RESUMEN
BACKGROUND: The head-up tilt test (HUT) is widely used to investigate unexplained syncope; however, in clinical practice, it is long and sometimes not well tolerated. OBJECTIVES: To compare the sensitivity, specificity, accuracy, and patients' tolerance of a conventional and shortened HUT. METHODS: Patients with a history of vasovagal syndrome (VVS) were randomized to a conventional HUT (group I) consisting of 20-minute passive tilt followed by 25 minutes after administration of sublingual isosorbide dinitrate (ISDN), or a shortened HUT (group II) where ISDN was given immediately after tilt and observed for 25 minutes. The control group consisted of age- and gender-matched subjects without VVS symptoms. A specific questionnaire to evaluate tolerance was applied. RESULTS: Sixty patients (29 ± 10 years, 82% female) were included. In group I, 22/30 patients had a positive HUT compared to 21/30 in group II (73% vs 70%, P = 0.77). There was also no difference in the accuracy between the two protocols (63% vs 73%, P = 0.24). The time to positivity was shorter in group II (13.2 minutes vs 30 minutes, P < 0.001). Within the control group (n = 60), the frequency of false-positives was 47% and 23% for the conventional and shortened HUT, respectively (P = 0.058). After conventional HUT, 65.2% subjects reported that the test was too long compared to 25% subjects after the shortened HUT (P = 0.002). CONCLUSION: In this study, the HUT without passive phase was not inferior to the conventional HUT regarding sensitivity, specificity, and accuracy. Furthermore, the shortened ISDN-potentiated protocol allowed faster diagnosis and was better tolerated.
Asunto(s)
Dinitrato de Isosorbide , Síncope Vasovagal/diagnóstico , Vasodilatadores , Adulto , Errores Diagnósticos , Femenino , Humanos , Isoproterenol , Dinitrato de Isosorbide/efectos adversos , Masculino , Nitroglicerina , Satisfacción del Paciente , Sensibilidad y Especificidad , Pruebas de Mesa Inclinada/métodos , Vasodilatadores/efectos adversos , Adulto JovenRESUMEN
O teste de inclinação (TI) é muito utilizado para a investigação de síncopes e pré-síncopes, pois possibilita o diagnóstico de diferentes tipos de disautonomias. A principal causa de síncope é a Síndrome Vasovagal, cujo diagnóstico é o mais frequente entre as indicações de TI. O exame é utilizado há cerca de 20 anos, mas muitos médicos desconhecem a metodologia. São importantes a indicação apropriada, após exclusão de causas cardíacas de síncope, e a orientação do paciente para garantir a tranquilidade e a segurança do teste. Existem controvérsias na literatura sobre a capacidade diagnóstica e a confiabilidade dos resultados. Os estudos com protocolos diversos podem explicar a variabilidade dos resultados. Nesta revisão, são colocadas as indicações e a metodologia recomendadas pelas diretrizes, complicações, limitações e perspectivas desse exame.
The head-up tilt test (HUTT) is widely used for investigation of syncope and presyncope, since it allows diagnosing different types of dysautonomia. The main cause of syncope is the vasovagal syndrome, the most common diagnosis among patients with HUTT indication. The test has been used for nearly 20 years, but many doctors are unaware of the methodology. After the cardiac causes of syncope are ruled out, the appropriate indication of the test and instructions to patients are important to ensure that the test will be carried out in a safe and relaxed manner. There are controversies in the literature over the diagnostic capacity and reliability of results. Studies with various protocols may explain the variability of results. This review describes the guidelines-recommended methodology and indications, complications, limitations and perspectives of this test.
El test de inclinación (TI) es muy utilizado para la investigación de síncopes y presíncopes, pues posibilita el diagnóstico de diferentes tipos de disautonomías. La principal causa de síncope es el Síndrome Vasovagal, cuyo diagnóstico es el más frecuente entre las indicaciones de TI. EL examen es utilizado hace cerca de 20 años, pero muchos médicos desconocen la metodología. Son importantes la indicación apropiada, después de exclusión de causas cardíacas de síncope, y la orientación del paciente para garantizar la tranquilidad y la seguridad del test. Existen controversias en la literatura sobre la capacidad diagnóstica y la confiabilidad de los resultados. Los estudios con protocolos diversos pueden explicar la variabilidad de los resultados. En esta revisión, son colocadas las indicaciones y la metodología recomendadas por las directrices, complicaciones, limitaciones y perspectivas de ese examen.
Asunto(s)
Humanos , Síncope Vasovagal/diagnóstico , Pruebas de Mesa Inclinada/normas , Reproducibilidad de los Resultados , Síndrome , Pruebas de Mesa Inclinada/métodos , Pruebas de Mesa Inclinada/tendenciasRESUMEN
BACKGROUND: Luminal esophageal temperature (LET) monitoring is one strategy to minimize esophageal injury during atrial fibrillation ablation procedures. However, esophageal ulceration and fistulas have been reported despite adequate LET monitoring. The objective of this study was to assess a novel approach to LET monitoring with a deflectable LET probe on the rate of esophageal injury in patients undergoing atrial fibrillation ablation. METHODS AND RESULTS: Forty-five consecutive patients undergoing an atrial fibrillation ablation procedure followed by esophageal endoscopy were included in this prospective observational pilot study. LET monitoring was performed with a 7F deflectable ablation catheter that was positioned as close as possible to the site of left atrial ablation using the deflectable component of the catheter guided by visualization of its position on intracardiac echocardiography. Ablation in the posterior left atrial was limited to 25 W and terminated when the LET increased 2°C from baseline. Endoscopy was performed 1 to 2 days after the procedure. All patients had at least 1 LET elevation >2°C necessitating cessation of ablation. Deflection of the LET probe was needed to accurately measure LET in 5% of patients when ablating near the left pulmonary veins, whereas deflection of the LET probe was necessary in 88% of patients when ablating near the right pulmonary veins. The average maximum increase in LET was 2.5±1.5°C. No patients had esophageal thermal injury on follow-up endoscopy. CONCLUSIONS: A strategy of optimal LET probe placement using a deflectable LET probe and intracardiac echocardiography guidance, combined with cessation of radiofrequency ablation with a 2°C rise in LET, may reduce esophageal thermal injury during left atrial ablation procedures.
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Fibrilación Atrial/cirugía , Temperatura Corporal , Quemaduras/prevención & control , Ablación por Catéter/efectos adversos , Fístula Esofágica/prevención & control , Esófago/lesiones , Monitoreo Intraoperatorio/métodos , Úlcera/prevención & control , Ultrasonografía Intervencional , Adulto , Anciano , Fibrilación Atrial/diagnóstico por imagen , Quemaduras/diagnóstico , Quemaduras/etiología , Ablación por Catéter/instrumentación , Catéteres , Distribución de Chi-Cuadrado , Diseño de Equipo , Fístula Esofágica/diagnóstico , Fístula Esofágica/etiología , Esofagoscopía , Esófago/diagnóstico por imagen , Esófago/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/instrumentación , Ontario , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Prospectivos , Úlcera/diagnóstico , Úlcera/etiología , Ultrasonografía Intervencional/instrumentaciónRESUMEN
The head-up tilt test (HUTT) is widely used for investigation of syncope and presyncope, since it allows diagnosing different types of dysautonomia. The main cause of syncope is the vasovagal syndrome, the most common diagnosis among patients with HUTT indication. The test has been used for nearly 20 years, but many doctors are unaware of the methodology. After the cardiac causes of syncope are ruled out, the appropriate indication of the test and instructions to patients are important to ensure that the test will be carried out in a safe and relaxed manner. There are controversies in the literature over the diagnostic capacity and reliability of results. Studies with various protocols may explain the variability of results. This review describes the guidelines-recommended methodology and indications, complications, limitations and perspectives of this test.
Asunto(s)
Síncope Vasovagal/diagnóstico , Pruebas de Mesa Inclinada/normas , Humanos , Reproducibilidad de los Resultados , Síndrome , Pruebas de Mesa Inclinada/métodos , Pruebas de Mesa Inclinada/tendenciasRESUMEN
FUNDAMENTO: A estenose arterial renal (EAR) é uma causa potencialmente reversível de hipertensão arterial sistêmica (HAS) e nefropatia isquêmica. Apesar da revascularização bem sucedida, nem todos os pacientes (pt) apresentam melhora clínica e alguns podem piorar. OBJETIVO: O presente estudo se destina a avaliar o valor do índice de resistividade renal (IR) como preditor dos efeitos da revascularização renal. MÉTODOS: Entre janeiro de 1998 e fevereiro de 2001, 2.933 pacientes foram submetidos ao duplex ultrassom renal. 106 desses pacientes apresentaram EAR significativa e foram submetidos a angiografia e revascularização renal. A pressão arterial (PA) foi medida antes e depois da intervenção, em intervalos de até 2 anos e as medicações prescritas foram registradas. Antes da revascularização, o IR foi medido em 3 locais do rim, sendo obtida uma média dessas medições. RESULTADOS: Dos 106 pacientes, 81 tiveram IR<80 e 25 RI>80. A EAR foi corrigida somente por angioplastia (PTA) em 25 pts, PTA + stent em 56 pts e cirurgicamente em 25 pts. Dos pacientes que se beneficiaram da revascularização renal; 57 dos 81 pacientes com IR <80 apresentaram melhora em comparação a 5 de 25 com IR > 80. Usando um modelo de regressão logística múltipla, o IR esteve significativamente associado à evolução da PA (p = 0,001), ajustado de acordo com os efeitos da idade, sexo, PAS, PAD, duração da hipertensão, o tipo de revascularização, número de fármacos em uso, nível de creatinina, presença de diabete melito, hipercolesterolemia, volume sistólico, doença arterial periférica e coronariana e tamanho renal (OR 99,6-95 por centoCI para OR 6,1-1.621,2). CONCLUSÃO: A resistividade intrarrenal arterial, medida por duplex ultrassom, desempenha um papel importante na predição dos efeitos pós revascularização renal para EAR.
BACKGROUND: Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE: This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS: Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS: Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95 percentCI for OR 6.1 to 1,621.2). CONCLUSION: Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.
Asunto(s)
Anciano , Femenino , Humanos , Masculino , Hipertensión Renovascular/terapia , Obstrucción de la Arteria Renal/terapia , Arteria Renal , Resistencia Vascular/fisiología , Angioplastia de Balón/métodos , Presión Sanguínea/fisiología , Métodos Epidemiológicos , Obstrucción de la Arteria Renal/fisiopatología , Stents , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
BACKGROUND: Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE: This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS: Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS: Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95%CI for OR 6.1 to 1,621.2). CONCLUSION: Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.
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Hipertensión Renovascular/terapia , Obstrucción de la Arteria Renal/terapia , Arteria Renal/diagnóstico por imagen , Resistencia Vascular/fisiología , Anciano , Angioplastia de Balón/métodos , Presión Sanguínea/fisiología , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Obstrucción de la Arteria Renal/fisiopatología , Stents , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands, usually with benign manifestations, whose typical clinical presentation includes the triad of headache, palpitations and diaphoresis. However, a wide range of signs and symptoms may be present. In the cardiovascular system, the most common signs are labile hypertension and sinus tachycardia. Systolic heart failure and ST-segment deviations mimicking myocardial infarction have also been reported, as well as QT interval prolongation and, rarely, ventricular tachycardia. We describe a challenging diagnosis of pheochromocytoma with many cardiovascular manifestations, which could have been missed due to the absence of typical symptoms.
RESUMEN
BACKGROUND AND AIMS: Slow conduction scarred areas are related with ventricular tachycardia (VT) arrhythmogenesis in nonischemic cardiomyopathy. The purpose of this study was to characterize the substrate in both epicardial and endocardial surfaces of the left ventricle and to evaluate the effectiveness of substrate mapping and ablation for VT in Chagas cardiomyopathy. METHODS AND RESULTS: Seventeen patients were evaluated prospectively using a simultaneous epicardial and endocardial electroanatomical substrate mapping and ablation. With a mean of 201 +/- 94 epicardial and 169 +/- 77 endocardial points, the epicardial voltage areas < or =0.5 mV were 56.8 +/- 40.6 (range 4.4 to 154.8 cm(2)) as compared to 22.5 +/- 15.8 cm(2) (range 5.4 to 61.0 cm(2); p = 0.004) in the endocardium. Analyzing the epicardial surface, there was a strong correlation between the bipolar voltage electrograms and the electrogram duration at the epicardium during sinus rhythm (r = 0.897, p < 0.0001). Acute success was obtained in 83.3% of patients with no serious complications. At the end of follow-up from 14 patients with acute success, 11 (78.6%) had been event-free based on implantable cardioverter defibrillator (ICD) interrogation logs. CONCLUSION: Chronic Chagas cardiomyopathy patients have larger epicardial as compared to endocardial substrate areas. Combined epicardial endocardial substrate mapping and ablation during sinus rhythm proves effective in preventing VT recurrences and appropriate ICD therapies.
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Mapeo del Potencial de Superficie Corporal/métodos , Ablación por Catéter/métodos , Cardiomiopatía Chagásica/complicaciones , Cardiomiopatía Chagásica/terapia , Desfibriladores Implantables , Taquicardia Ventricular/etiología , Taquicardia Ventricular/prevención & control , Adulto , Anciano , Enfermedad Crónica , Terapia Combinada , Endocardio/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pericardio/cirugía , Resultado del TratamientoRESUMEN
Catecholaminergic polymorphic ventricular tachycardia occurs in healthy children and young adults causing syncope and sudden cardiac death. This is a familial disease, which affect de novo mutation in 50% of the cases. At least two causative genes have been described to be localized in the chromosome 1; mutation of the ryanodine receptor gene and calsequestrin gene. The classical clinical presentation is syncope triggered by exercise and emotion in children and adolescents with no structural heart disease. Polymorphic ventricular tachycardia during treadmill testing, or after isoproterenol infusion, is the most common feature. Therapeutic options include, beta-blockers, calcium-channel blockers and, an implantable cardioverter defibrillator is indicated in high-risk patients. Risk stratification of this disease is very challenging, since some risk factors proved to be useful in some series but not in others. However, family history of sudden cardiac death and symptoms initiated in very young children are important predictors.
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Antagonistas Adrenérgicos beta/efectos adversos , Propranolol/efectos adversos , Taquicardia Ventricular/inducido químicamente , Antagonistas Adrenérgicos beta/administración & dosificación , Niño , Diagnóstico Diferencial , Relación Dosis-Respuesta a Droga , Electrocardiografía Ambulatoria , Resultado Fatal , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Propranolol/administración & dosificación , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologíaRESUMEN
A case of Wolff-Parkinson-White syndrome successfully treated by transcutaneous epicardial radiofrequency ablation is described in a patient with a posteroseptal accessory pathway who had failed prior attempts of conventional endocardial and coronary venous system approaches. Simultaneous endocardial and pericardial space mapping was performed and only ablation from the pericardial space was successful, suggesting an epicardial course of the accessory pathway.
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Ablación por Catéter/métodos , Pericardio/cirugía , Síndrome de Wolff-Parkinson-White/cirugía , Mapeo del Potencial de Superficie Corporal , Cateterismo Cardíaco , Electrocardiografía , Estudios de Seguimiento , Sistema de Conducción Cardíaco/cirugía , Tabiques Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
INTRODUCTION: This study assessed the role of electrophysiologic testing to identify therapeutic strategies for the treatment of patients with sustained ventricular tachycardia (VT) and chronic chagasic cardiomyopathy treated with amiodarone or sotalol. METHODS AND RESULTS: One hundred fifteen patients [69 men (60%); mean age 52 +/- 10 years] with chagasic cardiomyopathy presenting with symptomatic VT were studied after loading with Class III antiarrhythmic drugs; 78 had a history of sustained VT, and 37 with symptomatic nonsustained VT had sustained VT induced at baseline electrophysiologic study. All but 12 patients also underwent baseline electrophysiologic study. Mean left ventricular ejection fraction was 0.49 +/- 0.14. Based on results of electrophysiologic study after loading with Class III drugs, patients were divided into three groups: group 1 (n = 23) had no sustained VT induced; group 2 (n = 45) had only tolerated sustained VT induced; and group 3 (n = 47) had hemodynamically unstable sustained VT induced. After a mean follow-up of 52 +/- 32 months, total mortality rate was 39.1%; it was significantly higher in group 3 than in groups 2 and 1 [69%, 22.2%, and 26%, respectively, P < 0.0001, hazard ratio (HR) 10.4, 95% confidence interval (CI) 3.8, 21.8]. There was no significant difference in total mortality rate between groups 1 and 2 (P = 0.40, HR 1.5, 95% CI 0.75, 4.58). Cardiac mortality and sudden cardiac death rates also were higher in group 3 patients. CONCLUSION: In patients with chagasic cardiomyopathy and sustained VT, electrophysiologic testing can predict long-term efficacy of Class III antiarrhythmic drugs. This may help in the selection of patients for implantable cardioverter defibrillator therapy.
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Amiodarona/uso terapéutico , Antiarrítmicos/uso terapéutico , Cardiomiopatía Chagásica/diagnóstico , Cardiomiopatía Chagásica/terapia , Técnicas Electrofisiológicas Cardíacas , Sotalol/uso terapéutico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/terapia , Adulto , Brasil , Cardiomiopatía Chagásica/mortalidad , Muerte Súbita Cardíaca/epidemiología , Muerte Súbita Cardíaca/etiología , Quimioterapia Combinada , Terapia por Estimulación Eléctrica , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Prevención Secundaria , Volumen Sistólico/fisiología , Análisis de Supervivencia , Taquicardia Ventricular/mortalidad , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/terapiaRESUMEN
Coronary artery injury is a rare complication of radiofrequency catheter ablation. We describe the case of a 12-year-old girl who had an acute distal right coronary artery (RCA) occlusion during radiofrequency catheter ablation of a postero-septal accessory pathway treated with mechanical reperfusion utilizing an angioplasty guidewire. Coronary angiography performed at 1-year follow-up depicted normal left ventricular function, patent descending posterior artery and total occlusion of the postero-lateral branch, which was filled through a rich collateral circulation from the RCA marginal branch.
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Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Arterias/lesiones , Arterias/cirugía , Ablación por Catéter , Angiografía Coronaria , Vasos Coronarios/lesiones , Vasos Coronarios/cirugía , Reperfusión Miocárdica , Niño , Femenino , Estudios de Seguimiento , Humanos , TiempoRESUMEN
Relata-se um caso de mapeamento e ablaçäo epicárdica percutânea de taquicardia ventricular sustentada de etiologia chagásica em que foi utilizada angiografia ventricular direita para orientar a punçäo pericárdica. Com o posicionamento de 2 microcateteres octapolares, obteve-se a localizaçäo detalhada e a extensäo da zona de conduçäo lenta da taquicardia clínica. Constatou-se nessa regiäo encarrilhamento com fusäo oculta e ciclo de retorno igual ao ciclo de frequência da taquicardia. A aplicaçäo local de radiofrequência interrompeu a taquicardia em 4 segundos, näo sendo possível sua reinduçäo. Conclui-se que a punçäo pericárdica pode ser orientada pela angiografia do ventrículo direito e que a utilizaçäo de múltiplos cateteres com microeletrodos pode fornecer dados adicionais no mapeamento e na ablaçäo epicárdica da taquicardia ventricular de etiologia chagásica.