The VR leadless pacemaker: Results of an expert panel using the RAND/UCLA method.

BACKGROUND: Leadless pacemakers were developed to reduce complications associated with transvenous pacemaker implantation and long-term follow-up. Existing international guidelines lack detailed instructions on patients suitable for leadless pacemaker implantation. Our aim was to develop a consensus document that provides medical guidance for all health professionals involved in the indication and implantation of Transcatheter Pacing System single-chamber device (VR leadless) pacemakers for patients with atrial fibrillation or in sinus rhythm. METHODS: A panel of experts, including interventional and non-interventional cardiologists, used the Research ANd Development/University of California at Los Angeles (RAND/UCLA) method to rate the appropriateness of leadless pacemaker implantation for 64 scenarios in patients with atrial fibrillation and 192 scenarios in sinus rhythm. The scenarios were rated individually and again during a moderated group session. Median ratings and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or questionable. RESULTS: This consensus statement, based on available literature and the experts' opinions, summarizes recommendations for standardizing and optimizing leadless pacemaker implantation. The limitation for vascular access via the superior vena cava was the most influential variable when indicating leadless pacemaker implantation in both patients with atrial fibrillation and patients in sinus rhythm. CONCLUSIONS: Life expectancy, risk of infection, prosthetic valve, left ventricular ejection fraction (LVEF), limitation for vascular access via the superior vena cava, and mobility and exercise capacity determine who is advised to undergo VR leadless pacemaker implantation. More prospective studies are needed to optimize existing recommendations.

Efecto de la cardioversión eléctrica programada de fibrilación auricular sobre la función renal / Effect of programmed electrical cardioversion of atrial fibrillation on renal function

Resumen Introducción: Estudios previos han relacionado la presencia de fibrilación auricular (FA) con una tasa de filtrado glomerular estimada (TFGe) reducida. Objetivo: comparar la evolución de la TFGe en pacientes con FA persistente tras cardioversión eléctrica (CVE) programada en función de la existencia o no de recurrencias, así como la evolución de varios biomarcadores. Materiales y métodos: Cohorte prospectiva de pacientes con FA persistente remitidos a nuestro centro para CVE programada con seguimiento de un año. La TFGe se obtuvo mediante la fórmula CKD-EPI en el momento basal y a los 3 y 12 meses. Se midieron biomarcadores antes de la CVE y a los 12 meses. Resultados: Se incluyeron 92 pacientes con FA persistente, edad media de 64 ± 11 años. Al año de seguimiento y en el total de pacientes, la TFGe se redujo de 86,5 [74,6-97,6 a 84,5 [71,7-95,1 ml/min/1,73 m2 (p = 0,002) y la creatinina aumentó de 0,80 [0,72-0,94] mg/dl a 0,83 [0,74-0,97] mg/dl (p = 0,005). La TFGe se redujo al final del seguimiento, sin diferencia estadísticamente significativa entre los pacientes que presentaron recurrencia a los 12 meses y los que no. Las cifras de BNP y corina mejoraron a los 12 meses, mientras que las de galectina-3 no cambiaron, sin relación con la TFGe. Conclusiones: En los pacientes con FA persistente tratados con CVE programada se observó un empeoramiento de la TFGe al año de seguimiento. Los niveles de BNP y corina mejoraron al año de seguimiento. No hubo diferencias en los niveles de galectina-3.

Abstract Introduction: Previous studies have linked the presence of atrial fibrillation (AF) with a reduced estimated glomerular filtration rate (eGFR). Objective: to compare the evolution of eGFR in patients with persistent AF after elective electrical cardioversion (ECV) based on the existence or not of recurrences, as well as the evolution of various biomarkers. Materials and methods: Prospective cohort of patients with persistent AF referred to our center for elective EVC with a 1-year follow-up. The eGFR was obtained using the CKD-EPI formula at baseline and at 3 and 12 months. Biomarkers were measured before ECV and at 12 months. Results: 92 patients with persistent AF were included, mean age 64 ± 11 years. At one year of follow-up and in all patients, the eGFR decreased from 86.5 [74.6-97.6 to 84.5 [71.7-95.1 ml/min/1.73 m2 (p = 0.002) and creatinine increased from 0.80 [0.72-0.94] mg/dl to 0.83 [0.74-0.97] mg/dl (p = 0.005). The eGFR was reduced at the end of the follow-up, with no statistically significant difference between the patients who had recurrence at 12 months and those who did not. BNP and corin levels improved at 12 months, while galectin-3 did not change, unrelated to eGFR. Conclusions: In patients with persistent AF treated with elective ECV, a worsening of eGFR was observed at one year of follow-up. BNP and corin levels improve at one year of follow-up, there were no differences in galectin-3 levels.

Results of catheter ablation with zero or near zero fluoroscopy in pediatric patients with supraventricular tachyarrhythmias.

INTRODUCTION AND OBJECTIVES: Ionizing radiation exposure in catheter ablation procedures carries health risks, especially in pediatric patients. Our aim was to compare the safety and efficacy of catheter ablation guided by a nonfluoroscopic intracardiac navigation system (NFINS) with those of an exclusively fluoroscopy-guided approach in pediatric patients. METHODS: We analyzed catheter ablation results in pediatric patients with high-risk accessory pathways or supraventricular tachycardia referred to our center during a 6-year period. We compared fluoroscopy-guided procedures (group A) with NFINS guided procedures (group B). RESULTS: We analyzed 120 catheter ablation procedures in 110 pediatric patients (11±3.2 years, 70% male); there were 62 procedures in group A and 58 in group B. We found no significant differences between the 2 groups in procedure success (95% group A vs 93.5% group B; P=.53), complications (1.7% vs 1.6%; P=.23), or recurrences (7.3% vs 6.9%; P = .61). However, fluoroscopy time (median 1.1minutes vs 12minutes; P <.0005) and ablation time (median 96.5seconds vs 133.5seconds; P=.03) were lower in group B. The presence of structural heart disease was independently associated with recurrence (P=.03). CONCLUSIONS: The use of NFINS to guide catheter ablation procedures in pediatric patients reduces radiation exposure time. Its widespread use in pediatric ablations could decrease the risk of ionizing radiation.

Antithrombotic therapy and clinical outcomes at 1 year in the Spanish cohort of the EORP-AF Long-term General Registry.

BACKGROUND: Atrial fibrillation (AF) increases the risk of thromboembolism. We investigate the efficacy and safety of oral anticoagulation (OAC) therapy and explored the number needed to treat for net effect (NNTnet) of OAC in the Spanish cohort of the EURObservational Research Programme-AF (EORP-AF) Long-term General Registry. METHODS: The EORP-AF General Registry is a prospective, multicentre registry conducted in ESC countries, including consecutive AF patients. For the present analysis, we used the Spanish cohort, and the primary outcome was any thromboembolism (TE)/acute coronary syndrome (ACS)/cardiovascular death during the first year of follow-up. RESULTS: 729 AF patients were included (57.1% male, median age 75 [IQR 67-81] years, median CHA2 DS2 -VASc and HAS-BLED of 3 [IQR 2-5] and 2 [IQR 1-2], respectively). 548 (75.2%) patients received OAC alone (318 [43.6%] on VKAs and 230 [31.6%] on DOACs). After 1 year, the use of OAC alone showed lower rates of any TE/ACS/cardiovascular death (3.0%/year; p < 0.001) compared to other regimens, and non-use of OAC alone (HR 4.18, 95% CI 2.12-8.27) was independently associated with any TE/ACS/cardiovascular death. Balancing the effects of treatment, the NNTnet to provide an overall benefit of OAC therapy was 24. The proportion of patients on OAC increased at 1 year (87% to 88.1%), particularly on DOACs (33.6% to 39.9%) (p = 0.015), with low discontinuation rates. CONCLUSIONS: In this contemporary cohort of AF patients, OAC therapy was associated with better clinical outcomes at 1 year and positive NNTnet. OAC use slightly increased during the follow-up, with low discontinuation rates and higher prescription of DOACs.

Heterozygous Arrhythmogenic Cardiomyopathy-desmoplakin Mutation Carriers Exhibit a Subclinical Cutaneous Phenotype with Cell Membrane Disruption and Lack of Intercellular Adhesion.

Genetic variants that result in truncation in desmoplakin (DSP) are a known cause of arrhythmogenic cardiomyopathy (AC). In homozygous carriers, the combined involvement of skin and heart muscle is well defined, however, this is not the case in heterozygous carriers. The aim of this work is to describe cutaneous findings and analyze the molecular and ultrastructural cutaneous changes in this group of patients. Four women and eight men with a mean age of 48 ± 14 years were included. Eight met definitive criteria for AC, one was borderline and three were silent carriers. No relevant macroscopic changes in skin and hair were detected. However, significantly lower skin temperature (29.56 vs. 30.97 °C, p = 0.036) and higher transepidermal water loss (TEWL) (37.62 vs. 23.95 g m 2 h 1, p = 0.028) were observed compared to sex- and age-matched controls. Histopathology of the skin biopsy showed widening of intercellular spaces and acantholysis of keratinocytes in the spinous layer. Immunohistochemistry showed a strongly reduced expression of DSP in all samples. Trichogram showed regular nodules (thickening) compatible with pseudomonilethrix. Therefore, regardless of cardiac involvement, heterozygous patients with truncation-type variants in DSP have lower skin temperature and higher TEWL, constant microscopic skin involvement with specific patterns and pseudomonilethrix in the trichogram.

Utility and feasibility of the CartoUnivu™ system for atrial flutter ablation in patients with mechanical prosthetic valves.

Ablation of macroreentrant atrial tachycardia in patients with mechanical prosthetic valves represents a challenge for electrophysiologists, because of the complexity of the procedure and the potential complications. Moreover, the need for fluoroscopy in this type of procedure is greater, due to the risk of interference between the prosthetic valve and the ablation or mapping catheter. We present two cases of patients with mechanical prosthetic valves and atrial flutter who underwent successful ablation with no complications using the CartoUnivu™ tool, which integrates the electroanatomical map and the fluoroscopy image.

Electroanatomic Mapping and Intracardiac Echocardiography-Guided Approach for Left-Bundle Branch Area Pacing With Zero Fluoroscopy.

An 81-year-old man with second-degree atrioventricular block was admitted to our centre for pacemaker implantation. Electroanatomic mapping and intracardiac echocardiography-guided left-bundle branch area pacing was performed, entirely without fluoroscopy. It is the first report to describe intracardiac echocardiography for guiding sheath movements into the heart. In conclusion, the combined use of intracardiac echocardiography and intracardiac navigation system allows us to perform left-bundle branch pacing without fluoroscopy.

Un homme de 81 ans présentant un bloc auriculoventriculaire du second degré a été hospitalisé dans notre centre en vue de l'implantation d'un stimulateur cardiaque. On a effectué une cartographie électro-anatomique et une stimulation de la branche gauche guidée par échocardiographie intracardiaque, entièrement sans fluoroscopie. C'est la première fois qu'on décrit l'utilisation de l'échocardiographie intracardiaque pour guider les mouvements de la gaine dans le cœur. En conclusion, l'utilisation conjointe de l'échocardiographie intracardiaque et d'un système de navigation intracardiaque nous permet d'effectuer une stimulation de la branche gauche sans fluoroscopie.

Efecto de la ablación con catéter de venas pulmonares en la función renal de pacientes con fibrilación auricular. Estudio de cohortes prospectivo / Effect of pulmonary vein catheter ablation on kidney function in patients with atrial fibrillation. A prospective cohort study

INTRODUCCIÓN Y OBJETIVOS: Varios estudios han relacionado la presencia de fibrilación auricular (FA) con una tasa de filtrado glomerular estimada (TFGe) reducida. Nuestro objetivo es comparar la evolución de la TFGe en pacientes con FA tras ablación de venas pulmonares (VP) en función del éxito de la técnica, así como estudiar la relación entre TFGe y varios biomarcadores. MÉTODOS: Cohorte prospectiva de pacientes con FA remitidos a nuestro centro para ablación de VP con seguimiento de 1 año. La TFGe se obtuvo mediante la fórmula de la Chronic Kidney Disease Epidemiology Collaboration en el momento basal y a los 3 y 12 meses. Se midieron biomarcadores (péptido natriurético cerebral, corina y galectina-3) antes de la ablación y a los 12 meses. RESULTADOS: Se estudió a 124 pacientes (edad, 55±10 años; el 69,4% varones); 75 presentaban FA paroxística (60,5%). La media de la TFGe basal fue de 90,8 [77,8-100,0] ml/min/1,73 m2. La TFGe se incrementó al final del seguimiento, con diferencia estadísticamente significativa entre los pacientes que habían sufrido recurrencia a los 12 meses y los que no (-1,1 [-6,0 a 8,8] frente a 7,1 [-0,6 a 14,2] ml/min/1,73 m2; p = 0,017). La mejora de la TFGe a los 12 meses fue inversamente proporcional a la TFGe basal. Las cifras de péptido natriurético cerebral y corina mejoraron a los 12 meses, mientras que los de galectina-3 empeoraron, sin relación con la TFGe. CONCLUSIONES: En los pacientes con FA tratados con ablación de VP, se observó una mejora general de la TFGe, más marcada en el subgrupo que no tuvo recurrencias, aunque sin diferencias significativas en el análisis multivariante

INTRODUCTION AND OBJECTIVES: Several studies have linked the presence of atrial fibrillation (AF) with reduced estimated glomerular filtration rate (eGFR). Our objective was to compare changes in eGFR in patients with AF after pulmonary vein (PV) ablation depending on the success of the technique, as well as to examine the relationship between eGFR and several biomarkers. METHODS: Prospective cohort of patients with AF referred to our center for PV ablation with a 1-year follow-up. We estimated eGFR using the Chronic Kidney Disease Epidemiology Collaboration formula at baseline and at 3 and 12 months. Biomarkers (B-type natriuretic peptide, corin, and galectin-3) were measured before ablation and at 12 months. RESULTS: We studied 124 patients (age 55±10 years, 69.4% men). Seventy-five had paroxysmal AF (60.5%). The mean baseline eGFR was 90.8 [77.8-100.0] mL/min/1.73 m2. The eGFR increased at the end of follow-up, with a statistically significant difference between patients with recurrence at 12 months and those without (−1.1 [-6.0 to 8.8] mL/min/1.73 m2 vs 7.1 [−0.6 to 14.2] mL/min/1.73 m2, P=.017). The improvement in eGFR at 12 months was inversely proportional to baseline eGFR. B-type natriuretic peptide and corin levels improved at 12 months, while galectin-3 levels worsened, which was unrelated to eGFR. CONCLUSIONS: In patients with AF treated with PV ablation, an overall improvement in eGFR was observed, which was more marked in the subgroup without recurrences, although without significant differences on multivariate analysis

The Gut Microbiota and Its Implication in the Development of Atherosclerosis and Related Cardiovascular Diseases.

The importance of gut microbiota in health and disease is being highlighted by numerous research groups worldwide. Atherosclerosis, the leading cause of heart disease and stroke, is responsible for about 50% of all cardiovascular deaths. Recently, gut dysbiosis has been identified as a remarkable factor to be considered in the pathogenesis of cardiovascular diseases (CVDs). In this review, we briefly discuss how external factors such as dietary and physical activity habits influence host-microbiota and atherogenesis, the potential mechanisms of the influence of gut microbiota in host blood pressure and the alterations in the prevalence of those bacterial genera affecting vascular tone and the development of hypertension. We will also be examining the microbiota as a therapeutic target in the prevention of CVDs and the beneficial mechanisms of probiotic administration related to cardiovascular risks. All these new insights might lead to novel analysis and CVD therapeutics based on the microbiota.

Effect of pulmonary vein catheter ablation on kidney function in patients with atrial fibrillation. A prospective cohort study.

INTRODUCTION AND OBJECTIVES: Several studies have linked the presence of atrial fibrillation (AF) with reduced estimated glomerular filtration rate (eGFR). Our objective was to compare changes in eGFR in patients with AF after pulmonary vein (PV) ablation depending on the success of the technique, as well as to examine the relationship between eGFR and several biomarkers. METHODS: Prospective cohort of patients with AF referred to our center for PV ablation with a 1-year follow-up. We estimated eGFR using the Chronic Kidney Disease Epidemiology Collaboration formula at baseline and at 3 and 12 months. Biomarkers (B-type natriuretic peptide, corin, and galectin-3) were measured before ablation and at 12 months. RESULTS: We studied 124 patients (age 55±10 years, 69.4% men). Seventy-five had paroxysmal AF (60.5%). The mean baseline eGFR was 90.8 [77.8-100.0] mL/min/1.73 m2. The eGFR increased at the end of follow-up, with a statistically significant difference between patients with recurrence at 12 months and those without (-1.1 [-6.0 to 8.8] mL/min/1.73 m2 vs 7.1 [-0.6 to 14.2] mL/min/1.73 m2, P=.017). The improvement in eGFR at 12 months was inversely proportional to baseline eGFR. B-type natriuretic peptide and corin levels improved at 12 months, while galectin-3 levels worsened, which was unrelated to eGFR. CONCLUSIONS: In patients with AF treated with PV ablation, an overall improvement in eGFR was observed, which was more marked in the subgroup without recurrences, although without significant differences on multivariate analysis.

Recomendaciones de expertos en la mejora de la prevención efectiva del ictus isquémico en la fibrilación auricular no valvular: papel del rivaroxabán / Expert recommendations on improving effective ischemic stroke prevention in nonvalvular atrial fibrillation: the role of rivaroxaban

La fibrilación auricular aumenta de manera marcada el riesgo de ictus isquémico. A pesar de que los antagonistas de la vitamina K (AVK) reducen ese riesgo, tienen una eficacia limitada y numerosos inconvenientes que han hecho que durante años hubiese una proporción importante de pacientes con fibrilación auricular no anticoagulados. En cambio, no solo los ensayos clínicos, sino también los estudios en práctica clínica real y últimamente los estudios poblacionales, han demostrado que los anticoagulantes orales de acción directa (ACOD) tienen más eficacia y seguridad y un mejor beneficio clínico neto que los AVK. De hecho, en las regiones donde la prescripción de ACOD es mayor, está disminuyendo la incidencia de ictus isquémico, además de los costes generales asociados con la fibrilación auricular. A pesar de que en los últimos años ha aumentado la prescripción de ACOD, España es de los países con menores tasas de prescripción de toda Europa, lo que podría asociarse con mayores tasas de ictus isquémico. A pesar de que todas las guías posicionan los ACOD como de primera elección frente a los AVK para los pacientes con fibrilación auricular no valvular, en España, debido a las restricciones impuestas por el informe de posicionamiento terapéutico, con necesidad de visado, y también por la inercia terapéutica, es mayor la prescripción de AVK. Son necesarias medidas inmediatas para corregir esta situación, y así mejorar el pronóstico de nuestros pacientes

Atrial fibrillation markedly increases the risk of ischemic stroke. Although vitamin K antagonists (VKAs) reduce this risk, they have limited efficacy and several disadvantages, which has meant that over the years a substantial proportion of patients with atrial fibrillation have remained without anticoagulation. In contrast, clinical trials, studies in routine clinical practice and, more recently, population-based studies have all demonstrated that direct oral anticoagulants (DOACs) are more effective and safer than VKAs and also have a greater net clinical benefit. In fact, in regions where the DOAC prescription rate is high, the incidence of ischemic stroke has decreased, as have the overall costs associated with atrial fibrillation. Although the prescription of DOACs in Spain has increased in recent years, the country has one of the lowest prescription rates in Europe, which may be associated with a higher incidence of ischemic stroke. Despite clinical guidelines all recommending that DOACs should be used in preference to VKAs in patients with nonvalvular atrial fibrillation, more prescriptions are issued for VKAs in Spain, largely due to restrictions imposed by national statements on appropriate medicine use (including the need for approval), but also because of therapeutic inertia. Immediate action should be taken to correct this situation and to improve patients' prognoses

Perfil clínico de la miocardiopatía arritmogénica del ventrículo derecho con afección asociada del izquierdo / Clinical profile of arrhythmogenic right ventricular cardiomyopathy with left ventricular involvement

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Taquicardia ventricular diagnosticada por ecocardiografía: ¿fallan los criterios diagnósticos clínicos y electrocardiográficos? / Echocardiographic diagnosis of ventricular tachycardia: is there a problem with clinical and electrocardiographic diagnostic criteria?

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