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Pulmonary vein (PV) isolation is a well-established rhythm control therapy in atrial fibrillation (AF). Currently, there is no consensus on which ablation technique to use for the first procedure, cryoballoon (CB) or radiofrequency (RF). A retrospective cohort study was conducted on 1055 patients who underwent a first ablation, to assess both techniques based on the need for reablation. Patients with CB (n = 557) and RF (n = 498) ablations were clinically characterized and the need for reablation during a 30-month follow-up was used as the primary endpoint. Independent variables were analyzed to identify potential predictors. The need for reablation was significantly lower in the CB group than in the RF group (hazard ratio = 0.45 and 95% confident interval = 0.32–0.61; p < 0.001); in both paroxysmal and persistent AF, using a full-adjusted regression Cox model by age, sex, smoking, hypertension, diabetes mellitus, dyslipidemia, severe obstructive sleep apnea, dilated left atrium, persistent AF and early recurrence. RF ablation, dilated left atrium, persistent AF and early recurrence were identified as independent predictors of reablation. In addition, the CB-redo subgroup had a lower PV reconnection than the RF-redo subgroup. In conclusion, CB ablation suggests a reduction in the need for reablation and lower PV reconnection during the follow-up than RF ablation.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic Inc. Introduction Catheter ablation of atrial fibrillation, both cryoablation and radiofrequency pulmonary vein isolation, have demonstrated to be safe and effective techniques for treating symptomatic atrial fibrillation as a first procedure. However, about one in three patients may face a redo procedure due to AF recurrence. The most suitable technique for redo is unknown. Purpose The aim of this study is to assess the efficacy of cryoballoon AF ablation as a redo technique in patients with prior cryoballoon or radiofrequency AF ablation. Methods We analyzed a nation-wide real-world cryoablation registry (RECABA) and compared patients who were referred for a first cryoballoon AF ablation procedure with those who had previously undergone cryoballoon or radiofrequency pulmonary vein isolation. The primary endpoint was AF recurrence during the first year after a 3-month blanking period. We performed survival analysis and built univariate and multivariate cox regression models. Results From 1742 patients, 1625 had a 12-month follow-up visit. 1551 (95.45%) underwent a first cryoballoon ablation, whereas 33 (2.03%) had a previous CB ablation performed and 41 (2.52%) a previous RF ablation. Mean age was 58.6 ±10.4 years and 511 (31.5%) were women. 463 (28.5%) had persistent atrial fibrillation and there were no major clinical differences between groups. Prior-CB group had a higher share of veins without electrogram visualization, with a median of 100% (IQR 75%-100%), compared to prior-RF group (median 67%, IQR 25%-75%) and first procedure group (median 25%, IQR 0%-50%). Kruskal-Wallis test Chi2=54.35, p 12-month Kaplan–Meier estimate of freedom from AF recurrence after the blanking period was 78.5% (95% CI 76.2% - 80.7%) in the first procedure group, 61.0% (95% CI 41.4% - 75.8%) in the prior-CB and 89.2% (95% CI 73.6% - 95.9%) in the prior-RF group. Log-rank test Chi2=17.49, p Multivariate cox regression analysis pointed female sex, persistent AF, and prior-CB ablation as independent predictors of AF recurrence. The adjusted HR for AF recurrence of prior-CB ablation vs first-CB ablation was 3.13 (95% CI 1.82 -5.40) and for prior-RF vs first CB-ablation was 1.01 (95% CI 0.51 – 1.97). Conclusion Repeat cryoballoon AF ablation shows higher rates of AF recurrences compared to first CB procedures or after prior RF ablation. These data suggest that patients with AF recurrence after CB-ablation have worse arrhythmic outcomes and may benefit from other ablation techniques after a recurrence.

Introduction and objectives Atrioventricular block (AVB) in the presence of bradycardic drugs (BD) can be reversible, and pacemaker implantation is controversial. Our objective was to analyze the pacemaker implantation rate in the mid-term, after BD suspension, and to identify predictive factors. Methods We performed a cohort study that included patients attending the emergency department with high-grade AVB in the context of BD. We studied the persistence of AVB after BD discontinuation, recurrence in patients with AVB resolution, and the predictive variables associated with pacemaker requirement at 3 years. Results Of 127 patients included (age, 79 [71-83] years), BAV resolved in 60 (47.2%); among these patients, recurrence occurred during the 24-month median follow-up in 40 (66.6%). Pacemaker implantation was required in 107 patients (84.3%), despite BD discontinuation. On multivariable analysis, the variables associated with pacemaker need at 3 years were heart rate C I, 1.82-36.17), symptoms other than syncope (OR, 4.09; 95%CI, 1.18-14.13), and wide QRS (OR, 5.65; 95%CI, 1.77-18.04). Concomitant antiarrhythmic treatment was associated with AVB resolution (OR, 0.12; 95%CI, 0.02-0.66). Conclusions More than 80% of patients with AVB secondary to BD require pacemaker implantation despite drug discontinuation. Predictive variables were wide QRS, heart rate

Resumen Introduccion y objetivos El bloqueo auriculoventricular (BAV) en presencia de farmacos bradicardizantes (FBZ) puede ser reversible, y esta en controversia el implante de marcapasos. El objetivo es analizar la necesidad de tratamiento con marcapasos a medio plazo, tras la suspension de los FBZ, e identificar factores predictores. Metodos Se estudio a una cohorte de pacientes que acudieron a urgencias con BAV de alto grado mientras tomaban FBZ. Se estudio la persistencia de BAV tras la interrupcion del farmaco, la recurrencia en los pacientes con resolucion del BAV y las variables predictoras asociadas con la necesidad de marcapasos a los 3 anos de seguimiento. Resultados De 127 pacientes (edad, 79 [71-83] anos), en 60 (47,2%) se resolvio el BAV; de estos, en 40 (66,6%) el BAV recurrio en los 24 meses de seguimiento medio; 107 pacientes (84,3%) tuvieron indicacion de implante de marcapasos pese a suspenderse los FBZ. Las variables asociadas con la necesidad de marcapasos a los 3 anos en el multivariable fueron: frecuencia cardiaca Conclusiones Mas del 80% de los pacientes con BAV secundario a FBZ precisan implante de marcapasos a pesar de suspenderlos; los predictores son el QRS ancho, la frecuencia cardiaca

Introduction and objectives: This report presents the findings of the 2018 Spanish Catheter Ablation Registry. Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results: Data sent by 100 centers were analyzed, with a total number of 16,566 ablation procedures performed (the highest historically reported in this registry) for a mean of 165.5 ± 127.9 and a median of 119 procedures per center. The ablation targets most frequently treated were atrial fibrillation (n = 4234; 25.6%), atrioventricular nodal re-entrant tachycardia (n = 3525; 21.3%) and cavotricuspid isthmus (n = 3425; 20.7%). A new peak was observed in the ablation of atrial fibrillation, increasing the distance from the other substrates. The overall success rate was 91%. The rate of major complications was 2.2%, and the mortality rate was 0.04%. A total of 2.1% of the ablations were performed in pediatric patients. Conclusions: The Spanish Catheter Ablation Registry systematically and continuously enrolls the ablation procedures performed in Spain, showing a progressive increase in the number of ablations over the years, with a high success rate and low percentage of complications.

ObjectivesThe association between obesity and atrial fibrillation (AF) is well-established. We aimed to evaluate the impact of index body mass index (BMI) on AF recurrence at 12 months following catheter ablation using propensity-weighted analysis. In addition, periprocedural complications and fluoroscopy details were examined to assess overall safety in relationship to increasing BMI ranges.MethodsBaseline, periprocedural and follow-up data were collected on consecutive patients scheduled for AF ablation. There were no specific exclusion criteria. Patients were categorised according to baseline BMI in order to assess the outcomes for each category.ResultsAmong 3333 patients, 728 (21.8%) were classified as normal (BMI 2), 1537 (46.1%) as overweight (BMI 25.5–29.0 kg/m2) and 1068 (32.0%) as obese (BMI ≥30.0 kg/m2). Procedural duration and radiation dose were higher for overweight and obese patients compared with those with a normal BMI (p=0.002 and p2led to a 1.2-fold increased likelihood of experiencing recurrent AF at 12-months follow-up as compared with overweight patients (HR 1.223; 95% CI 1.047 to 1.429; p=0.011), while no significant correlation was found between overweight and normal BMI groups (HR 0.954; 95% CI 0.798 to 1.140; p=0.605) and obese versus normal BMI (HR 1.16; 95% CI 0.965 to 1.412; p=0.112).ConclusionsPatients with a baseline BMI ≥30 kg/m2have a higher recurrence rate of AF following catheter ablation and therefore lifestyle modification to target obesity preprocedure should be considered in these patients.

Introduction and objectives Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized by progressive fibrofatty replacement of predominantly right ventricular myocardium . This cardiomyopathy is a frequent cause of sudden cardiac death in young people and athletes. The aim of our study was to determine the incidence of pathological or likely pathological desmosomal mutations in patients with high-risk definite ARVC. Methods This was an observational, retrospective cohort study , which included 36 patients diagnosed with high-risk ARVC in our hospital between January 1998 and January 2015. Genetic analysis was performed using next-generation sequencing . Results Most patients were male (28 patients, 78%) with a mean age at diagnosis of 45 ± 18 years. A pathogenic or probably pathogenic desmosomal mutation was detected in 26 of the 35 index cases (74%): 5 nonsense, 14 frameshift, 1 splice, and 6 missense. Novel mutations were found in 15 patients (71%). The presence or absence of desmosomal mutations causing the disease and the type of mutation were not associated with specific electrocardiographic, clinical, arrhythmic, anatomic, or prognostic characteristics. Conclusions The incidence of pathological or likely pathological desmosomal mutations in ARVC is very high, with most mutations causing truncation. The presence of desmosomal mutations was not associated with prognosis.

Resumen Introduccion y objetivos La miocardiopatia arritmogenica del ventriculo derecho (MCAVD) es una cardiopatia hereditaria definida por la sustitucion progresiva de miocardio ventricular derecho por tejido fibroadiposo. Es causa frecuente de la muerte subita de jovenes atletas. El objetivo del presente estudio es conocer la incidencia de variantes desmosomicas patogenicas o probablemente patogenicas en pacientes con MCAVD definitiva de alto riesgo. Metodos El estudio de cohortes retrospectivo observacional incluyo a 36 pacientes diagnosticados de MCAVD definitiva de alto riesgo en nuestro hospital entre enero de 1998 y enero de 2015. El analisis genetico se realizo con next-generation sequencing. Resultados La mayoria eran varones (28 pacientes, 78%) con una media de edad al diagnostico de 45 ± 18 anos. Se detecto al menos 1 variante desmosomica patogenica o probablemente patogenica en 26 de los 35 casos indice (74%): 5 nonsense, 14 frameshift, 1 splice y 6 missense. En 15 pacientes (71%) se encontraron mutaciones nuevas. La presencia o la ausencia de mutaciones desmosomicas o la naturaleza de estas no se asociaron con caracteristicas electrocardiograficas, clinicas, arritmicas, anatomicas o pronosticas especificas. Conclusiones La incidencia de variantes desmosomicas patogenicas o probablemente patogenicas en MCAVD definitiva de alto riesgo fue muy alta, con mayoria de mutaciones que causan truncamiento. La presencia de mutaciones desmosomicas no se asocio con el pronostico.

Resumen Introduccion y objetivos Se describen los resultados del Registro Espanol de Ablacion con Cateter correspondientes al ano 2017. Metodos La recogida de datos se llevo a cabo de forma retrospectiva con la cumplimentacion de un formulario de recogida de datos de cada uno de los centros participantes. Resultados El numero total de procedimientos de ablacion fue de 15.284 realizados en 98 centros (mayor numero de centros y de procedimientos de ablacion comunicados historicamente en este registro) con una media de 156 ± 126 y una mediana de 136 procedimientos. El sustrato abordado con mas frecuencia ha sido por primera vez en el registro la fibrilacion auricular (n = 3.457; 22,6%), seguida del istmo cavotricuspideo (n = 3.449; 22,5%) y la taquicardia intranodular (n = 3.429; 22,4%). La tasa total de exito fue del 87%; la de complicaciones mayores, del 2,6% y la mortalidad, del 0,09%. Se ha producido un aumento de los procedimientos realizados sin apoyo de fluoroscopia hasta suponer un 6% del total de las ablaciones. Un 2,3% de las ablaciones se realizo en pacientes pediatricos. Conclusiones El Registro Espanol de Ablacion con Cateter recoge sistematica e ininterrumpidamente los procedimientos de ablacion realizados en Espana, y esto nos ha permitido observar un aumento progresivo del numero de ablaciones y de centros que las realizan manteniendo una tasa de exito elevada y unos porcentajes de complicaciones bajos.

INTRODUCTION Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited cardiomyopathy characterized by ventricular arrhythmias and heart failure. The variable phenotype suggesting that determined environmental factors may have an influence. The aim of our study was to discover the impact of the dynamic physical activity on patients with high-risk definite ARVC/D. METHODS AND RESULTS Collection of data on physical activity at the time of diagnosis was conducted at an in-person clinical interview. The intensity of the activity was classified in accordance with the mean frequency of weekly physical exercise sessions in the 10 years before diagnosis and into the following three groups of dynamic activity: high/competitive (>3 h/wk), moderate (1 to 3 h) and minimal/inactive (

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC/D) is an inherited cardiomyopathy characterized by ventricular arrhythmias and heart failure. The aim of our study was to analyze the impact of the ICD indication in the prognosis of patients with high-risk ARVC/D according to the consensus document. Methods The high-risk category includes patients who experienced cardiac arrest due to sustained ventricular tachycardia or ventricular fibrillation and patients with severe right or left ventricular dysfunction. We included 41 patients with high-risk ARVC/D: 33 in secondary prevention and 8 in primary prevention. Results We followed 41 patients during 6.37 ± 4.88 years. Twenty-six patients (63.4%) had at least one appropriate arrhythmic event: 24 p (72.7%) in secondary prevention and 2 p (25%) in primary prevention; p=0.02. Twenty-four patients (72.7%) in secondary prevention and five (62.5%) in primary prevention had a cardiovascular event such as arrhythmias, admission due to heart failure, heart transplantation or cardiovascular death. Conclusions High-risk ARVC/D patients had a high number of cardiovascular events, but their nature and treatment were different. Arrhythmic prognosis was worse in secondary prevention and most of the events found in primary prevention were related to heart failure and, therefore, without benefit of the ICD.

Introduction and objectives: This report describes the findings of the 2017 Spanish Catheter Ablation Registry. Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results: A total of 15 284 ablation procedures were performed by 98 institutions (the highest number of ablations and institutions historically reported in this registry), with a mean of 156 ± 126 and a median of 136 procedures per center. For the first time, the most frequently treated ablation target was atrial fibrillation (n = 3457; 22.6%), followed by cavotricuspid isthmus (n = 3449; 22.5%) and atrioventricular nodal re-entrant tachycardia (n = 3429; 22.4%). The overall success rate was 87%. The rate of major complications was 2.6%, and the mortality rate was 0.09%. The percentage of procedures performed without fluoroscopic support increased to 6% of all ablations, and 2.3% of all ablations were performed in pediatric patients. Conclusions: The Spanish Ablation Catheter Registry systematically and uninterruptedly collects data on the ablation procedures performed in Spain, revealing that both the number of ablations and the number of centers performing them has progressively increased, while maintaining a high success rate and a low percentage of complications.

Aims Hypertrophic cardiomyopathy is one of the main causes of sudden death in young people. Recent clinical practice guidelines include a risk prediction model for sudden death (HCM Risk-SCD), which facilitates the decision of whether to implant a defibrillator. The aim of our study was to ascertain the percentage of events in our series of primary prevention implantable cardioverter-defibrillator recipients with hypertrophic cardiomyopathy and whether HCM Risk-SCD predicts the onset of arrhythmic events. Methods and results This was an observational, retrospective cohort study, which included 48 primary prevention defibrillator recipient patients with HCM. We compiled their demographic and clinical characteristics, estimated 5-year risk using HCM Risk-SCD, and collected the documentation on arrhythmias during follow-up. The majority was male (66.7%) and mean age at implantation was 44.44 ± 14.46 years. Non-sustained ventricular tachycardia was the most prevalent risk factor (66.67%), followed by a family history of sudden death (47.92%). Mean HCM Risk-SCD was 6.15 ± 5.01%. HCM Risk-SCD was the only factor independently associated with the onset of ventricular tachyarrhythmia, above any other classic risk factor or association [odds ratio = 1.46 (95% confidence interval 1.051–2.013); P = 0.02]. None of the 11 patients estimated as low risk using HCM Risk-SCD suffered any appropriate events ( P < 0.05). Conclusions During an average follow-up of 4 years, 16.67% presented appropriate events (4.16%/year). HCM Risk-SCD predicted the onset of events more suitably than classic risk factors.

Resumen Introduccion y objetivo Realizamos este estudio para conocer si la normalizacion de la funcion ventricular tras terapia de resincronizacion (TRC) es mantenida a largo plazo, y su impacto sobre terapias con desfibrilador (DAI) y mortalidad cardiovascular. Metodos En pacientes con miocardiopatia dilatada idiopatica con DAI-TRC, se analizo la fraccion de eyeccion (FE) basal y tras 6 meses del implante, definiendo un grupo (A) que normalizo la FE (≥ 55%) y un grupo (B) restante, con seguimiento a largo plazo, para conocer la evolucion de la FE en ambos grupos y su impacto clinico-arritmico. Resultados De 47 pacientes incluidos, 10 normalizaron la FE a los 6 meses. Los unicos factores predictores fueron el volumen telesistolico del ventriculo (OR: 0,94; IC 95%: 0,92-0,97) y orificio regurgitante mitral (OR: 0,89; IC 95%: 0,86-0,93). Tras seguimiento ecocardiografico medio de 46 meses los pacientes del grupo A mantuvieron la FE preservada (61 ± 6 vs. 64 ± 6%; p = 0,342), y no presentaron ningun evento arritmico. El grupo B, sin mejoria significativa de la FE, presento mas eventos arritmicos (0 vs. 29,7%; p = 0,039). Ademas, en el grupo A no se registro muerte cardiovascular, frente al grupo B con 12 (0 vs. 32,4%; p = 0,031). Conclusiones La normalizacion de la FE a corto plazo en pacientes con miocardiopatia dilatada idiopatica tras TRC se mantiene en el tiempo, e identifica a pacientes con un excelente pronostico a largo plazo.

Background The Quartet™ quadripolar lead (St. Jude Medical Inc., St. Paul, MN, USA) offers 10 different left ventricle pacing configurations that may further influence hemodynamic parameters compared to traditional bipolar pacing configurations. The purpose of this study was to evaluate whether pacing from additional quadripolar lead vectors could enhance cardiac output (CO). Methods For each patient, CO was measured in “no-pacing” and in all the 10 configurations available, within 7 days of implantation of the device. Tip-ring, tip-right ventricular coil (RVC), and ring-RVC vectors were considered as traditional vectors. The seven additional configurations available in the quadripolar lead were considered as nontraditional vectors. CO was measured by ECHO. The best configuration was defined as the one presenting the highest CO measurement within configurations, which have a capture threshold

The purpose of this study was to evaluate the need for a permanent pacemaker after transcatheter aortic valve implantation with the CoreValve prosthesis (Medtronic, Inc., Minneapolis, Minnesota) using the new Accutrak delivery system (Medtronic, Inc.).The need for a permanent pacemaker is a recognized complication after transcatheter aortic valve implantation with the CoreValve prosthesis.Between April 23, 2008 and May 31, 2011, 195 consecutive patients with symptomatic aortic valve stenosis underwent transcatheter aortic valve implantation using the self-expanding CoreValve prosthesis. In 124 patients, the traditional delivery system was used, and in 71 patients, the Accutrak delivery system was used.There were no significant differences in baseline electrocardiographic characteristics between the traditional system and the Accutrak patients: PR interval: 153 ± 46 mm versus 165 ± 30 mm, p = 0.12; left bundle branch block: 22 (20.2%) versus 8 (12.7%), p = 0.21; right bundle branch block: 21 (19.3%) versus 8 (12.7%), p = 0.26. The depth of the prosthesis in the left ventricular outflow tract was greater with the traditional system than with the Accutrak system (9.6 ± 3.2 mm vs. 6.4 ± 3 mm, p0.001) and the need for a permanent pacemaker was higher with traditional system than with Accutrak (35.1% vs. 14.3%, p = 0.003). The predictors of the need for a pacemaker were the depth of the prosthesis in the left ventricular outflow tract (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 1.08 to 1.34, p0.001), pre-existing right bundle branch block (HR: 3.5, 95% CI: 1.68 to 7.29, p = 0.001), and use of the traditional system (HR: 27, 95% CI: 2.81 to 257, p = 0.004).The new Accutrak delivery system was associated with less deep prosthesis implantation in the left ventricular outflow tract, which could be related to the lower rate of permanent pacemaker requirement.

Introduccion y objetivos Los cambios en la conduccion auriculoventricular son frecuentes tras el implante percutaneo de la protesis aortica, pero se desconoce que mecanismos estan implicados y su evolucion. Analizamos las alteraciones electrocardiograficas y los predictores de la necesidad de marcapasos tras el implante percutaneo con la protesis aortica CoreValve®. Metodos Entre abril de 2008 y octubre de 2009 se ha tratado a 65 pacientes con estenosis aortica grave sintomatica mediante la protesis aortica CoreValve®. Se analizaron caracteristicas clinicas y electrocardiograficas y predictores de la necesidad de marcapasos por bloqueo auriculoventricular avanzado. Del analisis se excluyo a 3 pacientes por tener marcapasos y a un cuarto paciente que fallecio durante el procedimiento. Resultados La media de edad era 79 ± 7,8 anos y el EuroSCORE logistico, 20% ± 14%. El exito del implante fue del 98,4%. Tras el implante de la protesis, el 47,5% tenia bloqueo de rama izquierda y 21 pacientes (34,4%) precisaron de marcapasos definitivo. La necesidad de marcapasos se relaciono con la mayor profundidad de la protesis en el tracto de salida del ventriculo izquierdo (TSVI) (13 ± 2,5 frente a 8,8 ± 2,8 mm; p Conclusiones Tras el implante de la protesis aortica CoreValve®, un alto porcentaje de pacientes precisan de marcapasos definitivo por bloqueo auriculoventricular avanzado. El unico predictor independiente es la profundidad de la protesis en el TSVI y podria detectar precozmente la necesidad de marcapasos.

Although changes in atrioventricular conduction frequently occur after percutaneous implantation of an aortic valve prosthesis, little is known about the mechanisms involved or how these changes progress. We investigated ECG abnormalities and predictors of pacemaker need after percutaneous implantation of the CoreValve® aortic valve prosthesis.Between April 2008 and October 2009, 65 patients with symptomatic severe aortic stenosis received a CoreValve® prosthesis. Clinical and ECG parameters were recorded and predictors of pacemaker need due to advanced atrioventricular block were investigated. The analysis excluded three patients because they had pacemakers and a fourth who died during the procedure.The patients' mean age was 79 ± 7.8 years and their logistic EuroSCORE was 20 ± 14%. Implantation was successful in 98.4%. After implantation, 47.5% had left bundle branch block and 21 patients (34.4%) required a permanent pacemaker. The need for a pacemaker was associated with a greater depth of prosthesis implantation in the left ventricular outflow tract (LVOT): 13 ± 2.5 mm vs. 8.8 ± 2.8 mm (P.001). Moreover, depth was the only predictor: odds ratio 1.9, 95% confidence interval 1.19-3.05 (P.007). A cutpoint of 11.1 mm for the prosthesis depth in the LVOT had a sensitivity of 81% and a specificity of 84.6% for predicting the need for a pacemaker.After CoreValve® aortic valve prosthesis implantation, a high percentage of patients needed a permanent pacemaker for advanced atrioventricular block. The only independent predictor was the depth of the prosthesis in the LVOT, which could serve as an early indicator of pacemaker need.

El objetivo fue comparar el efecto de la terapia de resincronizacion cardiaca en la funcion ventricular y el remodelado inverso en pacientes en ritmo sinusal y fibrilacion auricular sin ablacion del nodulo auriculoventricular. Se analizaron parametros clinicos y ecocardiograficos antes y 6 meses tras la resincronizacion de 55 pacientes: 15 en fibrilacion auricular y 40 en ritmo sinusal. La programacion del dispositivo, el estrechamiento del QRS y la asincronia ecocardiografica tras el implante fueron similares en ambos grupos. Sin embargo, aunque en ambos grupos se observo mejoria significativa del volumen telesistolico y la fraccion de eyeccion, los pacientes en ritmo sinusal presentaron mayor remodelado inverso (reduccion del volumen telesistolico del 30,9% ± 24,6% contra el 12,5% ± 18,6%; p = 0,024) y aumento relativo en la fraccion de eyeccion (el 15,4% ± 12,6% y el 5% ± 7,2%; p = 0,010). La terapia de resincronizacion en pacientes con fibrilacion auricular sin ablacion del nodulo mejora significativamente la fraccion de eyeccion y el remodelado inverso, pero menos que en ritmo sinusal.

The aim of this study was to compare the effects of cardiac resynchronization therapy on left ventricular function and reverse remodeling in patients in sinus rhythm with the effects in patients with atrial fibrillation who have not undergone atrioventricular node ablation. Echocardiographic and clinical parameters were evaluated at baseline and after 6 months of cardiac resynchronization therapy in 55 patients: 15 had atrial fibrillation and 40 were in sinus rhythm. Device programming was similar in the 2 groups, as were the reductions in QRS interval and echocardiographic measures of asynchrony observed after implantation. However, although significant improvements in end-systolic volume and ejection fraction were seen in both groups, reverse remodeling was greater in patients in sinus rhythm (reduction in end-systolic volume 30.9%+/-24.6% vs 12.5%+/-18.6%; P=.024), as was the relative increase in ejection fraction (15.4%+/-12.6% vs 5.0%+/-7.2%; P=.010). Cardiac resynchronization therapy in patients with atrial fibrillation who had not undergone atrioventricular node ablation resulted in significant improvements in ejection fraction and reverse remodeling, but these were less than those observed in patients in sinus rhythm.

Aims Cardiac resynchronization therapy (CRT) reduces the degree of functional mitral regurgitation (FMR). However, FMR has also been associated with a lack of clinical response to CRT. We undertook this study to determine whether the presence of FMR influences the reverse remodelling induced by CRT. Methods and results We used Doppler echocardiography to assess 20 patients with dilated cardiomyopathy before and 6 months after undergoing CRT. We evaluated the effect of reverse remodelling (reduction ≥ 10% in end-systolic volume) according to the presence or absence of important FMR, defined as a regurgitant orifice area (ROA) of ≥ 0.20 cm2. Of the 20 patients (mean age, 64.7 ± 8.2 years, eight women), 9 had marked FMR (ROA 0.40 ± 0.12 cm2), 6 mild FMR (ROA 0.15 ± 0.02 cm2), and 5 had trivial or no FMR. CRT reduced the presence of mitral regurgitation by 33.3% and induced reverse remodelling in 60% of the patients. A ROA ≥ 0.20 cm2 was associated with a lack of reverse remodelling, despite presenting similar baseline characteristics and a reduction in asynchrony to the other patients. Reverse remodelling was produced in all the other patients, with a significant reduction in end-systolic volume (41.7 ± 21%; P = 0.003), accompanied by improvement in the ejection fraction ( P = 0.003) and myocardial performance index ( P = 0.027). Conclusion CRT improved FMR, although the baseline presence of important mitral regurgitation, with a ROA ≥ 0.20 cm2, in patients undergoing CRT was associated with a lack of response in reverse remodelling.

Introduccion y objetivos La aparicion de episodios frecuentes de taquicardia ventricular es un problema para los pacientes portadores de un desfibrilador implantable y en ocasiones requiere la combinacion de un tratamiento antiarritmico o una ablacion con radiofrecuencia. Hemos analizado los resultados de esta tecnica en el grupo de pacientes portadores de desfibrilador por taquicardia ventricular sincopal previa que presentaron taquicardia ventricular frecuente o incesante. Pacientes y metodo Se realizaron 18 procedimientos de ablacion en 11 varones de 67,64 ± 5,87 anos con estas caracteristicas; 10 pacientes habian presentado un infarto de miocardio 15,50 ± 5,08 anos antes y otro tenia una displasia arritmogenica del ventriculo derecho. Hasta la ablacion se produjeron 591,67 ± 1.020,34 episodios de taquicardia ventricular (rango, 7-2.604). Resultados El exito electrofisiologico inicial fue del 72,73% (n = 8). Tras un seguimiento de 39,10 ± 24,70 meses, el numero de descargas del desfibrilador disminuyo significativamente en todos los pacientes y paso de 52,82 ± 35,73 (rango, 7-130) a 0,64 ± 1,03 (rango, 0-3) (p = 0,001); 9 pacientes presentaron posteriormente alguna taquicardia ventricular; 6 enfermos necesitaron nuevos intentos de ablacion (2 por fracaso inicial, 3 por recurrencia y 1 por una taquicardia diferente). Con independencia del resultado electrofisiologico, todos los pacientes presentaron buena evolucion clinica a largo plazo. Conclusiones La ablacion con radiofrecuencia interrumpe de manera eficaz la situacion de taquicardia ventricular incesante o muy recurrente y reduce significativamente las descargas del desfibrilador, incluso tras el fracaso electrofisiologico, y es especialmente util en estas situaciones criticas, cuando otras terapias resultan ineficaces o insuficientes. Dado que nuestros pacientes son mayoritariamente isquemicos y muy proclives a presentar nuevos eventos arritmicos durante su seguimien to, la ablacion no se considero sustitutiva, sino complementaria del desfibrilador implantable.

The frequent occurrence of ventricular tachycardia can be a serious problem for patients with an implantable defibrillator, and may necessitate adjuvant antiarrhythmic therapy or radiofrequency catheter ablation. We analyzed the long-term results obtained with this latter therapy in patients suffering from frequent or continuous ventricular tachycardia.Eighteen ablation procedures were performed in 11 patients who had a defibrillator implanted because of previous syncopal ventricular tachycardia. All were men, aged 67.64 (5.87) years; 10 patients had had a myocardial infarction 15.50 (5.08) years earlier, and one suffered from arrhythmogenic right ventricular dysplasia.Electrophysiologically, treatment was initially successful in 8 patients (72.73%). After a follow-up period of 39.10 (24.70) months, the number of defibrillator discharges decreased significantly in all patients, from 52.82 (35.73) to 0.64 (1.03) (P=.001). During follow-up, ventricular tachycardia occurred in nine patients. In five, it took the same form as the ablated ventricular tachycardia. Six patients needed additional ablation procedures: two because of initial failure, three because of recurrence, and one because a different ventricular tachycardia occurred. In addition to the good electrophysiological results obtained, long-term clinical evolution was favorable in all patients.Radiofrequency ablation successfully disrupts frequent or continuous ventricular tachycardias and significantly reduces the defibrillator discharge rate even when ablation has failed electrophysiologically. It is particularly useful in these latter critical situations, in which other therapies are not sufficiently effective. Because our patients mainly had ischemic heart disease and were highly susceptible to new arrhythmias during follow-up, ablation complemented rather than replaced the implantable defibrillator.

reference group. They also found that normotensive individuals with preserved eGFR (≥90 ml/min/1.73 m) and moderately high ACR (30 to 299 mg/g) have an elevated risk of all-cause death [5]. The results are very similar to the results of our study. Therefore, to conclude that our results are inconsistent with the results of the previous studies may be the result of an incorrect interpretation of the results from the previous studies. Dr. Kawada requested the authors to add medication profiles for hypertension and diabetes mellitus [1]. We added the prevalence of hypertensive subjects on medication and diabetic subjects on medication in Table 2 of this paper. We are confident that the high risks of outcomes in individuals with preserved eGFR and albuminuria observed in our study reflect a true relationship. However, we agree with some of the comments by Dr. Kawada. We used too many explanatory variables in the multivariate-adjusted Poisson model and we share Dr. Kawada's concerns about type I error (overfitting) [6]. We hope the analyses were performed in the spirit of Dr. Kawada's intent. Finally, we strongly agree with the phrase “keeping a satisfactory number of events for the epidemiological study to keep the validity of the outcome” provided by Dr. Kawada. We appreciate having the opportunity to discuss the problem and we express our deepest gratitude to Dr. Kawada.

Introduccion y objetivos La indicacion de coronariografia en pacientes valvulares es recomendada de forma rutinaria previa a la realizacion de cirugia. La seleccion se hace en funcion de la edad, sexo y presencia de angina pero no suele estar basada en los factores de riesgo. El objetivo de este estudio es valorar marcadores que permitan predecir la probabilidad de lesion coronaria en este grupo de pacientes. Pacientes y metodos Se estudio retrospectivamente una poblacion de 541 pacientes con enfermedad valvular a los que se realizo coronariografia durante el periodo 1989-1994. De ellos, 301 eran varones y 240 mujeres con una edad media de 61,8 anos (rango, 34-82). Se relaciono la presencia de lesion coronaria con las variables edad, sexo, angina, hipertension, diabetes, hipercolesterolemia, tabaco, antecedentes familiares y la presencia de angina mediante analisis de regresion logistica. Resultados En 73 pacientes existia lesion coronaria superior al 50% (13,4%). La presencia de angina se aprecio en el 34,6% de los casos. El riesgo de lesion coronaria fue definido como odds ratio: angina 3,3, tabaco 2,6, diabetes 2,2, hipertension 1,8 y edad 1,4. El resto de variables no fueron predictoras de enfermedad coronaria. La probabilidad de lesion coronaria en pacientes sin angina y ausencia de los factores de riesgo descritos como predictores es del 4%. Si ademas analizamos la edad la probabilidad de enfermedad coronaria en pacientes menores de 65 anos era del 3% para los pacientes sin angina ni factores de riesgo, en cambio la probabilidad en el mismo grupo de pacientes > 65 anos fue del 6%. Conclusiones La ausencia de angina y de al menos los tres factores de riesgo descritos como predictores (tabaquismo, hipertension y diabetes) en pacientes menores de 65 anos permite descartar la enfermedad coronaria asociada en pacientes valvulares que van a ser intervenidos quirurgicamente lo que permite obviar la coronariografia en este grupo de pacientes.

The Quartet quadripolar lead (St. Jude Medical Inc., St. Paul, MN, USA) offers 10 different left ventricle pacing configurations that may further influence hemodynamic parameters compared to traditional bipolar pacing configurations. The purpose of this study was to evaluate whether pacing from additional quadripolar lead vectors could enhance cardiac output (CO).For each patient, CO was measured in "no-pacing" and in all the 10 configurations available, within 7 days of implantation of the device. Tip-ring, tip-right ventricular coil (RVC), and ring-RVC vectors were considered as traditional vectors. The seven additional configurations available in the quadripolar lead were considered as nontraditional vectors. CO was measured by ECHO. The best configuration was defined as the one presenting the highest CO measurement within configurations, which have a capture threshold3 V and a safety margin between the capture and the phrenic nerve stimulation thresholds.Fifty-one standard cardiac resynchronization therapy patients were enrolled. The mean of each patient's best CO obtained with traditional vectors was higher than the baseline nonpaced CO (4.16 L/min vs 3.64 L/min). The mean of each patient's best CO, including all 10 available configurations, was also higher than the baseline nonpaced CO (4.33 L/min vs 3.64 L/min). In addition, the mean of each patient's best CO obtained with the best configuration available through a quadripolar lead was better than the mean of each patient's best CO obtained with a traditional configuration. In 53% of patients, the best CO was obtained with a nontraditional vector unique to the quadripolar lead.A quadripolar lead offers multiple additional pacing options to increase CO acutely compared to conventional bipolar leads.