Ablation of paroxysmal atrial fibrillation. Between present and future

Pulmonary vein isolation (PVI) is the established cornerstone for atrial fibrillation (AF) ablation, indeed current guidelines recognize PVI as the gold standard for first-time AF ablation, regardless of if it is paroxysmal or persistent. Since 1998 when Ha & iuml;ssaguerre pioneered AF ablation demonstrating a burden reduction after segmental pulmonary vein (PV) ablation, our approach to PVI was superior in terms of methodology and technology. This review aims to describe how paroxysmal atrial fibrillation ablation has evolved over the last twenty years. We will focus on available techniques, a mechanistic understanding of paroxysmal AF genesis and the possibility of a tailored approach for the treatment of AF, before concluding with a future perspective

Increased plasma homocysteine predicts arrhythmia recurrence after minimally invasive epicardial ablation for nonvalvular atrial fibrillation

ObjectiveMinimally invasive epicardial ablation via right minithoracotomy is an emerging option for patients with drug-refractory nonvalvular atrial fibrillation. To guide the development of rational treatment algorithms, factors predisposing to recurrence of arrhythmia need to be quantified and eventually treated. We addressed the association of the plasma levels of homocysteine and the recurrence of atrial fibrillation after minimally invasive ablation.MethodsWe obtained peripheral blood samples from 104 patients at follow-up after arrhythmia surgery; the homocysteine concentration was expressed as micromoles per liter. Prospective follow-up was conducted through electrocardiogram Holter monitoring (average 18.5 ± 5.8 months). Stratified analysis (high vs low homocysteine) was based on the cutoff value for the last quartile of homocysteine concentration (16 μmol/L). Time-to-event and diagnostic performance analyses were performed.ResultsThe rate of freedom from atrial fibrillation was 89.4% at the end of follow-up. Elevated circulating homocysteine level, persistent type of atrial fibrillation, and increased left atrial dimension independently predicted the recurrence of atrial fibrillation during the follow-up (adjusted Cox regression). Patients with a high homocysteine level were more likely to have atrial fibrillation recurrence (stratified Kaplan–Meier, P < .001). The cutoff value for elevated homocysteine (16 μmol/L) yielded a good diagnostic performance in the prediction of atrial fibrillation recurrence (area under the receiver operating characteristic curve, 0.807).ConclusionsThe homocysteine level measured during the follow-up reliably predicts the risk of recurrence after epicardial ablation of nonvalvular atrial fibrillation via minithoracotomy. Specific treatments to reduce plasma homocysteine could be considered in the future in these patients

Neurological Disorders in Takotsubo Syndrome: Clinical Phenotypes and Outcomes

Background: Neurological disorders as a risk factor for Takotsubo syndrome (TTS) are not well characterized. The aim of the study was to evaluate TTS-associated neurological phenotypes and outcome. Methods and results: Patients with TTS enrolled in the international multicenter GEIST (German Italian Spanish Takotsubo) registry were analyzed. Prevalence, clinical characteristics, and short- and long-term outcomes of patients with TTS were recorded. A subgroup analysis of the 5 most represented neurological disorders was performed. In total, 400 (17%) of 2301 patients had neurological disorders. The most represented neurological conditions were previous cerebrovascular events (39%), followed by neurodegenerative disorders (30.7%), migraine (10%), epilepsy (9.5%), and brain tumors (5%). During hospitalization, patients with neurological disorders had longer in-hospital stay (8 [interquartile range, 5-12] versus 6 [interquartile range, 5-9] days; P&lt;0.01) and more often experienced in-hospital complications (27% versus 16%; P=0.01) mainly driven by cardiogenic shock and in-hospital death (12% versus 7.6% and 6.5% versus 2.8%, respectively; both P&lt;0.01). Survival analysis showed a higher mortality rate in neurological patients both at 60 days and long-term (8.8% versus 3.4% and 23.5% versus 10.1%, respectively; both P&lt;0.01). Neurological disorder was an independent predictor of both the 60-day and long-term mortality rate (odds ratio, 1.78 [95% CI, 1.07-2.97]; P=0.02; hazard ratio, 1.72 [95% CI, 1.33-2.22]; both P&lt;0.001). Patients with neurodegenerative disorders had the worst prognosis among the neurological disease subgroups, whereas patients with TTS with migraine had a favorable prognosis (long-term mortality rates, 29.2% and 9.7%, respectively). Conclusions: Neurological disorders identify a high-risk TTS subgroup for enhanced short- and long-term mortality rate. Careful recognition of neurological disorders and phenotype is therefore needed

Designing an Effective Governance Model for Data Collaboratives

Overview: Data Collaboratives have gained traction as interorganizational partnerships centered on data exchange. They enhance the collective capacity of responding to contemporary societal challenges using data, while also providing participating organizations with innovation capabilities and reputational benefits. Unfortunately, data collaboratives often fail to advance beyond the pilot stage and are therefore limited in their capacity to deliver systemic change. The governance setting adopted by a data collaborative affects how it acts over the short and long term. We present a governance design model to develop context-dependent data collaboratives. Practitioners can use the proposed model and list of key reflective questions to evaluate the critical aspects of designing a governance model for their data collaboratives. Practitioner Takeaways:Practitioners can develop a detailed understanding of the governance factors that influence the successful creation of data collaboratives.The governance design process model offers practitioners a tangible roadmap and concrete activities to help them revamp an existing data collaborative or create a new one.The list of reflective questions can guide practitioners' initial design efforts and help them assess the robustness of their data collaboratives' current governance models

A strange weakness: a case-report of dilated cardiomyopathy in a young patient with spontaneous coronary dissection

Introduction Atherosclerosis is the most common cause of coronary affections, but coronary dissection is certainly more insidious. This is the separation of the media apart from the other layers of the vessel wall, with or without intimal tear. Spontaneous coronary dissection is a rare event, especially in young men: only 150 cases were reported till 1986 and over 300 till date. The main consequence is an acute coronary occlusion with myocardial infarction and sudden death.Case report We report the case of a 28-year-old man, presented with a mild symptomatic spontaneous coronary dissection, consisting of a strange weakness, remained undetected until fortuitous medical analyses suggested the opportunity of further investigations. A clinical examination and an EKG showed the opportunity to perform a bidimensional echocardiogram at first, a low-dose dobutamine stress echocardiogram, then a regional myocardial perfusion and a non-invasive coronary flow reserve assessment. The patient has been properly and quickly screened and is now enlisted for cardiac transplantation.Conclusions In such cases the immediate identification and treatment of the affection can be crucial. In our experience the basic and advanced echocardiography allowed a sooner diagnosis than the usual proceeding based on coronarographic examination.</p

Giant Cardiac Fibroma in a Completely Asymptomatic Teenager

We report the case of a 19 years old “healthy” and asymptomatic patient accessing the Emergency Room after a car accident trauma. A routine electrocardiogram documented an intraventricular conduction disturbance. The subsequent transthoracic echocardiogram showed the presence of a voluminous heterogeneous intracardiac mass (10 × 10 × 8 cm), localized in the medium-apical cavity of the right ventricle and extended to the outflow tract. A mass debulking intervention was performed and the intraoperative biopsy samples allowed the diagnosis of cardiac fibroma. Because of dimension, intracardiac infiltration and relations, radical surgery was not an option; the patient was candidate for heart transplantation. This unique case highlights the questionable classification of cardiac fibromas as benign and the possibility of a delayed diagnosis because of late clinical presentation

Tako Tsubo syndrome: A literature review and a case report

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Recording of Brugada electrocardiogram pattern by an implantable cardiac monitor

A 51-year-old man with Brugada syndrome (BrS) electrocardiogram (ECG) type I pattern underwent implantable cardiac monitor (ICM) insertion. After pre-insertion potential mapping, we could observe the patient-specific repolarization abnormalities on the subcutaneous ECG provided by the ICM. A few weeks later, we received remotely a device recording with a higher ST-segment elevation and a longer duration of the interval between the onset of the coved elevation and its termination at the isoelectric line. Our observation supports the conceptual premise that ICM could add information on quantifying the amount of time with abnormal ECG patterns rather than only for the diagnosis of cardiac arrhythmias

No Reflow-phenomenon: from Current State of the Art to Future Perspectives

Early and successful myocardial reperfusion with primary percutaneous coronary intervention (pPCI) is the optimal therapy for patients presenting with ST segment elevation myocardial infarction (STEMI). Despite successful epicardial reopening of the infarct related artery, myocardial perfusion may not be restored in up to 40-50% of patients. This phenomenon, referred to as no-reflow (NR), recognizes several pathogenetic components including distal atherothrombotic embolization, ischaemic injury, reperfusion damage, intramyocardial hemorrhage and individual susceptibility of coronary microcirculation. However the complexity of pathogenesis remains still unclear. Moreover, cause NR plays a crucial role in patients prognosis, accurate detection is critical and multiple novel diagnostic modalities has been recently assessed.The NR phenomenon represents a challenge in the management of STEMI patients and has recently captured a growing interest of both basic scientists and interventional cardiologists. Although relevant efforts to transfer into real world practice new therapeutic strategies, to date there is still weak evidence of clinical improvement in this setting. Several strategies of prevention and treatment of NR have been proposed in the clinical arena including pharmacological and mechanical interventions. Nevertheless, the complexity of the phenomenon makes extremely unlikely for a single therapy to be effective. Understanding the interaction between the components of this pathway, along with exploring newer and more effective agents may enable patients to be treated with the most appropriate therapy