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espanolIntroduccion: La terapia de resincronizacion cardiaca presenta una tasa de un 25%-30% de pacientes “no respondedores”. La resincronizacion endocardica, en la que el cateter del ventriculo izquierdo se implanta en el endocardio, seria una alternativa para estos pacientes, aunque su evolucion a largo plazo no ha sido investigada. Objetivos: Evaluacion hemodinamica no invasiva a largo plazo de la resincronizacion endocardica en respondedores clinicos. Metodos: Se incluyeron pacientes implantados segun los criterios para resincronizacion, usando la tecnica Jurdham, con mas de 6 meses desde el implante. Todos eran respondedores clinicos. La respuesta hemodinamica se evaluo con un analizador de la funcion cardiaca, que mide los intervalos sistolicos (periodos preeyectivo y eyectivo) del ventriculo izquierdo y calcula automaticamente un indice de funcion sistolica y estimar la fraccion de eyeccion (Systocor mod IS100). Para determinar la eficacia mecanica de la TRCe se comparo la funcion cardiaca durante el modo biventricular con el bloqueo completo de la rama izquierda, espontaneo o por estimulacion unica del ventriculo derecho; los pacientes fueron sus propios controles. Se promediaron al menos 20 latidos en cada modo de estimulacion y se consideraron solo los cambios >1% con valor p Resultados: Se incluyeron 17 pacientes, con mediana de seguimiento de 43 meses, rango 9 a 78 meses. La resincronizacion endocardica, en comparacion con la activacion ventricular con BCRI, demostro que todos los pacientes acortaron el periodo preeyectivo en un promedio de 31 ms (15%), indicativo de disminucion de la disincronia interventricular causada por el BCRI. En todos aumento el indice de funcion sistolica en 0,3 (23%) y la FE en el 8,3%. En 12/17 (71%) aumento el periodo eyectivo en promedio 8,7 mseg (2,9%), lo que sugiere un aumento del volumen sistolico. En todos los cambios el valor de p fue menor de 0,01. Conclusiones: La TRCe ofrece mejoria hemodinamica significativa a largo plazo, detectada por intervalos sistolicos. EnglishBackground: Cardiac resynchronization therapy has 25% to 30% rate of “non-responder” patients. Endocardial cardiac resynchronization therapy (eCRT), in which the left ventricular catheter is implanted in the endocardium, would be an alternative for these patients; however, its long-term outcome has not been investigated. Objectives: The aim of this study was the long-term non-invasive hemodynamic evaluation of eCRT in clinical responders. Methods: Patients implanted according to the criteria for resynchronization, using the Jurdham technique, with more than 6 months after the implant, were included in the study. All were clinical responders. The hemodynamic response was evaluated with a cardiac function analyzer, which measures the left ventricular systolic intervals (preejection and ejection periods) and automatically calculates an index of systolic function and estimates the ejection fraction (Systocor mod IS100). To assess the mechanical efficacy of eCRT, the cardiac function during biventricular mode was compared with left bundle branch block (LBBB), either spontaneous or by single stimulation of the right ventricle, with patients as their own controls. At least 20 beats were averaged in each stimulation mode and only changes >1% with p Results: Seventeen patients were included, with a median follow-up of 43 months, (9 to 78 months). Endocardial resynchronization, compared with LBBB ventricular activation, showed that all patients shortened the preejection period by an average of 31 ms (15%), indicative of decreased interventricular dyssynchrony caused by LBBB. In all patients, systolic function index increased by 0.3 (23%) and the EF by 8.3%. In 12/17 of cases (71%) the ejective period increased on average 8.7 ms (2.9%), suggesting an increase in systolic volume. In all changes p was Conclusions: Endocardial resynchronization therapy offers significant long-term hemodynamic improvement, detected by systolic intervals.

Endocardial cardiac resynchronization therapy (eCRT) avoids the limitations and failures of coronary sinus (CS) resynchronization. However, data regarding long-term outcomes are lacking.The purpose of this study was to report the long-term outcome of eCRT performed using the Jurdham procedure in a real-world setting.eCRT was performed in patients who failed a CS implant or failed to respond to cardiac resynchronization therapy (CRT), or in selected patients requiring lifelong oral anticoagulation (OAC). Left ventricular ejection fraction (LVEF), New York Heart Association functional class (NYHA FC), and left ventricular stimulation parameters were assessed during long-term follow-up (FU).From August 2009 to March 2018, the Jurdham procedure was performed in 88 patients at 15 centers in 8 countries, with FU of 32.88 ± 61.52 months (range 0-88 months; 196 patient-years). NYHA FC improved from 2.9 preimplant to 1.3 during FU. LVEF increased10 percentage points from baseline in 7% of patients, between 10 and 20 percentage points in 11% of patients, and20 percentage points in 82% of patients. All-cause mortality at 60 months was 30.5%. Three transient ischemic attacks (1.53 per 100 patient-years) and 6 strokes (3.06 per 100 patient-years) occurred. Of the 6 patients with stroke, 4 (66%) had almost complete recovery.eCRT using the Jurdham procedure is an effective and safe technique in anticoagulated patients. This approach may be an attractive option for patients with failed CS implants or nonresponders to CS CRT. In addition, it might be a reasonable approach as a first option for treatment of patients requiring lifelong OAC.

Background Endocardial stimulation of the left ventricle for cardiac resynchronization therapy is a growing field of investigation. Despite the excellent results and absence of significant complications demonstrated thus far in the literature, the lack of a simple, straightforward, and standard technique limits its widespread utilization. Objective To assess the feasibility, safety, simplicity, and complications of a technique for inserting the left ventricle lead through a femoral transseptal sheath to the pectoral implant site, termed "the Jurdham procedure." Methods We performed the Jurdham procedure in 10 patients (8 men; 60.5 ± 1.8 years) in whom a coronary sinus lead implant had failed. A snared 85-cm standard active fixation endocardial pacing lead was implanted on the left ventricle endocardium through a femoral transseptal sheath with subsequent mobilization of the proximal end of the lead to the prepectoral area via the snare. Results Successful implant was achieved in all 10 patients without complications, with excellent acute and chronic pacing parameters. All patients remained on chronic oral anticoagulation therapy without thromboembolic or bleeding complications. No late complications have occurred. All patients have improved at least 1 New York Heart Association functional class and have remained clinically stable during the follow-up term. Conclusion The Jurdham procedure is a reliable, technically easy technique to achieve cardiac resynchronization therapy via the endocardial approach. In our initial experience, there has been an excellent clinical response without significant complications during short-term follow-up. Additional investigation is needed to define the precise indications and limitations of this procedure.

Objective: Torrent Guasp concept, that postulates that the ventricles are formed by a continuous muscle band, provides the basis for two aspects of left ventricular dynamics: The torsion mechanism and the rapid early diastolic filling by the suction effect. We investigated the electrophysiological basis of this mechanism, by electroanatomical left ventricular endoepicardial mapping (EEM) in five patients, during radiofrequency ablation. Results: The apical loop is activated by a simultaneous depolarization of the distal descending and proximal ascending band segments. At the point of crossing of both bands a radial activation spreads from the descending to the ascending band. From this point, begins a simultaneous and opposing activation of the proximal and distal ascending band. The activation of the distal ascending band segment is the latest. Conclusions: The activation sequence of the continuous band provides an electrophysiological basis for the ventricular torsion and suction mechanism.

Background Dynamic aortomyoplasty is an alternative technique to heart transplantation. The goal of our study was to evaluate the benefits of aortic counterpulsation obtained by dynamic thoracic aortomyoplasty in patients with heart failure refractory to pharmacologic treatment and contraindications to heart transplant or cardiomyoplasty. Methods In this study we compared preoperative and postoperative data from five out of six carefully selected patients who were treated with dynamic thoracic aortomyoplasty. This surgical technique wraps the right latissimus dorsi muscle flap around the ascending aorta. This muscle flap was electrically stimulated during diastole, following a muscle-conditioning protocol, to obtain diastolic augmentation. At the 6-month follow-up period we evaluated, invasively and noninvasively, the hemodynamic and clinical effects of aortomyoplasty. Results We observed a significant decrease in the number of hospitalizations ( P = 0.01), NYHA functional class ( P = 0.01), cardiothoracic ratio ( P = 0.02), right ventricular diameter ( P = 0.03), left atrial diameter ( P = 0.04), and pulmonary artery systolic pressure ( P = 0.04); and a significant increase in the 6-minute walking test ( P = 0.01), cardiac index ( P = 0.04), noninvasive evaluation of diastolic augmentation ( P = 0.01), left ventricular shortening fraction ( P = 0.01), and radioisotopic left ventricular ejection fraction ( P = 0.02). We also found a nonsignificant decrease in the left ventricular diameter ( P = 0.08) and wedge pressure ( P = 0.19); and a nonsignificant increase in peak oxygen consumption ( P = 0.13). Conclusions Dynamic thoracic aortomyoplasty in heart failure resulted in an important improvement of hemodynamic parameters, heart functional data, and clinical functional class, when comparing preoperative data with the 6-month follow-up data.

Objetivos Segun la hipotesis de Torrent-Guasp el corazon es una banda miocardica sin apoyos fijos, generadora de reduccion tridimensional y comportamiento de bomba de succion. Nuestro objetivo fue analizar la secuencia de activacion y correlacionarlo con la teoria de Torrent-Guasp. Metodos Se realizo estudio electrofisiologico con el programa Carto a 4 pacientes sin cardiopatia estructural de forma concomitante a ablacion de fibrilacion auricular (FA). Los mapas isocronicos y de secuencia de activacion, 50 ± 8 puntos endocardicos, se correlacionaron con electrocardiograma (ECG) de superficie. Resultados El inicio de la actividad endocardica del ventriculo izquierdo (VI) fue registrado en la punta y con secuencia compleja hacia la base, concluyendo en la zona perivalvular mitral. La activacion endocardica del VI finalizo cuando habia transcurrido el 60% del ECG (la fase final del ECG corresponde al epicardio). Entre la sistole y diastole se produce una fase de succion (100–120 ms), es activa en su contraccion muscular, produce alargamiento ventricular y caida de presion intraventricular, responsable del llenado del 70% del VI durante el 20% del tiempo diastolico. Conclusiones La contraccion sucesiva de los segmentos de la gran banda muscular genera un ciclo cardiaco continuo ( motus perpetuus cordis ). La fase diastolica de contraccion isovolumetrica implica considerar al corazon una bomba de succion y desarrollar nuevas interpretaciones fisiopatologicas y clasificaciones de la insuficiencia cardiaca basadas en la succion. El valor del apex en la cirugia de restauracion, la contraccion diastolica de la banda ascendente y la sincronizacion de la doble banda promueve el desarrollo de nuevos dispositivos y tecnicas quirurgicas.

Dynamic aortomyoplasty is an alternative to heart transplantation. The goal of our study was to evaluate the benefits of aortic counterpulsation obtained using dynamic aortomyoplasty in patients with heart failure refractory to pharmacologic treatment and with contraindications to heart transplant.In this study, we compared the pre-operative and post-operative data of 15 selected patients who underwent dynamic thoracic aortomyoplasty. In this surgical technique, the right latissimus dorsi muscle flap is wrapped around the ascending aorta. This muscle flap was electrically stimulated during diastole, following a muscle-conditioning protocol, to obtain diastolic augmentation. At 12-month follow-up, we evaluated invasively and non-invasively the hemodynamic, clinical, and functional effects of aortomyoplasty.When comparing pre-operative data with 12-month follow-up data, we observed a significant decrease in the number of hospitalizations (p0.001) and in the New York Heart Association functional class (p0.001), and we observed significant improvement in the walking test (p0.001) and in peak oxygen consumption (p0.05).Dynamic, biologic, chronic counterpulsation of the aorta using a latissimus dorsi flap (dynamic aortomyoplasty) in selected patients with severe heart failure significantly improved hemodynamic parameters, heart functional data, and clinical functional class. A larger clinical experience with a longer follow-up would be useful in evaluating this technique's clinical relevance.

Según la hipótesis de Torrent-Guasp el corazón es una banda miocárdica sin apoyo fijo que da lugar a una reducción tridimensional, comportándose como bomba de succión. Nuestro objetivo fue validar esta hipótesis correlacionándolo con datos quirúrgicos en el tratamiento de la insuficiencia cardíaca de origen isquémico mediante remodelado ventricular basada en este modelo cardíaco. Métodos: Se realizó restauración ventricular como tratamiento de la insuficiencia cardíaca de origen isquémico según la técnica elipsoidal en 12 pacientes (edad media 67 ± 7 años, varones 7). La clase funcional fue en todos los casos New York Heart Association (NYHA) III-IV y la fracción de eyección del ventrículo izquierdo (FEVI) inferior al 35%. Los procedimientos asociados fueron: revascularización coronaria en 10 pacientes (asociada a terapia celular en 6), terapia celular en 1, sustitución mitral + terapia celular en 1. A todos se les aplicó la técnica de reducción ventricular elipsoidal. Resultados: Un paciente falleció en el postoperatorio inmediato (8,5%) por causa no cardíaca. No se registró mortalidad tardía. El seguimiento medio fue de 35 ± 16 meses. La clase funcional según la NYHA pasó de 3,3 ± 0,4 a 1,4 ± 0,3 (p

"Completed" and "abortive" alternating Wenckebach periods occurred in a symptomatic female with calcification of the mitral annulus. These arrhythmias were attributed to transverse dissociation of the His bundle into two horizontal levels "connected in series," with 2:1 block in the "distal" level and Wenckebach periods in the "proximal" level. Intra-Hisian alternating Wenckebach periods resembled those resulting from transverse dissociation of other infra-AV nodal structures in that they are rare, usually symptomatic and require pacemaker implantation. This contrasts with the variety of rhythms resulting from transverse dissociation of the AV node which occur frequently, are not always malignant, and generally are not treated with implanted pacemakers.

Sudden death is a frequent cause of mortality worldwide, affecting people with either known or unknown heart disease. Coronary artery disease is its most common etiology. 1 The causal mechanisms of sudden death have become better understood with the study of animal models 2 and patients resuscitated from cardiac arrest. 3,4 Patients in whom an electrocardiographic recording is available at the time of death offer valuable information, but are scarce. 5–18 We present data from 8 patients with coronary artery disease in whom out-of-hospital cardiac arrest was documented by ambulatory electrocardiographic recording.

The effects on ventricular arrhythmias of a new class IA drug, flecainide, were compared with those of amiodarone in 10 patients with frequent, chronic, and stable ventricular ectopic beats (VEBs). The study consisted of an initial 1-week, placebo-controlled, baseline period followed by two 12-day, randomized, crossover, double-blind treatment periods with incremental dosage and 1 month of placebo between drug periods. Frequent VEBs, which were present in all 10 patients during both placebo control periods (30 or more VEBs/hour every hour, during 24-hour Holter monitoring), were markedly suppressed (reduction greater than 80%) in nine patients with both drugs (p less than 0.01). There was almost total abolition of the VEBs in six patients with flecainide, and the satisfactory results with a minimal dose in three demonstrate its fast onset of action. Side effects from either agent were infrequent and no discontinuation was necessary. We conclude from our study that flecainide is a highly effective antiarrhythmic agent.

Severe atherosclerosis of the lower limbs causes rest pain, skin ulcerations and gangrene. In such situations and when standard surgical treatment had failed or it is impossible to employ, spinal cord stimulation (SCS) seems to be of value. Since April 1985, we have used this technique on 19 patients. The results have been beneficial in 70.6% of the cases and have shown some evidence of increasing cutaneous flow. However, randomized series are required before accepting it as having a special place in the fight against atherosclerotic disease.