Prevalence and prognostic value of conduction disturbances in patients with the Brugada syndrome (BrS) remains poorly known. Electrocardiograms (ECGs) from 325 patients with BrS (47 ± 13 years, 258 ...men) with spontaneous (n = 143) or drug-induced (n = 182) type 1 ECG were retrospectively reviewed. Two hundred twenty-six patients (70%) were asymptomatic, 73 patients (22%) presented with unexplained syncope, and 26 patients (8%) presented with sudden death or implantable cardioverter-defibrillator appropriated therapies at diagnosis or during a mean follow-up of 48 ± 34 months. P-wave duration of ≥120 ms was present in 129 patients (40%), first degree atrioventricular block (AVB) in 113 (35%), right bundle branch block (BBB) in 90 (28%), and fascicular block in 52 (16%). Increased P-wave duration, first degree AVB, and right BBB were more often present in patients after drug challenge than in patients with spontaneous type 1 ST elevation. Left BBB was present in 3 patients. SCN5A mutation carriers had longer P-wave duration and longer PR and HV intervals. In multivariate analysis, first degree AVB was independently associated with sudden death or implantable cardioverter-defibrillator appropriated therapies (odds ratio 2.41, 95% confidence interval 1.01 to 5.73, p = 0.046) together with the presence of syncope and spontaneous type 1 ST elevation. In conclusion, conduction disturbances are frequent and sometimes diffuse in patients with BrS. First degree AVB is independently linked to outcome and may be proposed to be used for individual risk stratification.
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.
Characteristics of multiple-loop atrial tachycardia (AT) circuits have never precisely examined.
In 193 consecutive post-atrial fibrillation ablation patients with AT, 44 multiple-loop ATs including ...42 dual-loop AT and 2 triple-loop AT in 41 (21.2%) were diagnosed with the high-resolution mapping system and analyzed off-line.
In dual-loop ATs, 3 types were identified: type M, a combination of 2 anatomic macroreentrant ATs (AMATs) in 19 (43.2%); type MN, with 1 AMAT and 1 non-AMAT in 12 (27.3%); and type N with 2 non-AMATs in 11 (25.0%). The remaining 2 triple-loop ATs (4.5%) were a combination of perimitral-, roof-dependent-, and non-AMAT. At least 1 AMAT was included in 33 (75.0%), and 1 non-AMAT in 25 (56.8%). Of the ATs with at least 1 non-AMAT circuit, a pulmonary vein formed part of the circuit in 16/25 (64.0%). The length of the common isthmus was 3.6±1.4 cm in type M, 1.6±0.7 cm in type MN, and 1.1±0.7 cm in type N (
<0.0001). The area of the common isthmus was 12.92±7.68, 2.46±1.53, and 0.90±0.81 cm
, in Type M, MN, and N (
<0.0001). The narrowest width of the common isthmus was 1.8±0.7 cm, 1.1±0.3 cm, and 0.7±0.3 cm in type M, MN, and N (
<0.0001), respectively. The electrograms in the common isthmus showed longer duration and lower voltage in type N, type MN, and type M (duration: 106±25 ms, 87±27 ms, and 69±27 ms;
=0.006; and voltage: 0.06±0.02 mV, 0.22±0.21 mV, and 0.57±0.50 mV;
<0.0001), respectively.
Multiple-loop ATs are complex, frequently including anatomic circuits. They have specific characteristics determined by the combination of AMAT and non-AMAT.
Background Little data are available in women presenting with ventricular fibrillation (VF) in the setting of acute myocardial infarction (AMI). We assessed frequency, predictors of VF, and outcomes, ...with a special focus on women compared with men. Methods and Results Data were analyzed from the FAST‐MI (French Registry of Acute ST‐Elevation or Non‐ST‐Elevation Myocardial Infarction) program, which prospectively included 14 406 patients admitted to French cardiac intensive care units ≤48 hours from AMI onset between 1995 and 2015 (mean age, 66±14 years; 72% men; mean left ventricular ejection fraction, 52±12%; 59% with ST‐segment–elevation myocardial infarction). A total of 359 patients developed VF during AMI, including 81 women (2.0% of 4091 women) and 278 men (2.7% of 10 315 men, P =0.02). ST‐segment–elevation myocardial infarction (odds ratio OR, 2.29 95% CI, 1.75–2.99; P <0.001) was independently associated with the onset of VF during AMI. In contrast, female sex (OR, 0.73 95% CI, 0.56–0.95; P =0.02), hypertension (OR, 0.75 95% CI, 0.60–0.94; P =0.01), and prior myocardial infarction (OR, 0.69 95% CI, 0.50–0.96; P =0.03) were protective factors. Women were less likely to have cardiac intervention than men (percutaneous coronary intervention during hospitalization 48.1% versus 66.9%, respectively; P =0.04) with a higher 1‐year mortality in women compared with men (50.6% versus 37.4%, respectively; P =0.03), including increased in‐hospital mortality (42.0% versus 32.7%, respectively; P =0.12). After adjustment, female sex was no longer associated with a worse 1‐year mortality (adjusted hazard ratio, 1.10 95% CI, 0.75–1.61; P =0.63). Conclusions Women have lower risk of developing VF during AMI compared with men. However, they are less likely to receive cardiac interventions than men, possibly contributing to missed opportunities of improved outcomes.
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and ...fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta‐analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow‐up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
During the same period, a total of 450 NKX2.5 gene screenings were performed. ...approximately 90% of the genetic analyses were negative. Structural cardiomyopathy was observed in 14 patients (28%) ...(7 left ventricular noncompaction, 4 hypertrophic cardiomyopathy, 2 dilated cardiomyopathy DCM, 1 restrictive/constrictive) with a preserved left ventricular ejection fraction in 44 of 48 patients.
Background Cardiac adrenergic receptor gene polymorphisms have the potential to influence risk of developing ventricular fibrillation (VF) during ST-segment-elevation myocardial infarction, but no ...previous study has comprehensively investigated those most likely to alter norepinephrine release, signal transduction, or biased signaling. Methods and Results In a case-control study, we recruited 953 patients with ST-segment-elevation myocardial infarction without previous cardiac history, 477 with primary VF, and 476 controls without VF, and genotyped them for
Arg389Gly and Ser49Gly,
Gln27Glu and Gly16Arg, and
Ins322-325Del. Within each minor allele-containing genotype, haplotype, or 2-genotype combination, patients with incident VF were compared with non-VF controls by odds ratios (OR) of variant frequencies referenced against major allele homozygotes. Of 156 investigated genetic constructs, 19 (12.2%) exhibited significantly (
<0.05) reduced association with incident VF, and none was associated with increased VF risk except for
Gly389 homozygotes in the subset of patients not receiving β-blockers.
Gly49 carriers (prevalence 23.0%) had an OR (95% CI) of 0.70 (0.49-0.98), and the
322-325 deletion (Del) carriers (prevalence 13.5%) had an OR of 0.61 (0.39-0.94). When present in genotype combinations (8 each), both
Gly49 carriers (OR, 0.67 0.56-0.80) and
Del carriers (OR, 0.57 0.45- 0.71) were associated with reduced VF risk. Conclusions In ST-segment-elevation myocardial infarction, the adrenergic receptor minor alleles
Gly49, whose encoded receptor undergoes enhanced agonist-mediated internalization and β-arrestin interactions leading to cardioprotective biased signaling, and
Del322-325, whose receptor causes disinhibition of norepinephrine release, are associated with a lower incidence of VF. Registration URL: https://clinicaltrials.gov; Unique identifier: NCT00859300.
Atrial arrhythmia (AA) is common among patients with cardiac amyloidosis (CA), who have an increased risk of intracardiac thrombus. The aim of this study was to explore the prognostic impact of ...vitamin K-antagonists (VKA) and direct oral anticoagulants (DOAC) in patients with CA.
273 patients with CA and history of AA with long term anticoagulation-69 (25%) light chain amyloidosis (AL), 179 (66%) wild-type transthyretin amyloidosis (ATTRwt) and 25 (9%) variant transthyretin amyloidosis (ATTRv)-were retrospectively included between January 2012 and July 2020. 147 (54%) and 126 (46%) patients received VKA and DOAC, respectively. Patient receiving VKA were more likely to have AL with renal dysfunction, higher NT-proBNP and troponin levels. Patients with ATTRwt were more likely to receive DOAC therapy. There were more bleeding complications among patients with VKA (20 versus 10%;
= 0.013) but no difference for stroke events (4 vs. 2%;
= 0.223), as compared to patients with DOAC. A total of 124 (45%) patients met the primary endpoint of all-cause mortality: 96 (65%) and 28 (22%) among patients with VKAs and DOACs, respectively (
< 0.001). After multivariate analysis including age and renal function, VKA was no longer associated with all-cause mortality.
Among patients with CA and history of AA receiving oral anticoagulant, DOACs appear to be at least as effective and safe as VKAs.
Ventricular fibrillation (VF) storm after myocardial infarction (MI) is a life-threatening condition that necessitates multiple defibrillations. Catheter ablation is a potentially effective treatment ...strategy for VF storm refractory to optimal medical treatment. However, its impact on patient survival has not been verified in a large population.
We conducted a multicenter, retrospective observational study involving consecutive patients who underwent catheter ablation of post-MI refractory VF storm without preceding monomorphic ventricular tachycardia. The target of ablation was the Purkinje-related ventricular extrasystoles triggering VF. The primary outcome was in-hospital and long-term mortalities. Univariate logistic regression and Cox proportional-hazards analysis were used to evaluate clinical characteristics associated with in-hospital and long-term mortalities, respectively.
One hundred ten patients were enrolled (age, 65±11years; 92 men; left ventricular ejection fraction, 31±10%). VF storm occurred at the acute phase of MI (4.5±2.5 days after the onset of MI during the index hospitalization for MI) in 43 patients (39%), the subacute phase (>1 week) in 48 (44%), and the remote phase (>6 months) in 19 (17%). The focal triggers were found to originate from the scar border zone in 88 patients (80%). During in-hospital stay after ablation, VF storm subsided in 92 patients (84%). Overall, 30 (27%) in-hospital deaths occurred. The duration from the VF occurrence to the ablation procedure was associated with in-hospital mortality (odds ratio for each 1-day increase, 1.11 95% CI, 1.03-1.20; P=0.008). During follow-up after discharge from hospital, only 1 patient developed recurrent VF storm. However, 29 patients (36%) died, with a median survival time of 2.2 years (interquartile range, 1.2-5.5 years). Long-term mortality was associated with left ventricular ejection fraction <30% (hazard ratio, 2.54 95% CI, 1.21-5.32; P=0.014), New York Heart Association class ≥III (hazard ratio, 2.68 95% CI, 1.16-6.19; P=0.021), a history of atrial fibrillation (hazard ratio, 3.89 95% CI, 1.42-10.67; P=0.008), and chronic kidney disease (hazard ratio, 2.74 95% CI, 1.15-6.49; P=0.023).
In patients with MI presenting with focally triggered VF storm, catheter ablation of culprit triggers is lifesaving and appears to be associated with short- and long-term freedom from recurrent VF storm. Mortality over the long-term follow-up is associated with the severity of underlying cardiovascular disease and comorbidities in this specific patient population.
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