Radiofrequency catheter ablation of atrlal tachycardia due to myocarditis six months after a viper bite

The present report describes a 20-year old man who developed an incessant atrial tachycardia several days after snakebite. Antiarrhythmic treatment was ineffective and six months later radiofrequency ablation of atrial tachycardia was successfully performed. A chronic arrythmia was considered as manifestation of toxic-allergic myocarditis. The possible mechanisms leading to myocarditis are discussed.

Myocarditis Secondary to COVID 19 Infection: A Case-Report

Introduction: Coronavirus disease 2019 (COVID 19) is an emerging viral infection caused by the strain of coronavirus SARS-CoV-2, primarily affecting the respiratory system. However, it can be responsible for heart damage. The aim of this work was to report a case of symptomatic myocarditis in a 53-year-old patient. Patient and Observation: We report the case of a 53-year-old patient with no particular history or cardiovascular risk factor found who had consulted in June 2020 in a hospital for dyspnea, dizziness and palpitations in whom the electrocardiogram had demonstrated ventricular tachycardia. The echocardiography was normal and coronary artery disease was ruled out on coronary angiography and antiarrhythmic treatment allowed it to regress. Two months later, after a break in therapy, this tachycardia recurred despite several electrical and chemical cardioversions. Subsequently, myocarditis was suspected. This motivated the realization of a cardiac magnetic resonance imaging (MRI) which came back in favor of myocarditis. As part of the etiological research, RT-PCR and COVID 19 serology were requested and the serology returned positive for IgG. Conclusion: COVID 19 disease is known for its respiratory manifestations. However, several cases of cardiac involvement, in particular myocardial damage, have been described and among these, a considerable proportion of arrhythmias. They can be multifactorial in origin, due to the virus itself, or the prolongation of the QT interval from various drug therapies. These arrhythmias are the source of sudden death, hence the interest of RT-PCR and COVID 19 serology, but also the need for early and appropriate management, as well as long-term monitoring of patients. cured patients.

Pharmacologic Therapy for Engraftment Arrhythmia Induced by Transplantation of Human Cardiomyocytes

BackgroundEngraftment arrhythmias (EAs) are observed in large animal studies of intramyocardial transplantation of human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) for myocardial infarction. Although transient, the risk posed by EA presents a barrier to clinical translation.ObjectivesWe hypothesized that clinically approved antiarrhythmic drugs can prevent EA-related mortality as well as suppress tachycardia and arrhythmia burden.MethodshPSC-CM were transplanted into the infarcted porcine heart by surgical or percutaneous delivery to induce EA. Following a screen of antiarrhythmic agents, a prospective study was conducted to determine the effectiveness of amiodarone plus ivabradine in preventing cardiac death and suppressing EA.ResultsEA was observed in all subjects, and amiodarone-ivabradine treatment was well-tolerated. None of the treated subjects experienced the primary endpoint of cardiac death, unstable EA or heart failure compared to 5/8 (62.5%) in the control cohort (hazard ratio 0.00; 95% confidence interval, 0–0.297; p = 0.002). Overall survival including two deaths in the treated cohort from immunosuppression-related infection showed borderline improvement with treatment (hazard ratio 0.21; 95% confidence interval, 0.03–1.01; p = 0.05). Without treatment, peak heart rate averaged 305 ± 29 beats per min (bpm), whereas in treated subjects peak daily heart rate was significantly restricted to 185±9 bpm (p = 0.006). Similarly, treatment reduced peak daily EA burden from 96.8 ± 2.9% to 76.5 ± 7.9% (p = 0.003). Antiarrhythmic treatment was safely discontinued after approximately one-month of treatment without recrudescence of arrhythmia.ConclusionsThe risk of engraftment arrhythmia following hPSC-CM transplantation can be reduced significantly by combined amiodarone and ivabradine drug therapy.Condensed AbstractEngraftment arrhythmia (EA) is a transient but serious complication of cardiac remuscularization therapy. Using a porcine model of cardiac remuscularization and EA, ivabradine and amiodarone were independently effective in suppressing tachycardia and arrhythmia, respectively. Baseline amiodarone combined with adjunctive ivabradine successfully prevented cardiac death, unstable EA and heart failure (hazard ratio 0.00; 95% confidence interval, 0–0.297; p = 0.002) and significantly suppressed peak daily heart rate and arrhythmia burden (p=0.006 and 0.003, respectively). Antiarrhythmic treatment was successfully discontinued after one-month without recrudescence of arrhythmia. We conclude that EA can be suppressed by combined amiodarone and ivabradine drug therapy.

Pulmonary veins isolation as a first line therapy in paroxysmal atrial fibrillation? More and more yes

There is still debate as to whether pulmonary vein isolation should be the first-line treatment in symptomatic patients with atrial fibrillation. Recently, two other strong arguments for yes, occurred. At the Congress of the European Society of Cardiology, the results of two randomized, multicentre studies were presented: Cryo-FIRST and STOP-AF FIRST. In the above studies, balloon cryoablation (without prior antiarrhythmic treatment attempt) was associated with a statistically significant reduction of arrhythmia recurrences compared to the control group treated with AA drugs. Importantly, it was also associated with a comparable safety profile.

673Bipolar radiofrequency ablation supported by non-ionic catheter irrigation

Introduction Bipolar radiofrequency catheter ablation (Bi-RFCA) or irrigation of ablation catheter (AC) using non-ionic coolant, such as dextrose-5 in water (D5W), are novel ways to improve lesion formation in case of arrhythmia refractoriness. Combination of these two methods has not yet been described. Puprose To determine feasibility and effectiveness of Bi-RFCA additionally supported by non-ionic catheter irrigation for treatment of refractory premature ventricular complexes (PVC) or ventricular tachycardia (VT). Methods Consecutive patients after failed extensive Bi-RFCA or D5W-irrigated ablation for symptomatic PVCs or non-sustained VT (nsVT) underwent Bi-RFCA supported with D5W coolant. Results We ultimately enrolled 2 patients (2 males, age 64 ± 12 years) after failed extensive ablations for the left ventricular summit PVCs and nsVT to undergo Bi-RFCA supported with D5W irrigation of both AC and intracardiac return electrode (IRE). Previous pharmacological antiarrhythmic treatment consisting of at least one drug and catheter ablation failed in both patients. Bi-RFCA was delivered between earliest activation sites located in the left/right aortic commissure and the left pulmonic cusp (Figure). Efforts were made to achieve safe distance from coronary arteries, AC, and IRE. Bipolar RFCA (35 ± 7W power, 8 ± 4 applications, 199 ± 166s RF time) led to acute elimination of PVCs in both patients. Baseline impedance oscillated around 250Ω and initial 50-70Ω impedance drop was observed during first 20s of bipolar applications, followed by impedance rise up to 350-450Ω. No steam pop occurred and there were no complications during procedures. All antiarrhythmic drugs were discontinued. Follow-up lasted 8 ± 2 months, there was no nsVT recurrence and 90,4% PVC burden reduction was achieved: from 30000 to 3100 PVC/day in patient #1 and from 39000 to 3500 PVC/day in patient #2. Both patients remained symptom-free. Conclusion Bi-RFCA can be additionally supported using non-ionic D5W coolant. Such approach is feasible and can be safe and effective. More data on impedance imbalance during D5W-supported bipolar RF applications is warranted. Abstract Figure. Fluoroscopic view and 12-lead ECG

Feasibility of Radiofrequency Catheter Ablation in the Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is a worldwide epidemic that has hit about 33 million people. In clinical studies, the efficacy of antiarrhythmic therapy and catheter ablation in the treatment of AF was compared, and controversial results were obtained. Objective. To analyze three advanced publications in recent years, which, according to the authors, are of fundamental importance for the choice of radiofrequency catheter ablation as a treatment option for AF. Results and discussion. In the CABANA study catheter ablation was compared with antiarrhythmic therapy and showed significant improvement in the quality of life. Within 3 years, AF recurrence rate was 69% in the group of antiarrhythmic treatment and 50% in the catheter ablation group. The proportion of patients with non-paroxysmal AF decreased from 57% to 26% with antiarrhythmic treatment and up to 16% with catheter ablation. Among the serious complications in the catheter ablation group were tamponades (0.8%), minor hematomas (2.3%) and pseudoaneurysms (1.1%). Thyroid dysfunction (1.6%) and proarrhythmogenic effect (0.8%) were observed in the group of antiarrhythmic therapy. In the CASTLE-AF (HF) study, 179 patients were randomly selected for catheter ablation, and 184 for antiarrhythmic therapy. All of them were in NYHA class II, III or IV, had left ventricular ejection fraction 35% or less, and used implantable defibrillator. In the mean follow-up of 37.8 months, significantly less patients died after catheter ablation (24 [13.4%] versus 46 [25.0%]), and less were hospitalized due to worsening heart failure (37 [20.7%] versus 66 [35.9%]). ATTEST is the first randomized controlled trial that has demonstrated slowing down of the progression of AF after catheter ablation. Radiofrequency ablation was performed in 128 patients, antiarrhythmic therapy was applied in 127 patients. Within 3 years, the incidence of persistent AF or atrial tachycardia was lower in patients treated with ablation compared with patients on antiarrhythmic therapy (2.4% vs. 17.5%; P = 0.0009). Conclusions. The expected benefit of catheter ablation of AF in comparison with drug therapy is as follows: increase in the probability of maintaining sinus rhythm, improvement of the quality of life, decrease in the number of hospitalizations and all-cause mortality in patients with heart failure, decrease in fatigue.

P6248High use of direct oral anticoagulants in elderly patients with non valvular atrial fibrillation: results of REFLEJA study

Background Older patients with atrial fibrillation (AF) have a higher thromboembolic and hemorrhagic risk, however oral anticoagulation (OAC) continues to be underutilized. Purpose To analyze the use of direct oral anticoagulant (DOAC) in patients older than 80 years. Methods The REFLEJA study is a single-centre prospective observational registry including 1039 consecutive outpatients with nonvalvular AF. Results Among ≥80 years patients (n=376) there were more women (57.7% vs 41.5%; p<0.001), permanent AF (66.5 vs 42%; <0.001), heart failure (HF) (29.8 vs 20.2%, p<0.001) and vascular disease (19.7 vs 12.8%, p=0.003), although without differences in bleeding (5.9 vs 3,8%, p=0.12) and previous strokes (9.3 vs 7.1%, p=0.20). Despite a higher CHA2DS2-VASc score (4.4±1.1 VS 2.9±1.6, p<0.001), HASBLED score >2 (34.6 vs. 23.7%; p<0.001) and chronic kidney disease (CKD) (51.5 vs. 22.6%, p<0.001), total use of OAC was higher among those older (94.9% vs 90%, p=0.005). There were no differences in the prescription of DOAC (64.1% vs 69.3%, p=0.08), although lower doses (45.8 vs. 12.2%, p<0.005) were more frecuent among older patients. In multivariate analysis, HF (OR 0.60, CI 0.40–0.90; p=0.013) and CKD (OR 0.55, CI 0.41–0.76; p<0.001) were independent risk factors for the prescription of DOAC, but not age ≥80 years (OR 1.16, CI 0.58–2.31, P=0.67). Baseline characteristics Total <80 years ≥80 years p value Hypertension (%) 81.5 77.9 88 <0.001 Diabetes mellitus (%) 26.3 25.7 26.7 0.71 Malignancy (%) 6.6 6.5 6.9 0.78 Coronary artery disease (%) 12.1 10.8 14.4 0.08 Anemia (%) 16.3 12.5 23.2 <0.001 DOAC (%) 67.6 69.3 64.1 0.08 Low doses DOAC (%) 15.9 12.2 45.8 <0.001 CHA2DS2-VASc score 3.4±1.6 2.9±1.6 4.4±1.1 <0.001 HAS-BLED score 1.2±0.8 1.1±0.8 1.4±0.7 <0.001 Glomerular filtration rate (ml/min) 70.9±24.9 76.2±23.1 61.5±25 <0.001 Antiarrhythmic treatment (%) 7.3 9.6 3.1 0.005 Permanent AF 50.5 41.7 66.2 <0.001 DOAC: direct oral anticoagulants; HAS-BLED score: without INR lability; AF: atrial fibrillation. Conclusion The proportion of elderly anticoagulated patients in our environment is very high and advanced age was not associated with a lower use of DOAC.

P4609The use of stellate ganglion block in the management of electrical storm reduces VA burden by 92% and completely excludes the need for general anesthesia

Background The electrical ventricular storm (ES) is a life-threatening condition. The treatment is based on addressing the triggering cause, influencing reversible factors, patient sedation, and antiarrhythmics. Suppressing the massive sympathetic surge is a keystone in the emergent management. Stellate ganglion block (SGB) might serve this purpose. Purpose To show the efficacy of ultrasound-guided SGB in the management of ES. Methods Retrospective analysis of case series. All ES patients in whom SGB was used. SGB was performed after the initial failure of reversible factors modification + sedation + antiarrhythmics. We compared the mean VA burden 2 days before vs. 7 days after SGB (to show the long effect of SGB). 31 patients (5 females). Procedure date between 01.03.2017 and 21.11.2018. Mean LVEF 27±9%. Etiology: 74% ischemic vs. 26% non-ischemic cardiomyopathy. Antiarrhythmic treatment: amiodarone 27 pt. (87%), trimecaine 3pt (10%), digoxin 2 pt. (6%), beta-blocker 28 pt. (90%). Results The ES management including SGB resulted in a significant decrease (92%) in VA burden (mean 26,0 episodes/day vs. 0,6 episodes/day; p<0.001). Separately, ATP episodes were reduced by 99%, external or ICD shocks by 76%. There was no need for general anesthesia as a last resort in refractory ES. 30-days mortality 12,9%. No significant adverse events have been noticed, 10 pt. (32,3%) have developed Horner syndrome, which always disappeared in 24 hours. Conclusion Ultrasound-guided SGB in the management of ES is safe and very effective. Randomized prospective studies are required to precisely determine the effect of SGB.