Computer Simulation of Catheter Cryoablation for Pulmonary Vein Isolation.

Cryoablation is a well-established medical procedure for surgically treating atrial fibrillation. Cryothermal catheter therapy induces cellular necrosis by freezing the insides of pulmonary veins, with the goal of disrupting abnormal electrical heart signals. Nevertheless, tissue damage induced by cold temperatures may also lead to other complications after cardiac surgery. In this sense, the simulation of catheter ablation can provide safer environments for training and the performance of cryotherapy interventions. Therefore, in this paper, we propose a novel approach to help better understand how temperature rates can affect this procedure by using computer tools to develop a simulation framework to predict lesion size and determine optimal temperature conditions for reducing the risk of major complications. The results showed that a temperature profile of around -40 °C caused less penetration, reduced necrotic damage, and smaller lesion size in the tissue. Instead, cryotherapy close to -60 °C achieved a greater depth of temperature flow inside the tissue and a larger cross-section area of the lesion. With further development and validation, the framework could represent a cost-effective strategy for providing personalized modeling, better planning of cryocatheter-based treatment, and preventing surgical complications.

Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação / Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization

Resumo Fundamento O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. Objetivo Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). Método Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. Resultados A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). Conclusão Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Abstract Background Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. Objective To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). Methods This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. Results The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). Conclusions In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

Oclusão percutânea da comunicação interatrial do tipo seio venoso com stent coberto: a importância dos métodos de imagem para impressão de modelos tridimensionais e a melhor tomada de decisão clínica / Percutaneous occlusion of sinus venosus atrial septal defect using a covered stent: the importance of imaging methods for printing three-dimensional models and better clinical decision-making

A comunicação interatrial do tipo seio venoso superior geralmente acompanha-se de uma conexão venosa anômala de veia ou veias pulmonares superiores ou médias direitas, que drenam diretamente na veia cava superior ou, ainda, na junção cavoatrial. Relatamos o caso de uma paciente do sexo feminino, de 62 anos, com diagnóstico de comunicação interatrial do tipo seio venoso, com sobrecarga das câmaras direitas, para quem foi planejado o procedimento de oclusão percutânea do defeito por meio da realização prévia de tomografia cardiovascular e, sequencialmente, estudo anatômico tridimensional, com o software de acesso público 3D Slicer. Além disso, foi realizada a impressão do modelo em resina para inspeção e simulação de implante de um stent. A paciente foi tratada de maneira percutânea com um stent Chetham-Platinum coberto de 60mm de extensão, com oclusão total do defeito, ausência de shunts residuais e direcionamento do fluxo da veia pulmonar superior direita para o átrio esquerdo por comunicação posterior entre os átrios, condição essencial para a realização desse tipo de procedimento. O planejamento do procedimento de oclusão percutânea da comunicação interatrial do tipo seio venoso passa por avaliação criteriosa dos exames de imagem. A impressão de modelos virtuais ou físicos, derivados da angiotomografia cardíaca, é fundamental para estudo detalhado do defeito e das estruturas anatômicas associadas, minimizando a ocorrência de complicações.

A superior sinus venosus atrial septal defect is usually accompanied by an anomalous venous connection to a right superior or middle pulmonary vein or veins, draining directly into the superior vena cava or even into the cavoatrial junction. This is a case report of a 62-year-old female patient, diagnosed with a sinus venosus atrial septal defect, with overload of the right chambers, for whom a percutaneous occlusion procedure was planned, using a previous cardiovascular tomography and, sequentially, a three-dimensional anatomical study, with the publicly available software 3D Slicer. In addition, a resin model was printed for inspection and simulation of a stent implantation. The patient was treated percutaneously with a 60-mm covered Chetham-Platinum stent, with total occlusion of the defect, absence of residual shunts, and draining flow from the right superior pulmonary vein to the left atrium, through a posterior communication between the atria, a sine qua non prerequisite to perform this type of procedure. Planning of the percutaneous occlusion procedure of the sinus venosus atrial septal defect involves careful evaluation of imaging tests. The printing of virtual or physical models, derived from computed tomography angiography of the heart, is essential for a detailed study of the defect and associated anatomical structures, minimizing the occurrence of complications.

Sinus Node Artery Occlusion During Cardiac Denervation Procedures.

Cardioneural ablation is a novel treatment for functional bradycardia. However, the risk of acute complications is still unknown. The aim of this case report is to describe acute occlusion of the sinus node artery after cardiac denervation procedures in 2 patients and to encourage measures to prevent it, such as evaluating the aortic angulation in older patients before the procedure and by monitoring signs of sinus failure during ablation in patients with electroanatomical maps showing a constricted aspect of the right atrium. (Level of Difficulty: Advanced.).

ablación de fibrilación auricular como tratamiento de primera línea: revisión de la literatura / Ablation as a first line treatment for atrial fibrillation: a review

RESUMEN La ablación con radiofrecuencia (RF) o con Criobalón (CRIO) en pacientes con fibrilación auricular (FA) paroxística y persistente es un tratamiento seguro y eficaz en pacientes seleccionados. Datos recientes demuestran que la ablación proporciona mejores resultados en comparación con fármacos antiarrítmicos (FAA) en el tratamiento de la FA temprana. Los estudios que comparan RF y CRIO mostraron una eficacia y seguridad comparables en el aislamiento de venas pulmonares (PVI) para pacientes con FA paroxística sintomática. OBJETIVOS: Revisar estudios clínicos que comparan el tratamiento de la FA con ablación versus FAA como terapia de primera línea en pacientes con FA sin tratamiento previo. La eficacia y la seguridad se compararán entre las dos cohortes y entre los subgrupos. MÉTODO: Se incluye un total de 6 estudios en los que participaron 1212 pacientes con FA: 609 pacientes fueron aleatorizados a ablación de FA y 603 a tratamiento farmacológico En comparación con el tratamiento con FAA, la ablación se asoció con una reducción en la recurrencia de arritmias auriculares (32,3 % frente a 53 %; riesgo relativo [RR], 0,62; IC del 95 %, 0,51-0,74; P < 0,001; I 2 = 40 %, NNT: 5). El uso de ablación también se asoció con una reducción de las arritmias auriculares sintomáticas (11,8 % frente a 26,4 %; RR, 0,44; IC del 95 %, 0,27-0,72; P = 0,001; I 2 = 54%) y hospitalización (5,6% vs 18,7%; RR, 0,32; IC 95%, 0,19-0,53; P< 0,001) sin diferencias significativas en los eventos adversos graves entre los grupos (4,2 % frente a 2,8 %; RR, 1,52; IC del 95 %, 0,81-2,85; P = 0,19). CONCLUSIÓN: En pacientes con FA paroxística, una estrategia de control precoz del ritmo cardíaco, se asocia con una mayor probabilidad de supervivencia, menos procedimientos repetidos, menos hospitalizaciones y, probablemente, una disminución en la progresión a FA persistente.

INTRODUCTION: Radiofrequency (RF) or cryoballoon (CRYO) ablation in patients with paroxysmal and persistent atrial fibrillation (AF) are safe and effective treatments in selected patients. Recent data show that ablation provides better results compared to antiarrhythmic drugs (AAD) in the treatment of early AF. Studies comparing RF and CRYO showed comparable efficacy and safety in pulmonary vein isolation (PVI) for patients with symptomatic paroxysmal AF. OBJETIVES: Review of clinical trials comparing treatment of AF with ablation versus AAD as first-line therapy in patients with AF with no previous treatment. Efficacy and safety are compared between the two cohorts and between subgroups. METHODS: A total of 6 studies involving -212 AF patients were included: 609 were randomized to AF ablation and 603 to pharmacological treatment. Ablation, compared with AAD, was associated with a reduction in recurrence of atrial arrhythmias (32.3% vs. 53%; relative risk [RR], 0.62; 95% CI, 0.51-0.74, P< 0.001, I2 = 40%, NNT: 5). The use of ablation was also associated with a reduction in symptomatic atrial arrhythmias (11.8% vs. 26.4%; RR, 0.44; 95% CI, 0.27-0.72; P= 0.001; I2 = 54%) and hospitalization (5.6% vs 18.7%; RR, 0.32; 95% CI, 0.19-0.53; P <0.001) with no significant differences in major adverse events (4.2% vs. 2.8%; RR, 1.52; 95% CI, 0.81-2.85; P=0.19). CONCLUSION: In patients with paroxysmal AF, an early cardiac rhythm control with ablation is associated with a higher probability of survival, fewer repeat procedures, fewer hospitalizations, and probably a decrease in progression to persistent AF.

Surgical Removal of The Mechanical Valve Leaflet Dislocated into The Pulmonary Vein

ABSTRACT Accidental detachment of mechanical valve leaflet during implantation is a rare and potentially serious complication. When the lost leaflet cannot be found by direct visualisation, additional diagnostic procedures are necessary to detect it. Computer tomography is the best detection method, but the patient needs reoperation. We presented a patient in whom the detached leaflet migrated and became trapped into the left inferior pulmonary vein. The computed tomography (CT) scan was used to reveal leaflets, and successful extirpation was performed in the second operation.

Surgical Removal of The Mechanical Valve Leaflet Dislocated into The Pulmonary Vein.

Accidental detachment of mechanical valve leaflet during implantation is a rare and potentially serious complication. When the lost leaflet cannot be found by direct visualisation, additional diagnostic procedures are necessary to detect it. Computer tomography is the best detection method, but the patient needs reoperation. We presented a patient in whom the detached leaflet migrated and became trapped into the left inferior pulmonary vein. The computed tomography (CT) scan was used to reveal leaflets, and successful extirpation was performed in the second operation.

Locais de Reconexão na Técnica de Reablação após Isolamento das Veias Pulmonares com Criobalão em Pacientes com Fibrilação Atrial Paroxística / Reconnection Sites in Redo Ablation after Cryoballoon Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation

Resumo Fundamento Na fibrilação atrial paroxística (FAP), o isolamento das veias pulmonares com criobalão (IVP-CB) tem eficácia semelhante à da ablação por radiofrequência (IVP-RF). Em procedimentos de reablação após IVP-RF, a reconexão das VPs é alta, ao passo que em pacientes com reablação após IVP-CB, as informações são escassas. Objetivo Determinar os locais de reconexão das VPs em pacientes que foram submetidos à reablação após IVP-CB inicial. Métodos Pacientes que foram submetidos a um procedimento de reablação de fibrilação atrial, após um IVP-CB inicial para FAP foram incluídos. O mapeamento eletroanatômico do AE foi utilizado. Um local de reconexão foi definido com a presença de uma voltagem de 0,3mV ou maior nas VPs e condução unidirecional ou bidirecional nas VPs durante o ritmo sinusal. Os locais de reconexão foram identificados por meio de corte paraesternal longitudinal e posteriormente ablacionados com radiofrequência. Resultados Dos 165 pacientes submetidos ao IVP inicial, 27 necessitaram reablações, dos quais 18 (66,6%) eram do sexo masculino, com média de idade de 55+12,3 anos. O tempo de recorrência foi de 8,9+6,4 meses. A reconexão das VPs foi encontrada em 21 (77,8%) pacientes. Houve um total de 132 lacunas de condução, seis por paciente, 3,6 por VP. Um número significativo de lacunas ocorreu na região ântero-superior da VP superior esquerda (VPSE) e nas regiões septal e inferior da VP superior direita (VPSD). Conclusões As VPs superiores apresentaram os locais de maior reconexão, principalmente na região anterior da VPSE e na região septal da VPSD. A razão por trás disso pode ser devido à maior espessura da parede atrial e à dificuldade em alcançar o contato de criobalão adequado.

Abstract Background In paroxysmal atrial fibrillation (PAF), pulmonary vein isolation using cryoballoon (CB-PVI) has similar efficacy as radiofrequency ablation (RF-PVI) has. In redo ablation procedures following RF-PVI, PV reconnection is high, whereas in patients with redo following CB-PVI, information is scarce. Objective To determine the sites of PV reconnection in patients who underwent redo ablation after initial CB-PVI. Methods Patients who underwent an AF redo procedure, following an initial CB-PVI for PAF were included. LA electroanatomic mapping was used. A reconnection site was defined as the presence of a voltage of 0.3mV or greater in the PV and unidirectional or bidirectional conduction in the PV during sinus rhythm. Reconnections sites were identified using a clock-face view description and were ablated with radiofrequency afterwards. Results Out of the 165 patients who underwent initial PVI, 27 required redo ablations, of which 18 (66.6%) were males, with a mean age of 55+12.3 years. The time of recurrence was 8.9+6.4 months. PV reconnection was found in 21 (77.8%) patients. There was a total of 132 conduction gaps, six per patient, 3.6 per PV. A significant number of gaps were in the anterosuperior region of the left superior PV (LSPV), and in the septal and inferior regions of the right superior PV (RSPV). Conclusions The upper PVs had the most reconnection sites, mostly at the anterior region of the LSPV and the septal region of the RSPV. The reason behind this may be due to greater atrial wall thickness, and difficulty in achieving adequate cryoballoon contact.

Experiencia latinoamericana en crioablación de fibrilación auricular paroxística y persistente con criobalón de segunda generación. Resultados en agudo y a 12 meses / Latin-American experience in cryoablation of paroxysmal and persistent atrial fibrillation using second generation cryo-balloon. Acute success and 12 months of follow-up

Resumen Objetivo: La ablación por catéteres es una técnica habitual para tratar la fibrilación auricular (FA). Son escasos los datos prospectivos y multicéntricos con resultados a mediano plazo de la crioablación de venas pulmonares en América Latina. El objetivo es evaluar la seguridad y la eficacia de la ablación por criobalón de segunda generación en pacientes con FA paroxística o persistente en América Latina. Método: Se evaluaron las características del procedimiento y los resultados en agudo y a 12 meses Se incluyeron pacientes con FA mayores de 18 años a quienes se realizara desconexión de venas pulmonares con criobalón de segunda generación. Se definió como fallo al tratamiento cualquier episodio de FA, aleteo auricular o taquicardia auricular de más de 30 segundos fuera del periodo de cegamiento de 90 días. Resultados: Se incluyeron 218 pacientes (57 ± 11 años, 66.5% hombres, CHA2DS2-VASc 1.2 ± 1.1). Presentaron FA paroxística el 83.9%, FA persistente el 12.8% y FA persistente de larga duración el 2.3%. Quince pacientes presentaban antecedentes de aleteo auricular. Habían fracasado a una droga antiarrítmica el 89.4%. El éxito en agudo se obtuvo en 211 pacientes (96.8%). El tiempo promedio del procedimiento fue de 73.2 ± 26.7 minutos, el tiempo de fluoroscopia fue de 21.4 ± 23.9 minutos y el tiempo total de ocupación del laboratorio fue de 114.6 ± 41.3 minutos. Durante los 12 meses de seguimiento, el tiempo libre de recurrencia de FA fue del 88.6% en FA paroxística y del 73.1% en FA persistente. Veintiún pacientes (9.6%) presentaron eventos adversos relacionados con el procedimiento. Conclusiones: Estos resultados indican que la desconexión de venas pulmonares con criobalón es un tratamiento seguro y efectivo para la FA en América Latina.

Abstract Objective: Catheter ablation has become a usual technique to treat atrial fibrillation (AF). Medium-term results of prospective and multicenter data concerning pulmonary veins cryoablation in Latin America are limited. The objective is to assess the safety and efficacy of ablation by second generation cryoballoon in patients with paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (PerAF) in Latin America. Method: We evaluate the characteristics of the procedure and the acute and 12-month results. Inclusion criteria include patients over 18 years old with AF who have a planned procedure of pulmonary veins isolation with second generation cryoballoon. Treatment failure was defined as any episode of AF, atrial flutter or atrial tachycardia greater than 30 seconds outside the 90-day blinded period. Results: A total of 218 patients (57 ± 11 years, 66.5% men, CHA2DS2-VASc 1.2 ± 1.1) were included in the study. Of these, 83.9% evidenced PAF, 12.8% PerAF, and 2.3% long-standing PerAF. Fifteen with history of atrial flutter. Most patients had failed at least one antiarrhythmic drug (89.4%). The acute success of the procedure was obtained in 211 patients (96.8%). The average procedure time was 73.2 ± 26.7 min, the fluoroscopy time was 21.4 ± 23.9 min, and the total lab occupancy time was 114.6 ± 41.3 min. During the 12-month follow-up, freedom from AF recurrence was 88.6% in PAF, and 73.1% in PerAF. Twenty-one patients experienced device or procedure-related complications (9.6%). Conclusions: These results support pulmonary veins electrical isolation with cryoballoon as an effective treatment for AF in Latin America.

Successful Repair of Infantile Scimitar Syndrome with Contralateral Pulmonary Vein Stenosis in an Infant.

Infantile scimitar syndrome (SS) is a rare congenital heart disease and has high mortality. Guidelines have not been established, but surgery is indicated in symptomatic patients. Despite the various surgical approaches, outcomes continue to be disappointing. We present our surgical experience with an infantile SS patient who had stenotic pulmonary veins contralateral to the hypoplastic lung with complicated anatomy. There are few cases with this complex pathology in the literature. Moreover, our patient was the first transplant-free survivor with this complexity in the literature.

Latin-American experience in cryoablation of paroxysmal and persistent atrial fibrillation using second generation cryo-balloon. Acute success and 12 months of follow-up / Experiencia latinoamericana en crioablación de fibrilación auricular paroxística y persistente con criobalón de segunda generación. Resultados en agudo y a 12 meses

Objective: Catheter ablation has become a usual technique to treat atrial fibrillation (AF). Medium-term results of prospective and multicenter data concerning pulmonary veins cryoablation in Latin America are limited. The objective is to assess the safety and efficacy of ablation by second generation cryoballoon in patients with paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (PerAF) in Latin America. Method: We evaluate the characteristics of the procedure and the acute and 12-month results. Inclusion criteria include patients over 18 years old with AF who have a planned procedure of pulmonary veins isolation with second generation cryoballoon. Treatment failure was defined as any episode of AF, atrial flutter or atrial tachycardia greater than 30 seconds outside the 90-day blinded period. Results: A total of 218 patients (57 ± 11 years, 66.5% men, CHA2DS2-VASc 1.2 ± 1.1) were included in the study. Of these, 83.9% evidenced PAF, 12.8% PerAF, and 2.3% long-standing PerAF. Fifteen with history of atrial flutter. Most patients had failed at least one antiarrhythmic drug (89.4%). The acute success of the procedure was obtained in 211 patients (96.8%). The average procedure time was 73.2 ± 26.7 min, the fluoroscopy time was 21.4 ± 23.9 min, and the total lab occupancy time was 114.6 ± 41.3 min. During the 12-month follow-up, freedom from AF recurrence was 88.6% in PAF, and 73.1% in PerAF. Twenty-one patients experienced device or procedure-related complications (9.6%). Conclusions: These results support pulmonary veins electrical isolation with cryoballoon as an effective treatment for AF in Latin America.

Objetivo: La ablación por catéteres es una técnica habitual para tratar la fibrilación auricular (FA). Son escasos los datos prospectivos y multicéntricos con resultados a mediano plazo de la crioablación de venas pulmonares en América Latina. El objetivo es evaluar la seguridad y la eficacia de la ablación por criobalón de segunda generación en pacientes con FA paroxística o persistente en América Latina. Método: Se evaluaron las características del procedimiento y los resultados en agudo y a 12 meses Se incluyeron pacientes con FA mayores de 18 años a quienes se realizara desconexión de venas pulmonares con criobalón de segunda generación. Se definió como fallo al tratamiento cualquier episodio de FA, aleteo auricular o taquicardia auricular de más de 30 segundos fuera del periodo de cegamiento de 90 días. Resultados: Se incluyeron 218 pacientes (57 ± 11 años, 66.5% hombres, CHA2DS2-VASc 1.2 ± 1.1). Presentaron FA paroxística el 83.9%, FA persistente el 12.8% y FA persistente de larga duración el 2.3%. Quince pacientes presentaban antecedentes de aleteo auricular. Habían fracasado a una droga antiarrítmica el 89.4%. El éxito en agudo se obtuvo en 211 pacientes (96.8%). El tiempo promedio del procedimiento fue de 73.2 ± 26.7 minutos, el tiempo de fluoroscopia fue de 21.4 ± 23.9 minutos y el tiempo total de ocupación del laboratorio fue de 114.6 ± 41.3 minutos. Durante los 12 meses de seguimiento, el tiempo libre de recurrencia de FA fue del 88.6% en FA paroxística y del 73.1% en FA persistente. Veintiún pacientes (9.6%) presentaron eventos adversos relacionados con el procedimiento. Conclusiones: Estos resultados indican que la desconexión de venas pulmonares con criobalón es un tratamiento seguro y efectivo para la FA en América Latina.

Successful repair of infantile scimitar syndrome with contralateral pulmonary vein stenosis in an infant

Abstract Infantile scimitar syndrome (SS) is a rare congenital heart disease and has high mortality. Guidelines have not been established, but surgery is indicated in symptomatic patients. Despite the various surgical approaches, outcomes continue to be disappointing. We present our surgical experience with an infantile SS patient who had stenotic pulmonary veins contralateral to the hypoplastic lung with complicated anatomy. There are few cases with this complex pathology in the literature. Moreover, our patient was the first transplant-free survivor with this complexity in the literature.

Prenatal diagnosis of total anomalous pulmonary venous connection: 2D and 3D echocardiographic findings.

Total anomalous pulmonary venous connection (TAPVC) is a rare cyanotic congenital heart disease that accounts for less than 1% of all congenital heart diseases. TAPVC is characterized by the absence of pulmonary venous drainage into the left atrium. It is underdiagnosed in utero, with prenatal detection rates of less than 1.4%. The prenatal diagnosis of TAPVC affects the postnatal outcome, particularly in obstructive forms (critical TAPVC), since planned delivery and perinatal management are mandatory. Thus, identifying the ultrasound key markers of TAPVC is important for the prenatal diagnosis and perinatal assistance. The ventricular size discrepancy (right ventricle > left ventricle) can be a useful marker. Furthermore, the increased retroatrial distance between the left atrium and the aorta could be a diagnostic marker for prenatal TAPVC, especially when the left atrium is small. Three- (3D) and four-dimensional ultrasonography may improve the prenatal diagnosis of TAPVC. This study reviews the two (2D) and 3D ultrasonographic markers used in the antenatal diagnosis of TAPVC, with a focus on the tools that can be used by sonographers, obstetricians, and fetal medicine specialists to improve the prenatal diagnosis of TAPVC, and when to refer the case to a fetal cardiac specialist.

Left atrial appendage thrombosis and persistent atrial fibrillation: combined treatment with a totally thoracoscopic approach

Abstract Minimally invasive surgical ablation is generally contraindicated in patients with atrial fibrillation and thrombosis of the left atrial appendage. We have treated three of these patients using an innovative technique based on a bilateral video-thoracoscopic approach, performing a continuous encircling lesion at the pulmonary veins outflow with radio-frequency ablation, simultaneously excluding the left atrial appendage. The postoperative course was uneventful, without neurologic events and all patients maintained a stable sinus rhythm at 1-year follow-up. This procedure represents a new mini-invasive method to treat persistent atrial fibrillation when partial thrombosis of the left atrial appendage contraindicates other ablation techniques.

Left Atrial Appendage Thrombosis and Persistent Atrial Fibrillation: combined Treatment with a Totally Thoracoscopic Approach.

Minimally invasive surgical ablation is generally contraindicated in patients with atrial fibrillation and thrombosis of the left atrial appendage. We have treated three of these patients using an innovative technique based on a bilateral video-thoracoscopic approach, performing a continuous encircling lesion at the pulmonary veins outflow with radio-frequency ablation, simultaneously excluding the left atrial appendage. The postoperative course was uneventful, without neurologic events and all patients maintained a stable sinus rhythm at 1-year follow-up. This procedure represents a new mini-invasive method to treat persistent atrial fibrillation when partial thrombosis of the left atrial appendage contraindicates other ablation techniques.

Experiência de um Centro Brasileiro com Crioablação para Isolamento Elétrico das Veias Pulmonares na Fibrilação Atrial Paroxística e Persistente - Resultados Preliminares no Brasil / Experience in a Brazilian Center with Cryoablation for Electric Isolation of the Pulmonary Veins in Paroxysmal and Persistent Atrial Fibrillation - Preliminary Results in Brazil

Resumo Fundamento O isolamento elétrico das veias pulmonares é reconhecidamente base fundamental para o tratamento não farmacológico da fibrilação atrial (FA) e, portanto, tem sido recomendado como passo inicial na ablação de FA em todas as diretrizes. A técnica com balão de crioenergia, embora amplamente utilizada na América do Norte e Europa, ainda se encontra em fase inicial em muitos países em desenvolvimento, como o Brasil. Objetivo Avaliar o sucesso e a segurança da técnica de crioablação em nosso serviço, em pacientes com FA paroxística e persistente. Métodos Cento e oito pacientes consecutivos com FA sintomática e refratária ao tratamento farmacológico foram submetidos à crioablação para isolamento das veias pulmonares. Os pacientes foram separados em dois grupos, de acordo com a classificação convencional da FA paroxística (duração de até sete dias) e persistente (FA por mais de sete dias). Dados de recorrência e segurança do procedimento foram analisados respectivamente como desfechos primário e secundário. O nível de significância adotado foi de 5%. Resultados Cento e oito pacientes, com idade média de 58±13 anos, 84 do sexo masculino (77,8%), foram submetidos ao procedimento de crioablação de FA. Sessenta e cinco pacientes apresentavam FA paroxística (60,2%) e 43, FA persistente (39,2%). O tempo médio do procedimento foi de 96,5±29,3 minutos e o tempo médio de fluoroscopia foi de 29,6±11,1 minutos. Foram observadas cinco (4,6%) complicações, nenhuma fatal. Considerando a evolução após os 3 meses iniciais, foram observadas 21 recorrências (19,4%) em período de um ano de seguimento. As taxas de sobrevivência livre de recorrência nos grupos paroxístico e persistente foram de 89,2% e 67,4%, respectivamente. Conclusão A crioablação para isolamento elétrico das veias pulmonares é um método seguro e eficaz para tratamento da FA. Nossos resultados estão consoantes com demais estudos, que sugerem que a tecnologia pode ser utilizada como abordagem inicial, mesmo nos casos de FA persistente. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background Electrical isolation of the pulmonary veins is recognized as the cornerstone of non-pharmacological treatment of Atrial Fibrillation (AF), and therefore, has been recommended as the first step in AF ablation according to all guidelines. Even though the cryoballoon technology is widely used in North America and Europe, this experience is still incipient in many developing countries such as Brazil. Objective To evaluate initial results regarding success and safety of the new technology in patients with persistent and paroxysmal AF. Methods One hundred and eight consecutive patients with symptomatic AF refractory to pharmacological treatment were submitted to cryoablation for isolation of the pulmonary veins. Patients were separated into two groups according to AF classification: persistent (AF for over one week); or paroxysmal (shorter episodes). Recurrence and procedural safety data were analyzed respectively as primary and secondary outcomes. The level of significance was 5%. Results One hundred and eight patients, with mean age 58±13 years, 84 males (77.8%), underwent cryoablation. Sixty-five patients had paroxysmal AF (60.2%) and 43 had persistent AF (39.2%). The mean time of the procedure was 96.5±29.3 minutes and the mean fluoroscopy time was 29.6±11.1 minutes. Five (4.6%) complications were observed, none fatal. Considering a blanking period of 3 months, 21 recurrences (19.4%) were observed in a one-year follow-up period. The recurrence-free survival rates of AF in the paroxysmal and persistent groups were 89.2% and 67.4%, respectively. Conclusion Cryoablation for electrical isolation of the pulmonary veins is a safe and effective method for the treatment of AF. Our results are consistent with other studies suggesting that this technology can be used as an initial technique even in cases of persistent AF.

Compression of the Left Atrium and Pulmonary Veins Due to Ascending and Descending Aortic Aneurysms.

An 89-year-old female patient presented to our cardiology outpatient clinic complaining of shortness of breath and back pain. Chest X-ray demonstrated a widened mediastinum. Transthoracic echocardiography showed an ascending aortic aneurysm and the modified apical 5-chamber view showed that left atrium was compressed between the ascending and descending aortas. Color Doppler turbulence was also seen in the compressed area. A contrast-enhanced chest computed tomography scan in axial and coronal planes showed that left atrium and pulmonary veins were compressed by ascending and descending aortic aneurysms. Herein, we illustrated this rare condition diagnosed by transthoracic echocardiography in combination with computed tomography.

Thoracoscopic Pulmonary Vein and Left Atrial Posterior Wall Isolation Combined with Left Atrial Appendage Resection in Patients with Long-Standing Persistent Atrial Fibrillation.

OBJECTIVE: To evaluate the efficacy and safety of a modified technique for totally thoracoscopic left atrial posterior wall and pulmonary vein isolation in patients with long-standing persistent atrial fibrillation. METHODS: From April 2017 to December 2018, we included in this study 28 consecutive patients who underwent thoracoscopic left atrial posterior wall and pulmonary vein radiofrequency isolation combined with left atrial appendage resection. We used a device with irrigated electrodes (Medtronic Cardioblate Gemini-s). The original surgical technique "GALAXY" proposed by Doty in 2012 was modified. The number of ablations was significantly increased, and frequent position changing of the ablation device and change of device angulation were added. RESULTS: Sinus rhythm was restored in all patients. There was no operative mortality, no myocardial infarction, and no stroke or transient ischemic attack. One patient required sternotomy and another survived left anterolateral thoracotomy due to bleeding. A 180-day follow-up (24-hour Holter monitoring) revealed no sign of recurrence of atrial fibrillation or other supraventricular arrhythmia in any patient. Mean follow-up was nine months (range: 6-16 months). At the last follow-up, 26 patients (92,9%) were in sinus rhythm (24-hour Holter monitoring). CONCLUSION: A frequent ablation device position changing during the surgery makes it possible to achieve complete left atrial posterior wall and pulmonary veins isolation.  An increased number of applications allows to avoid a false positive transmural damage assessment showed by impedance drop. Also, frequent position changing of the ablation device and increased number of applications do not affect the number of postoperative complications.