Publications by authors named "Luis C Saenz"

16 Publications

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Preface.

Card Electrophysiol Clin 2021 Jun;13(2):xv

Cardiac Electrophysiology, Fundacion CardioInfantil, Calle 163A # 13B-60, Bogota, Colombia. Electronic address:

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http://dx.doi.org/10.1016/j.ccep.2021.04.002DOI Listing
June 2021

Interatrial septal tachycardias following atrial fibrillation ablation or cardiac surgery: Electrophysiological features and ablation outcomes.

Heart Rhythm 2021 May 11. Epub 2021 May 11.

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

Background: Interatrial septal tachycardias (IAS-ATs) following atrial fibrillation (AF) ablation or cardiac surgery are rare, and their management is challenging.

Objective: The purpose of this study was to investigate the electrophysiological features and outcomes associated with catheter ablation of IAS-AT.

Methods: We screened 338 patients undergoing catheter ablation of ATs following AF ablation or cardiac surgery. Diagnosis of IAS-AT was based on activation mapping and analysis of response to atrial overdrive pacing.

Results: Twenty-nine patients (9%) had IAS-AT (cycle length [CL] 311 ± 104 ms); 16 (55%) had prior AF ablation procedures (median 3; range 1-5), 3 (10%) had prior surgical maze, and 12 (41%) had prior cardiac surgery (including atrial septal defect surgical repair in 5 and left atrial myxoma resection in 1). IAS substrate abnormalities were documented in all patients. Activation mapping always demonstrated a diffuse early IAS breakout with centrifugal biatrial activation, and atrial overdrive pacing showed a good postpacing interval (equal or within 25 ms of the AT CL) only at 1 or 2 anatomically opposite IAS sites in all cases. Ablation was acutely successful in 27 patients (93%) (from only the right IAS in 2, only the left IAS in 9, both IAS sides with sequential ablation in 13, and both IAS sides with bipolar ablation in 3). After median follow-up of 15 (6-52) months, 17 patients (59%) remained free from recurrent arrhythmias.

Conclusion: IAS-ATs are rare and typically occur in patients with evidence of IAS substrate abnormalities and prior cardiac surgery. Catheter ablation can be challenging and may require sequential unipolar ablation or bipolar ablation.
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http://dx.doi.org/10.1016/j.hrthm.2021.04.036DOI Listing
May 2021

Quality indicators for the care and outcomes of adults with atrial fibrillation.

Europace 2021 Apr;23(4):494-495

First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Curie-Sklodowskiej Str 9, 41-800 Zabrze, Poland.

Aims: To develop quality indicators (QIs) that may be used to evaluate the quality of care and outcomes for adults with atrial fibrillation (AF).

Methods And Results: We followed the ESC methodology for QI development. This methodology involved (i) the identification of the domains of AF care for the diagnosis and management of AF (by a group of experts including members of the ESC Clinical Practice Guidelines Task Force for AF); (ii) the construction of candidate QIs (including a systematic review of the literature); and (iii) the selection of the final set of QIs (using a modified Delphi method). Six domains of care for the diagnosis and management of AF were identified: (i) Patient assessment (baseline and follow-up), (ii) Anticoagulation therapy, (iii) Rate control strategy, (iv) Rhythm control strategy, (v) Risk factor management, and (vi) Outcomes measures, including patient-reported outcome measures (PROMs). In total, 17 main and 17 secondary QIs, which covered all six domains of care for the diagnosis and management of AF, were selected. The outcome domain included measures on the consequences and treatment of AF, as well as PROMs.

Conclusion: This document defines six domains of AF care (patient assessment, anticoagulation, rate control, rhythm control, risk factor management, and outcomes), and provides 17 main and 17 secondary QIs for the diagnosis and management of AF. It is anticipated that implementation of these QIs will improve the quality of AF care.
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http://dx.doi.org/10.1093/europace/euaa253DOI Listing
April 2021

Recommendations for the measurement of the QT interval during the use of drugs for COVID-19 infection treatment. Updatable in accordance with the availability of new evidence.

J Interv Card Electrophysiol 2020 Nov 16;59(2):315-320. Epub 2020 May 16.

International Center of Arrhythmias, Fundación CardioInfantilI-Instituto de Cardiología, Bogotá, Colombia.

COVID-19 infection has shown rapid growth worldwide, and different therapies have been proposed for treatment, in particular, the combination of immune response modulating drugs such as chloroquine and hydroxychloroquine (antimalarials) alone or in combination with azithromycin. Although the clinical evidence supporting their use is scarce, the off label use of these drugs has spread very quickly in face of the progression of the epidemic and the high mortality rate in susceptible populations. However, these medications can pathologically prolong the QT interval and lead to malignant ventricular arrhythmias such that organized guidance on QT evaluation and management strategies are important to reduce morbidity associated with the potential large-scale use.
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http://dx.doi.org/10.1007/s10840-020-00765-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229438PMC
November 2020

Recommendations for the organization of electrophysiology and cardiac pacing services during the COVID-19 pandemic : Latin American Heart Rhythm Society (LAHRS) in collaboration with: Colombian College Of Electrophysiology, Argentinian Society of Cardiac Electrophysiology (SADEC), Brazilian Society Of Cardiac Arrhythmias (SOBRAC), Mexican Society Of Cardiac Electrophysiology (SOMEEC).

J Interv Card Electrophysiol 2020 Nov 29;59(2):307-313. Epub 2020 Apr 29.

Universidad de Campinas, Campinas, Brazil.

COVID-19 is a rapidly evolving public health emergency that has largely impacted the provision of healthcare services around the world. The challenge for electrophysiology teams is double; on one side preventing disease spread by limiting all nonessential face-to-face interactions, but at the same time ensuring continued care for patients who need it. These guidelines contain recommendations regarding triaging in order to define what procedures, device checks and clinic visits can be postponed during the pandemic. We also discuss best practices to protect patients and healthcare workers and provide guidance for the management of COVID-19 patients with arrhythmic conditions.
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http://dx.doi.org/10.1007/s10840-020-00747-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189002PMC
November 2020

Septal Coronary Venous Mapping to Guide Substrate Characterization and Ablation of Intramural Septal Ventricular Arrhythmia.

JACC Clin Electrophysiol 2019 07 8;5(7):789-800. Epub 2019 May 8.

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Heart Rhythm Service, Queen's University, Kingston, Ontario, Canada. Electronic address:

Objectives: This study describes the use of septal coronary venous mapping to facilitate substrate characterization and ablation of intramural septal ventricular arrhythmia (VA).

Background: Intramural septal VA represents a challenge for substrate definition and catheter ablation.

Methods: Between 2015 and 2018, 12 patients with structural heart disease, recurrent VA, and suspected intramural septal substrate underwent a septal coronary venous procedure in which mapping was performed by advancement of a wire into the septal perforator branches of the anterior interventricular vein. A total of 5 patients with idiopathic VA were also included as control subjects to compare substrate characteristics.

Results: Patients were 63 ± 14 years of age, and 11 (92%) were men. Most patients with structural heart disease had nonischemic cardiomyopathy (83%). Six patients underwent ablation for premature ventricular contractions (PVC) and 6 for ventricular tachycardia. All patients had larger septal unipolar voltage abnormalities than bipolar voltage abnormalities (mean area 35.3 ± 16.8 cm vs. 10.7 ± 8.4 cm, respectively; p = 0.01), Patients with idiopathic VA had normal voltage. Septal coronary venous mapping revealed low-voltage, fractionated, and multicomponent electrograms in sinus rhythm in all patients with substrate compared to that in patients with idiopathic VA (amplitude 0.9 ± 0.9 mV vs. 4.4 ± 3.7 mV, respectively; p = 0.007; and duration 147 ± 48 ms vs. 92 ± 10 ms, respectively; p = 0.03). Ablation targeted early activation, pace map match, and/or good entrainment sites from intraseptal recording. Over a mean follow-up of 339 ± 240 days, the PVC and insertable cardioverter-defibrillator therapies burden were significantly reduced (from a mean of 22 ± 11% to 4 ± 8%; p = 0.005; and a mean 5 ± 2 to 1 ± 1; p = 0.001, respectively). Most patients (80%) with idiopathic VA remained arrhythmia free.

Conclusions: In patients with suspected intramural septal VA, mapping of the septal coronary veins may be helpful to characterize the arrhythmia substrate, identify ablation targets, and guide endocardial ablation.
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http://dx.doi.org/10.1016/j.jacep.2019.04.011DOI Listing
July 2019

Left atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: Procedural and cost considerations.

Heart Rhythm 2019 03;16(3):334-342

Division of Cardiac Electrophysiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas. Electronic address:

Background: Imaging guidance for left atrial appendage (LAA) closure (LAAC) conventionally consists of transesophageal echocardiography (TEE) and fluoroscopy under general anesthesia (GA). Intracardiac echocardiography (ICE) can eliminate the need for GA, expedite procedural logistics, and reduce the patient experience to a simple venous puncture.

Objective: The purpose of this study was to define optimal ICE views and compare procedural parameters and cost of ICE vs TEE during LAAC with the Watchman device.

Methods: Optimal ICE views of the LAA for Watchman implant were delineated using Carto-Sound and 3-dimensional rendition of the LAA in 6 patients. Procedural and financial parameters of 104 consecutive patients with standard indications for LAAC undergoing Watchman implant using ICE guidance through a single transseptal puncture (n = 53 [51%]) were compared with those of TEE-guided implants (n = 51 [49%]) in 3 centers.

Results: Clinical characteristics were similar between the 2 groups. Total in-room, turnaround, and fluoroscopy times all were shorter using ICE (P <.05) under local anesthesia compared to the TEE group. Implant success was 100% in both groups without peri-device leaks or procedural complications. Follow-up TEE showed no significant peri-device leak in both groups. Total hospital charges for ICE with local anesthesia vs TEE were similar, as were total hospital direct and indirect costs. Professional fees were significantly lower with ICE and local anesthesia than with TEE because the charge of anesthesia staff was avoided.

Conclusion: ICE-guided Watchman implant is safe, feasible, and comparable in cost to TEE during LAAC with a Watchman device but avoids GA and expedites procedure turnaround.
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http://dx.doi.org/10.1016/j.hrthm.2018.12.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6400300PMC
March 2019

Percutaneous transhepatic venous access for atrial tachyarrhythmia ablation in patients with single ventricle and interrupted inferior vena cava.

HeartRhythm Case Rep 2019 Jan 17;5(1):31-35. Epub 2018 Oct 17.

International Arrhythmia Center, Cardiology Institute, Fundación Cardioinfantil, University of La Sabana, Bogota, Colombia.

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http://dx.doi.org/10.1016/j.hrcr.2018.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6342726PMC
January 2019

Use of Intracardiac Echocardiography in Interventional Cardiology: Working With the Anatomy Rather Than Fighting It.

Circulation 2018 05;137(21):2278-2294

Section of Cardiac Electrophysiology (A.E., D.C., F.E.M., F.G.)

The indications for catheter-based structural and electrophysiological procedures have recently expanded to more complex scenarios, in which an accurate definition of the variable individual cardiac anatomy is key to obtain optimal results. Intracardiac echocardiography (ICE) is a unique imaging modality able to provide high-resolution real-time visualization of cardiac structures, continuous monitoring of catheter location within the heart, and early recognition of procedural complications, such as pericardial effusion or thrombus formation. Additional benefits are excellent patient tolerance, reduction of fluoroscopy time, and lack of need for general anesthesia or a second operator. For these reasons, ICE has largely replaced transesophageal echocardiography as ideal imaging modality for guiding certain procedures, such as atrial septal defect closure and catheter ablation of cardiac arrhythmias, and has an emerging role in others, including mitral valvuloplasty, transcatheter aortic valve replacement, and left atrial appendage closure. In electrophysiology procedures, ICE allows integration of real-time images with electroanatomic maps; it has a role in assessment of arrhythmogenic substrate, and it is particularly useful for mapping structures that are not visualized by fluoroscopy, such as the interatrial or interventricular septum, papillary muscles, and intracavitary muscular ridges. Most recently, a three-dimensional (3D) volumetric ICE system has also been developed, with potential for greater anatomic information and a promising role in structural interventions. In this state-of-the-art review, we provide guidance on how to conduct a comprehensive ICE survey and summarize the main applications of ICE in a variety of structural and electrophysiology procedures.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.117.031343DOI Listing
May 2018

Ventricular Tachycardia in the Setting of Chagasic Cardiomyopathy: Use of Voltage Mapping to Characterize Endoepicardial Nonischemic Scar Distribution.

Circ Arrhythm Electrophysiol 2017 Nov;10(11)

From the International Arrhythmia Center at CardioInfantil Foundation-Cardiac Institute, Bogotá, Colombia (R.S.-B., W.B., F.M., J.A., J.D.R., A.E., D.R., L.C.S.); Electrophysiology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (V.B.); and Division of Cardiology, Electrophysiology Program, Hospital of the University of Pennsylvania, Philadelphia (D.J.C., F.E.M., F.C.G.).

Background: Chagasic cardiomyopathy (CC) is the most frequent nonischemic substrate causing left ventricular (LV) tachycardia in Latin America. Systematic characterization of the LV epicardial/endocardial scar distribution and density in CC has not been performed. Additionally, the usefulness of unipolar endocardial electroanatomic mapping to identify epicardial scar has not been assessed in this setting.

Methods And Results: Nineteen patients with CC undergoing detailed epicardial and endocardial LV tachycardia mapping and ablation were included. A total of 8494 epicardial and 6331 endocardial voltage signals and 314 epicardial/endocardial matched pairs of points were analyzed. Basal lateral LV scar involvement was observed in 18 of 19 patients. Bipolar voltage mapping demonstrated larger epicardial than endocardial scar and core-dense (≤0.5 mV) scar areas (28 [20-36] versus 19 [15-26] and 21 [2-49] versus 4 [0-7] cm; =0.049 and =0.004, respectively). Bipolar epicardial and endocardial voltages within scar were low (0.4 [0.2-0.55] and 0.54 [0.33-0.87] mV, respectively) and confluent, indicating a dense/transmural scarring process in CC. The endocardial unipolar voltage value (with a newly proposed ≤4-mV cutoff) predicted the presence and extent of epicardial bipolar scar (<0.001).

Conclusions: CC causes a unique ventricular tachycardia substrate concentrated to the basal lateral LV, with marked epicardial predominance. The scar pattern is particularly dense and transmural as compared with the more erratic/patchy scar patterns seen in other nonischemic cardiomyopathies. Endocardial unipolar voltage mapping serves to characterize epicardial scar in this setting.
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http://dx.doi.org/10.1161/CIRCEP.116.004950DOI Listing
November 2017

How to map and ablate left ventricular summit arrhythmias.

Heart Rhythm 2017 01 21;14(1):141-148. Epub 2016 Sep 21.

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

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http://dx.doi.org/10.1016/j.hrthm.2016.09.018DOI Listing
January 2017

Arrhythmias in chagasic cardiomyopathy.

Card Electrophysiol Clin 2015 Jun;7(2):251-68

Hospital Cardiologico, Rodovia SC 401, 121, Itacorubi, Florianopolis, Santa Catarina, Brazil, CEP: 88030-000. Electronic address:

Chagas disease, a chronic parasitosis caused by the protozoa Trypanosoma cruzi, is an increasing worldwide problem because of the number of cases in endemic areas and the migration of infected individuals to more developed regions. Chagas disease affects the heart through cardiac parasympathetic neuronal depopulation, immune-mediated myocardial injury, parasite persistence in cardiac tissue with secondary antigenic stimulation, and coronary microvascular abnormalities causing myocardial ischemia. A lack of knowledge exists for risk stratification, management, and prevention of ventricular arrhythmias in patients with chagasic cardiomyopathy. Catheter ablation can be effective for the management of recurrent ventricular tachycardia.
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http://dx.doi.org/10.1016/j.ccep.2015.03.016DOI Listing
June 2015

Using the initial vector from surface electrocardiogram to distinguish the site of outflow tract tachycardia.

Pacing Clin Electrophysiol 2007 Jul;30(7):891-8

Department of Medicine/Cardiac Electrophysiology Section, University of California, San Francisco, California 94143-1354, USA.

Background: The purpose of this study is to determine whether initial vector force might best distinguish tachycardias arising from the right ventricular (RV) outflow tract (OT) versus aortic sinus cusps (ASCs).

Methods: Among 45 patients with OT tachycardia, we measured the time from the earliest QRS onset in any lead to local onset and to the first QRS peak/nadir in each surface leads during VT. We compared the earliest phase differences among patients with foci in RVOT (n = 32) and in ASCs (n = 13) (determined by ablation), using unpaired t-tests. We determined the optimum cut-points by analyzing the receiver-operator characteristics curves, and derived an algorithm to discriminate ASC from RVOT foci.

Results: Compared with an RVOT focus, origin in the ASC was associated with lower likelihood that the earliest lead of QRS activation was V2 (4/13 [12%] vs 29/32 [88%], P = 0.0001), later initial peak/nadir in III (110 +/- 19 vs 93 +/- 16 ms, P = 0.0026) and V2 (75 +/- 26 vs 42 +/- 19 ms, P < 0.0001). After determining the optimum cut-points for each, we found that the presence of any one of these findings discriminated well between RVOT and ASC foci (sensitivity 92%, specificity 88%, positive predictive value 75%, and negative predictive value 97%). The sensitivity and specificity using standard ECG criteria were inferior to the vector approach.

Conclusions: The ECG phase differences during VT can distinguish the origin of OT-VT. Earliest onset or first peak/nadir in V2 and early initial peak/nadir in the inferior leads suggest a RVOT focus.
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http://dx.doi.org/10.1111/j.1540-8159.2007.00777.xDOI Listing
July 2007

Efficacy of catheter ablation of atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy.

Heart Rhythm 2006 Mar;3(3):275-80

Section of Pacing & Electrophysiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Background: Although pulmonary vein (PV) antrum isolation is effective in curing atrial fibrillation (AF) in a variety of heart diseases, results in patients with hypertrophic obstructive cardiomyopathy (HOCM) have not been reported.

Objectives: The purpose of this study was to report the results and outcome of PV antrum isolation in patients with AF and HOCM.

Methods: Data from patients with AF and HOCM who underwent PV antrum isolation between February 2002 and May 2004 were analyzed retrospectively. An intracardiac echocardiographic-guided ablation technique with an 8-mm-tip catheter was used in all patients. Patients were followed in the outpatient clinic at 3, 6, and 12 months after ablation.

Results: Twenty-seven patients with AF and HOCM (mean age 55 +/- 10 years) underwent PV antrum isolation. Mean AF duration was 5.4 +/- 3.6 years. AF was paroxysmal in 14 (52%), persistent in 9 (33%), and permanent in 4 (15%). During a mean follow-up of 341 +/- 237 days, 13 patients (48%) had AF recurrence. Of these patients, five maintained sinus rhythm (SR) with antiarrhythmic drugs, one patient remained in persistent AF, and seven patients underwent a second PV antrum isolation. After the second PV antrum isolation, five patients remained in SR, giving a final success rate of 70% (19/27). Two patients had recurrence after second PV antrum isolation; one maintained SR with antiarrhythmic drugs and one remained in persistent AF.

Conclusion: Compared with previously reported results in patients with lone AF, AF recurrence after the first PV antrum isolation is higher in patients with HOCM. However, after repeated ablation procedures, long-term cure can be achieved in a sizable number of patients. PV antrum isolation is a feasible therapeutic option in patients with AF and HOCM.
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http://dx.doi.org/10.1016/j.hrthm.2005.11.013DOI Listing
March 2006

Short- and long-term success of substrate-based mapping and ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia.

Circulation 2005 Jun 13;111(24):3209-16. Epub 2005 Jun 13.

Section of Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

Background: Multiple morphologies, hemodynamic instability, or noninducibility may limit ventricular tachycardia (VT) ablation in patients with arrhythmogenic right ventricular dysplasia (ARVD). Substrate-based mapping and ablation may overcome these limitations. We report the results and success of substrate-based VT ablation in ARVD.

Methods And Results: Twenty-two patients with ARVD were studied. Traditional mapping for VT was limited because of multiple/changing VT morphologies (n=14), nonsustained VT (n=10), or hemodynamic intolerance (n=5). Sinus rhythm CARTO mapping was performed to define areas of "scar" (<0.5 mV) and "abnormal" myocardium (0.5 to 1.5 mV). Ablation was performed in "abnormal" regions, targeting sites with good pace maps compared with the induced VT(s). Linear lesions were created in these areas to (1) connect the scar/abnormal region to a valve continuity or other scar or (2) encircle the scar/abnormal region. Eighteen patients had implanted cardioverter defibrillators, 15 had implanted cardioverter defibrillator therapies, and 7 had sustained VT (6 with syncope). VTs (3+/-2 per patient) were induced (cycle length, 339+/-94 ms), and scar was identified in all patients. Scar areas were related to the tricuspid annulus, proximal right ventricular outflow tract, and anterior/inferior-apical walls. Lesions connected abnormal regions to the annulus (n=12) or other scars (n=4) and/or encircled abnormal regions (n=13). Per patient, a mean of 38+/-22 radiofrequency lesions was applied. Short-term success was achieved in 18 patients (82%). VT recurred in 23%, 27%, and 47% of patients after 1, 2, and 3 years' follow-up, respectively.

Conclusions: Substrate-based ablation of VT in ARVD can achieve a good short-term success rate. However, recurrences become increasingly common during long-term follow-up.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.104.510503DOI Listing
June 2005