Ablación y neuromodulación en tormenta arrítmica: serie de 4 casos y revisión de la literatura / Ablation and neuromodulation in arrhythmic storm: a report of 4 cases and literature review

Resumen: Se presenta una serie de 4 casos clínicos de pacientes con y sin cardiopatía estructural, que tuvieron uno o más episodios de tormenta arrítmica. Se describen los tratamientos con sus resultados y una revisión bibliográfica con los avances en el tema más allá de la ablación con catéter.

Abstract: We present 4 clinical cases of patients with and without structural heart disease, who had one or more episodes of arrhythmic storm. Treatments, results and a bibliographic review with advances beyond catheter ablation are described.

Predictores de éxito de la ablación desde el seno no coronario de la raíz aórtica de taquicardias auriculares con origen en la proximidad del nodo auriculoventricular / Predictores of success of the ablation from the not coronary bosom of the aortic root of taquicardias earphones with origin in the proximity of the node atrioventricular

Introducción. Las taquicardias auriculares (TA) con origen en la proximidad del nodo AV representan hasta el 10 por ciento de las TA. El tratamiento con readiofrecuencia(RF) implica riesgo de lesión del nodo AV. Pacientes. Se evaluaron 11 pacientes de una serie de 61 TA con activación auricular más precoz en la proximidad del nodo AV. Resultados. La aplicación de RF tuvo éxito en 10 localizaciones: 5 perihisiana derecha, 1 foramen oval derecho, 1 septum interauricular izquierdo y 3 seno no coronario de Valsalva. La morfología de la onda P y la longitud de ciclo de las TA no fueron diferentes entre las localizaciones. La activación auricular menor a 80ms y un electrograma unipolar con morfología QS fueron observados solo en pacientes con éxito desde la raíz aórtica. El mapa de isocronas con CARTO de la aurícula derecha no fue útil en predecir el lugar de éxito. La aplicación de RF en la raíz aórtica terminó la taquicardia en zonascon precocidades entre 20 y 35 ms.Conclusión. No se encontraron predictores del lugar de éxito de la aplicación de radiofrecuencia en pacientes con TA originada en la proximidad del nodo AV. El acceso aórtico retrógrado puede ser eficiente y seguro en el tratamiento de algunas TA.

Introduction. Focal atrial tachycardias (AT) originating from near the AV node represent 10 per cent of AT. Radiofrequency (RF) treatment implies risk of impairing AV conduction. Patients. The study population included 11 patients of a consecutive series of 61 with AT in whom mapping of the right atrium revealed earliest activation near the AV node. Results. Radiofrequency current was successful in 10 patients: 5 right perihisian, 1 right oval foramen, 1 left side of the interatrial septum and 3 in the noncoronary sinus of Valsalva; applications of RF and cryoablation,only transiently terminated the arrhythmia. The Pwave morphology and cycle length of AT did not differ between different locations. Atrial activation was shorter 80 ms and unipolar electrogram with QS morphology, were only present in patients with ablation procedure performed at the aortic root. CARTO© isochronal maps of right atrium not useful to identify successful ablationsite. Mapping the aortic root found precocities from 20 to 35 ms at noncoronary sinus, RF energy delivered from this site successfully terminated the tachycardia. Conclusion. There were no good predictors for the best ablation approach in patients with atrial tachycardia originating near AV node. Aortic approach may be safe and efficient on the treatment of AT.

[Inducibility of atrial arrhythmias after adenosine and isoproterenol infusion in patients referred for atrial fibrillation ablation]. / Inducibilidad de arritmias auriculares tras la infusión de adenosina e isoproterenol en pacientes con fibrilación auricular remitidos para ablación.

INTRODUCTION AND OBJECTIVES: The identification and ablation of atrial ectopic foci could complement the conventional empirical pulmonary vein approach and may increase the success rate of atrial fibrillation ablation. Although both adenosine and isoproterenol infusion have been reported to induce ectopics, no clear findings on their use during ablation have been published. Our aim was to investigate the utility of these two pharmacologic maneuvers in patients referred for atrial fibrillation ablation. METHODS: The effects of adenosine infusion, isoproterenol infusion, or both were evaluated in 53 patients with refractory atrial fibrillation referred for ablation. Patients were in sinus rhythm during evaluation. RESULTS: Administration of adenosine or isoproterenol induced atrial arrhythmias in 46 patients (87%). Arrhythmia inducibility was similar in those with paroxysmal and those with persistent atrial fibrillation (87% and 86%, respectively). Atrial ectopics alone were induced in 31 patients (65%), atrial tachycardia in four (8%), and atrial fibrillation in 13 (27%). In 10 patients (19%), ectopic foci were located outside the pulmonary veins and subsequently underwent ablation. In 32 of the 46 patients with inducible arrhythmias, only the induced ectopic foci were ablated (mean 1.4 [0.6] targets per patient). The long-term success rate of first procedures was 66%. CONCLUSION: Adenosine and isoproterenol infusion induced atrial ectopics in most patients with drug-refractory atrial fibrillation while they were in sinus rhythm. In almost 20%, the ectopic foci were located outside the pulmonary veins. The effectiveness of induced ectopic-guided ablation observed in our patient series supports the clinical utility of this approach.

Inducibilidad de arritmias auriculares tras la infusión de adenosina e isoproterenol en pacientes con fibrilación auricular remitidos para ablación / Inducibility of atrial arrhythmias after adenosine and isoproterenol infusion in patients referred for atrial fibrillation ablation

Introducción y objetivos. La identificación y la ablación de focos ectópicos podría realizarse de forma complementaria al abordaje empírico de las 4 venas pulmonares, con el fin de aumentar la tasa de éxito de la ablación de la fibrilación auricular (FA). Nuestro objetivo fue analizar la inducibilidad farmacológica de ectopia auricular en pacientes con FA, así como la reproducibilidad, la localización y el significado clínico de la arritmia inducida. Métodos. Se analizó el resultado de la infusión de adenosina e isoproterenol en 53 pacientes con FA referidos para ablación que presentaban ectopia abundante en Holter previos y ausencia de ésta en el momento de la ablación (o densidad insuficiente para su cartografía). Resultados. En 46 pacientes (87%) se indujo alguna arritmia auricular tras la administración de adenosina y/o isoproterenol. La tasa de inducibilidad en pacientes con FA paroxística y persistente fue del 87 y el 86%, respectivamente. Se indujo ectopia aislada en 31 pacientes (65%), taquicardia auricular en 4 pacientes (8%) y FA en 13 pacientes (27%). En 10 pacientes (19%), la ectopia inducida tuvo una localización extrapulmonar. En 32 de los 46 pacientes inducibles (70%) se ablacionó exclusivamente la ectopia inducida (1,4 ± 0,6 sustratos por paciente), y se obtuvo un éxito a largo plazo en 21 pacientes (66%). Conclusiones. La infusión de adenosina e isoproterenol en pacientes con FA presenta una alta tasa de inducción de arritmias auriculares, que, en cerca de un 20% de los casos, proceden de focos extrapulmonares. La eficacia de la ablación guiada por la ectopia inducida apoya la relevancia clínica de ésta

Introduction and objectives. The identification and ablation of atrial ectopic foci could complement the conventional empirical pulmonary vein approach and may increase the success rate of atrial fibrillation ablation. Although both adenosine and isoproterenol infusion have been reported to induce ectopics, no clear findings on their use during ablation have been published. Our aim was to investigate the utility of these two pharmacologic maneuvers in patients referred for atrial fibrillation ablation. Methods. The effects of adenosine infusion, isoproterenol infusion, or both were evaluated in 53 patients with refractory atrial fibrillation referred for ablation. Patients were in sinus rhythm during evaluation. Results. Administration of adenosine or isoproterenol induced atrial arrhythmias in 46 patients (87%). Arrhythmia inducibility was similar in those with paroxysmal and those with persistent atrial fibrillation (87% and 86%, respectively). Atrial ectopics alone were induced in 31 patients (65%), atrial tachycardia in four (8%), and atrial fibrillation in 13 (27%). In 10 patients (19%), ectopic foci were located outside the pulmonary veins and subsequently underwent ablation. In 32 of the 46 patients with inducible arrhythmias, only the induced ectopic foci were ablated (mean 1.4 [0.6] targets per patient). The long-term success rate of first procedures was 66%. Conclusions. Adenosine and isoproterenol infusion induced atrial ectopics in most patients with drug-refractory atrial fibrillation while they were in sinus rhythm. In almost 20%, the ectopic foci were located outside the pulmonary veins. The effectiveness of induced ectopic-guided ablation observed in our patient series supports the clinical utility of this approach

[Optimized transseptal approach for left ventricular tachycardia ablation in a patient with a mechanical prosthetic aortic valve]. / Optimización del abordaje transeptal para la ablación de una taquicardia ventricular izquierda en un paciente con una prótesis mecánica aórtica.

Prosthetic valves may make ventricular access difficult in radiofrequency catheter ablation. This case report describes an optimized atrial transseptal approach to access the ventricle in a patient with left ventricular tachycardia and a mechanical prosthetic aortic valve.