Symptom burden guiding invasive electrophysiological study in paroxysmal supraventricular tachycardia: The believe SVT registry.

BACKGROUND AND OBJECTIVE: Patients with palpitations clinically suggestive of paroxysmal supraventricular tachycardia (PSVT) are often managed conservatively until ECG-documentation of the tachycardia, leading to high impact on life quality and healthcare resource utilization. We evaluated results of electrophysiological study (EPS), and ablation when appropriate, among these patients, with special focus on gender differences in management. METHODS: BELIEVE SVT is a European multicenter, retrospective registry in tertiary hospitals performing EPS in patients with palpitations, without ECG-documentation of tachycardia or preexcitation, and considered highly suggestive of PSVT by a cardiologist or cardiac electrophysiologist. We analyzed clinical characteristics, results of EPS and ablation, complications, and clinical outcomes during follow-up. RESULTS: Six-hundred eighty patients from 20 centers were included. EPS showed sustained tachycardia in 60.9% of patients, and substrate potentially enabling AVNRT in 14.7%. No major/permanent complications occurred. Minor/transient complications were reported in 0.84% of patients undergoing diagnostic-only EPS and 1.8% when followed by ablation. During a 3.4-year follow-up, 76.2% of patients remained free of palpitations recurrence. Ablation (OR: 0.34, P < .01) and male gender (OR: 0.58, P = .01) predicted no recurrence. Despite a higher female proportion among patients with recurrence, (77.2% vs 63.5% among those asymptomatic during follow-up, P < .01), 73% of women in this study reported no recurrence of palpitations after EPS. CONCLUSIONS: EPS and ablation are safe and effective in preventing recurrence of nondocumented palpitations clinically suggestive of PSVT. Despite a lower efficacy, this strategy is also highly effective among women and warrants no gender differences in management.

QRS axis and polarity in the inferior leads during left bundle branch pacing: Novel criteria in the search for better results.

BACKGROUND: Left bundle branch pacing (LBBP) may be achieved in various anatomical sites within the interventricular septum (IVS), thus influencing paced QRS duration (QRSd).The purpose of this study was to determine whether paced QRS axis (QRSâ) and predominant polarity in inferior leads could be associated with a shorter paced QRSd. METHODS: We analyzed paced QRSd, QRSâ, polarity in inferior leads, and IVS thickness in patients referred for LBBP. Three paced morphology patterns in the inferior leads were considered: All positive (P), all negative (N) and intermediate (combination of isoelectric, positive, and negative complexes, (I). Patients were divided into two groups according to a paced QRSd < 120 or ≥ 120 ms. RESULTS: A total of 125 patients were included (age 76 ± 10 years, 46% female). Mean baseline QRSâ was 8 ± 37°. Paced QRSd was significantly shorter as compared to baseline (120 ± 10 vs. 127 ± 33 ms; p = .017) and significantly different according to paced QRS morphology pattern in the inferior leads (P 49%, 119 ± 9; N 30%, 126 ± 12; I 21%; 113 ± 10 ms; p < .001) or paced QRSâ (Normal 59%, 116 ± 1; Right 6%, 129 ± 1; Left 35%, 124 ± 11 ms; p < .001). On multivariate analysis, a QRSâ > -30°(OR 5.79 [2.40-13.93; 95% CI] p = .001), an Intermediate pattern in inferior leads (OR 3.00 [1.67-8.43; 95% CI] p = .037), and an IVS thickness ≤ 10 mm (OR 2.59 [1.10-6.10; 95% CI]; p = .029) were significantly associated with a paced QRSd < 120 ms. CONCLUSIONS: During LBBP, a QRSâ > -30° and intermediate final polarity in inferior leads are associated with a shorter paced QRSd.

Systematic Workflow and Electrogram guidance to reduce X-ray Exposure Time during cryoballoon ablation of atrial fibrillation: the SWEET-Cryo strategy.

AIMS: Cryoballoon pulmonary vein isolation (CB-PVI) offers similar efficacy to point-by-point radiofrequency PVI for patients with atrial fibrillation (AF), but generally with higher X-ray exposure. Strategies aimed at reducing fluoroscopy mostly rely on other costly imaging techniques, limiting their applicability. We designed a Systematic Workflow and Electrogram guidance to reduce X-ray Exposure Time during CB-PVI (SWEET-Cryo) strategy and analysed its impact on fluoroscopy use and acute procedural and clinical outcomes. METHODS AND RESULTS: We enrolled 100 patients with paroxysmal or persistent AF undergoing CB-PVI by two operators with different levels of expertise. Patients treated with the SWEET-Cryo strategy (prospective cohort; n = 50) or conventional fluoroscopy (retrospective control cohort; n = 50) were compared. When applied by the senior operator, the SWEET-Cryo strategy significantly reduced the mean fluoroscopy time (FT) (2.6 ± 1.25 vs. 20.3 ± 10.8 min) and mean dose area product (DAP) (5.1 ± 3.8 vs. 35.3 ± 22.3 Gy cm2) compared with those of the control group, respectively (P < 0.001). Significant reductions in FT (6.4 ± 2.5 min vs. 32.5 ± 10.05) and DAP (13.9 ± 7.7 vs. 92.3 ± 63.8) were also achieved by the less experienced operator (P < 0.001). No difference was observed in acute and long-term complications or freedom from AF between fluoroscopy strategies during a 33-month median follow-up. Mean FT was maintained below 3 min in randomly selected cases performed during the follow-up period. CONCLUSION: In contrast to conventional protocols and regardless of the operator's experience, the optimized SWEET-Cryo strategy dramatically reduced fluoroscopy exposure during CB-PVI. The efficacy, safety, or added costs of the ablation procedure were not compromised.

Atrioventricular block following prolonged focal cryoablation for parahisian premature ventricular complexes.

A 54-year-old woman with symptomatic premature ventricular contractions (PVC) was referred for electrophysiological study. The earliest activation was located at the parahisian area, so it was decided to ablate using cryoenergy. No AV conduction impairment was observed during cryomapping. PVCs were abolished after the first 15 seconds of cryoablation, without recurrence. However, after 354 seconds of cryoablation, a mild PR prolongation was followed by first degree and 2-to-1 AV block. Termination of cryoablation led to complete recovery without definitive damage and with elimination of the PVC. This case illustrates how lesion formation using cryoenergy can continue to evolve even after several minutes, highlighting the need of monitoring throughout the whole target duration.

A constant postpacing interval in response to overdrive pacing with variable number of beats: An aid in the identification of entrainment for a particular pacing train during macroreentrant atrial tachycardias.

BACKGROUND: When pacing trains with a constant cycle length (CL) but increasing number of beats are introduced during a macroreentrant atrial tachycardia (MAT), the postpacing interval (PPI) is expected to increase if entrainment does not occur but could be stable if entrainment occurs. We tested the ability of PPI analysis to detect entrainment. METHODS: Synchronized pacing trains with increasing number of beats (1-20) were delivered from the coronary sinus (CS) and lateral right atrium (RA) at a CL 20 ms shorter than the MAT CL. Pacing trains were grouped in pairs differing by one-paced beat, and the ∆PPI measured. RESULTS: In an initial prospective cohort of 21 patients (48% had left atrial flutter) the mean ∆PPI was 21.3 ± 5.6 ms for pairs of pacing trains in which neither entrained the MAT and 2.8 ± 1.4 ms for those in which both entrained the MAT (P < .0001). Results were similar for common vs atypical flutter, PPI-TCL ≤30 ms vs PPI-TCL >30 ms, presence vs absence of antiarrhythmic drugs and faster vs slower MAT. When an index pacing train was compared to one with two-paced beats less, a PPI difference of <19 ms identified entrainment with 95% sensitivity and 98% specificity. In a validation cohort of 16 patients, this cut-off value resulted in sensitivity and specificity of 90% and 94%. CONCLUSIONS: A relatively constant ∆PPI in response to overdrive pacing with identical CL but different number of beats allows accurate discrimination between trains that entrained vs those which did not entrain a MAT.

Geometrical and functional cardiac changes after cardiac surgery: a phisiopatological explanation based on speckle tracking.

Cardiac surgery induces geometrical and functional changes, which are not clearly explained. Objective: to investigate the physiopathology of the heart after cardiac surgery using advanced techniques of echocardiography. Thirty patients undergoing cardiac surgery had echocardiographic study prior and after surgery. Left and right ventricular (RV) longitudinal displacement and strain were studied with speckle-tracking. Using longitudinal displacement, we defined a static longitudinal reference-point (sLRP) to which the other segments moved during systole. Transversal displacement and global function were determined by conventional-echo. Left and RV segments showed systolic longitudinal displacement towards the apex, which was the sLRP before surgery; and towards the medium segment of lateral RV-wall one week after surgery. The displacement of basal RV segment towards this sLRP was smaller, causing decreased TAPSE. Apical segments showed an inverse displacement towards the new sLRP, and septum displacement was decreased or inverted towards the lateral RV-wall, causing paradoxus septal motion. RV-wall longitudinal strain was reduced (- 23.1 ± 8.6 vs. - 14.6 ± 5.3;p < 0.001), RV transversal fractional shortening was increased (36.5 ± 10.5 vs. 41.7 ± 13; p = 0.011), and the RV fractional area change was unchanged (46.7 ± 9.5 vs. 47.8 ± 11.7; p = 0.625). The medium segment of RV lateral wall, in contact with sternotomy, remains static after surgery and acts as a new sLRP towards which the rest of segments move, explaining the reduction of TAPSE and paradoxus septal motion. The longitudinal strain of the lateral RV-wall gets impaired, but an increase of transversal motion maintains global RV function.

Accuracy and reproducibility of novel echocardiographic three-dimensional automated software for the assessment of the aortic root in candidates for thanscatheter aortic valve replacement.

AIMS: A specialized three-dimensional transoesophageal echocardiography (3D-TOE) reconstruction tool has recently been introduced; the system automatically configures a geometric model of the aortic root from the images obtained by 3D-TOE and performs quantitative analysis of these structures. The aim of this study was to compare the measurements of the aortic annulus (AA) obtained by the new model to that obtained by 3D-TOE and multidetector computed tomography (MDCT) in candidates to transcatheter aortic valve implantation (TAVI) and to assess the reproducibility of this new method. METHODS AND RESULTS: We included 31 patients who underwent TAVI. The AA diameters and area were evaluated by the manual 3D-TOE method and by the automatic software. We showed an excellent correlation between the measurements obtained by both methods: intra-class correlation coefficient (ICC): 0.731 (0.508-0.862), r: 0.742 for AA diameter and ICC: 0.723 (0.662-0.923), r: 0.723 for the AA area, with no significant differences regardless of the method used. The interobserver variability was superior for the automatic measurements than for the manual ones. In a subgroup of 10 patients, we also found an excellent correlation between the automatic measurements and those obtained by MDCT, ICC: 0.941 (0.761-0.985), r: 0.901 for AA diameter and ICC: 0.853 (0.409-0.964), r: 0.744 for the AA area. CONCLUSION: The new automatic 3D-TOE software allows modelling and quantifying the aortic root from 3D-TOE data with high reproducibility. There is good correlation between the automated measurements and other 3D validated techniques. Our results support its use in clinical practice as an alternative to MDCT previous to TAVI.

Left ventricular vortices as observed by vector flow mapping: main determinants and their relation to left ventricular filling.

BACKGROUND: Swirling flow, organized in vortices, contributes to adequate left ventricular function. In this study, we apply a novel echocardiographic flow-mapping technique, vector flow mapping (VFM), to evaluate the main characteristics of left ventricular vortices and its relation to filling parameters. METHODS: Forty-eight subjects underwent conventional transthoracic echocardiographic examination with additional intracardiac flow assessment with VFM using a Aloka Alpha-10 system and experimental VFM analysis software. To analyze vortex behavior, its rotation direction, duration, location inside the left ventricle, size, and intensity were assessed in apical long-axis view. Its relation to conventional left ventricular filling parameters was then analyzed. RESULTS: Two vortex components were consistently identified following each transmitral filling wave. The anterior component of these visualized vortices was analyzed, due to its higher significance in the cardiac cycle, following early filling (V1) and atrial contraction (V2). Differences were observed in several aspects of vortex behavior between V1 and V2, particularly in patients with normal left ventricular filling parameters. These differences may be related to varying roles of vortices in different periods of the cardiac cycle. CONCLUSIONS: Vector flow mapping allowed visualization and measurement of several parameters defining vortex behavior inside the cardiac cycle. The differences observed in these parameters between vortices in different phases of the cardiac cycle may be related to their role in optimizing cardiac function.

Guidance of treatment of perivalvular prosthetic leaks.

Percutaneous closure of paravalvular leaks has grown into becoming a widely considered option for treatment of hemodynamically significant regurgitation in patients with valve prosthesis. Guidance provided by the use of cardiovascular imaging techniques before and during the intervention has proved its relevance to improve accuracy and, with it, the outcome of the procedure. It has also been essential in the successful evolution of the technique and the development of devices specifically designed for it. The present work reviews the role of imaging before, during and after treatment of perivalvular prosthetic leaks and the most recent and significant advances in it.