Publications by authors named "Simon A Castro"

24 Publications

  • Page 1 of 1

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

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

Patients With Acute Ischemic Stroke Who Receive Brain Magnetic Resonance Imaging Demonstrate Favorable In-Hospital Outcomes.

J Am Heart Assoc 2020 10 10;9(20):e016987. Epub 2020 Oct 10.

Department of Medicine Bridgeport Hospital-Yale New Haven Health Bridgeport CT.

Background Use of inpatient brain magnetic resonance imaging (MRI) in patients with acute ischemic stroke is highly institution dependent and has been associated with increased length and cost of hospital stay. We examined whether inpatient brain MRI in patients with acute ischemic stroke is associated with improved clinical outcomes to justify its resource requirements. Methods and Results The National Inpatient Sample database was queried retrospectively to find 94 003 patients who were admitted for acute ischemic stroke and then received inpatient brain MRI between 2012 and 2014. Multivariable regression analysis was performed with respect to a control group to assess for differences in the rates of inpatient mortality and complications, as well as the length and cost of hospital stay based on brain MRI use. Inpatient brain MRI was independently associated with lower rates of inpatient mortality (1.67% versus 3.09%; adjusted odds ratio [OR], 0.60; 95% CI, 0.53-0.68; <0.001), gastrostomy (2.28% versus 2.89%; adjusted OR, 0.82; 95% CI, 0.73-0.93; <0.001), and mechanical ventilation (1.97% versus 2.82%; adjusted OR, 0.68; 95% CI, 0.60-0.77; <0.001). Brain MRI was independently associated with ≈0.32 days (8%) and $1131 (11%) increase in the total length (<0.001) and cost (<0.001) of hospital stay, respectively. Conclusions Inpatient brain MRI in patients with acute ischemic stroke is associated with substantial decrease in the rates of inpatient mortality and complications, at the expense of marginally increased length and cost of hospitalization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.120.016987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763386PMC
October 2020

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

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

Performance of Prognostic Heart Failure Models in Patients With Nonischemic Cardiomyopathy Undergoing Ventricular Tachycardia Ablation.

JACC Clin Electrophysiol 2019 07 8;5(7):801-813. Epub 2019 May 8.

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

Objectives: This study sought to assess the performance of established risk models in predicting outcomes after catheter ablation (CA) in patients with nonischemic dilated cardiomyopathy (NIDCM) and ventricular tachycardia (VT).

Background: A correct pre-procedural risk stratification of patients with NIDCM and VT undergoing CA is crucial. The performance of different pre-procedural risk stratification approaches to predict outcomes of CA of VT in patients with NIDCM is unknown.

Methods: The study compared the performance of 8 prognostic scores (SHFM [Seattle Heart Failure Model], MAGGIC [Meta-analysis Global Group in Chronic Heart Failure], ADHERE [Acute Decompensated Heart Failure National Registry], EFFECT [Enhanced Feedback for Effective Cardiac Treatment-Heart Failure], OPTIMIZE-HF [Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure], CHARM [Candesartan in Heart Failure-Assessment of Reduction in Mortality], EuroSCORE [European System for Cardiac Operative Risk Evaluation], and PAINESD [Chronic Obstructive Pulmonary Disease, Age > 60 Years, Ischemic Cardiomyopathy, New York Heart Association Functional Class III or IV, Ejection Fraction <25%, Presentation With VT Storm, Diabetes Mellitus]) for the endpoints of death/cardiac transplantation and VT recurrence in 282 consecutive patients (age 59 ± 15 years, left ventricular ejection fraction: 36 ± 13%) with NIDCM undergoing CA of VT. Discrimination and calibration of each model were evaluated through area under the curve (AUC) of receiver-operating characteristic curve and goodness-of-fit test.

Results: After a median follow-up of 48 (interquartile range: 19-67) months, 43 patients (15%) died, 24 (9%) underwent heart transplantation, and 58 (21%) experienced VT recurrence. The prognostic accuracy of SHFM (AUC = 0.89; goodness-of-fit p = 0.68 for death/transplant and AUC = 0.77; goodness-of-fit p = 0.16 for VT recurrence) and PAINESD (AUC = 0.83; goodness-of-fit p = 0.24 for death/transplant and AUC = 0.68; goodness-of-fit p = 0.58 for VT recurrence) were significantly superior to that of other scores.

Conclusions: In patients with NIDCM and VT undergoing CA, the SHFM and PAINESD risk scores are powerful predictors of recurrent VT and death/transplant during follow-up, with similar performance and significantly superior to other scores. A pre-procedural calculation of the SHFM and PAINESD can be useful to predict outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2019.04.001DOI Listing
July 2019

Noninvasive Programmed Ventricular Stimulation-Guided Management Following Ventricular Tachycardia Ablation.

JACC Clin Electrophysiol 2019 06 1;5(6):719-727. Epub 2019 May 1.

Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study sought to determine the impact of repeat catheter ablation (CA) prior to hospital discharge based on inducibility of clinical ventricular tachycardia (VT) during noninvasive programmed ventricular stimulation (NIPS).

Background: Inducibility of clinical VT during NIPS performed several days after CA identifies patients at high risk of recurrence. The impact of NIPS-guided repeat CA has not been reported.

Methods: Consecutive patients with structural heart disease undergoing CA of VT followed by NIPS were studied. Clinical VT was defined by comparison with 12-lead electrocardiograms and stored implantable cardioverter-defibrillator electrograms from spontaneous VT episodes. Among those with inducible clinical VT at NIPS, VT-free survival was compared between those in whom ablation was repeated (group 1) versus those in whom ablation was not repeated (group 2) prior to hospital discharge.

Results: Among 469 patients (64 ± 12 years of age; 85% males; 60% ischemic), 216 patients (46%) underwent NIPS 3 days (interquartile range: 2 to 4 days) after CA. Clinical VT was induced in 45 patients (21%). Among those 45, CA was repeated in 11 patients (24%). There were no significant differences in baseline clinical or index CA characteristics between groups 1 and 2. Over a median 36-month follow-up, only 1 patient (9%) in group 1 experienced VT recurrence compared to 24 patients (71%) in group 2 (p < 0.01). In univariate Cox regression, repeat CA guided by NIPS (hazard ratio: 0.07; 95% confidence interval: 0.01 to 0.58; p = 0.01) was the only predictor of VT-free survival.

Conclusions: In patients with inducible clinical VT during post-ablation NIPS, repeat CA was associated with significantly lower risk of subsequent recurrence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2019.03.007DOI Listing
June 2019

Comparison of the arrhythmogenic substrate between men and women with nonischemic cardiomyopathy.

Heart Rhythm 2019 09 28;16(9):1414-1420. Epub 2019 Mar 28.

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Outcomes of ventricular tachycardia (VT) ablation in structural heart disease have been reported to differ by sex. Whether this is due to differences in the underlying arrhythmogenic substrates among patients with nonischemic cardiomyopathy (NICM) remains unclear.

Objective: The purpose of this study was to compare the characteristics of arrhythmogenic substrates between women and men with NICM.

Methods: We analyzed 160 consecutive patients (26 women) with NICM who were undergoing VT ablation at the Hospital of the University of Pennsylvania. Of these 160 patients, 59 (13 women) underwent cardiac magnetic resonance (CMR) before the ablation procedure. The arrhythmogenic substrate was analyzed qualitatively and quantitatively by CMR and/or detailed electroanatomic mapping.

Results: There were no significant differences in left ventricular scar percentage as defined by CMR (9.5% ± 7.8% in women vs 11.2% ± 8.6% in men; P = .5), endocardial bipolar voltage (<1.5 mV; 11.3% ± 19.3% in women vs 11.5% ± 16.3% in men; P = .4), endocardial unipolar voltage (<8.3 mV; 38.0% ± 30.8% in women vs 45.6% ± 30.9% in men; P = .2), or epicardial bipolar voltage (<1.0 mV; 21.5% ± 38.9% in women vs 10.7% ± 13.9% in men; P = .6). There were no significant differences in scar transmurality as defined by CMR (5 categories: endocardial, midwall, epicardial, transmural, and right ventricular endocardial). Similarly, there were no significant differences in scar distribution as defined by CMR or electroanatomic mapping (anteroseptal vs inferolateral).

Conclusion: Scar percentage, transmurality, and distribution are similar between women and men with NICM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2019.03.024DOI Listing
September 2019

Potential Role of PET in Assessing Ventricular Arrhythmias.

PET Clin 2019 Apr 1;14(2):281-291. Epub 2019 Feb 1.

Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA. Electronic address:

Ventricular arrhythmias (VAs) are a major cause of morbidity and mortality, especially in patients with structural heart disease. In the last decade, advanced imaging modalities, such as cardiac MR and nuclear imaging, have progressively demonstrated to play a central role in the diagnosis and management of patients presenting with VAs. PET is acquiring a growing role thanks to its capability to assess different pathophysiologic aspects of the arrhythmogenic substrate by evaluating abnormal myocardial perfusion, presence of inflammation, myocardial viability, and sympathetic innervation. This review describes the principles and main clinical applications of PET imaging in the setting of VAs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cpet.2018.12.009DOI Listing
April 2019

Electrophysiologic Substrate, Safety, Procedural Approaches, and Outcomes of Catheter Ablation for Ventricular Tachycardia in Patients After Aortic Valve Replacement.

JACC Clin Electrophysiol 2019 01 26;5(1):28-38. Epub 2018 Sep 26.

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

Objectives: This study sought to investigate the substrate, procedural strategies, safety, and outcomes of catheter ablation (CA) for ventricular tachycardia (VT) in patients with aortic valve replacement (AVR).

Background: VT ablation in patients with AVR is challenging, particularly when mapping and ablation in the periaortic region are necessary.

Methods: We identified consecutive patients with mechanical, bioprosthetic, and transcatheter AVR who underwent CA for VT refractory to antiarrhythmic drugs and analyzed VT substrate, approach to LV access, complications, and long-term outcomes.

Results: Overall, 29 patients (87% men, mean age 67.9 ± 9.8 years, left ventricular ejection fraction 39 ± 10%) with prior AVR (13 mechanical, 15 bioprosthetic, 1 transcatheter AVR) underwent 40 ablations from 2004 to 2016. Left-sided mapping/CA was performed in 27 patients (36 procedures). Access was retrograde aortic in 11 procedures (all bioprosthetic), transseptal in 24 (13 mechanical; 10 bioprosthetic; 1 transcatheter AVR), or transventricular septal in 1. Periaortic bipolar or unipolar scar was detected in all 24 patients in whom detailed periaortic mapping was performed. Clinical VT circuit(s) involved the periaortic region in 10 patients (34%), 2 (7%) had bundle branch re-entry VT, and 17 (59%) had substrate unrelated to AVR. There were 2 major complications (both related to vascular access). Only 2 patients (9.1%) had VT recurrence. Over median follow-up of 12.8 months, 11 patients died (none as a result of recurrent VT).

Conclusions: Whereas most patients undergoing CA for VT after AVR had VT from substrate unrelated to AVR, periaortic scar is universally present and bundle branch re-entry can be the VT mechanism. CA can be safely performed with excellent long-term VT elimination.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2018.08.008DOI Listing
January 2019

Identifying Risk and Management of Acute Haemodynamic Decompensation During Catheter Ablation of Ventricular Tachycardia.

Arrhythm Electrophysiol Rev 2018 Dec;7(4):282-287

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

Radiofrequency catheter ablation (CA) has an established role in the management of patients with structural heart disease presenting with recurrent ventricular tachycardia (VT). Due to the complex underlying substrate, high burden of comorbidities and concomitant heart failure (HF) status, these patients may be at higher risk of periprocedural complications. The prolonged low-output state related to VT induction and mapping, as well as the fluid overload due to irrigated CA and the use of general anaesthesia, may decompensate the HF status, leading to multiple-organ failure and increase in early post-procedural mortality. Proper identification of patients at high risk of periprocedural acute haemodynamic decompensation (AHD) has important implications in terms of procedural planning (i.e. prophylactic use of mechanical assistance devices) and pre-procedural management in order to optimise the HF status. In the present manuscript we focus on the clinical predictors of AHD and the strategies to improve pre-procedural risk stratification, as well as the evidence supporting the use of haemodynamic support during CA procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15420/aer.2018.36.3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304792PMC
December 2018

Clinical applications of feature-tracking cardiac magnetic resonance imaging.

World J Cardiol 2018 Nov;10(11):210-221

NorthWest Cardiac Imaging Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, United Kingdom.

Cardiovascular diseases represent the leading cause of mortality and morbidity in the western world. Assessment of cardiac function is pivotal for early diagnosis of primitive myocardial disorders, identification of cardiac involvement in systemic diseases, detection of drug-related cardiac toxicity as well as risk stratification and monitor of treatment effects in patients with heart failure of various etiology. Determination of ejection fraction with different imaging modalities currently represents the gold standard for evaluation of cardiac function. However, in the last few years, cardiovascular magnetic resonance feature tracking techniques has emerged as a more accurate tool for quantitative evaluation of cardiovascular function with several parameters including strain, strain-rate, torsion and mechanical dispersion. This imaging modality allows precise quantification of ventricular and atrial mechanics by directly evaluating myocardial fiber deformation. The purpose of this article is to review the basic principles, current clinical applications and future perspectives of cardiovascular magnetic resonance myocardial feature tracking, highlighting its prognostic implications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4330/wjc.v10.i11.210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6259029PMC
November 2018

Long-Term Outcome of Catheter Ablation for Treatment of Bundle Branch Re-Entrant Tachycardia.

JACC Clin Electrophysiol 2018 03 19;4(3):331-338. Epub 2018 Mar 19.

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

Objectives: This study reports the long-term outcome of patients with bundle branch re-entrant tachycardia (BBRT) who underwent catheter ablation for ventricular tachycardia (VT).

Background: BBRT is an uncommon mechanism of VT. Data on long-term outcomes of patients with BBRT treated with catheter ablation are insufficient.

Methods: Between 2005 and 2016, 32 patients had a sustained VT due to a bundle branch re-entrant mechanism. Diagnosis of BBRT was established per standard published criteria.

Results: The mode of presentation was syncope in 17 patients (53%) and palpitations in 15 (47%). BBRT was inducible in all subjects, and successful ablation of the right bundle branch in 19 patients (59%) or the left bundle branch in 13 patients (41%) was performed. During follow-up of 95 ± 36 months, 6 patients (19%) died, 3 of progressive heart failure and 3 of noncardiac causes. Recurrent VT due to BBRT did not occur in any patient. At baseline, 25 patients (78%) had a prolonged HV interval (>55 ms) and 7 (22%) had a normal HV interval (≤55 ms). In patients with a normal HV interval, there was only 1 death (due to malignancy), and no one developed heart block during 90 ± 36 months of follow-up. Ten patients (31%) had normal left ventricular (LV) function (LV ejection fraction ≥50%), and 22 (69%) had depressed LV function (LV ejection fraction <50%). No deaths were recorded in patients with normal LV function (5 with no implantable cardioverter-defibrillator) compared with 6 deaths among patients with depressed LV function (n = 22; p = 0.07).

Conclusions: Radiofrequency ablation of the bundle branch is an effective therapy for treatment of BBRT. Sustained BBRT can be seen in patients with normal LV systolic function and HV interval with excellent long-term outcomes after ablation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2017.11.021DOI Listing
March 2018

Characterization of the Electroanatomic Substrate in Cardiac Sarcoidosis: Correlation With Imaging Findings of Scar and Inflammation.

JACC Clin Electrophysiol 2018 03 29;4(3):291-303. Epub 2017 Nov 29.

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

Objectives: This study sought to characterize the electroanatomic (EAM) substrate in patients with cardiac sarcoidosis (CS) and ventricular tachycardia and its relationship to imaging findings of inflammation and fibrosis.

Background: CS is characterized by coexistence of active inflammation and replacement fibrosis.

Methods: A total of 42 patients with CS based on established criteria and ventricular tachycardia underwent high-density EAM mapping. Abnormal electrograms (EGM) were collected and independently classified as multicomponent fractionated, isolated, late, and split according to standard criteria and regardless of the peak-to-peak bipolar/unipolar voltage. A total of 29 patients (69%) underwent pre-procedural cardiac magnetic resonance (CMR) and positron emission tomography (PET)/computed tomography (CT). The distribution of EAM substrate was correlated with regions of late gadolinium enhancement (LGE) on CMR and increased 18F-fluorodeoxyglucose uptake on PET/CT.

Results: Of 21,451 bipolar and unipolar EGM, 4,073 (19%) were classified as abnormal with a predominant distribution in the basal perivalvular segments and interventricular septum. Using the standard bipolar (<1.5 mV) and unipolar (<8.3 mV for left ventricle <5.5 mV for the right) voltage cutoff values, 40% and 22% of the abnormal EGM were located outside the EAM low-voltage areas, respectively. LGE was present in 26 of 29 patients (90%), whereas abnormal 18F-fluorodeoxyglucose uptake in 14 of 29 patients (48%) with imaging. Segments with abnormal EGM had more LGE-evident scar transmurality [median: 24% (interquartile range [IQR]: 4% to 40%) vs. median: 5% (IQR: 0% to 15%); p < 0.001] and lower metabolic activity (median: 20 g glucose [IQR: 14 g to 30 g] vs. median: 29 g glucose [IQR: 18 g to 39 g]; p < 0.001). Overall, the agreement between the presence of abnormal EGM was higher with the presence of LGE (κ = 0.51; p < 0.001) than with the presence of active inflammation (κ = -0.12; p = 0.003).

Conclusions: In patients with CS and ventricular tachycardia, pre-procedural imaging with CMR and PET/CT can be useful in detecting EAM abnormalities that are potential targets for substrate ablation. Abnormal EGM were more likely located in segments with more scar transmurality (LGE) at CMR and a lower degree of inflammation on PET.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2017.09.175DOI Listing
March 2018

Long-Term Outcomes of Catheter Ablation of Electrical Storm in Nonischemic Dilated Cardiomyopathy Compared With Ischemic Cardiomyopathy.

JACC Clin Electrophysiol 2017 07 26;3(7):767-778. Epub 2017 Apr 26.

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

Objectives: The goal of this study was to determine the long-term outcomes of catheter ablation (CA) of electrical storm in patients with nonischemic dilated cardiomyopathy (NIDCM) compared with patients with ischemic cardiomyopathy (ICM).

Background: CA of ventricular tachycardia (VT) electrical storm has been shown to improve VT-free survival in patients with ICM. Data on the outcomes of CA of electrical storm in patients with NIDCM are insufficient.

Methods: The study included 267 consecutive patients with NIDCM (n = 71; ejection fraction 32 ± 14%) and ICM (n = 196; ejection fraction 28 ± 12%). Endo-epicardial CA was performed in 59 (22%) patients. CA was guided by activation and entrainment mapping for tolerated VT and pacemapping/targeting of abnormal substrate for unmappable VT.

Results: After a median follow-up of 45 (25th to 75th percentile: 9 to 71) months and 1 (25th to 75th percentile: 1 to 8) procedures, 76 (29%) patients died, 25 (9%) underwent heart transplantation, 87 (33%) experienced VT recurrence, and 13 (5%) had recurrence of electrical storm. Overall VT-free survival was 54% at 60 months (48% in NIDCM and 54% in ICM; p = 0.128). Patients with VT recurrence experienced a median of 2 (1 to 10) VT episodes in the 5 (1 to 14) months after the procedure. Death/transplantation-free survival was 62% at 60 months (53% in NIDCM and 64% in ICM; p = 0.067). Persistent inducibility of any VT with cycle length ≥250 ms at programmed stimulation at the end of the procedure was the only independent predictor of VT recurrence. Low ejection fraction, New York Heart Association functional class, and VT recurrence over follow-up independently predicted death/transplantation.

Conclusions: CA of electrical storm was similarly effective in patients with NIDCM compared with patients with ICM, with elimination of electrical storm in 95% of cases and achievement of complete VT control at long-term follow-up in most patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2017.01.020DOI Listing
July 2017

Outcomes with prophylactic use of percutaneous left ventricular assist devices in high-risk patients undergoing catheter ablation of scar-related ventricular tachycardia: A propensity-score matched analysis.

Heart Rhythm 2018 10 10;15(10):1500-1506. Epub 2018 May 10.

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

Background: The PAINESD score predicts the risk of periprocedural acute hemodynamic decompensation (AHD) and postprocedural mortality in patients undergoing catheter ablation (CA) of scar-related ventricular tachycardia (VT). The role of prophylactic placement of percutaneous left ventricular assist devices (pLVADs) in high-risk patients is unknown.

Objective: The purpose of this study was to evaluate the outcomes of prophylactic use of pLVAD in high-risk patients undergoing CA of scar-related VT.

Methods: We included 75 patients undergoing CA of scar-related VT in whom a prophylactic pLVAD was implanted because of perceived high risk. The control population was a propensity-matched group of 75 patients who did not undergo prophylactic pLVAD placement. The PAINESD score was used for propensity matching.

Results: The median PAINESD score was 13 (41% with score ≥15) in the prophylactic pLVAD group and 12 (40% with score ≥15) in the control group. Periprocedural AHD occurred in 5 patients (7%) in the prophylactic pLVAD group and in 17 patients (23%) in the control group (P < .01). The 12-month cumulative incidence of VT was 40% in the prophylactic pLVAD group vs 41% in the control group (P = .97), while the 12-month incidence of death/transplant was 33% vs 66%, respectively (P < .01). In multivariable analysis, left ventricular ejection fraction (HR 0.97, 95% CI 0.95-0.99, P = .03), chronic kidney disease (HR 2.24, 95% CI 1.35-3.72, P < .01), VT recurrence (HR 2.33, 95% CI 1.31-4.14, P < .01), and prophylactic pLVAD (HR 0.28, 95% CI 0.16-0.49, P < .01) were all independently associated with death/transplant.

Conclusion: Prophylactic pLVAD placement in high-risk patients undergoing CA of scar-related VT is associated with a reduced risk of AHD and death/transplant during follow-up without affecting VT-free survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2018.04.028DOI Listing
October 2018

Prognostic role of serial quantitative evaluation of F-fluorodeoxyglucose uptake by PET/CT in patients with cardiac sarcoidosis presenting with ventricular tachycardia.

Eur J Nucl Med Mol Imaging 2018 07 2;45(8):1394-1404. Epub 2018 Apr 2.

Division of Nuclear Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA.

Background: Positron emission tomography (PET) with F-fluorodeoxyglucose (FDG) has shown to be useful in diagnosis, staging and monitoring of cardiac sarcoidosis (CS) but its interpretation is not standardized.

Objectives: We sought to investigate the clinical impact of serial quantitative FDG uptake analysis in patients with CS presenting with ventricular tachycardia (VT) treated by catheter ablation (CA).

Methods: We followed 20 patients (51 ± 9 years, 70% males) with CS and VT who underwent CA, with 92 serial FDG-PET scans (3-10 per patient). Myocardial FDG-avid lesions were quantified using three parameters: maximum standardized uptake value (SUV), partial-volume corrected mean standardized uptake value (SUV) and partial-volume corrected volume-intensity product [lesion metabolic activity (LMA)]. The volume-intensity product of the entire heart [global cardiac metabolic activity (gCMA)] and the background cardiac metabolic activity (bCMA: difference between gCMA and LMA) were also calculated. The primary end-point was the occurrence of major adverse cardiac events (MACE), including death, heart transplant, hospitalization for heart failure and implantable cardioverter defibrillator (ICD) appropriate interventions. Evolution of echocardiographic parameters over follow-up was also assessed.

Results: During a median follow-up of 35 (20-66) months, 18 MACE (1 death, 2 heart transplants, 12 ICD appropriate interventions, 3 hospitalizations) occurred in 12 (60%) patients. At univariable analysis, lack of PET improvement (defined by decrease in LMA of at least 25%) was the only variable associated with cardiac events during follow-up. In particular, non-responders had a 20-fold higher risk of MACE at follow-up (HR 18.96, 95% CI 2.26-159.27; p = 0.007). Moreover, a significant linear inverse relationship was observed between changes in LMA and changes in left ventricular ejection fraction over follow-up (β = -20.11; p = 0.003).

Conclusions: In patients with CS and VT, temporal change in FDG uptake evaluated by a quantitative approach is associated with parallel change in systolic function. Moreover, reduction in FDG uptake is strongly associated with fewer MACE at long-term follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00259-018-4001-8DOI Listing
July 2018

Intravascular fracture of the Impella device during removal.

HeartRhythm Case Rep 2017 Dec 6;3(12):584-585. Epub 2017 Oct 6.

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrcr.2017.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741812PMC
December 2017

Impact of timing of recurrence following catheter ablation of scar-related ventricular tachycardia on subsequent mortality.

Pacing Clin Electrophysiol 2017 Sep 26;40(9):1010-1016. Epub 2017 Aug 26.

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

Background: Catheter ablation (CA) has an established role in scar-related ventricular tachycardia (VT), but the risk of recurrences is substantial and the appropriate intensity of postablation monitoring unknown. The implication of timing of postablation VT recurrence has not been adequately investigated.

Methods: We studied 120 consecutive patients with scar-related VT (age 60 ± 15 years, left ventricular ejection fraction 39 ± 16%, 52% ischemic etiology) with at least 2 years of follow-up. Timing of VT recurrence was classified as very early (<1 month), early (1-6 months), or late (>6 months).

Results: At 24 months follow-up, 53 (44%) patients had recurrent VT, with eight (15%) having very early recurrence, 17 (32%) early recurrence, and 28 (53%) late recurrence. Mortality rates at 2 years were significantly higher in patients with very early VT recurrence (38%) compared to those with early (12%), late (7%), and no (3%) recurrences (log-rank P < 0.001). Very early VT recurrence was associated with an increased risk of death (odds ratio = 5.68, 95% confidence interval = 1.06-30.62, P = 0.04), while recurrent VT beyond 6 months was not associated with increased risk of mortality (P = 0.94).

Conclusions: Timing of VT recurrence following CA of scar-related VT impacts subsequent risk of mortality. Patients experiencing VT recurrence within 1-6 months from the procedure are at particularly high risk. These data support the importance of intense postablation monitoring for at least 6 months after the procedure to identify patients with early VT recurrence who may benefit from additional therapeutic interventions to improve outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/pace.13149DOI Listing
September 2017

Incremental value of electroanatomical mapping for the diagnosis of arrhythmogenic right ventricular cardiomyopathy in a patient with sustained ventricular tachycardia.

HeartRhythm Case Rep 2016 Nov 9;2(6):469-472. Epub 2016 Sep 9.

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

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrcr.2016.06.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419974PMC
November 2016

Outcomes of Catheter Ablation of Idiopathic Outflow Tract Ventricular Arrhythmias With an R Wave Pattern Break in Lead V2: A Distinct Clinical Entity.

J Cardiovasc Electrophysiol 2017 May 21;28(5):504-514. Epub 2017 Mar 21.

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

Introduction: In outflow tract ventricular arrhythmias (OT-VAs), an abrupt loss of the R wave in lead V2 compared to V1 and V3 (pattern break in V2-PBV2) suggests an origin close to the anterior interventricular sulcus (anatomically opposite to lead V2) and adjacent to proximal coronaries. We studied the outcome of catheter ablation of OT-VAs with a PBV2.

Methods And Results: Of 130 consecutive patients with idiopathic left bundle block morphology OT-VAs and transition ≤V4, 12 (9%) had PBV2. Outcomes in this group were compared to the remaining 118 patients. Patients with PBV2 were more likely to be younger (41 ± 18 vs. 50 ± 14 years, P = 0.0384) and women (11 [92%] vs. 70 [59%], P = 0.0302). The earliest activation was at the RVOT in seven, left coronary cusp (LCC) in one, anterior interventricular vein (AIV) in two and the epicardium in two. In five (42%) cases (earliest activation in the AIV in two, epicardium in two, and RVOT below the valve level in one), ablation was aborted due to proximity to the left anterior descending (LAD) coronary artery. After 36 ± 17 months and 1.3 ± 0.5 procedures, VAs elimination was achieved in 58% of patients with PBV2 compared to 89% of the reference population (P = 0.0125) with effective site in five of seven at the most anterior and leftward RVOT adjacent to the pulmonic valve (PV).

Conclusions: OT-VAs with PBV2 demonstrate a unique ECG pattern and challenging catheter ablation. Proximity to LAD precludes ablation in about half. Long-term VA suppression could be achieved in only 58% of cases most commonly when the earliest site is at the anterior and leftward RVOT just under the PV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.13183DOI Listing
May 2017

Long-Term Outcome After Catheter Ablation of Ventricular Tachycardia in Patients With Nonischemic Dilated Cardiomyopathy.

Circ Arrhythm Electrophysiol 2016 Oct;9(10)

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

Background: Catheter ablation (CA) of ventricular tachycardia (VT) in patients with nonischemic dilated cardiomyopathy can be challenging because of the complexity of underlying substrates. We sought to determine the long-term outcomes of endocardial and adjuvant epicardial CA in nonischemic dilated cardiomyopathy.

Methods And Results: We examined 282 consecutive patients (aged 59±15 years, 80% males) with nonischemic dilated cardiomyopathy who underwent CA. Ablation was guided by activation/entrainment mapping for tolerated VT and pacemapping/targeting of abnormal electrograms for unmappable VT. Adjuvant epicardial ablation was performed for recurrent VT or persistent inducibility after endocardial-only ablation. Epicardial ablation was performed in 90 (32%) patients. Before ablation, patients failed a median of 2 antiarrhythmic drugs), including amiodarone, in 166 (59%) patients. The median follow-up after the last procedure was 48 (19-67) months. Overall, VT-free survival was 69% at 60-month follow-up. Transplant-free survival was 76% and 68% at 60- and 120-month follow-up, respectively. Among the 58 (21%) patients with VT recurrence, CA still resulted in a significant reduction of VT burden, with 31 (53%) patients having only isolated (1-3) VT episodes in 12 (4-35) months after the procedure. At the last follow-up, 128 (45%) patients were only on β-blockers or no treatment, 41 (15%) were on sotalol or class I antiarrhythmic drugs, and 62 (22%) were on amiodarone.

Conclusions: In patients with nonischemic dilated cardiomyopathy and VT, endocardial and adjuvant epicardial CA is effective in achieving long-term VT freedom in 69% of cases, with a substantial improvement in VT burden in many of the remaining patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCEP.116.004328DOI Listing
October 2016

Long-Term Outcomes of Catheter Ablation of Ventricular Tachycardia in Patients With Cardiac Sarcoidosis.

Circ Arrhythm Electrophysiol 2016 08;9(8)

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

Background: Catheter ablation (CA) of ventricular tachycardia (VT) in patients with cardiac sarcoidosis can be challenging because of the complex underlying substrate. We sought to determine the long-term outcome of CA of VT in patients with cardiac sarcoidosis.

Methods And Results: We enrolled 31 patients (age, 55±10 years) with diagnosis of cardiac sarcoidosis based on Heart Rhythm Society criteria and VT who underwent CA. In 23 (74%) patients, preprocedure cardiac magnetic resonance imaging and positron emission tomographic (PET) evaluation were performed. Preprocedure magnetic resonance imaging was positive for late gadolinium enhancement in 21 of 23 (91%) patients, whereas abnormal 18-fluorodeoxyglucose uptake was found in 15 of 23 (65%) cases. In 14 of 15 patients with positive PET at baseline, PET was repeated after 6.1±3.7-month follow-up. After a median follow-up of 2.5 (range, 0-10.5) years, 1 (3%) patient died and 4 (13%) underwent heart transplant. Overall VT-free survival was 55% at 2-year follow-up. Among the 16 (52%) patients with VT recurrences, CA resulted in a significant reduction of VT burden, with 8 (50%) having only isolated (1-3) VT episodes and only 1 patient with recurrent VT storm. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET at baseline, and lack of PET improvement over follow-up were associated with increased risk of recurrent VT.

Conclusions: In patients with cardiac sarcoidosis and VT, CA is effective in achieving long-term freedom from VT or improvement in VT burden in the majority of patients. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET scan at baseline, or lack of improvement at repeat PET over follow-up predict worse arrhythmia-free survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCEP.116.004333DOI Listing
August 2016
-->