New-Onset Ventricular Tachycardia After Cardiac Resynchronization Therapy

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Cardiac CT With Delayed Enhancement in the Characterization of Atrial Arrhythmias Structural Substrate: Relationship Between CT-Segmented Scar and Electro-Anatomic Mapping

BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of catheter-based strategies for AF ablation and has proven to be effective in treating paroxysmal atrial fibrillation (PAF). PVs reconnection after AF ablation is the main cause of AF recurrence and results from non-contiguous or non-transmural RF lesions as the consequence of insufficient RF delivery in the thickest myocardial areas. Similarly, excessive RF delivery in thin regions of the left atrial (LA) wall is associated to increased complication rate. Multidetector computed tomography (MDCT) have been reliably validated to assess left atrial wall thickness (LAWT). AIMS: To determine if adapting radiofrequency (RF) to the left atrial wall thickness (LAWT) is feasible, effective, and safe during paroxysmal atrial fibrillation (PAF) ablation in comparison with the standard approach. METHODS AND RESULTS: Consecutive patients referred for PAF first ablation were prospectively enrolled and divided into 2 groups, the LAWT-Group and the No-LAWT (i.e. control) Group. 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 39 patients (79% male, age 60 ± 9.5 years) were included. LAWT Group showed a significantly shorter procedural time (101±30 vs 133±38 min, p=0.007), fluoroscopy time (6.7±3,4 vs 12±0.4, p=0,02) and a trend for a lower radiation dose (3.8±3.1 vs 6.3±4.9 Gy/cm2, p= 0.06), with a comparable radiofrequency (13±1.7 vs 15±7.4 min, p=NS) time. Radiofrequency power used posteriorly resulted significantly inferior to the anterior one (37±2.5 vs 53±19 watts, p<0,001). Right PVs showed a significantly lower tailored AI (382±13 vs 433±35, p<0,001), while for left PV AI resulted comparable between groups (397±22 vs 409± 105, p=NS). LAWT groups showed 100% of first pass PV isolation and no recurrences during 12 months follow-up, while No-LAWT patients experiences 2 no first pass (10%) and 2 AA recurrences (10%) at 1 year. CONCLUSIONS: Personalized AF ablation with the Ablate-By-LAWT protocol using a single catheter technique and adapting the AI to LAWT is feasible and more effective than the conventional approach, with a comparable safety

The cold facts of long-term ECG monitoring

Two recently published trials have provided evidence in favor of longer ECG monitoring among patients with cryptogenic stroke (CS). In the CRYSTAL-AF trial, new atrial fibrillation (AF) was detected in 12.4% of patients with implantable monitor when compared with 2% among those receiving standard follow-up. A similar result was observed in the EMBRACE trial in which AF was detected in 16.1% of patients who received 30-day event recorder (3.2% in controls). These data are compelling in convincing us that long-term ECG technologies have superior sensitivity for the detection of AF in CS; however, clinical specificity for the definition of CS etiology of such findings cannot be established and can be lower than expected, leaving open questions about the etiologic weight of AF in CS. The causative role of AF in this subpopulation remains to be proven, and diagnostic routes cannot be solely unbalanced toward the research of AF

Clinical implications of long-term ECG monitoring: from loop recorder to devices remote control

Long-term ECG monitoring has become nowadays an indispensable technology for prevention, management and treatment of many cardiac issues. Today long-term ECG monitoring is achievable through loop recorders and cardiac devices like pacemaker, implantable cardioverter-defibrillators and cardiac resynchronization therapy device-defibrillators, all of which associated with remote monitoring. Targeted long-term ECG monitoring patients who have recurrent non-documented episodes of palpitations, unexplained episodes of syncope, cryptogenic stroke or patients with a cardiomyopathy needing a risk stratification, may benefit from long-term ECG monitoring

Thromboembolic risk and effect of oral anticoagulation according to atrial fibrillation patterns: A systematic review and meta‐analysis

Oral anticoagulation (OAC) is recommended in both paroxysmal atrial fibrillation (pxAF) and nonparoxysmal AF (non-pxAF), but disagreement exists in classes of recommendation. Data on incidence/rate of stroke in pxAF are conflicting, and OAC is often underused in this population. The objectives of the meta-analysis were to investigate different impact on outcomes of pxAF and non-pxAF, with and without OAC. Two reviewers searched for prospective studies on risk of stroke and systemic embolism (SE) in pxAF and non-pxAF, with and without OAC. Quality of evidence was assessed according to GRADE approach. Stroke combined with SE was the main outcome. Meta-regression was performed to evaluate OAC effect on stroke and SE incidence rate. We identified 18 studies. For a total of 239 528 patient-years of follow-up. The incidence rate of stroke/SE was 1.6% (95% confidence interval [CI]: 1.3%-2.0%) in pxAF and 2.3% (95% CI: 2.0%-2.7%) in non-pxAF. Paroxysmal AF was associated with a lower risk of overall thromboembolic (TE) events (risk ratio: 0.72, 95% CI: 0.65-0.80, P &lt; 0.00001) compared with non-pxAF. In both groups, the annual rate of TE events decreased as proportion of patients treated with OAC increased. Non-pxAF showed a reduction from 3.7% to 1.7% and pxAF from 2.5% to 1.2%. Major bleeding rates did not differ among groups. Stroke/SE risk is significantly lower, although clinically meaningful, in pxAF. OAC consistently reduces TE event rates across any AF pattern. As a whole, these data provide the evidence to warrant OAC irrespective of the AF pattern in most (virtually all) patients