Publications by authors named "Mercedes Ortiz"

34 Publications

Stakeholder-Generated Implementation Strategies to Promote Evidence-Based ADHD Treatment in Community Mental Health.

Adm Policy Ment Health 2021 May 14. Epub 2021 May 14.

Florida International University, Miami, FL, USA.

Community implementation of evidence-based practices (EBPs) for Attention Deficit/Hyperactivity Disorder (ADHD) is greatly lacking. A recent randomized community-based trial of an EBP for ADHD (Supporting Teens' Autonomy Daily; STAND) demonstrated suboptimal implementation and effectiveness outcomes. In the present study, we conducted an Innovation Tournament (IT) with agency staff stakeholders (N = 26) to identify barriers to successful implementation of STAND and implementation strategies for a revised service delivery model. We conducted member-checking of agency staff-generated ideas with parents (N = 226) and subsequent querying of additional parent (N = 226) and youth-generated (N = 205) strategies to improve care. Go-Zone plots were utilized to identify strategies with the highest feasibility and importance. Practical barriers (i.e., transportation, scheduling difficulties) and parent/youth engagement were the most commonly cited obstacles to successful implementation of STAND in community contexts. Eighteen "winning" implementation strategies were identified that survived member checking. These were classified as train and educate stakeholders (n = 5; e.g., train agency supervisors to deliver supervision, digitize treatment materials and trainings), engage consumers (n = 9; e.g., begin treatment with rapport building sessions, increase psychoeducation), provide interactive assistance (n = 2; e.g., add group supervision, increase roleplay in supervision), and use of evaluative/iterative strategies (n = 2; e.g., perform fidelity checks, supervisor review of session recordings). Parents and youth desired longer duration of treatment and increased focus on maintenance. Strategies will be developed and tested as part of a pilot effectiveness trial designed to refine STAND's service delivery model.Trial Registration NCT02694939 www.clinicaltrials.gov.
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http://dx.doi.org/10.1007/s10488-021-01143-5DOI Listing
May 2021

Top problems of adolescents and young adults with ADHD during the COVID-19 pandemic.

J Psychiatr Res 2021 04 14;136:190-197. Epub 2021 Feb 14.

Florida International University, 11200 SW 8th Street, Miami, FL, USA.

Objective: ADHD symptom severity appears to be exacerbated during the COVID-19 pandemic. The present study surveyed top problems experienced by adolescents and young adults (A/YAs) with ADHD during the COVID-19 pandemic to identify possible reasons for symptom escalation and potential targets for intervention. We also explored perceived benefits of the pandemic for A/YAs with ADHD.

Method: At the outbreak of the COVID-19 pandemic (April-June 2020), we administered self and parent ratings about current and pre-pandemic top problem severity and benefits of the pandemic to a sample of convenience (N = 134 A/YAs with ADHD participating in a prospective longitudinal study).

Results: The most common top problems reported in the sample were social isolation (parent-report: 26.7%; self-report: 41.5%), difficulties engaging in online learning (parent-report: 23.3%, self-report: 20.3%), motivation problems (parent-report: 27.9%), and boredom (self-report: 21.3%). According to parent (d = 0.98) and self-report (d = 1.33), these top problems were more severe during the pandemic than in prior months. Contrary to previous speculation, there was no evidence that pandemic-related changes mitigated ADHD severity. Multi-level models indicated that A/YAs with higher IQs experienced severer top problems exacerbations at the transition to the COVID-19 pandemic.

Conclusions: For A/YAs with ADHD, several risk factors for depression and school dropout were incurred during the early months of the COVID-19 pandemic. A/YAs with ADHD should be monitored for school disengagement and depressive symptoms during the COVID-19 pandemic. Recommended interventions attend to reducing risk factors such as increasing social interaction, academic motivation, and behavioral activation among A/YAs with ADHD.
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http://dx.doi.org/10.1016/j.jpsychires.2021.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009847PMC
April 2021

Implementing Parent-Teen Motivational Interviewing + Behavior Therapy for ADHD in Community Mental Health.

Prev Sci 2020 Feb 26. Epub 2020 Feb 26.

Center for Children and Families, Florida International University, Miami, FL, USA.

Despite the promise of psychosocial interventions for adolescent Attention Deficit Hyperactivity Disorder (ADHD), there are no studies that examine their implementation in community mental health contexts. In this study, we evaluate the implementation of community-based Supporting Teens' Autonomy Daily (STAND), a parent-teen Motivational Interviewing + Behavior Therapy intervention for adolescents with ADHD. Adolescents with ADHD (N = 225), who were clients at four community mental health agencies, received treatment from 82 therapists. There was double randomization of adolescents and therapists to STAND or Usual Care (UC). Nearly all therapists randomized to STAND completed the training and regularly attended supervision, rating STAND as acceptable and lower burden than UC practices. In the STAND group, MI competence and implementation were lower than in university trials (benchmark range, 19.5% for reflection to question ratio to 83.1% for technical globals). MI integrity in the STAND group was significantly higher than UC across most MITI indices. Content fidelity was adequate in STAND's engagement and skills phases (76.4-85.0%), but not its planning phase (24.4%). Therapists commonly neglected weekly review of goals and home practice and deviated from manualized pace and sequencing of therapy tasks. Learning MI was more challenging for bilingual therapists and therapists with more years of experience. STAND was delivered with higher integrity in earlier sessions and office-based sessions. Discussion identifies future directions for exporting adolescent ADHD interventions to community settings. Patient outcome data for this trial is presented elsewhere. Trial Registration: NCT02694939 www.clinicaltrials.gov.
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http://dx.doi.org/10.1007/s11121-020-01105-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483638PMC
February 2020

Epicardial Connections Involving Pulmonary Veins: The Prevalence, Predictors, and Implications for Ablation Outcome.

Circ Arrhythm Electrophysiol 2020 01 15;13(1):e007544. Epub 2020 Jan 15.

Electrophysiology and Arrhythmia Unit, Centro integral de Enfermedades Cardiovasculares (HM CIEC), Hospital Universitario HM Monteprincipe, HM Hospitales, University CEU-San Pablo, Madrid, Spain (M.T.B.-L., J.G.-M., A.B., E.C., M.A., M.O., J.A.).

Background: The presence of epicardial connections (ECs) between pulmonary veins (PVs) and other anatomic structures may hinder PV isolation. In this study, we analyzed their prevalence, location, associated factors, and clinical implications.

Methods: Five hundred thirty-four consecutive patients with atrial fibrillation undergoing radiofrequency ablation were included. We considered that an EC was present if: (1) the first pass around the PV antrum did not produce PV isolation and (2) subsequent atrial activation during PV pacing showed that the earliest site was located away from the ablation line and later activation sites were observed near the ablation line. Clinical and electrophysiological variables were collected from all patients. Patients were followed during 12.9±9.4 months, and any documented atrial tachyarrhythmia after the 3-month blanking period was classified as a recurrence.

Results: Out of the 534 patients included, 72 (13.5%) were found to have 81 ECs. There was a significant association between the presence of ECs and structural heart disease (15.3% in patients without ECs versus 36.5% in patient with ECs; <0.001) and patent foramen ovale (4.6% versus 13.5%; =0.002). The presence of a left common trunk was significantly associated with the absence of ECs (29.6% in patients without ECs versus 16.2% in patients with ECs; =0.014). Patients with ECs had lower acute success in PV isolation compared with patients without ECs (99.1% versus 86.1%; <0.001). After adjusting for age, sex, type of atrial fibrillation, left atrium area, hypertension, structural heart disease, presence of left common trunk, patent foramen ovale, and time for atrial fibrillation diagnosis to the ablation, we found a significantly higher risk of atrial tachyarrhythmia recurrences in patients with ECs compared with patients without ECs (hazard ratio, 1.7 [95% CI, 1.1-2.9]; =0.04).

Conclusions: ECs between PVs and other adjacent structures are frequent in patient with atrial fibrillation (prevalence: 13.5%). Structural heart disease and a patent foramen ovale are strongly associated with the presence of ECs. ECs reduce the acute and chronic success of PV isolation.
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http://dx.doi.org/10.1161/CIRCEP.119.007544DOI Listing
January 2020

Academic impairment among high school students with ADHD: The role of motivation and goal-directed executive functions.

J Sch Psychol 2019 12 22;77:67-76. Epub 2019 Nov 22.

University of Washington School of Medicine, Seattle Children's Hospital, USA.

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with academic failure in high school; however the underpinnings of these difficulties are insufficiently understood. This study examined deficits in self-regulated learning in a sample of high school students with ADHD (n = 32) compared to demographically similar classmates without ADHD (n = 18). A multimethod battery of self and parent rating scales and cognitive tasks measured aspects of intrinsic motivation, extrinsic motivation, and goal-directed executive functions. A multiple regression modeled predictors of current Grade Point Average (GPA). Results indicated that high school students with ADHD placed lower value on academics (d = .99), were less likely to use goal-setting strategies (d = .95), possessed lower levels of metacognition (d = 1.86), and showed significant deficits in task-based cognitive flexibility (d = .80). After controlling for covariates, the set of self-regulated learning variables explained 23% of the variance in GPA, with metacognition (6% of variance explained) and cognitive flexibility (7% of variance explained) serving as significant predictors of outcome. Findings suggest that higher-order executive function deficits play a critical role in the academic functioning of high school students and students with ADHD show large deficits in these areas. Thus, interventions that target metacognition and cognitive flexibility (i.e., the ability to think through decisions before acting, inhibit automatic responses, and make effective decisions for a desired goal) may be particularly promising to remediate ADHD-related academic problems in high school.
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http://dx.doi.org/10.1016/j.jsp.2019.10.005DOI Listing
December 2019

A constant postpacing interval in response to overdrive pacing with variable number of beats: An aid in the identification of entrainment for a particular pacing train during macroreentrant atrial tachycardias.

J Cardiovasc Electrophysiol 2019 12 2;30(12):2657-2667. Epub 2019 Oct 2.

Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain.

Background: When pacing trains with a constant cycle length (CL) but increasing number of beats are introduced during a macroreentrant atrial tachycardia (MAT), the postpacing interval (PPI) is expected to increase if entrainment does not occur but could be stable if entrainment occurs. We tested the ability of PPI analysis to detect entrainment.

Methods: Synchronized pacing trains with increasing number of beats (1-20) were delivered from the coronary sinus (CS) and lateral right atrium (RA) at a CL 20 ms shorter than the MAT CL. Pacing trains were grouped in pairs differing by one-paced beat, and the ∆PPI measured.

Results: In an initial prospective cohort of 21 patients (48% had left atrial flutter) the mean ∆PPI was 21.3 ± 5.6 ms for pairs of pacing trains in which neither entrained the MAT and 2.8 ± 1.4 ms for those in which both entrained the MAT (P < .0001). Results were similar for common vs atypical flutter, PPI-TCL ≤30 ms vs PPI-TCL >30 ms, presence vs absence of antiarrhythmic drugs and faster vs slower MAT. When an index pacing train was compared to one with two-paced beats less, a PPI difference of <19 ms identified entrainment with 95% sensitivity and 98% specificity. In a validation cohort of 16 patients, this cut-off value resulted in sensitivity and specificity of 90% and 94%.

Conclusions: A relatively constant ∆PPI in response to overdrive pacing with identical CL but different number of beats allows accurate discrimination between trains that entrained vs those which did not entrain a MAT.
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http://dx.doi.org/10.1111/jce.14196DOI Listing
December 2019

Metacognitive and motivation deficits, exposure to trauma, and high parental demands characterize adolescents with late-onset ADHD.

Eur Child Adolesc Psychiatry 2020 Apr 6;29(4):537-548. Epub 2019 Aug 6.

Florida International University, Miami, USA.

The objective of this study is to evaluate support for three hypotheses about the etiology of adolescent-onset ADHD symptoms: (1) a "cool" cognitive load hypothesis, (2) a "hot" rewards processing hypothesis, and (3) a trauma exposure hypothesis. Participants (N = 50) were drawn from two public high schools in a culturally diverse metropolitan area. A detailed procedure for identifying and confirming late-onset ADHD cases is described. Adolescents with late-onset ADHD (n = 15) were identified and compared to childhood-onset (n = 17) and non-ADHD classmates (n = 18). Adolescents and parents completed measures of neurocognition, rewards' processing, clinical profile, and environmental demands. Late-onset cases were clinically and neurocognitively indistinguishable from childhood-onset cases; however, they experienced higher demands from parents (d = 1.09). Compared to the non-ADHD group, late-onset cases showed significant deficits in metacognition (d = 1.25) and academic motivation (d = 0.80), as well as a pronounced history of multiple trauma exposure (OR 11.82). At 1-year follow-up, ADHD persisted in 67.7% of late-onset cases. Late-onset cases (26.7%) were more likely than childhood-onset cases (0.0%) to transfer to alternative schools by 1-year follow-up. Multiple factors may contribute to adolescent-onset ADHD. Adolescents with metacognition and motivation deficits may be at greatest risk for the late-onset ADHD phenotype, particularly in highly demanding environments. Exposure to traumatic stress may play a key role in the exacerbation of existing deficits or onset of new symptoms. Late-onset ADHD was persistent in most cases and associated with higher risk for school disengagement than childhood-onset ADHD. Further work is needed to better understand the etiologies of late-onset ADHD symptoms.
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http://dx.doi.org/10.1007/s00787-019-01382-wDOI Listing
April 2020

Electrogram voltage and pacing threshold before ablation, measured by mini-electrodes, predict parameters indicative of transmural lesions in the human atrium.

J Interv Card Electrophysiol 2020 Apr 2;57(3):443-452. Epub 2019 May 2.

Electrophysiology Laboratory and Arrhythmia Unit, Hospital Madrid Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Avda. Montepríncipe, 25 28660, Madrid, Boadilla del Monte, Spain.

Purpose: An important attenuation of the atrial signal recorded with mini-electrodes (ME) embedded in an 8-mm tip was associated with a transmural radiofrequency lesion. Our aim was to assess if parameters obtained from ME or conventional bipoles before applications predict successful atrial lesions.

Methods: We prospectively included 33 consecutive patients undergoing cavotricuspid isthmus (CTI) ablation. Electrogram voltages and pacing thresholds were measured with ME and conventional bipoles before and after radiofrequency (RF) applications. The time before the loss of capture during applications was recorded. Lesions were considered successful, in accordance with preclinical data, if ME voltage decreased > 54%.

Results: Of 207 applications, 107 could be analyzed. During applications, voltages decreased more in the ME than in the conventional bipoles (66.8 ± 26.1% vs 37.5 ± 42.5%, P = 0.001). Likewise, pacing threshold increased significantly more using the ME (86.3 ± 22.9% ME, 52.6 ± 35.6% conventional, P = 0.001). ME pre-ablation voltages were significantly higher and pacing thresholds significantly lower in successful lesions (voltage 0.88 ± 0.71 vs 0.26 ± 0.18 mV, P = 0.0001; threshold 1.6 ± 1.7 vs 2.8 ± 3.0, P = 0.04). Neither of these parameters with conventional bipoles nor time to loss of capture showed differences. A ME voltage > 0.33 mV and a pacing threshold < 1.5 mA predicted a successful lesion with 0.78 and 0.6 sensitivity and 0.78 and 0.59 specificity.

Conclusions: Certain pre-ablation parameters derived from ME such as electrogram voltage and pacing threshold differ from those obtained by a conventional configuration and can predict a successful atrial lesion.
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http://dx.doi.org/10.1007/s10840-019-00539-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196083PMC
April 2020

Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter.

J Interv Card Electrophysiol 2020 Apr 21;57(3):333-343. Epub 2018 Sep 21.

Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain.

Purpose: Ablation of atrioventricular (AV) conduction and pacemaker implantation is the therapy of last resort for symptomatic atrial tachyarrythmias when rhythm and rate control fail, but is far from ideal. To evaluate whether interatrial electrical disconnection as a result of catheter ablation is feasible and of potential clinical utility as a means of non-pharmacological heart rate control.

Methods: Eleven patients with medically refractory atrial fibrillation or left atrial flutter and symptomatic rapid ventricular response were included. The ablation strategy consisted primarily of right atrial ablation of the interatrial electrical connections, which were located by electroanatomical activation maps performed during coronary sinus stimulation. Successive activation maps were performed as each connection was blocked. If the procedure was considered unsuccessful AV nodal ablation was performed.

Results: The coronary sinus ostium was earliest in 10/11 and could be ablated in 5/10 patients. Interatrial conduction block was only achieved in one patient (9.1%). An unexpected AV nodal modulation with an increase in the Wenckebach cycle length (> 50 ms) occurred in 8/11 patients. These patients remained without pacemaker implantation and only 1/8 required AV nodal ablation during the 1-year follow-up. Quality of life questionnaires indicated significant improvement in patients with AV nodal modulation.

Conclusion: Interatrial electrical disconnection by right atrial catheter ablation is a not feasible with present day technology. The extensive right atrial septal ablation performed resulted in significant AV nodal modulation in most patients, which persisted and resulted in improvement in quality of life.
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http://dx.doi.org/10.1007/s10840-018-0448-6DOI Listing
April 2020

Atrial mapping during pulmonary vein pacing to detect conduction gaps in a second pulmonary vein isolation procedure.

J Interv Card Electrophysiol 2018 Nov 25;53(2):195-205. Epub 2018 May 25.

Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain.

Background: Finding the conduction gaps in redo PV isolation procedures is challenging, and several maneuvers have been described. In the present study, we analyze the pace and map (P&M) maneuver [atrial mapping during pulmonary vein (PV) pacing] to locate the gaps in redo PV isolation procedures.

Methods: Consecutive patients undergoing a second PV isolation procedure at a single institution over a 4-year period were included. For the last 2 years, all the patients (n = 38) studied underwent PV isolation based on the P&M maneuver and were compared to the previous patients (n = 45). The atrial side of the ablation line was mapped with the ablation catheter during PV pacing, and the earliest site was considered a gap site.

Results: Shorter radiofrequency time was required to obtain PV isolation in the P&M group (485 ± 374 vs. 864 ± 544 s; p < 0.001), which remained significant after adjusting for the number of reconnected PVs (p = 0.01). We did not find significant differences in the procedure duration (106 ± 46 vs. 112 ± 53 min; p = 0.57) and arrhythmia recurrence during 1-year follow-up (26.6 vs. 28.9%; p = 0.82) after adjusting for several confounding factors (HR 1.32; 95% CI 0.5-3.4; p = 0.57).

Conclusions: P&M is a simple maneuver to identify the gaps in ablation lines around the PV. It remains efficacious in redo procedures despite the difficulties in localizing the ablation lines performed in the first procedure. The P&M maneuver reduced the radiofrequency time required to isolate the PV without compromising the efficacy.
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http://dx.doi.org/10.1007/s10840-018-0371-xDOI Listing
November 2018

Relationship between left atrium catheter contact force and pacing threshold.

J Interv Card Electrophysiol 2017 Aug 27;49(2):147-155. Epub 2017 Apr 27.

Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain.

Purpose: The purpose of this study is to analyze the relationship between contact force (CF) and pacing threshold in left atrium (LA).

Methods: Six to ten LA sites were studied in 28 consecutive patients with atrial fibrillation undergoing pulmonary vein isolation. Median CF, bipolar and unipolar electrogram voltage, impedance, and bipolar and unipolar thresholds for consistent constant capture and for consistent intermittent capture were measured at each site.

Results: Pacing threshold measurements were performed at 188 LA sites. Both unipolar and bipolar pacing thresholds correlated significantly with median CF; however, unipolar pacing threshold correlated better (unipolar: Pearson R -0.45; p < 0.001; Spearman Rho -0.62; p < 0.001, bipolar: Pearson R -0.39; p < 0.001; Spearman Rho -0.52; p < 0.001). Consistent constant capture threshold had better correlation with median CF than consistent intermittent capture threshold for both unipolar and bipolar pacing (Pearson R -0.45; p < 0.001 and Spearman Rho -0.62; p < 0.001 vs. Pearson R -0.35; p < 0.001; Spearman Rho -0.52; p < 0.001). The best pacing threshold cutoff point to detect a good CF (>10 g) was 3.25 mA for unipolar pacing with 69% specificity and 73% sensitivity. Both increased to 80% specificity and 74% sensitivity for sites with normal bipolar voltage and a pacing threshold cutoff value of 2.85 mA.

Conclusions: Pacing thresholds correlate with CF in human not previously ablated LA. Since the combination of a normal bipolar voltage and a unipolar pacing threshold <2.85 mA provide reasonable parameters of validity, pacing threshold could be of interest as a surrogate for CF in LA.
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http://dx.doi.org/10.1007/s10840-017-0253-7DOI Listing
August 2017

Unexpectedly short postpacing interval in a left free wall accessory pathway mediated tachycardia: A pitfall of the corrected postpacing interval algorithm?

Indian Pacing Electrophysiol J 2016 May - Jun;16(3):109-112. Epub 2016 Aug 31.

Electrophysiology Laboratory and Arrhythmia Unit, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain.

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http://dx.doi.org/10.1016/j.ipej.2016.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5067834PMC
August 2016

Atrial mapping during pulmonary vein pacing: a novel maneuver to detect and close residual conduction gaps in an ablation line.

J Interv Card Electrophysiol 2016 Dec 1;47(3):299-307. Epub 2016 Jul 1.

Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain.

Background: Location of residual conduction gaps on ablation lines around pulmonary veins (PV) is challenging, and several maneuvers have been described. Atrial mapping during PV pacing-the "pace and map" maneuver-could localize gaps.

Methods And Results: We prospectively studied 209 patients undergoing PV isolation at a single institution over a 25-month period. In 24 (11.4 %) patients, 26 PV remained connected after an ablation line and an initial conventional gap closure protocol. The atrial side of the ablation line was mapped with the ablation catheter during PV pacing, and the earliest site was considered a gap site. Ablation at these gap sites resulted in bidirectional PV conduction block in 22 PV (85 %) in 21 patients (88 %), after 2.2 ± 1.6 radiofrequency applications and 8.2 ± 4.8 min. Early PV reconnection (≥20 min) occurred in 0 PV (0 %). During a mean follow-up of 12 ± 6 months, eight patients (33 %) had arrhythmia recurrences.

Conclusions: The "pace and map" maneuver is a relatively simple and efficacious means to identify gaps in ablation lines around PV, focusing on the atrial rather than the PV side of the line. It could be considered among the ways to eliminate residual conduction gaps.
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http://dx.doi.org/10.1007/s10840-016-0159-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110596PMC
December 2016

Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.

Eur Heart J 2017 May;38(17):1329-1335

Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.

Aims: Intravenous procainamide and amiodarone are drugs of choice for well-tolerated ventricular tachycardia. However, the choice between them, even according to Guidelines, is unclear. We performed a multicentre randomized open-labelled study to determine the safety and efficacy of intravenous procainamide and amiodarone for the acute treatment of tolerated wide QRS complex (probably ventricular) tachycardia.

Methods And Results: Patients were randomly assigned to receive intravenous procainamide (10 mg/kg/20 min) or amiodarone (5 mg/kg/20 min). The primary endpoint was the incidence of major predefined cardiac adverse events within 40 min after infusion initiation. Of 74 patients included, 62 could be analysed. The primary endpoint occurred in 3 of 33 (9%) procainamide and 12 of 29 (41%) amiodarone patients (odd ratio, OR = 0.1; 95% confidence interval, CI 0.03-0.6; P = 0.006). Tachycardia terminated within 40 min in 22 (67%) procainamide and 11 (38%) amiodarone patients (OR = 3.3; 95% CI 1.2-9.3; P = 0.026). In the following 24 h, adverse events occurred in 18% procainamide and 31% amiodarone patients (OR: 0.49; 95% CI: 0.15-1.61; P: 0.24). Among 49 patients with structural heart disease, the primary endpoint was less common in procainamide patients (3 [11%] vs. 10 [43%]; OR: 0.17; 95% CI: 0.04-0.73, P = 0.017).

Conclusions: This study compares for the first time in a randomized design intravenous procainamide and amiodarone for the treatment of the acute episode of sustained monomorphic well-tolerated (probably) ventricular tachycardia. Procainamide therapy was associated with less major cardiac adverse events and a higher proportion of tachycardia termination within 40 min.
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http://dx.doi.org/10.1093/eurheartj/ehw230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5410924PMC
May 2017

Accurate Dosing of Antiretrovirals at Home Using a Foilized, Polyethylene Pouch to Prevent the Transmission of HIV From Mother to Child.

Medicine (Baltimore) 2015 Jun;94(25):e1030

From the Department of Biomedical Engineering (AC, RM), Duke University, Durham, North Carolina, USA; and Hospital Gineco-Obstetrico Enrique C Sotamayor (MO), Guayaquil, Ecuador.

Mother-to-child HIV transmission rates remain elevated in countries with high home birth rates. This risk can be dramatically reduced if infants receive antiretroviral (ARV) medication within 24 hours after birth. However, many barriers prevent access to these medications immediately after delivery, for example, there is currently no suitable mechanism to preserve predosed ARVs in the home during the months before birth. In response to this, students of the Duke University developed the Pratt pouch, a foilized polyethylene packet designed to preserve predosed ARVs.This cross-sectional study presents the data from the first clinical trials of the Pratt pouch in Guayaquil, Ecuador.Fourteen HIV-positive mothers and nurses were observed using the pouch to deliver a dose of ARVs to an infant. Weight measurements, time, and notes on spillage were taken at each observation period. Successful usage was quantitatively assessed through the calculation of dosing accuracy based on the volume of liquid medication emptied from the pouch. Additionally, mothers were surveyed after a month of using the device at home to assess their perception of the accuracy, acceptability, and ease of use of the pouch. Used pouches were collected for physical analysis of tearing.Observed users delivered accurate doses (M = 101.1%, standard deviation = 8.2%) in an average time of 2.6 minutes. A total of 2869 used pouches were recovered. No seal failures or failed attempts at opening/delivering the pouches were observed or detected. Forty-three mothers were surveyed. All mothers (100%) reported that they were able to follow their physician's treatment plan, all pouches were received in good condition and the pictorial sheets provided clear instructions.We conclude that the Pratt pouch is a highly accurate and easy-to-use device for delivering liquid oral ARVs to infants and is appropriate for prepackaging ARVs for home use.
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http://dx.doi.org/10.1097/MD.0000000000001030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504570PMC
June 2015

Low recurrence rate after nodal reentrant tachycardia cryoablation with an 8-mm tip catheter and prolonged applications.

Rev Esp Cardiol (Engl Ed) 2015 Apr 21;68(4):345-6. Epub 2015 Feb 21.

Unidad de Electrofisiología Cardiaca y Arritmología Clínica, Centro Integral de Enfermedades Cardiovasculares, Hospital Universitario Montepríncipe, Grupo HM Hospitales, Universidad CEU-San Pablo, Madrid, Spain.

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http://dx.doi.org/10.1016/j.rec.2014.11.011DOI Listing
April 2015

Comparison of radiofrequency catheter ablation of drivers and circumferential pulmonary vein isolation in atrial fibrillation: a noninferiority randomized multicenter RADAR-AF trial.

J Am Coll Cardiol 2014 Dec;64(23):2455-67

University of Michigan, Ann Arbor, Michigan.

Background: Empiric circumferential pulmonary vein isolation (CPVI) has become the therapy of choice for drug-refractory atrial fibrillation (AF). Although results are suboptimal, it is unknown whether mechanistically-based strategies targeting AF drivers are superior.

Objectives: This study sought to determine the efficacy and safety of localized high-frequency source ablation (HFSA) compared with CPVI in patients with drug-refractory AF.

Methods: This prospective, multicenter, single-blinded study of 232 patients (age 53 ± 10 years, 186 males) randomized those with paroxysmal AF (n = 115) to CPVI or HFSA-only (noninferiority design) and those with persistent AF (n = 117) to CPVI or a combined ablation approach (CPVI + HFSA, superiority design). The primary endpoint was freedom from AF at 6 months post-first ablation procedure. Secondary endpoints included freedom from atrial tachyarrhythmias (AT) at 6 and 12 months, periprocedural complications, overall adverse events, and quality of life.

Results: In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months after a single procedure but, after redo procedures, was noninferior to CPVI at 12 months for freedom from AF and AF/AT. Serious adverse events were significantly reduced in the HFSA group versus CPVI patients (p = 0.02). In persistent AF, there were no significant differences between treatment groups for primary and secondary endpoints, but CPVI + HFSA trended toward more serious adverse events.

Conclusions: In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months but was noninferior to CPVI at 1 year in achieving freedom of AF/AT and a lower incidence of severe adverse events. In persistent AF, CPVI + HFSA offered no incremental value. (Radiofrequency Ablation of Drivers of Atrial Fibrillation [RADAR-AF]; NCT00674401).
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http://dx.doi.org/10.1016/j.jacc.2014.09.053DOI Listing
December 2014

Clinical impact of defibrillation testing at the time of implantable cardioverter-defibrillator insertion.

Cardiol J 2015 ;22(3):253-9

Background: Ventricular fibrillation is routinely induced during implantable cardioverter-defibrillator insertion to assess defibrillator performance, but this strategy is experiencing a progressive decline. We aimed to assess the efficacy of defibrillator therapies and long-term outcome in a cohort of patients that underwent defibrillator implantation with and without defibrillation testing.

Methods: Retrospective observational series of consecutive patients undergoing initial defibrillator insertion or generator replacement. We registered spontaneous ventricular arrhythmias incidence and therapy efficacy, and mortality.

Results: A total of 545 patients underwent defibrillator implantation (111 with and 434 without defibrillation testing). After 19 (range 9-31) months of follow-up, the death rate per observation year (4% vs. 4%; p = 0.91) and the rate of patients with defibrillator-treated ventricular arrhythmic events per observation year (with test: 10% vs. without test: 12%; p = 0.46) were similar. The generalized estimating equations-adjusted first shock probability of success in patients with test (95%; CI 88-100%) vs. without test (98%; CI 96-100%; p = 0.42) and the proportion of successful antitachycardia therapies (with test: 87% vs. without test: 80%; p = 0.35) were similar between groups. There was no difference in the annualized rate of failed first shock per patient and per shocked patient between groups (5% vs. 4%; p = 0.94).

Conclusions: In this observational study, that included an unselected population of patients with a defibrillator, no difference was found in overall mortality, first shock efficacy and rate of failed shocks regardless of whether defibrillation testing was performed or not.
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http://dx.doi.org/10.5603/CJ.a2014.0062DOI Listing
September 2016

Update: Arrhythmias (V). Paroxysmal supraventricular tachycardias and preexcitation syndromes.

Rev Esp Cardiol (Engl Ed) 2012 May 28;65(5):456-69. Epub 2012 Mar 28.

Unidad de Electrofisiología Cardiaca y Arritmología Clínica, Grupo Hospital de Madrid, Universidad CEU-San Pablo, Madrid, Spain.

Paroxysmal supraventricular tachycardias are fast and usually regular rhythms that require some structure above the bifurcation of the His bundle to be continued. The 3 most common types are atrial tachycardias, atrioventricular nodal reentrant tachycardias, and tachycardias mediated by an accessory pathway. The last two varieties are discussed in the present manuscript. Their prognosis is benign regarding life expectancy but typically they are symptomatic and chronically recurrent, producing a certain disability. They usually occur in people without structural heart disease. Pharmacologic therapy is possible, but given the high efficacy of catheter ablation, these procedures are frequently chosen. Ventricular preexcitation is due to the presence of an accessory pathway, usually atrioventricular. The clinical course can be asymptomatic, generating a characteristic electrocardiographic pattern, produce paroxysmal supraventricular tachycardias, or facilitate other types of arrhythmias. Very rarely, they can cause sudden cardiac death. The treatment of choice for symptomatic patients is catheter ablation of the accessory pathway. The therapeutic attitude towards asymptomatic preexcitation remains controversial.
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http://dx.doi.org/10.1016/j.recesp.2011.11.026DOI Listing
May 2012

Implantable defibrillator electrograms and origin of left ventricular impulses: an analysis of regionalization ability and visual spatial resolution.

J Cardiovasc Electrophysiol 2012 May 8;23(5):506-14. Epub 2011 Dec 8.

Cardiology Department, Hospital General Universitario Gregorio Marañon, Spain.

Introduction: The implantable cardioverter-defibrillator (ICD) electrogram (EG) is a documentation of ventricular tachycardia. We prospectively analyzed EGs from ICD electrodes located at the right ventricle apex to establish (1) ability to regionalize origin of left ventricle (LV) impulses, and (2) spatial resolution to distinguish between paced sites.

Methods And Results: LV electro-anatomic maps were generated in 15 patients. ICD-EGs were recorded during pacing from 22 ± 10 LV sites. Voltage of far-field EG deflections (initial, peak, final) and time intervals between far-field and bipolar EGs were measured. Blinded visual analysis was used for spatial resolution. Initial deflections were more negative and initial/peak ratios were larger for lateral versus septal and superior versus inferior sites. Time intervals were shorter for apical versus basal and septal versus lateral sites. Best predictive cutoff values were voltage of initial deflection <-1.24 mV, and initial/peak ratio >0.45 for a lateral site, voltage of final deflection <-0.30 for an inferior site, and time interval <80 milliseconds for an apical site. In a subsequent group of 9 patients, these values predicted correctly paced site location in 54-75% and tachycardia exit site in 60-100%. Recognition of paced sites as different by EG inspection was 91% accurate. Sensitivity increased with distance (0.96 if ≥ 2 cm vs 0.84 if < 2 cm, P < 0.001) and with presence of low-voltage tissue between sites (0.94 vs 0.88, P < 0.001).

Conclusions: Standard ICD-EG analysis can help regionalize LV sites of impulse formation. It can accurately distinguish between 2 sites of impulse formation if they are ≥2 cm apart.
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http://dx.doi.org/10.1111/j.1540-8167.2011.02233.xDOI Listing
May 2012

Successful catheter cryoablation of Hisian ectopy using 2 new diagnostic criteria based on unipolar and bipolar recordings of the His electrogram.

J Cardiovasc Electrophysiol 2012 Mar 14;23(3):325-9. Epub 2011 Nov 14.

Cardiac Electrophysiology and Clinical Arrhythmology Unit, Madrid Hospital Group, CEU-San Pablo University, Madrid, Spain.

We describe the case of a 61-year-old woman who underwent successful catheter cryoablation of a symptomatic Hisian ectopy. Diagnosis was based on features of the HV interval assessed from a bipolar recording during mapping. The location of the arrhythmic focus was identified using simultaneous unipolar and bipolar recordings of the His electrogram. This case report highlights the use of 2 new criteria for the diagnosis and mapping of Hisian ectopy, and the successful use of cryothermia for the ablation of extrasystoles arising from the His bundle.
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http://dx.doi.org/10.1111/j.1540-8167.2011.02217.xDOI Listing
March 2012

Incidence, determinants, and prognostic implications of true pleomorphism of ventricular tachycardia in patients with implantable cardioverter-defribillators: a substudy of the DATAS Trial.

Circ Arrhythm Electrophysiol 2011 Feb 13;4(1):33-42. Epub 2010 Nov 13.

Hospital Gregorio Marañon, Madrid, Spain.

Background: The occurrence of monomorphic ventricular tachycardia (M-VT) with >1 QRS morphology during the same episode (pleomorphism [PL]) or in different episodes (multiple morphologies [MM]) has been described through ECG. Implantable cardioverter-defribillator (ICD) electrograms (EGs) provide the opportunity to analyze virtually all spontaneous M-VT episodes. We sought to study the incidence, determinants, and prognostic significance of PL and MM as assessed by ICD-EG in a prospective series of patients with ICDs.

Methods And Results: Spontaneous episodes of M-VT were analyzed before ICD intervention. PL was defined as >1 ICD-EG morphology, each having ≥6 consecutive identical beats during the same VT episode, and MM as >1 ICD-EG morphology in different M-VT episodes in the same patient. We analyzed 1881 M-VT episodes from 315 patients followed for 17 months. PL and MM occurred in 6% and 19%, respectively, of the total population (16% and 62% of patients with M-VT). Recurrent M-VT as diagnosis for ICD indication predicted PL and MM. Patients with PL more frequently developed MM (85% versus 15%; P<0.001) compared to patients without PL. Total mortality (5%) was significantly higher in patients with PL (20%), in patients with MM (11.5%), and in women (12%). In multivariate analysis, only PL (odds ratio, 5.33; P=0.009) and female sex (odds ratio, 3.1; P=0.038) predicted mortality.

Conclusions: In a prospective series of patients with ICDs, mostly indicated for secondary prevention, both PL and MM of VT, as judged by ICD-EG, were not uncommon and were strongly associated. Female sex and the development of PL VT were the only independent predictors of mortality.
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http://dx.doi.org/10.1161/CIRCEP.110.957068DOI Listing
February 2011

Spectral analysis of sustained and non-sustained ventricular fibrillation in patients with an implantable cardioverter-defibrillator.

Rev Esp Cardiol 2009 Jun;62(6):690-3

Unidad de Arritmias, Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Murcia, España.

The mechanisms responsible for the maintenance and termination of ventricular fibrillation (VF) are poorly understood. The aim of this study was to compare the spectral characteristics of the electrical signal during sustained and non-sustained VF in patients with an implantable cardioverter-defibrillator. The study included 51 patients who had had at least one episode of sustained VF (i.e., duration >5 s and requiring shock administration) and non-sustained VF (i.e., duration >3 s and spontaneously terminated) that were recorded by the device set in a unipolar configuration. Spectral analysis of the first 3 s of each episode was performed. The dominant frequency was higher in sustained VF (4.6+/-0.7 Hz) than in non-sustained VF (4.3+/-0.6 Hz; P=.01), while the other parameters were similar. Although the spectral characteristics of sustained and non-sustained VF were similar, differences were observed during the first 3 s that could be used in algorithms for the early detection of non-sustained VF.
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http://dx.doi.org/10.1016/s1885-5857(09)72234-0DOI Listing
June 2009

Spectral analysis of intracardiac electrograms during induced and spontaneous ventricular fibrillation in humans.

Europace 2009 Mar 24;11(3):328-31. Epub 2008 Dec 24.

Arrhythmia Unit, Hospital Universitario Virgen de la Arrixaca de Murcia, El Palmar, Murcia 30120, Spain.

Aims: Very limited data are available on the differences between spontaneous and induced episodes of ventricular fibrillation (VF) in humans. The aim of the study was to compare the spectral characteristics of the electrical signal recorded by an implantable cardioverter defibrillator (ICD) during both types of episodes.

Methods And Results: Thirteen ICD patients with at least one spontaneous and one induced VF recorded by the device were included in the study. A spectral representation was obtained for the first 3 s of the intracardiac unipolar electrogram during VF. The dominant frequency (f(d)), the peak power at f(d), an organization index (OI), a bandwidth measurement, and an estimate of the correlation with a sinusoidal wave (leakage) were estimated for each episode. The f(d) was higher in induced episodes (4.75 +/- 0.57 vs. 3.95 +/- 0.59 Hz for the spontaneous episodes, P = 0.002), as well as the degree of organization assessed by the OI, bandwidth, and leakage parameters.

Conclusion: Clinical and induced VF episodes in humans have different spectral characteristics. Changes in the electrophysiological substrate or in the location of the arrhythmia wavefront at onset could play a role to explain the observed differences.
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http://dx.doi.org/10.1093/europace/eun366DOI Listing
March 2009

[Predictors of intrahospitalary mortality in the upper gastrointestinal variceal bleeding due to chronic liver disease treated endoscopically].

Acta Gastroenterol Latinoam 2008 Mar;38(1):43-50

Jefe del Servicio de Terapia Intensiva del Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina.

Unlabelled: Upper gastrointestinal variceal bleeding is one of the most serious complications in patients with chronic liver disease. The aim of this trial is to identify in hospital mortality predictors in this illness.

Material And Methods: 106 hospitalizations due to this disease from October 2001 to April 2006 in cohort design. In hospital mortality was confronted with age, sex, liver disease etiology, Apache II score at admission, variceal severity, severity of the hepatic failure evaluated according to the Child Pugh's classes, a history of variceal bleeding, initial endoscopic treatment failure, haemostatic failure within the first 48 hours, and rebleeding after 48 hours from admission. In order to identify independent mortality predictors, all the variables correlated significantly with hospital mortality were selected. For the quantitative variable APACHE II score at admission, the best mortality discrimination value was chosen.

Results: independent in hospital mortality predictors were: initial endoscopic treatment failure (p = 0.005), haemostatic failure in the first 48 hours (p = 0.012), and Child Pugh C class (p = 0.024). Although male sex, Apache II score at admission and rebleeding after 48 hours were also significantly related to mortality by univaried model, they did not qualify as independent predictors.

Conclusions: the independent predictors of intrahospitalary mortality in patients with variceal bleeding due to chronic liver disease, and first-line of endoscopic treatment were: 1) Initial haemostatic endoscopic treatment failure, 2) Haemostatic failure in the first 48 hs, and 3) Child Pugh C class hepatic failure at admission.
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March 2008

Effects of the location of myocardial infarction on the spectral characteristics of ventricular fibrillation.

Pacing Clin Electrophysiol 2008 Jun;31(6):660-5

Arrhythmia Unit, Hospital Universitario Virgen de la Arrixaca de Murcia, Murcia, Spain.

Background: The location of the myocardial infarction (MI) might modify the spectral characteristics of ventricular fibrillation (VF) in humans.

Objective: To evaluate the effect of the location of the infarcted area on the spectral parameters of VF.

Methods: Patients with chronic MI (29 anterior, 32 inferior) and induced VF during cardioverter defibrillator implant were retrospectively studied. Dominant frequency (f(d)), organization index (OI), and power of the harmonic peaks were calculated in the device-stored electrograms (EGM) during sinus rhythm (SR) and VF.

Results: The f(d) of the VF was not affected by the left ventricular ejection fraction (LVEF) or the MI location (anterior: 4.54 +/- 0.74 Hz, inferior: 4.77 +/- 0.48 Hz, n.s.). The OI was also similar in both groups. However, in patients with inferior MIs, normalized peak power at f(d) was higher (118.3 +/- 18.5 vs 100.6 +/- 28.2, P < 0.01) and the normalized peak power of the harmonics was lower than in the anterior MI group. The analysis of EGM during SR showed similar results. The size of the necrotic area and its distance to the recording electrode might partially explain these results.

Conclusion: In our series, the spectral characteristics of the EGMs during VF showed significant differences depending on the MI localization. A higher fraction of energy (in the low-frequency region) was seen in inferior MIs, whereas the peak power at the harmonics increased in anterior MIs. A similar effect was seen during SR and VF, suggesting that it is caused by local electrophysiology abnormalities induced by the MI rather than by different intrinsic characteristics of the VF.
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http://dx.doi.org/10.1111/j.1540-8159.2008.01068.xDOI Listing
June 2008

Differentiation of ventricular and supraventricular tachycardias based on the analysis of the first postpacing interval after sequential anti-tachycardia pacing in implantable cardioverter-defibrillator patients.

Heart Rhythm 2007 Mar 10;4(3):316-22. Epub 2006 Nov 10.

Laboratorio de Electrofisiología, Departamento de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.

Background: Current discrimination algorithms do not completely avoid inappropriate tachycardia detection.

Objectives: This study analyzes the discrimination capability of the changes of the first postpacing interval (FPPI) after successive bursts of anti-tachycardia pacing (ATP) trains in implantable cardioverter-defibrillator (ICD)-recorded tachycardias.

Methods: We included 50 ICD patients in this prospective study. We hypothesized that the FPPI variability (FPPIV) when comparing bursts with different numbers of beats would be shorter in ventricular tachycardias (VTs) compared with supraventricular tachycardias (SVTs). The ATP (5-10 pulses, 91% of tachycardia cycle length) was programmed for tachycardias >240 ms.

Results: Anti-tachycardia pacing was delivered during 37 sinus tachycardias (STs) in an exercise test, 96 induced VTs in an electrophysiological study, and 198 spontaneous episodes (144 VTs and 54 SVTs). The FPPI remained stable after all ATP bursts in VT but changed continuously in SVT; when comparing bursts of 5 and 10 pulses, the FPPIV was shorter in VT (34 +/- 65 vs.138 +/- 69, P<.0001, in all T and 12 +/- 20 vs. 138 +/- 69, P<.0001, in T>or=320 ms) than in SVT. In T>or=320 ms an FPPIV
Conclusions: Analysis of FPPIV after ATP discriminates ICD-detected T. Successive bursts (of ATP) trains at 91% of tachycardia cycle length are safe, despite being delivered before rhythm classification.
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http://dx.doi.org/10.1016/j.hrthm.2006.10.032DOI Listing
March 2007