Background: Despite the improvement in detection and surgical therapy in the last years, the outc... more Background: Despite the improvement in detection and surgical therapy in the last years, the outcome of patients affected by colorectal carcinoma (CRC) remains limited by metastatic relapse. The aim of this study was to investigate the presence of free tumor DNA in the plasma of CRC patients in order to understand its possible prognostic role.
Background-Efficacy of endocardial ventricular tachycardia (VT) ablation in arrhythmogenic right ... more Background-Efficacy of endocardial ventricular tachycardia (VT) ablation in arrhythmogenic right ventricular cardiomyopathy/dysplasia may be limited by epicardial VT, right ventricular thickening, or both. We sought to characterize the endocardial versus epicardial substrate, measure right ventricular free wall thickness, and determine epicardial ablation efficacy in patients with right ventricular cardiomyopathy/dysplasia. Methods and Results-Thirteen consecutive patients (3 female; aged 43Ϯ15 years; range, 17 to 70 years) undergoing endocardial and epicardial sinus rhythm voltage mapping and epicardial VT ablation after failed endocardial VT ablation were included. In each patient, the low bipolar voltage area (Ͻ1.0 mV for epicardium and Ͻ1.5 mV for endocardium) was more extensive on the epicardium (95Ϯ47 versus 38Ϯ32 cm 2 ; PϽ0.001) and was uniformly marked by multicomponent and late electrograms. The basal right ventricular thickness assessed by electroanatomic map was Ͼ10 mm in 6 of 13 patients compared with 5 to 10 mm in 4 reference patients without structural disease. Twenty-seven VTs were targeted on the epicardium with the use of activation, entrainment, or pace mapping with focal/linear ablation and targeting of late potentials. Epicardial VTs were targeted opposite normal endocardium in 10 patients (77%) and/or opposite ineffective endocardial ablation sites in 11 patients (85%). During 18Ϯ13 months, 10 of the 13 patients (77%) had no VT, with 2 patients having only a single VT at 2 and 38 months, respectively.
Usefulness of 12-lead ECG for predicting an epicardial origin for ventricular tachycardia (VT) ar... more Usefulness of 12-lead ECG for predicting an epicardial origin for ventricular tachycardia (VT) arising from the right ventricle (RV) has not been assessed. An epicardial approach is sometimes warranted to eliminate RV VT. The purpose of this study was investigate the hypothesis that specific ECG features identify an epicardial origin for RV VT. To mimic an endocardial or epicardial origin, we paced representative sites in 13 patients undergoing RV endocardial/epicardial mapping (134/180 pace map sites). QRS duration from epicardial vs endocardial sites was not different (183 +/- 27 ms vs 185 +/- 28 ms, P = .3). Reported cut-off values for identifying epicardial left ventricular origin, pseudo-delta wave (> or =34 ms), intrinsicoid deflection time (> or =85 ms), and RS complex (> or =121 ms) did not apply to the RV. A Q wave in lead II, III, or aVF was more likely noted from inferior epicardial vs endocardial sites (53/73 vs 16/43, P <.01). A Q wave in lead I was more frequently present from epicardial vs endocardial anterior RV sites (30/82 vs 5/52, P <.001). QS in lead V(2) was noted from anatomically matched epicardial anterior RV sites (22/33 vs 13/33, P <.05). In the RV outflow tract, no ECG feature distinguishing epicardial/endocardial origin reached statistical significance. A Q wave or QS in leads that best reflect local activation suggest an epicardial origin for RV depolarization and may help in identifying a probable epicardial site of origin for RV VT. QRS duration and reported criteria for epicardial origin of VT in the left ventricle do not identify a probable epicardial origin in the RV.
Background: We sought to compare the efficacy and collateral damage during pulmonary vein (PV) is... more Background: We sought to compare the efficacy and collateral damage during pulmonary vein (PV) isolation in a canine model using three different ablation strategies.Methods: Normal dogs (three each) were randomized to high power (70 W, 20 seconds, 60°C, Hi), medium power (50 W, 60 seconds, 50°C; Med), or irrigated-tip (35 W, 60 seconds, 45°C; Cool) ablation. Two transseptal punctures were performed and right and left superior PV electrical isolation was performed using the assigned ablation strategy. Animals survived for 30 days.Results: There was no difference in the number of lesions required to achieve PV isolation (Hi vs Med vs Cool; 43 vs 38 vs 44 lesions; P = NS). At sacrifice, Hi and Med lesions showed gross evidence of endocardial cratering and eschar formation. Corresponding histopathology showed transmural atrial necrosis with granulation tissue and fibrosis. Cool lesions demonstrated superficial endocardial white patches. The corresponding histopathology was subendocardial fibrosis with full and partial thickness necrosis of the atrial wall. One Hi animal had a large thrombus adherent to the left atrial wall above the left superior PV. PV stenosis was noted in one of three Hi and one of three Med, and none of three Cool. There were visible burns to the lung overlying the left atrial wall in one of three Hi, one of three Med, and none of three Cool. The esophagus demonstrated no evidence of serosal injury.Conclusions: The Hi and Med power 8-mm-tip ablation strategies for achieving PV isolation appear to result in excessive tissue destruction. Irrigated-tip lesions resulted in less endocardial eschar formation, PV stenosis, and damage to collateral structures.
BACKGROUND Identification of an epicardial origin for left ventricular tachycardia (LV-VT) based ... more BACKGROUND Identification of an epicardial origin for left ventricular tachycardia (LV-VT) based on electrocardiogram (ECG) criteria facilitates the approach to catheter ablation. Reported criteria, although helpful, may not apply uniformly to all LV regions.
The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The ... more The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The objective of this study was to establish normal values for the QT interval in newborns of different ethnic origin. Between 2005 and 2006, ECGs were obtained during the first 48 h of life from 1305 full-term newborns at the Hospital del Mar in Barcelona, Spain. The mean corrected QT interval (QTc) was 417.79 (28.47) ms. A QTc longer than 440 ms was observed in 240 newborns (18.33%). The frequency of a pathologic QTc in Spanish newborns was 17.9%, compared with 27.7% in those of Maghreb or Near Eastern origin (P=.016), and 28.2% in those of Indian or Pakistani origin (P=.033). The QTc may vary for genetic reasons. A routine neonatal ECG is advisable only in ethnic groups in which the QTc is lengthened, to help counter the greater risk of sudden death in these infants.
Aims The difference between the stimulus-atrial and ventriculo-atrial intervals (SA-VA) and betwe... more Aims The difference between the stimulus-atrial and ventriculo-atrial intervals (SA-VA) and between the post-pacing interval and the tachycardia cycle length (PPI-TCL) during entrainment from the right ventricular apex distinguishes atrioventricular node reentrant (AVNRT) from orthodromic atrioventricular reentrant tachycardia (AVRT). We hypothesized that these features still apply when entrainment is performed from the para-Hisian region. Methods and results Forty-seven supraventricular tachycardias (34 AVNRT/13 AVRT) were included. The SA-VA and PPI-TCL were obtained in all patients by using two right-sided diagnostic catheters. In 24 of them, these measurements were also performed upon His-bundle capture during entrainment. A paced QRS widening of 40 ms during entrainment, when compared with the tachycardia QRS width, identified absence of His-bundle capture, P , 0.001. A SA-VA .75 ms distinguished AVNRT from AVRT, P , 0.001 (sensitivity/specificity 97%/100%). A PPI-TCL .100 ms was diagnostic of AVNRT, P , 0.001 (sensitivity/specificity 97%/92%). Upon His-bundle capture, the SA-VA and PPI-TCL shortened in AVNRT (121 + 23 to 66 + 24 ms; 139 + 30 to 85 + 31 ms, respectively, P , 0.001) and no longer differentiated AVNRT from AVRT. Conclusion Para-Hisian entrainment without His-bundle capture distinguishes AVNRT from AVRT with the advantage of using only two diagnostic catheters.
To evaluate the long-term mortality rate and to determine independent mortality risk factors in p... more To evaluate the long-term mortality rate and to determine independent mortality risk factors in patients with bifascicular block (BFB). Patients with BFB are known to have a higher mortality risk than the general population, not only related to progression to atrio-ventricular block but also due to the presence of malignant ventricular arrhythmias. Previous observational and epidemiological studies including a high proportion of patients with structural heart disease have shown an important cardiac mortality rate and may not reflect the real outcome of patients with BFB. From March 1998 until December 2006, we prospectively studied 259 consecutive BFB patients, 213 (82%) of whom presenting with syncope/pre-syncope, undergoing electrophysiological study. After a median follow-up of 4.5 years (P25:2.16-P75:6.41), 53 patients (20.1%) died, 19 (7%) of whom due to cardiac aetiology. Independent total mortality predictors were age [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.01-1.09], NYHA class>or=II (HR 2.17, 95% CI 1.05-4.5), atrial fibrillation (HR 2.96, 95% CI 1.1-7.92), and renal dysfunction (HR 4.26, 95% CI 2.04-9.01). An NYHA class of >or=II (HR 5.45, 95% CI 2.01-14.82) and renal failure (HR 3.82, 95% CI 1.21-12.06) were independent predictors of cardiac mortality. No independent predictors of arrhythmic death were found. Total mortality, especially of cardiac cause, is lower than previously described in BFB patients. Advanced NYHA class and renal failure are predictors of cardiac mortality.
HDL-C. In subjects with metabolic syndrome (MetS), a high-risk population, while ADN was lower co... more HDL-C. In subjects with metabolic syndrome (MetS), a high-risk population, while ADN was lower compared with non-MetS, only A2 (moderate drinker) retained adequate ADN, and the linear increase of HDL-C was blunted in A3 (heavy drinker). Conclusion: These results suggest that U-shaped relationship between alcohol consumption and risk of cardiovascular events is explained in part by change of adiponectin level rather than HDL-C.
Incremental Pacing for the Diagnosis of Cavotricuspid Isthmus Block. Background: Complete conduct... more Incremental Pacing for the Diagnosis of Cavotricuspid Isthmus Block. Background: Complete conduction block of the cavotricuspid isthmus (CTI) reduces atrial flutter recurrences after ablation. Incremental rapid pacing may distinguish slow conduction from complete CTI conduction block.Methods and Results: Fifty-two patients (67 ± 9 years) undergoing 55 CTI ablation procedures were included. With ablation, double potentials (DPs) separated by an isoelectric line of ≥30 ms were obtained. Incremental atrial pacing (600–250 ms) was performed from coronary sinus (CS) and low lateral right atrium (LLRA). A <20 ms increase in the DPs distance during incremental pacing was indexed as complete CTI block. In 8 patients, an initial <20 ms DPs distance increase was noted; direct complete isthmus block was suggested and no additional ablation performed. In the remaining, the CTI line was remapped for conduction gaps and additional radiofrequency energy pulses applied. Complete block, as indexed by incremental pacing, occurred in 46 of 55 procedures, with one flutter recurrence (follow-up 8 ± 2 months): DPs interval variation of 116 ± 20 to 123 ± 20 ms (CS), P = 0.21; and 122 ± 25 to 135 ± 35 ms (LLRA), P = 0.17. The remaining 9 patients (persistent rate-dependent DPs increase) presented 3 flutter recurrences, P = 0.01: DP distance from 127 ± 15 to 161 ± 18 ms (CS), P < 0.001; and 114 ± 24 to 142 ± 10 ms (LLRA), P = 0.007.Conclusion: Incremental pacing distinguishes complete CTI block from persistent conduction. Such identification, accompanied by additional ablation to achieve block, should minimize flutter recurrences after ablative therapy. (J Cardiovasc Electrophysiol, Vol. 21, pp. 33–39, January 2010)
Recibido el 12 de febrero de 2009. Aceptado para su publicación el 19 de octubre de 2009. Introdu... more Recibido el 12 de febrero de 2009. Aceptado para su publicación el 19 de octubre de 2009. Introducción y objetivos. Los pacientes con bloqueo bifascicular (BBF) pueden evolucionar a bloqueo auriculoventricular (BAV) avanzado, especialmente en presencia de síncope o intervalo HV prolongado. Otras variables podrían ayudar a definir qué pacientes se beneficiarán de un marcapasos (MP) profiláctico.
Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmon... more Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmonary vein, pulmonary vein atrial tachycardia (PV-AT) can be difficult to recognize on an ECG. The aim of this study was to identify clinical and electrophysiologic characteristics specific to PV-AT, including sinus P-wave duration and notching.
Introduction and objectives. Patients with chronic bifascicular block (BFB) can progress to advan... more Introduction and objectives. Patients with chronic bifascicular block (BFB) can progress to advanced atrioventricular block (AVB), especially when syncope or a prolonged HV interval is present. It is possible that other variables could help identify patients who would benefit from prophylactic pacemaker implantation.
Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmon... more Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmonary vein, pulmonary vein atrial tachycardia (PV-AT) can be difficult to recognize on an ECG. The aim of this study was to identify clinical and electrophysiologic characteristics specific to PV-AT, including sinus P-wave duration and notching.
Circulation-arrhythmia and Electrophysiology, 2010
a, Pe Pe e e e e enn nn nn nn nnsy sy sy sy sy sy sylv lv lv lv lv lv van an an an an an ania ia ... more a, Pe Pe e e e e enn nn nn nn nnsy sy sy sy sy sy sylv lv lv lv lv lv van an an an an an ania ia i ia ia ia ia.1 Abstract Background: ECG criteria identifying epicardial (EPI) origin for ventricular tachycardia (VT) in non-ischemic cardiomyopathy (NICM) have not been determined. Endocardial (ENDO) and EPI basal left ventricle fibrosis characterizes the VT substrate. Methods and Results: We assessed the QRS from 102 basal-superior/lateral EPI and 67 comparable ENDO pacemaps (PM) in 14 patients with NICM. Pacemapping focused on low bipolar voltage areas. Published morphology: q wave in lead I (QWL1), no q waves in inferior leads and interval criteria: pseudo-delta wave (PdW) 34ms, intrinsicoid deflection time 85ms, shortest RS complex 121ms and maximum deflection index (MDI) 0.55 were assessed for ability to identify EPI origin. Sixteen EPI and 8 ENDO of the 34 mapped VTs (71%) in the study population and 14 EPI and 7 ENDO VTs from an 11 patient validation cohort were localized to basal-superior/lateral left ventricle and corroborated pacing data. A QWL1 was seen in EPI but not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 EPI VTs (sensitivity 88%) and was seen in 1/8 ENDO VT's (specificity 88%). None of the remaining criteria achieved similar sensitivity without specificity <50%. We identified 4 criteria (q waves in inferior leads, PdW 75 ms, MDI 0.59 and QWL1) having 95% specificity and 20% sensitivity in identifying EPI/ENDO origin for PMs. This four-step algorithm identified the origin in 109/115 PMs (95%), 21/24 VTs (88%) in study population and 19/21 VTs (90%) in validation cohort. Conclusion: Morphologic ECG features that describe the initial QRS vector can help identify basal-superior/lateral EPI VTs in NICM. or or or or or or or a a a a a a abi bi bi bi bi bi bili li li li li li lity ty ty ty ty ty ty t t t t t t to o o o o o o id id id id id id ide e e e e e e %) in n n n n n n t t t t t t the he he he he he he s s s s s s stu tu tu tu tu tu tudy dy dy dy dy dy dy p a c o not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 8 o it i hi d i il iti it ith t ifi it <5 and 7 ENDO VTs from an 11 patient validation cohort were loc or/lateral left ventricle and corroborated pacing data. A QWL1 not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 88%) and was seen in 1/8 ENDO VT's (specificity 88%). No it i hi d i il iti it ith t ifi it <5 by guest on October 3, 2016 http://circep.ahajournals.org/ Downloaded from Fourteen patients with NICM undergoing ENDO and EPI catheter mapping and ablation for drug refractory ventricular arrhythmias were included in the study.
The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitati... more The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitations. However, in the setting of nondocumented palpitations the value of the electrophysiologic study (EPS) needs additional investigation. We investigated the utility of the EPS in patients with nondocumented palpitations. A total of 172 patients with normal electrocardiographic findings and nondocumented palpitations underwent an EPS. The clinical and electrophysiologic characteristics were assessed. The symptoms were longlasting (>5 minutes) in 56%. Sudden onset was present in 99%, and termination was rapid in 65%. Neck palpitations were reported in 36%. The EPS findings were normal in 86 patients (50%); atrioventricular nodal reentrant tachycardia was induced in 43, orthodromic reentrant tachycardia in 9, and nonsustained atrial tachycardia/fibrillation (AT/AF) in 34. Long-lasting episodes, sudden termination, and neck palpitations predicted positive EPS findings and were associated with reentrant supraventricular tachycardia (p <0.001). The induction of AT/AF was associated with age >50 years and structural heart disease (p <0.001). After 53 ؎ 36 months of follow-up, 92% of patients with negative EPS findings were symptom free. Only 32% of patients with induced AT/AF remained free of symptoms (p <0.001). The recurrence of palpitations was more prevalent among patients with structural heart disease and aged >50 years (p <0.001). In conclusion, 50% of patients with nondocumented palpitations had positive EPS findings. A long duration, sudden termination, and neck palpitations, together with structural heart disease and age >50 years, predicted tachycardia inducibility and recurrence and could help in selecting patients suitable for EPS and ablation.
Background: Despite the improvement in detection and surgical therapy in the last years, the outc... more Background: Despite the improvement in detection and surgical therapy in the last years, the outcome of patients affected by colorectal carcinoma (CRC) remains limited by metastatic relapse. The aim of this study was to investigate the presence of free tumor DNA in the plasma of CRC patients in order to understand its possible prognostic role.
Background-Efficacy of endocardial ventricular tachycardia (VT) ablation in arrhythmogenic right ... more Background-Efficacy of endocardial ventricular tachycardia (VT) ablation in arrhythmogenic right ventricular cardiomyopathy/dysplasia may be limited by epicardial VT, right ventricular thickening, or both. We sought to characterize the endocardial versus epicardial substrate, measure right ventricular free wall thickness, and determine epicardial ablation efficacy in patients with right ventricular cardiomyopathy/dysplasia. Methods and Results-Thirteen consecutive patients (3 female; aged 43Ϯ15 years; range, 17 to 70 years) undergoing endocardial and epicardial sinus rhythm voltage mapping and epicardial VT ablation after failed endocardial VT ablation were included. In each patient, the low bipolar voltage area (Ͻ1.0 mV for epicardium and Ͻ1.5 mV for endocardium) was more extensive on the epicardium (95Ϯ47 versus 38Ϯ32 cm 2 ; PϽ0.001) and was uniformly marked by multicomponent and late electrograms. The basal right ventricular thickness assessed by electroanatomic map was Ͼ10 mm in 6 of 13 patients compared with 5 to 10 mm in 4 reference patients without structural disease. Twenty-seven VTs were targeted on the epicardium with the use of activation, entrainment, or pace mapping with focal/linear ablation and targeting of late potentials. Epicardial VTs were targeted opposite normal endocardium in 10 patients (77%) and/or opposite ineffective endocardial ablation sites in 11 patients (85%). During 18Ϯ13 months, 10 of the 13 patients (77%) had no VT, with 2 patients having only a single VT at 2 and 38 months, respectively.
Usefulness of 12-lead ECG for predicting an epicardial origin for ventricular tachycardia (VT) ar... more Usefulness of 12-lead ECG for predicting an epicardial origin for ventricular tachycardia (VT) arising from the right ventricle (RV) has not been assessed. An epicardial approach is sometimes warranted to eliminate RV VT. The purpose of this study was investigate the hypothesis that specific ECG features identify an epicardial origin for RV VT. To mimic an endocardial or epicardial origin, we paced representative sites in 13 patients undergoing RV endocardial/epicardial mapping (134/180 pace map sites). QRS duration from epicardial vs endocardial sites was not different (183 +/- 27 ms vs 185 +/- 28 ms, P = .3). Reported cut-off values for identifying epicardial left ventricular origin, pseudo-delta wave (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =34 ms), intrinsicoid deflection time (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =85 ms), and RS complex (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =121 ms) did not apply to the RV. A Q wave in lead II, III, or aVF was more likely noted from inferior epicardial vs endocardial sites (53/73 vs 16/43, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01). A Q wave in lead I was more frequently present from epicardial vs endocardial anterior RV sites (30/82 vs 5/52, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). QS in lead V(2) was noted from anatomically matched epicardial anterior RV sites (22/33 vs 13/33, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.05). In the RV outflow tract, no ECG feature distinguishing epicardial/endocardial origin reached statistical significance. A Q wave or QS in leads that best reflect local activation suggest an epicardial origin for RV depolarization and may help in identifying a probable epicardial site of origin for RV VT. QRS duration and reported criteria for epicardial origin of VT in the left ventricle do not identify a probable epicardial origin in the RV.
Background: We sought to compare the efficacy and collateral damage during pulmonary vein (PV) is... more Background: We sought to compare the efficacy and collateral damage during pulmonary vein (PV) isolation in a canine model using three different ablation strategies.Methods: Normal dogs (three each) were randomized to high power (70 W, 20 seconds, 60°C, Hi), medium power (50 W, 60 seconds, 50°C; Med), or irrigated-tip (35 W, 60 seconds, 45°C; Cool) ablation. Two transseptal punctures were performed and right and left superior PV electrical isolation was performed using the assigned ablation strategy. Animals survived for 30 days.Results: There was no difference in the number of lesions required to achieve PV isolation (Hi vs Med vs Cool; 43 vs 38 vs 44 lesions; P = NS). At sacrifice, Hi and Med lesions showed gross evidence of endocardial cratering and eschar formation. Corresponding histopathology showed transmural atrial necrosis with granulation tissue and fibrosis. Cool lesions demonstrated superficial endocardial white patches. The corresponding histopathology was subendocardial fibrosis with full and partial thickness necrosis of the atrial wall. One Hi animal had a large thrombus adherent to the left atrial wall above the left superior PV. PV stenosis was noted in one of three Hi and one of three Med, and none of three Cool. There were visible burns to the lung overlying the left atrial wall in one of three Hi, one of three Med, and none of three Cool. The esophagus demonstrated no evidence of serosal injury.Conclusions: The Hi and Med power 8-mm-tip ablation strategies for achieving PV isolation appear to result in excessive tissue destruction. Irrigated-tip lesions resulted in less endocardial eschar formation, PV stenosis, and damage to collateral structures.
BACKGROUND Identification of an epicardial origin for left ventricular tachycardia (LV-VT) based ... more BACKGROUND Identification of an epicardial origin for left ventricular tachycardia (LV-VT) based on electrocardiogram (ECG) criteria facilitates the approach to catheter ablation. Reported criteria, although helpful, may not apply uniformly to all LV regions.
The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The ... more The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The objective of this study was to establish normal values for the QT interval in newborns of different ethnic origin. Between 2005 and 2006, ECGs were obtained during the first 48 h of life from 1305 full-term newborns at the Hospital del Mar in Barcelona, Spain. The mean corrected QT interval (QTc) was 417.79 (28.47) ms. A QTc longer than 440 ms was observed in 240 newborns (18.33%). The frequency of a pathologic QTc in Spanish newborns was 17.9%, compared with 27.7% in those of Maghreb or Near Eastern origin (P=.016), and 28.2% in those of Indian or Pakistani origin (P=.033). The QTc may vary for genetic reasons. A routine neonatal ECG is advisable only in ethnic groups in which the QTc is lengthened, to help counter the greater risk of sudden death in these infants.
Aims The difference between the stimulus-atrial and ventriculo-atrial intervals (SA-VA) and betwe... more Aims The difference between the stimulus-atrial and ventriculo-atrial intervals (SA-VA) and between the post-pacing interval and the tachycardia cycle length (PPI-TCL) during entrainment from the right ventricular apex distinguishes atrioventricular node reentrant (AVNRT) from orthodromic atrioventricular reentrant tachycardia (AVRT). We hypothesized that these features still apply when entrainment is performed from the para-Hisian region. Methods and results Forty-seven supraventricular tachycardias (34 AVNRT/13 AVRT) were included. The SA-VA and PPI-TCL were obtained in all patients by using two right-sided diagnostic catheters. In 24 of them, these measurements were also performed upon His-bundle capture during entrainment. A paced QRS widening of 40 ms during entrainment, when compared with the tachycardia QRS width, identified absence of His-bundle capture, P , 0.001. A SA-VA .75 ms distinguished AVNRT from AVRT, P , 0.001 (sensitivity/specificity 97%/100%). A PPI-TCL .100 ms was diagnostic of AVNRT, P , 0.001 (sensitivity/specificity 97%/92%). Upon His-bundle capture, the SA-VA and PPI-TCL shortened in AVNRT (121 + 23 to 66 + 24 ms; 139 + 30 to 85 + 31 ms, respectively, P , 0.001) and no longer differentiated AVNRT from AVRT. Conclusion Para-Hisian entrainment without His-bundle capture distinguishes AVNRT from AVRT with the advantage of using only two diagnostic catheters.
To evaluate the long-term mortality rate and to determine independent mortality risk factors in p... more To evaluate the long-term mortality rate and to determine independent mortality risk factors in patients with bifascicular block (BFB). Patients with BFB are known to have a higher mortality risk than the general population, not only related to progression to atrio-ventricular block but also due to the presence of malignant ventricular arrhythmias. Previous observational and epidemiological studies including a high proportion of patients with structural heart disease have shown an important cardiac mortality rate and may not reflect the real outcome of patients with BFB. From March 1998 until December 2006, we prospectively studied 259 consecutive BFB patients, 213 (82%) of whom presenting with syncope/pre-syncope, undergoing electrophysiological study. After a median follow-up of 4.5 years (P25:2.16-P75:6.41), 53 patients (20.1%) died, 19 (7%) of whom due to cardiac aetiology. Independent total mortality predictors were age [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.01-1.09], NYHA class&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=II (HR 2.17, 95% CI 1.05-4.5), atrial fibrillation (HR 2.96, 95% CI 1.1-7.92), and renal dysfunction (HR 4.26, 95% CI 2.04-9.01). An NYHA class of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=II (HR 5.45, 95% CI 2.01-14.82) and renal failure (HR 3.82, 95% CI 1.21-12.06) were independent predictors of cardiac mortality. No independent predictors of arrhythmic death were found. Total mortality, especially of cardiac cause, is lower than previously described in BFB patients. Advanced NYHA class and renal failure are predictors of cardiac mortality.
HDL-C. In subjects with metabolic syndrome (MetS), a high-risk population, while ADN was lower co... more HDL-C. In subjects with metabolic syndrome (MetS), a high-risk population, while ADN was lower compared with non-MetS, only A2 (moderate drinker) retained adequate ADN, and the linear increase of HDL-C was blunted in A3 (heavy drinker). Conclusion: These results suggest that U-shaped relationship between alcohol consumption and risk of cardiovascular events is explained in part by change of adiponectin level rather than HDL-C.
Incremental Pacing for the Diagnosis of Cavotricuspid Isthmus Block. Background: Complete conduct... more Incremental Pacing for the Diagnosis of Cavotricuspid Isthmus Block. Background: Complete conduction block of the cavotricuspid isthmus (CTI) reduces atrial flutter recurrences after ablation. Incremental rapid pacing may distinguish slow conduction from complete CTI conduction block.Methods and Results: Fifty-two patients (67 ± 9 years) undergoing 55 CTI ablation procedures were included. With ablation, double potentials (DPs) separated by an isoelectric line of ≥30 ms were obtained. Incremental atrial pacing (600–250 ms) was performed from coronary sinus (CS) and low lateral right atrium (LLRA). A <20 ms increase in the DPs distance during incremental pacing was indexed as complete CTI block. In 8 patients, an initial <20 ms DPs distance increase was noted; direct complete isthmus block was suggested and no additional ablation performed. In the remaining, the CTI line was remapped for conduction gaps and additional radiofrequency energy pulses applied. Complete block, as indexed by incremental pacing, occurred in 46 of 55 procedures, with one flutter recurrence (follow-up 8 ± 2 months): DPs interval variation of 116 ± 20 to 123 ± 20 ms (CS), P = 0.21; and 122 ± 25 to 135 ± 35 ms (LLRA), P = 0.17. The remaining 9 patients (persistent rate-dependent DPs increase) presented 3 flutter recurrences, P = 0.01: DP distance from 127 ± 15 to 161 ± 18 ms (CS), P < 0.001; and 114 ± 24 to 142 ± 10 ms (LLRA), P = 0.007.Conclusion: Incremental pacing distinguishes complete CTI block from persistent conduction. Such identification, accompanied by additional ablation to achieve block, should minimize flutter recurrences after ablative therapy. (J Cardiovasc Electrophysiol, Vol. 21, pp. 33–39, January 2010)
Recibido el 12 de febrero de 2009. Aceptado para su publicación el 19 de octubre de 2009. Introdu... more Recibido el 12 de febrero de 2009. Aceptado para su publicación el 19 de octubre de 2009. Introducción y objetivos. Los pacientes con bloqueo bifascicular (BBF) pueden evolucionar a bloqueo auriculoventricular (BAV) avanzado, especialmente en presencia de síncope o intervalo HV prolongado. Otras variables podrían ayudar a definir qué pacientes se beneficiarán de un marcapasos (MP) profiláctico.
Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmon... more Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmonary vein, pulmonary vein atrial tachycardia (PV-AT) can be difficult to recognize on an ECG. The aim of this study was to identify clinical and electrophysiologic characteristics specific to PV-AT, including sinus P-wave duration and notching.
Introduction and objectives. Patients with chronic bifascicular block (BFB) can progress to advan... more Introduction and objectives. Patients with chronic bifascicular block (BFB) can progress to advanced atrioventricular block (AVB), especially when syncope or a prolonged HV interval is present. It is possible that other variables could help identify patients who would benefit from prophylactic pacemaker implantation.
Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmon... more Introduction and objectives. Although atrial tachycardia (AT) frequently originates in the pulmonary vein, pulmonary vein atrial tachycardia (PV-AT) can be difficult to recognize on an ECG. The aim of this study was to identify clinical and electrophysiologic characteristics specific to PV-AT, including sinus P-wave duration and notching.
Circulation-arrhythmia and Electrophysiology, 2010
a, Pe Pe e e e e enn nn nn nn nnsy sy sy sy sy sy sylv lv lv lv lv lv van an an an an an ania ia ... more a, Pe Pe e e e e enn nn nn nn nnsy sy sy sy sy sy sylv lv lv lv lv lv van an an an an an ania ia i ia ia ia ia.1 Abstract Background: ECG criteria identifying epicardial (EPI) origin for ventricular tachycardia (VT) in non-ischemic cardiomyopathy (NICM) have not been determined. Endocardial (ENDO) and EPI basal left ventricle fibrosis characterizes the VT substrate. Methods and Results: We assessed the QRS from 102 basal-superior/lateral EPI and 67 comparable ENDO pacemaps (PM) in 14 patients with NICM. Pacemapping focused on low bipolar voltage areas. Published morphology: q wave in lead I (QWL1), no q waves in inferior leads and interval criteria: pseudo-delta wave (PdW) 34ms, intrinsicoid deflection time 85ms, shortest RS complex 121ms and maximum deflection index (MDI) 0.55 were assessed for ability to identify EPI origin. Sixteen EPI and 8 ENDO of the 34 mapped VTs (71%) in the study population and 14 EPI and 7 ENDO VTs from an 11 patient validation cohort were localized to basal-superior/lateral left ventricle and corroborated pacing data. A QWL1 was seen in EPI but not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 EPI VTs (sensitivity 88%) and was seen in 1/8 ENDO VT's (specificity 88%). None of the remaining criteria achieved similar sensitivity without specificity <50%. We identified 4 criteria (q waves in inferior leads, PdW 75 ms, MDI 0.59 and QWL1) having 95% specificity and 20% sensitivity in identifying EPI/ENDO origin for PMs. This four-step algorithm identified the origin in 109/115 PMs (95%), 21/24 VTs (88%) in study population and 19/21 VTs (90%) in validation cohort. Conclusion: Morphologic ECG features that describe the initial QRS vector can help identify basal-superior/lateral EPI VTs in NICM. or or or or or or or a a a a a a abi bi bi bi bi bi bili li li li li li lity ty ty ty ty ty ty t t t t t t to o o o o o o id id id id id id ide e e e e e e %) in n n n n n n t t t t t t the he he he he he he s s s s s s stu tu tu tu tu tu tudy dy dy dy dy dy dy p a c o not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 8 o it i hi d i il iti it ith t ifi it <5 and 7 ENDO VTs from an 11 patient validation cohort were loc or/lateral left ventricle and corroborated pacing data. A QWL1 not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 88%) and was seen in 1/8 ENDO VT's (specificity 88%). No it i hi d i il iti it ith t ifi it <5 by guest on October 3, 2016 http://circep.ahajournals.org/ Downloaded from Fourteen patients with NICM undergoing ENDO and EPI catheter mapping and ablation for drug refractory ventricular arrhythmias were included in the study.
The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitati... more The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitations. However, in the setting of nondocumented palpitations the value of the electrophysiologic study (EPS) needs additional investigation. We investigated the utility of the EPS in patients with nondocumented palpitations. A total of 172 patients with normal electrocardiographic findings and nondocumented palpitations underwent an EPS. The clinical and electrophysiologic characteristics were assessed. The symptoms were longlasting (>5 minutes) in 56%. Sudden onset was present in 99%, and termination was rapid in 65%. Neck palpitations were reported in 36%. The EPS findings were normal in 86 patients (50%); atrioventricular nodal reentrant tachycardia was induced in 43, orthodromic reentrant tachycardia in 9, and nonsustained atrial tachycardia/fibrillation (AT/AF) in 34. Long-lasting episodes, sudden termination, and neck palpitations predicted positive EPS findings and were associated with reentrant supraventricular tachycardia (p <0.001). The induction of AT/AF was associated with age >50 years and structural heart disease (p <0.001). After 53 ؎ 36 months of follow-up, 92% of patients with negative EPS findings were symptom free. Only 32% of patients with induced AT/AF remained free of symptoms (p <0.001). The recurrence of palpitations was more prevalent among patients with structural heart disease and aged >50 years (p <0.001). In conclusion, 50% of patients with nondocumented palpitations had positive EPS findings. A long duration, sudden termination, and neck palpitations, together with structural heart disease and age >50 years, predicted tachycardia inducibility and recurrence and could help in selecting patients suitable for EPS and ablation.
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Papers by Victor Bazan