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De Angelis G, De Luca A, Merlo M, Nucifora G, Rossi M, Stolfo D, Barbati G, De Bellis A, Masè M, Santangeli P, Pagnan L, Muser D, Sinagra G. Prevalence and prognostic significance of ischemic late gadolinium enhancement pattern in non-ischemic dilated cardiomyopathy. Am Heart J 2022; 246:117-124. [PMID: 35045326 DOI: 10.1016/j.ahj.2022.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Typical late gadolinium enhancement (LGE) patterns in dilated cardiomyopathy (DCM) include intramyocardial and subepicardial distribution. However, the ischemic pattern of LGE (subendocardial and transmural) has also been reported in DCM without coronary artery disease (CAD), but its correlates and prognostic significance are still not known. On these bases, this study sought to describe the prevalence and prognostic significance of the ischemic LGE pattern in DCM. METHODS A total of 611 DCM patients with available cardiac magnetic resonance were retrospectively analyzed. A composite of all-cause-death, major ventricular arrhythmias (MVAs), heart transplantation (HTx) or ventricular assist device (VAD) implantation was the primary outcome of the study. Secondary outcomes were a composite of sudden cardiac death or MVAs and a composite of death for refractory heart failure, HTx or VAD implantation. RESULTS Ischemic LGE was found in 7% of DCM patients without significant CAD or history of myocardial infarction, most commonly inferior/inferolateral/anterolateral. Compared to patients with non-ischemic LGE, those with ischemic LGE had higher prevalence of hypertension and atrial fibrillation or flutter. Ischemic LGE was associated with worse long-term outcomes compared to non-ischemic LGE (36% vs 23% risk of primary outcome events at 5 years respectively, P = .006), and remained an independent predictor of primary outcome after adjustment for clinically and statistically significant variables (adjusted hazard ratio 2.059 [1.055-4.015], P = .034 with respect to non-ischemic LGE). CONCLUSIONS The ischemic pattern of LGE is not uncommon among DCM patients without CAD and is independently associated with worse long-term outcomes.
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Santangeli P. Right Atrium to Left Ventricle Puncture for VT Ablation in Patients with Mechanical Aortic and Mitral Valves: a Step-by-Step Approach. J Cardiovasc Electrophysiol 2022; 33:2094-2099. [PMID: 35332599 DOI: 10.1111/jce.15467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/15/2022] [Accepted: 03/19/2022] [Indexed: 11/27/2022]
Abstract
In patients with mechanical valves in the aortic and mitral positions, percutaneous access to the left ventricle (LV) for catheter ablation (CA) of ventricular tachycardia (VT) is challenging. We have recently described a novel percutaneous trans-right atrial (RA) access to the LV via a femoral venous approach for CA of VT in patients with mechanical aortic and mitral valves. With this approach, an iatrogenic Gerbode-type of ventricular septal defect is created with direct puncture of the inferior and medial aspect of the RA anatomically adjacent to the inferior-septal LV. The technique involves the use of steerable sheaths, dedicated radiofrequency (RF) wires, and intracardiac echocardiography (ICE) guidance. The procedure has been documented feasible and safe in a series of consecutive patients with aortic and mitral mechanical valves and VT related to LV substrate. In this article, the procedural details of this novel approach are described in a step-by-step fashion. This article is protected by copyright. All rights reserved.
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103
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Siripanthong B, Asatryan B, Hanff TC, Chatha SR, Khanji MY, Ricci F, Muser D, Ferrari VA, Nazarian S, Santangeli P, Deo R, Cooper LT, Mohiddin SA, Chahal CAA. The Pathogenesis and Long-Term Consequences of COVID-19 Cardiac Injury. JACC Basic Transl Sci 2022; 7:294-308. [PMID: 35165665 PMCID: PMC8828362 DOI: 10.1016/j.jacbts.2021.10.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 12/14/2022]
Abstract
COVID-19 myocardial injury results from immune and hypercoagulability responses. Long-term cardiac consequences of COVID-19 include structural and functional changes. Myocarditis after COVID-19 vaccination is uncommon (highest risk in teenage males). Larger population-based studies are necessary to validate these early results.
The mechanisms of coronavirus disease-2019 (COVID-19)–related myocardial injury comprise both direct viral invasion and indirect (hypercoagulability and immune-mediated) cellular injuries. Some patients with COVID-19 cardiac involvement have poor clinical outcomes, with preliminary data suggesting long-term structural and functional changes. These include persistent myocardial fibrosis, edema, and intraventricular thrombi with embolic events, while functionally, the left ventricle is enlarged, with a reduced ejection fraction and new-onset arrhythmias reported in a number of patients. Myocarditis post-COVID-19 vaccination is rare but more common among young male patients. Larger studies, including prospective data from biobanks, will be useful in expanding these early findings and determining their validity.
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Guandalini GS, Santangeli P, Schaller R, Pothineni NVK, Briceño DF, Enriquez A, Razminia P, Tung R, Marchlinski FE, Garcia FC. Intramyocardial mapping of ventricular premature depolarizations via septal venous perforators: Differentiating the superior intraseptal region from left ventricular summit origins. Heart Rhythm 2022; 19:1475-1483. [DOI: 10.1016/j.hrthm.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 02/25/2022] [Accepted: 03/04/2022] [Indexed: 11/04/2022]
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105
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Mariani MV, Piro A, Magnocavallo M, Chimenti C, Della Rocca D, Santangeli P, Natale A, Fedele F, Lavalle C. ORIGINAL ARTICLESCatheter Ablation For Papillary Muscle Arrhythmias A Systematic Review. Pacing Clin Electrophysiol 2022; 45:519-531. [PMID: 35147225 PMCID: PMC9302647 DOI: 10.1111/pace.14462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/07/2021] [Accepted: 01/30/2022] [Indexed: 11/25/2022]
Abstract
Background Catheter ablation of papillary muscle ventricular arrhythmias (PM‐VAs) has been associated with unsatisfactory results. Features that may affect acute and long‐term procedural outcomes are not well established. Objective To systematically review the available data in the literature assessing efficacy and safety of PM‐VAs catheter ablation. Methods An online search of PubMed, Cochrane Registry, Web of Science, Scopus and EMBASE libraries (from inception to March 1, 2021) was performed, in addition to manual screening. Twenty‐one observational noncontrolled case‐series were considered eligible for the systematic review, including 536 patients. Results Postero‐medial PM harbored 60.8% of PM‐VAs, while antero‐lateral PM and right ventricular PMs 34.9% and 4.3% of cases, respectively. The mean acute success rate of the index ablation procedure was 88.1% (95% CI 82.8% to 91.9%, p < .001, I2 0%). After a mean follow‐up period of 15.5 ± 17.4 months, pooled long‐term arrhythmia‐free rate was 69.2%, while the pooled long‐term success rate after multiple ablation procedure was 84.9%. Overall, procedure complications occurred in nine patients (1.7%) and no procedure‐related deaths were reported. The use of intracardiac echocardiography (ICE) as well as contact force sensing (CFS) and irrigated catheters during ablation was associated with higher rates of arrhythmia‐freedom at long‐term follow‐up. Conclusions Catheter ablation is an effective and safe strategy for PM‐VAs, with an acute success rate of 88.1%, a long‐term success rate of 69.2%, with a relatively low procedural complication rate. The use of ICE, irrigated catheters and catheters with CFS capability was associated with higher rates of arrhythmia‐freedom at long‐term follow‐up.
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Tschabrunn CM, Santangeli P. Maximizing papillary muscle radiofrequency ablation size: Importance of catheter orientation. J Cardiovasc Electrophysiol 2022; 33:696-697. [PMID: 35132708 DOI: 10.1111/jce.15403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
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Daw JM, Chahal CAA, Arkles JS, Callans DJ, Dixit S, Epstein AE, Frankel DS, Garcia FC, Hyman MC, Kumareswaran R, Lin D, Nazarian S, Riley MP, Santangeli P, Schaller RD, Supple GE, Tschabrunn C, Marchlinski FE, Deo R. Longitudinal Electrocardiographic Assessment in the Brugada Syndrome. Heart Rhythm O2 2022; 3:233-240. [PMID: 35734292 PMCID: PMC9207730 DOI: 10.1016/j.hroo.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The type 1 electrocardiographic (ECG) pattern diagnostic of Brugada syndrome (BrS) can be dynamic. Limited studies have rigorously evaluated the temporal stability of the Brugada ECG pattern. Objective We sought to evaluate fluctuations of the Brugada pattern in serial resting ECGs from BrS patients managed within a large health care system. Methods In our cohort of BrS patients with at least 2 standard, resting ECGs recorded on separate clinical encounters, we evaluated serial changes in the Brugada pattern and categorized patients into 1 of 3 groups: dynamic was defined as the presence of both type 1 and non–type 1 patterns in available ECGs; the provoked-only group was defined as having a non–type 1 Brugada pattern across resting ECGs; and the persistent group was defined as having a type 1 pattern on all ECGs. We also evaluated the clinical risk in this cohort according to the Shanghai risk score. Results In 72 patients with BrS (mean age 46 ± 15 years, 69% male), 828 standard, resting ECGs were recorded over a median duration of 30.2 (interquartile range 6.3–68.1) months. The dynamic group comprised 50 (69% of the cohort) patients, the provoked-only group consisted of 17 patients (24% of the cohort), and the persistent group included 5 patients. No significant differences were detected in the total number of ECGs evaluated during the follow-up period between any of the groups. Only sinus node dysfunction and a prior cardiac arrest were associated with the persistent type 1 group. The majority of patients had a low annualized risk of lethal arrhythmic events. Conclusion Most BrS patients have a dynamic Brugada pattern noted on longitudinal, resting ECGs. Expert consensus statements should provide clarity on the frequency of obtaining resting ECGs in patients suspected of having BrS during follow-up.
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Bode W, Santangeli P. Ablation Index to Guide Radiofrequency Ablation in the Left Ventricle: Are We There Yet? J Cardiovasc Electrophysiol 2022; 33:713-714. [DOI: 10.1111/jce.15380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 12/01/2022]
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K Pothineni NV, Voruganti D, Agnihotri K, Gopinathannair R, Lakkireddy D, Santangeli P. Safety of Atrial Fibrillation Ablation in the Young - A Real World Analysis. J Atr Fibrillation 2021; 13:20200489. [PMID: 34950355 DOI: 10.4022/jafib.20200489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 06/28/2020] [Accepted: 07/26/2020] [Indexed: 11/10/2022]
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Liu C, Witschey WRT, Santangeli P, Han Y. Spontaneous intramyocardial haemorrhage in a patient with wild-type transthyretin cardiac amyloidosis. Eur Heart J 2021; 42:4929. [PMID: 33346807 DOI: 10.1093/eurheartj/ehaa1026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/07/2020] [Indexed: 11/13/2022] Open
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De Angelis G, De Luca A, Merlo M, Nucifora G, Rossi M, Stolfo D, De Bellis A, Barbati G, Santangeli P, Mase M, Pagnan L, Muser D, Sinagra G. 73 Prevalence and prognostic significance of ischaemic late gadolinium enhancement pattern in non-ischaemic dilated cardiomyopathy. Eur Heart J Suppl 2021. [DOI: 10.1093/eurheartj/suab142.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
Typical late gadolinium enhancement (LGE) patterns in dilated cardiomyopathy (DCM) include intramyocardial and subepicardial distribution. However, the ischaemic pattern of LGE (subendocardial and transmural) has also been reported in DCM without coronary artery disease (CAD), but its correlates and prognostic significance are still not known. On these bases, this study sought to describe the prevalence and prognostic significance of the ischaemic LGE pattern in DCM.
Methods and results
611 DCM patients with available cardiac magnetic resonance were retrospectively analysed. A composite of all-cause-death, major ventricular arrhythmias (MVAs), heart transplantation (HTx) or ventricular assist device (VAD) implantation was the primary outcome of the study. Secondary outcomes were a composite of sudden cardiac death or MVAs and a composite of death for refractory heart failure, HTx or VAD implantation. Ischaemic LGE was found in 7% of DCM patients without significant CAD or history of myocardial infarction, most commonly inferior/inferolateral/anterolateral. Compared to patients with non-ischaemic LGE, those with ischaemic LGE had higher prevalence of hypertension and atrial fibrillation or flutter. Ischaemic LGE was associated with worse long-term outcomes compared to non-ischaemic LGE (36% vs. 23% risk of primary outcome events at 5 years, respectively, P = 0.006), and remained an independent predictor of primary outcome after adjustment for clinically and statistically significant variables [adjusted hazard ratio 2.059 (1.055–4.015), P = 0.034 with respect to non-ischaemic LGE].
Conclusions
The ischaemic pattern of LGE is not uncommon among DCM patients without CAD and is independently associated with worse long-term outcomes.
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Tschabrunn CM, Zado ES, Schaller R, Garcia FC, Kumareswaran R, Hsue W, Santangeli P, Marchlinski FE. Isolated critical epicardial arrhythmogenic substrate abnormalities in patients with arrhythmogenic right ventricular cardiomyopathy and ventricular tachycardia. Heart Rhythm 2021; 19:538-545. [PMID: 34883271 DOI: 10.1016/j.hrthm.2021.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Ventricular tachycardia (VT) substrate abnormalities in arrhythmogenic right ventricular cardiomyopathy (ARVC) typically involve both the right ventricular (RV) endocardium (ENDO) and epicardium (EPI). OBJECTIVE The purpose of this study was to examine the prevalence, electrophysiological features, and outcomes of catheter ablation of VT in patients with isolated epicardial substrate (IES) abnormalities. METHODS We studied 71 consecutive patients with VT who met Task Force criteria for ARVC and underwent detailed ENDO and EPI mapping. Patients with critical IES demonstrated (1) confluent EPI bipolar abnormal electrograms (EGMs) and (2) no or minor (<5.0 cm2) RV ENDO low bipolar voltage. Induced VTs were localized using activation mapping, entrainment mapping, and/or pacemapping. RESULTS Twelve patients (17%) had IES. Extensive EPI bipolar low-voltage area (Bi-LVA; 74 ± 40 cm2) and EGM abnormalities were identified in all patients. Uni-ENDO LVA (<5.5 mV) was seen in 11 of 12 patients (92%) (41 ± 25 cm2) and corresponded to EPI RV bipolar abnormalities. A median of 2 VTs (range 1-7; cycle length 288 ± 68 ms) were induced and localized to the EPI. EPI ablation resulted in noninducibility of all targeted VTs. Preablation cardiac magnetic resonance (CMR) imaging was performed in 10 of 12 patients with RV dyskinesis and/or late gadolinium enhancement in only 4 of 10 patients. During follow-up of 56 ± 46 months, 9 of 12 patients (75%) remained VT-free. CONCLUSION In patients with ARVC and VT, substrate abnormalities can uncommonly be isolated to the RV EPI. Detection of critical IES may be limited with CMR imaging but suggested by ENDO unipolar EGM abnormalities. EPI ablation eliminates VT in these patients and typically results in long-term VT-free survival.
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Liuba I, Muser D, Chahal A, Tschabrunn C, Santangeli P, Kuo L, Frankel DS, Callans DJ, Garcia F, Supple GE, Schaller RD, Dixit S, Lin D, Nazarian S, Kumareswaran R, Arkles J, Riley MP, Hyman MC, Walsh K, Guandalini G, Arceluz M, Pothineni NVK, Zado ES, Marchlinski F. Substrate Characterization and Outcome of Catheter Ablation of Ventricular Tachycardia in Patients With Nonischemic Cardiomyopathy and Isolated Epicardial Scar. Circ Arrhythm Electrophysiol 2021; 14:e010279. [PMID: 34847692 DOI: 10.1161/circep.121.010279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The substrate for ventricular tachycardia (VT) in left ventricular (LV) nonischemic cardiomyopathy may be epicardial. We assessed the prevalence, location, endocardial electrograms, and VT ablation outcomes in LV nonischemic cardiomyopathy with isolated epicardial substrate. METHODS Forty-seven of 531 (9%) patients with LV nonischemic cardiomyopathy and VT demonstrated normal endocardial (>1.5 mV)/abnormal epicardial bipolar low-voltage area (LVA, <1.0 mV and signal abnormality). Abnormal endocardial unipolar LVA (≤8.3 mV) and endocardial bipolar split electrograms and predictors of ablation success were assessed. RESULTS Epicardial bipolar LVA (27.3 cm2 [interquartile range, 15.8-50.0]) localized to basal (40), mid (8), and apical (3) LV with basal inferolateral LV most common (28/47, 60%). Of 44 endocardial maps available, 40 (91%) had endocardial unipolar LVA (24.5 cm2 [interquartile range, 9.4-68.5]) and 29 (67%) had characteristic normal amplitude endocardial split electrograms opposite the epicardial LVA. At mean of 34 months, the VT-free survival was 55% after one and 72% after multiple procedures. Greater endocardial unipolar LVA than epicardial bipolar LVA (hazard ratio, 10.66 [CI, 2.63-43.12], P=0.001) and number of inducible VTs (hazard ratio, 1.96 [CI, 1.27-3.00], P=0.002) were associated with VT recurrence. CONCLUSIONS In patients with LV nonischemic cardiomyopathy and VT, the substrate may be confined to epicardial and commonly basal inferolateral. LV endocardial unipolar LVA and normal amplitude bipolar split electrograms identify epicardial LVA. Ablation targeting epicardial VT and substrate achieves good long-term VT-free survival. Greater endocardial unipolar than epicardial bipolar LVA and more inducible VTs predict VT recurrence.
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Shim DJ, Maher TR, Laham RJ, Santangeli P, Zimetbaum PJ, d'Avila A. Novel use of preprocedure imaging for planning and guidance of right atrium-to-left ventricle access for catheter ablation of ventricular tachycardia. HeartRhythm Case Rep 2021; 7:726-730. [PMID: 34820267 PMCID: PMC8602118 DOI: 10.1016/j.hrcr.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Siontis KC, Santangeli P, Muser D, Marchlinski FE, Zeppenfeld K, Hoogendoorn JC, Narasimhan C, Sauer WH, Zipse MM, Kapa S, Vedantham V, Rosenthal DG, Robinson MR, Patton KK, Murgatroyd F, Chicos AB, Soejima K, Roukoz H, Sacher F, Bhan A, Appelbaum J, Dickfeld T, Mankad P, Ellenbogen KA, Kron J, Kim HM, Froehlich J, Eagle KA, Bogun FM, Crawford TC. Outcomes Associated With Catheter Ablation of Ventricular Tachycardia in Patients With Cardiac Sarcoidosis. JAMA Cardiol 2021; 7:175-183. [PMID: 34787643 DOI: 10.1001/jamacardio.2021.4738] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Ventricular tachycardia (VT) is associated with high mortality in patients with cardiac sarcoidosis (CS), and medical management of CS-associated VT is limited by high failure rates. The role of catheter ablation has been investigated in small, single-center studies. Objective To investigate outcomes associated with VT ablation in patients with CS. Design, Setting, and Participants This cohort study from the Cardiac Sarcoidosis Consortium registry (2003-2019) included 16 tertiary referral centers in the US, Europe, and Asia. A total of 158 consecutive patients with CS and VT were included (33% female; mean [SD] age, 52 [11] years; 53% with ejection fraction [EF] <50%). Exposures Catheter ablation of CS-associated VT and, as appropriate, medical treatment. Main Outcomes and Measures Immediate and short-term outcomes included procedural success, elimination of VT storm, and reduction in defibrillator shocks. The primary long-term outcome was the composite of VT recurrence, heart transplant (HT), or death. Results Complete procedural success (no inducible VT postablation) was achieved in 85 patients (54%). Sixty-five patients (41%) had preablation VT storm that did not recur postablation in 53 (82%). Defibrillator shocks were significantly reduced from a median (IQR) of 2 (1-5) to 0 (0-0) in the 30 days before and after ablation (P < .001). During median (IQR) follow-up of 2.5 (1.1-4.9) years, 73 patients (46%) experienced VT recurrence and 81 (51%) experienced the composite primary outcome. One- and 2-year rates of survival free of VT recurrence, HT, or death were 60% and 52%, respectively. EF less than 50% and myocardial inflammation on preprocedural 18F-fluorodeoxyglucose positron emission tomography were significantly associated with adverse prognosis in multivariable analysis for the primary outcome (HR, 2.24; 95% CI, 1.37-3.64; P = .001 and HR, 2.93; 95% CI, 1.31-6.55; P = .009, respectively). History of hypertension was associated with a favorable long-term outcome (adjusted HR, 0.51; 95% CI, 0.28-0.92; P = .02). Conclusions and Relevance In this observational study of selected patients with CS and VT, catheter ablation was associated with reductions in defibrillator shocks and recurrent VT storm. Preablation LV dysfunction and myocardial inflammation were associated with adverse long-term prognosis. These data support the role of catheter ablation in conjunction with medical therapy in the management of CS-associated VT.
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Markman TM, Brown CR, Yang L, Guandalini GS, Hyman MC, Arkles JS, Santangeli P, Schaller RD, Supple GE, Deo R, Nazarian S, Dixit S, Callans DJ, Epstein AE, Marchlinski FE, Groeneveld PW, Frankel DS. Persistent Opioid Use After Cardiac Implantable Electronic Device Procedures. Circulation 2021; 144:1590-1597. [PMID: 34780252 DOI: 10.1161/circulationaha.121.055524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prescription opioids are a major contributor to the ongoing epidemic of persistent opioid use (POU). The incidence of POU among opioid-naïve patients after cardiac implantable electronic device (CIED) procedures is unknown. METHODS This retrospective cohort study used data from a national administrative claims database from 2004 to 2018 of patients undergoing CIED procedures. Adult patients were included if they were opioid-naïve during the 180-day period before the procedure and did not undergo another procedure with anesthesia in the next 180 days. POU was defined by filling an additional opioid prescription >30 days after the CIED procedure. RESULTS Of the 143 400 patients who met the inclusion criteria, 15 316 (11%) filled an opioid prescription within 14 days of surgery. Among these patients, POU occurred in 1901 (12.4%) patients 30 to 180 days after surgery. The likelihood of developing POU was increased for patients who had a history of drug abuse (odds ratio, 1.52; P=0.005), preoperative muscle relaxant (odds ratio, 1.52; P<0.001) or benzodiazepine (odds ratio, 1.23; P=0.001) use, or opioid use in the previous 5 years (OR, 1.76; P<0.0001). POU did not differ after subcutaneous implantable cardioverter defibrillator or other CIED procedures (11.1 versus 12.4%; P=0.5). In a sensitivity analysis excluding high-risk patients who were discharged to a facility or who had a history of drug abuse or previous opioid, benzodiazepine, or muscle relaxant use, 8.9% of the remaining cohort had POU. Patients prescribed >135 mg of oral morphine equivalents had a significantly increased risk of POU. CONCLUSIONS POU is common after CIED procedures, and 12% of patients continued to use opioids >30 days after surgery. Higher initially prescribed oral morphine equivalent doses were associated with developing POU.
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Arceluz M, Frankel D, Tschabrunn C, Santangeli P, Bravo P, Supple G, Muser D, Callans D, Schaller R, Hyman M, Kumareswaran R, Riley M, Lin D, Arkles J, Marchlinski F. Role of QRS amplitude, fractionation and duration in predicting clinical response to anti-inflammatory treatment in cardiac sarcoidosis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Low QRS amplitude (QRSa), QRS fractionation (QRSf) and longer QRS duration (QRSd) are markers of myocardial fibrosis and inflammation in non-ischemic cardiomyopathy (NICM).
Objective
To determine if reduction of inflammation with treatment of cardiac sarcoidosis (CS) may reverse these 12 lead ECG parameter changes.
Methods
21 patients (pts) with CS and VT ablation with a positive baseline positron emission tomographic (PET 1) scan were studied. All pts received prednisone ≥40 mg for 4 to 8 weeks followed by a taper and maintenance with methotrexate ± low-dose prednisone, <10 mg/day, until clinically stable and resolution of inflammation on PET 2 one year after initial. In addition, pts with low LV ejection fraction (13/21) received guideline directed medical therapy for heart failure. Pts at 1yr with positive PET2 (9) were compared to those with negative PET2 (12). Baseline and 1yr 12-lead ECGs were analyzed for QRSd, ≥2QRSf contiguous leads and QRSa in the limb leads.
Results
Pts in PET2(+) vs PET2(−) groups has similar gender (men 89% vs 100%, p=0.42), age (57±8 vs 56±10 years, p=0.8) and LV ejection fraction (41±11 vs 46±11, p=0.31). Baseline 12-lead ECGs showed similar QRSd, ≥2QRSf contiguous leads and QRSa for PET2(+) vs PET2(−); P all >0.15 (Table 1). At 1 yr there was a lower prevalence of ≥2QRSf contiguous leads and strong trend for shorter QRS duration and larger QRSa in lead DI if PET2(−) vs PET2(+). 4 pts demonstrated loss of QRSf 2 contiguous leads and/or increase in QRSa in DI by at least 0.15 mV from baseline if PET2(−) and none if PET2(+).
Conclusions
In pts with CS and VT, reversal of inflammation may result in a greater QRSa and reduction in QRSf. An increase in QRSa in lead 1 by >0.15mV and/or loss of QRSf identifies a clear positive response to treatment and negative PET at 1 year.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Richard T and Angela Clark Innovation Fund in Cardiovascular Medicine, the Mark S Marchlinski EP Research and Education Fund and the Winkelman Family Fund in Cardiovascular Innovation. Table 1
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Pothineni NVK, Santangeli P. Electrophysiology and Interventional Cardiology Procedure Volumes During the Coronavirus Disease 2019 Pandemic. Card Electrophysiol Clin 2021; 14:105-110. [PMID: 35221077 PMCID: PMC8556575 DOI: 10.1016/j.ccep.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has imposed an unprecedented health care crisis across the globe. Health care efforts across the world have been diverted to tackling the pandemic since early 2020. Hospitals and health care systems have undertaken major restructuring in an effort to deliver health care to an increasing number of patients affected by COVID-19. Although great focus has been placed on treating those individuals suffering from COVID-19, clinicians must simultaneously balance caring for patients who are not actively infected. In anticipation of an exponential increase in COVID-19 cases, health care systems developed strategies to channel available resources to meet the rapidly rising demands of COVID-19. This change was noticed significantly in the field of invasive cardiology as well. Many cardiac catheterization and electrophysiology (EP) laboratories canceled elective procedures to limit the burden on hospital resources and preserve personal protective equipment (PPE). Major societies published guidance statements delineating patient selection for procedures during the exponential phase of the pandemic growth. Patient care was triaged and those waiting for elective procedures were managed with expectant care or noninvasive approaches to preserve hospital resources and personnel. In the current article, we review the impact of the COVID-19 pandemic and its response to the volume of interventional cardiology (IC) and EP procedures across the world.
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Arceluz MR, Liuba I, Tschabrunn CM, Frankel DS, Santangeli P, Supple GE, Schaller RD, Garcia FC, Callans DJ, Guandalini GS, Walsh K, Nazarian S, Zado ES, Marchlinski FE. Sinus rhythm QRS amplitude and fractionation in patients with nonischemic cardiomyopathy to identify ventricular tachycardia substrate and location. Heart Rhythm 2021; 19:187-194. [PMID: 34601127 DOI: 10.1016/j.hrthm.2021.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ventricular tachycardia (VT) substrate in left ventricular (LV) nonischemic cardiomyopathy (NICM) consists of fibrosis with surviving myocardium. OBJECTIVE The purpose of this study was to determine whether, in patients with LV NICM and sustained VT, reduced QRS amplitude and QRSf during sinus rhythm can identify the presence and location of abnormal septal (S-NICM) and/or free-wall (FW-NICM) VT substrate. METHODS We compared patients with NICM and VT (group 1) with electroanatomic mapping septal (S-NICM; n = 21) or free-wall (FW-NICM; n = 20) VT substrate to a 38-patient reference cohort (group 2) with cardiac magnetic resonance imaging (cMRI) and NICM but no VT referred for primary prevention implantable cardioverter-defibrillator (26 [68.4%] with late gadolinium enhancement). RESULTS Group 1 had lower QRS amplitude in leads II (0.60 ± 0.22 vs 0.86 ± 0.35, P <.001), aVR (0.60 ± 0.24 vs 0.75 ± 0.31, P = .002), aVF (0.48 ± 0.20 vs 0.70 ± 0.28, P <.001), and V2 (1.09 ± 0.52 vs 1.38 ± 0.55, P = .001) than group 2. QRS <0.55 mV in lead aVF identified VT and accompanying substrate with sensitivity 70% and specificity 71%. Most group 1 and group 2 patients had 12-lead ECG QRS fractionation (QRSf) in ≥2 contiguous leads (78% vs 63.2%, P = .14). Sensitivity and specificity for ≥2 QRSf leads identifying respective regional electroanatomic or cMRI abnormalities were 76% and 50% for inferior, 44% and 87% for lateral, and 21% and 89% for anterior leads. CONCLUSION In LV NICM, low frontal plane QRS (<0.55 mV in aVF) is associated with VT substrate. Although multilead QRS fractionation is associated with the presence and location of VT substrate, it is frequently identified in patients without VT with cMRI abnormalities.
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Pothineni NVK, Santangeli P. Concomitant Atrial Fibrillation Ablation and Appendage Occlusion: Ready for Prime Time? JACC Case Rep 2021; 3:1413-1414. [PMID: 34557682 PMCID: PMC8446243 DOI: 10.1016/j.jaccas.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Alsalem AB, Santangeli P. Catheter ablation of ventricular fibrillation in hypertrophic cardiomyopathy: Pushing the boundaries. J Cardiovasc Electrophysiol 2021; 32:2995-2996. [PMID: 34453382 DOI: 10.1111/jce.15228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
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Saksena S, Nagarakanti R, Slee AE, Lakkireddy DR, Shah DC, Biase LD, Lewalter TW, Santangeli P, Natale A. B-PO04-186 ATRIAL FIBRILLATION IS ASSOCIATED WITH WORSENING OF HEART FAILURE (HF) AND CARDIOVASCULAR HOSPITALIZATIONS (CVH) IN HF WITH PRESERVED EJECTION FRACTION (HFPEF) IN MINORITIES AND SPECIFIC CO-MORBIDITIES. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Thosani AJ, Friehling M, Liu E, Chenarides J, Santangeli P, Belden W, Shaw G. B-PO04-076 DIRECT IMAGING AND ANATOMIC RECONSTRUCTION OF THE RIGHT PHRENIC NERVE WITH INTRACARDIAC ECHOCARDIOGRAPHY: A MULTICENTER FEASIBILITY STUDY. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ptaszek LM, Koruth JS, Santangeli P, Piccini JP, Ranjan R, Mahapatra S, Pipenhagen C, Fish J, Moon B, Ambrosius NM, Boudlali H, Jensen J. B-PO02-109 SAFE AND EFFECTIVE DELIVERY OF HIGH-POWER, SHORT-DURATION RADIOFREQUENCY ABLATION LESIONS WITH A NOVEL, FLEXIBLE-TIP RADIOFREQUENCY ABLATION CATHETER. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Muser D, Magnani S, Nucifora G, Pieroni M, Enriquez A, Castro SA, Garcia FC, Callans DJ, Frankel DS, Selvanayagam J, Collini V, Arkles J, Lin D, Schaller RD, Zado ES, Tschabrunn CM, Marchlinski FE, Santangeli P. B-PO01-079 INCREMENTAL PROGNOSTIC VALUE OF MYOCARDIAL DEFORMATION IN PATIENTS WITH NON-ISCHEMIC DILATED CARDIOMYOPATHY: A FEATURE-TRACKING CARDIAC MAGNETIC RESONANCE STUDY. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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