferior extension [RIE]), and 4 had both LIE and RIE exits. The distance from the CS ostium to LIE exits was 14 ± 6 mm. RIE exits were located on the TA posterior to the CS ostium (between 5 and 6 o'clock in the left anterior oblique projection). Ablation targeting these exits or conventional slow pathway succeeded in long-term elimination of AVNRT in 13 of the 14 patients (93%). There were no complications. CONCLUSIONS: Catheter ablation targeting the exit sites of LIE or RIE mapped at the CS or TA holds promise as an effective and safe alternative approach to the current targets of ablation for atypical AVNRT cases.

Asunto(s)

Ablación por Catéter , Taquicardia por Reentrada en el Nodo Atrioventricular , Femenino , Humanos , Ablación por Catéter/métodos , Taquicardia por Reentrada en el Nodo Atrioventricular/fisiopatología , Taquicardia por Reentrada en el Nodo Atrioventricular/cirugía , Masculino , Persona de Mediana Edad , Anciano , Adulto , Resultado del Tratamiento

RESUMEN

We present a case of orthodromic atrioventricular re-entrant tachycardia exhibiting both right and left bundle branch block pattern wide QRS morphologies caused by bilateral bystander nodoventricular (NV) accessory pathways. These wide QRS morphologies came from pre-excitation accompanied by delta waves. In the context of NV accessory pathways, left-sided manifest NV accessory pathways are rare.

RESUMEN

BACKGROUND: Atrial anti-tachycardia pacing (A-ATP) of the right atrium (RA) has been shown to decrease the burden of atrial fibrillation (AF) in patients with dual-chamber pacemakers. The aim of this study is to identify the novel predictors of effective A-ATP for terminating AF in patients with AF undergoing catheter ablation. METHODS: This study included 41 consecutive patients undergoing a first ablation procedure for paroxysmal (PAF: n = 21) or persistent (PEF: n = 20) AF. We prospectively evaluated predictors of AF termination after A-ATP. The coefficient of variation (CoV = SD/mean × 100) of the dominant frequencies (DFs) was calculated to evaluate the variability in atrial activation. RESULTS: AF was terminated by A-ATP in 29% of PAF and 5% of PEF patients. In these patients, simultaneous high-rate pacing from the RA and the coronary sinus (CS) terminated AF in 71% of patients, in whom the mean AF cycle length (CL) before A-ATP was longer (214 ± 23 vs. 177 ± 35 ms, p = 0.02) and became slower after A-ATP (234 ± 37 vs. 176 ± 32 ms, p < 0.01), compared to unsuccessful patients. The CoV of the DFs before A-ATP were lower in both RA (6.2 ± 2.0 vs. 15.3 ± 7.9, p = 0.02) and CS (11.0 ± 7.9 vs. 24.3 ± 9.3, p < 0.01) in successful patients. CONCLUSIONS: Simultaneous biatrial A-ATP from the RA and CS could terminate AF in patients with PAF. The predictors for successful termination include longer AF CL and higher AF stability.

RESUMEN

We report a 17-year-old woman with hypertrophic cardiomyopathy (HCM) successfully resuscitated from ventricular fibrillation while taking cibenzoline. During exercise-stress testing before implanting an implantable cardioverter-defibrillator, ventricular tachycardia was induced and thought to be a proarrhythmia due to the use-dependent effect of the Na channel blockade with cibenzoline. In patients with arrhythmogenic substrates such as HCM, it is critical to pay attention to the proarrhythmic effects of class I antiarrhythmic drugs while increasing heart rate.

Asunto(s)

Cardiomiopatía Hipertrófica/complicaciones , Prueba de Esfuerzo/efectos adversos , Imidazoles/uso terapéutico , Taquicardia Ventricular/complicaciones , Taquicardia Ventricular/terapia , Fibrilación Ventricular/complicaciones , Fibrilación Ventricular/tratamiento farmacológico , Adolescente , Antiarrítmicos/uso terapéutico , Reanimación Cardiopulmonar/métodos , Ejercicio Físico , Femenino , Humanos , Sotalol/uso terapéutico

RESUMEN

We report a 77-year-old human on renal dialysis for end-stage renal disease with heart failure and atrial fibrillation (AF) complicated by a high ventricular frequency. The underlying disease was thought as tachycardia-induced-cardiomyopathy. Intravenous infusion of amiodarone was initiated, and direct current cardioversion succeeded in converting AF to sinus rhythm. Then, excessive increases in the QT and Tpeak-Tend (Tp-e) intervals were seen and hypokalemia induced by hemodialysis led to the development of numerous episodes of torsades de pointes (TdP). Magnesium repletion was effective in preventing TdP, while Tp-e intervals returned to the previous values 2 days after the discontinuation of amiodarone.

Asunto(s)

Amiodarona/efectos adversos , Antiarrítmicos/efectos adversos , Cardiomiopatías/tratamiento farmacológico , Torsades de Pointes/inducido químicamente , Anciano , Amiodarona/uso terapéutico , Antiarrítmicos/uso terapéutico , Electrocardiografía/métodos , Humanos , Masculino , Torsades de Pointes/diagnóstico

RESUMEN

There is little data on management and outcomes of atrial fibrillation (AF) patients on direct oral anticoagulants (DOAC) undergoing general surgery.We retrospectively assessed 98 surgeries in 85 nonvalvular AF patients aged 73 ± 8 (59 men) receiving DOACs. Cardiac, emergency, and minimally invasive surgeries were excluded.The CHA2DS2-VASc score ranged from 0 to 8. The DOACs being given were: dabigatran, 16; rivaroxaban, 25; apixaban, 28; and edoxaban, 16. While the DOACs were not suspended in 11 cases, they were interrupted for a median of 2.0 days before surgery and restarted at a median of 3.0 days after surgery. There were 9 complications (9.2%), 3 instances of thromboembolism and 6 bleeding. Thromboembolism occurred at a mean of 3.0 postoperative days, all of which occurred before resumption of DOACs, while bleeding events occurred at a mean of 4.0 postoperative days. Two of the 3 patients with thromboembolism went into cardiopulmonary arrest during the event, but were resuscitated. There were significantly more patients with congestive heart failure or combined antiplatelets in the patients with complications. The complication group had a significantly higher HAS-BLED score and lower preoperative hemoglobin level. There were no significant differences in the management of DOAC interruption between those with complications and without.The perioperative complication rate in nonvalvular AF patients undergoing elective surgery treating with DOACs was 9.2%. Patients with congestive heart failure, receiving combined therapy with antiplatelets, a higher HAS-BLED score, or lower preoperative hemoglobin level were at higher risk. Further studies evaluating the ideal perioperative DOAC protocol are warranted.

Asunto(s)

Fibrilación Atrial/tratamiento farmacológico , Enfermedades de las Arterias Carótidas/epidemiología , Infarto Cerebral/epidemiología , Inhibidores del Factor Xa/administración & dosificación , Infarto del Miocardio/epidemiología , Atención Perioperativa/métodos , Hemorragia Posoperatoria/epidemiología , Tromboembolia/prevención & control , Anciano , Anciano de 80 o más Años , Antitrombinas/administración & dosificación , Fibrilación Atrial/complicaciones , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Dabigatrán/administración & dosificación , Procedimientos Quirúrgicos del Sistema Digestivo , Procedimientos Quirúrgicos Electivos , Embolia/epidemiología , Endoscopía , Femenino , Humanos , Masculino , Procedimientos Ortopédicos , Complicaciones Posoperatorias/epidemiología , Pirazoles/administración & dosificación , Piridinas/administración & dosificación , Piridonas/administración & dosificación , Estudios Retrospectivos , Rivaroxabán/administración & dosificación , Tiazoles/administración & dosificación , Tromboembolia/etiología , Procedimientos Quirúrgicos Urológicos , Procedimientos Quirúrgicos Vasculares

RESUMEN

BACKGROUND: The feasibility and safety of pulmonary vein isolation (PVI) using cryoballoon (CB) for paroxysmal atrial fibrillation (PAF) with minimally interrupted apixaban has not fully explored. METHODS: In this multicenter, randomized prospective study, we enrolled patients with PAF undergoing CB or radiofrequency (RF) ablation with interrupted (holding 1 dose) apixaban. The primary composite end point consisted of bleeding events, including pericardial effusion and major bleeding requiring blood transfusion, or thromboembolic events at 4 weeks after ablation; secondary end points included early recurrence of AF and procedural duration. RESULTS: A total of 250 patients underwent PVI (125 assigned to the RF ablation and 125 assigned to the CB ablation). The primary end point occurred in 1 patient in the CB ablation group (0.8%; 90% confidence interval [CI], 0.04 to 3.70) and 3 patients in the RF group (2.4%, P = .622; risk ratio, 0333; 90% CI, 0.05 to 2.20). All events were pericardial effusion, all of whom recovered after pericardiocentesis. Early recurrence of AF occurred in 4 patients (3.2%) in the RF group and in 6 patients (4.8%) in the CB group (P = .749). The procedural duration was shorter in the CB group than that in the RF group (136.5 ± 39.9 vs 179.5 ± 44.8 min, P < .001). CONCLUSION: CB ablation with minimally interrupted apixaban was feasible and safe in patients with PAF undergoing PVI, which was equivalent to RF ablation.

RESUMEN

BACKGROUND: The feasibility and safety of lead extraction of cardiac implantable electronic devices (CIEDs) in the elderly Asian population remain uncertain. We report the outcome and safety of transvenous excimer laser-assisted lead extraction of CIEDs in Japanese patients aged ≥80 years. METHODS: Consecutive 235 patients (age 67±15 years, 167 male) undergoing lead extraction of CIED with an excimer laser system (Philips, Andover, MA, USA) were included. RESULTS: Of 235 consecutive patients, 51 (22%) were ≥80 years (age 86±5 years, 14 were aged ≥90 years; 42 had pacemakers, 3 had implantable cardioverter defibrillators, and 6 had cardiac resynchronization therapy devices). The median implant duration was 110±95 months. Patients aged ≥80 years had lower body mass index (BMI, 20.7±3.1kg/m2 vs. 22.6±3.4kg/m2, p<0.001), higher incidence of CIED infection (98% vs. 63%, p<0.010), and longer duration of hospitalization (31±17 days vs. 24 ± 31 days, p<0.001) than patients aged <80 years. There were no differences between the age groups in the rate of complete retrieval (94.1% vs. 95.1%, p=0.726) and major complications, including cardiac tamponade and cardiogenic shock (2.0% vs. 2.7%, p=1.000). CONCLUSIONS: Excimer laser-assisted lead extraction was safe and feasible in the Japanese elderly population with low BMI, despite the high likelihood of procedural complications. Early removal of infected CIEDs should be performed without delay in elderly Asian populations.

Asunto(s)

Desfibriladores Implantables , Remoción de Dispositivos , Láseres de Excímeros , Marcapaso Artificial , Adulto , Anciano , Anciano de 80 o más Años , Pueblo Asiatico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven

RESUMEN

INTRODUCTION: Isolation of the left atrial appendage (LAA) is often performed in persistent atrial fibrillation (AF). Propagation patterns in the LAA during AF remain to be elucidated. We sought to characterize propagation patterns in the LAA during AF in persistent AF. METHODS: Persistent AF patients undergoing catheter ablation were studied. Pulmonary vein isolation (PVI) was performed during continuous AF. If AF was not terminated by PVI, bi-atrial mapping was performed using a multi-electrode catheter during AF. Maps were collected at each site for 30 seconds and analyzed offline with a novel software, CARTOFINDER. This software made automatic determinations of whether activation was focal or rotational. The left atrium (LA) was divided into five regions, of which the LAA was one, and the right atrium (RA) into three. RESULTS: Eighty patients were studied (62 ± 10 years, 65 males). On average, 9.6 ± 2.2 and 4.1 ± 1.2 maps were created in the LA and RA, respectively. The LAA was mapped in 70 patients, resulting in 85 maps. In the LAA, activation was identified as focal more often than rotational (64 [91%] vs 10 [14%] patients, P < .001), seven patients displayed both. The number of focal activation events was greatest in the LAA (28.5 events/30 seconds [interquartile range, 15-54]) of the eight atrial regions. During focal activation, sites designated as earliest activation frequently covered a wide area, rather than being localized to a discrete site (5.4 ± 3.1 electrodes). CONCLUSIONS: The results of this study suggest that focal activation is a major mechanism underlying the arrhythmogenicity of the LAA in persistent AF.

Asunto(s)

Potenciales de Acción , Apéndice Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Función del Atrio Izquierdo , Técnicas Electrofisiológicas Cardíacas , Endocardio/fisiopatología , Frecuencia Cardíaca , Venas Pulmonares/fisiopatología , Anciano , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Ablación por Catéter , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Venas Pulmonares/cirugía , Factores de Tiempo

RESUMEN

A 75-year-old man was admitted for repeat ablation of atrial fibrillation. At 30 min after infusion of 3.5 ml of ethanol into the vein of Marshall, inferior ST-segment elevation with coronary arterial vasospasm was observed. This is the first report of coronary vasospasm after chemical ablation of the vein of Marshall. (Level of Difficulty: Intermediate.).

RESUMEN

PURPOSE: Ripple map (RM) is a novel method for displaying activation pattern on the surface of a cardiac chamber. The aim of this study was to determine the utility of the RM in interpreting the atrial propagation in atrial tachycardia (AT) in comparison with a conventional local activation (LAT) map. METHODS: Three-dimensional electroanatomical mapping and ablation of AT were performed using multielectrode catheters and the CARTO3 ConfiDENSE Module (Biosense Webster). LAT maps and RMs were retrospectively reviewed by two independent observers who were blinded to the ablation results. RESULTS: High-density maps (1683 ± 1362 points) of 45 ATs (274 ± 64 ms; macroreentry 28, focal 17) were obtained in 39 patients. Of the 45 ATs, 41 (91%) were terminated by catheter ablation. A retrospective review of the LAT map alone by two observers resulted in correct diagnosis in 27% (12 ATs), whereas additional reviews of the RMs improved the diagnostic accuracy to 80% (36 ATs, P < 0.001). The diagnostic accuracy using the RM was equally high for macroreentrant (79%) and focal ATs (82%, P = 1.000). Of the 33 LAT maps in disagreement with the observers, adjusting the window-of-interest (WOI) after reviewing the RMs achieved diagnostic agreement of 91% (30 ATs). CONCLUSION: RMs allow us to have precise understanding of the atrial propagation on high-density CARTO maps for both focal and macroreentrant ATs, which is particularly useful for cases with difficult-to-interpret LAT maps.

Asunto(s)

Ablación por Catéter , Mapeo Epicárdico/métodos , Taquicardia Supraventricular/fisiopatología , Taquicardia Supraventricular/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos

RESUMEN

BACKGROUND: Conventional coagulation assays have poor sensitivity and specificity for assessing the anticoagulant effect of direct oral anticoagulants (DOACs). This study aimed to evaluate the causes and consequences of the excessive prolongation of coagulation time in patients with nonvalvular atrial fibrillation who receive DOACs. METHODS: We retrospectively analysed 1521 patients (age, 66 ± 12 years). The prothrombin time (PT) and activated partial thromboplastin time (APTT) were averaged if they were measured more than twice depending on the respective DOAC and dosage across individuals. Excessive coagulation time prolongation was defined as PT or APTT of >2 standard deviations over the median for each DOAC. RESULTS: In all, 1913 DOAC cases were found. Excessive prolongation (EP), which was noted in 88 patients (5.8%), was found to be significantly associated with inappropriately high DOAC dosage and body weight (≤ 60 kg). During follow-up (median, 8.9 months), thromboembolisms developed in 10 patients (0.66%) and bleeding events in 85 (5.6%). Bleeding events were significantly higher in patients with excessive prolongation (EP group) than in those without (P = 0.013). Of the 53 patients in the EP group, 15 (28%) were positive for antiphospholipid antibodies, 6 (11%) had inappropriately high prescription dosages, 4 (8%) had coagulation factor deficiencies, and 3 (6%) had severe liver dysfunction. CONCLUSIONS: Bleeding event rates were remarkably higher in patients receiving DOACs that caused EP of PT or APTT. Thus, following the current guidelines and administering the recommended dose of DOACs are fundamentally important. Patients with the body weight of <60 kg should be considered for dosage reduction or DOAC withdrawal.

Asunto(s)

Anticoagulantes/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Coagulación Sanguínea/efectos de los fármacos , Tromboembolia/prevención & control , Administración Oral , Anciano , Fibrilación Atrial/sangre , Fibrilación Atrial/complicaciones , Pruebas de Coagulación Sanguínea , Dabigatrán/administración & dosificación , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Japón/epidemiología , Masculino , Pronóstico , Piridinas/administración & dosificación , Estudios Retrospectivos , Tiazoles/administración & dosificación , Tromboembolia/epidemiología , Tromboembolia/etiología

Asunto(s)

Fibrilación Atrial/terapia , Aleteo Atrial/terapia , Estimulación Cardíaca Artificial/métodos , Taquicardia/terapia , Anciano , Electrocardiografía , Humanos , Masculino

RESUMEN

Recent studies have demonstrated the utility of cardiac sympathetic denervation (CSD) in patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and catheter or surgical ablation. We present our experience with bilateral CSD in a patient with a recurrent VT despite attempts at treatment with catheter ablation and antiarrhythmic drugs, and this is the first description of the successful management of an idiopathic refractory VT with a bilateral CSD and concomitant oral amiodarone, occurring after catheter ablation of persistent atrial fibrillation and idiopathic outflow tract premature ventricular contractions.

Asunto(s)

Síndrome de Robo Coronario-Subclavio/etiología , Anastomosis Interna Mamario-Coronaria/efectos adversos , Esfuerzo Físico , Síncope/etiología , Circulación Coronaria , Síndrome de Robo Coronario-Subclavio/diagnóstico por imagen , Síndrome de Robo Coronario-Subclavio/fisiopatología , Síndrome de Robo Coronario-Subclavio/terapia , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Síncope/diagnóstico , Síncope/fisiopatología , Síncope/prevención & control , Resultado del Tratamiento

RESUMEN

BACKGROUND: Transvenous lead extractions have been performed using 40-Hz laser sheaths. Recently, a new 80-Hz laser sheath became available, but only a few reports have compared the effectiveness of the 40- and 80-Hz laser sheaths. Methods and Results: This study included 215 patients. Lead extractions using only laser sheaths were analyzed. The clinical characteristics, extraction parameters, and extraction tools were evaluated. The procedures were performed with 40-Hz sheaths in 150 patients (group 1: 270 leads) and 80-Hz sheaths in 65 (group 2: 99 leads). No statistically significant differences were observed in the clinical parameters except for sex. The mean implant duration was 95.3±86.0 and 78.2±56.8 months in groups 1 and 2, respectively (P=0.07). The respective mean laser time and number of laser pulses were 48.5±52.1 and 48.1±56.1 s (P=0.96) and 2,035.0±2,384.0 and 3,955.1±2,339.3 pulses (P<0.0001). Complete removal was achieved for 97.4% of the leads and in 98.0% in both groups (P=0.38). Major complications occurred in 2.0% and 3.1% of the patients in groups 1 and 2, respectively (P=0.94). CONCLUSIONS: Transvenous lead extraction using high-frequency laser sheaths was as highly successful as with low-frequency laser sheaths in Japanese patients.

Asunto(s)

Desfibriladores Implantables/efectos adversos , Falla de Equipo , Láseres de Excímeros , Marcapaso Artificial/efectos adversos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad

RESUMEN

In patients requiring an implantable cardioverter defibrillator (ICD), the combined use of a prior pacemaker and a subcutaneous ICD (S-ICD) could be an alternative treatment option to implantation of new leads or upgrading of pacemakers to an ICD if vascular access is limited. Here, we assessed the prevalence of S-ICD's eligibility according to surface electrogram screening in those receiving cardiac resynchronization therapy (CRT). S-ICD's eligibility was assessed in patients with a CRT pacemaker or a CRT defibrillator using the S-ICD template screening tool. Eligibility was defined as fulfillment of the template in both supine and upright positions in one or more leads during biventricular pacing. Among 44 patients (34 men, age: 67 ± 12), 36 (82%) were found to be eligible. The T/QRS amplitude ratio in lead II was significantly lower in those who were eligible (0.31 ± 0.16 versus 0.44 ± 0.18 in the ineligible group, P = 0.04). The lead position, underlying disease, and other electrocardiographic findings were not different between those who were eligible and those who were not. The majority of patients with biventricular pacing were eligible for S-ICD based on current screening tests and may benefit from this treatment. Further study is required.

Asunto(s)

Terapia de Resincronización Cardíaca/métodos , Desfibriladores Implantables/estadística & datos numéricos , Electrocardiografía/instrumentación , Insuficiencia Cardíaca/terapia , Marcapaso Artificial/estadística & datos numéricos , Anciano , Terapia Combinada , Determinación de la Elegibilidad/normas , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Tamizaje Masivo/métodos , Persona de Mediana Edad , Prevalencia , Prevención Secundaria/normas , Tejido Subcutáneo , Resultado del Tratamiento

RESUMEN

BACKGROUND: Optimal management of advisory implantable cardioverter defibrillator (ICD) leads has not been established. Several studies were reported concerning the lead extraction of advisory ICD leads, but the implant duration of those studies was short. We estimated the efficacy of lead extractions of advisory ICD leads with a relatively longer duration in Japanese patients. METHODS: We retrospectively analyzed 28 patients who underwent a lead extraction at Kokura Memorial Hospital and Tokyo Medical and Dental University Hospital [Fidelis (Medtronic, Minneapolis, MN, USA): n=19, Riata (St. Jude Medical, Sylmar, CA, USA): n=8, Isoline (SORIN CRM SAS, Clamart, France): n=1]. The mean implant duration was 63.3±19.3 months. The indications were device related infections in 3, electrical lead failures in 18, electrical lead failures and venous obstructions in 3, and prophylactic reasons in 4 patients. Inappropriate shocks because of electrical lead failures were observed in 9 patients. RESULTS: Complete removals were achieved of all 28 advisory leads. In 23 out of 28 patients, new ICD leads were implanted during the same procedure. In one patient, open chest surgery was performed for a hemothorax that occurred during a new ICD lead implantation just after successfully removing the advisory ICD lead. There were no other major or minor complications. CONCLUSION: Transvenous extractions of advisory ICD leads with relatively long implant duration were performed with a high success rate and low complication and mortality rate in Japanese patients.

Asunto(s)

Desfibriladores Implantables/efectos adversos , Remoción de Dispositivos/métodos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Estudios Retrospectivos , Factores de Tiempo , Tokio , Resultado del Tratamiento