Pub Date : 2019-10-01DOI: 10.1161/CIRCEP.119.007864
M. Middeldorp, D. Lau, P. Sanders
Cardiovascular risk factors have been recognized to contribute to abnormal atrial remodeling leading to increased incident atrial fibrillation (AF) as well as AF progression and poorer outcomes with rhythm control strategies.1 There has been an increasing focus on obesity as a modifiable risk factor contributing to the AF substrate because of its rising prevalence.2 In an individual with metabolic syndrome, a stepwise increase in the AF risk has been described with increasing number of risk components including impaired fasting glucose, elevated blood pressure, increased waist circumference, and dyslipidemia.3 Fortunately, the abnormal AF substrate has been shown to be partially reversible when the underlying risk factors are aggressively targeted.4–8 The risk factor management clinic targeted weight-loss of at least 10% with dietary control, frequent moderate-intensity exercise up to 250 min/wk, blood pressure <130/80 mm Hg, glycaemic control with HbA1c ≤6.5%, active screening for obstructive sleep apnea with continuous positive airway pressure therapy to achieve apnea-hypopnea index <5/h, complete smoking cessation, alcohol consumption to <30 g/wk and lipid management.9 These strategies have resulted in reducing AF burden and symptoms, improving catheter ablation outcomes, and reversal of AF accompanied by beneficial reverse cardiac remodeling.4–8 Notably, the subjects included in these studies have mean body mass index (BMI) in the range of 30 to 34 kg/m2. Data remain lacking in those who are morbidly obese (BMI ≥40 kg/m2) and with regards to alternate weightloss strategy. A single-center observational study in obese individuals with a BMI of 38±4 kg/m2 and long-standing persistent AF failed to observe improvement in AF symptoms or burden despite significant weight-loss and raised the possibility of a point of no return in terms of the impact of weight-loss.10 It is in this context that the series of articles presented by Donnellan et al11,12 on the role of bariatric surgery (BS) on the outcomes of AF ablation in morbidly obese individuals further advances our knowledge on the importance of risk factor management in the spectrum of obese individuals undergoing ablation. In their first report, they present data on 239 patients who were morbidly obese and underwent AF ablation (defined as BMI ≥40 or ≥35 kg/m2 with obesity-related complications).11 Of these 51 had undergone BS before ablation. At a mean follow-up of 36 months after ablation, 20% who had undergone BS compared to 61% without BS had recurrent arrhythmia (P<0.0001).11 These results are further expanded using the same cohort in a study published in the Journal.12 In this article, the authors compared in a 2:1 manner the 51 morbidly obese patients who underwent BS with ageand gender-matched 102 nonobese and 102 morbidly obese patients without prior BS who underwent catheter ablation around the same time period. The BMI between the 3 groups was significantly different: 25.6±3 kg/m2 in t
{"title":"Is Bypassing Traditional Weight-Loss the Answer for Atrial Fibrillation?","authors":"M. Middeldorp, D. Lau, P. Sanders","doi":"10.1161/CIRCEP.119.007864","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007864","url":null,"abstract":"Cardiovascular risk factors have been recognized to contribute to abnormal atrial remodeling leading to increased incident atrial fibrillation (AF) as well as AF progression and poorer outcomes with rhythm control strategies.1 There has been an increasing focus on obesity as a modifiable risk factor contributing to the AF substrate because of its rising prevalence.2 In an individual with metabolic syndrome, a stepwise increase in the AF risk has been described with increasing number of risk components including impaired fasting glucose, elevated blood pressure, increased waist circumference, and dyslipidemia.3 Fortunately, the abnormal AF substrate has been shown to be partially reversible when the underlying risk factors are aggressively targeted.4–8 The risk factor management clinic targeted weight-loss of at least 10% with dietary control, frequent moderate-intensity exercise up to 250 min/wk, blood pressure <130/80 mm Hg, glycaemic control with HbA1c ≤6.5%, active screening for obstructive sleep apnea with continuous positive airway pressure therapy to achieve apnea-hypopnea index <5/h, complete smoking cessation, alcohol consumption to <30 g/wk and lipid management.9 These strategies have resulted in reducing AF burden and symptoms, improving catheter ablation outcomes, and reversal of AF accompanied by beneficial reverse cardiac remodeling.4–8 Notably, the subjects included in these studies have mean body mass index (BMI) in the range of 30 to 34 kg/m2. Data remain lacking in those who are morbidly obese (BMI ≥40 kg/m2) and with regards to alternate weightloss strategy. A single-center observational study in obese individuals with a BMI of 38±4 kg/m2 and long-standing persistent AF failed to observe improvement in AF symptoms or burden despite significant weight-loss and raised the possibility of a point of no return in terms of the impact of weight-loss.10 It is in this context that the series of articles presented by Donnellan et al11,12 on the role of bariatric surgery (BS) on the outcomes of AF ablation in morbidly obese individuals further advances our knowledge on the importance of risk factor management in the spectrum of obese individuals undergoing ablation. In their first report, they present data on 239 patients who were morbidly obese and underwent AF ablation (defined as BMI ≥40 or ≥35 kg/m2 with obesity-related complications).11 Of these 51 had undergone BS before ablation. At a mean follow-up of 36 months after ablation, 20% who had undergone BS compared to 61% without BS had recurrent arrhythmia (P<0.0001).11 These results are further expanded using the same cohort in a study published in the Journal.12 In this article, the authors compared in a 2:1 manner the 51 morbidly obese patients who underwent BS with ageand gender-matched 102 nonobese and 102 morbidly obese patients without prior BS who underwent catheter ablation around the same time period. The BMI between the 3 groups was significantly different: 25.6±3 kg/m2 in t","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74430465","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1161/CIRCEP.119.007517
S. Virk, Saurabh Kumar
October 2019 1 Catheter ablation of atrial fibrillation (AF) is a technically challenging procedure with suboptimal long-term success rates, non-negligible risk of major complications, and significant radiation exposure. In recent years, remote magnetic navigation (RMN) systems have emerged that offer increased precision and greater stability of catheter-tissue contact. Despite considerable enthusiasm surrounding the potential benefits of RMN systems, a rigorous analysis of their impact on the clinical outcomes and procedural efficiency of AF ablation is lacking. We thus conducted a meta-analysis to assess the relative safety and efficacy of RMN versus manual catheter navigation (MCN) for AF ablation. We searched Medline, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) databases for controlled studies comparing outcomes of AF ablation performed with RMN versus MCN. The primary efficacy end point was freedom from AF at ≥1-year follow-up. The primary safety end point was major periprocedural complications. Secondary end points included fluoroscopy and procedure durations. Meta-analyses were performed using random-effects models. Fifteen observational studies met criteria for inclusion, involving a total of 3246 patients (RMN=1475; MCN=1771; Table).1–15 Compared with MCN, RMN was associated with reduced major periprocedural complications (relative risk, 0.51; 95% CI, 0.29–0.91; I2=0%; P=0.02). In the 12 studies with ≥1-year median followup, late recurrence of AF was not significantly reduced (relative risk, 0.97; 95% CI, 0.89–1.05; I2=0%; P=0.43). Fluoroscopy times were significantly shorter with RMN (mean difference, 13.3 minutes; 95% CI, 6.9–19.7; I2=99%; P<0.001) but total procedure (mean difference, 51.3 minutes; 95% CI, 32.0–70.6; I2=94%; P<0.001) and radiofrequency ablation (mean difference, 15.7 minutes; 95% CI, 8.2–23.2; I2=94%; P<0.001) durations were significantly longer. In our meta-analysis, RMN was associated with almost 50% lower risk of major procedural complications compared with MCN. The enhanced safety of RMN may be because of lower contact force exerted by magnetic-tipped catheters and their increased flexibility. Although prior studies have largely failed to demonstrate a significant risk reduction, they were likely underpowered because of their small sample sizes and low event rates.1,3,5,9,12,13 Of note, the population in this metaanalysis represents a relatively low-risk AF cohort with preserved left ventricular function in the majority of patients and few comorbidities. Further studies are thus required to assess whether the safety benefits of RMN translate to higher-risk AF ablation cohorts. Long-term freedom from AF following catheter ablation is dependent on the formation of durable transmural lesions that maintain bidirectional conduction block between ablated sites and surrounding cardiac tissue. Stability of cathetertissue contact is a key determinant of lesion size and transmurality. It has thus be
{"title":"Remote Magnetic Versus Manual Catheter Navigation for Atrial Fibrillation Ablation: A Meta-Analysis.","authors":"S. Virk, Saurabh Kumar","doi":"10.1161/CIRCEP.119.007517","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007517","url":null,"abstract":"October 2019 1 Catheter ablation of atrial fibrillation (AF) is a technically challenging procedure with suboptimal long-term success rates, non-negligible risk of major complications, and significant radiation exposure. In recent years, remote magnetic navigation (RMN) systems have emerged that offer increased precision and greater stability of catheter-tissue contact. Despite considerable enthusiasm surrounding the potential benefits of RMN systems, a rigorous analysis of their impact on the clinical outcomes and procedural efficiency of AF ablation is lacking. We thus conducted a meta-analysis to assess the relative safety and efficacy of RMN versus manual catheter navigation (MCN) for AF ablation. We searched Medline, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) databases for controlled studies comparing outcomes of AF ablation performed with RMN versus MCN. The primary efficacy end point was freedom from AF at ≥1-year follow-up. The primary safety end point was major periprocedural complications. Secondary end points included fluoroscopy and procedure durations. Meta-analyses were performed using random-effects models. Fifteen observational studies met criteria for inclusion, involving a total of 3246 patients (RMN=1475; MCN=1771; Table).1–15 Compared with MCN, RMN was associated with reduced major periprocedural complications (relative risk, 0.51; 95% CI, 0.29–0.91; I2=0%; P=0.02). In the 12 studies with ≥1-year median followup, late recurrence of AF was not significantly reduced (relative risk, 0.97; 95% CI, 0.89–1.05; I2=0%; P=0.43). Fluoroscopy times were significantly shorter with RMN (mean difference, 13.3 minutes; 95% CI, 6.9–19.7; I2=99%; P<0.001) but total procedure (mean difference, 51.3 minutes; 95% CI, 32.0–70.6; I2=94%; P<0.001) and radiofrequency ablation (mean difference, 15.7 minutes; 95% CI, 8.2–23.2; I2=94%; P<0.001) durations were significantly longer. In our meta-analysis, RMN was associated with almost 50% lower risk of major procedural complications compared with MCN. The enhanced safety of RMN may be because of lower contact force exerted by magnetic-tipped catheters and their increased flexibility. Although prior studies have largely failed to demonstrate a significant risk reduction, they were likely underpowered because of their small sample sizes and low event rates.1,3,5,9,12,13 Of note, the population in this metaanalysis represents a relatively low-risk AF cohort with preserved left ventricular function in the majority of patients and few comorbidities. Further studies are thus required to assess whether the safety benefits of RMN translate to higher-risk AF ablation cohorts. Long-term freedom from AF following catheter ablation is dependent on the formation of durable transmural lesions that maintain bidirectional conduction block between ablated sites and surrounding cardiac tissue. Stability of cathetertissue contact is a key determinant of lesion size and transmurality. It has thus be","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75296224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-30DOI: 10.1161/CIRCEP.119.007644
J. Jež, G. Caluori, T. Jadczyk, F. Lehár, M. Pešl, Tomas Kulik, S. Belaskova, Václav Kubeš, Z. Stárek
October 2019 1 Ventricular arrhythmias are one of the most life-threatening conditions. Radiofrequency ablation (RFA) is one of the most important treatment options for ventricular tachycardia. The therapy is constantly advancing with modern technology implementation.1 RFA invasive treatment is commonly performed via catheter with the support of 3-dimensional electroanatomic mapping systems,2 with either manual navigation (MAN) or robotic remote magnetic-navigated (RMN) catheters3 (Figure [A]). A comparative and contact force-stratified biophysical evidence of the RMN ablation features is still missing and might impair further spreading of the technique and its benefits. The data that support the findings of this study are available from the corresponding author upon reasonable request. The protocol used in this study was approved by the Ethical Commission of Veterinary and Pharmaceutical University in Brno. The study was performed on ten 6-month-old female large white swine (weight 50–60 kg). The animals were prepared and monitored as previously reported.4 The animals were divided into 5 groups of 2 pigs, according to target force (MAN-5G, -10G, -15G, and -20G to compare with RMN). Carto 3 (Biosense Webster Inc) was used to support navigation and ablation. Each animal underwent 8 endocardial RFA applications in selected areas of the left ventricle (Figure [B]) Orientation of the catheter tip to the wall of the heart was as perpendicular as possible. The same generator settings were used in all study groups (40 W with limited power if the temperature exceeded 50°C, maximum duration of 60 seconds, irrigation rate of 20 mL/min). Whole hearts were fixed in 10% PFA and scanned in transversal view by 9.4T MRI (Soucek et al, under review). Selected lesions were then cut on the transversal plane and prepared for histopathologic examination via hematoxylin/ eosin staining. If not otherwise stated, continuous data are presented as raw means±SDs. For groups comparisons, the significance levels were calculated using the F test with Kenward-Roger adjustment. An ablation composite index (ACI) was implemented in this study, to integrate all the procedural parameters and findings, defined as Equation 1:
{"title":"Remotely Navigated Ablations in Ventricle Myocardium Result in Acute Lesion Size Comparable to Force-Sensing Manual Navigation.","authors":"J. Jež, G. Caluori, T. Jadczyk, F. Lehár, M. Pešl, Tomas Kulik, S. Belaskova, Václav Kubeš, Z. Stárek","doi":"10.1161/CIRCEP.119.007644","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007644","url":null,"abstract":"October 2019 1 Ventricular arrhythmias are one of the most life-threatening conditions. Radiofrequency ablation (RFA) is one of the most important treatment options for ventricular tachycardia. The therapy is constantly advancing with modern technology implementation.1 RFA invasive treatment is commonly performed via catheter with the support of 3-dimensional electroanatomic mapping systems,2 with either manual navigation (MAN) or robotic remote magnetic-navigated (RMN) catheters3 (Figure [A]). A comparative and contact force-stratified biophysical evidence of the RMN ablation features is still missing and might impair further spreading of the technique and its benefits. The data that support the findings of this study are available from the corresponding author upon reasonable request. The protocol used in this study was approved by the Ethical Commission of Veterinary and Pharmaceutical University in Brno. The study was performed on ten 6-month-old female large white swine (weight 50–60 kg). The animals were prepared and monitored as previously reported.4 The animals were divided into 5 groups of 2 pigs, according to target force (MAN-5G, -10G, -15G, and -20G to compare with RMN). Carto 3 (Biosense Webster Inc) was used to support navigation and ablation. Each animal underwent 8 endocardial RFA applications in selected areas of the left ventricle (Figure [B]) Orientation of the catheter tip to the wall of the heart was as perpendicular as possible. The same generator settings were used in all study groups (40 W with limited power if the temperature exceeded 50°C, maximum duration of 60 seconds, irrigation rate of 20 mL/min). Whole hearts were fixed in 10% PFA and scanned in transversal view by 9.4T MRI (Soucek et al, under review). Selected lesions were then cut on the transversal plane and prepared for histopathologic examination via hematoxylin/ eosin staining. If not otherwise stated, continuous data are presented as raw means±SDs. For groups comparisons, the significance levels were calculated using the F test with Kenward-Roger adjustment. An ablation composite index (ACI) was implemented in this study, to integrate all the procedural parameters and findings, defined as Equation 1:","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75968666","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1161/CIRCEP.119.007465
C. Schmidt, F. Wiedmann, C. Beyersdorf, Zhihan Zhao, I. El-Battrawy, H. Lan, G. Szabó, Xin Li, S. Lang, S. Korkmaz‐Icöz, K. Rapti, A. Jungmann, Antonius Ratte, O. Müller, M. Karck, G. Seemann, I. Akin, M. Borggrefe, Xiaobo Zhou, H. Katus, Dierk Thomas
BACKGROUND Despite an increasing understanding of atrial fibrillation (AF) pathophysiology, translation into mechanism-based treatment options is lacking. In atrial cardiomyocytes of patients with chronic AF, expression, and function of tandem of P domains in a weak inward rectifying TASK-1 (K+ channel-related acid-sensitive K+ channel-1) (K2P3.1) atrial-specific 2-pore domain potassium channels is enhanced, resulting in action potential duration shortening. TASK-1 channel inhibition prevents action potential duration shortening to maintain values observed among sinus rhythm subjects. The present preclinical study used a porcine AF model to evaluate the antiarrhythmic efficacy of TASK-1 inhibition by adeno-associated viral anti-TASK-1-siRNA (small interfering RNA) gene transfer. METHODS AF was induced in domestic pigs by atrial burst stimulation via implanted pacemakers. Adeno-associated viral vectors carrying anti-TASK-1-siRNA were injected into both atria to suppress TASK-1 channel expression. After the 14-day follow-up period, porcine cardiomyocytes were isolated from right and left atrium, followed by electrophysiological and molecular characterization. RESULTS AF was associated with increased TASK-1 transcript, protein and ion current levels leading to shortened action potential duration in atrial cardiomyocytes compared to sinus rhythm controls, similar to previous findings in humans. Anti-TASK-1 adeno-associated viral application significantly reduced AF burden in comparison to untreated AF pigs. Antiarrhythmic effects of anti-TASK-1-siRNA were associated with reduction of TASK-1 currents and prolongation of action potential durations in atrial cardiomyocytes to sinus rhythm values. Conclusions Adeno-associated viral-based anti-TASK-1 gene therapy suppressed AF and corrected cellular electrophysiological remodeling in a porcine model of AF. Suppression of AF through selective reduction of TASK-1 currents represents a new option for antiarrhythmic therapy.
{"title":"Genetic Ablation of TASK-1 (Tandem of P Domains in a Weak Inward Rectifying K+ Channel-Related Acid-Sensitive K+ Channel-1) (K2P3.1) K+ Channels Suppresses Atrial Fibrillation and Prevents Electrical Remodeling.","authors":"C. Schmidt, F. Wiedmann, C. Beyersdorf, Zhihan Zhao, I. El-Battrawy, H. Lan, G. Szabó, Xin Li, S. Lang, S. Korkmaz‐Icöz, K. Rapti, A. Jungmann, Antonius Ratte, O. Müller, M. Karck, G. Seemann, I. Akin, M. Borggrefe, Xiaobo Zhou, H. Katus, Dierk Thomas","doi":"10.1161/CIRCEP.119.007465","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007465","url":null,"abstract":"BACKGROUND\u0000Despite an increasing understanding of atrial fibrillation (AF) pathophysiology, translation into mechanism-based treatment options is lacking. In atrial cardiomyocytes of patients with chronic AF, expression, and function of tandem of P domains in a weak inward rectifying TASK-1 (K+ channel-related acid-sensitive K+ channel-1) (K2P3.1) atrial-specific 2-pore domain potassium channels is enhanced, resulting in action potential duration shortening. TASK-1 channel inhibition prevents action potential duration shortening to maintain values observed among sinus rhythm subjects. The present preclinical study used a porcine AF model to evaluate the antiarrhythmic efficacy of TASK-1 inhibition by adeno-associated viral anti-TASK-1-siRNA (small interfering RNA) gene transfer.\u0000\u0000\u0000METHODS\u0000AF was induced in domestic pigs by atrial burst stimulation via implanted pacemakers. Adeno-associated viral vectors carrying anti-TASK-1-siRNA were injected into both atria to suppress TASK-1 channel expression. After the 14-day follow-up period, porcine cardiomyocytes were isolated from right and left atrium, followed by electrophysiological and molecular characterization.\u0000\u0000\u0000RESULTS\u0000AF was associated with increased TASK-1 transcript, protein and ion current levels leading to shortened action potential duration in atrial cardiomyocytes compared to sinus rhythm controls, similar to previous findings in humans. Anti-TASK-1 adeno-associated viral application significantly reduced AF burden in comparison to untreated AF pigs. Antiarrhythmic effects of anti-TASK-1-siRNA were associated with reduction of TASK-1 currents and prolongation of action potential durations in atrial cardiomyocytes to sinus rhythm values. Conclusions Adeno-associated viral-based anti-TASK-1 gene therapy suppressed AF and corrected cellular electrophysiological remodeling in a porcine model of AF. Suppression of AF through selective reduction of TASK-1 currents represents a new option for antiarrhythmic therapy.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89602438","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1161/CIRCEP.119.007762
Michael Eskander, V. Pretorius, U. Birgersdotter-Green
Transvenous lead extraction (TLE) is a complex yet effective procedure to remove indwelling leads belonging to cardiac devices with a potential for serious complications. Consequently, the 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction maintains that TLE be performed only at centers with an environment fully supportive of a lead extraction program, which includes a team-based approach, incorporating equipment and capable of managing all potential complications.1 An experienced center will evaluate the patient based on the current presentation and comorbid conditions, while incorporating the procedural and patient-related risks. Despite our best evaluation and preparation, however, a flawless risk stratification approach for those in consideration for TLE remains elusive. Patients with prior sternotomy (PS) is a group of interest due to theoretical mediastinal scarring which may protect against vascular tears and conversely increased adhesions and fibrosis which may delay precious life-saving surgical access after vascular complication from TLE. Historically, patients with PS have been shown to have increased operative morbidity and mortality. In a Swiss cohort undergoing coronary artery bypass grafting, postoperative mortality rate was 9.6% (57/594) in PS compared with 2.8% (87/3184) in those with no prior sternotomy (NPS). Low cardiac output syndrome, intraaortic balloon pump support, prolonged ventilatory support (>24 hours), hemorrhage and gastrointestinal complications were prominent features in those with PS as compared with those undergoing primary coronary artery bypass grafting. While some recently published data may suggest PS as a predictor of clinical success in the setting of TLE, there continues to be a significant risk of urgent cardiac surgery—which carries high mortality, and appropriate planning with cardiothoracic backup is crucial.3,4 In this issue, Tsang et al5 present a single-center experience with prior sternotomy on outcomes in transvenous lead extractions. Of 1480 patients undergoing TLE, 455 had PS and were more likely to be male and have more comorbid conditions (coronary artery disease, hypertension, diabetes mellitus, and chronic kidney disease) than those with NPS. Patients with PS were more likely to have defibrillator leads (70.1% versus 62.3%; P=0.004) and more leads extracted per case (2.1±1.0 versus 1.9±0.9; P=0.006) though mean lead dwell time was similar between patient groups. Despite some baseline differences, procedural success rates were similar in both groups, 97.6% in the PS versus 98.4% in the NPS group (P=0.257). Major complications occurred in 9 (2.0%) PS patients and 23 (2.2%) patients with NPS (P=0.746). Notably, patients with EDITORIAL
经静脉导联拔管(TLE)是一种复杂而有效的方法，用于去除属于心脏装置的留置导联，具有潜在的严重并发症。因此，2017年关于心血管植入式电子设备导联管理和拔管的HRS专家共识声明认为，TLE只能在完全支持导联拔管项目的中心进行，其中包括以团队为基础的方法，整合设备并能够管理所有潜在的并发症经验丰富的中心将根据患者目前的表现和合并症对患者进行评估，同时考虑手术风险和患者相关风险。然而，尽管我们进行了最好的评估和准备，对于那些考虑TLE的人来说，一个完美的风险分层方法仍然是难以捉摸的。先前胸骨切开术(PS)的患者是一个值得关注的群体，因为理论上的纵隔瘢痕可以防止血管撕裂，相反，粘连和纤维化的增加可能会延迟ttle血管并发症后宝贵的挽救生命的手术通路。从历史上看，PS患者的手术发病率和死亡率都有所增加。在瑞士接受冠状动脉旁路移植术的队列中，PS患者的术后死亡率为9.6%(57/594)，而没有胸骨切开术(NPS)的患者的术后死亡率为2.8%(87/3184)。低心输出量综合征、主动脉内球囊泵支持、延长通气支持时间(>24小时)、出血和胃肠道并发症是PS患者与初级冠状动脉旁路移植术患者相比的突出特征。虽然最近发表的一些数据可能表明，PS是TLE临床成功的一个预测指标，但仍然存在紧急心脏手术的重大风险，这带来了高死亡率，适当的计划与心胸后援是至关重要的。在这篇文章中，Tsang等人提出了一项单中心的经验，先前的胸骨切开术对经静脉铅提取的结果有影响。在1480名接受TLE治疗的患者中，455名患者患有PS，与NPS患者相比，这些患者更有可能是男性，并且有更多的合并症(冠状动脉疾病、高血压、糖尿病和慢性肾脏疾病)。PS患者更有可能使用除颤器导联(70.1%对62.3%;P=0.004)和更多的引线提取(2.1±1.0 vs 1.9±0.9;P=0.006)，但患者组间平均导联停留时间相似。尽管有一些基线差异，但两组的手术成功率相似，PS组为97.6%，NPS组为98.4% (P=0.257)。PS组9例(2.0%)，NPS组23例(2.2%)出现严重并发症(P=0.746)。值得注意的是，社论患者
{"title":"Prior Sternotomy in Transvenous Lead Extraction: Risk Analysis Tempered by Clinical Experience.","authors":"Michael Eskander, V. Pretorius, U. Birgersdotter-Green","doi":"10.1161/CIRCEP.119.007762","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007762","url":null,"abstract":"Transvenous lead extraction (TLE) is a complex yet effective procedure to remove indwelling leads belonging to cardiac devices with a potential for serious complications. Consequently, the 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction maintains that TLE be performed only at centers with an environment fully supportive of a lead extraction program, which includes a team-based approach, incorporating equipment and capable of managing all potential complications.1 An experienced center will evaluate the patient based on the current presentation and comorbid conditions, while incorporating the procedural and patient-related risks. Despite our best evaluation and preparation, however, a flawless risk stratification approach for those in consideration for TLE remains elusive. Patients with prior sternotomy (PS) is a group of interest due to theoretical mediastinal scarring which may protect against vascular tears and conversely increased adhesions and fibrosis which may delay precious life-saving surgical access after vascular complication from TLE. Historically, patients with PS have been shown to have increased operative morbidity and mortality. In a Swiss cohort undergoing coronary artery bypass grafting, postoperative mortality rate was 9.6% (57/594) in PS compared with 2.8% (87/3184) in those with no prior sternotomy (NPS). Low cardiac output syndrome, intraaortic balloon pump support, prolonged ventilatory support (>24 hours), hemorrhage and gastrointestinal complications were prominent features in those with PS as compared with those undergoing primary coronary artery bypass grafting. While some recently published data may suggest PS as a predictor of clinical success in the setting of TLE, there continues to be a significant risk of urgent cardiac surgery—which carries high mortality, and appropriate planning with cardiothoracic backup is crucial.3,4 In this issue, Tsang et al5 present a single-center experience with prior sternotomy on outcomes in transvenous lead extractions. Of 1480 patients undergoing TLE, 455 had PS and were more likely to be male and have more comorbid conditions (coronary artery disease, hypertension, diabetes mellitus, and chronic kidney disease) than those with NPS. Patients with PS were more likely to have defibrillator leads (70.1% versus 62.3%; P=0.004) and more leads extracted per case (2.1±1.0 versus 1.9±0.9; P=0.006) though mean lead dwell time was similar between patient groups. Despite some baseline differences, procedural success rates were similar in both groups, 97.6% in the PS versus 98.4% in the NPS group (P=0.257). Major complications occurred in 9 (2.0%) PS patients and 23 (2.2%) patients with NPS (P=0.746). Notably, patients with EDITORIAL","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86787617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1161/CIRCEP.118.007118
Ying Tian, E. Wittwer, S. Kapa, Christopher J. McLeod, P. Xiao, P. Noseworthy, S. Mulpuru, A. Deshmukh, Hon-chi Lee, M. Ackerman, S. Asirvatham, T. Munger, Xingpeng Liu, P. Friedman, Y. Cha
BACKGROUND Percutaneous stellate ganglion blockade (SGB) has been used for drug-refractory electrical storm due to ventricular arrhythmia (VA); however, the effects and long-term outcomes have not been well studied. METHODS This study included 30 consecutive patients who had drug-refractory electrical storm and underwent percutaneous SGB between October 1, 2013, and March 31, 2018. Bupivacaine, alone or combined with lidocaine, was injected into the neck with good local anesthetic spread in the vicinity of the left stellate ganglion (n=15) or both stellate ganglia (n=15). Data were collected for patient clinical characteristics, immediate and long-term outcomes, and procedure-related complications. RESULTS Clinical characteristics included age, 58±14 years; men, 73.3%; and left ventricular ejection fraction, 34±16%. At 24 hours, 60% of patients were free of VA. Patients whose VA was controlled had a lower hospital mortality rate than patients whose VA continued (5.6% versus 50.0%; P=0.009). Implantable cardioverter-defibrillator interrogation showed a significant 92% reduction in VA episodes from 26±41 to 2±4 in the 72 hours after SGB (P<0.001). Patients who died during the same hospitalization (n=7) were more likely to have ischemic cardiomyopathy (100% versus 43.5%; P=0.03) and recurrent VA within 24 hours (85.7% versus 26.1%; P=0.009). There were no procedure-related major complications. CONCLUSIONS SGB effectively attenuated electrical storm in more than half of patients without procedure-related complications. Percutaneous SGB may be considered for stabilizing ventricular rhythm in patients for whom other therapies have failed.
背景:经皮星状神经节阻滞(SGB)已被用于治疗室性心律失常(VA)引起的药物难治性电风暴;然而，其影响和长期结果尚未得到很好的研究。方法本研究纳入了2013年10月1日至2018年3月31日期间连续30例难治性电风暴患者经皮SGB。布比卡因单用或联用利多卡因颈部注射，局部麻醉良好，分布于左侧星状神经节附近(n=15)或双侧星状神经节附近(n=15)。收集患者临床特征、近期和长期结果以及手术相关并发症的数据。结果年龄:58±14岁;男性,73.3%;左室射血分数，34±16%。在24小时内，60%的患者没有VA。VA得到控制的患者的医院死亡率低于VA继续存在的患者(5.6%对50.0%;P = 0.009)。植入式心律转复除颤器审讯显示，在SGB后72小时内，VA发作从26±41次减少到2±4次，显著减少92% (P<0.001)。在同一住院期间死亡的患者(n=7)患缺血性心肌病的可能性更大(100%比43.5%;P=0.03)和24小时内VA复发(85.7% vs 26.1%;P = 0.009)。无手术相关的主要并发症。结论ssgb有效地减弱了半数以上患者的电风暴，无手术相关并发症。经皮SGB可用于稳定其他治疗失败的患者的心室节律。
{"title":"Effective Use of Percutaneous Stellate Ganglion Blockade in Patients With Electrical Storm.","authors":"Ying Tian, E. Wittwer, S. Kapa, Christopher J. McLeod, P. Xiao, P. Noseworthy, S. Mulpuru, A. Deshmukh, Hon-chi Lee, M. Ackerman, S. Asirvatham, T. Munger, Xingpeng Liu, P. Friedman, Y. Cha","doi":"10.1161/CIRCEP.118.007118","DOIUrl":"https://doi.org/10.1161/CIRCEP.118.007118","url":null,"abstract":"BACKGROUND\u0000Percutaneous stellate ganglion blockade (SGB) has been used for drug-refractory electrical storm due to ventricular arrhythmia (VA); however, the effects and long-term outcomes have not been well studied.\u0000\u0000\u0000METHODS\u0000This study included 30 consecutive patients who had drug-refractory electrical storm and underwent percutaneous SGB between October 1, 2013, and March 31, 2018. Bupivacaine, alone or combined with lidocaine, was injected into the neck with good local anesthetic spread in the vicinity of the left stellate ganglion (n=15) or both stellate ganglia (n=15). Data were collected for patient clinical characteristics, immediate and long-term outcomes, and procedure-related complications.\u0000\u0000\u0000RESULTS\u0000Clinical characteristics included age, 58±14 years; men, 73.3%; and left ventricular ejection fraction, 34±16%. At 24 hours, 60% of patients were free of VA. Patients whose VA was controlled had a lower hospital mortality rate than patients whose VA continued (5.6% versus 50.0%; P=0.009). Implantable cardioverter-defibrillator interrogation showed a significant 92% reduction in VA episodes from 26±41 to 2±4 in the 72 hours after SGB (P<0.001). Patients who died during the same hospitalization (n=7) were more likely to have ischemic cardiomyopathy (100% versus 43.5%; P=0.03) and recurrent VA within 24 hours (85.7% versus 26.1%; P=0.009). There were no procedure-related major complications.\u0000\u0000\u0000CONCLUSIONS\u0000SGB effectively attenuated electrical storm in more than half of patients without procedure-related complications. Percutaneous SGB may be considered for stabilizing ventricular rhythm in patients for whom other therapies have failed.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84682608","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1161/CIRCEP.119.007278
D. Tsang, Adryan A Perez, T. Boyle, R. Carrillo
BACKGROUND A history of open-heart surgery has been a heavily debated topic in transvenous lead extraction. This study evaluates the impact of prior sternotomy on transvenous lead extraction outcomes. METHODS Data for all patients undergoing transvenous lead extraction at a tertiary referral center were prospectively gathered from 2004 to 2017. Relevant clinical information was compared between patients with a history of sternotomy before transvenous lead extraction and those without. After considering baseline differences, multivariate regression, and propensity-matched analysis were performed. Outcome variables included major and minor complication rates, clinical success, and in-hospital mortality as defined by the 2017 Heart Rhythm Society consensus statement. RESULTS Of 1480 patients in the study period, 455 had a prior sternotomy. When compared with patients with no prior sternotomy, those with prior sternotomy were more likely to be older, male, and present with more comorbidities and leads targeted for extraction. No statistical differences were identified in major and minor complication rates (P=0.75, P=0.41), clinical success rate (P=0.26), and in-hospital mortality (P=0.08). In patients with prior sternotomy, there were no instances of pericardial effusion after extraction. Prior sternotomy was not an independent predictor of clinical or procedural outcomes. No associations were elucidated after propensity-matched analysis. CONCLUSIONS In a large, single-center series, no differences in clinical or procedural outcomes were elucidated between patients with a history of sternotomy and those without. Patients with sternotomies before lead extraction who experienced vascular or cardiac perforations clinically presented with hemothoraces rather than pericardial effusions.
{"title":"Effect of Prior Sternotomy on Outcomes in Transvenous Lead Extraction.","authors":"D. Tsang, Adryan A Perez, T. Boyle, R. Carrillo","doi":"10.1161/CIRCEP.119.007278","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007278","url":null,"abstract":"BACKGROUND\u0000A history of open-heart surgery has been a heavily debated topic in transvenous lead extraction. This study evaluates the impact of prior sternotomy on transvenous lead extraction outcomes.\u0000\u0000\u0000METHODS\u0000Data for all patients undergoing transvenous lead extraction at a tertiary referral center were prospectively gathered from 2004 to 2017. Relevant clinical information was compared between patients with a history of sternotomy before transvenous lead extraction and those without. After considering baseline differences, multivariate regression, and propensity-matched analysis were performed. Outcome variables included major and minor complication rates, clinical success, and in-hospital mortality as defined by the 2017 Heart Rhythm Society consensus statement.\u0000\u0000\u0000RESULTS\u0000Of 1480 patients in the study period, 455 had a prior sternotomy. When compared with patients with no prior sternotomy, those with prior sternotomy were more likely to be older, male, and present with more comorbidities and leads targeted for extraction. No statistical differences were identified in major and minor complication rates (P=0.75, P=0.41), clinical success rate (P=0.26), and in-hospital mortality (P=0.08). In patients with prior sternotomy, there were no instances of pericardial effusion after extraction. Prior sternotomy was not an independent predictor of clinical or procedural outcomes. No associations were elucidated after propensity-matched analysis.\u0000\u0000\u0000CONCLUSIONS\u0000In a large, single-center series, no differences in clinical or procedural outcomes were elucidated between patients with a history of sternotomy and those without. Patients with sternotomies before lead extraction who experienced vascular or cardiac perforations clinically presented with hemothoraces rather than pericardial effusions.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80623046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1161/CIRCEP.119.007707
B. Narasimhan, H. Tandri
The increasing use of implantable defibrillators for sudden death prevention and the recent advances in heart failure therapies have significantly altered the natural history of heart disease. An unfortunate consequence of this is the increasing incidence of refractory tachyarrhythmias. The most serious of ventricular arrhythmias (VA) is the electrical storm, defined as ≥3 episodes of sustained ventricular tachyarrhythmia over a 24-hour period.1 The annual incidence varies from 2% to 10% and is associated with a 2to 8-fold increase in mortality. This is most likely a testament to the severely compromised underlying myocardial substrate than to the electrical storm itself. It is well established that the sympathetic nervous system plays an integral role in initiating and driving electrical storm.2 Pharmacological approaches to sympathetic blockade using β-blockers though effective have several shortcomings. The sympathetic nervous system involves multiple nonadrenergic pathways and neuromodulators which are unaffected by these medications. Additionally, the β2 receptor which is untouched by the conventionally cardio-selective β-blockers appears to play an integral proarrhythmic role as well. These shortcomings are overcome by surgical approaches where the cardiac sympathetic supply in its entirety is decentralized. The earliest attempt at surgical sympathectomy was over a century ago when Jonnesco3 performed a left cardiac sympathetic denervation in a successful attempt to relieve refractory angina in syphilitic aortitis.2 Since that time the field has burgeoned with a number of interventions targeting multiple sites along the sympathetic chain. These range from thoracic epidural/general anesthesia, stellate ganglion blockade, renal artery denervation to surgical stellate ganglion resection. Cardiac sympathetic denervation is undeniably beneficial in certain conditions—however, consensus about where it fits into regular practice remains to be established. Percutaneous stellate ganglion blockade (PC-SGB) is currently the least invasive method available, and its role in management of electrical storm is comprehensively explored in this issue of Heart Rhythm by Tian et al.4 In the largest prospective study of PC-SGB to date, 30 patients presenting with drug-refractory electric storm between 2013 and 2018 were included (58±14 years, 73.3% males, mean left ventricular election fraction, 34±15). Ultrasound guidance was used in the majority of patients with half the study population undergoing a left-sided stellate block, with bilateral blockade in the remainder. An incremental approach was used with an initial left-sided SGB, and progression to bilateral block if recurrence of arrhythmia was noted within 10 minutes. Rise in ipsilateral arm temperature was used as a surrogate for efficacy of block, though the authors themselves indicate that the temperatures were inadequately measured. EDITORIAL
{"title":"Stellate Block in Refractory Ventricular Tachycardia: The Calm After the Storm.","authors":"B. Narasimhan, H. Tandri","doi":"10.1161/CIRCEP.119.007707","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007707","url":null,"abstract":"The increasing use of implantable defibrillators for sudden death prevention and the recent advances in heart failure therapies have significantly altered the natural history of heart disease. An unfortunate consequence of this is the increasing incidence of refractory tachyarrhythmias. The most serious of ventricular arrhythmias (VA) is the electrical storm, defined as ≥3 episodes of sustained ventricular tachyarrhythmia over a 24-hour period.1 The annual incidence varies from 2% to 10% and is associated with a 2to 8-fold increase in mortality. This is most likely a testament to the severely compromised underlying myocardial substrate than to the electrical storm itself. It is well established that the sympathetic nervous system plays an integral role in initiating and driving electrical storm.2 Pharmacological approaches to sympathetic blockade using β-blockers though effective have several shortcomings. The sympathetic nervous system involves multiple nonadrenergic pathways and neuromodulators which are unaffected by these medications. Additionally, the β2 receptor which is untouched by the conventionally cardio-selective β-blockers appears to play an integral proarrhythmic role as well. These shortcomings are overcome by surgical approaches where the cardiac sympathetic supply in its entirety is decentralized. The earliest attempt at surgical sympathectomy was over a century ago when Jonnesco3 performed a left cardiac sympathetic denervation in a successful attempt to relieve refractory angina in syphilitic aortitis.2 Since that time the field has burgeoned with a number of interventions targeting multiple sites along the sympathetic chain. These range from thoracic epidural/general anesthesia, stellate ganglion blockade, renal artery denervation to surgical stellate ganglion resection. Cardiac sympathetic denervation is undeniably beneficial in certain conditions—however, consensus about where it fits into regular practice remains to be established. Percutaneous stellate ganglion blockade (PC-SGB) is currently the least invasive method available, and its role in management of electrical storm is comprehensively explored in this issue of Heart Rhythm by Tian et al.4 In the largest prospective study of PC-SGB to date, 30 patients presenting with drug-refractory electric storm between 2013 and 2018 were included (58±14 years, 73.3% males, mean left ventricular election fraction, 34±15). Ultrasound guidance was used in the majority of patients with half the study population undergoing a left-sided stellate block, with bilateral blockade in the remainder. An incremental approach was used with an initial left-sided SGB, and progression to bilateral block if recurrence of arrhythmia was noted within 10 minutes. Rise in ipsilateral arm temperature was used as a surrogate for efficacy of block, though the authors themselves indicate that the temperatures were inadequately measured. EDITORIAL","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73611970","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1161/CIRCEP.119.007582
J. Kron, A. Mauro, A. Bonaventura, S. Toldo, Fadi N. Salloum, K. Ellenbogen, A. Abbate
September 2019 1 Cardiac sarcoidosis (CS) can occur in ≤25% of patients with sarcoidosis in other organ systems leading to life-threatening ventricular arrhythmias, heart block, heart failure, and death. An essential part of the innate immune system, the inflammasome is a macromolecular structure in the cell that responds to a danger signal by releasing IL (interleukin)-1β and amplifying the inflammatory response.1 IL-1β is indeed the prototypical proinflammatory cytokine processed within the inflammasome.1 A role for IL-1β in the pathogenesis of sarcoidosis has been proposed. IL-1β participates in the pathogenesis of granuloma formation in the mouse.2 The ratio of IL-1 receptor antagonist/IL-1β was a marker in predicting the persistence of pulmonary granulomatous lesions in patients.3 Importantly, the main mechanism of action of IL-1β is to activate the nuclear transcription factor NF-kB (nuclear factor-kappa B), also a target of glucocorticoids. We hypothesized that CS would lead to the formation of the inflammasome. We studied cardiac pathology specimens from 3 patients with a diagnosis of CS based on Heart Rhythm Society 2014 Consensus Statement Criteria4 obtained from the left ventricle during total artificial heart implantation in 1 patient and left ventricular assist device implantation and subsequent orthotopic heart transplant in 2 patients. The regions of the heart to be sampled were chosen based on abnormalities upon macroscopic inspection. The study was approved by the Institutional Review Board of the Virginia Commonwealth University, Richmond, VA. Patient No. 1 is a 59-year-old man with pulmonary sarcoidosis who presented with complete heart block, ventricular tachycardia, and left ventricular systolic dysfunction. The patient was treated with prednisone, mycophenolate mofetil, and hydroxychloroquine. Cardiac 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) 1 month before total artificial heart showed severe-intensity FDG uptake in the apical septum and inferior walls (Figure [A and B]). Because of progressive heart failure symptoms, he underwent total artificial heart followed 7 months later by orthotopic heart transplant. Patient No. 2 is a 60-year-old woman with biopsy-proven pulmonary sarcoidosis who presented with complete atrioventricular block and left ventricular systolic dysfunction. FDG-PET performed 2 months before left ventricular assist device showed moderate-intensity diffuse FDG uptake extending into the left ventricular apex (Figure [E and F]). She then underwent Heartmate II implantation followed 3 months later by orthotopic heart transplant. Patient No. 3 is a 64-year-old male with sinus node dysfunction and nonischemic cardiomyopathy. Cardiac PET showed FDG uptake concerning for CS and hilar and mediastinal lymphadenopathy. Carinal lymph node biopsy showed noncaseating granulomas. He was treated with prednisone and methotrexate. FDG-PET performed showed mild-intensity patchy hypermetabolic activity
{"title":"Inflammasome Formation in Granulomas in Cardiac Sarcoidosis.","authors":"J. Kron, A. Mauro, A. Bonaventura, S. Toldo, Fadi N. Salloum, K. Ellenbogen, A. Abbate","doi":"10.1161/CIRCEP.119.007582","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007582","url":null,"abstract":"September 2019 1 Cardiac sarcoidosis (CS) can occur in ≤25% of patients with sarcoidosis in other organ systems leading to life-threatening ventricular arrhythmias, heart block, heart failure, and death. An essential part of the innate immune system, the inflammasome is a macromolecular structure in the cell that responds to a danger signal by releasing IL (interleukin)-1β and amplifying the inflammatory response.1 IL-1β is indeed the prototypical proinflammatory cytokine processed within the inflammasome.1 A role for IL-1β in the pathogenesis of sarcoidosis has been proposed. IL-1β participates in the pathogenesis of granuloma formation in the mouse.2 The ratio of IL-1 receptor antagonist/IL-1β was a marker in predicting the persistence of pulmonary granulomatous lesions in patients.3 Importantly, the main mechanism of action of IL-1β is to activate the nuclear transcription factor NF-kB (nuclear factor-kappa B), also a target of glucocorticoids. We hypothesized that CS would lead to the formation of the inflammasome. We studied cardiac pathology specimens from 3 patients with a diagnosis of CS based on Heart Rhythm Society 2014 Consensus Statement Criteria4 obtained from the left ventricle during total artificial heart implantation in 1 patient and left ventricular assist device implantation and subsequent orthotopic heart transplant in 2 patients. The regions of the heart to be sampled were chosen based on abnormalities upon macroscopic inspection. The study was approved by the Institutional Review Board of the Virginia Commonwealth University, Richmond, VA. Patient No. 1 is a 59-year-old man with pulmonary sarcoidosis who presented with complete heart block, ventricular tachycardia, and left ventricular systolic dysfunction. The patient was treated with prednisone, mycophenolate mofetil, and hydroxychloroquine. Cardiac 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) 1 month before total artificial heart showed severe-intensity FDG uptake in the apical septum and inferior walls (Figure [A and B]). Because of progressive heart failure symptoms, he underwent total artificial heart followed 7 months later by orthotopic heart transplant. Patient No. 2 is a 60-year-old woman with biopsy-proven pulmonary sarcoidosis who presented with complete atrioventricular block and left ventricular systolic dysfunction. FDG-PET performed 2 months before left ventricular assist device showed moderate-intensity diffuse FDG uptake extending into the left ventricular apex (Figure [E and F]). She then underwent Heartmate II implantation followed 3 months later by orthotopic heart transplant. Patient No. 3 is a 64-year-old male with sinus node dysfunction and nonischemic cardiomyopathy. Cardiac PET showed FDG uptake concerning for CS and hilar and mediastinal lymphadenopathy. Carinal lymph node biopsy showed noncaseating granulomas. He was treated with prednisone and methotrexate. FDG-PET performed showed mild-intensity patchy hypermetabolic activity ","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83548750","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1161/hae.0000000000000043
{"title":"Correction to: Nonequilibrium Reactivation of Na\u0000 +\u0000 Current Drives Early Afterdepolarizations in Mouse Ventricle","authors":"","doi":"10.1161/hae.0000000000000043","DOIUrl":"https://doi.org/10.1161/hae.0000000000000043","url":null,"abstract":"","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74580820","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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