Cardioneuroablación como tratamiento del síncope reflejo: reporte de un caso

Resumen: El síncope mediado neuralmente es un trastorno causado por un reflejo autónomo anormalmente amplificado que involucra componentes tanto simpáticos como parasimpáticos. Es la causa más frecuente de síncope en personas jóvenes y su tratamiento sigue siendo un desafío, ya que no se ha demostrado que alguna terapia farmacológica prevenga por completo su recurrencia. En los últimos años ha surgido una técnica denominada cardioneuroablación, que consiste en la ablación por radiofrecuencia de los plexos ganglionares (PG) parasimpáticos, con buenos resultados a corto y largo plazo en la prevención de síncope recurrente, según los diferentes grupos de investigación. Presentamos el primer caso en Chile de un hombre joven con síncopes mediados neuralmente recurrentes que fue tratado con esta técnica en el Hospital Regional de Concepción.

Abstract: Cardioneuroablation is a novel method that can be used to treat reflex syncope. Although the experience with this technique is relatively limited it provides a more physiological way to treat this condition. The first case in Chile is herein reported along with a discussion of the subject.

Feasibility and safety of a transvenous lead extraction program implementation in South America: Challenges, early outcomes, and global collaboration-A single-center experience.

Background: Transvenous lead extraction is the standard of care for cardiac implantable electronic device (CIED) malfunction/infection-related removal. However, data on its performance and results in underdeveloped countries are limited. Objective: The purpose of this study was to report the feasibility and efficacy of a lead extraction program in a tertiary hospital in Chile, South America. Methods: Patients requiring CIED removal at the Electrophysiology Division of the Hospital las Higuera's were retrospectively analyzed. Outcomes including procedure-related mortality, procedural success and failure, and cardiac and vascular complications were reported. Results: A total of 15 patients were analyzed (median age 68 [interquartile range 52-75] years; 80% male). Patients with lead extraction difficulty index >10 represented 33% of patients. Infection was the indication for removal in all patients, with pocket infection (80%). Mechanical rotational tools were used in 66% of cases, and a total of 29 leads were removed. Procedural success was accomplished in 93% of cases. There was 1 (7%) intraprocedural complication and no procedure-related mortality. Conclusions: The development of a lead management program is feasible, safe, and effective in underdeveloped countries.

Implantation of cardioverter defibrillators with minimal fluoroscopy using a three-dimensional navigation system: a feasibility study.

AIMS: Fluoroscopy is necessary to implant cardioverter defibrillators using the conventional approach. Modern electroanatomic navigation systems allow the visualization of multiple catheters and, as they are capable of rendering precise geometrical reconstructions of cardiac chambers, have been used for fluoroscopy-free electrophysiological procedures. The aim of our study was to assess the feasibility of non-fluoroscopic implants using a three-dimensional navigation system. METHODS AND RESULTS: The NavX system was used to create the virtual anatomies of heart chambers and thoracic veins. Defibrillator leads were placed at stable positions using exclusively the electrical and anatomical information provided by the navigator. A single fluoroscopy shot confirmed final lead positions. Thirty-five consecutive patients had 30 single-chamber and 5 dual-chamber defibrillators implanted. Cardiac chambers geometries were developed in 10 ± 4.3 min. Ventricular and atrial leads were implanted, with suitable positions and electrical parameters being achieved, in 18 ± 22 and 16 ± 9 min, respectively. The final confirmatory shot was the only fluoroscopy needed in 31 (89%) cases. Two patients needed fluoroscopy-guided relocation of the ventricular lead due to high defibrillation threshold and a breakdown of the active-fixation mechanism, respectively. In one patient the ventricular lead was totally extracted and reimplanted because a loop has formed in the vena cava, and one patient required fluoroscopy-guided subclavian puncture. In five cases (16%), the position of the proximal defibrillation coil was minimally modified with fluoroscopy due to incomplete geometric reconstruction of the superior vena cava. CONCLUSION: Fluoroscopy-free defibrillators implantation is feasible using a navigation system. Suitable placement of the proximal coil is a critical stage and requires a reliable and complete reconstruction of the superior vena cava.

Organized atrial tachycardias after atrial fibrillation ablation.

The efficacy of catheter-based ablation techniques to treat atrial fibrillation is limited not only by recurrences of this arrhythmia but also, and not less importantly, by new-onset organized atrial tachycardias. The incidence of such tachycardias depends on the type and duration of the baseline atrial fibrillation and specially on the ablation technique which was used during the index procedure. It has been repeatedly reported that the more extensive the left atrial surface ablated, the higher the incidence of organized atrial tachycardias. The exact origin of the pathologic substrate of these trachycardias is not fully understood and may result from the interaction between preexistent regions with abnormal electrical properties and the new ones resultant from radiofrequency delivery. From a clinical point of view these atrial tachycardias tend to remit after a variable time but in some cases are responsible for significant symptoms. A precise knowledge of the most frequent types of these arrhythmias, of their mechanisms and components is necessary for a thorough electrophysiologic characterization if a new ablation procedure is required.

Atrial flutter ablation through the azygous continuation in a patient with inferior vena cava interruption.

Ablation of atrial flutter (AFL) requires linear radiofrequency application; these procedures are usually performed via a femoral approach from the inferior vena cava (IVC). Congenital anomalies of this venous system may limit catheter ablation. This report presents ablation of an AFL through the azygous continuation and also reviews the prevalence of congenital IVC interruption among patients referred for AFL ablation.

Effectiveness of catheter ablation of ventricular tachycardia in elderly patients with structural heart disease.

INTRODUCTION AND OBJECTIVES: The implantable cardioverter-defibrillator (ICD) is a well-recognized means of providing effective treatment for patients with ventricular tachycardia (VT) and structural heart disease. However, the benefits of these devices in patients with limited life-expectancy have been questioned. Moreover, the long-term efficacy of catheter ablation of VT in this setting is unknown. METHODS: This study involved 33 consecutive patients aged over 75 years with structural heart disease who underwent catheter ablation of VT. We investigated the efficacy of the procedure and its complications, and evaluated patient outcomes during follow-up. RESULTS: The patients' mean age at the time of the procedure was 79.7 (3.7) years. Twenty-seven had ischemic heart disease and 6 had dilated cardiomyopathy. Their mean left ventricular ejection fraction (LVEF) was 35.9 (8.9%). Ablation of clinical VT was successful in 28 patients (84.8%). There were no statistically significant differences in the efficacy of ablation between patients with post-infarction scars (88.9%) and those with dilated cardiomyopathy (66.7%; P=.17). An ICD was implanted after the procedure in 4 patients. Complications associated with the procedure occurred in only 3 patients. Twenty patients were contacted later, after a mean follow-up period of 38.5 (27.7) months. Nine (mean age, 82.2 [4.6] years) were still alive and reported a good quality of life, without recurrent arrhythmias. CONCLUSIONS: Catheter ablation of VT in elderly patients with structural heart disease appeared to be effective and relatively safe. It could provide an alternative to ICD implantation in this patient group.

Resultados de la ablación con catéter de la taquicardia ventricular en pacientes ancianos con cardiopatía estructural / Effectiveness of catheter ablation of ventricular tachycardia in elderly patients with structural heart disease

Introducción y objetivos. El desfibrilador automático implantable (DAI) es una terapia aceptada para pacientes con taquicardia ventricular (TV) y cardiopatía estructural, pero se cuestiona su beneficio en pacientes con expectativa de vida limitada. Asimismo, se desconoce la eficacia de la ablación con catéter a largo plazo en este contexto. Métodos. Se incluyó en el estudio a 33 pacientes consecutivos de edad > 75 años sometidos a ablación con catéter de una TV sobre cardiopatía estructural. Se analizaron la eficacia y las complicaciones del procedimiento, así como la evolución de los pacientes en el seguimiento. Resultados. La media de edad en el momento del procedimiento fue de 79,7 ± 3,7 años; 27 pacientes tenían cardiopatía isquémica (CI) y 6, miocardiopatía dilatada (MCD). La fracción de eyección del ventrículo izquierdo (FEVI) fue 35,9% ± 8,9%. Se logró realizar la ablación con éxito de la TV clínica en 28 pacientes (84,8%). No se encontraron diferencias en la eficacia de la ablación entre los pacientes con cicatriz postinfarto (88,9%) y aquellos con MCD (66,7%) (p = 0,17). Se implantó un DAI tras el procedimiento a 4 pacientes. Únicamente se produjeron complicaciones relacionadas con la ablación en 3 pacientes. Se logró contactar con 20 pacientes, con un seguimiento medio de 38,5 ± 27,7 meses; 9 pacientes sobreviven en la actualidad (media de edad, 82,2 ± 4,6 años) y refieren una buena calidad de vida, sin recurrencias arrítmicas. Conclusiones. La ablación de TV en pacientes ancianos con cardiopatía estructural parece eficaz y relativamente segura, y podría constituir una alternativa al DAI en esta población seleccionada (AU)

Introduction and objectives. The implantable cardioverter-defibrillator (ICD) is a well-recognized means of providing effective treatment for patients with ventricular tachycardia (VT) and structural heart disease. However, the benefits of these devices in patients with limited life-expectancy have been questioned. Moreover, the long-term efficacy of catheter ablation of VT in this setting is unknown. Methods. This study involved 33 consecutive patients aged over 75 years with structural heart disease who underwent catheter ablation of VT. We investigated the efficacy of the procedure and its complications, and evaluated patient outcomes during follow-up. Results. The patients’ mean age at the time of the procedure was 79.7 (3.7) years. Twenty-seven had ischemic heart disease and 6 had dilated cardiomyopathy. Their mean left ventricular ejection fraction (LVEF) was 35.9 (8.9%). Ablation of clinical VT was successful in 28 patients (84.8%). There were no statistically significant differences in the efficacy of ablation between patients with post-infarction scars (88.9%) and those with dilated cardiomyopathy (66.7%; P=.17). An ICD was implanted after the procedure in 4 patients. Complications associated with the procedure occurred in only 3 patients. Twenty patients were contacted later, after a mean follow-up period of 38.5 (27.7) months. Nine (mean age, 82.2 [4.6] years) were still alive and reported a good quality of life, without recurrent arrhythmias. Conclusions. Catheter ablation of VT in elderly patients with structural heart disease appeared to be effective and relatively safe. It could provide an alternative to ICD implantation in this patient group (AU)