Arritmias e alterações cardíacas no paciente cirrótico / Arrhythmias and cardiac alterations in the cirrhotic patient

No Brasil, a cirrose é um problema de saúde pública, que afeta aproximadamente 2 milhões de pessoas. As causas mais comuns são a doença hepática alcoólica, as hepatites virais e a doença hepática não alcoólica. A relação entre desordens cardíacas e hepatopatias é descrita na literatura, e a mais importante delas é o prolongamento do intervalo QT. A cirrose, independente de sua causa, é uma patologia frequentemente encontrada na população brasileira. Por este motivo, elucidar dados referentes às arritmias cardíacas em pacientes cirróticos é de grande importância dentro do estudo desta subpopulação. O objetivo deste artigo é fazer uma revisão de literatura com as informações referentes a epidemiologia, fisiopatologia, fatores de risco e prognóstico para as arritmias cardíacas em portadores de cirrose. (AU)

In Brazil, cirrhosis is a public health problem affecting approximately 2 million people. The most common causes are alcoholic liver disease, viral hepatitis, and non-alcoholic liver disease. The relationship between cardiac disorders and liver diseases is described in the literature, and the most important one is the QT interval prolongation. Cirrhosis, regardless of its causes, is a pathology that is frequently found in the Brazilian population. For this reason, elucidating data regarding cardiac arrhythmias in cirrhotic patients is of great importance within the study of this subpopulation. The aim of this article is to review the literature with information on the epidemiology, pathophysiology, risk factors, and prognosis for cardiac arrhythmias in patients with cirrhosis. (AU)

Compound Heterozygous SCN5A Mutations in a Toddler - Are they Associated with a More Severe Phenotype? / Heterozigose Composta no Gene SCN5A em Criança - Há Associação com Gravidade da Doença?

Abstract Compound heterozygosity has been described in inherited arrhythmias, and usually associated with a more severe phenotype. Reports of this occurrence in Brugada syndrome patients are still rare. We report a study of genotype-phenotype correlation after the identification of new variants by genetic testing. We describe the case of an affected child with a combination of two different likely pathogenic SCN5A variants, presenting sinus node dysfunction, flutter and atrial fibrillation, prolonged HV interval, spontaneous type 1 Brugada pattern in the prepubescent age and familiar history of sudden death.

Resumo A heterozigose composta é descrita em arritmias hereditárias, geralmente associada a um fenótipo mais grave. Relatos dessa ocorrência em pacientes com síndrome de Brugada ainda são raros. Neste estudo, descrevemos o caso de uma criança com a combinação de duas novas variantes distintas no gene SCN5A, apresentando disfunção do nó sinusal, flutter e fibrilação atrial, intervalo HV prolongado, padrão tipo 1 espontâneo de Brugada na idade pré-puberal e história familiar de morte súbita.

Clinical Differences between Subtypes of Atrial Fibrillation and Flutter: Cross-Sectional Registry of 407 Patients / Diferenças Clínicas entre Subtipos de Fibrilação Atrial e Flutter: Registro Transversal de 407 Pacientes

Atrial fibrillation and atrial flutter account for one third of hospitalizations due to arrhythmias, determining great social and economic impacts. In Brazil, data on hospital care of these patients is scarce.

Predictors of Sick Sinus Syndrome in Patients after Successful Radiofrequency Catheter Ablation of Atrial Flutter

PURPOSE: The identification of sick sinus syndrome (SSS) in patients with atrial flutter (AFL) is difficult before the termination of AFL. This study investigated the patient characteristics used in predicting a high risk of SSS after AFL ablation. MATERIALS AND METHODS: Out of 339 consecutive patients who had undergone radiofrequency ablation for AFL from 1991 to 2012, 27 (8%) had SSS (SSS group). We compared the clinical characteristics of patients with and without SSS (n=312, no-SSS group). RESULTS: The SSS group was more likely to have a lower body mass index (SSS: 22.5+/-3.2; no-SSS: 24.0+/-3.0 kg/m2; p=0.02), a history of atrial septal defects (ASD; SSS: 19%; no-SSS: 6%; p=0.01), a history of coronary artery bypass graft surgery (CABG; SSS: 11%; no-SSS: 2%; p=0.002), and a longer flutter cycle length (CL; SSS: 262.3+/-39.2; no-SSS: 243.0+/-40; p=0.02) than the no-SSS group. In multivariate analysis, a history of ASD [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.2-11.4, p=0.02] and CABG (7.1, 95% CI 1.5-32.8, p=0.01) as well as longer flutter CL (1.1, 95% CI 1.0-1.2, p=0.04) were independent risk factors for SSS. CONCLUSION: A history of ASD and CABG as well as longer flutter CL increased the risk of SSS after AFL ablation. While half of the patients with SSS after AFL ablation experienced transient SSS, heart failure was associated with irreversible SSS.

Curso de Atualização em Cardiologia: aula 8: Arritmias para conduta clínica / Course Updating in Cardiologyclass 8: Arrhythmias for clinical conduct

As arritmias cardíacas apresentam grande prevalência na prática clínica diária e, desta forma, o diagnóstico correto é fundamental para a instituição da terapia adequada. O reconhecimento dos principais sinais e sintomas clínicos associados à interpretação criteriosa do eletrocardiograma são peças determinantes do sucesso terapêutico. Neste artigo serão abordadas as principais arritmias supraventriculares e ventriculares, no que diz respeito à sua apresentação clínica, critérios eletrocardiográficos, conduta imediata e em longo prazo. Vale enfatizar que a arritmologia atual oferece inúmeras opções terapêuticas efetivas e curativas para a grande maioria dos pacientes.

Supraventricular tachycardia in children.

Several different mechanisms are responsible for paroxysmal supraventricular tachycardia in children. Different forms of tachycardia occur at different age. Atrio-ventricular reentry tachycardia results from the presence of congenital atrio-ventricular bypass tracts and is frequently encountered at all ages. Infants may present with ectopic atrial tachycardia or atrial flutter. Atrio-ventricular node reentry tachycardia becomes more frequent in adolescence. Atrial scarring resulting from open heart surgery predisposes to complex intra-atrial reentry. Certain forms of congenital and acquired heart disease are associated with specific types of arrhythmia. Many children with paroxysmal supraventricular tachycardia do not require any therapy. The decision to proceed with treatment should be based on the frequency and severity of symptoms and on the effect of arrhythmia on the quality of life. Infants require medical treatment because of the difficulty to recognize symptoms of tachycardia and a risk of heart failure. Patients with Wolff-Parkinson-White syndrome as well as those with significant heart disease are at risk of sudden death. Syncope in children with paroxysmal tachycardia may indicate a severe fall in cardiac output from extremely rapid heart rate. Patients with potentially life-threatening arrhythmia should not participate in competitive physical activities. Treatment options have undergone significant evolution over the past decade. Indications for the use of specific antiarrhythmic medications have been refined. Contemporary catheter ablation procedures employ different forms of energy allowing for safe and effective procedures. Catheter ablation is the treatment of choice for symptomatic paroxysmal tachycardia in school children and in some infants who failed medical treatment. Surgery is the preferred treatment in few selected cases. The goal of this review is to present the state of the art approach to the diagnosis and management of paroxysmal supraventricular tachycardia in infants, children and adolescents.

Flutter auricular: Resultados inmediatos y alejados de la fulguración con radiofrecuencia del istmo cavo-tricuspídeo / Results of radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus for atrial flutter

Background: Radiofrequency ablation of the inferior vena cavatricuspid valve isthmus relieves atrial flutter in 95percent of cases. Aim: To evaluate the long term results of radiofrequency ablation of the inferior vena cavatricuspid valve isthmus in atrial flutter. Material and methods: Retrospective review of 86 patients with common atrial flutter, treated with radiofrequency ablation of the isthmus, while in sinus rhythm or flutter. Patients were contacted by telephone for a new clinical and electrocardiographic assessment, three to 40 months after the procedure. Results: Of all the patients treated, five died and five were lost from follow up, thus 76 patients (mean age 56 years, 58 males) were contacted for reassessment. At the moment of the procedure, 51percent had an underlying cardiac disease and 25percent had high blood pressure. All referred palpitations, 25percent had dyspnea, 84percent were receiving antiarrhythmic drugs and 33percent were on oral anticoagulants. Flutter was paroxystic in 83percent and chronic in 17percent. Fulguration was successful in all patients; one patient presented a high grade atrioventricular block as a complication of the procedure. At reassessment, 82percent of patients were in sinus rhythm, 16percent had atrial fibrillation and 2percent, an atypical flutter. Conclusions: Radiofrequency fulguration is a safe and effective treatment of atrial flutter.

Ablaçäo com radiofrequência do flutter atrial tipo I. importância do bloqueio bidirecional do istmo entre a veia cava inferior e o anel valva tricúspide / Type I atrial flutter radiofrequency ablation. Importance of bidirectional block of isthmus between the inferior vena cava and between the ring of tricuspid valva

Objetivo - Estudar a importância clínica da determinação eletrofisiológica da presença de bloqueio bidirecional na condução pelo istmo localizado entre a veia cava inferior e o anel da valva tricúspide (VCI-AT), após a ablação do flutter atrial tipo I (FL) com radiofreqüência (RF). Métodos - Quarenta pacientes consecutivos (idade média 51+11 anos) com FL foram submetidos a ablação do istmo VCI-AT com RF. Em 30 pacientes (GI), o sucesso foi avaliado pela interrupção e não reiducação do FL com estimulação atrial programada. No últimos 10 pacientes foi avaliada também a condução bidirecional pelo istmo, com cateteres posicionados na sua entrada e saída e em cada lado da linha de bloqueio. O bloqueio foi considerado bidirecional quando ocorrido nos dois sentidos e unidirecional quando ocorrido em um só sentido. Resultados - Vinte e seis (86 por cento) pacientes do GI e 10 (100 por cento) do GII tiveram sucesso imediato (p=0,5558). Durante o seguimento, 7 (30 por cento) de 23 pacientes do GI e 3 (30 por cento) de 9 do GII tiveram recorrência de FL (p=NS). Os três pacientes do GII que apresentaram recorrência tinham bloqueio unidirecional, enquanto os seis casos sem recorrência tinham bloqueio bidirecional (p=0,012). Conclusão - A demonstração de bloqueio bidirecional no istmo VCI-AT, obtida imediatamente após a ablação do FL com RF, relaciona-se a menor índice de recorrência clínica, devendo ser o critério preferencial para término do procedimento.

Papel de la adenosina sobre la acción antiarrítmica de los digitálicos / Role of adenosine on the antiarrhythmic action of digitalis

La acción de la adenosina sobre el periodo refractario funcional de los tejidos auriculares y en la cancelación del flutter auricular, es semejante a la de los digitálicos. Tal hecho sugiere la posible existencia de una participación adenílica en la acción digitálica. Por ello medimos las concentraciones plasmáticas de adenosina al infundir ouabaína, e investigamos el efecto del digitálico sobre el periodo refractario de tejidos auriculares y sobre el flutter en condiciones de inhibición colinérgico y bloqueo purinérgico. En perros, se administró ouabaína hasta inducir fibrilación ventricular. Se obtuvo sangre del seno coronario y de la vena femoral, midiendo la adenosina por cromatagrafía de líquidos. El periodo refractario se midió con la ténica del estímulo extra acoplado. El flutter se indujo al estimular el haz internodal posterior. Los resultados muestran que la concentración de adenosina se elevó más de 100 por ciento en plama de seno coronario; el efecto de la ouabaína sobre el periodo refractario no se modificó con la inhibición colinérgica, pero sí fue inhibido por aminofilina; el digitálico modificó su acción en la cancelación del flutter en presencia de aminofilina. Conclusión: en la acción antiarrítmica de los digitálicos parece participar un componente adenílico que resulta de la liberación de adenosina del corazón

Fulguración con radiofrecuencia de haces paraespecíficos derechos / Radiofrequency ablation of right accessory pathways

Background: Accessory pathways are muscular connections between auricles and ventricles, present in different points of mitral and tricuspid annuluses. These pathways participate in 50 percent of Paroxysmal supraventricular tachycardias and the definitive cure of the arrhythmia is their ablation. Aim: To report our experience in patients with right accessory pathways. Patients and methods: 50 consecutive patients treated between 1990 and 1996 are reported. Eight had a history of syncope, two had a diagnosis of Epstein disease and 36 had a pre-excitation in the surface electrocardiogram. Results: Fifty four accessory pathways were identified, since four patients had two pathways. Twenty four pathways were posteroseptal, 15 were lateral, 9 were medioseptal and 6 were anteroseptal. One patient had also a nodal reentry tachycardia. Fulguration was attempted in 39 patients and it was finally successful in 32. Three patients required more than one session. There were six relapses and all were successfully ablated in a second session. A mean of 28 radiofrequency applications were done (range 1- 76), mean laboratory time was 6 hours and mean radioscopy time was 70 min. Four patients had a transient atrioventricular conductor blockade. Conclusions: Radiofrequency ablation of accessory pathways has a high degree of success and a low rate of complications

Taquicardia e "flutter" atriais / Atrial flutter and tachycardia

A taquicardia e o "flutter" atriais são arritmias relativamente freqüentes na população, podendo em alguns casos constituir problema terapêutico sério. Neste artigo, é feita revisão da fisiopatologia de ambas as taquicardias, com ênfase nos aspectos importantes para as bases de seu tratamento, desde os achados em modelos experimentais até o mapeamento dos circuitos em humanos. Também é revista sua apresentação clínica e diagnóstico diferencial, propondo-se algoritmos para um diagnóstico mais preciso. Finalmente, é feita revisão extensa das técnicas atuais e perspectivas futuras de seu tratamento, desde o uso de drogas antiarrítmicas até técnicas de ablação por catéter e cirúrgica dos circuitos.

Ablación con radiofrecuencia del flutter atrial tipo I: combinación de las técnicas electrofisiológica y anatómica / Radiofrequency ablation in type I atrial flutter

El flutter atrial (FLA) tipo I es una de las arritmias supraventriculares más frecuentes en la práctica clínica. Se produce por un mecanismo de reentrada dentro del atrio derecho (AD). Esta reentrada tiene sitios críticos donde se puede aplicar radiofrecuencia (RF) y, así, bloquear el circuito. Las técnicas hasta hoy descritas para aplicar RF son la electrofisiológica y la anatómica; al utilizarlas en forma separada, han demostrado éxito por arriba del 80 por ciento cada una. Nosotros combinamos ambas técnicas para tratar 35 pacientes con FLA tipo I (22 hombres y 13 mujeres) con edad media de 40.8 ñ 15 años (9 - 70). El FLA se asoció alguna cardiopatía en 21 (60 por ciento) casos. Todos los enfermos fueron resistentes al tratamiento médico. El éxito fue de 82.8 por ciento (29/35). Al comparar los pacientes con fracaso vs éxito, se encontró que tenía mayor edad (51.8 vs 38.5 años, p < 0.05), mayor prevalencia de cardiopatía estructural (83.3 por ciento vs 55.1 por ciento p NS), menor longitud de ciclo de las ondas de FLA (195 vs 254, p = 0.052), más tiempo de evolución (129.6 vs 68.1 meses, p NS), mayor diámetro auricular izquierdo (41.2 vs 36.7 mm, p = 0.052) y frecuente asociación con fibrilación atrial (33.3 por ciento vs 3.4 por ciento, p = 0.02). No hubo complicaciones. Seis pacientes (20.6 por ciento) presentaron recidiva. La media de seguimiento fue de 8.37 ñ 8.8 meses (1-36). Estos resultados demuestran que el FLA tipo I puede ser tratado con alto porcentaje de éxito, y bajo riesgo de complicaciones, combinando las técnicas electrofisiológica y anatómica. Predicen fracaso del procedimiento una mayor edad y la asociación con fibrilación atrial (p < 0.05). Concluimos que la ablación con RF es el tratamiento de elección en aquellos pacientes con FLA tipo I, resistentes al tratamiento médico. Recomendamos que el procedimiento sea realizado tan pronto como sea posible una vez detectado el FLA, puesto que favorece mayor porcentaje de éxito

Radiofrequency catheter ablation in type I atrial flutter: preliminary experience of 10 cases.

Common atrial flutter results from macroreentry in the right atrium. Catheter ablation of slow conduction, between tricuspid annulus and inferior vena cava (TA-IVC) or tricuspid annulus and coronary sinus ostium (TA-CS os) has been reported to terminate and prevent recurrence of this arrhythmia. We reported 10 consecutive patients, 7 men and 3 women, who underwent radiofrequency catheter ablation of common atrial flutter. The mean age was 59.4 +/- 11.2 years (range 42-82 years). During the paroxysmal atrial flutter, all patients had palpitation, 4 had dyspnea on exertion, 3 patients had syncope and 1 patient had presyncope. The mean duration of symptoms was 5.7 +/- 4.9 years (range 0.5-13 years). Two patients had dilated cardiomyopathy, 1 Ebstein's anomaly and 1 chronic obstructive pulmonary disease. Four patients (40%) had history of atrial fibrillation (AF) before ablation. The mean cycle length of atrial rhythm was 257.2 +/- 36.6 ms. Ablation was done by anatomical approach and could terminate arrhythmia in 9 patients (90%), 7 from TA-IVC, 2 from TA-CS os without major complication. The mean number of applications was 20.4 +/- 16.9 and turned atrial flutter to normal sinus rhythm in 13.5 +/- 10.7 seconds. Fluoroscopic and procedure times were 38.4 +/- 31.4 and 157.2 +/- 68.8 minutes, respectively. During the follow-up period of 24.0 +/- 28.7 weeks, 2 patients had recurrent atrial arrhythmia, 1 atrial fibrillation and 1 atrial flutter type I, giving the final success rate of 70 per cent. All patients who had recurrence or failure had a history of paroxysmal AF before ablation. In conclusion, radiofrequency catheter ablation in atrial flutter type I, using anatomical approach, is an effective treatment to terminate and prevent this arrhythmia in short term follow-up. It may be considered as an alternative treatment in patients with atrial flutter who were refractory to antiarrhythmic agents.

Fulguración con radiofrecuencia en pacientes con flutter auricular típico / Radiofrequency fulguration in patients with common atrial flutter

Nine patients (8 males) whose ages ranged from 6 to 72 years old were studied. Two patients had an operated congenital cardiopathy, 2 had high blood pressure, 1 has no subject previously to radiofrequency ablation due to a left paraspecific pathway; 1 developed a cardiac failure secondary to tachycardia and 3 relapses in the first month after the procedure, of these, 2 patients were succesfully treated again. After a mean follow up of 4.5 months, these patients are asymptomatic and without antiarrythmic drugs. Analyzis of obtained signals, showed that radiofrequency that interrupted atrial flutter always occurred in zones of double potentials. Radiofrequency ablation is an effective tretament for atrial flutter and the zone of succesful ablation is associated to the presence of double atrial potentials

Avances en el tratamiento de las taquiarritmias: rol de los métodos no farmacológicos / Advances in the treatment of the tachiarrhythmias: role of nonpharmacological methods

Nonpharmacological methods are a novel therapeutic option for tachiarrhytmias. Transctheter ablation or surgery can cure many arrhythmias, avoiding the collateral effects of antiarrhythmic drugs. Likewise, implantable defibrillators, have changed life expectancy of patients with high risk arrhythmias or sudden survivors. However, the high cost and sophistication of these methods, preclude their widespread use, thus limiting the number of patients that can be benefited. This article reviews the main nonpharmacological techniques for treatment arrhythmias, their results and complications

Patofisiología del flutter y la fibrilaicón auriculares en los pacientes con síndrome de Wolff-Parkinson-White en relación a un caso tratado con éxito por fulguración del haz de His / Pathophysiology of flutter and fibrillation in patiens with Wolff-Parkinson-White syndrome

La presencia del flutter y fibrilación auriculares son hallazgos frecuentes en los pacientes con síndrome de Wolff-Parkinson-White. La patofisiología de dichos transtornos del ritmo en estos pacientes no se conoce conc erteza, por lo que el tratamiento generalmente es empírico, y orientado a la sintomatología. Aquí se presenta el caso de un enfermo con síndrome de Wolff-Parkinson-White con taquicardias reciprocantes ortodrómicas y episodios de flutter auricular que desaparecieron después de la fulguración del haz de His. Esto sugiere que la presencia del flutter auricular en tales pacientes requiere de un circuito de reentrada completo