Clinical and Electrophysiologic Features of Syncope in Chronic Chagasic Heart Disease

Syncope in CCHD. Introduction: Syncope in patients with chronic Chagasic heart disease (CCHD) is a frequent hut poorly studied problem.
Methods and Results: Fifty-three patients with CCHD and recurrent syncope were followed for 2 to 127 months. They were classified into the following groups: G-I (n = 15) without inducible ventricular tachycardia (VT) and normal HV interval; G-II (n = 17) with only inducible VT; G-III (n = 11) with only an abnormal HV interval; and G-IV (n = 10) with both an inducible VT and an abnormal HV interval. Empiric pharmacologic therapy was given in G-I; pharmacologic therapy guided by electrophysiologic: study in G-II; atrioventricular pacing in G-III; and empiric pharmacologic with atrioventricular pacing in G-IV. Age and sex were similar among groups; New York Heart Association Functional Class I symptoms were more prevalent (P = 0.0001) in G-I. The ejection fraction by echocardiography was higher in G-I (P = 0.01221. The density of premature ventricular complexes by Duller monitoring was similar among groups. The complexity of premature ventricular complexes by Holler was significantly higher in G-II (P = 0.0270); this variable, analyzed from the exercise electrocardiogram, was not different among groups. All deaths were sudden, prevalence was higher in G-II and absent in G-III, and recurrence of syncope was similar among groups.
Conclusion: The most probable causes of recurrent syncope were VT (43%) with poor prognosis, and paroxysmal atrioventricular block (21%) with a favorable prognosis. Absence of congestive heart failure, complexity of premature ventricular complexes by Holler, and absence of intraventricular heart block showed statistical correlation with normal electrophysiologic study, inducible VT, and normal HV interval, respectively.     

A Fast and Reliable Algorithm to Localize Accessory Pathways Based on the Polarity of the QRS Complex on the Surface ECG During Sinus Rhythm

d 'AVILA, A., et al .: A Fast and Reliable Algorithm to Localize Accessory Pathways Based on the Polarity of the QRS Complex on the Surface ECG During Sinus Rhythm . Background: Many criteria have been published to localize accessory pathways from the 12-lead EGG during sinus rhythm. This study analyzed whether the localization of an accessory pathway could be predicted by using the polarity of the QRS complex during sinus rhythm on the surface ECG, instead of the delta wave polarity as used in many reports. Methods: The ECGs of 140 patients with an overt and single accessory pathway were evaluated. Eight localizations were taken into account. The precise location was previously known from successful radiofrequency ablation sites. Results: In 128 patients (92%), the new algorithm allowed an accurate diagnosis of the site of implantation of the accessory pathway. Conclusion: Analysis of the polarity of the QRS complex on five electrocardiographic leads provides an easy, fast and reliable way to localize accessory pathways during sinus rhythm.     

Quantitative Analysis of Sclerotherapy Results by Using Digital Photography and a Computer Program

BACKGROUND: Despite different telangiectasia treatments in the lower limbs, there is no method standardization for results assessment, making comparison between the existing treatments conflicting. OBJECTIVE: To compare the assessment carried out by a group of specialists with the assessment carried out by a computer program, according to clearance degree of telangiectasias during treatment by sclerotherapy. MATERIALS AND METHODS: Nineteen patients (21 studied areas) with telangiectasias of thighs and popliteal fossa were assessed, with a mean age of 37.5 (21-59) years old, all female. The pre- and posttreatment photos were standardized as per distance, light exposure, and aperture time. The sclerotherapy sessions were performed with 75% glucose. The clearance degree of telangiectasias was judged by a group of six doctors and by a computer program that analyzed the initial and final photos. The results of such assessment were compared according to concordance and correlation. RESULTS: There was no statistical difference between the assessments carried out by the specialists and the assessments carried out by the computer program according to the sclerotherapy results. CONCLUSION: The assessment carried out by the computer program was equivalent to the assessment carried out by the specialists in the judgment of clearance degree of telangiectasias of the lower limbs.     

Culprit-Only or Multivessel Percutaneous Coronary Stenting in Patients with Non-ST-Segment Elevation Acute Coronary Syndromes: One-Year Follow-Up

Objective: To investigate the major cardiac events at 1-year follow-up of multivessel versus culprit-vessel stenting in patients presenting with non-ST elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD).
Introduction: Percutaneous coronary intervention is a standard revascularization strategy for patients with NSTE-ACS. However, when these patients have MVD it is not clear whether multivessel (MVR) is superior to culprit-vessel revascularization (CVR).
Methods: We screened 1,100 consecutive patients with NSTE-ACS from an institutional database. Comparisons of 1-year outcomes between multivessel and culprit-vessel revascularized patients were made. The primary outcome was the composite (MACE) of death, myocardial infarction (MI), or any revascularization. Secondary end-points were the components of the composite end-point. Regression analysis was performed to detect predictors of MACE.
Results: A total of 609 patients were considered for this analysis: 204 (33.5%) and 405 (66.5%) had MVR and CVR treatment, respectively. The strategy adopted was based on a clinical decision. The incidence of MACE was lower in MVR (9.45% vs. 16.34%, P = 0.02) with lower revascularization rate (7.46% vs. 13.86%, P = 0.04) than in CVR. There was no difference in death (1.99% vs. 1.98%, P = 0.8) nor death/MI (2.49% vs. 3.22%, P = 0.8) between MVR and CVR, respectively. Multivariate analysis showed CVR as the only independent predictor of improved MACE (OR 0.66, CI95% 1.12–3.47, P = 0.01).
Conclusion: Multivessel stenting in patients with NSTE-ACS and multivessel disease using a clinical decision of treatment is associated with lower rate of MACE driven by lower repeat revascularization, compared with culprit-vessel stenting, without difference in rates of death or MI.     

Independent risk factors for renal damage in a series of primary vesicoureteral reflux: A multivariate analysis

Aim:   The aim of this study was to investigate risk factors associated with different extents of renal parenchyma involvement in a paediatric series of primary vesicoureteral reflux (VUR).
Methods:   A total of 549 patients with VUR were analyzed. The variable of interest was renal scar, assessed by technetium-99m dimercaptosuccinic acid scan, and classified into three subtypes: focal scar, multiple cortical scarring and diffuse scars with a contracted renal unit. The multinomial regression model was applied to identify independent variables associated with each subtype of renal damage.
Results:   After adjustment, four variables remained independently associated with a contracted renal unit: reflux grades III–V (odds ratio (OR) = 9.7; 95% confidence interval (CI) = 4.1–21.0), age at diagnosis (OR = 3; 95% CI = 1.6–5.1), unilateral reflux (OR = 2.1; 95% CI = 1.2–3.8), and male sex (OR = 2; 95% CI = 1.1–3.8). Two variables were associated with multiple scars: reflux grades III–V (OR = 13.8; 95% CI = 7.4–26.0) and age at diagnosis (OR = 1.9; 95% CI = 1.2–3.0). Two variables were associated with a focal scar: reflux grades III–V (OR = 7.9, 95% CI CI = 3.8–16.4) and male sex as a protective factor (OR = 0.5; 95% CI = 0.25–1.0).
Conclusion:   Our findings suggest that the development of a contracted renal unit is probably due to congenital malformation, more commonly observed in male infants with high-grade reflux.     

QTc Prolongation and Family History of Sudden Death in a Patient with Desmin Cardiomyopathy

This case report describes a pregnant female patient who presented with new‐onset congestive heart failure symptoms and prolonged QTc, with strong family history of sudden death. Endomyocardial biopsy and genetic testing revealed myocardial desmin accumulation and a previously described mutation in the DES (desmin) gene, as well as variants in two LQT genes, SCN5A and KCNH2. The case highlights the phenotypic variability for a particular desmin genotype, and the possible interaction of desminopathy with LQT variants not independently associated with large differences in current properties or QT prolongation from wild type. (PACE 2011; 34:e105–e108)     

Endocardial and Epicardial Ablation Guided by Nonsurgical Transthoracic Epicardial Mapping to Treat Recurrent Ventricular Tachycardia

Nonsurgical Epicardial Ablation. Introduction : An epicardial site of origin of ventricular tachycardia (VT) may explain unsuccessful endocardial radiofrequency (RF) catheter ablation. A new technique to map the epicardial surface of the heart through pericardial puncture was presented recently and opened the possibility of using epicardial mapping to guide endocardial ablation or epicardial catheter ablation. We report the efficacy and safety of these two approaches to treat 10 consecutive patients with VT and Chagas' disease.
Methods and Results : Epicardial mapping was carried out with a regular steerable catheter introduced into the pericardial space. An epicardial circuit was found in 14 of 18 mapable VTs induced in 10 patients. Epicardial mapping was used to guide endocardial ablation in 4 patients and epicardial ablation in 6. The epicardial earliest activation site occurred 107 ± 60 msec earlier than the onset of the QRS complex. At the epicardial site used to guide endocardial ablation, earliest activation occurred 75 ± 55 msec before the QRS complex. Epicardial mid-diastolic potentials and/or continuous electrical activity were seen in 7 patients. After 4.8 ± 2.9 seconds of epicardial RF applications, VT was rendered noninducible. Hemopericardium requiring drainage occurred in 1 patient; 3 others developed pericardial friction without hemopericardium. Patients remain asymptomatic 5 to 9 months after the procedure. Interruption during endocardial pulses occurred after 20.2 ± 14 seconds (P = 0.004), hut VT was always reinducible and the patients experienced a poor outcome.
Conclusion : Epicardial mapping does not enhance the effectiveness of endocardial pulses of RF. Epicardial applications of RF energy can safely and effectively treat patients with VT and Chagas' disease.