Although implantable cardioverter defibrillators offer the best protection against sudden cardiac death, catheter ablation for ventricular arrhythmias (VAs) can modify or prevent this event from ...occurring. In order to achieve a successful ablation, the correct identification of the underlying arrhythmogenic substrate is mandatory to tailor the pre-procedural planning of an ablative procedure as appropriately as possible. We propose that several of the imaging modalities currently used could be merged, including echocardiography (also intracardiac), cardiac magnetic resonance, cardiac computed tomography, nuclear techniques, and electroanatomic mapping. The aim of this state-of-the-art review is to present the value of each modality, that is, its benefits and limitations, in the assessment of arrhythmogenic substrate. Moreover, VAs can be also idiopathic, and in this paper we will underline the role of these techniques in facilitating the ablative procedure. Finally, a hands-on workflow for approaching such a VA and future perspectives will be presented.
Izhodišče: Katetrska ablacija je danes uveljavljena metoda zdravljenja preddvorne fibrilacije (AF). O zgodnjih in srednjeročnih izidih smo že poročali. Tokrat želimo predstaviti še dolgoročne ...klinične izide.
Metode: Spremljali smo vse bolnike, pri katerih smo v obdobju 2003‒2009 prvič opravili katetrsko ablacijo paroksizmalne ali vztrajajoče AF zaradi neučinkovitosti antiaritmičnega zdravljenja. Upoštevali smo tudi ablacijske posege zaradi tipične atrijske undulacije (AU) po letu 1999. Glavni cilj ablacijskega posega je bil popolna električna osamitev pljučnih ven (PV). Uporabili smo metodo segmentne radiofrekvenčne ablacije s fluoroskopskim nadzorom in beleženjem elektrogramov na krožnem katetru »laso«. Pri bolnikih s tipično AU smo opravili linijsko ablacijo kavotrikuspidalne ožine. Bolnike smo spremljali vsaj 5 let po doseženi popolni osamitvi PV oz. do telefonskega razgovora v aprilu 2020 oz. do morebitne smrti. Razvrstili smo jih v tri skupine: a) uspešne, tj. v stabilnem sinusnem ritmu z nemotečimi palpitacijami do 5 min, brez rednega antiaritmičnega zdravljenja, b) delno uspešne, ko so bili pretežno v sinusnem ritmu, z epizodami dokumentirane AF/AU do enkrat letno in tudi občasno uporabo antiaritmičnih zdravil v ustreznih odmerkih in c) neuspešne, tj. s pogostimi epizodami AF/AU, neučinkovitim antiaritmičnim zdravljenjem v ustreznih odmerkih ali z dolgotrajno vztrajajočo AF/AU. Ablacijski poseg smo ponovili zaradi recidiva AF/AU, vendar ne prej kot po 3 mesecih. Ob sumu na ponovitev aritmije smo naročili serijske posnetke EKG in Holterjevega monitoriranja. Podatke smo vrednotili s Kaplan-Meierjevo analizo, testom-t in Fisherjevim testom. Vrednost p < 0,05 je bila značilna.
Rezultati: V raziskavo smo uvrstili 128 bolnikov (95 moških, 33 žensk; mediana starost pri prvem posegu zaradi AF je bila 54,5 let, rang 19–75), pri katerih smo opravili povprečno 1,7 ablacijskega posega zaradi AF oziroma 2 posega, če smo upoštevali še ablacije AU. Spremljanje je zaključilo 117 bolnikov (85 moških in 32 ženskah) po povprečno 11,7 letih (mediana 140 mesecev, rang 21–230 mesecev). Umrlo je 10 bolnikov (6 moških, 4 ženske), nihče pa zaradi ablacijskega posega. Od soobolevnosti sta bili v ospredju maligna bolezen in ščitnična disfunkcija. Verjetnost za ohranitev stabilnega sinusnega ritma je bila po 10 letih približno 50-odstotna. Po 15-odstotnem padcu verjetnosti za sinusni ritem v prvem letu je bil padec nato linearen, in sicer 4 % letno. Ablacijsko zdravljenje je bilo uspešno pri 54 bolnikih (46 %), delno uspešno pri 25 (21 %) in neuspešno pri 38 bolnikih (33 %, manj uspešno pri ženskah, p < 0,05). V zadnjih 10 letih spremljanja smo opravili manjši del ablacijskih posegov ‒ 46 (16 %). Antiaritmična zdravila je prejemalo 38 bolnikov (32 %), pretežno amiodaron in propafenon. Med ablacijskim posegom smo povzročili tamponado pri 5 bolnikih (4 %). Nihče od njih ni potreboval kirurškega posega. Drugih večjih zapletov ni bilo.
Zaključek: Ablacijsko zdravljenje AF je dolgoročno dovolj uspešno, varno in po podatkih drugih avtorjev tudi cenovno učinkovito. Zato ga lahko priporočimo večini bolnikov z AF. Za celostno obravnavo bolnikov z AF pa so pomembni tudi: ureditev odpravljivih dejavnikov tveganja, antiaritmično zdravljenje in kakovostno antikoagulacijsko zdravljenje.
Bolezni perikarda so lahko izoliran bolezenski proces, ali pa so del sistemskih bolezenskih stanj. V zahodnem svetu, kjer je prevalenca tuberkuloze nizka, je perikarditis najpogosteje povezan z ...virusnimi okužbami, avtoimunskimi procesi ali pa malignomi. Glede na klinično sliko lahko bolezni perikarda razdelimo v nekaj glavnih sindromov: perikarditis, izoliran perikardni izliv, tamponada srca, konstrikcijski perikarditis in mase/ciste v perikardu. Zadnje smernice Evropskega kardiološkega združenja prinašajo nekaj novosti na področju triažiranja in diagnosticiranja bolnikov z boleznimi perikarda, predvsem pa se jasneje opredelijo do strategij zdravljenja posameznih perikardnih sindromov. Članek povzema evropske smernice in vključuje prilagoditve za naše razmere.
Izvleček
Refleksna nevrokardiogena sinkopa je ena izmed najbolj pogostih oblik izgube zavesti, pri kateri prekomeren odziv parasimpatičnega živčnega sistema vodi do padca krvnega pritiska preko ...vazodilatacije in/ali znižanja srčnega utripa. Gre za sinkopo, ki praviloma ni povezana z organsko boleznijo, zato je njena prognoza dobra in umrljivost ni povečana, lahko pa vpliva na kvaliteto življenja. Z novo metodo zdravljenja - kardionevroablacijo - želimo doseči izboljšanje kvalitete življenja pri pacientih s pogostimi epizodami refleksne nevrokardiogene sinkope s prevladujočo kardioinhibitorno komponento, pri katerih nefarmakološki in farmakološki načini zdravljenja niso učinkoviti, vstavitev srčnega spodbujevalnika pa zaradi mladosti odsvetovana. Gre za perkutani elektrofiziološki poseg, kjer z radiofrekvenčno ablacijo z endokardialne strani uničimo specifične parasimpatične ganglije epikardialno na srcu. Na ta način dosežemo delno parasimpatično denervacijo srca in s tem zmanjšamo ali odpravimo prekomeren vpliv parasimpatičnega živčevja na srce in posledično tudi kardioinhibitorno komponentno refleksne nevrokardiogene sinkope.
Ventricular tachycardia (VT) poses a significant risk for sudden death and heart failure exacerbation in patients with ischemic heart disease. Catheter-based radiofrequency ablation is the last ...treatment option for patients with frequent VT recurrences despite antiarrhythmic drugs. The aim was to present our retrospective catheter ablation data in this group of patients.The majority of 34 patients, who underwent percutaneous endocardial radiofrequency catheter ablation, were male, median age 67.5 years, who presented with electrical storm, had underlying cardiomyopathy after remote inferior wall myocardial infarction and preceding myocardial revascularization procedure, and had been implanted with cardioverter-defibrillator (ICD). Two ablation methods were used: linear ablation and/or scar homogenization. Acute ablation success (non-inducibility of any VT) was achieved in 59 % of procedures. VT could not be interrupted in 2 (6 %) patients. Pericardial tamponade that needed surgical intervention occurred in one procedure (2 %), and was related to inadvertent perforation of the right ventricular apex with a diagnostic catheter. Seven (20 %) patients died and additional 3 were lost from the median of 31 (6–151, rank) months of follow-up. No late VT recurrences were demonstrated in 20 (59 %) patients, and rare in 4 (12 %). Overall, the ablation procedure was successful in 71 % of patients.Catheter ablation gave very good long-term clinical result in about two-thirds of our patients with ischaemic cardiomyopathy and frequent VT recurrences. Catheter ablation, preferably with scar homogenization approach, should be considered early to reduce the number of VT episodes and ICD discharges.
The aim was to determine cardiovascular responses to an arbitrary protocol of transcutaneous low-level vagus nerve electrical stimulation (tVNS).
Study was performed in 15 male volunteers, mean age ...23 years. Data were collected during two sessions – sham stimulation (no stimulation) and stimulation. Each session included one-hour resting phase followed by 15-min autonomic nervous system testing phase (Valsalva, deep breathing, wet-cold face tests), all in supine position. The right tragus stimulation parameters were: 20 Hz, constant current at sensation threshold, 1 ms rectangular pulse width. The ECG, noninvasive arterial blood pressure and thoracic impedance cardiography measurements were recorded and analyzed continuously with the Task Force® Monitor (CNSystems Medizintechnik GmbH, Graz, Ver. 2.2.10.0). t-Test for paired samples, paired Wilcoxon signed-rank, and one-way ANOVA for repeated measurements were carried out. P < 0.05 was considered significant.
We demonstrated significant reductions of left ventricular contractility and output parameters, a trend for heart rate reduction, and resulting beneficial reduction of left ventricular work load. However, significant increases of blood pressure and total peripheral resistance were recognized, possibly as a reflex response.
It seems that our tVNS protocol has a potential for cardiac autonomic modulation. This gives us opportunity to advance our stimulation parameters with participant-specific adjustments. Further studies are however needed to prove the therapeutic potential of such approach in different patient groups.
•Noninvasive arterial blood pressure and thoracic impedance cardiography measurements were recorded and analysed continuosly•Significant reduction of cardiac contractility and output were seen during low-level transcutaneous vagus nerve stimulation•This gives the opportunity to adjust stimulation parameters individually
The object of the proposed paper is to design and analyze the performance of a non-contact heart rate variability (
) measuring device based on ultrasound transducers. The rationale behind ...non-contact
measurement is the goal of obtaining a means of long term monitoring of a patient's heart performance. Due to its complexity as a non-contact measuring device, influential physical quantities, error source and other perturbations were thoroughly investigated. For medical purposes it is of utmost importance to define the target uncertainty of a measuring method from the side of physicians, while it is the role of scientists to realistically evaluate all uncertainty contributions. Within this paper we present a novelty method of non-contact
measurement based on ultrasound transducers operating at two frequencies simultaneously. We report laboratory results and clinical evaluations are given for healthy subjects as well as patients with known heart conditions. Furthermore, laboratory tests were conducted on subjects during a relaxation period, and after 1 min physical activity.
Background: Intracardiac echocardiography (ICE) is an established imaging modality for guiding electrophysiology procedures, with a rapidly expanding role also in other percutaneous structural ...interventions. Endomyocardial biopsy (EMB) is another potential application where ICE can be used to guide diagnosis of cardiac tumors.1-3 Here we present our first case of a cardiac tumor in which EMB was guided by ICE.
Case report: 62-year-old man with a history of non-Hodgkin lymphoma treated with radiation and chemotherapy 10 years ago was admitted due to acute coronary syndrome. Coronary angiogram showed a subtotal occlusion of already collateralized RCA. Due to induced ischemia on myocardial perfusion imaging postponed percutaneous coronary intervention of RCA was performed. During diagnostic work-up at admission when pulmonary embolism was at first suspected, CTA was performed. It showed a heterogeneous formation in the right ventricle (RV) with a thickness of up to 16 mm, that extended from the base towards the apex and into the interventricular septum at the level of the tricuspid ring (Figure 1). According to the CT appearance the mass was suspected to be a liposarcoma. Transthoracic echocardiography showed a hypoechogenic form in the RV, clearly defined after application of contrast for left ventricular opacification. Due to previous history of malignancy PET CT was done that revealed hypometabolic RV mass without any sign of distant metastasis. Percutaneous biopsy of the cardiac mass for histopathological diagnosis was performed guided by ICE and fluoroscopy. ICE allowed continuous imaging of intracardiac
structures and clear visualization of the cardiac mass in the RV outflow tract under the pulmonary valve (Figure 2). On angiography there was no evidence of flow restriction. A cardiac biopsy catheter was percutaneously inserted into the RV and with the guidance of ICE accurate positioning of the bioptome was achieved. Three tumor specimens were taken for analysis. The histology revealed lipoma, with no evidence of malignancy. In the absence of any cardiac functional disturbances surgical therapy could be avoided and follow-up was proposed.
Conclusion: Cardiac masses are rare and often incidental findings. Histology provides definite diagnosis and ICE could be a valuable tool for guiding biopsy procedure. Our first experience confirmed the benefits of ICE that are real-time visualization of cardiac structures,
facilitating proper positioning of biopsy catheter, good patient tolerability and the lack of need for general anesthesia. Therefore, with ICE guided percutaneous biopsy the more invasive diagnostic open heart procedures could be avoided.
The aim of this study was to characterize cardiovascular autonomic responses during two constant current intensities below sensory threshold of transcutaneous auricular nerve stimulation (taNS). On ...this basis, a protocol for taNS with autonomic modulatory potential could be proposed.
We included 26 men and 24 women, mean age 26. Data were collected during three randomly allocated 20-minute right tragus stimulation sessions – a) no-stimulation (sham), b) 90 µA (arbitrary), and c) 130 µA (near the lowest sensory threshold in majority). Stimulation was 20 Hz, rectangular pulse width of 2 ms, duty cycle 2-second on/off. To assess autonomic responses, we continuously recorded ECG, non-invasive arterial blood pressure (BP) and thoracic impedance cardiography data. Ten-minute data were compared. Fast Fourier transform of RR intervals was performed on 10-minute recordings as well. Low frequency and high frequency power spectra were calculated. Friedman test or one-way ANOVA for repeated measurements and Mann-Whitney or Wilcoxon’s signed-rank test, or t-test were carried out. P < 0.05 was considered significant.
At 130 µA stimulation, cardiac output significantly decreased (p < 0.05), driven by significant heart rate drop in women, and stroke volume and contractility drop in men, pointing to a gender-related autonomic responses. We observed no significant changes in BP, or variability parameters. Significantly higher body size and BP were found in men, as expected.
It seems that tested taNS protocol has a potential for cardiac autonomic modulation in majority of young healthy men as well as women. Further studies are however needed to prove the therapeutic potential of this stimulation protocol in different patient groups.
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