Mahaim fiber-mediated tachycardia

© 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. Todos os direitos reservados.We present the case of a previously healthy 42-year-old man who attended the emergency department due to a sudden onset of rapid and regular palpitations. The ECG showed 190 bpm, wide QRS with left bundle branch block tachycardia. He was started on amiodarone with progression to 230 bpm, wide QRS tachycardia with multiple morphologies, followed by spontaneous conversion to sinus rhythm, normal PR interval and rS pattern in LIII. The echocardiogram was negative for structural heart disease. The electrophysiological study demonstrated the presence of an accessory pathway with anterograde decremental conduction and no retrograde conduction. Both episodes of clinical tachycardia were induced. A diagnosis of Mahaim fiber-mediated antidromic atrioventricular reentrant tachycardia and pre-excited atrial fibrillation was made. Mapping was performed with detection of an M potential (His-like) at the lateral region of the tricuspid ring followed by radiofrequency ablation with immediate success criteria. Post-ablation there was a change to a qR pattern in LIII. At 12-months follow-up there was no recurrence of the tachycardia.É apresentado um caso de um doente de 42 anos, previamente saudável, com episódio de palpitações de início súbito, rápidas e regulares que motivaram ida ao serviço de urgência. O ECG mostrou taquicardia regular, 190 bpm, QRS alargados e padrão de bloqueio de ramo esquerdo. Foi instituída perfusão de amiodarona com progressão para taquicardia irregular, 230 bpm com QRS alargados e de diferentes morfologias seguida de conversão espontânea a ritmo sinusal, com intervalo PR de duração normal e padrão rS em DIII. O ecocardiograma não mostrava cardiopatia estrutural. O estudo eletrofisiológico demonstrou a presença de via acessória sem capacidade de condução retrógrada e com condução anterógrada com propriedades decrementais; e indução de ambas as taquidisritmias clínicas. Foi feito o diagnóstico de taquicardia de reentrada auriculoventricular antidrômica e de fibrilação auricular pré-excitada mediadas por via acessória do tipo Mahaim. Foi efetuado mapeamento com detecção de potencial M (His-like) no nível do anel tricúspide lateral e feita ablação com radiofrequência com critérios de sucesso imediato. Após ablação verificou-se alteração do padrão em DIII para qR. Após 12 meses de seguimento não se verificou recorrência da taquidisritmia.info:eu-repo/semantics/publishedVersio

Otimizar o prognóstico na fibrilhação auricular: um apelo à ação em Portugal

© 2020 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. This is an open access article under the CC-BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis.A arritmia mais comum na população adulta em todo o mundo, a fibrilhação auricular (FA), contribui decisivamente para a elevada mortalidade e morbilidade cardiovascular, com repercussões na economia da saúde. A anticoagulação oral (ACO) é a chave para a prevenção do acidente vascular cerebral na FA. Nos últimos anos, os resultados dos grandes ensaios clínicos com os ACO não antagonista da vitamina K mudaram o paradigma na trombocardiologia. Apesar deste avanço, o risco vascular residual associado à FA silenciosa, hemorragia, morte súbita prematura e insuficiência cardíaca continua a ser significativo. Os autores fazem uma revisão dos dados epidemiológicos da FA, a importância das novas ferramentas para a deteção precoce da FA, o papel atual da ablação por cateter no controlo do ritmo na FA, o estado da arte na ACO periprocedimento, a gestão ideal de hemorragias graves, as causas de morte prematura residual e estratégias futuras para a melhoria do prognóstico da FA.info:eu-repo/semantics/publishedVersio

Hipertensão pulmonar tromboembólica crónica: experiência inicial de doentes submetidos a tromboendarterectomia pulmonar

© 2021 Published by Elsevier España, S.L.U. on behalf of Sociedade Portuguesa de Cardiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Introduction and objectives: Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. Methods: Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. Results: 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5,2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n=3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. Conclusion: Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.Introdução e objetivos A tromboendarterectomia pulmonar (TP) é um procedimento potencialmente curativo em doentes com hipertensão pulmonar (HP) tromboembólica crónica (TEC). O objetivo deste trabalho é reportar a experiência inicial de um centro português de tratamento de HP em doentes submetidos a TP num centro de referência cirúrgico internacional. Métodos Estudo observacional prospetivo de doentes consecutivos com diagnóstico de CTEPH seguidos em centro nacional de tratamento de HP e submetidos a TP em centro de referência cirúrgico internacional entre outubro de 2015 e março de 2019. Parâmetros clínicos, funcionais, laboratoriais, imagiológicos e hemodinâmicos foram obtidos nos 12 meses precedentes à cirurgia e repetidos entre quatro a seis meses após a TP. Resultados Foram submetidos a TP 27 doentes consecutivos (59% do sexo feminino) com mediana de 60 (49-71) anos. Durante um seguimento mediano de 34 (21-48) meses, verificou‐se melhoria da classe funcional em todos os doentes, tendo ocorrido apenas um óbito de causa cardíaca. Do ponto de vista hemodinâmico, observou‐se redução da pressão média na artéria pulmonar de 48 (42-59) mmHg para 26 (22-38) mmHg, aumento do débito cardíaco de 3,3 (2,9-4,0) L/min para 4,9 (4,2-5,5) L/min e redução das resistências vasculares pulmonares de 12,1 (7,2-15,5) uW para 3,5 (2,6-5,2) uW. Tendo em conta os parâmetros hemodinâmicos avaliados pós‐TP e a sua evolução durante o seguimento clínico, 44% (n = 12) dos doentes deixaram de ter critérios de HP, 44% (n = 12) mantiveram HP e 11% (n = 3) evoluíram com recorrência de HP. Laboratorialmente, a salientar redução do NT‐proBNP de 868 (212–1730) pg/mL para 171 (98–382) pg/mL. Dos parâmetros de função sistólica ventricular direita, verificou‐se melhoria da excursão e velocidade de pico sistólicas longitudinais do plano do anel tricúspide de 14 (13-14) mm e 9 (8-10) cm/s para 17 (16-18) mm e 13 (11-15) cm/s, respetivamente. Dos 26 doentes com critérios de disfunção sistólica ventricular direita pré‐cirurgia, 85% (n = 22) apresentaram critérios de recuperação. A proporção de doentes sob terapêutica vasodilatadora específica diminuiu de 93% para 44% (p < 0,001) e a proporção daqueles requerendo OLD diminuiu de 52% para 26% (p = 0,003). A distância percorrida no teste dos seis minutos de marcha aumentou em cerca de 25% relativamente ao valor prévio à intervenção cirúrgica e apenas oito doentes mantiveram dessaturação significativa durante a prova. Conclusão A TP realizada em centro cirúrgico de elevado volume é um procedimento seguro e com impacto muito favorável em médio prazo nos parâmetros funcionais, hemodinâmicos e de função ventricular direita em doentes com HPTEC operável. É possível, para centros de tratamento de HP sem diferenciação em TP, a referenciação dos doentes com segurança e efetividade a um centro cirúrgico internacional em que para tal seja necessário aerotransporte.info:eu-repo/semantics/publishedVersio

Heart rate and blood pressure in mitral valve prolapse patients : divergent effects of long-term propranolol therapy. Correlations with catecholamines

Copyright © 2007 Published by Elsevier Inc.Introduction: There is a well-known association between mitral valve prolapse (MVP) and low blood pressure (BP), although patients (P) often have high levels of catecholamines (CAT) and high heart rate (HR). To our knowledge, there are no studies about the effects of long-term adrenergic b-blockade on these parameters. Methods: Twenty normal individuals (N)—8 males (M) (49.9 F 12.9 years) and 12 females (F) (41.8 F 11.8 years); 46 MVP P—15 M (49.3 F 15.5 years) and 31 F (42.0 F 12.8 years). Phase1—in both N and P free of medication, determination of (1) 24H urinary epinephrine (E) and norepinephrine (NE) by HPLC; (2) rest HR by ECG; (3) 24H ambulatory HR and BP (ABM). Phase2—same tests in MVP P while taking propranolol by 10 to 12 months. Results: CAT ng/mg creatinine: E—M 5.1 F 2.5 (N), 9.1 F 3.9 (Ph1), 7.9 F 3.1 (Ph2); F 6.2 F 3.5 (N), 13.0 F 9.7 (Ph1), 10.7 F 6.7 (Ph2). Higher in P ( P b .01), lower under propranolol ( P = .002). NE—M 22.2 F 7.2 (N), 36.8 F 16.8 (Ph1), 27.4 F 10.6 (Ph2); F 28.1 F 7.3 (N), 46.2 F 18.1 (Ph1), 33.0 F 12.9 (Ph2). Higher in P ( P b .01), lower under propranolol ( P b .001). HR—M 75 F 5.4 (N), 79 F 7.2 (Ph1), 65 F 3.8 (Ph2); F 74 F 3.2 (N), 80 F 6.5 (Ph1), 69 F 6.2 (Ph2). Lower under propranolol ( P b .0001). ABM: phase1—HR higher in P. SBP and DBP lower in P. Phase2—lower HR whereas higher SBP and DBP in P under propranolol. No correlation between BP and CAT. Correlation between E levels and rest HR. Conclusions: These MVP patients had high levels of CAT, high HR, and low BP. With long-term b-blockade, HR decreased related to E, but BP raised, supporting the role of b2 receptors supercoupling on low BP in MVP.info:eu-repo/semantics/publishedVersio

Heart rate and blood pressure in mitral valve prolapse patients : divergent effects of long-term propranolol therapy and correlations with catecholamines

Copyright © 2007 The Anatolian Journal of Cardiology.Objective: There is a well known association between mitral valve prolapse (MVP) and low blood pressure (BP), although patients often have high levels of catecholamines and high heart rate (HR). The main objective of our study was to evaluate the effects of long-term adrenergic beta-blockade on these parameters. Methods: The study population consisted of 46 patients with MVP and the control group consisted of 20 normal individuals. The study had two phases: in the first phase, patients were free of medications. In the second phase, patients were under treatment with propranolol for 10 to 12 months. The tests were performed in normal individuals and patients in the first phase. Only patients underwent the same tests in the second phase. Measurement of urinary epinephrine and norepinephrine levels, by high performance liquid chromatography, was done. Rest HR was determined by electrocardiogram (ECG), and ambulatory blood pressure and HR were evaluated by 24 hours ambulatory blood pressure monitoring (ABPM) using the auscultatory method. Results: The levels of epinephrine and norepinephrine were significantly higher in patients than in normal controls and decreased under propranolol. Rest and ambulatory HR were higher in patients and decreased under propranolol. The 24 hours systolic and diastolic BPs were lower in patients, and their values increased under propranolol. Heart rate decreasing and epinephrine levels reduction were positively correlated. No correlation was found between BP increase and catecholamine levels. Conclusion: The study results show divergent effects of propranolol on blood pressure, which increased, and on heart rate, that decreased, in patients with MVP. Heart rate decrease was an expected result and depends, namely, on b1 receptors blockade. Increase in BP is an unusual response to adrenergic beta-blockade in normal conditions, and this finding supports the preponderance of b2 receptors on the BP control in patients with MVP.info:eu-repo/semantics/publishedVersio

Utility of pace-matching mapping in the ablation of idiopathic ventricular tachyarrhythmias

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017.Introduction: The electroanatomical mapping of idiopathic ventricular tachyarrhythmias (iVT) - premature ventricular contractions (PVC) and idiopathic ventricular tachycardia (VT) - is dependent on the recording of spontaneous PVC or induction of the clinical VT during the procedure to obtain the iVT activation map. The presence of infrequent and non-inducible iVT may preclude ablation. Pace-matching (PM) mapping of the anatomical region on interest, using the PaSo™ algorithm, may allow to circumvent this limitation. Purpose: Determination of the utility of the PaSo™pace-matching mapping for iVT ablation Methods: A single-center retrospective study was made, with inclusion of consecutive patients undergoing iVT ablation between October 2013 and October 2016. It was collected electroanatomical data, including the highest correlation obtained by PM (PaSo™). Success of the procedure was assessed (defined as the elimination of spontaneous PVC during the electrophysiological study and non-inducible iVT at the end) and the ability of the PaSo™ pace-matching mapping to guide effective ablation was determined. Results: 29 patients were studied (62.1% women, mean age 52.8±14.7 years). 65.5% presented symptomatic frequent PVC and 34.5% VT. The most frequent anatomic origin was the right ventricular outflow tract (58.6%), followed by the left coronary cusp (20.7%), mitro-aortic continuity (13.8%) and papillary muscles (6.9%). The ablation was successful (PVC elimination during the procedure) in 75.9% of the cases. In 79.3% of the cases it was possible to obtain an activation map; in 20.7% (6 cases) it was only possible to obtain a pace-matching map, because ocurred suppression of PVC during the procedure, and success was achieved in 5 of these cases. There was no relationship between success and anatomical region of origin of the iVT. The mean value of the better pace-matching correlation was 94.45% ± 3.95%, being significantly higher when the zone of interest was located in the right ventricle (95.71±3.23 vs. 92.68±4.3, p=0.04). There was a positive and significant association between the PaSo™ correlation value and success (r=0.554; p=0.007). Significantly higher correlations were observed in successful ablations [95.9% vs 92%; p=0.006), and the PaSo™ correlation value was a good predictor of success (AUC: 0.874, 95% CI 0.74–1.0, p=0.003). The pace-matching threshold of 93.55% predicted ablation success with 86.4% sensitivity and 85.7% specificity. Conclusion: In patients with iVT, pace-matching mapping provides a suitable method for performing ablation procedure, and it is essential in patients where spontaneous suppression of PVC occurs during the procedure. The achievement of a pace-matching correlation>93.55% conveniently identifies the dysrhythmic focus, allowing increasing of ablation success.info:eu-repo/semantics/publishedVersio

Cost and burden of hypercholesterolemia In Portugal

Copyright © 2014 Published by Elsevier Inc.Hypercholesterolemia is a risk factor for ciculatory diseases. This study estimates the impact of hypercholesterolemia on populations’ health levels and its economic impact in Portugal.info:eu-repo/semantics/publishedVersio

Atrial fibrillation ablation : the added value of adenosine test in confirming pulmonary vein isolation

© The European Society of Cardiology 2018. All rights reserved.Introduction: Adenosine test has been increasingly used to confirm pulmonary vein isolation (PVI) in patients undergoing ablation of atrial fibrillation (AF). However, its impact on the success of ablation remains unknown. Purposes: To evaluate the results of the adenosine triphosphate (ATP) test in patients undergoing PVI and assess the success of ablation related to the use of this test (adenosine-guided PVI versus conventional PVI). Methods: Single-center prospective study of consecutive patients undergoing first AF ablation procedure, started at January 2013. After ablation, the persistence of PVI was tested with adenosine triphosphate administration (15–30mg by intravenous route). When adenosine triphosphate-induced pulmonary vein conduction (termed as reconduction) was observed, additional energy applications of radiofrequency were applied to obtain persistent isolation on retesting. Cardiac event recorder was performed at 7 days, 3, 6 and 12 months after ablation and annually from the 2nd year. The adenosine triphosphate-induced reconduction rate was evaluated depending on the pulmonary vein involved. The impact of adenosine test implementation in the success of the ablation at 365 days (recurrence of AF or supraventricular tachycardia) was determined by analysis of overall survival using Kaplan-Meier method. Results: Adenosine test was performed on 151 patients, with reconduction detected on at least one of the pulmonary veins in 11 patients (33.8%) and in 17.6% of the 641 pulmonary veins evaluated, with no statistically significant difference between the different veins. The overall success rate of AF ablation at 365 days was 72% and did not differ significantly between adenosine-guided PVI versus conventional PVI (74.3% versus 70.8%, P = NS), although the duration of follow-up had been shorter in the first group (median of 13.0 vs. 38.3 months; p<0.001). Conclusion: The adenosine-induced reconduction occurs in about one third of the patients. However, the additional adenosine-guided energy applications do not seem to increase the overall success of ablation. We found no significant reduction in the 1 year incidence of recurrent atrial tachyarrhythmias by ATP-guided PVI compared with conventional PVI.info:eu-repo/semantics/publishedVersio

Implantation of ICD and CRT-D in the elderly population : will it be a limiting factor?

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017Introduction: Implantable cardioverter defibrillator (ICD) and cardiac resynchronization (CRT-D) implantation in elderly patients is effective in preventing sudden death, although limited by the natural shorter life expectancy. The different device brands present very variable survival estimates and it has been discussed the availability of less expensive, less longevity generators for the elderly population. Purpose: To determine if the expected survival rate in the elderly patient population (≥75 years) should influence the selection of the desired longevity of the devices. Methods: A retrospective single-center study of consecutive patients who underwent implantation of ICD or CRT-D after November 1995. The mean survival of patients undergoing 1st implant or generator replacement at an advanced age (≥75 years) was evaluated and compared to the effective longevity of the generators. Cumulative survival analyzes using the Kaplan Meier method were used. Results: A total of 1312 cardiac devices were implanted, of which 163 generators in elderly patients (53% CDI and 47% CRT-D). Of these, 77% corresponded to the 1st implant. The median survival after implantation of the elderly patients was 6.8 years, not differing according to the type of device (Log-rank P = NS). The median longevity of CDI generators was 6.9 years, in line with the expected survival of elderly patients. Conversely, the median CRT-D longevity was 5.8 years, lower than the average survival of the elderly. For this reason, 21% of these CRT-D carriers were subsequently subjected to generator replacement, due to battery exhaustion. Conclusion: The effective longevity of ICDs is in agreement with an expected survival of elderly patients, for which it will not make sense to provide generators of shortened longevity for this population. The effective longevity of the CRTs is lower than the survival expectancy of the treatments, so that, paradoxically, generators with increased longevity should be favored.info:eu-repo/semantics/publishedVersio