Personalized pulmonary vein isolation with very high-power short-duration lesions guided by left atrial wall thickness: the QDOT-by-LAWT randomized trial.

AIMS: Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using very high-power short-duration (vHPSD) radiofrequency (RF) ablation proved to be safe and effective. However, vHPSD applications result in shallower lesions that might not be always transmural. Multidetector computed tomography-derived left atrial wall thickness (LAWT) maps could enable a thickness-guided switching from vHPSD to the standard-power ablation mode. The aim of this randomized trial was to compare the safety, the efficacy, and the efficiency of a LAWT-guided vHPSD PVI approach with those of the CLOSE protocol for PAF ablation (NCT04298177). METHODS AND RESULTS: Consecutive patients referred for first-time PAF ablation were randomized on a 1:1 basis. In the QDOT-by-LAWT arm, for LAWT ≤2.5 mm, vHPSD ablation was performed; for points with LAWT > 2.5 mm, standard-power RF ablation titrating ablation index (AI) according to the local LAWT was performed. In the CLOSE arm, LAWT information was not available to the operator; ablation was performed according to the CLOSE study settings: AI ≥400 at the posterior wall and ≥550 at the anterior wall. A total of 162 patients were included. In the QDOT-by-LAWT group, a significant reduction in procedure time (40 vs. 70 min; P < 0.001) and RF time (6.6 vs. 25.7 min; P < 0.001) was observed. No difference was observed between the groups regarding complication rate (P = 0.99) and first-pass isolation (P = 0.99). At 12-month follow-up, no significant differences occurred in atrial arrhythmia-free survival between groups (P = 0.88). CONCLUSION: LAWT-guided PVI combining vHPSD and standard-power ablation is not inferior to the CLOSE protocol in terms of 1-year atrial arrhythmia-free survival and demonstrated a reduction in procedural and RF times.

Personalized pulmonary vein antrum isolation guided by left atrial wall thickness for persistent atrial fibrillation.

AIMS: Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF. METHODS AND RESULTS: Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50-67), fluoroscopy time was 43 s (IQR 20-71), and radiofrequency (RF) time was 16.5 min (IQR 14.3-18.4). The median AI tailored to the local LAWT was 387 (IQR 360-410) for the anterior wall and 335 (IQR 300-375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up. CONCLUSION: In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).

Cerebral Embolic Protection During Transseptal Biopsy of Left Atrial Mass.

Diagnostic biopsy of a left atrial mass is technically feasible but has the risk of tumor embolization causing stroke or seeding. In this case report, we highlight the technical steps for left atrial mass biopsy under transesophageal echocardiography guidance by using cerebral embolic protection. Pathologic examination disclosed low-grade B-cell lymphoma. (Level of Difficulty: Advanced.).

Un nuevo método no invasivo en la valoración integral de la fibrilación auricular por tomografía cardíaca / A novel, non-invasive, integral imaging assessment in atrial fibrillation by cardiac tomography

Resumen Objetivo: Analizar la utilidad clínica y la viabilidad de la tomografía cardíaca multidetector (TCMD) en la valoración de pacientes con fibrilación auricular (FA). Material y métodos: Estudio prospectivo de casos y controles en 84 sujetos (54 con FA y 30 controles). La morfología de la orejuela izquierda (OI) se clasificó en cactus, ala de pollo, manga de viento y coliflor. La presencia de trombo en la OI, el antecedente de accidente cerebrovascular y la escala CHA2DS2-VASc se compararon con parámetros obtenidos por TCMD. Resultados: La fracción de expulsión de la aurícula izquierda (FEAI) y la fracción de expulsión de la orejuela izquierda (FEOI) fueron más bajas en los individuos con FA (p < 0.001). El volumen indexado de la aurícula izquierda (VIAI) fue mayor en los pacientes con FA (p < 0.001). Se observó una correlación inversa entre la FEAI y el VIAI (r = -0.38, p < 0.001). La morfología tipo coliflor fue la más frecuente en enfermos con FA, mientras que la de tipo cactus predominó en los controles. La de tipo coliflor fue la más relacionada con presencia de trombos (p < 0.01), así como una calificación CHA2DS2-VASc alta. La velocidad de flujo fue menor en los pacientes con FA (p < 0.001). Conclusión: La TCMD es un método novedoso y no invasivo para una valoración integral en la FA. Los resultados de este estudio podrían mejorar la precisión, la utilidad clínica y el análisis de estratificación del riesgo en la FA. Los autores proponen incluir este nuevo método en la valoración integral del riesgo tromboembólico en pacientes con FA.

Abstract Objective: To analyze the clinical utility and feasibility of the multidetector cardiac tomography (MDCT) in multi-parametric imaging assessment in atrial fibrillation (AF) patients. Material and methods: Prospective case-control study in 84 subjects (54 AF subjects and 30 healthy subjects). Left atrial appendage (LAA) morphology was classified as: cactus, chicken wing, wind sock, cauliflower. Intra-cardiac thrombus, stroke history and CHA2DS2-VASC scale were compared to cardiac MDCT atrial imaging assessment. Results: Left atrial ejection fraction (LAEF) and LAA ejection fraction (LAAEF) were lower in AF subjects (p < 0.001), left atrial volume index (LAVI) was higher in AF subjects (p < 0.001). An inverse correlation between LAEF and LAVI was found (r = −0.38, p < 0.001). Cauliflower LAA morphology frequency was higher in AF subjects, whereas cactus LAA morphology frequency was higher in controls. Cauliflower LAA morphology was associated with thrombus presence (p < 0.01) as well as a higher CHA2DS2-VASc score. Flow velocity were lower in AF subject compared to controls (p < 0.001). Conclusion: MDCT is a novel, non-invasive, worldwide available method for an integral assessment in AF. Our results could improve precision, clinical utility and risk stratification analysis in AF. Our proposal is to include this new method into the global cardiovascular and thrombotic risk assessment in AF patients.

The Role of Multimodality Imaging in HIV-Associated Cardiomyopathy.

Despite marked advances in therapeutics, HIV infection remains a leading cause of morbidity and mortality worldwide. HIV infection is associated with cardiovascular complications including myocardial dysfunction. The description of HIV-associated cardiomyopathy (HIVAC) has evolved over time from a predominantly dilated cardiomyopathy with systolic dysfunction to one of subclinical diastolic dysfunction. Multimodality cardiovascular imaging plays an integral role in our understanding of the etiology and pathogenesis of HIVAC. Such imaging is also essential in the evaluation of individuals with chronic HIV disease who present with cardiac symptoms, especially of heart failure. In the present review, we will highlight current evidence for the role of multimodality imaging in establishing the diagnosis, etiology and pathophysiology of HIVAC as well as guiding treatment and assessing prognosis.

Update on noninvasive imaging of right ventricle dysfunction in pulmonary hypertension.

Pulmonary hypertension (PH) is a progressive disease affecting patients across the life span. The pathophysiology primarily involves the pulmonary vasculature and right ventricle (RV), but eventually affects the left ventricular (LV) function as well. Safe, accurate imaging modalities are critical for diagnosis, serial monitoring, and tailored therapy. While cardiac catheterization remains the conventional modality for establishing diagnosis and serial monitoring, noninvasive imaging has gained considerable momentum in providing accurate assessment of the entire RV-pulmonary axis. In this state-of-the-art review, we will discuss the most recent developments in echocardiography, magnetic resonance imaging, and computed tomography in PH evaluation from pediatric to adult population.

Cardiac imaging studies in the COVID-19 pandemic.

COVID-19 is an acute respiratory syndrome caused by coronavirus-2 (SARS COV2). The different cardiac imaging methods have issued specific recommendations for the different imaging methods in this pandemic, so it is essential to emphasize the recommendations for carrying out these studies.

El COVID-19 es un síndrome respiratorio agudo ocasionado por el coronavirus-2 (SARS COV2). Los diferentes métodos de imagen cardiaca han dictado recomendaciones específicas de los diferentes métodos de imagen en esta pandemia, por lo que es indispensable recalcar las recomendaciones para la realización de estos estudios.

Use of Contemporary Imaging Techniques for Electrophysiological and Device Implantation Procedures.

Recent technological advances in cardiac imaging allow the visualization of anatomic details up to millimeter size in 3-dimensional format. Thus, it is not surprising that electrophysiologists increasingly rely upon cardiac imaging for the diagnosis, treatment, and subsequent management of patients affected by various arrhythmic disorders. Cardiac imaging methods reviewed in the present work involve: 1) the prediction of arrhythmic risk for sudden cardiac death in patients with heart disease; 2) catheter ablation of atrial fibrillation or ventricular tachycardia; and 3) cardiac resynchronization therapy. Future integration of diagnostic and interventional cardiac imaging will further increase the effectiveness of cardiac electrophysiological procedures and will help in delivering patient-specific therapies with ablation and cardiac implantable electronic devices.

Estudios de imagen cardiaca en la pandemia COVID-19 / Cardiac imaging studies in the COVID-19 pandemic

Resumen El COVID-19 es un síndrome respiratorio agudo ocasionado por el coronavirus-2 (SARS COV2). Los diferentes métodos de imagen cardiaca han dictado recomendaciones específicas de los diferentes métodos de imagen en esta pandemia, por lo que es indispensable recalcar las recomendaciones para la realización de estos estudios.

Abstract COVID-19 is an acute respiratory syndrome caused by coronavirus-2 (SARS COV2). The different cardiac imaging methods have issued specific recommendations for the different imaging methods in this pandemic, so it is essential to emphasize the recommendations for carrying out these studies.

Severe stenosis of left coronary artery originating from right sinus of Valsalva treated with off-pump coronary artery bypass surgery.

Anomalous origin of the left coronary artery originating from the opposite sinus of Valsalva is a coronary anomaly with a consistently low prevalence rate. Different patterns have been described for this type of anomaly with respect to the position and course of the coronary arteries. The interarterial type can be considered a malignant variant, as it is characterized by a left main coronary artery that is positioned between the aortic root and the pulmonary artery root, and it frequently presents with syncope or aborted sudden cardiac death. Other symptoms or clinical presentations include the presence or development of angina, acute myocardial infarction and ventricular tachycardia. We present the case of a 49-year old man who presented with a new onset of chest pain; a coronary angiogram showed an anomalous left main coronary artery arising from the right Valsalva sinus, accompanied by a long and severe stenosis. It was found that multi-scan cardiac tomography is very useful in identifying the position of the coronary arteries when coronary anomalies occur.