Isolated left ventricular noncompaction (ILVNC) is a rare form of cardiomyopathy characterized by... more Isolated left ventricular noncompaction (ILVNC) is a rare form of cardiomyopathy characterized by prominent left ventricular trabeculations and intertrabecular recesses. Most common clinical manifestations are severe systolic and diastolic dysfunction, conduction abnormalities and cardioembolic events. Evidence based recommendations for the prevention of thromboembolic events in ILVNC have not been established. We report the case of a young woman initially diagnosed with hypertrophic cardiomyopathy (HCM) without systolic dysfunction who presented with left hemiparesis due to a large right hemispheric ischemic stroke, later diagnosed with ILVNC. A 30-year-old female with a previous diagnosis of HCM and an implantable cardioverter defibrillator (ICD) for primary prevention presented with complaints of left sided weakness and slurred speech. The patient was diagnosed with an ischemic right caudate/lentiform infarct, compatible with a cardioembolic stroke. A Transthoracic echocardiogram...
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2013
Isolated left ventricular noncompaction is a rare form of cardiomyopathy characterized by promine... more Isolated left ventricular noncompaction is a rare form of cardiomyopathy characterized by prominent left ventricular trabeculations and intertrabecular recesses. The typical clinical manifestations are severe systolic and diastolic dysfunction, conduction abnormalities, and cardiac embolic events theorized to result from thrombus formation within the intertrabecular recesses. Evidence-based recommendations for preventing thromboembolic events in isolated left ventricular noncompaction have not been established. We report the case of a woman who, at 10 years of age, had been diagnosed with hypertrophic cardiomyopathy without systolic dysfunction. At age 30, she presented with left hemiparesis consequent to a large right-hemispheric ischemic stroke, and she was diagnosed with isolated left ventricular noncompaction. In addition to discussing the patient's case, we review the medical literature that pertains to isolated left ventricular noncompaction.
Journal of cardiovascular pharmacology and therapeutics, 2010
Dronedarone is a multichannel blocker with electrophysiologic effects similar to amiodarone. Dron... more Dronedarone is a multichannel blocker with electrophysiologic effects similar to amiodarone. Dronedarone has been documented to prevent atrial fibrillation recurrences and also has efficacy in slowing the ventricular response during episodes of atrial fibrillation. However, in the ANDROMEDA trial, dronedarone was associated with increased mortality when tested in New York Heart Association (NYHA) III/IV patients with left ventricular ejection fractions of less than 35%, who also had a recent hospitalization for decompensated heart failure. When such high-risk patients with heart failure were excluded in the ATHENA trial, dronedarone treatment resulted in a statistical reduction in the composite primary end point of all-cause mortality or cardiovascular hospitalization. In ATHENA, dronedarone reduced cardiovascular hospitalizations even though in the DIONY-SOS trial dronedarone had less effect than amiodarone on suppressing atrial fibrillation recurrences. The most appropriate patien...
Cardiac resynchronization therapy (CRT) is an established treatment modality for systolic heart f... more Cardiac resynchronization therapy (CRT) is an established treatment modality for systolic heart failure. Aimed to produce simultaneous biventricular stimulation and correct the lack of ventricular synchrony in selected patients with congestive heart failure, CRT has shown to improve mortality and reduce hospital admissions when compared to medical treatment. At present, the indication criteria for the implantation of a CRT device include an ejection fraction of less than 35%, heart failure symptoms consistent with NYHA functional class III-IV and a QRS complex duration equal or longer than 120 milliseconds. It has been reported that 30% of patients who meet those criteria still may not derive clinical benefit from CRT. Due to the existing diversity of imagin modalities and resources for their process and analysis, a great expectation in terms of more accurate diagnosis of ventricular dyssynchrony has been raised. Reilable identification of dyssynchrony could allow us to better predi...
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing, Jan 20, 2015
The anatomical reconstruction of the left atrium (LA) and pulmonary veins with fast anatomical ma... more The anatomical reconstruction of the left atrium (LA) and pulmonary veins with fast anatomical mapping (FAM) and intracardiac echocardiography (ICE) using the Carto 3 system (Biosense Webster, Inc) provides real-time guidance to catheter manipulation during ablation of atrial fibrillation (AF). The present study compared real-time LA volume reconstruction using FAM and ICE. In addition, the contribution of respiratory gating was assessed. LA reconstruction was created using FAM and ICE in 60 consecutive patients (mean age 63 ± 9 years; 38 males) undergoing AF ablation. In the first 30 patients, FAM and ICE were performed without respiratory gating. In the last 30 patients, FAM and ICE were performed with respiratory gating. LA volumes determined by FAM were larger than those obtained with ICE in the absence of respiratory gating (n = 30; 129.5 ± 44 vs 110 ± 39.7 cm(3); p = 0.001). However, respiratory gating reduced LA volume determined with FAM by 17.7 ± 6.6 % resulting in similar ...
tedisamil versus placebo for treating atrial fibrillation/atrial flutter patients with onset of l... more tedisamil versus placebo for treating atrial fibrillation/atrial flutter patients with onset of less than 48 hours.4 In the placebo-treated patients with atrial fibrillation, four of 46 (9%) converted to sinus rhythm. Treatment with tedisamil 0.4mg/kg converted atrial fibrillation to sinus rhythm in 24 of 52 patients (46%), and in 24 of 42 patients (57%) in the 0.6mg/kg group (p<0.001 for
La ablación de fibrilación auricular puede resultar pro-arrítmica. Las taquicardias auriculares p... more La ablación de fibrilación auricular puede resultar pro-arrítmica. Las taquicardias auriculares por macro-reentrada han sido reportadas hasta en 1/3 de los pacientes que son sometidos a ablación de fibrilación auricular. Métodos y Resultados: En el presente trabajo se utilizo un abordaje electrofisiológico para eliminar potenciales auriculares izquierdos fraccionados durante ritmo sinusal, sin la intención de crear líneas de bloqueo. Trescientos pacientes consecutivos con fibrilación auricular (paroxística n=218; persistente n=82) fueron incluidos. Luego del aislamiento eléctrico de las venas pulmonares, los potenciales auriculares fraccionados identificados como blancos de ablación en la aurícula izquierda fueron de mayor duración y menor voltaje que los electrogramas del tejido auricular adyacente (97.2±23.4 vs 42.1±17.3 ms; y 0.83 ± 0.7 mV vs 2.75±1.3 mV, p<0.001). Ochenta y siete pacientes (29%) requirieron de un segundo procedimiento de ablación. Después de un promedio de 19±5 meses, 234 pacientes (78%) mantuvieron ritmo sinusal sin evidencia de recurrencia de fibrilación auricular y solo 4 (1.3%) presentaron taquicardia auricular por macro-reentrada.
Most cardiovascular implantable electronic devices (CIEDs) require a ventricular lead to be place... more Most cardiovascular implantable electronic devices (CIEDs) require a ventricular lead to be placed across the tricuspid valve. Tricuspid regurgitation (TR) is an understudied clinical complication of right ventricular lead implantation and its clinical significance is unknown. We review the incidence, predictors, and current management of TR as a complication of ventricular lead implantation. Emerging technologies, including leadless pacing devices and subcutaneous systems, offer the benefit of little or none tricuspid valve disruption.
Importance: AliveCor ECG is an FDA approved ambulatory cardiac rhythm monitor that records a sing... more Importance: AliveCor ECG is an FDA approved ambulatory cardiac rhythm monitor that records a single channel (lead I) ECG rhythm strip using an iPhone. In the past few years, the use of smartphones and tablets with health related applications has significantly proliferated. Objective: In this initial feasibility trial, we attempted to reproduce the 12 lead ECG using the bipolar arrangement of the AliveCor monitor coupled to smart phone technology. Methods: We used the AliveCor heart monitor coupled with an iPhone cellular phone and the AliveECG application (APP) in 5 individuals. Results: In our 5 individuals, recordings from both a standard 12 lead ECG and the AliveCor generated 12 lead ECG had the same interpretation.
The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of dron... more The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of dronedarone (Multaq®, Sanofi-Aventis Limited, UK) to submit evidence on the clinical and cost effectiveness of the anti-arrhythmic drug (AAD) for the treatment of atrial fibrillation (AF) and atrial flutter, as part of the Institute&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s single technology appraisal (STA) process. The Centre for Reviews and Dissemination and the Centre for Health Economics, both at the University of York, were commissioned to act as the independent Evidence Review Group (ERG). This article provides a description of the company submission, the ERG review and NICE&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s subsequent decisions regarding the use of dronedarone within the UK NHS. The ERG review comprised a critique of the submitted evidence on the clinical effectiveness and cost effectiveness of dronedarone. The ERG examined the search strategy used to obtain relevant evidence, the selection of studies included in the assessment, outcome measures chosen and statistical methods employed. The ERG also validated the manufacturer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s decision analytic model and used it to explore the robustness of the cost-effectiveness results to key assumptions. The main clinical effectiveness evidence supporting the use of dronedarone as a treatment for AF came from four randomized controlled trials. These trials were compared with a broader set of trials examining the effectiveness of other AADs for AF: amiodarone, sotalol and class 1c agents (flecainide and propafenone). The evidence suggested that all AADs decreased the recurrence of AF but dronedarone had the smallest effect. A mixed treatment comparison analysis of the trials showed that dronedarone was associated with a lower risk of all-cause mortality than other AADs, but this was highly uncertain. There was limited evidence to assess the effect of dronedarone on stroke, and no statistically significant differences between dronedarone and other AADs were found for treatment discontinuation. From the evidence presented by the manufacturer, dronedarone appeared highly cost effective in each of the population groups examined compared with using standard baseline therapy alone as first-line treatment, or compared with sotalol or amiodarone as first-line AAD, with incremental cost-effectiveness ratios (ICERs) well below £20,000 per QALY gained. The ICER for dronedarone relative to class 1c agents was around £19,000 per QALY. Although the evidence presented by the manufacturer indicated that dronedarone was cost effective, the estimates of treatment effect relative to other AADs and safety in the longer term were highly uncertain. The NICE Appraisal Committee in its preliminary guidance did not recommend the use of dronedarone for AF. However, following the response from a large number of consultees and commentators, NICE revised its preliminary guidance to allow the use of the drug in a specific subgroup of AF patients with additional cardiovascular risk factors.
... Figura 5. Imágenes obtenidas con seguimiento del ruido de moteado correspondientes al ventríc... more ... Figura 5. Imágenes obtenidas con seguimiento del ruido de moteado correspondientes al ventrículo izquierdo en la vista apical de cuatro cáma-ras. El índice de deformación global (GS=-81%) sugiere contractilidad pobre y se corresponde con la baja fracción de eyección. ...
Journal of Interventional Cardiac Electrophysiology, 2013
Purpose Cardiac rhythm management devices (CRMD) require a ventricular lead to be placed across t... more Purpose Cardiac rhythm management devices (CRMD) require a ventricular lead to be placed across the tricuspid valve. Tricuspid regurgitation (TR) is an under-recognized clinical complication of lead implantation and its clinical significance is unknown. We studied the incidence of hospitalizations for congestive heart failure (CHF) exacerbation among patients with worsening TR after ventricular lead implantation. Methods We reviewed 148 patients (age 68±15) that received a CRMD. TR and pulmonary artery systolic pressure (PASP) measured by Doppler echocardiography before and after CRMD implantation were analyzed. Hospitalizations for CHF exacerbation post-implantation were counted. Results Follow-up was 32±14 months. Ninety-nine (67 %) patients had no change, 24 (16 %) slight, and 9 (6 %) significant increase in TR after CRMD implantation, while 13 (9 %) patients had slight and 3 (2 %) significant improvement. Patients with a significant increase in TR had higher incidence of hospitalizations (1.7±0.5) compared to patients with slight (0.8±1; p =0.006) or no increase (0.5±1; p =0.0002) in TR. Patients with significant increase in TR had a greater change in PASP (25 mmHg; p =0.002) after device implantation compared to those with a slight (10 mmHg; p =0.002) or no increase (0.7 mmHg; p =0.17). Conclusion Increased TR following CRMD implantation is relatively common (33 %) and correlated with subsequent risk of hospitalization for heart failure. A preventive strategy and close monitoring for development or worsening of CHF after CRMD implantation may help prevent hospital admissions.
Journal of Interventional Cardiac Electrophysiology, 2010
With the availability of catheter ablation for the elimination of complex cardiac arrhythmias, ne... more With the availability of catheter ablation for the elimination of complex cardiac arrhythmias, new imaging tools have enhanced the safety and efficacy of procedures performed in the electrophysiology laboratory. We review the use of intracardiac ultrasound (ICE) as the modality that allows real-time monitoring and reconstruction of cardiac anatomy. Practical technical information related to the use of ICE in ablation procedures in general and particular aspects related to ablation of atrial fibrillation, atrial flutter, ventricular tachycardia, and arrhythmias in adults with congenital heart disease are discussed in this manuscript.
Journal of Interventional Cardiac Electrophysiology, 2009
Cardiac resynchronization therapy (CRT) is a well established treatment modality in heart failure... more Cardiac resynchronization therapy (CRT) is a well established treatment modality in heart failure. Using standard techniques, placement of the left ventricular (LV) lead is usually successful; however LV lead placement failure remains a clinical problem. In the present report, the standard over-the-wire technique was not successful due to absence of the necessary support to place the lead into a tortuous vein. This was achieved using balloon occlusion of the great cardiac vein distal to the target vessel. An 81 year old female candidate for CRT presented for biventricular pacemaker implantation. After placement of the right ventricular lead, the CS was cannulated and an occlusive venogram was performed. A lateral branch was selected as the target vessel. Initial attempts at cannulating the vessel were unsuccessful due to the guidewire and telescoping delivery system prolapsing into the great cardiac vein. The acute angle prevented instrumentation of the branch with the tools available. A second parallel CS sheath was advanced to drive a balloon catheter used to occlude the great cardiac vein distal to the target vessel. This provided support for the guidewire and lead allowing their advancement through the tortuous vessel. Consecutive traction on the balloon during also helped to reflect the lead towards the vessel. The lead remained stable in its final position on the lateral wall of the LV with appropriate thresholds and no diaphragmatic stimulation. We report a case where balloon occlusion of the great cardiac vein distal to the target branch aided in advancing the LV lead into the desired position. This approach can be used in navigating lead placement to branches thought to be unreachable. Techniques such as this can decrease the failure rate of CRT implants.
Isolated left ventricular noncompaction (ILVNC) is a rare form of cardiomyopathy characterized by... more Isolated left ventricular noncompaction (ILVNC) is a rare form of cardiomyopathy characterized by prominent left ventricular trabeculations and intertrabecular recesses. Most common clinical manifestations are severe systolic and diastolic dysfunction, conduction abnormalities and cardioembolic events. Evidence based recommendations for the prevention of thromboembolic events in ILVNC have not been established. We report the case of a young woman initially diagnosed with hypertrophic cardiomyopathy (HCM) without systolic dysfunction who presented with left hemiparesis due to a large right hemispheric ischemic stroke, later diagnosed with ILVNC. A 30-year-old female with a previous diagnosis of HCM and an implantable cardioverter defibrillator (ICD) for primary prevention presented with complaints of left sided weakness and slurred speech. The patient was diagnosed with an ischemic right caudate/lentiform infarct, compatible with a cardioembolic stroke. A Transthoracic echocardiogram...
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2013
Isolated left ventricular noncompaction is a rare form of cardiomyopathy characterized by promine... more Isolated left ventricular noncompaction is a rare form of cardiomyopathy characterized by prominent left ventricular trabeculations and intertrabecular recesses. The typical clinical manifestations are severe systolic and diastolic dysfunction, conduction abnormalities, and cardiac embolic events theorized to result from thrombus formation within the intertrabecular recesses. Evidence-based recommendations for preventing thromboembolic events in isolated left ventricular noncompaction have not been established. We report the case of a woman who, at 10 years of age, had been diagnosed with hypertrophic cardiomyopathy without systolic dysfunction. At age 30, she presented with left hemiparesis consequent to a large right-hemispheric ischemic stroke, and she was diagnosed with isolated left ventricular noncompaction. In addition to discussing the patient's case, we review the medical literature that pertains to isolated left ventricular noncompaction.
Journal of cardiovascular pharmacology and therapeutics, 2010
Dronedarone is a multichannel blocker with electrophysiologic effects similar to amiodarone. Dron... more Dronedarone is a multichannel blocker with electrophysiologic effects similar to amiodarone. Dronedarone has been documented to prevent atrial fibrillation recurrences and also has efficacy in slowing the ventricular response during episodes of atrial fibrillation. However, in the ANDROMEDA trial, dronedarone was associated with increased mortality when tested in New York Heart Association (NYHA) III/IV patients with left ventricular ejection fractions of less than 35%, who also had a recent hospitalization for decompensated heart failure. When such high-risk patients with heart failure were excluded in the ATHENA trial, dronedarone treatment resulted in a statistical reduction in the composite primary end point of all-cause mortality or cardiovascular hospitalization. In ATHENA, dronedarone reduced cardiovascular hospitalizations even though in the DIONY-SOS trial dronedarone had less effect than amiodarone on suppressing atrial fibrillation recurrences. The most appropriate patien...
Cardiac resynchronization therapy (CRT) is an established treatment modality for systolic heart f... more Cardiac resynchronization therapy (CRT) is an established treatment modality for systolic heart failure. Aimed to produce simultaneous biventricular stimulation and correct the lack of ventricular synchrony in selected patients with congestive heart failure, CRT has shown to improve mortality and reduce hospital admissions when compared to medical treatment. At present, the indication criteria for the implantation of a CRT device include an ejection fraction of less than 35%, heart failure symptoms consistent with NYHA functional class III-IV and a QRS complex duration equal or longer than 120 milliseconds. It has been reported that 30% of patients who meet those criteria still may not derive clinical benefit from CRT. Due to the existing diversity of imagin modalities and resources for their process and analysis, a great expectation in terms of more accurate diagnosis of ventricular dyssynchrony has been raised. Reilable identification of dyssynchrony could allow us to better predi...
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing, Jan 20, 2015
The anatomical reconstruction of the left atrium (LA) and pulmonary veins with fast anatomical ma... more The anatomical reconstruction of the left atrium (LA) and pulmonary veins with fast anatomical mapping (FAM) and intracardiac echocardiography (ICE) using the Carto 3 system (Biosense Webster, Inc) provides real-time guidance to catheter manipulation during ablation of atrial fibrillation (AF). The present study compared real-time LA volume reconstruction using FAM and ICE. In addition, the contribution of respiratory gating was assessed. LA reconstruction was created using FAM and ICE in 60 consecutive patients (mean age 63 ± 9 years; 38 males) undergoing AF ablation. In the first 30 patients, FAM and ICE were performed without respiratory gating. In the last 30 patients, FAM and ICE were performed with respiratory gating. LA volumes determined by FAM were larger than those obtained with ICE in the absence of respiratory gating (n = 30; 129.5 ± 44 vs 110 ± 39.7 cm(3); p = 0.001). However, respiratory gating reduced LA volume determined with FAM by 17.7 ± 6.6 % resulting in similar ...
tedisamil versus placebo for treating atrial fibrillation/atrial flutter patients with onset of l... more tedisamil versus placebo for treating atrial fibrillation/atrial flutter patients with onset of less than 48 hours.4 In the placebo-treated patients with atrial fibrillation, four of 46 (9%) converted to sinus rhythm. Treatment with tedisamil 0.4mg/kg converted atrial fibrillation to sinus rhythm in 24 of 52 patients (46%), and in 24 of 42 patients (57%) in the 0.6mg/kg group (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001 for
La ablación de fibrilación auricular puede resultar pro-arrítmica. Las taquicardias auriculares p... more La ablación de fibrilación auricular puede resultar pro-arrítmica. Las taquicardias auriculares por macro-reentrada han sido reportadas hasta en 1/3 de los pacientes que son sometidos a ablación de fibrilación auricular. Métodos y Resultados: En el presente trabajo se utilizo un abordaje electrofisiológico para eliminar potenciales auriculares izquierdos fraccionados durante ritmo sinusal, sin la intención de crear líneas de bloqueo. Trescientos pacientes consecutivos con fibrilación auricular (paroxística n=218; persistente n=82) fueron incluidos. Luego del aislamiento eléctrico de las venas pulmonares, los potenciales auriculares fraccionados identificados como blancos de ablación en la aurícula izquierda fueron de mayor duración y menor voltaje que los electrogramas del tejido auricular adyacente (97.2±23.4 vs 42.1±17.3 ms; y 0.83 ± 0.7 mV vs 2.75±1.3 mV, p<0.001). Ochenta y siete pacientes (29%) requirieron de un segundo procedimiento de ablación. Después de un promedio de 19±5 meses, 234 pacientes (78%) mantuvieron ritmo sinusal sin evidencia de recurrencia de fibrilación auricular y solo 4 (1.3%) presentaron taquicardia auricular por macro-reentrada.
Most cardiovascular implantable electronic devices (CIEDs) require a ventricular lead to be place... more Most cardiovascular implantable electronic devices (CIEDs) require a ventricular lead to be placed across the tricuspid valve. Tricuspid regurgitation (TR) is an understudied clinical complication of right ventricular lead implantation and its clinical significance is unknown. We review the incidence, predictors, and current management of TR as a complication of ventricular lead implantation. Emerging technologies, including leadless pacing devices and subcutaneous systems, offer the benefit of little or none tricuspid valve disruption.
Importance: AliveCor ECG is an FDA approved ambulatory cardiac rhythm monitor that records a sing... more Importance: AliveCor ECG is an FDA approved ambulatory cardiac rhythm monitor that records a single channel (lead I) ECG rhythm strip using an iPhone. In the past few years, the use of smartphones and tablets with health related applications has significantly proliferated. Objective: In this initial feasibility trial, we attempted to reproduce the 12 lead ECG using the bipolar arrangement of the AliveCor monitor coupled to smart phone technology. Methods: We used the AliveCor heart monitor coupled with an iPhone cellular phone and the AliveECG application (APP) in 5 individuals. Results: In our 5 individuals, recordings from both a standard 12 lead ECG and the AliveCor generated 12 lead ECG had the same interpretation.
The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of dron... more The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of dronedarone (Multaq®, Sanofi-Aventis Limited, UK) to submit evidence on the clinical and cost effectiveness of the anti-arrhythmic drug (AAD) for the treatment of atrial fibrillation (AF) and atrial flutter, as part of the Institute&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s single technology appraisal (STA) process. The Centre for Reviews and Dissemination and the Centre for Health Economics, both at the University of York, were commissioned to act as the independent Evidence Review Group (ERG). This article provides a description of the company submission, the ERG review and NICE&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s subsequent decisions regarding the use of dronedarone within the UK NHS. The ERG review comprised a critique of the submitted evidence on the clinical effectiveness and cost effectiveness of dronedarone. The ERG examined the search strategy used to obtain relevant evidence, the selection of studies included in the assessment, outcome measures chosen and statistical methods employed. The ERG also validated the manufacturer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s decision analytic model and used it to explore the robustness of the cost-effectiveness results to key assumptions. The main clinical effectiveness evidence supporting the use of dronedarone as a treatment for AF came from four randomized controlled trials. These trials were compared with a broader set of trials examining the effectiveness of other AADs for AF: amiodarone, sotalol and class 1c agents (flecainide and propafenone). The evidence suggested that all AADs decreased the recurrence of AF but dronedarone had the smallest effect. A mixed treatment comparison analysis of the trials showed that dronedarone was associated with a lower risk of all-cause mortality than other AADs, but this was highly uncertain. There was limited evidence to assess the effect of dronedarone on stroke, and no statistically significant differences between dronedarone and other AADs were found for treatment discontinuation. From the evidence presented by the manufacturer, dronedarone appeared highly cost effective in each of the population groups examined compared with using standard baseline therapy alone as first-line treatment, or compared with sotalol or amiodarone as first-line AAD, with incremental cost-effectiveness ratios (ICERs) well below £20,000 per QALY gained. The ICER for dronedarone relative to class 1c agents was around £19,000 per QALY. Although the evidence presented by the manufacturer indicated that dronedarone was cost effective, the estimates of treatment effect relative to other AADs and safety in the longer term were highly uncertain. The NICE Appraisal Committee in its preliminary guidance did not recommend the use of dronedarone for AF. However, following the response from a large number of consultees and commentators, NICE revised its preliminary guidance to allow the use of the drug in a specific subgroup of AF patients with additional cardiovascular risk factors.
... Figura 5. Imágenes obtenidas con seguimiento del ruido de moteado correspondientes al ventríc... more ... Figura 5. Imágenes obtenidas con seguimiento del ruido de moteado correspondientes al ventrículo izquierdo en la vista apical de cuatro cáma-ras. El índice de deformación global (GS=-81%) sugiere contractilidad pobre y se corresponde con la baja fracción de eyección. ...
Journal of Interventional Cardiac Electrophysiology, 2013
Purpose Cardiac rhythm management devices (CRMD) require a ventricular lead to be placed across t... more Purpose Cardiac rhythm management devices (CRMD) require a ventricular lead to be placed across the tricuspid valve. Tricuspid regurgitation (TR) is an under-recognized clinical complication of lead implantation and its clinical significance is unknown. We studied the incidence of hospitalizations for congestive heart failure (CHF) exacerbation among patients with worsening TR after ventricular lead implantation. Methods We reviewed 148 patients (age 68±15) that received a CRMD. TR and pulmonary artery systolic pressure (PASP) measured by Doppler echocardiography before and after CRMD implantation were analyzed. Hospitalizations for CHF exacerbation post-implantation were counted. Results Follow-up was 32±14 months. Ninety-nine (67 %) patients had no change, 24 (16 %) slight, and 9 (6 %) significant increase in TR after CRMD implantation, while 13 (9 %) patients had slight and 3 (2 %) significant improvement. Patients with a significant increase in TR had higher incidence of hospitalizations (1.7±0.5) compared to patients with slight (0.8±1; p =0.006) or no increase (0.5±1; p =0.0002) in TR. Patients with significant increase in TR had a greater change in PASP (25 mmHg; p =0.002) after device implantation compared to those with a slight (10 mmHg; p =0.002) or no increase (0.7 mmHg; p =0.17). Conclusion Increased TR following CRMD implantation is relatively common (33 %) and correlated with subsequent risk of hospitalization for heart failure. A preventive strategy and close monitoring for development or worsening of CHF after CRMD implantation may help prevent hospital admissions.
Journal of Interventional Cardiac Electrophysiology, 2010
With the availability of catheter ablation for the elimination of complex cardiac arrhythmias, ne... more With the availability of catheter ablation for the elimination of complex cardiac arrhythmias, new imaging tools have enhanced the safety and efficacy of procedures performed in the electrophysiology laboratory. We review the use of intracardiac ultrasound (ICE) as the modality that allows real-time monitoring and reconstruction of cardiac anatomy. Practical technical information related to the use of ICE in ablation procedures in general and particular aspects related to ablation of atrial fibrillation, atrial flutter, ventricular tachycardia, and arrhythmias in adults with congenital heart disease are discussed in this manuscript.
Journal of Interventional Cardiac Electrophysiology, 2009
Cardiac resynchronization therapy (CRT) is a well established treatment modality in heart failure... more Cardiac resynchronization therapy (CRT) is a well established treatment modality in heart failure. Using standard techniques, placement of the left ventricular (LV) lead is usually successful; however LV lead placement failure remains a clinical problem. In the present report, the standard over-the-wire technique was not successful due to absence of the necessary support to place the lead into a tortuous vein. This was achieved using balloon occlusion of the great cardiac vein distal to the target vessel. An 81 year old female candidate for CRT presented for biventricular pacemaker implantation. After placement of the right ventricular lead, the CS was cannulated and an occlusive venogram was performed. A lateral branch was selected as the target vessel. Initial attempts at cannulating the vessel were unsuccessful due to the guidewire and telescoping delivery system prolapsing into the great cardiac vein. The acute angle prevented instrumentation of the branch with the tools available. A second parallel CS sheath was advanced to drive a balloon catheter used to occlude the great cardiac vein distal to the target vessel. This provided support for the guidewire and lead allowing their advancement through the tortuous vessel. Consecutive traction on the balloon during also helped to reflect the lead towards the vessel. The lead remained stable in its final position on the lateral wall of the LV with appropriate thresholds and no diaphragmatic stimulation. We report a case where balloon occlusion of the great cardiac vein distal to the target branch aided in advancing the LV lead into the desired position. This approach can be used in navigating lead placement to branches thought to be unreachable. Techniques such as this can decrease the failure rate of CRT implants.
Uploads
Papers by Javier Banchs