Paced P-wave duration as a significant predictor for atrial high-rate episodes in patients with cardiac implantable electronic devices

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial pacing can unmask or aggravate a preexisting interatrial block (IAB).

Purpose

The purpose of our study was to determine whether atrial pacing is associated with the development of atrial high-rate episodes (AHRE) during follow-up.

Methods

Patients with cardiac implantable electronic devices (CIED), no previous documented atrial fibrillation, and with a 6-month minimum follow-up were included. Sinus and paced P-wave duration were measured. AHRE was defined as an episode of atrial rate ≥ 225 bpm with a minimum duration of 5 min, excluding those documented during the first three months after implantation.

Results

Two hundred twenty patients were included (75 ± 10 years, 61% male). After a mean follow-up of 59±25 months, 46% of patients presented AHRE. Mean paced P-wave duration was significantly longer than sinus P-wave duration (154±27 vs 115±18 ms; p < 0.001). Sinus and paced P-waves were significantly longer in those who developed AHRE (sinus: 119±20 vs 112±16; p = 0.006; paced: 161±29 vs 148±23; p < 0.001). A paced P-wave ≥160 ms was the best predictor of AHRE, especially those lasting >24 h (OR 4.2 (95% CI) [1.6-11.4]; p = 0.004). In a multivariate analysis, a paced P-wave ≥160 ms (OR: 1.84; 95% CI [1.03–3.28]; p = 0.038), a CHA2DS2-VASc score ≥4 (OR: 2.01; 95% CI [1.13–3.55]; p = 0.016), and a LA SI dimension ≥ 55 mm (OR 2.69; 95% CI [1.48–4.90]; p = 0.001) were independent predictors augmenting AHRE.

Conclusion

Atrial pacing significantly prolongs P-wave duration and is associated with further development of AHRE. A paced P-wave ≥160 ms is a strong predictor of AHRE and should be taken into consideration as a new definition of IAB in the presence of atrial pacing.

Do we need imaging support to minimize radiation exposure in cryo-ablation for atrial fibrillation? The VLADIMIR strategy

Introduction and objective

Cryoballoon pulmonary vein isolation (CB-VPI) is non-inferior to radiofrequency ablation in patients with atrial fibrillation. Although protocols aiming to reduce radiation exposure have been developed, most of them use intracardiac echocardiography (ICE) or electroanatomic mapping (EAM) systems, which significantly increase procedure costs or may not be widely available. Previous studies aiming at fluoroscopy reduction have been published, achieving median fluoroscopy times around 10 minutes.

We developed a novel strategy to achieve Very Low rADIoscopic exposure to Minimize Ionizing Radiation during cryoablation of atrial fibrillation (VLADIMIR) (Table 1). The aim of this study was to assess its impact in acute procedural and clinical outcomes.

Methods

Consecutive patients undergoing CB-VPI were prospectively enrolled, treated with the VLADIMIR strategy and compared to a retrospective cohort of patients having undergone CB-VPI performed by the same operators with conventional fluoroscopy strategy. Primary end-points were fluoroscopy time and total dose area product (DAP). Secondary end-points were intraprocedural or early post-procedural complications.

Results

A total of 84 patients were enrolled. 50 patients underwent CB-VPI with conventional fluoroscopy strategy and in 34 patients the Vladimir strategy was applied. Vladimir group had significant lower median fluoroscopy time (2.98 min vs 20.65 min, p<0.001) and significant lower median DAP (4.15 Gy·cm2 vs 34.12 Gy·cm2, p<0.001) as compared with conventional fluoroscopy strategy group. Results from prespecified subgroup analysis between operators (senior vs fellow trainee) were consistent. No significant differences were found between both groups in periprocedural complications (Table 2).

Conclusion

The Vladimir protocol significantly reduces fluoroscopy time and radiation exposure during CB-VPI without affecting the rate of periprocedural complications.

Funding Acknowledgement

Type of funding sources: None. Table 1. The VLADIMIR strategyTable 2

Clinical recurrence of palpitations following slow pathway ablation in patients with suspected paroxysmal supraventricular tachycardias but non-documented, non-inducible tachycardias

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation is recommended as first-line treatment in patients with atrioventricular nodal reentry tachycardias (AVNRT). However, the best therapeutic modality in patients with dual AV nodal physiology but non-inducible tachycardias in electrophysiological study (EPS) remains controversial, especially when no tachycardias have been documented.

Our objective was to evaluate the results of empirical slow pathway ablation in patients showing dual AV nodal physiology but non-inducible AVNRT.

Methods

Multicenter, retrospective, observational registry of consecutive patients undergoing EPS due to clinical suspicion of paroxysmal supraventricular tachycardias (PSVT), but with no prior ECG documentation. Clinical, EPS and ablation (when performed) data were collected and andalyzed. 

Results

427 patients of 12 centers were included. Mean age was 46.3 ±16.1 and 297 (69.6%) were females. AVNRT was induced in 188 patients (typical in 181 cases, atypical in 7). Dual AV nodal physiology with or without single nodal echo beats, but with no sustained tachycardia and without evidence of accessory pathway was present in 68 patients. Ablation of the slow pathway was performed in 187/188 patients with AVNRT and in 30/68 patients with dual physiology. Among subjects with non-inducible tachycardia, ablation reduced significantly recurrences (39.5% in non-ablated vs. 16.7%; p = 0.04), with a level equivalent to those with ablated AVNRT(14.4% vs. 16.7%; p = 0.75). Procedure-related complications were similar in both groups: empirical ablation n = 1; 3.3% vs. induced tachycardia n = 6; 3.2% (p = 0.98).

Conclusions

In patients with high clinical suspicion of PSVT but non-documented and non-inducible arrhythmias, the presence of dual AV nodal physiology makes AVNRT a likely mechanism of the clinical tachycardia. Catheter ablation of slow pathway reduces the risk of recurrence to a level equivalent to those with inducible and ablated AVNRT. AVNRT (n = 188) Dual nodal physiology (n = 68) p value Age (years) 48.6 ± 16.3 41.9 ± 14.0 <0.01 Female 71.8% 67.7% 0.52 Years symptomatic 9.3 ± 11.3 3.6 ± 8.1 <0.01 Sudden onset 83.9% 88.0% 0.54 Abrupt end 73.4% 74.6% 0.96 Previous rate-slowing drugs 30.9% 25.0% 0.36 Previous antiarrhythmic drugs 5.9% 2.9% 0.35 Isoproterenol in EPS 70.0% 89.7% <0.01

Recurrence of palpitations following electrophysiological study and ablation in suspected but undocumented paroxysmal supraventricular tachycardias: follow-up results of the BELIEVE-SVT registry

Funding Acknowledgements

Type of funding sources: None.

Introduction

ECG documentation of paroxysmal supraventricular tachycardias (PSVT) may be challenging due to their short duration and usually abrupt end.  As ablation represents first-line treatment of this pathologies, it is not uncommon that physicians refer patients to electrophysiological study (EPS) when symptoms are suggestive of PSVT even though no ECG documentation has been obtained. Our objective was to evaluate the results of ablation performed in patients with induced arrhythmias in EPS but no previous ECG documentation.

Methods

Retrospective and observational multicenter registry of consecutive patients undergoing EPS, followed or not by ablation, referred because of undocumented clinical suspicion of PSVT. We collected clinical, EPS and clinical follow-up data, along with data regarding ablation, when performed. Descriptive statistical analysis was carried out using Stata.

Results

427 patients of 12 centers were included. Mean age was 46.3 ± 16.1 and 297 (69.6%) were females. Sustained arrhythmias were induced in most patients (n = 255; 59.7%) and ablation was performed in 274 (64.2%). 10 complications (2.3% of procedures) were reported: 3 transient AV block, 2 PR interval prolongation, 2 puncture-related hematoma, 2 painful sites of puncture and 1 catheter entrapment in mitral chordae.

During a mean follow-up of 3.1 ± 2.0 years, 111 patients experienced recurrence of palpitations, mostly (n = 77; 69.4%) without ECG documentation. Clinical recurrence was more frequent in subjects who had not been ablated (41.8% vs 17.2% in ablated patients; risk ratio 2.44 (CI 95% 1.77-3.36); p < 0.001). Table 1 shows types of clinical recurrences.

Conclusions

EPS in patients with high clinical suspicion of PSVT, followed by ablation when tachycardia is induced is effective in preventing future recurrences of palpitations. Early referral for EPS can, therefore, reduce visits to the emergency room, admissions and healthcare burden due to other low-yield, unnecessary tests. Type of recurrence ECG documentation 34(8.0%) ·Sinus rhythm 12(2.8%) ·Atrial tachycardia 6(1.4%) ·Typical atrioventricular nodal reentrant tachycardia 5(1.2%) ·Atrial fibrillation 5(1.2%) ·Premature ventricular beats 3(0.7%) ·Orthodromic atriventricular tachycardia 2(0.5%) Non documented recurrence 77(18.0%)

HIV infection, risk behaviors, and depressive symptoms among Puerto Rican sex workers

This paper examines the association of depressive symptoms with human immunodeficiency virus (HIV) infection and risk behaviors among 127 sex workers. Data were obtained by a structured interview and blood specimens tested for HIV. Findings showed a high prevalence rate of depressive symptoms for all sex workers regardless of HIV infection status. Results of a logistic regression analysis indicated that the use of injected drugs and engaging in unprotected intercourse with clients were strongly associated with a high level of depressive symptoms.

Studies on infant diarrhea. I. A comparison of the effects of milk feeding and intravenous therapy upon the composition and volume of the stool and urine

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