Publications by authors named "Daniele Muser"

97 Publications

Substrate Characterization and Outcomes of Ventricular Tachycardia Ablation in Titin Cardiomyopathy: A Multicenter Study.

Circ Arrhythm Electrophysiol 2021 Jul 28. Epub 2021 Jul 28.

Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA.

- Truncating variants of the titin gene (TTNtv) are a leading cause of dilated cardiomyopathy (DCM) and have been associated with an increased risk of ventricular arrhythmias. This study evaluated the substrate distribution and the acute and long-term outcomes of patients with TTN-related cardiomyopathy undergoing ventricular tachycardia (VT) ablation. - This multicenter registry included 15 patients with DCM (age 59±11 years, 93% male, ejection fraction 30±12%) and genotypically confirmed TTNtvs who underwent VT ablation between July 2014 and July 2020. - All patients presented with sustained monomorphic VT, including electrical storm in 4 of them. A median of 2 VTs per patient were induced during the procedure (cycle-length 318±68 ms) and the predominant morphologies were left bundle branch block with inferior axis (39%) and right bundle branch block with inferior axis (29%). A complete map of the left ventricle (LV) was created in 12 patients and showed voltage abnormalities mainly at the periaortic (92%) and basal septal region (58%). A preprocedural cardiac magnetic resonance imaging was available in 13 patients and in 11 there was evidence of LV delayed gadolinium enhancement, with predominantly midmyocardial distribution. Sequential ablation from both sides of the septum was required in 47% of patients to target septal intramural substrate and epicardial ablation was performed in 20%. At the end of the procedure, the clinical VT was noninducible in all patients, while in 3 cases a non-clinical VT was still inducible. After a follow-up of 26.5±23.0 months, 53% of patients experienced VT recurrence, 20% received transplant or mechanical circulatory support and 7% died. - The arrhythmogenic substrate in TTN-related cardiomyopathy involves the basal septal and perivalvular regions. Long-term outcomes of catheter ablation are modest, with high recurrence rate, likely related to an intramural location of VT circuits.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCEP.121.010006DOI Listing
July 2021

Pitfalls in arrhythmogenic left ventricular cardiomyopathy (ALVC). A review of the literature with considerations on a single case of sudden death in a juvenile athlete.

J Forensic Leg Med 2021 Aug 29;82:102208. Epub 2021 Jun 29.

Dipartimento di Area Medica, Medicina Legale, Università Degli Studi di Udine, Piazzale Santa Maria Della Misericordia 15, 33100, Udine, Italy. Electronic address:

Sudden cardiac death (SCD) in young athletes represents a challenging issue in forensic practice. The pathologist is frequently asked to establish the cause of death basing upon anatomical findings and to evaluate the role of the physician in preparticipation evaluation (PPE) and eligibility decision. Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a leading cause of SCD during sport activity. However, in the last few years, forms with predominant or even isolated involvement of the left ventricle (LV) have progressively been correlated with a high risk of SCD. We present a case of SCD in an apparently healthy 19-year-old semi-professional football player. Annual PPEs performed in accordance with international and Italian recommendations, were unremarkable. At autopsy, a 1-cm area of subepicardial fibro-fatty replacement was observed at the postero-lateral wall of the LV. The finding was diagnostic of arrhythmogenic left ventricular cardiomyopathy (ALVC). A review of this rare pathology has been performed under a forensic perspective, focusing on the evaluation of the medico-legal responsibility of the physician in the PPE and on the morphological aspects of the disease. Current diagnostic criteria and recommendations result to be focused on the right ventricular pattern, with a risk of misdiagnosis for isolated LV forms. Furthermore, few detailed autopsies cases concerning ALVC have been published. There is a need, therefore, to study this rare disease with a careful and revised approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jflm.2021.102208DOI Listing
August 2021

Use of Sutureless and Rapid Deployment Prostheses in Challenging Reoperations.

J Cardiovasc Dev Dis 2021 Jun 25;8(7). Epub 2021 Jun 25.

Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy.

Sutureless and rapid-deployment bioprostheses have been introduced as alternatives to traditional prosthetic valves to reduce cardiopulmonary and aortic cross-clamp times during aortic valve replacement. These devices have also been employed in extremely demanding surgical settings, as underlined in the present review. Searches on the PubMed and Medline databases aimed to identify, from the English-language literature, the reported cases where both sutureless and rapid-deployment prostheses were employed in challenging surgical situations, usually complex reoperations sometimes even performed as bailout procedures. We have identified 25 patients for whom a sutureless or rapid-deployment prosthesis was used in complex redo procedures: 17 patients with a failing stentless bioprosthesis, 6 patients with a failing homograft, and 2 patients with the failure of a valve-sparing procedure. All patients survived reoperation and were reported to be alive 3 months to 4 years postoperatively. Sutureless and rapid-deployment bioprostheses have proved effective in replacing degenerated stentless bioprostheses and homografts in challenging redo procedures. In these settings, they should be considered as a valid alternative not only to traditional prostheses but also in selected cases to transcatheter valve-in-valve solutions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jcdd8070074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8305208PMC
June 2021

Post-discharge arrhythmic risk stratification of patients with acute myocarditis and life-threatening ventricular tachyarrhythmias.

Eur J Heart Fail 2021 Jul 1. Epub 2021 Jul 1.

Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste and University of Trieste, Trieste, Italy.

Aims: The outcomes of patients presenting with acute myocarditis and life-threatening ventricular arrhythmias (LT-VA) are unclear. The aim of this study was to assess the incidence and predictors of recurrent major arrhythmic events (MAEs) after hospital discharge in this patient population.

Methods And Results: We retrospectively analysed 156 patients (median age 44 years; 77% male) discharged with a diagnosis of acute myocarditis and LT-VA from 16 hospitals worldwide. Diagnosis of myocarditis was based on histology or the combination of increased markers of cardiac injury and cardiac magnetic resonance (CMR) Lake Louise criteria. MAEs were defined as the relapse, after discharge, of sudden cardiac death or successfully defibrillated ventricular fibrillation, or sustained ventricular tachycardia (sVT) requiring implantable cardioverter-defibrillator therapy or synchronized external cardioversion. Median follow-up was 23 months [first to third quartile (Q1-Q3) 7-60]. Fifty-eight (37.2%) patients experienced MAEs after discharge, at a median of 8 months (Q1-Q3 2.5-24.0 months; 60.3% of MAEs within the first year). At multivariable Cox analysis, variables independently associated with MAEs were presentation with sVT [hazard ratio (HR) 2.90, 95% confidence interval (CI) 1.38-6.11]; late gadolinium enhancement involving ≥2 myocardial segments (HR 4.51, 95% CI 2.39-8.53), and absence of positive short-tau inversion recovery (STIR) (HR 2.59, 95% CI 1.40-4.79) at first CMR.

Conclusions: Among patients discharged with a diagnosis of myocarditis and LT-VA, 37.2% had recurrences of MAEs during follow-up. Initial CMR pattern and sVT at presentation stratify the risk of arrhythmia recurrence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ejhf.2288DOI Listing
July 2021

Impact of the COVID-19 lockdown on the arrhythmic burden of patients with implantable cardioverter-defibrillators.

Pacing Clin Electrophysiol 2021 06 28;44(6):1033-1038. Epub 2021 May 28.

Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: In Italy, a nationwide full lockdown was declared between March and May 2020 to hinder the novel coronavirus disease 2019 (COVID-19) pandemic. The potential individual health effects of long-term isolation are largely unknown. The current study investigated the arrhythmic consequences of the COVID-19 lockdown in patients with defibrillators (ICDs) living in the province of Ferrara, Italy.

Methods: Both the arrhythmias and the delivered ICD therapies as notified by the devices were prospectively collected during the lockdown period (P1) and compared to those occurred during the 10 weeks before the lockdown began (P2) and during the same period in 2019 (P3). Changes in outcome over the three study periods were evaluated for significance using McNemar's test.

Results: A total of 413 patients were included in the analysis. No differences were found concerning either arrhythmias or shocks or anti-tachycardia pacing. Only the number of patients experiencing non-sustained ventricular tachycardias (NSVTs) during P1 significantly decreased as compared to P2 (p = 0.026) and P3 (p = 0.009). The subgroup analysis showed a significant decrease in NSVTs during P1 for men (vs. P2, p = 0.014; vs. P3, p = 0.040) and younger patients (vs. P2, p = 0.002; vs. P3, p = 0.040) and for ischemic etiology (vs. P2, p = 0.003). No arrhythmic deaths occurred during P1.

Conclusions: The complete nationwide lockdown, as declared by the Italian government during the first COVID-19 pandemic peak, did not impact on the incidence of arrhythmias in an urban cohort of patients with ICDs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/pace.14280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207039PMC
June 2021

Carotid artery molecular calcification assessed by [F]fluoride PET/CT: correlation with cardiovascular and thromboembolic risk factors.

Eur Radiol 2021 Apr 17. Epub 2021 Apr 17.

Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.

Objectives: There is growing evidence that sodium fluoride ([F]fluoride) PET/CT can detect active arterial calcifications at the molecular stage. We investigated the relationship between arterial mineralization in the left common carotid artery (LCC) assessed by [F]fluoride PET/CT and cardiovascular/thromboembolic risk.

Methods: In total, 128 subjects (mean age 48 ± 14 years, 51% males) were included. [F]fluoride uptake in the LCC was quantitatively assessed by measuring the blood-pool-corrected maximum standardized uptake value (SUVmax) on each axial slice. Average SUVmax (aSUVmax) was calculated over all slices and correlated with 10-year risk of cardiovascular events estimated by the Framingham model, CHA2DS2-VASc score, and level of physical activity (LPA).

Results: The aSUVmax was significantly higher in patients with increased risk of cardiovascular (one-way ANOVA, p < 0.01) and thromboembolic (one-way ANOVA, p < 0.01) events, and it was significantly lower in patients with greater LPA (one-way ANOVA, p = 0.02). On multivariable linear regression analysis, age ( = 0.07, 95% CI 0.05 - 0.10, p < 0.01), body mass index ( = 0.02, 95% CI 0.01 - 0.03, p < 0.01), arterial hypertension ( = 0.15, 95% CI 0.08 - 0.23, p < 0.01), and LPA ( = -0.10, 95% CI -0.19 to -0.02, p=0.02) were independent associations of aSUVmax.

Conclusions: Carotid [F]fluoride uptake is significantly increased in patients with unfavorable cardiovascular and thromboembolic risk profiles. [F]fluoride PET/CT could become a valuable tool to estimate subjects' risk of future cardiovascular events although still major trials are needed to further evaluate the associations found in this study and their potential clinical usefulness.

Key Points: • Sodium fluoride ([F]fluoride) PET/CT imaging identifies patients with early-stage atherosclerosis. • Carotid [F]fluoride uptake is significantly higher in patients with increased risk of cardiovascular and thromboembolic events and inversely correlated with the level of physical activity. • Early detection of arterial mineralization at a molecular level could help guide clinical decisions in the context of cardiovascular risk assessment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00330-021-07917-7DOI Listing
April 2021

Why does catheter ablation of premature ventricular contractions in arrhythmogenic right ventricular cardiomyopathy fail?

J Cardiovasc Electrophysiol 2021 06 14;32(6):1675-1677. Epub 2021 Apr 14.

Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.15022DOI Listing
June 2021

Procainamide for the Rapid Suppression of Premature Ventricular Contractions: An (Almost) Forgotten Tool in the Cardiologist's Armamentarium.

Diagnostics (Basel) 2021 Feb 20;11(2). Epub 2021 Feb 20.

Cardiac Imaging Unit, NorthWest Heart Centre, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK.

In the last few years, cardiac magnetic resonance (CMR) imaging has progressively acquired a central role in the diagnosis and management of patients with ventricular arrhythmias (VA) [...].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/diagnostics11020357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924344PMC
February 2021

Periprocedural Acute Kidney Injury in Patients With Structural Heart Disease Undergoing Catheter Ablation of VT.

JACC Clin Electrophysiol 2021 02 28;7(2):174-186. Epub 2020 Oct 28.

Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to examine the impact of periprocedural acute kidney injury (AKI) in scar-related ventricular tachycardia (VT) patients undergoing radiofrequency catheter ablation (RFCA) on short- and long-term outcomes.

Background: The clinical significance of periprocedural AKI in patients with scar-related VT undergoing RFCA has not been previously investigated.

Methods: This study included 317 consecutive patients with scar-related VT undergoing RFCA (age: 64 ± 13 years, mean left ventricular ejection fraction: 33 ± 13%, 55% ischemic cardiomyopathy). Periprocedural AKI was defined as an absolute increase in creatinine of ≥0.3 mg/dl over 48 h or an increase of >1.5× the baseline values within 1 week post-procedure.

Results: Periprocedural AKI occurred in 31 patients (10%). Independent predictors of AKI included chronic kidney disease (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 1.48 to 7.96; p = 0.004), atrial fibrillation (OR: 2.42; 95% CI: 1.01 to 5.78; p = 0.047), and peri-procedural acute hemodynamic decompensation (OR: 3.98; 95% CI: 1.17 to 13.52; p = 0.003). After a median follow-up of 39 months (interquartile range: 6 to 65 months), 95 patients (30%) died. Periprocedural AKI was associated with increased risk of early mortality (within 30 days; hazard ratio [HR]: 9.91; 95% CI: 2.87 to 34.22; p < 0.001) and late mortality (within 1 year) (HR: 4.57; 95% CI: 2.08 to 10.05; p < 0.001). After multivariable adjustment, AKI remained independently associated with increased risk of early and late mortality (HR: 4.49; 95% CI: 1.1 to 18.36; p = 0.04, and HR: 3.28; 95% CI: 1.43 to 7.49; p = 0.005, respectively).

Conclusions: Periprocedural AKI occurs in 10% of patients undergoing RFCA of scar-related VT and is strongly associated with increased risk of early and late post-procedural mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.08.018DOI Listing
February 2021

Myocardial Substrate Characterization by CMR T Mapping in Patients With NICM and No LGE Undergoing Catheter Ablation of VT.

JACC Clin Electrophysiol 2021 Jul 27;7(7):831-840. Epub 2021 Jan 27.

Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: The goal of this study was to characterize the relationship between DF, the electroanatomic mapping (EAM) substrate, and outcomes of catheter ablation of VT in NICM.

Background: A substantial proportion of patients with nonischemic dilated cardiomyopathy (NICM) and ventricular tachycardia (VT) do not have scar detectable by cardiac magnetic resonance late gadolinium enhancement (LGE) imaging. In these patients, the significance of diffuse fibrosis (DF) detected with T mapping has not been previously investigated.

Methods: This study included 51 patients with NICM and VT undergoing catheter ablation (median age 55 years; 77% male subjects) who had no evidence of LGE on pre-procedural cardiac magnetic resonance. Post-contrast T relaxation time determined on the septum was assessed as a surrogate of DF burden. The extent of endocardial low-voltage areas (LVAs) at EAM was correlated with T mapping data.

Results: Bipolar LVAs were present in 22 (43%) patients (median extent 15 cm [8 to 29 cm]) and unipolar LVA in all patients (median extent 48 cm [26 to 120 cm]). A significant inverse correlation was found between T values and both unipolar-LVA (R = 0.64; β = -0.85; p < 0.01) and bipolar-LVA (R = 0.16; β = -1.63; p < 0.01). After a median follow-up of 45 months (22 to 57 months), 2 (4%) patients died, 3 (6%) underwent heart transplantation, and 8 (16%) experienced VT recurrence. Shorter post-contrast T time was associated with an increased risk of VT recurrence (hazard ratio: 1.16; 95% confidence interval: 1.03 to 1.33 per 10 ms decrease; p = 0.02).

Conclusions: In patients with NICM and no evidence of LGE undergoing catheter ablation of VT, DF estimated by using post-contrast T mapping correlates with the voltage abnormality at EAM and seems to affect post-ablation outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.10.002DOI Listing
July 2021

Prognostic Value of Nonischemic Ringlike Left Ventricular Scar in Patients With Apparently Idiopathic Nonsustained Ventricular Arrhythmias.

Circulation 2021 Apr 6;143(14):1359-1373. Epub 2021 Jan 6.

Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia.

Background: Left ventricular (LV) scar on late gadolinium enhancement (LGE) cardiac magnetic resonance has been correlated with life-threatening arrhythmic events in patients with apparently idiopathic ventricular arrhythmias (VAs). We investigated the prognostic significance of a specific LV-LGE phenotype characterized by a ringlike pattern of fibrosis.

Methods: A total of 686 patients with apparently idiopathic nonsustained VA underwent contrast-enhanced cardiac magnetic resonance. A ringlike pattern of LV scar was defined as LV subepicardial/midmyocardial LGE involving at least 3 contiguous segments in the same short-axis slice. The end point of the study was time to the composite outcome of all-cause death, resuscitated cardiac arrest because of ventricular fibrillation or hemodynamically unstable ventricular tachycardia and appropriate implantable cardioverter defibrillator therapy.

Results: A total of 28 patients (4%) had a ringlike pattern of scar (group A), 78 (11%) had a non-ringlike pattern (group B), and 580 (85%) had normal cardiac magnetic resonance with no LGE (group C). Group A patients were younger compared with groups B and C (median age, 40 vs 52 vs 45 years; <0.01), more frequently men (96% vs 82% vs 55%; <0.01), with a higher prevalence of family history of sudden cardiac death or cardiomyopathy (39% vs 14% vs 6%; <0.01) and more frequent history of unexplained syncope (18% vs 9% vs 3%; <0.01). All patients in group A showed VA with a right bundle-branch block morphology versus 69% in group B and 21% in group C (<0.01). Multifocal VAs were observed in 46% of group A patients compared with 26% of group B and 4% of group C (<0.01). After a median follow-up of 61 months (range, 34-84 months), the composite outcome occurred in 14 patients (50.0%) in group A versus 15 (19.0%) in group B and 2 (0.3%) in group C (<0.01). After multivariable adjustment, the presence of LGE with ringlike pattern remained independently associated with increased risk of the composite end point (hazard ratio, 68.98 [95% CI, 14.67-324.39], <0.01).

Conclusions: In patients with apparently idiopathic nonsustained VA, nonischemic LV scar with a ringlike pattern is associated with malignant arrhythmic events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.120.047640DOI Listing
April 2021

Sight Is a Faculty, Seeing Is an Art: Rethinking Left Atrial Macro-Re-Entry in 3 Dimensions.

JACC Clin Electrophysiol 2020 12;6(14):1824-1826

Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.10.013DOI Listing
December 2020

Role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia.

J Cardiovasc Med (Hagerstown) 2021 Oct;22(10):727-737

Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan.

Ventricular tachycardia is a major health issue in patients with structural heart disease (SHD). Implantable cardioverter defibrillator (ICD) therapy has significantly reduced the risk of sudden cardiac death (SCD) in such patients, but on the other hand, it has led to frequent ICD shocks as an emerging problem, being associated with poor quality of life, frequent hospitalizations and increased mortality. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias, as the coexistence of surviving myocardial fibres within fibrotic tissue leads to the formation of slow conduction pathways and to a dispersion of activation and refractoriness that constitutes the milieu for ventricular tachycardia circuits. Catheter ablation has repeatedly proven to be well tolerated and highly effective in treating VT and in the last two decades has benefited from continuous efforts to determine ventricular tachycardia mechanisms by integration with a wide range of invasive and noninvasive imaging techniques such as intracardiac echocardiography, cardiac magnetic resonance, multidetector computed tomography and nuclear imaging. Cardiovascular imaging has become a fundamental aid in planning and guiding catheter ablation procedures by integrating structural and electrophysiological information, enabling the ventricular tachycardia arrhythmogenic substrate to be characterized and effective ablation targets to be identified with increasing precision, and allowing the development of new ablation strategies with improved outcomes. In this review, we provide an overview of the role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2459/JCM.0000000000001121DOI Listing
October 2021

Concealed SARS-CoV-2 interstitial pneumonia unmasked by infarct-like acute myocarditis.

Eur Heart J Case Rep 2020 Oct 5;4(FI1):1-2. Epub 2020 Jun 5.

Radiology Division, SS.ma Annunziata Hospital, Azienda USL di Ferrara, Cento, Ferrara, Italy; and Cardiology Department, S. Anna Hospital, University of Ferrara, Ferrara, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ehjcr/ytaa158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314076PMC
October 2020

Mobile health applications for the detection of atrial fibrillation: a systematic review.

Europace 2021 01;23(1):11-28

Department of Cardiology, Hopital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium.

Aims: Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart failure. We aimed to conduct a systematic review of the literature and summarize the performance of mobile health (mHealth) devices in diagnosing and screening for AF.

Methods And Results: We conducted a systematic search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Forty-three studies met the inclusion criteria and were divided into two groups: 28 studies aimed at validating smart devices for AF diagnosis, and 15 studies used smart devices to screen for AF. Evaluated technologies included smartphones, with photoplethysmographic (PPG) pulse waveform measurement or accelerometer sensors, smartbands, external electrodes that can provide a smartphone single-lead electrocardiogram (iECG), such as AliveCor, Zenicor and MyDiagnostick, and earlobe monitor. The accuracy of these devices depended on the technology and the population, AliveCor and smartphone PPG sensors being the most frequent systems analysed. The iECG provided by AliveCor demonstrated a sensitivity and specificity between 66.7% and 98.5% and 99.4% and 99.0%, respectively. The PPG sensors detected AF with a sensitivity of 85.0-100% and a specificity of 93.5-99.0%. The incidence of newly diagnosed arrhythmia ranged from 0.12% in a healthy population to 8% among hospitalized patients.

Conclusion: Although the evidence for clinical effectiveness is limited, these devices may be useful in detecting AF. While mHealth is growing in popularity, its clinical, economic, and policy implications merit further investigation. More head-to-head comparisons between mHealth and medical devices are needed to establish their comparative effectiveness.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/europace/euaa139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842109PMC
January 2021

Outcomes of Percutaneous Trans-Right Atrial Access to the Left Ventricle for Catheter Ablation of Ventricular Tachycardia in Patients With Mechanical Aortic and Mitral Valves.

JAMA Cardiol 2020 Sep 30. Epub 2020 Sep 30.

Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Importance: In patients with mechanical valves in the aortic and mitral positions, percutaneous access to the left ventricle (LV) via a transfemoral approach for catheter ablation of ventricular tachycardia (VT) has been considered infeasible.

Objective: To describe the outcomes of a novel percutaneous trans-right atrial (RA) access to the LV via a femoral venous approach for catheter ablation of VT in patients with mechanical aortic and mitral valves.

Design, Setting, And Participants: This observational study included consecutive patients with mechanical valves in the aortic and mitral positions and recurrent monomorphic drug-refractory VT associated with an LV substrate. Percutaneous LV access was performed from a transfemoral venous route with the aid of a deflectable sheath and a radiofrequency wire by creating an iatrogenic Gerbode defect with direct puncture of the inferior and medial aspect of the RA, adjacent to the inferior-septal process of the LV (ISP-LV), under intracardiac echography guidance. Once the wire crossed to the LV, balloon dilatation of the ventriculotomy site (with a noncompliant balloon; diameter, 8 to 10 mm) was performed to facilitate passage of the sheath within the LV.

Exposures: Percutaneous trans-RA access to the LV via puncture of the ISP-LV to perform catheter ablation of VT in patients with mechanical aortic and mitral valves.

Main Outcomes And Measures: Feasibility and safety of a trans-RA access to the LV for catheter ablation of VT.

Results: A total of 4 patients (mean [SD] age, 60 [7] years; mean [SD] LV ejection fraction, 31% [9%]) with recurrent VT associated with an LV substrate (ischemic cardiomyopathy, 3 patients; nonischemic cardiomyopathy, 1 patient) and mechanical valves in the aortic and mitral position underwent trans-RA access through the ISP-LV for catheter ablation of VT. The time to obtain LV access ranged from 60 minutes (first case) to 22 minutes (last case) (mean [SD], 36 [15] minutes). No complications associated with the access occurred. In particular, in the 3 patients with preserved atrioventricular conduction at baseline, no new conduction abnormalities were observed after the access. Complete VT noninducibility at programmed ventricular stimulation was achieved in 3 cases, and no patient had VT recurrence at a median follow-up of 14 months (range, 6-21 months).

Conclusions And Relevance: A percutaneous trans-RA access to the LV via a femoral venous approach for catheter ablation of VT in patients with mechanical aortic and mitral valves is feasible and appears safe. This novel technique may allow for catheter ablation of VT in a population of patients in whom conventional LV access via retrograde aortic or atrial transseptal routes is not possible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2020.4414DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941197PMC
September 2020

State of the Art Review on Genetics and Precision Medicine in Arrhythmogenic Cardiomyopathy.

Int J Mol Sci 2020 Sep 10;21(18). Epub 2020 Sep 10.

Department of Cardiology, Royal Papworth Hospital, Cambridge CB2 0AY, UK.

Arrhythmogenic cardiomyopathy (ACM) is an inherited cardiomyopathy characterised by ventricular arrhythmia and an increased risk of sudden cardiac death (SCD). Numerous genetic determinants and phenotypic manifestations have been discovered in ACM, posing a significant clinical challenge. Further to this, wider evaluation of family members has revealed incomplete penetrance and variable expressivity in ACM, suggesting a complex genotype-phenotype relationship. This review details the genetic basis of ACM with specific genotype-phenotype associations, providing the reader with a nuanced perspective of this condition; whilst also proposing a future roadmap to delivering precision medicine-based management in ACM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/ijms21186615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554944PMC
September 2020

Clinical management of electrical storm: a current overview.

J Cardiovasc Med (Hagerstown) 2020 Sep 8. Epub 2020 Sep 8.

Department of Cardiology, Policlinico Universitario Umberto I, Roma.

: The number of patients affected by electrical storm has been continuously increasing in emergency departments. Patients are often affected by multiple comorbidities requiring multidisciplinary interventions to achieve a clinical stability. Careful reprogramming of cardiac devices, correction of electrolyte imbalance, knowledge of underlying heart disease and antiarrhythmic drugs in the acute phase play a crucial role. The aim of this review is to provide a comprehensive overview of pharmacological treatment, latest transcatheter ablation techniques and advanced management of patients with electrical storm.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2459/JCM.0000000000001107DOI Listing
September 2020

Epicardial Ablation in Nonischemic Ventricular Tachyardia.

Card Electrophysiol Clin 2020 09 9;12(3):321-328. Epub 2020 Jul 9.

Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA. Electronic address:

In patients with nonischemic cardiomyopathy, epicardial ablation is critical in targeting epicardial paravalvular substrate. Epicardial access and ablation can be performed safely with attention to epicardial structures, such as the coronary arteries, phrenic nerve, and epicardial fat. This review explores the indications, techniques, complications, and outcomes of epicardial ablation in patients with nonischemic cardiomyopathy. Although epicardial ablation adds to the complexity and risk of the ablation procedure, it is a vital tool that, combined with endocardial mapping and ablation, improves outcomes in patients with nonischemic cardiomyopathy suffering from ventricular arrhythmias.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ccep.2020.05.004DOI Listing
September 2020

Epicardial Ablation of Idiopathic Ventricular Tachycardia.

Card Electrophysiol Clin 2020 09 27;12(3):295-312. Epub 2020 Jun 27.

Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. Electronic address:

Ventricular arrhythmias (VAs) occurring in the absence of structural heart disease or ion channelopathies are referred to as idiopathic. They can clinically present with frequent monomorphic premature ventricular contractions, nonsustained ventricular tachycardia (VT), or sustained VT, and generally share a benign prognosis. Approximately 4% to 10% of idiopathic VAs have an epicardial site of origin, represented in most cases by the left ventricular summit and, less frequently, by the cardiac crux. Epicardial foci can be addressed by catheter ablation via the coronary venous system tributaries. In rarer instances, a direct epicardial access from a subxiphoid approach is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ccep.2020.04.005DOI Listing
September 2020

Detection of Intramural Excitable Substrate With Frequency Analysis of Unipolar Electrograms: A Novel Application of Unipolar Electrogram Mapping.

JACC Clin Electrophysiol 2020 07;6(7):770-772

Department of Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.04.004DOI Listing
July 2020

Editorial commentary: Acute myocarditis: An overview on emerging evidence.

Trends Cardiovasc Med 2021 08 18;31(6):380-381. Epub 2020 Jul 18.

Cardiology Division, Cardiothoracic Department, ASST Santi Paolo e Carlo University Hospital, Milano, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.tcm.2020.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368148PMC
August 2021

Risk Stratification of Patients With Apparently Idiopathic Premature Ventricular Contractions: A Multicenter International CMR Registry.

JACC Clin Electrophysiol 2020 06 18;6(6):722-735. Epub 2019 Dec 18.

Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, Adelaide, Australia; Cardiac Imaging Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom. Electronic address:

Objectives: This study investigated the prevalence and prognostic significance of concealed myocardial abnormalities identified by cardiac magnetic resonance (CMR) imaging in patients with apparently idiopathic premature ventricular contractions (PVCs).

Background: The role of CMR imaging in patients with frequent PVCs and otherwise negative diagnostic workup is uncertain.

Methods: This was a multicenter, international study that included 518 patients (age 44 ± 15 years; 57% men) with frequent (>1,000/24 h) PVCs and negative routine diagnostic workup. Patients underwent a comprehensive CMR protocol including late gadolinium enhancement imaging for detection of necrosis and/or fibrosis. The study endpoint was a composite of sudden cardiac death, resuscitated cardiac arrest, and nonfatal episodes of ventricular fibrillation or sustained ventricular tachycardia that required appropriate implantable cardioverter-defibrillator therapy.

Results: Myocardial abnormalities were found in 85 (16%) patients. Male gender (odds ratio [OR]: 4.28; 95% confidence interval [CI]: 2.06 to 8.93; p = 0.01), family history of sudden cardiac death and/or cardiomyopathy (OR: 3.61; 95% CI: 1.33 to 9.82; p = 0.01), multifocal PVCs (OR: 11.12; 95% CI: 4.35 to 28.46; p < 0.01), and non-left bundle branch block inferior axis morphology (OR: 14.11; 95% CI: 7.35 to 27.07; p < 0.01) were all significantly related to the presence of myocardial abnormalities. After a median follow-up of 67 months, the composite endpoint occurred in 26 (5%) patients. Subjects with myocardial abnormalities on CMR had a higher incidence of the composite outcome (n = 25; 29%) compared with those without abnormalities (n = 1; 0.2%; p < 0.01).

Conclusions: CMR can identify concealed myocardial abnormalities in 16% of patients with apparently idiopathic frequent PVCs. Presence of myocardial abnormalities on CMR predict worse clinical outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2019.10.015DOI Listing
June 2020

Ventricular Arrhythmias in Myocarditis: Prognostic Role of Electroanatomic Voltage Mapping.

JACC Clin Electrophysiol 2020 05;6(5):583-585

Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania,USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.01.008DOI Listing
May 2020

Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management.

Heart Rhythm 2020 09 5;17(9):1463-1471. Epub 2020 May 5.

Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Mayo Clinic, Rochester, Minnesota; Royal Papworth Hospital, Cambridge, United Kingdom. Electronic address:

Human coronavirus-associated myocarditis is known, and a number of coronavirus disease 19 (COVID-19)-related myocarditis cases have been reported. The pathophysiology of COVID-19-related myocarditis is thought to be a combination of direct viral injury and cardiac damage due to the host's immune response. COVID-19 myocarditis diagnosis should be guided by insights from previous coronavirus and other myocarditis experience. The clinical findings include changes in electrocardiogram and cardiac biomarkers, and impaired cardiac function. When cardiac magnetic resonance imaging is not feasible, cardiac computed tomographic angiography with delayed myocardial imaging may serve to exclude significant coronary artery disease and identify myocardial inflammatory patterns. Because many COVID-19 patients have cardiovascular comorbidities, myocardial infarction should be considered. If the diagnosis remains uncertain, an endomyocardial biopsy may help identify active cardiac infection through viral genome amplification and possibly refine the treatment risks of systemic immunosuppression. Arrhythmias are not uncommon in COVID-19 patients, but the pathophysiology is still speculative. Nevertheless, clinicians should be vigilant to provide prompt monitoring and treatment. The long-term impact of COVID-19 myocarditis, including the majority of mild cases, remains unknown.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2020.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199677PMC
September 2020

Collateral injury of the conduction system during catheter ablation of septal substrate in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 07 5;31(7):1726-1739. Epub 2020 May 5.

Department of Medicine, Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: In patients with nonischemic cardiomyopathy (NICM) little is known about the clinical impact of catheter ablation (CA) of septal ventricular tachycardia (VT) resulting in the collateral injury of the conduction system (CICS).

Methods And Results: Ninety-five consecutive patients with NICM underwent CA of septal VT. Outcomes in patients with no baseline conduction abnormalities who developed CICS (group 1, n = 28 [29%]) were compared to patients with no CICS (group 2, n = 17 [18%]) and to patients with preexisting conduction abnormalities or biventricular pacing (group 3, n = 50 [53%]). Group-1 patients were younger, had a higher left ventricular ejection fraction and a lower prevalence of New York Heart Association III/IV class compared to group 3 while no significant differences were observed with group 2. After a median follow-up of 15 months, VT recurred in 14% of patients in group 1, 12% in group 2 (P = .94) and 32% in group 3 (P = .08) while death/transplant occurred in 14% of patients in group 1, 18% in group 2 (P = .69) and 28% in group 3 (P = .15). A worsening of left ventricular ejection fraction (LVEF) (median LVEF variation, -5%) was observed in group 1 compared to group 2 (median LVEF variation, 0%; P < .01) but not group-3 patients (median LVEF variation, -4%; P = .08) with a consequent higher need for new biventricular pacing in group 1 (43%) compared to group 2 (12%; P = .03) and group 3 (16%; P < .01).

Conclusions: In patients with NICM and septal substrate, sparing the abnormal substrate harboring the conduction system provides acceptable VT control while preventing a worsening of the systolic function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.14498DOI Listing
July 2020

Radiofrequency-Assisted Transseptal Access for Atrial Fibrillation Ablation Via a Superior Approach.

JACC Clin Electrophysiol 2020 03 29;6(3):272-281. Epub 2020 Jan 29.

Division of Cardiology, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study describes the technique and outcomes of atrial fibrillation (AF) ablation via a superior approach in patients with interrupted or absent inferior vena cavas (IVCs).

Background: In patients with interrupted or absent IVCs, transseptal access cannot be obtained via standard femoral venous access. In these patients, alternative strategies are necessary to permit catheter ablation in the left atrium (LA). This study reports on the outcomes of AF ablation from a superior venous access with a radiofrequency (RF)-assisted transseptal puncture (TSP) technique.

Methods: This study identified patients with interrupted or absent IVCs who underwent AF ablation via a superior approach at 2 ablation centers from 2010 to 2019.

Results: Fifteen patients (mean age: 50.8 ± 11.2 years; 10 men; 10 with paroxysmal AF) with interrupted or absent IVCs underwent AF ablation with transseptal access via a superior approach. Successful TSP was performed either with a manually bent RF transseptal needle (early cases: n = 4) or using a RF wire (late cases: n = 11); this approach permitted LA mapping and ablation in all patients. Mean time required to perform single (n = 8) or double (n = 7) TSP was 16.1 ± 4.8 min, and mean total procedure time was 227.9 ± 120.7 min (fluoroscopy time: 57.0 ± 28.5 min). LA mapping and ablation were successfully performed in all patients.

Conclusions: In patients with AF undergoing catheter ablation and who had a standard transseptal approach via femoral venous approach is impossible due to anatomic constraints, RF-assisted transseptal access via a superior approach can be an effective alternative strategy to permit LA mapping and ablation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2019.10.019DOI Listing
March 2020

Trends in Successful Ablation Sites and Outcomes of Ablation for Idiopathic Outflow Tract Ventricular Arrhythmias.

JACC Clin Electrophysiol 2020 02 27;6(2):221-230. Epub 2019 Nov 27.

Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to examine clinical characteristics of procedural and long-term outcomes in patients undergoing catheter ablation (CA) of outflow tract ventricular arrhythmias (OT-VAs) over 16 years.

Background: CA is an effective treatment strategy for OT-VAs.

Methods: Patients undergoing CA for OT-VAs from 1999 to 2015 were divided into 3 periods: 1999 to 2004 (early), 2005 to 2010 (middle), and 2011 to 2015 (recent). Successful ablation site (right ventricular OT, aortic cusps/left ventricular OT, or coronary venous system/epicardium), VA morphology (right bundle branch block or left bundle branch block), and acute and clinical success rates were assessed.

Results: Six hundred eighty-two patients (336 female) were included (early: n = 97; middle: n = 204; recent: n = 381). Over time there was increase in use of irrigated ablation catheters and electroanatomic mapping, and more VAs were ablated from the aortic cusp/left ventricular OT or coronary venous system/epicardium (14% vs. 45% vs. 56%; p < 0.0001). Acute procedural success was achieved in 585 patients (86%) and was similar between groups (82% vs. 84% vs. 88%; p = 0.27). Clinical success was also similar between groups (86% vs. 87% vs. 88%; p = 0.94), but more patients in earlier periods required repeat ablation (18% vs. 17% vs. 9%; p = 0.02). Overall complication rate was 2% (similar between groups).

Conclusions: Over a 16-year period there was an increase in patients undergoing CA for OT-VTs, with more ablations performed at non-right ventricular outflow tract locations using electroanatomic mapping and irrigated-tip catheters. Over time, single procedure success has improved and complications have remained limited.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2019.10.004DOI Listing
February 2020
-->