Isolated cases of monomorphic ventricular tachycardia (MVT) in patients with Brugada syndrome (BrS) have been reported.
We aimed to describe the incidence and characteristics of MVT in a cohort of ...patients with BrS who had received an implantable cardioverter-defibrillator (ICD).
Data from 834 patients with BrS implanted with an ICD in 15 tertiary hospitals between 1993 and 2014 were included.
The mean age of enrolled patients was 45.3 ± 13.9 years; 200 patients (24%) were women. During a mean follow-up of 69.4 ± 54.3 months, 114 patients (13.7%) experienced at least 1 appropriate ICD intervention, with MVT recorded in 35 patients (4.2%) (sensitive to antitachycardia pacing in 15 42.8%). Only QRS width was an independent predictor of MVT in the overall population. Specifically, 6 (17.1%) patients presented with right ventricular outflow tract tachycardia (successfully ablated from the endocardium in 4 and epicardial and endocardial ablation in 1), 2 patients with MVT arising from the left ventricle (1 successfully ablated in the supra lateral mitral annulus), and 2 (5.7%) patients with bundle branch reentry ventricular tachycardia. Significant structural heart disease was ruled out by echocardiography and/or cardiac magnetic resonance imaging.
In this retrospective study, 4.2% of patients with BrS implanted with an ICD presented with MVT confirmed as arising from the right ventricular outflow tract tachycardia in 6, patients with MVT arising from the left ventricle in 2, and patients with bundle branch reentry ventricular tachycardia in 2. Endocardial and/or epicardial ablation was successful in 80% of these cases. These data imply that the occurrence of MVT should not rule out the possibility of BrS. This finding may also be relevant for ICD model selection and programming.
Contact force (CF) information may improve the safety and efficacy of ablation for paroxysmal atrial fibrillation (PAF).
The purpose of this study was to assess the impact of CF data on ablation for ...PAF.
Patients undergoing first-time PAF ablation were randomized at 7 UK centers to ablation with (CF-on) or without (CF-off) CF data available to the operator, using the same ablation catheter and mapping system. An ablation CF of 5-40g was targeted. Pulmonary vein (PV) reconnection was assessed with adenosine at 60 minutes. Follow-up for arrhythmia recurrence was for 1 year with 7-day Holter recordings at 6 and 12 months.
One hundred seventeen patients were studied (59 CF-on, 58 CF-off). In the CF-on group, a reduction in acute PV reconnection rates (22% vs 32%, P = .03) but no significant difference in 1-year success rates off antiarrhythmic drugs (49% vs 52%, P = .9) was observed. There was no difference in major complication rates: 2 of 59 (3%) CF-on, 3 of 58 (5%) CF-off (P = .7). Procedural and fluoroscopy times were not significantly different (P>.5). Overall mean CFs per ablation were not different between groups (13.4 9.1-19.6g CF-on, 13.4 7.4-22.4g CF-off, P = .5), but a greater proportion of readings in the CF-on group were in the target range (80% vs 68%, P<.001).
This randomized multicenter study demonstrated that CF data availability was associated with reduced acute PV reconnection but not improved 1-year success rates, procedural and fluoroscopy times, or complication rates. There was a reduction in extremes of CF, above and below the study target range, suggesting greater CF control during ablation.
The treatment of choice for atrioventricular nodal reentrant tachycardia (AVNRT) is catheter ablation of the atrioventricular nodal slow pathway.
The purpose of this study was to ascertain whether ...cryoablation (Cryo) with 6-mm-tip catheters is as effective as radiofrequency ablation (RF).
Patients who had catheter ablation for AVNRT between 2005 and 2008 were identified. The main outcome measure was overall success without the use of an alternative energy source and no recurrence.
Two hundred eighty-eight procedures in 272 patients were identified; 184 were female (68%), and the mean age was 53 +/- 14 (17-88) years. There were 123 Cryo and 149 RF procedures. Cryo had a lower overall success rate (83% vs. 93%; P = .02). Mean procedure times were similar in both groups (90 minutes; P = .5). Fluoroscopy time was longer with Cryo: 16 (7-48) versus 14 (5-50) minutes (P = .04). Only one case of atrioventricular block was observed in the RF group (0.7%). Cryo was more expensive than RF ( pounds sterling 3141 vs. pounds sterling 2153).
Even when delivering multiple lesions with 6-mm-tip catheters, Cryo is less effective than RF. RF is recommended as a first-line treatment, although the only major complication occurred in the RF group.
Implantation of a left ventricular (LV) lead fails in 5% to 10% of patients in whom cardiac resynchronization therapy (CRT) is attempted. Alternatives for delivery of CRT are surgical epicardial and ...endocardial transvenous leads. Endocardial transseptal LV lead delivery is challenging because of the absence of dedicated equipment designed for this procedure.
The purpose of this study was to describe a new technique for delivery of a transseptal LV lead.
This dual approach from the right femoral vein and left subclavian vein involves use of an Endrys transseptal needle and Mullins sheath to deliver a gooseneck snare from the left subclavian vein into the right atrium that can then be used to deliver a deflectable sheath into the left atrium. An active fixation lead is advanced into the LV through the sheath and screwed into the lateral wall.
The procedure was performed successfully in 12 patients in whom transvenous LV lead implantation had previously failed. The Endrys transseptal needle, ideally suited for this technique, facilitated passage of the gooseneck snare into the left atrium with no difficulty. Median procedure time was 148 minutes (interquartile range IQR 113-176 minutes), and median fluoroscopy time was 16 minutes (IQR 10-19 minutes). There was no need for repeat procedures after median follow-up of 97 days (IQR 36-313 days).
This approach using an Endrys needle and a gooseneck snare provides a reliable and effective alternative technique for delivery of an endocardial LV lead that is delivered easily through a deflectable sheath inserted transseptally into the LV.
BACKGROUND:Biomaterials derived from human adipose extracellular matrix have shown promise in vitro and in animal studies as an off-the-shelf adipogenic matrix for sustained volume replacement. ...Herein, we report the results of a randomized prospective study conducted with allograft adipose matrix (AAM) grafted into the pannus of presurgical abdominoplasty patients 3 or 6 months before scheduled surgery. This is the first report of a longitudinal histologic analysis of AAM in clinical use.
METHODS:Ten healthy patients undergoing elective abdominoplasty were recruited to receive AAM before surgery. Enrolled subjects were randomized into either a 3-month follow-up cohort or a 6-month follow-up cohort. Subjects were monitored for adverse events associated with AAM grafting in addition to undergoing serial biopsy. Following surgical excision of the pannus, representative samples from the AAM surgical sites were stained and evaluated with hematoxylin and eosin for tissue morphology, Masson’s trichrome for collagen, and perilipin for adipocytes.
RESULTS:All subjects tolerated AAM with no severe adverse events reported. At 3 months following implantation, AAM remained visible within the confines of the subjects’ native surrounding adipose tissue with sparse adipocytes apparent within the matrix. By 6 months, AAM had remodeled and was primarily composed of perilipin-positive adipocytes. Histologic analysis confirmed tissue remodeling (hematoxylin and eosin), adipogenesis (perilipin), and angiogenesis (Masson’s trichrome) occurred with the presence of AAM.
CONCLUSIONS:AAM is a safe, allogeneic, off-the-shelf regenerative matrix that is adipogenic and noninflammatory and promotes angiogenesis.
Catheter ablation of atrial fibrillation (AF) is a physically demanding procedure for the operator, involving radiation exposure, and has limited success rates. Remote robotic navigation (RRN) may ...offer benefit to the procedure, though only 1 previous small randomized trial has assessed this.
This study aimed to investigate the impact of RRN on 1-year single-procedure success rates.
RRN was compared to manual ablation in a randomized control trial setting by using an intention-to-treat analysis.
A total of 157 patients underwent ablation (116/157 (74%) persistent AF; 67/116 (58%) of these long-standing persistent AF). There were no significant differences between the RRN and manual groups with respect to 1-year single-procedure success rates (19/78 (24%) and 26/78 (33%), respectively; P = .29), acute wide area circumferential ablation reconnection rates, complication rates, or procedure times. On multivariable analysis, fluoroscopy times were significantly shorter in the RRN group. The number of catheter displacements during ablation was lower in the RRN group, as was subjectively assessed operator fatigue. The crossover rate from RRN to manual ablation was 11/78 (14%), mainly secondary to technical problems with the RRN system. A learning curve was evident for RRN ablation: the fluoroscopy and procedure times were significantly lower after the first 10 cases in an operator's experience.
This randomized trial showed no difference in the success rate for catheter ablation of AF between a RRN and manual approach. The results highlight the learning curve for RRN ablation and suggest that the use of this technology leads to an improvement in fluoroscopy times, catheter stability, and operator fatigue.
Abstract Background The relative importance of focal drivers, multiple wavelets, rotors and endocardial-epicardial circuits in the maintenance of persistent AF remains unclear. Our objective was to ...characterize AF wavefront (WF) dynamics during persistent AF. Methods The Ensite 3000 (St Jude Medical) non-contact mapping system was used to map the LA of 15 patients with persistent AF. Wavefronts were classified into planar WFs, rotors or focal WFs. For each new WF the site of origin, the unipolar electrogram, and propagation patterns were determined. Results AF was characterized by highly unstable patterns of activation with random combinations of 1–2 propagating planar wavefronts alternating with focal activations in a dynamic process. Stable reentry circuits and rotors were never seen. A total of 499 wavefront patterns were analyzed in this study (416 planar wavefronts and 83 focal wavefronts). In an individual patient planar WFs accounted for 67 ± 35% of activations with lifespans of 98 ± 86 ms. Focal activations accounted for 29.7 ± 33.5% of activations with lifespans of 76 ± 95 ms. The most common sites for new WF generation were the PVs (33%), LA roof (23%), anterior LA (15%), LAA (11%), and posterior LA (8%). The most common unipolar electrogram morphologies observed were QS pattern (34%), rS (29%), CFAE (26%), QR (7%) and Rs (4%), suggesting WFs may originate from both the endocardial and epicardial surfaces. Conclusion Human persistent AF is characterized by the formation of highly unstable WFs consisting of various combinations of one to two planar WFs and brief focal activations without any evidence of rotors or sustained focal sources.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
The presence of dynamic substrate changes may facilitate functional block and reentry in ventricular tachycardia (VT).
We aimed to study dynamic ventricular repolarization changes in critical regions ...of the VT circuit during sensed single extrastimulus pacing known as the Sense Protocol (SP).
Twenty patients (aged 67 ± 9 years, 17 male) underwent VT ablation. A bipolar voltage map was obtained during sinus rhythm (SR) and right ventricular SP pacing at 20 ms above ventricular effective refractory period. Ventricular repolarization maps were constructed. Ventricular repolarization time (RT) was calculated from unipolar electrogram T waves, using the Wyatt method, as the dV/dtmax of the unipolar T wave. Entrainment or pace mapping confirmed critical sites for ablation.
The median global repolarization range (max-min RT per patient) was 166 ms (interquartile range IQR 143–181 ms) during SR mapping vs 208 ms (IQR 182–234) during SP mapping (P = .0003 vs intrinsic rhythm). Regions of late potentials (LP) had a longer RT during SP mapping compared to regions without LP (mean 394 ± 40 ms vs 342 ± 25 ms, P < .001). In paired regions of normal myocardium there was no significant spatial dispersion of repolarization (SDR)/10 mm2 during SP mapping vs SR mapping (SDR 11 ± 6 ms vs 10 ± 6 ms, P = .54). SDR/10 mm2 was greater in critical areas of the VT circuit during SP mapping 63 ± 29 ms vs SR mapping 16 ± 9 ms (P < .001).
Ventricular repolarization is prolonged in regions of LP and increases dynamically, resulting in dynamic SDR in critical areas of the VT circuit. These dynamic substrate changes may be an important factor that facilitates VT circuits.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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