Revista Portuguesa de Cardiologia (English Edition)最新文献

Introduction

Recurrent ventricular tachycardia (VT) episodes have a negative impact on the clinical outcome of implantable cardioverter-defibrillator (ICD) patients. Modification of the arrhythmogenic substrate has been used as a promising approach for treating recurrent VTs. However, there are limited data on long-term follow-up.

Aim

To analyze long-term results of VT substrate-based ablation using high-density mapping in patients with severe left ventricular (LV) dysfunction and recurrent appropriate ICD therapy.

Methods

We analyzed 20 patients (15 men, 55% with non-ischemic cardiomyopathy, age 58±15 years, LV ejection fraction 32±5%) and repeated appropriate shocks or arrhythmic storm (>2 shocks/24 h) despite antiarrhythmic drug therapy and optimal heart failure medication. All patients underwent ventricular programmed stimulation (600 ms/S3) to document VT. A sinus rhythm (SR) voltage map was created with a three-dimensional electroanatomic mapping system (CARTO, Biosense Webster, CA) using a PentaRay® high-density mapping catheter (Biosense Webster, CA) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0.5 mV – dense scar; 0.5-1.5 mV – border zone; ≥1.5 mV – healthy tissue) and to provide high-resolution electrophysiological mapping. Substrate modification included elimination of local abnormal ventricular activities (LAVAs) during SR (fractionated, split, low-amplitude/long-lasting, late potentials, pre-systolic), and linear ablation to obtain scar homogenization and dechanneling. Pace-mapping techniques were used when capture was possible. The LV approach was retrograde in nine cases, transseptal in five and epi-endocardial in four. In two patients ablation was performed inside the right ventricle.

Results

LAVAs and scar areas were modified in all patients. Mean procedure duration was 149 min (105-220 min), with radiofrequency ranging from 18 to 70 min (mean 33 min) and mean fluoroscopy time of 15 min. Non-inducibility was achieved in 75% of cases (in four patients with hemodynamic deterioration and an LV assist device, VT inducibility was not performed). There were two cases of pericardial tamponade, drained successfully. During a follow-up of 50±24 months, 65% had no VT recurrences. Among the seven patients with recurrences, three underwent redo ablation and four, with fewer VT episodes, received appropriate ICD therapy. There were five hospital readmissions due to heart failure decompensation, one patient died in the first week after unsuccessful ablation of a VT storm and three died (stroke and pneumonia) >1 year after ablation.

Conclusion

Catheter ablation based on substrate modification is feasible and safe in patients with frequent VTs and severe LV dysfunction. This approach may be of clinical relevance, with potential long-term benefits in reducing VT burden.

Hypertrophic cardiomyopathy is one of the main causes of sudden cardiac death in young athletes. Differentiating between this pathological condition and ‘athlete's heart’ can be quite challenging, warranting a thorough clinical and imaging assessment. Clinicians often rely on detraining-induced attenuation of electrocardiographic and echocardiographic findings as a means of distinguishing between pathological and physiological cardiac remodeling. This report describes detraining-related regression of left ventricular hypertrophy in a young soccer player with a diagnosis of hypertrophic cardiomyopathy. It challenges the dogma that regression of electrocardiographic abnormalities and left ventricular hypertrophy is exclusive to physiological remodeling and questions the impact of exercise training in the phenotypic expression and progression of hypertrophic cardiomyopathy.

Introduction and Objectives

Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame.

Methods

We retrospectively determined the per-procedure prevalence of physiological assessment in 40 821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed.

Results

Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages <40, 40-55 and >55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology.

Conclusions

Our study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes.

Introduction

Type 1 diabetes (T1D) is a chronic disease with peak incidence in adolescence; it has a major impact on morbidity and mortality, especially cardiovascular. Diabetic cardiomyopathy is characterized by structural and functional lesions in the absence of other diseases and is involved in the progression to heart failure. Echocardiography has led to the identification of early cardiac lesions, despite controversial results in the literature in patients with T1D.

Objective

The objective of this study is to assess cardiac changes in individuals with TD1 compared to the control group using conventional two-dimensional Doppler and advanced speckle tracking echocardiography.

Methods

This is a case-control study with 40 asymptomatic, normotensive T1D patients aged 20 to 50 years and 40 healthy subjects. Two-dimensional echocardiography was performed to measure myocardial thickness and cardiac chambers. Tissue Doppler echocardiography was used for diastolic analysis and speckle tracking echocardiography to quantify ventricular systolic function.

Results

The mean age was 33 years in both groups, with an average T1D duration of 18 years; 20% of patients with T1D had diabetic retinopathy; 12.5% kidney injury; and 10% peripheral neuropathy. There were differences in the left ventricular diastolic function parameters (lateral E’, middle E’ and S/D ratio) and right ventricle (tricuspid E and tricuspid E’/A’ ratio). The mean value of the global longitudinal strain was -21.7% (+- 2.3) in the T1D group and -21.0% (+-2.0) in the control group (p=0.21).

Conclusion

Echocardiography revealed a reduction in indices of diastolic function in T1D compared to the control group, which may be the initial cardiac lesion in diabetes.

Introduction

Balloon pulmonary angioplasty (BPA) is an alternative therapy in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or residual/recurrent pulmonary hypertension (PH) after surgery. The aim of this study was to assess the short-term efficacy and safety of a BPA program.

Methods

This prospective single-center study included all BPA sessions performed in CTEPH patients between 2017 and 2019. Clinical assessment including WHO functional class, plasma biomarkers, 6-min walk test (6MWT) and right heart catheterization was performed at baseline and six months after the last BPA session.

Results

A total of 57 BPA sessions were performed in 11 CTEPH patients (64% with inoperable disease, 82% under pulmonar vasodilator therapy). Nine patients completed both the BPA program and a minimum six-month follow-up period. There were significant improvements in WHO functional class (p=0.004) and 6MWT (mean increase of 42 m; p=0.050) and a trend for significant hemodynamic improvement: 25% decrease in mean pulmonary artery pressure (mPAP) (p=0.082) and 42% decrease in pulmonary vascular resistance (PVR) (p=0.056). In the group of patients with severely impaired hemodynamics (three patients with mPAP >40 mmHg), the reduction was significant: 51% in mPAP (p=0.013) and 67% in PVR (p=0.050). Prostacyclin analogs and long-term oxygen therapy were withdrawn in all patients. Minor complications were recorded in 25% of patients. There were no major complications or deaths.

Conclusions

A BPA strategy on top of pulmonary vasodilator therapy further improves symptoms, exercise capacity and hemodynamics with an acceptable risk-benefit ratio in patients with inoperable CTEPH or residual/recurrent PH after surgery.