Bilateral Cardiac Sympathectomy and Extrapericardial Coil Implantation for the Management of Electrical Storm.

We present a novel multidisciplinary approach for the treatment of electrical storm combining bilateral cardiac sympathectomy, extrapericardial coil insertion, and implantable cardioverter defibrillator upgrade in a patient with nonischemic cardiomyopathy and ventricular arrhythmias refractory to conventional therapies. (Level of Difficulty: Advanced.).

Fusion pacing in patients with right bundle branch block who undergo cardiac resynchronization therapy.

PURPOSE: Patients with right bundle branch block (RBBB) are less likely to respond to cardiac resynchronization therapy (CRT). We aimed to assess whether patients with RBBB respond to CRT with biventricular fusion pacing. METHODS: Consecutive patients with RBBB at a single tertiary care center, who were implanted with a CRT device capable of biventricular fusion pacing using SyncAV programming, were assessed and compared to a historical cohort of CRT patients with RBBB. QRSd was measured and compared during intrinsic conduction, nominal CRT pacing and manual electrocardiogram-based optimized SyncAV programming. Left ventricular ejection fraction (LVEF) was also compared before and 6 months after CRT. RESULTS: We included 8 consecutive patients with RBBB (group 1) who were able to undergo SyncAV programming and 16 patients with RBBB (group 2) from a historical cohort. In group 1, compared to mean intrinsic conduction QRSd (155 ± 13 ms), mean nominally-paced QRSd was 156 ± 15 ms (ΔQRSd 1.3 ± 11.6; p = 0.77) and SyncAV-optimized paced QRSd was 135 ± 14 ms (ΔQRSd -20.0 ± 20.4; p = 0.03 and ΔQRSd -21.3 ± 16.3; p = 0.008; compared to intrinsic conduction and nominal pacing respectively). In group 2, mean QRSd with nominal pacing was 160 ± 24 ms (ΔQRSd 3.8 ± 33.4; p = 0.66 compared to intrinsic conduction). In group 1, baseline LVEF was 22.1 ± 11.5 and after 6 months of follow-up was 27.8 ± 8.6 (p = 0.047). In group 2, the baseline LVEF was 27.2 ± 10.6 and after 6 months of follow-up was 25.0 ± 10.0 (p = 0.45). CONCLUSIONS: CRT programed to allow biventricular fusion pacing significantly improved electrical synchrony and LVEF in patients with RBBB. Larger studies are required to confirm these findings.

Optimization of Chronic Cardiac Resynchronization Therapy Using Fusion Pacing Algorithm Improves Echocardiographic Response.

BACKGROUND: Whether reprogramming of cardiac resynchronization therapy (CRT) to increase electrical synchrony translates into echocardiographic improvement remains unclear. SyncAV is an algorithm that allows fusion of intrinsic conduction with biventricular pacing. We aimed to assess whether reprogramming chronically implanted CRT devices with SyncAV is associated with improved echocardiographic parameters. METHODS: Patients at a quaternary center with previously implanted CRT devices with a programmable SyncAV algorithm underwent routine electrocardiography-based SyncAV optimization during regular device clinic visits. This analysis included only patients who could be programmed to the SyncAV algorithm (i.e., in sinus rhythm with intrinsic atrioventricular conduction). Echocardiography was performed before and 6 months after CRT optimization. RESULTS: Of 64 consecutive, potentially eligible patients who underwent assessment, 34 who were able to undergo SyncAV programming were included. Their mean age was 74 ± 9 years, 41% were female, and 59% had ischemic cardiomyopathy. The mean time from CRT implant to SyncAV optimization was 17.8 ± 8.5 months. At 6-month follow-up, SyncAV optimization was associated with a significant increase in left ventricular ejection fraction (LVEF) (mean LVEF 36.5% ± 13.3% vs 30.9% ± 13.3%; P < 0.001) and a reduction in left ventricular end-systolic volume (LVESV) (mean LVESV 110.5 ± 57.5 mL vs 89.6 ± 52.4 mL; P < 0.001) compared with baseline existing CRT programming. CONCLUSION: CRT reprogramming to maximize biventricular fusion pacing significantly increased LVEF and reduced LVESV in patients with chronic CRT devices. Further studies are needed to assess if a continuous fusion pacing algorithm improves long-term clinical outcomes and to identify which patients are most likely to derive benefit.

CONTEXTE: On ignore si la reprogrammation du dispositif de resynchronisation cardiaque (DRC) afin d'améliorer la synchronisation électrique se traduit réellement par une amélioration échocardiographique. L'algorithme SyncAV permet de fusionner la conduction intrinsèque et la stimulation biventriculaire. Nous avons tenté de déterminer si la reprogrammation à l'aide de l'algorithme SyncAV d'un DRC implanté de façon permanente permet d'améliorer les paramètres échocardiographiques. MÉTHODOLOGIE: Les patients d'un centre de soins quaternaires porteurs d'un DRC doté d'un algorithme SyncAV programmable ont subi une optimisation électrocardiographique de routine de cet algorithme à l'occasion d'une consultation de suivi. L'analyse ne portait que sur les patients dont le dispositif pouvait être programmé au moyen de l'algorithme SyncAV (c.-à-d. en rythme sinusal avec conduction auriculoventriculaire intrinsèque). Une échocardiographie a été réalisée avant l'optimisation du DRC, puis 6 mois après. RÉSULTATS: Sur les 64 patients consécutifs potentiellement admissibles qui ont fait l'objet d'une évaluation, 34 sujets dont le DRC pouvait être programmé à l'aide de l'algorithme SyncAV ont été retenus. Les sujets avaient en moyenne 74 ± 9 ans; 41 % d'entre eux étaient des femmes, et 59 % présentaient une cardiomyopathie ischémique. Le temps écoulé entre l'implantation du DRC et l'optimisation au moyen de l'algorithme SyncAV était en moyenne de 17,8 ± 8,5 mois. Au moment du suivi à 6 mois, l'optimisation au moyen de l'algorithme SyncAV a été associée à une augmentation significative de la fraction d'éjection ventriculaire gauche (FEVG) (FEVG moyenne de 36,5 % ± 13,3 % vs 30,9 % ± 13,3 %; p < 0,001) et à une réduction du volume télésystolique ventriculaire gauche (VTSVG) (VTSVG moyen de 110,5 ± 57,5 mL vs 89,6 ± 52,4 mL; p < 0,001) comparativement à la programmation initiale du DRC. CONCLUSION: La reprogrammation du DRC afin de maximiser la stimulation biventriculaire par fusion a considérablement augmenté la FEVG et réduit le VTSVG chez les patients porteurs d'un DRC permanent. D'autres études sont nécessaires pour déterminer si un algorithme de stimulation par fusion en continu permet d'améliorer les résultats cliniques à long terme et pour établir le profil des patients les plus susceptibles de bénéficier d'une telle intervention.

Cardiac resynchronization therapy reprogramming to improve electrical synchrony in patients with existing devices.

BACKGROUND: Optimal programming of cardiac resynchronization therapy (CRT) has not yet been fully elucidated. A novel algorithm (SyncAV) has been developed to improve electrical synchrony by fusion of the triple wavefronts: intrinsic, right ventricular (RV)-paced, and left ventricular (LV)-paced. METHODS: Consecutive patients at a single tertiary care center with a previously implanted CRT device with SyncAV algorithm (programmable negative AV hysteresis) were evaluated. QRS duration (QRSd) was measured during 1) intrinsic conduction, 2) existing CRT pacing as chronically programmed by treating physician, 3) using the device-based QuickOpt™ algorithm for optimization of AV and VV delays, and 4) ECG-based optimized SyncAV programming. The paced QRSd was assessed and compared to intrinsic conduction and between the different modes of programming. RESULTS: Of 64 consecutive, potentially eligible patients who underwent assessment, 34 patients who were able to undergo SyncAV programming were included. Mean intrinsic conduction QRSd was 163 ±â€¯24 ms. In comparison, the mean QRSd was 152 ±â€¯25 ms (-11.1 ±â€¯19.0) during existing CRT pacing, 160 ±â€¯25 ms (-4.1 ±â€¯25.2) using the QuickOpt™ algorithm and 138 ±â€¯23 (-24.9 ±â€¯17.2) using ECG-based optimized SyncAV programming. SyncAV optimization resulted in significant reductions in QRSd compared to existing CRT pacing (P = 0.02) and QuickOpt™ (P < 0.001). Of the 32% of patients who did not have QRS narrowing with existing CRT, 72% experienced QRS narrowing with SyncAV. CONCLUSION: ECG-based atrio-ventricular delay optimization using SyncAV significantly improved electrical synchrony in patients with a previously implanted CRT. Further studies are needed to assess the impact on long-term outcomes.

Via acessória médio-septal: papel do eletrocardiograma como preditor da localização no estudo eletrofisiológico / Midseptal accessory pathway: the role of the electrocardiogram in predicting the location on the electrophysiology study

Introdução: A aplicação do eletrocardiograma de 12 derivações para localizar a via acessória na síndrome de Wolff-Parkinson-White é útil para o planejamento terapêutico invasivo. Este estudo teve como objetivo definir as características eletrocardiográficas preditoras da localização médio-septal e relatar os resultados obtidos em pacientes submetidos a ablação por radiofrequência. Método: Estudo retrospectivo e longitudinal, analisando características eletrocardiográficas pré e pós-ablação e informações referentes aos resultados após o procedimento. Resultados: Integraram o estudo 91 pacientes, 11 dos quais apresentaram via acessória com localização médio-septal. As características eletrocardiográficas preditoras da via médio-septal foram: padrão de bloqueio de ramo esquerdo em V1 (odds ratio = 50; P = 0,008), onda delta positiva em D3 (odds ratio = 20,8; P = 0,04) e complexo QRS não positivo em V2 (odds ratio = 15,2; P = 0,003). Nessa sequência, os achados foram combinados na forma de algoritmo para predizer a localização da via médio-septal, com acurácia de 92,3%, sensibilidade de 90,4%, especificidade de 92,5% e valor preditivo negativo de 87,9%. O sucesso foi menor na via médio-septal que nas demais vias (45,5% e 87,5%, respectivamente; P = 0,001). Com relação às complicações, não houve diferença estatística de indução de bloqueio atrioventricular entre a via médio-septal e as demais vias. Conclusão: Os achados eletrocardiográficos foram capazes de predizer a via médio-septal com boa acurácia. Houve mais insucesso na via médio-septal e taxas similares de complicações nas outras vias.

Background:The application of 12-lead electrocardiogram to locate the accessory pathway in Wolff-Parkinson-White syndrome is useful invasive therapy planning. The aim of this study is to define electrocardiographiccharacteristics that predict the midseptal accessory pathway location and report the results obtained in patientsundergoing radiofrequency ablation.Method:Retrospective, longitudinal study analyzing electrocardiogramfeatures pre and post-ablation and information related to post-procedure results.Results:Ninety-one patientswere included, of which 11 had midseptal accessory pathway location. These electrocardiographic characteristicswere predictive of midseptal accessory pathway: left bundle branch block pattern in V1 (odds ratio = 50; P = 0.008),positive delta wave in D3 (odds ratio = 20.8; P = 0.04) and QRS complex non-positive in V2 (odds ratio = 15.2;P = 0.003). Subsequently, the findings were combined as an algorithm to predict the location of the midseptalaccessory pathway, with an accuracy of 92.3%, sensitivity of 90.4%, specificity of 92.5% and negative predictivevalue of 87.9%. Success was lower in the midseptal pathway than in other pathways (45.5% and 87.5% respectively;P = 0.001). With regard to complications, there was no statistical difference in induction of atrioventricular blockbetween midseptal pathway and the other pathways.Conclusion:The electrocardiographic findings were able to predict the midseptal accessory pathway with good accuracy. There were more failures in the midseptal accessorypathway and similar complication rates for the other pathways.

Via acessória médio-septal: papel do eletrocardiograma como preditor da localização no estudo eletrofisiológico / Midseptal accessory pathway: the role of the electrocardiogram in predicting the location on the electrophysiological study

A aplicação do eletrocardiograma de 12 derivações para localizar a via acessória nasíndrome de Wolff-Parkinson-White é útil para o planejamento terapêutico invasivo. Este estudo teve como objetivodefinir as características eletrocardiográficas preditoras da localização médio-septal e relatar os resultados obtidosem pacientes submetidos a ablação por radiofrequência. Método: Estudo retrospectivo e longitudinal, analisandocaracterísticas eletrocardiográficas pré e pós-ablação e informações referentes aos resultados após o procedimento.Resultados: Integraram o estudo 91 pacientes, 11 dos quais apresentaram via acessória com localização médio-septal.As características eletrocardiográficas preditoras da via médio-septal foram: padrão de bloqueio de ramo esquerdo emV1 (odds ratio = 50; P = 0,008), onda delta positiva em D3 (odds ratio = 20,8; P = 0,04) e complexo QRS não positivoem V2 (odds ratio = 15,2; P = 0,003). Nessa sequência, os achados foram combinados na forma de algoritmo parapredizer a localização da via médio-septal, com acurácia de 92,3%, sensibilidade de 90,4%, especificidade de92,5% e valor preditivo negativo de 87,9%. O sucesso foi menor na via médio-septal que nas demais vias (45,5%e 87,5%, respectivamente; P = 0,001). Com relação às complicações, não houve diferença estatística de indução debloqueio atrioventricular entre a via médio-septal e as demais vias. Conclusão: Os achados eletrocardiográficosforam capazes de predizer a via médio-septal com boa acurácia. Houve mais insucesso na via médio-septal e taxassimilares de complicações nas outras vias.

Aterosclerose subclínica: um desafio diagnóstico / Subclinical atherosclerosis: a diagnostic challenge

A doença arterial coronária e o acidente vascular cerebral continuam sendo os principais representantes da doença cardiovascular aterosclerótica, estando na liderança das causas de morbidade e mortalidade na maioria dos países...