Sustained ventricular tachycardia in structural heart disease

Ventricular arrhythmias are responsible for the majority of sudden cardiac deaths (SCD), particularly in patients with structural heart disease. Coronary artery disease, essentially previous myocardial infarction, is the most common heart disease upon which sustained ventricular tachycardia (VT) occurs, being reentry the predominant mechanism. Other cardiac conditions, such as idiopathic dilated cardiomyopathy, Chagas disease, sarcoidosis, arrhythmogenic cardiomyopathies, and repaired congenital heart disease may also present with VT in follow-up. Analysis of the 12-lead electrocardiogram (ECG) is essential for diagnosis. There are numerous electrocardiographic criteria that suggest VT with good specificity. The ECG also guides us in locating the site of origin of the arrhythmia and the presence of underlying heart disease. The electrophysiological study provides valuable information to establish the mechanism of the arrhythmia and guide the ablation procedure, as well as to confirm the diagnosis when dubious ECG. Given the poor efficacy of antiarrhythmic drug therapy, adjunctive catheter ablation contributes to reduce the frequency of VT episodes and the number of shocks in patients implanted with a cardioverter-defibrillator (ICD). ICD therapy has proven to be effective in patients with aborted SCD or sustained VT in the presence of structural heart disease. It is the only therapy that improves survival in this patient population and its implantation is unquestioned nowadays

Antegrade or Retrograde Accessory Pathway Conduction: Who Dies First?

A 36 year-old man with Wolff Parkinson White syndrome due to a left-sided accessory pathway (AP) was referred for catheter ablation. Whether abolition of antegrade and retrograde AP conduction during ablation therapy occurs simultaneously, is unclear. At the ablation procedure, radiofrequency delivery resulted in loss of preexcitation followed by a short run of orthodromic tachycardia with eccentric atrial activation, demonstrating persistence of retrograde conduction over the AP after abolition of its antegrade conduction. During continued radiofrequency delivery at the same position, the fifth non-preexcitated beat failed to conduct retrogradely and the tachycardia ended. In this case, antegrade AP conduction was abolished earlier than retrograde conduction

Radiofrequency catheter ablation of frequent premature ventricular contractions using ARRAY multi-electrode balloon catheter

Background: The noncontact mapping system facilitates the mapping of premature ventricular contractions (PVCs) and ventricular tachycardia (VT) using a 64-electrode expandable balloon catheter (ARRAY, St. Jude Medical). The aim of this study is to analyze the results and follow-up of the PVC ablation using this system. Methods and results: Prospective and consecutive patients with frequent PVCs (6,000 or more) or monomorphic VT, suspected to be originated on the right ventricular outflow tract (RVOT), were included. The balloon catheter was positioned in the RVOT. Eighteen patients, 9 women, mean age 48 years (youngest/oldest 19–65) were included. Sixteen patients presented no structural heart disease. The origin of the arrhythmia was RVOT (n = 15), right ventricular inflow tract (n = 1), and left ventricular outflow tract (n = 2). Acute success was achieved in 15 patients; in 2 patients radiofrequency was not applied due to security reasons (origin site close to left coronary artery origin). The mean follow-up was 15 months (min. 4, max. 26); 13 patients presented abolition of the arrhythmia without drugs and 1 patient required antiarrhythmic drugs for arrhythmia control (previously ineffective). As an only complication, a femoral artery-venous fistula was observed. Conclusions: The noncontact mapping system using a multielectrode balloon allows right ventricular arrhythmia treatment with a high rate of efficacy and safety

Clinical impact of defibrillation testing at the time of implantable cardioverter-defibrillator insertion

Background: Ventricular fibrillation is routinely induced during implantable cardioverter- -defibrillator insertion to assess defibrillator performance, but this strategy is experiencing a progressive decline. We aimed to assess the efficacy of defibrillator therapies and long-term outcome in a cohort of patients that underwent defibrillator implantation with and without defibrillation testing. Methods: Retrospective observational series of consecutive patients undergoing initial defibrillator insertion or generator replacement. We registered spontaneous ventricular arrhythmias incidence and therapy efficacy, and mortality. Results: A total of 545 patients underwent defibrillator implantation (111 with and 434 without defibrillation testing). After 19 (range 9–31) months of follow-up, the death rate per observation year (4% vs. 4%; p = 0.91) and the rate of patients with defibrillator-treated ventricular arrhythmic events per observation year (with test: 10% vs. without test: 12%; p = 0.46) were similar. The generalized estimating equations-adjusted first shock probability of success in patients with test (95%; CI 88–100%) vs. without test (98%; CI 96–100%; p = 0.42) and the proportion of successful antitachycardia therapies (with test: 87% vs. without test: 80%; p = 0.35) were similar between groups. There was no difference in the annualized rate of failed first shock per patient and per shocked patient between groups (5% vs. 4%; p = 0.94). Conclusions: In this observational study, that included an unselected population of patients with a defibrillator, no difference was found in overall mortality, first shock efficacy and rate of failed shocks regardless of whether defibrillation testing was performed or not.Hadid, C.; Atienza, F.; Strasberg, B.; Arenal, Á.; Codner, P.; González-Torrecilla, E.; Datino, T.... (2015). Clinical impact of defibrillation testing at the time of implantable cardioverter-defibrillator insertion. Cardiology Journal. 22(3):253-259. doi:10.5603/Cj.a2014.0062S25325922

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias

withdrawn 2017 hrs ehra ecas aphrs solaece expert consensus statement on catheter and surgical ablation of atrial fibrillation

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Application and Comparison of the CHADS2 and CHA2DS2-VASc Risk Scores in a Population with Atrial Fibrillation

IntroductionThe CHADS2 score and the CHA2DS2-VASc score recently adopted by the medicalcommunity have been developed with international registry data and are widely usedin clinical practice. However, they have not been evaluated in national registries.ObjectivesThe aims of this study were first to evaluate the predictive power of the CHADS2and CHA2DS2-VASc stroke risk scores in the Atrial Fibrillation Registry conductedby the Argentine Society of Cardiology Research Area and second to compare bothscoring systems.MethodsThe Atrial Fibrillation Registry of 2001 was a multicenter, prospective study of allconsecutive patients with chronic atrial fibrillation (permanent and persistent)treated in 70 medical centers in Argentina. Demographic data, socioeconomic characteristics,background and clinical features were obtained. A 2-year follow-up wasperformed to assess stroke rate. For the present analysis patients without anticoagulanttreatment were selected. In this population, the two risk score systems wereassessed; a ROC curve was built for each score (reported as C statistic) and bothscoring systems were compared.ResultsThe study population consisted of 303 patients (49.3 %) not receiving anticoagulanttherapy. The stroke rate in the selected population was 9.5%. Both scoring systemspredicted significant stroke risk.The stroke rate increased as the CHADS2 and the CHA2DS2-VASc scores were higher,and were similar in both risk scales.The CHADS2 and CHA2DS2-VASc scores had C statistic values of 0.67 (0.55-0.78)and 0.69 (0.59 to 0.78), respectively, without significant differences between them.The score analyses divided into three risk profiles -low, moderate and high- revealedthat the predictive power decreased markedly. The C statistic of the CHADS2 was0.63 (95% CI 0.57-0.68) and that of the CHA2DS2-VASc score was 0.57 (95% CI 0.51-0.62, with a slightly better predictive trend for the CHADS2 score but without statisticalsignificance.ConclusionsThe two scoring systems used to predict stroke in an Argentine population of patientswith persistent and permanent atrial fibrillation have a similar predictivepower comparable to results reported in the literature.Introducción:El puntaje   CHADS2 y  el recientemente adoptado por la comunidad médica     CHA2DS2 VASc Han sido confeccionados con datos de registros internacionales y son ampliamente usados en la práctica  clínica, sin embargo, no han sido testeados en registros nacionales.Objetivo:El objetivo del presente estudio es evaluar el poder de predicción de los puntajes  de riesgo de ACV  (CHADS2 y CHA2DS2 VASc  ) en el registro de fibrilación auricular realizado por área de investigación de nuestra sociedad y comparar ambos sistemas de puntajes.Métodos:El registro de fibrilación auricular fue un estudio Multicéntrico y prospectivo de todos los pacientes consecutivos asistidos con Fibrilación Auricular Crónica (permanente y persistente) en 70 centros médicos de Argentina realizado en año 2001.Se obtuvieron los datos demográficos, las características socioeconómicas, los antecedentes y las características clínicas de la población con fibrilación auricular crónica (permanente y persistente).Se realizó un seguimiento a 2 años evaluando la tasa de  ACV . Se seleccionaron los pacientes sin tratamiento anticoagulante para el análisis. Se Testeo en esta población los dos sistemas de puntajes de riesgo confeccionándose una curva de ROC para cada puntaje (informándose como C estadístico) y realizándose un comparación entre ambos sistemas de puntajes.Resultados:El 49, 3 % (303 pacientes) de los pacientes seguidos no recibían tratamiento anticoagulante y esta fue nuestra población en estudio. La tasa de ACV en la población seleccionada  fue del  9,5 %.Los dos sistemas de puntajes de riesgo predijeron el ACV significativamente.En la tabla se ve la tasa de ACV por cada punto sumado. 012345678CHADS22,6%5.1%9,1%14,2%12,5%50%0%  CHADVASC0%2,8%6.3%1,4%14,4%20%7,6%22,2%  El C estadístico para ACV del CHADS2 fue de 0,67 (0,55-0,78) y C estadístico para ACV del CHA2DS2 VASc fue 0,69 (0,59-0,78)  sin diferencias significativas entre ambos. Conclusiones En una población  con fibrilación auricular de la república Argentina se observó que los 2 sistemas de puntajes  de predicción de ACV en pacientes con FA permanente y persistente  tienen un similar poder de predicción entre ellos y similar al reportado en la literatura

Ablación por catéter en pacientes con tormenta eléctrica. La calma tras la tempestad

Introducción: La ablación por catéter (AC) es beneficiosa en pacientes con taquicardia ventricular (TV) recurrente. Nuestro objetivo es revisar los casos de tormenta eléctrica (TE) tratados con AC. Métodos: Análisis retrospectivo de pacientes con TE debida a TV monomorfa sostenida (TVMS) tratados mediante AC. Se definió éxito del procedimiento: ausencia de TV inducible al final del mismo; éxito parcial: inducción de TV no clínica; no éxito: inducibilidad de la TV clínica. Resultados: Se realizaron 16 procedimientos en 14 pacientes: 10 exitosos, 3 éxito parcial y 3 no exitosos. Todos los pacientes evolucionaron sin arritmia ventricular inmediatamente post-ablación. Diez pacientes (71,4%) evolucionaron sin TV y 86,7% sin TE (seguimiento 8 [3-30] meses). Cinco pacientes (35,7%) murieron de causa no arrítmica. Conclusiones: La AC se asocia a una supresión aguda de TV en todos los pacientes con TE debida a TVMS y a una evolución sin recurrencia en la mayoría de ellos