Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Cardiac Resynchronization Via Left Ventricular Anterior Wall Pacing
Get PDFA case of cardiac resynchronization is presented with paced-QRS narrowing effected via a left ventricular (LV) lead placed at an anterior cardiac vein after failed implantation at the lateral wall due to phrenic nerve stimulation. Data are presented indicating that an anterior LV pacing site selection may not be that bad after all, particularly when biventricular pacing from this position produces a QRS that is narrower than the baseline native QRS. Rhythmos 2018;13(1):10-11.
The Contemporary Role of Percutaneous Coronary Intervention in Left Main Disease Management
Get PDFSince the 1980s coronary artery bypass grafting (CABG) has been considered as the gold standard for treating left main disease. The continuous evolution of tools and techniques concerning coronary angioplasty and the advent of drug-eluting stents (DES) have established percutaneous coronary intervention (PCI) as a possible alternative to CABG. Initial randomized studies that were conducted during the previous decade, with main representative the SYNTAX study, compared conventional CABG to PCI with first generation DES and showed non-inferiority regarding hard clinical outcomes. The results of two randomized studies comparing CABG versus PCI with second generation DES were simultaneously published in the end of 2016 to further support PCI as a credible alternative to CABG for patients with left main disease with low and intermediate SYNTAX scores. A Heart Team is indispensable to best evaluate the anatomic parameters of coronary lesions, the clinical variables and the technical possibilities regarding disease complexity in order to define the ideal revascularization strategy for each patient in the elective setting. Percutaneous treatment for left main disease has been increasingly performed during the last decade, since the procedural steps and optimal techniques for left main PCI are nowadays standardized and well described in expert consensus documents and therefore should be respected and applied in order to optimize patient outcomes. Rhythmos 2018;13(3):48-53
TAVI in Bicuspid Aortic Valve Stenosis: Cautiously Feasible
Get PDFBicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation with a prevalence of 0.4% to 2%. For a long time, a BAV has not been considered an indication for transcatheter aortic valve implantation (TAVI) due to insufficient technology and poor procedural results conferred by a challenging valvular anatomy leading to poor stability of the prosthetic valve and/or paravalvular regurgitation due to distorted native valve leaflets. Large randomized controlled TAVI trials typically excluded bicuspid aortic stenosis (AS) because of its unique anatomic features. However, current technological advancements are apparently changing this landscape, and over the last few years, TAVI appears technically feasible, albeit a demanding procedure, and has been used to treat severe bicuspid AoV stenosis with promising results, as shown, apart from earlier case reports and patient series, in several recent observational studies and comparative trials between patients with tricuspid and patients with BAV. Thus, current literature cautiously supports a role of TAVI in selected BAV AS patients; however, the final role of this technique in this challenging group of patients will need to be determined from randomized controlled trials comparing TAVI with surgical replacement and studies comparing TAVI in bicuspid and tricuspid aortic valves. Technological advancements appear to play a significant and crucial role in rendering the transcatheter approach feasible, efficacious and safe. Rhythmos 2017;12(3): 40-44
Cardiology News / Recent Literature Review / Third Quarter 2017
Get PDFHCS 2017, 28th Panhellenic Cardiology Congress: Athens, 19-21/10/2017TCT Congress: Denver, Colorado, 29/10-2/11/2017AHA Meeting: Anaheim, Ca, 11-15/11/2017ACC.18 Congress: Orlando, FL, 10-12/3/2018HRS Meeting: Boston, 9-12/5/2018ESC Meeting: Munich, 25-29/8/2018 Long QT syndrome (LQTS): Although Outcomes Have Improved, 1 in 4 Patients with Prior Symptoms Experience at Least 1 Subsequent, Albeit Nonlethal, Cardiac Event Demanding Further Optimization of Treatment Strategies Among 606 patients with LQTS (LQT1 in 47%, LQT2 in 34%, and LQT3 in 9%), a potentially lethal cardiac channelopathy with a 1-5% annual risk of LQTS-triggered syncope, aborted cardiac arrest, or sudden cardiac death, there were 166 (27%) patients who were symptomatic prior to their first Mayo Clinic evaluation at a median age of 12 years at first symptom. Treatment strategies included no active therapy in 47 (8%) patients, beta-blockers alone in 350 (58%) patients, ICDs alone in 25 (4%) patients, left cardiac sympathetic denervation alone in 18 (3%) patients, and combination therapy in 166 (27%) patients. Over a median follow-up of 6.7 years, 556 (92%) patients did not experience a cardiac event. Only 8 of 440 (2%) previously asymptomatic patients experienced a single event. In contrast, 42 of 166 (25%) previously symptomatic patients experienced >1 events. Among the 30 patients with >2 events, 2 patients died and 3 LQT3 patients underwent cardiac transplantation (Rohatgi RK et al, J Am Coll Cardiol 2017;70:453–62). TRAC-AF Study: Temperature-Controlled Irrigated Ablation Produces Rapid, Efficient, and Durable PV Isolation A novel irrigated RF catheter (DiamondTemp -DT) designed with a diamond-embedded tip (for rapid cooling) and thermocouples to monitor tissue temperature, was first used in 6 pigs for atrial ablation in a temperature control mode (60°C/50 W) until there was ∼80% EGM amplitude reduction; lesion histology revealed transmurality in 51 of 55 lesions (92.7%). In a clinical feasibility study, the study group of 35 patients having PV isolation with the DT catheter, compared with a control group of 35 patients undergoing PV isolation with a standard force-sensing catheter, had shorter mean RF application duration (26.3 ± 5.2 min vs. 89.2 ± 27.2 min; p < 0.001), shorter mean fluoroscopic time (11.2 ± 8.5 min vs. 19.5 ± 6.8 min; p < 0.001), and lower acute dormant PV reconduction (0 of 35 vs. 5 of 35; p = 0.024). At 3 months, among 23 patients undergoing remapping, 39 of 46 PV pairs (84.8%) remained durably isolated in 17 of these patients (73.9%) (Iwasawa J et al, J Am Coll Cardiol 2017;70:542-553)... (excerpt
Preventing Sudden Death in Idiopathic Dilated Cardiomyopathy: A Difficult to Settle Issue
Get PDFRisk stratification for sudden cardiac death in non-ischemic dilated cardiomyopathy remains a difficult and controversial issue. This is currently guided by left ventricular ejection fraction, severity of heart failure symptoms according to New York Heart Association classification, and the morphology and duration of the QRS complex. The results of a recent study stirred some initial controversy with regards to the utility of the implantable cardioverter defibrillator in these patients, however, a subsequent meta-analysis confirmed prior findings of the survival-prolonging benefit of device therapy. These issues are herein briefly reviewed. Rhythmos 2017;12(1):1-6.
Percutaneous Closure of Patent Foramen Ovale for Cryptogenic Stroke: The Issue is Finally Settled
Get PDFBased on newer data from randomized controlled trials and meta-analyses, the previously controversial and highly debated issue of patent foramen ovale (PFO) closure in patients with cryptogenic stroke is finally settled in favor of closure over medical therapy for the secondary prevention of cryptogenic stroke attributable to paradoxical embolism. One PFO closure device finally received FDA approval in October 2016. Rhythmos 2017; 12(4):60-62
Focal Ablation of Atrial Fibrillation: The Target Remains Elusive
Get PDFContemporary technology using mapping tools and algorithms in animal and computer models has suggested discrete atrial fibrillation (AF)-sustaining mechanisms in the form of electric rotors as focal areas of AF perpetuation. When these focal sites were targeted, ablation initially appeared promising in reducing the recurrence rates of AF. However, many other investigators have been unable to reproduce this kind of success with focal impulse and rotor modulation (FIRM)-guided ablation, and have cast doubts on the effectiveness of this novel technique that could have led to a paradigm-shift in our approach to AF ablation. A single randomized trial that was recently published in a high-impact cardiology journal indicating poor results of rotor ablation was subsequently retracted amidst a cloud of controversy and doubt about the flaws and conflicts of current medical publishing. Thus, until further evidence from ongoing and future randomized studies becomes available, the target of focal ablation for AF patients continues to remain elusive. Rhythmos 2017;12(2):21-25
Effect of Diabetes Mellitus on Atrial Fibrillation Catheter Ablation Outcomes
Get PDFPatients with diabetes mellitus commonly are suffering from atrial fibrillation since these two conditions share pathophysiological mechanisms. Catheter ablation of atrial fibrillation is the cornerstone therapy for rhythm control in symptomatic patients with paroxysmal or persistent atrial fibrillation. Data regarding the efficacy and safety of catheter ablation from large randomized clinical trials in this population are limited. The only available data from small clinical trials and meta-analyses have shown a superiority of catheter ablation compared to antiarrhythmic drugs although there are some limitations. Rhythmos 2017;12(2):26-28
Secondary Percutaneous Revascularization for Severe Unprotected Left Main Disease After Surgical Turndown
Get PDFPatients with severe left main and/or multi-vessel coronary artery disease (CAD) and contraindications or extremely high risk for surgical revascularization that are subsequently referred for percutaneous coronary intervention (PCI) have been increasing in clinical practice. We present the case of a patient with a previous history of aortic valve replacement and coronary artery bypass grafting (CABG) hospitalized because of angina recurrence and a functional test with myocardial scintigraphy that showed extensive myocardial ischemia. The coronary angiogram revealed severe left main and two-vessel disease with totally occluded bypass grafts, while revascularization by re-do CABG was rejected. The patient was finally treated by a technically challenging high-risk unprotected left main PCI. Rhythmos 2017;12(2):29-32
The “Elpis” Registry on Percutaneous Coronary Interventions: A Three-Year Experience
Get PDFThe advent of percutaneous coronary intervention (PCI) transformed the treatment of obstructive coronary artery disease (CAD) by creating a less invasive revascularization option to coronary-artery bypass grafting (CABG).1 Although, randomized controlled clinical trials (RCTs) are the gold standard in medical research, there is not always the possibility to conduct properly designed RCTs. The gap between evidence from RCTs and clinical practice can be filled by epidemiological studies and properly designed registries.2 The results of the Hellenic Heart Registry on Percutaneous Coronary Interventions (HHR-PCI), a national registry of patients with stable angina or acute coronary syndromes who underwent PCI, were only recently published.3 The purpose of the current study is to report the experience of a newly formed Catheterization laboratory at a tertiary hospital of Athens and to compare its findings to those reported by the HHR-PCI... (excerpt