Prior reports on patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) focused on individuals with advanced forms of the disease. Data on the diagnostic performance of ...various testing modalities in newly identified individuals suspected of having ARVC/D are limited.
The purpose of the Multidisciplinary Study of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia was to study the clinical characteristics and diagnostic evaluation of a large group of patients newly identified with ARVC/D.
A total of 108 newly diagnosed patients with suspected ARVC/D were prospectively enrolled in the United States and Canada. The patients underwent noninvasive and invasive tests using standardized protocols that initially were interpreted by the enrolling center and adjudicated by blind analysis in six core laboratories. Patients were followed for a mean of 27 +/- 16 months (range 0.2-63 months).
The clinical profile of these newly diagnosed patients differs from the profile of reported patients with more advanced disease. There was considerable difference in the initial and final classification of the presence of ARVC/D after the diagnostic tests were evaluated by the core laboratories. Final clinical diagnosis was 73 affected, 28 borderline, and 7 unaffected. Individual tests agreed with the final diagnosis in 50% to 70% of the 73 patients with a final classification of affected.
The clinical profile of 108 newly diagnosed probands with suspected ARVC/D indicates that a combination of diagnostic tests is needed to evaluate the presence of right ventricular structural, functional, and electrical abnormalities. Echocardiography, right ventricular angiography, signal-averaged ECG, and Holter monitoring provide optimal clinical evaluation of patients suspected of ARVC/D.
Biomarkers are important prognostic tools in various cardiovascular conditions, including coronary artery disease and heart failure. Although their utility in cardiac electrophysiology (EP) is less ...established, biomarkers may guide EP clinical practice by identifying patients at risk for developing arrhythmias and their complications, in addition to augmenting therapeutic decisions by targeting appropriate pharmacologic and interventional therapies to patients who may benefit most. In this review, we focus on the prognostic role of high-sensitivity cardiac troponin (hs-cTn) assays—which detect subclinical cardiac myocyte damage—in cardiac arrhythmias and their sequelae. We review the current literature on hs-cTn and its impact on various arrhythmia disease states and also provide suggestions for future research in this field. In conclusion, although the utility of hs-cTn assays remains at an investigational stage in cardiac EP, studies to date have suggested value as a prognostic biomarker in atrial fibrillation and as a screening marker for patients at high risk of sudden cardiac death (both in the general population and among those with hypertrophic cardiomyopathy).
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Most studies of catheter ablation for the treatment of ventricular tachycardia (VT) are relatively small observational trials.
The purpose of this study was to define the relative risk of VT ...recurrence in patients undergoing catheter ablation as an adjunct to medical therapy versus medical therapy alone in a pooled analysis of controlled studies.
Randomized and nonrandomized controlled trials of patients who underwent adjunctive catheter ablation of VT versus medical therapy alone were sought. MEDLINE, EMBASE, the Cochrane central register of controlled trials (CENTRAL), and Web of Science were searched from 1965 to July 2010. Supplemental searches included Internet resources, reference lists, and reports of arrhythmia experts. Three authors independently reviewed and extracted the data regarding baseline characteristics, ablation methodology, medical therapy, complications, VT recurrences, mortality, and study quality.
Five studies were included totaling 457 participants with structural heart disease. Adjunctive catheter ablation was performed in 58% of participants, whereas 42% received medical therapy alone for VT. Complications of catheter ablation included death (1%), stroke (1%), cardiac perforation (1%), and complete heart block (1.6%). Using a random-effects model, a statistically significant 35% reduction in the number of patients with VT recurrence was noted with adjunctive catheter ablation (P<.001). There was no statistically significant difference in mortality.
Catheter ablation as an adjunct to medical therapy reduces VT recurrences in patients with structural heart disease and has no impact on mortality.
Cardiac magnetic resonance (CMR) T1 mapping is an emerging tool for objective quantification of myocardial fibrosis.
To (a) establish the feasibility of left atrial (LA) T1 measurements, (b) ...determine the range of LA T1 values in patients with atrial fibrillation (AF) vs healthy volunteers, and (c) validate T1 mapping vs LA intracardiac electrogram voltage amplitude measures.
CMR imaging at 1.5 T was performed in 51 consecutive patients before AF ablation and in 16 healthy volunteers. T1 measurements were obtained from the posterior LA myocardium by using the modified Look-Locker inversion-recovery sequence. Given the established association of reduced electrogram amplitude with fibrosis, intracardiac point-by-point bipolar LA voltage measures were recorded for the validation of T1 measurements.
The median LA T1 relaxation time was shorter in patients with AF (387 interquartile range 364-428 ms) compared to healthy volunteers (459 interquartile range 418-532 ms; P < .001) and was shorter in patients with AF with prior ablation compared to patients without prior ablation (P = .035). In a generalized estimating equations model, adjusting for data clusters per participant, age, rhythm during CMR, prior ablation, AF type, hypertension, and diabetes, each 100-ms increase in T1 relaxation time was associated with 0.1 mV increase in intracardiac bipolar LA voltage (P = .025).
Measurement of the LA myocardium T1 relaxation time is feasible and strongly associated with invasive voltage measures. This methodology may improve the quantification of fibrotic changes in thin-walled myocardial tissues.
The extent of left atrial (LA) late gadolinium enhancement (LGE), as a surrogate for fibrosis, has been associated with atrial fibrillation (AF) recurrence after catheter ablation. Furthermore, there ...is ex vivo evidence that islands of fibrosis may anchor fibrillatory rotors.
The purpose of this study was to examine the anatomical association of AF rotors with LA and right atrial (RA) LGE on cardiac magnetic resonance.
The cohort included 9 patients with persistent AF (mean age 61.1 ± 9.7 years) who underwent LGE cardiac magnetic resonance before AF ablation using the focal impulse and rotor modulation system. The extent of LA and RA LGE was quantified globally and in each of the 7 sectors: LA posterior/inferior wall, anterior wall, roof, left and right pulmonary vein antra, and RA lateral and septal regions. The multivariable association of rotor incidence with global and per sector LGE extent was examined using multivariable Bernoulli logistic regression estimated by generalized estimating equations.
The mean RA and LA volumes were 113.2 ± 37.31 and 143.03 ± 58.25 mL, respectively. The mean RA and LA LGE burden was 17.2% ± 11.0% and 17.4% ± 14.4%, respectively. A total of 18 LA rotors and 9 RA rotors were identified in all patients. No univariable or multivariable association was observed between global or per sector LGE extent and focal impulse and rotor modulation rotor incidence.
In this cohort of patients, there was no association between AF rotor incidence and the global or regional extent of RA and LA LGE.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Fleischmann, Kirsten E., MD, MPH, FACC; Beckman, Joshua A., MD, FACC; Buller, Christopher E., MD, FACC ...
Journal of the American College of Cardiology,
11/2009, Volume:
54, Issue:
22
Journal Article
Peer reviewed
Open access
The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. ...there are ...circumstances in which deviations from these guidelines may be appropriate.\n42 1.14 to 1.76 Appendix 3 Perioperative Beta Blockade in Noncardiac Surgery Studies: Summary Table AAA indicates abdominal aortic aneurysm; bpm, beats per minute; CAD, coronary artery disease; CHF, congestive heart failure; CI, confidence interval; DSE, dobutamine stress echocardiography; HR, hazard ratio; MI, myocardial infarction; n, number; NNT, number needed to treat; NWMA, new wall-motion abnormality; OR, odds ratio; RCRI, Revised Cardiac Risk Index; RCT, randomized controlled trial; and RR, relative risk.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives This study aims to compare the performance of electrophysiology fellows in transseptal catheterization (TSP-C) after conventional (Conv-T) or simulator training (Sim-T). Background Current ...training for TSP-C, an increasingly used procedure, relies on performance on patients with supervision by an experienced operator. Virtual reality, a new training option, could improve post-training performance. Methods Fellows inexperienced in TSP-C were enrolled and randomly assigned to Conv-T or Sim-T. The post-training performance of each fellow was evaluated and scored in 3 consecutive patient-based procedures by an experienced operator blinded to the fellow's training assignment. Results Fourteen fellows were randomized to Conv-T (n = 7) or to Sim-T (n = 7) and, after training, performed 42 TSP-Cs independently. Training time was significantly longer for Conv-T than for Sim-T (median 30 days vs. 4 days; p = 0.0175). The Conv-T fellows had significantly lower post-training performance scores (median 68 vs. 95; p = 0.0001) and a higher number of recurrent errors (median 3 vs. 0; p = 0.0006) when compared with Sim-T fellows. Conclusions The TSP-C training with virtual reality results in shorter training times and superior post-training performance.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Ablation success was defined in accordance with the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society consensus document as freedom from AF, atrial ...flutter, or atrial tachycardia lasting 30 seconds or longer after a 3-month blanking period. The ablation strategy involved a combined minimally invasive, off-pump thoracoscopic surgical approach using the Atricure bipolar radiofrequency clamp (Atricure, West Chester, Ohio), a bipolar radiofrequency linear pen, and a conventional endocardial irrigated radiofrequency catheter ablation system (ThermoCool, Biosense Webster, Diamond Bar, California).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Individuals with chronic kidney disease, particularly those requiring dialysis, are at high risk of sudden cardiac death (SCD). However, comprehensive data for the full-spectrum of kidney ...function and SCD risk in the community are sparse. Furthermore, newly developed equations for estimated glomerular filtration rate (eGFR) and novel filtration markers might add further insight to the role of kidney function in SCD. Methods We investigated the associations of baseline eGFRs using either serum creatinine, cystatin C, or both (eGFRcr, eGFRcys, and eGFRcr-cys), cystatin C itself, and β2 -microglobulin (B2M) with SCD (205 cases through 2001) among 13,070 blacks and whites ARIC participants at baseline during 1990–92 using Cox regression models accounting for potential confounders. Results Low eGFR was independently associated with SCD risk: for example, HR for eGFR <45 vs ≥90 ml/min/1.73m2 was 3.71 (95%CI 1.74–7.90) with eGFRcr; 5.40 (2.97–9.83) with eGFRcr-cys; and 5.24 (3.01–9.11) with eGFRcys. When eGFRcr and eGFRcys were included together in a single model, the association was only significant for eGFRcys. When three eGFR, cystatin C, and B2M were divided into quartiles, B2M demonstrated the strongest association with SCD (HR for 4th quartile vs 1st quartile 3.48 (2.03–5.96) vs. ≤2.7 for the other kidney markers). Conclusions Kidney function was independently and robustly associated with SCD in the community, particularly when cystatin C or B2M was used. These results suggest the potential value of kidney function as a risk factor for SCD and the advantage of novel filtration markers over eGFRcr in this context. Index words. Sudden cardiac death (SCD); estimated glomerular filtration rate (eGFR); kidney function; cystatin C; β2 -microglobulin (B2M); β-trace protein (BTP); chronic kidney disease (CKD); Atherosclerosis Risk in Communities (ARIC) Study
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