Diagnostic yield of implantable loop recorders: Results from the Hellenic registry

AIMS

Implantable loop recorders (ILRs) are increasingly being used for long-term cardiac monitoring in different clinical settings. The aim of this study was to investigate the real-world performance of ILRs-including the time to diagnosis- in unselected patients with different ILR indications.

METHODS AND RESULTS

In this multicenter, observational study, 871 patients with an indication of pre-syncope/syncope (61.9%), unexplained palpitations (10.4%), and atrial fibrillation (AF) detection with a history of cryptogenic stroke (CS) (27.7%) underwent ILR implantation. The median follow-up was 28.8 ± 12.9 months. In the presyncope/syncope group, 167 (31%) received a diagnosis established by the device. Kaplan-Meier estimates indicated that 16.9% of patients had a diagnosis at 6 months, and the proportion increased to 22.5% at 1 year. Of 91 patients with palpitations, 20 (22%) received a diagnosis based on the device. The diagnosis established at 12.2% of patients at 6 months, and the proportion increased to 13.3% at 1 year. Among 241 patients with CS, 47 (19.5%) were diagnosed with AF. The diagnostic yield of the device was 10.4% at 6 months and 12.4% at 1 year. In all cases, oral anticoagulation was initiated. Overall, ILR diagnosis altered the therapeutic strategy in 26.1% in presyncope/syncope group, 2.2% in palpitations group, and 3.7% in CS group in addition to oral anticoagulation initiation.

CONCLUSIONS

In this real-world patient population, ILR determines diagnosis and initiates a new therapeutic management in nearly one fourth of patients. ILR implantation is valuable in the evaluation of patients with unexplained presyncope/syncope, CS and palpitations.

Cryoablation versus hybrid radiofrequency with high- and very-high-power short-duration catheter ablation for the treatment of paroxysmal atrial fibrillation

BACKGROUND

High-power short-duration (HPSD) and very-high-power short-duration (vHPSD-90 W/4 s) radiofrequency (RF) technology has reduced the procedure time of pulmonary vein isolation (PVI) using RF without compromising the efficacy of the technique. The current study compares the novel technology of HPSD/vHPSD with cryoablation (CRYO) in terms of efficacy, safety, and procedure time in a cohort of symptomatic patients with paroxysmal atrial fibrillation (pAF).

METHODS

This is a prospective, non-randomized trial. Patients with pAF received either CRYO or HPSD/vHPSD RF PVI. The primary endpoint of the study was arrhythmia recurrence in a 12 month follow-up period. Secondary endpoints included procedure time, fluoroscopy time, and safety.

RESULTS

104 patients were included (45 in HPSD/vHPSD and 59 in CRYO), with comparable characteristics between groups. The follow-up was 12.4 ± 0.5 months. There was no significant difference regarding arrhythmia recurrences during the early post-procedural period of the first 3 months (8.9% recurrences in HPSD/vHPSD versus 5.1% in CRYO-p 0.463) and in the mid-term follow-up of 12 months (17.8% recurrences in HPSD/vHPSD versus 10.2% in CRYO-p 0.385). Safety was excellent for both procedures. CRYO was a procedure of significantly shorter duration (64.64 ± 8.94 min versus 75.29 ± 18.30 min, p = 0.0001) at the expense of longer fluoroscopy time (HPSD/vHPSD 5.34 ± 1.83 versus 7.89 ± 3.70 min CRYO, p 0.001).

CONCLUSIONS

HPSD/vHPSD and CRYO in pAF were comparable regarding the arrhythmia recurrence rates in a 12-month follow-up with excellent safety. The hybrid approach of HPSD/vHPSD has accelerated RF-PVI compared to conventional RF, but CRYO remains a procedure of significantly shorter duration at the expense of longer fluoroscopy time.

Descending aorta to right atrial fistula: Transcatheter embolization of a very rare anomaly with coils

Key Clinical Message

Descending aorta to right atrial (RA) fistula is a rare and distinct clinical entity mimicking patent ductus arteriosus (PDA) and it may lead to rapid development of pulmonary vascular disease. Correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important. Interventional management is the treatment of choice.

Abstract

We present a case report of a trisomy 21 infant with atrial and ventricular septal defects and small patent ductus arteriosus (PDA) complicated by the presence of descending aorta to right atrial (RA) fistula with large left to right shunt leading to rapid increase in pulmonary vascular resistance. Transcatheter occlusion of the fistula followed by closure of the PDA with Nit-Occlud coil systems led to decreased pulmonary pressure and resistance permitting successful surgical repair of the patient's intracardiac defects with good outcome over 3 years of follow-up. Descending aorta to RA fistula is a rare and distinct clinical entity mimicking PDA and its correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important as it may lead to rapid development of pulmonary vascular disease.

Converting the Fontan Circulation: Challenges and Evolution

The Fontan operation, the final palliative step after a series of complex operations in patients with univentricular hearts, has undergone multiple modifications throughout the last decades, with the goal of finding the method which combines the optimal hemodynamic effects of the Fontan circulation with minimal long term side effects. An understanding of the operative evolution and subsequent side effects, as well as the management thereof seems imperative. Since its inception by Francis Fontan the, now obsolete, initial atriopulmonary connection has passed through several milestones into having now reached the era of total cavopulmonary connection. However, recently published results bring to light the new option of biventricular conversion which comes to challenge the management of Fontan patients as we know it. Currently, there is no consensus as to whether to continue with palliation in this challenging group of patients or proceed with heart transplantation. In this collective review, we provide a historic overview of the Fontan evolution as well as future insights, discussing the perspectives of options for patients with failing Fontan, including the latest addition of biventricular correction.

Electrocardiographic changes after balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension: Data from the Hellenic Registry

BACKGROUND

Balloon pulmonary angioplasty (BPA) has provided an effective invasive treatment for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). The hemodynamic improvement achieved by BPA has significantly increased the long-term prognosis of these patients, mostly by reversing the negative remodeling of the right ventricle (RV).

MATERIALS AND METHODS

In a cohort of 17 patients with symptomatic CTEPH hemodynamic data were collected before and after the completion of BPA sessions. After the confirmation of statistically significant hemodynamic improvement, we examined the changes in certain prespecified electrocardiographic (ECG) parameters (PR interval duration, QRS duration, QTc interval duration, R wave and S wave amplitude in lead I, R wave and S wave amplitude in precordial leads V1, V5 and V6) before the initiation and one month after the completion of BPA sessions. In addition, ECGs were qualitatively assessed before and after treatment for the presence of ECG abnormalities related to PH, proposed by the guidelines of the European Society of Cardiology (ESC). The term ESC criteria 1-6 was used for their description.

RESULTS

Statistically significant correlation (p < 0.05) was found between the reduction in mean pulmonary artery pressure (mPAP) and the decrease of the depth of the S wave in leads I (p 0.0069), V5 (p 0.0003), V6 (p 0.0011) and in the R wave amplitude in leads V5 (p 0.0122) and V6 (p 0.0185). From the ESC criteria, RV strain pattern was the commonest in the initial cohort, with significant improvement after therapies.

CONCLUSION

Hemodynamic improvement after BPA therapies is correlated with improved ECG amplitude parameters in leads I, V5 and V6. RV strain pattern is common among untreated patients with significant improvement after therapies.

Contemporary management of ventricular arrhythmias in heart failure

Enhanced ventricular arrhythmogenesis is commonly experienced by patients in the end-stage of heart failure spectrum. A high burden of ventricular arrhythmias can affect the ventricular systolic function, lead to unexpected hospitalizations and further deteriorate the prognosis. Management of ventricular arrhythmias in this population is challenging. Implantable cardioverter-defibrillators are protective for the immediate termination of life-threatening arrhythmias but they have no impact in reducing the arrhythmic burden. Combination treatment with invasive (catheter ablation, mechanical hemodynamic support, sympathetic denervation) and noninvasive (antiarrhythmic drugs, medical therapy for heart failure, programming of implantable devices) therapies is commonly required. The aim of this review is to present the available therapeutic options, with main focus on recently published data for catheter ablation and provide a stepwise treatment approach.