Association of beat-to-beat P-wave analysis index to the extent of left atrial low-voltage areas in patients with paroxysmal atrial fibrillation.

BACKGROUND: Left atrial (LA) fibrosis has been shown to be associated with atrial fibrillation (AF) recurrence. Beat-to-beat (B2B) index is a non-invasive classifier, based on B2B P-wave morphological and wavelet analysis, shown to be associated with AF incidence and recurrence. In this study, we tested the hypothesis that the B2B index is associated with the extent of LA low-voltage areas (LVAs) on electroanatomical mapping. METHODS: Patients with paroxysmal AF scheduled for pulmonary vein isolation, without evident structural remodeling, were included. Pre-ablation electroanatomical voltage maps were used to calculate the surface of LVAs (<0.5 mV). B2B index was compared between patients with small versus large LVAs. RESULTS: 35 patients were included (87% male, median age 62). The median surface area of LVAs was 7.7 (4.4-15.8) cm2 corresponding to 5.6 (3.3-12.1) % of LA endocardial surface. B2B index was 0.57 (0.52-0.59) in patients with small LVAs (below the median) compared to 0.65 (0.56-0.77) in those with large LVAs (above the median) (p=0.009). In the receiver operator characteristic curve analysis for predicting large LVAs, the c-statistic was 0.75 (p=0.006) for B2B index and 0.81 for the multivariable model including B2B index (multivariable p=0.04) and P-wave duration. CONCLUSION: In patients with paroxysmal AF without overt atrial myopathy, B2B P-wave analysis appears to be a useful non-invasive correlate of low-voltage areas-and thus fibrosis-in the LA. This finding establishes a pathophysiological basis for B2B index and its potential usefulness in the selection process of patients who are likely to benefit most from further invasive treatment.

P-Wave Beat-to-Beat Analysis to Predict Atrial Fibrillation Recurrence after Catheter Ablation.

The identification of patients prone to atrial fibrillation (AF) relapse after catheter ablation is essential for better patient selection and risk stratification. The current prospective cohort study aims to validate a novel P-wave index based on beat-to-beat (B2B) P-wave morphological and wavelet analysis designed to detect patients with low burden AF as a predictor of AF recurrence within a year after successful catheter ablation. From a total of 138 consecutive patients scheduled for AF ablation, 12-lead ECG and 10 min vectorcardiogram (VCG) recordings were obtained. Univariate analysis revealed that patients with higher B2B P-wave index had a two-fold risk for AF recurrence (HR: 2.35, 95% CI: 1.24-4.44, p: 0.010), along with prolonged P-wave, interatrial block, early AF recurrence, female gender, heart failure history, previous stroke, and CHA2DS2-VASc score. Multivariate analysis of assessable predictors before ablation revealed that B2B P-wave index, along with heart failure history and a history of previous stroke or transient ischemic attack, are independent predicting factors of atrial fibrillation recurrence. Further studies are needed to assess the predictive value of the B2B index with greater accuracy and evaluate a possible relationship with atrial substrate analysis.

Reel syndrome-An uncommon etiology of ICD dysfunction.

Reel syndrome occurs due to the rotation of the implantable device on its transverse axis with subsequent coiling of the leads around the pulse generator. Device interrogation and chest X-ray should be performed in any case of device malfunction.

Association of QT dispersion with mortality and arrhythmic events-A meta-analysis of observational studies.

BACKGROUND: The risk stratification of coronary heart disease (CHD) and/or heart failure (HF) patients with easily measured electrocardiographic markers is of clinical importance. The aim of this meta-analysis is to indicate whether increased QT dispersion (QTd) is associated with fatal and nonfatal outcomes in patients with CHD and/or HF. METHODS: We systematically searched MEDLINE and Cochrane databases without restrictions until August 15, 2018 using the keyword "QT dispersion". Studies including data on the association between QTd and all-cause mortality, sudden cardiac death (SCD) or arrhythmic events in patients with HF and/or CHD were classified as eligible. RESULTS: In the analysis including patients with CHD and/or HF, we found that QTd did not differ significantly in patients with SCD compared to no SCD patients while QTd was significantly greater in the group of all-cause mortality patients and in patients who experienced a sustained ventricular arrhythmia. Subgroup analysis showed that in myocardial infarction studies, QTd was significantly higher in patients with an arrhythmic event compared to arrhythmic event-free patients while a nonsignificant difference was found in QTd in patients who died from any cause compared to survivors. Similarly, in HF patients, the QTd was significantly greater in patients with an arrhythmic event while a nonsignificant difference was found regarding all-cause mortality and SCD outcomes. CONCLUSIONS: QTd has a prognostic role for stratifying myocardial infarction or HF patients who are at higher risk of arrhythmic events. However, no prognostic role was found regarding all-cause mortality or SCD in this patient population.

Clinical characteristics and long-term clinical course of patients with Brugada syndrome without previous cardiac arrest: a multiparametric risk stratification approach.

AIMS: Risk stratification in Brugada syndrome (BrS) still represents an unsettled issue. In this multicentre study, we aimed to evaluate the clinical characteristics and the long-term clinical course of patients with BrS. METHODS AND RESULTS: A total of 111 consecutive patients (86 males; aged 45.3 ± 13.3 years) diagnosed with BrS were included and followed-up in a prospective fashion. Thirty-seven patients (33.3%) were symptomatic at enrolment (arrhythmic syncope). An electrophysiological study (EPS) was performed in 59 patients (53.2%), and ventricular arrhythmias were induced in 32 (54.2%). A cardioverter defibrillator was implanted in 34 cases (30.6%). During a mean follow-up period of 4.6 ± 3.5 years, appropriate device therapies occurred in seven patients. Event-free survival analysis (log-rank test) showed that spontaneous type-1 electrocardiogram pattern (P = 0.008), symptoms at presentation (syncope) (P = 0.012), family history of sudden cardiac death (P < 0.001), positive EPS (P = 0.024), fragmented QRS (P = 0.004), and QRS duration in lead V2 > 113 ms (P < 0.001) are predictors of future arrhythmic events. Event rates were 0%, 4%, and 60% among patients with 0-1 risk factor, 2-3 risk factors, and 4-5 risk factors, respectively (P < 0.001). Current multiparametric score models exhibit an excellent negative predictive value and perform well in risk stratification of BrS patients. CONCLUSIONS: Multiparametric models including common risk factors appear to provide better risk stratification of BrS patients than single factors alone.

Right ventricular outflow tract low-voltage areas identify the site of origin of idiopathic ventricular arrhythmias: A high-density mapping study.

INTRODUCTION: Electronatomical mapping allows direct and accurate visualization of myocardial abnormalities. This study investigated whether high-density endocardial bipolar voltage mapping of the right ventricular outflow tract (RVOT) during sinus rhythm may guide catheter ablation of idiopathic ventricular arrhythmias (VAs). METHODS AND RESULTS: Forty-four patients (18 males, mean age: 38.1 ± 13.8 years) with idiopathic RVOT VAs and negative cardiac magnetic resonance imaging underwent a stepwise mapping approach for the identification of the site of origin (SOO). High-density electronatomical mapping (1096.6 ± 322.3 points) was performed during sinus rhythm and identified at least two low bipolar voltage areas less than 1 mV (mean amplitude of 0.20 ± 0.10 mV) in 39 of 44 patients. The mean low-voltage surface area was 1.4 ± 0.8 cm2 . Group 1 consisted of 28 patients exhibiting low-voltage areas and high-arrhythmia burden during the procedure. Pace match to the clinical VAs was produced in one of these low-voltage areas. Activation mapping established the SOO at these sites in 27 of 28 cases. Group 2 comprised 11 patients exhibiting abnormal electroanatomical mapping, but very low-arrhythmia burden during the procedure. Pace mapping produced a near-perfect or perfect match to the clinical VAs in one of these areas in 9 of 11 patients which was marked as potential SOO and targeted for ablation. During the follow-up period, 25 of 28 patients from group 1 (89%) and 7 of 9 patients from group 2 (78%) were free from VAs. CONCLUSIONS: Small but detectable very low-voltage areas during mapping in sinus rhythm characterize the arrhythmogenic substrate of idiopathic RVOT VAs and may guide successful catheter ablation.

Ventricular septal rupture following myocardial infarction: A potentially fatal complication.

Mechanical complications of acute myocardial infarction include ventricular septal rupture (VSR), free wall rupture, and ischemic mitral regurgitation. Postinfarction VSR is a rare but serious complication of myocardial infarction. VSR has a lower incidence in the era of new reperfusion therapies. However, clinicians should be aware of this potentially fatal complication as the mortality remains extremely high. Early diagnosis and treatment are the cornerstones of achieving a better outcome.

Safety, long-term outcomes and predictors of recurrence following a single catheter ablation procedure for atrial fibrillation.

Background: Data regarding long-term outcomes of atrial fibrillation (AF) catheter ablation are limited. This study evaluated the safety, long-term efficacy and predictors of recurrence after a single left atrial ablation procedure in patients with paroxysmal (PAF) and non-paroxysmal AF (NPAF). Methods: Data from 520 patients (354 males, mean age 57.08 ± 11.33 years) with PAF (n = 356, 68.5%) or NPAF (n = 164, 31.5%) who underwent a single radiofrequency ablation procedure were analysed. Across the NPAF group, there were 143 (27.5%) patients with persistent AF and 21 (4%) with long-standing persistent AF. The mean follow-up period was 39.05 ± 20.83 months (range 19-60 months). Results: Arrhythmia recurrence was observed in 102/356 (28.7%) of PAF patients and in 63/164 (38.4%) of NPAF patients. In patient with PAF, sinus rhythm maintenance was observed in 76.9%, 73% and 71.3% of patients at 1, 2 and 5 years of follow-up, respectively. In patients with NPAF, sinus rhythm was maintained in 68.7%, 63.4% and 61.6% of patients at 1, 2 and 5 years of follow-up, respectively. Independent predictors of AF recurrence were left atrial diameter (OR 1.15, 95% CI 1.10-1.21, p < 0.01) as well as early arrhythmia recurrence during the blanking period of 3 months after the procedure (OR 8.13, 95% CI 5.10-12.82, p < 0.01). Major complications were observed in 11 patients (2.1%). Conclusions: Long-term arrhythmia-free survival rates remain high among PAF and NPAF patients after a single catheter ablation procedure. Left atrial diameter and early arrhythmia recurrence were independent predictors of late arrhythmia recurrence in both PAF and NPAF patients.

Left atrial voltage mapping using a new impedance-based algorithm in patients with paroxysmal atrial fibrillation.

AIMS: Atrial fibrosis is associated with the pathogenesis and progression of atrial fibrillation (AF). We sought to evaluate the extent of left atrial (LA) scarring in patients with paroxysmal AF (PAF) undergoing catheter ablation using a new impedance-based algorithm. METHODS: We prospectively enrolled 73 consecutive patients (43 males, 58 years) with PAF who underwent pulmonary vein antral isolation. We first performed high-density bipolar voltage mapping during sinus rhythm using Tissue Proximity Indicator (TPI), one of the features of the ConfiDense mapping module integrated in the electroanatomic mapping system. A dense LA shell was created initially without TPI (mean points 2,411) and subsequently activating TPI (mean points 1,167). Each point was classified according to the peak-to-peak bipolar voltage electrogram based on two criteria (criterion A: healthy >0.8 mV, border zone: 0.4-0.8 mV, scarred: <0.4 mV; criterion B: healthy: >0.5 mV, border zone: 0.25-0.5 mV, scarred: <0.25 mV). RESULTS: LA voltage analysis represented significantly smaller scarred areas when mapping was performed with TPI-ON compared with TPI-OFF in both voltage criteria (average LA voltage area: 3.02 ± 5.28 cm2 vs 9.15 ± 13.11 cm2 vs in criterion A and 1.19 ± 2.54 cm2 vs 5.61 ± 9.56 cm2 in criterion B). A statistically significant voltage difference was observed in all segments of the left atrium between the two mapping protocols, particularly on the inferior wall. CONCLUSION: A more specific delineation of LA fibrosis may be produced using the TPI feature of the ConfiDense mapping module, through elimination of false-positive annotated mapping points due to low contact.

A rare complication of pacemaker implantation.

Lead perforation is a life-threatening rare complication of pacemaker or defibrillator lead implantation. Clinical examination, electrocardiogram, device interrogation, echocardiography, chest x-ray, and chest computed tomography scan can help in the diagnosis. Clinicians should be aware because early diagnosis and treatment are the cornerstones for achieving a better outcome.

A "tilt" toward cinefluoroscopy.

Fluoroscopy permits rapid and straightforward assessment of mechanical valve function and allows a distinction between normal and malfunctional prostheses, acting as a complementary diagnostic step.

Safety and efficacy of DOACs vs acenocoumarol in patients undergoing catheter ablation of atrial fibrillation.

BACKGROUND: Thromboembolic complications can be life-threatening during atrial fibrillation (AF) catheter ablation. The aim of our study was to evaluate the safety and efficacy of continuous treatment using direct oral anticoagulants (DOACs) as an alternative to uninterrupted acenocoumarol for periprocedural anticoagulation. HYPOTHESIS: Continuous treatment with DOACs has similar safety and efficacy compared to acenocoumarol. METHODS: We enrolled 474 patients (mean age, 58 years; 68.4% male) undergoing AF catheter ablation between June 2013 and December 2016. All patients were equally assigned to take acenocoumarol (group 1, 136 patients) or DOACs (group 2, 338 patients) for ≥2 months before the procedure. We compared thromboembolic and bleeding complications between the 2 groups. RESULTS: Our analysis showed no significant difference in major and minor complications between the 2 patient groups. Specifically, 3 of 136 patients (2.2%) using uninterrupted acenocoumarol had a major complication (1 patient [0.7%] had transient ischemic attack resolved 8 hours later, 1 [0.7%] had pericardial tamponade, and 1 [0.7%] had a subcapsular renal hematoma) and 2 patients (1.4%) had minor complications (1 [0.7%] pseudoaneurysm and 1 [0.7%] groin hematoma). In group 2, 1 of 338 patients (0.3%) had a major complication (transient ischemic attack). In the same group, 7 patients (2.1%) had a minor complication (1 patient [0.3%] presented with pseudoaneurysm, 4 [1.2%] with pericardial effusion <1 cm, 1 [0.3%] femoral arteriovenous fistula between the femoral artery and femoral vein, and 1 [0.7%] groin hematoma). CONCLUSIONS: DOACs and acenocoumarol have similar safety and effectiveness regarding thromboembolic complications prevention without increasing bleeding complications.

Bevacizumab, pemetrexed and carboplatin in first-line treatment of non-small cell lung cancer patients: Focus on patients with brain metastases.

Data concerning bevacizumab plus pemetrexed plus carboplatin as first-line treatment for patients with non-squamous non-small cell lung cancer (NSCLC) with or without brain metastases (BM) are lacking. The present study analyzed the efficacy and safety of this combination as induction therapy, followed by maintenance therapy with bevacizumab plus pemetrexed in non-squamous NSCLC patients with or without BM. Treatment-naïve patients with advanced non-squamous NSCLC and an Eastern Cooperative Oncology Group performance status score of 0-2 were eligible. Treatment consisted of carboplatin (area under the curve of 5), pemetrexed (500 mg/m2) and bevacizumab (15 mg/kg) every 3 weeks for 6 cycles. Responders and patients with stable disease received maintenance therapy with bevacizumab plus pemetrexed until disease progression, which was evaluated every 3 cycles, or unacceptable toxicity. Kaplan-Meier median progression-free survival (PFS) and overall survival (OS) times were the primary endpoints, and safety was the secondary endpoint. In total, 39 patients, aged 44-78 years (median, 60 years), were treated; 11 (28.2%) of whom presented with BM. The majority of patients (56.4%) completed 6 cycles of induction therapy, and 26 patients continued on to maintenance therapy. The median PFS time was 8.2 months [95% confidence interval (CI), 7.05-9.35] and the median OS time was 14.0 months (95% CI, 8.46-19.54). Median PFS and OS times did not differ significantly between patients with or without BM (log rank (Mantel-Cox): PFS, P=0.748 and OS, P=0.447). The majority of patients (76.9%) did not experience adverse events during treatment. Overall, bevacizumab plus pemetrexed plus carboplatin as induction therapy, followed by bevacizumab plus pemetrexed as maintenance therapy was effective and well tolerated in advanced NSCLC, whether brain metastases were present or not.