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To describe a simple and useful technique for acute management of massive hemopericardium inside the Electrophysiology (EP) laboratory METHODS AND RESULTS: Five patients from a single center experience were identified, all with blood loss above 1000 ml after initial pericardiocenthesis. Using two long 8.5 F transseptal sheaths inside the pericardium space, with continuous negative pressure, allowed the complete cessation of bleeding or hemodynamic maintenance until definitive surgical repair in all patients CONCLUSION: The use of two long sheaths for blood drainage, instead of conventional pericardiocenthesis, might be helpful to manage massive hemopericardium inside EP lab, avoiding urgent cardiac surgery or maintaining clinical stability until surgical staff is available.

Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and non-ischemic cardiomyopathy (NICM) populations.Multicentric observational registry included 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-day mortality and procedure-related complications.Most of the patients were male (85%), with IHD (67%) and mean age of 63 ± 13 years. During a mean follow-up of 3 ± 2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class III / IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The identified independent predictors of mortality were C-ABL, ES, LVEF, age, and NYHA class III / IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction = 0.04). Mortality at 30 days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P = 0.777), as was complication rate (10.3% vs. 15.1%, respectively, P = 0.336).A combined or sequential endo-epicardial VT ablation strategy was associated with lower VT recurrence and lower all-cause death in IHD and NICM patients undergoing repeated procedures. Both approaches seemed equally safe.

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC), a rare inherited disease, causes ventricular tachycardia, sudden cardiac death, and heart failure (HF). We investigated ARVC clinical features, genetic findings, natural history, and the occurrence of life-threatening arrhythmic events (LTAEs), HF death, or heart transplantation (HF-death/HTx) to identify risk factors. Methods: The clinical course of 111 consecutive patients with definite ARVC, predictors of LTAE, HF-death/HTx, and combined events were analyzed in the entire cohort and in a subgroup of 40 patients without sustained ventricular arrhythmia before diagnosis. Results: The 5-year cumulative probability of LTAE was 30% and HF-death/HTx was 10%. Predictors of HF-death/HTx were reduced right ventricle ejection fraction (HR: 0.93; P =0.010), HF symptoms (HR: 4.37; P =0.010), epsilon wave (HR: 4.99; P =0.015), and number of leads with low QRS voltage (HR: 1.28; P =0.001). Each additional lead with low QRS voltage increased the risk of HF-death/HTx by 28%. Predictors of LTAE were prior syncope (HR: 1.81; P =0.040), number of leads with T wave inversion (HR: 1.17; P =0.039), low QRS voltage (HR: 1.12; P =0.021), younger age (HR: 0.97; P =0.006), and prior ventricular arrhythmia/ventricular fibrillation (HR: 2.45; P =0.012). Each additional lead with low QRS voltage increased the risk of LTAE by 17%. In patients without ventricular arrhythmia before clinical diagnosis of ARVC, the number of leads with low QRS voltage (HR: 1.68; P =0.023) was independently associated with HF-death/HTx. Conclusions: Our study demonstrated the characteristics of a specific cohort with a high prevalence of arrhythmic burden at presentation, male predominance, younger age and HF severe outcomes. Our main results suggest that the presence and extension of low QRS voltage can be a risk predictor for HF-death/HTx in ARVC patients, regardless of the arrhythmic risk. This study can contribute to the global ARVC risk stratification, adding new insights to the international current scientific knowledge.

Since December 2019 we have observed the rapid advance of the severe acute respiratory syndrome caused by the new coronavirus (SARS-CoV-2). The impact of the clinical course of a respiratory infection is little known in patients with hereditary arrhythmias, due to the low prevalence of these diseases. Patients who present with infectious conditions may exacerbate hidden or well-controlled primary arrhythmias, due to several factors, such as fever, electrolyte disturbances, drug interactions, adrenergic stress and, eventually, the septic patient's own myocardial damage. The aim of this review is to highlight the main challenges we may encounter during the Covid 19 pandemic, specifically in patients with hereditary arrhythmias, with emphasis on the congenital long QT syndrome (LQTS), Brugada syndrome (SBr), ventricular tachycardia polymorphic catecholaminergic (CPVT) and arrhythmogenic right ventricular cardiomyopathy.Desde dezembro de 2019, observamos o rápido avanço da síndrome respiratória aguda grave causada pelo coronavírus 2019 (SARS-CoV-2). O impacto da evolução clínica de uma infecção respiratória é pouco conhecido em pacientes portadores de arritmias hereditárias, devido à baixa prevalência dessas doenças. Os pacientes que apresentam quadros infecciosos podem exacerbar arritmias primárias ocultas ou bem controladas, por diversos fatores, tais como febre, distúrbios eletrolíticos, interações medicamentosas, estresse adrenérgico e, eventualmente, o próprio dano miocárdico do paciente séptico. O objetivo desta revisão é destacar os principais desafios que podemos encontrar durante a pandemia pela Covid 19, especificamente nos pacientes com arritmias hereditárias, com destaque para a síndrome do QT longo congênito (SQTL), a síndrome de Brugada (SBr), a taquicardia ventricular polimórfica catecolaminérgica (TVPC) e a cardiomiopatia arritmogênica do ventrículo direito.

Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros. Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz.

The PAINESD risk score was developed in 2015 as a tool to stratify the risk of acute hemodynamic decompensation during ventricular tachycardia (VT) ablation in structural heart disease patients and further then used for post procedure 30-day mortality prediction. The original cohort however did not include Chagas disease (ChD) patients. We aim to evaluate the relevance of the score in a ChD population. The PAINESD risk score gives weighted values for specific characteristics (chronic obstructive pulmonary disease, age > 60 years, ischemic cardiomyopathy, New York Heart Association [NYHA] functional class 3 or 4, ejection fraction less than 25%, VT storm, and diabetes). The score was applied in a retrospective cohort of ChD VT ablations in a single tertiary center in Brazil. Data were collected by VT study reports and patient record analysis at baseline and on follow-up. Between January 2013 and December 2018, 157 VT catheter ablation procedures in 121 ChD patients were analyzed. Overall, 30-day mortality was 9.0%. Multivariate analysis correlated NYHA functional class (HR 1.78, 95% CI 1.03–3.08, P 0.038) and the need for urgent surgery (HR 31.5, 95% CI 5.38–184.98, P < 0.001), as well as a tendency for VT storm at presentation (HR 2.72, 95% CI 0.87–8.50, P 0.084) as risk factors for the primary endpoint. The median PAINESD risk score in this population was 3 (3–8). The area under the receiver operating characteristic (ROC) curve was 0.64 (95% CI 0.479–0.814). The PAINESD risk score did not perform well in predicting 30-day mortality in ChD patients. Pre-procedure NYHA functional class and the need for urgent surgery due to refractory pericardial bleeding were independently associated with increased 30-day mortality. Prospective studies are needed to take final conclusions in Chagas disease when using PAINESD score.

Chagas disease is caused by infection from the protozoan parasite Trypanosoma cruzi. Although it is endemic to Latin America, global migration has led to an increased incidence of Chagas in Europe, Asia, Australia, and North America. Following acute infection, up to 30% of patients will develop chronic Chagas disease, with most patients developing Chagasic cardiomyopathy. Chronic Chagas cardiomyopathy is highly arrhythmogenic, with estimated annual rates of appropriate implantable cardioverter-defibrillator therapies and electrical storm of 25% and 9.1%, respectively. Managing arrhythmias in patients with Chagasic cardiomyopathy is a major challenge for the clinical electrophysiologist, requiring intimate knowledge of cardiac anatomy, advanced training, and expertise. Endocardial-epicardial mapping and ablation strategy is needed to treat arrhythmias in this patient population, owing to the suboptimal long-term success rate of endocardial mapping and ablation alone. We also describe innovative approaches to improve acute and long-term clinical outcomes in patients with refractory ventricular arrhythmias following catheter ablation, such as bilateral cervicothoracic sympathectomy and bilateral renal denervation, among others.

Resumo Fundamento A ablação da taquicardia atrial (TA) com local de ativação mais precoce próxima ao feixe de His é um desafio, devido ao risco de bloqueio de AV completo por sua proximidade ao sistema de His-Purkinje (SHP). Uma alternativa para minimizar esse risco é posicionar o cateter na cúspide não coronária (CNC), que é anatomicamente contígua à região para-Hissiana. Objetivos O objetivo deste estudo foi fazer uma revisão de literatura e avaliar as características eletrofisiológicas, a segurança e o índice de sucesso de aplicação de radiofrequência (RF) por cateter na CNC para o tratamento de TA para-Hissiana em uma série de casos. Métodos Avaliamos retrospectivamente dez pacientes (Idade: 36±10 anos) que foram encaminhados para ablação de taquicardia paroxística supraventricular (TPSV) e haviam sido diagnosticados com TA focal para-Hissiana confirmada por manobras eletrofisiológicas clássicas. Para a análise estatística, um P valor d

A 57 year-old patient with dilated cardiomyopathy, long-standing persistent atrial fibrillation, heart failure and episodes of gastrointestinal bleeding underwent AF ablation with pulmonary vein isolation, homogeneization of septal scar, posterior wall isolation and also left atrial appendage isolation. Additionally, because of the high risk of embolism, underwent left atrial appendage occlusion.

Background Epicardial mapping and ablation are frequently necessary to eliminate ventricular tachycardia (VT) in patients with Chagas disease. Nonetheless, there are no randomized controlled trials demonstrating the role of this strategy. Objective We conducted this randomized controlled trial to evaluate the efficacy and safety of combined epicardial ablation in patients with Chagas disease. Methods We randomized patients with Chagas disease and VT in a 1:1 fashion to either the endocardial (endo) mapping and ablation group or the combined endocardial/epicardial (endo/epi) mapping and ablation group. The efficacy end points were measured by VT inducibility and all-ventricular arrhythmia recurrence. Safety was assessed by the rate of periprocedural complications. Results Thirty patients were enrolled, and most were male. The median age was 67 (Q1: 58; Q3: 70) years in the endo group and 58 (Q1: 43; Q3: 66) years in the endo/epi group. The left ventricular ejection fraction was 33.0% ± 9.5% and 35.2% ± 11.5%, respectively P = .13. Acute success (non-reinducibility of clinical VT) was obtained in 13 patients (86%) in the endo/epi group and in 6 patients (40%) in the endo-only group (P = .021). There were 12 patients with VT recurrence (80%) in the endo-only group and 6 patients (40%) in the endo/epi group (P = .02) (by intention-to-treat analysis). Epicardial ablation was ultimately performed in 9 patients (60%) in the endo-only group because of an absence of endocardial scar or maintenance of VT inducibility. There was no difference in complications between the groups. Conclusion Combining endo/epi VT catheter ablation in patients with Chagas disease significantly increases short- and long-term freedom from all-ventricular arrhythmias. Epicardial access did not increase periprocedural complication rates.

Introducao Em dezembro de 2019, foram relatados os primeiros casos da doenca causada pelo novo coronavirus (COVID-19), originarios de Wuhan, China. Desde a declaracao de pandemia em marco de 2020 por Organizacao Mundial da Saude (OMS), com disseminacao intercontinental, vivenciamos intensa busca por um tratamento seguro e eficaz. Estudos in vitro demonstraram algum efeito da cloroquina contra o novo coronavirus, intermediada pela glicosilacao dos receptores celulares de SARS-CoV e pelo aumento do pH endossomico, bloqueando a invasao celular pelo virus. [...]

OBJECTIVE To compare the prevalence of esophageal and periesophageal thermal injury in patients undergoing radiofrequency (RF) atrial fibrillation (AF) ablation using 8 mm tip catheters during three different esophageal protection strategies. METHODS Forty-five consecutive patients with paroxysmal or persistent AF underwent first ablation procedure, besides esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS) performed before and after the pulmonary vein (PV) isolation. Before the procedure, patients were randomly assigned to one of three esophageal lesion protection strategies: group I-without any protective or monitoring dispositive and limiting RF applications to 30 W for 20 seconds, in left atrium posterior wall (LAPW); group II-power and time of RF delivery, up to 50 W for 20 seconds at LAPW, limited by esophageal temperature monitoring; group III-applications of RF in LAPW with fixed power application of 50 W for 20 seconds during continuous esophageal cooling. RESULTS Baseline characteristics of patients were similar in all groups. The four PVs were isolated in 14 (93.3%), 13 (86.7%), and 15 (100%) patients, respectively in groups I, II, and III. The mean RF power was significantly higher (P

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In the treatment of atrial fibrillation (AF), the most frequently sustained arrhythmia, with catheter ablation (CA) or electrical cardioversion (ECV), the periprocedural period is one of the most critical phases. Currently, the use of new direct action oral anticoagulants (DOAC) is increasingly frequent; however, in the real world, there are still few data on studies on the thrombus incidence in the left atrium (TrLA) or dense spontaneous contrast (DSC) on transesophageal echocardiogram (TEE).To evaluate the prevalence of events and association with risk factors in patients using DOACs. Primary objective: to analyze the prevalence of thrombus in the LA by TEE in patients using DOAC undergoing ECV/CA. Second, evaluate the association of comorbidities with the presence of thrombi and DSC.Retrospective cohort, single-center study with patients followed at the Arrhythmia Outpatient Unit (InCor-HCFMUSP). Patients indicated for procedures and using DOACs were selected, and their clinical/echocardiographic data were analyzed. A significance level of 5% was considered.354 patients were included, a total of 400 procedures, from March 2012-March 2018. Thrombus in the LA was found in 11 patients (2.8%), associated with advanced age (p=0.007) and higher CHA2DS2-VASc (plt;0.001) score. DSC in the LA before TEE was found in 29 patients (7.3%), with lower LVEF (plt;0.038) and greater LA dimension (plt;0.0001).The incidence of LA thrombus and DSC in patients using DOC in the context of AF ECV/CA, although small, is not negligible. Patients with higher CHA2DS2-VASc scores, especially older and with larger LA diameter, are more prone to these echocardiographic findings.No tratamento da fibrilação atrial (FA), a arritmia sustentada mais frequente, com ablação por cateter (ABL) ou cardioversão elétrica (CVE), o período periprocedimento é uma das fases mais críticas. Atualmente, o uso de novos anticoagulantes orais de ação direta (DOAC) é cada vez mais frequente, no entanto, no mundo real, ainda existem poucos dados de estudos sobre a incidência de trombo no átrio esquerdo (TrAE) ou contraste espontâneo denso (CE) no ecocardiograma transesofágico (ETE).Analisar a prevalência de TrAE, por ETE, em pacientes em uso de DOAC submetidos à CVE/ABL. Secundariamente: avaliar a associação de comorbidades com a presença de trombos e CE.Estudo de coorte retrospectivo, unicêntrico, com pacientes do Ambulatório de Arritmia (InCor-HCFMUSP). Foram selecionados e analisados dados clínicos e ecocardiográficos no prontuário da instituição de pacientes com indicação de procedimentos e em uso de DOACs. Considerado um nível de significância de 5%.Foram incluídos 354 pacientes, no total de 400 procedimentos, de março de 2012-março de 2018. TrAE foi encontrado em 11 pacientes (2,8%), associado com idade avançada (p=0,007) e CHA2DS2-VASc maior (plt;0,001). Foi encontrado CE no AE no procedimento antes da ETE em 29 pacientes (7,3%), com menor FEVE (plt;0,038) e maior dimensão do AE (plt;0,0001).A incidência de TrAE e CE em pacientes em uso de DOAC no contexto de CVE/ABL de FA, embora pequena, não é desprezível. Pacientes com escore CHA2DS2-VASc maior, principalmente mais idosos e com diâmetro do AE maior, são mais propensos a esses achados ecocardiográficos.

The atrioventricular (AV) reentrant tachycardia (AVRT) is the most common cause of supraventricular tachycardia (SVT) in the young pediatric population. Some newborns might present with congestive heart failure and require interventional treatment. Catheter ablation in small infants (

In this chapter, the main prognostic markers of Chagas heart disease are addressed, with an emphasis on the most recent findings and questions, establishing the basis for a broad discussion of recommendations and new approaches to managing Chagas cardiopathy. The main biological and genetic markers and the contribution of the electrocardiogram, echocardiogram and cardiac magnetic resonance are presented. We also discuss the most recent therapeutic proposals for heart failure, thromboembolism and arrhythmias, as well as current experience in heart transplantation in patients suffering from severe Chagas cardiomyopathy. The clinical and epidemiological challenges introduced by acute Chagas disease due to oral contamination are discussed. In addition, we highlight the importance of ageing and comorbidities in influencing the outcome of chronic Chagas heart disease. Finally, we discuss the importance of public policies, the vital role of funding agencies, universities, the scientific community and health professionals, and the application of new technologies in finding solutions for better management of Chagas heart disease.

Introduction: The autonomous system plays an important role as a trigger of cardiac arrhythmias. Cardiac sympathetic denervation (CSD) achieved by stellate and proximal thoracic ganglia resection has been reported as an alternative approach for the management of ventricular arrhythmias (VA) in structural heart disease (SHD) patients. Insufficient data regarding Chagas Disease (ChD) is available. Methods: Patients who underwent CSD for better management of ventricular arrhythmias (VA) in SHD, mainly ChD, in a single tertiary center in Brazil were evaluated for safety and efficacy outcomes. Results: Between June 2014 and March 2020, fourteen patients (age 59±7.5, 85% male, mean ejection fraction 30.5±7.9%) were submitted to left or bilateral CSD. In a median follow-up time of 143 (Q1: 30; Q3: 374) days, eight patients (57,2%) presented VT recurrence. A significant reduction in the median burden of ventricular arrhythmias comparing six months before and after procedure (10 to 0; p=0.004). For the nine ChD patients, the median burden of appropriate therapies was also reduced (11 to 0; p=0.008). There were two cases of clinically relevant pneumothorax and three cases of transient hemodynamic instability, but no direct procedure-related deaths occurred. Additionally, there was no long-term adverse events, Conclusion: CSD is safe and seems to be effective in reducing the burden of VT/VT storm in SHD patients, including ChD patients. Randomized trials are needed to clarify its role in the management of these patients.

Resumo Fundamento O diagnóstico diferencial de taquicardia de QRS largo, entre taquicardia ventricular (TV) ou taquicardia supraventricular com condução aberrante (TSV-A) é algumas vezes difícil de ser feito na sala de emergência. Objetivo Avaliar a acurácia de um algoritmo novo e simples para a detecção de TV no eletrocardiograma (ECG) em pacientes com taquicardia de QRS largo. Métodos ECGs de 12 derivações para detecção de taquicardia de QRS largo foram obtidos prospectivamente de 120 pacientes durante estudo eletrofisiológico. Seis médicos com diferentes experiências analisaram os ECGs, e fizeram o diagnóstico com base no algoritmo D12V16, que envolve a análise da polaridade predominante do complexo QRS nas derivações I, II, V1 e V6. O diagnóstico foi comparado com os obtidos pelo algoritmo tradicional de Brugada e pelo estudo eletrofisiológico, o qual é considerado padrão ouro. Adotou-se um nível de significância de 5% (p

BACKGROUND Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and nonischemic cardiomyopathy (NICM) patients. METHODS Multicentric observational registry including 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-days mortality and procedure-related complications. RESULTS Most of the patients were male (85%), with IHD (67%) and mean age of 63±13 years. During a mean follow-up of 3±2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class III/IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The independent predictors of mortality were C-ABL, ES, LVEF, age and NYHA class III/IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction=0.04). Mortality at 30-days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P=0.777), as was complication rate (10.3% vs. 15.1% respectively, P=0.336). CONCLUSION A combined endo-epicardial approach was associated with greater VT-free survival and lower all-cause death in IHD and NICM patients undergoing repeated VT catheter ablations. Both strategies seem equally safe.

Background Chagas disease (ChD) is a major cause of non-ischemic cardiomyopathy (NICM) in Latin America and is becoming more frequent in other parts of the world, especially due to immigration movements. Ventricular Tachycardia (VT) is more common in this type of NICM than others, and finding an effective treatment strategy still is a challenge. Catheter ablation is an option, but there is poor data regarding its efficacy and safety. Purpose Evaluate the outcomes after VT catheter ablation in ChD patients. Methods Data were collected by VT studies reports and patient record analysis, including comorbidities and clinical status at baseline and on follow-up. We analyzed all-cause mortality, one-year VT recurrence rate and procedure related major complications. Results Between January 2013 and December 2018, 157 catheter ablation procedures in 121 ChD patients were performed in our institution. The mean follow-up time was 22.6±22.1 (mean ± SD) months. Overall post procedure mortality was 33.1%, and mean survival time was 51.2 months (95% CI: 44.8–58. NYHA functional class (p=0.022), ejection fraction (p=0.020) and immediate ablation result (p 0.002) were predictors of all-cause mortality in the follow-up. Clinical VT inducibility after ablation was a predictor of VT recurrence at one year (p=0.04). An epicardial approach was performed in 125 (79%) procedures, and accidental right ventricle (RV) puncture occurred in 23 (18.4%), in which open-chest surgery for bleeding hemostasis was necessary in 4 procedures (3.2%). Conclusion Mortality and recurrence rates in ChD patients after VT ablation were high, and correlated with heart failure severity. Epicardial approach is often necessary in this subset of patients. There was a correlation between immediate ablation results and recurrence. Kaplan-Meier of cumulative survival Funding Acknowledgement Type of funding source: None

Background Patients with ischemic (IHD) and nonischemic (NICM) dilated heart disease and reduced left ventricular ejection fraction are at increased risk of ventricular tachycardias (VTs) or sudden cardiac death. VT catheter ablation is an invasive treatment modality for antiarrhythmic drugs-resistant VT that reduces arrhythmic episodes, improves quality of life and improves survival in patients with electrical storm. Direct comparison of the outcomes from combined and non-combined endoepicardial ablations is limited by patient characteristics, follow-up durations, protocols heterogeneity and scarcity of randomized trials. We aim to investigate the long-term clinical outcomes of these 2 strategies in the IHD and NICM populations. Methods Multicentric observational registry including 316 consecutive patients who underwent combined (C-ABL) and non-combined (NC-ABL) endoepicardial ventricular tachycardia (VT) ablation for drug-resistant VT between January 2008 and July 2019. Chagas' disease patients were excluded. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-days mortality and procedure-related complications. Results Most of the patients were male (85%), with IHD (67%) and a mean age of 63±13 years. During a mean follow-up of 3±2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified storm (ES) at presentation (HR=2.17; 95% CI 1.44–3.25), IHD (HR=0.53, 95% CI 0.36–0.78), left ventricular ejection fraction (LEVF) (HR=0.97, 95% CI 0.95–0.99), New York Heart Association (NYHA) functional class III or IV (HR=1.79, 95% CI 1.13–2.85) and C-ABL (HR=0.49, 95% CI 0.27–0.92) as independent predictors of VT recurrence. In 135 patients undergoing two or more ablation procedures only C-ABL (HR=0.36, 95% CI 0.17–0.80) and ES at presentation (HR=2.42, 95% CI 1.24–4.70) were independent predictors of arrhythmia recurrence. The independent predictors of all-cause mortality were ES (HR=2.17, 95% CI 1.33–3.54), LVEF (HR=0.95, 95% CI 0.92–0.98), age (HR=1.03, 95% CI 1.01–1.05), NYHA functional class III or IV (HR=2.04, 95% CI 1.12–3.73), and C-ABL (HR=0.22, 95% CI 0.05–0.91). The survival benefit was only seen in patients with a previous ablation (P for interaction=0.04) – Figure 1. Mortality at 30-days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P=0.777), as was the complication rate (10.3% vs. 15.1% respectively, P=0.336). Conclusion A combined endo-epicardial approach appears to be associated with greater VT-free survival and overall survival in ischemic and nonischemic patients undergoing repeated VT catheter ablations. Both strategies seem equally safe. Survival analysis for C-ABL vs NC-ABL Funding Acknowledgement Type of funding source: None

We thank Dr Shah and colleagues for their interest, analysis of the presented data and comments related to our paper1. Circumferential PV isolation using 8mm tip catheter is still currently used in our institution for some patients due to economic reasons, so we can provide AF ablation for a portion of the population for whom there is no private insurance available, with adequate safety and results (recurrence rate in this series was 15.6% in a follow-up of 11±5 months)2. Those catheters have two temperature sensors, thus reducing the risk of clot formation on the tip of the catheter. For the same reason, our institutional standard when using such catheters is to deliver RF applications in temperature-controlled mode with maximum temperature of 55oC. This mode of RF application is different compared to irrigated tip catheters and the mode of application used in the cited experimental study mentioned by the authors, in which it was used power-controlled RF applications.3 Due to the temperature-controlled mode of RF application, the cooling of esophagus generates a convective cooling of the atrial wall close to the esophagus and the catheter interface, leading to the higher power RF application that was observed in Group III.2 Probably due to this higher power of application, there was a higher rate of esophageal and periesophageal lesions injuries in the esophageal cooling group. This rate was however acceptable, since we used esophagogastroduodenoscopies (EGD) combined with radial endosonographies (EUS), that is a high sensitivity method of screening for esophageal lesion. Additionally, there were no severe or clinically significant lesions in any of the patients. A prior experimental model we performed some years ago also suggests this hypothesis.4 This model was similar to the one used by Montoya and cols3 and we could find deeper lesions with esophageal cooling and temperature-controlled applications, but similar depth, when power-controlled applications were performed.4 In silico models could also be used to evaluate the different effects of esophageal cooling using temperature or power-controlled RF applications. So, we think that the flow used in our studied balloon was not the reason for the findings, but the mode of application, although even in the esophageal cooling group the incidence of lesions was low. This was a prototype balloon used for the first time in clinical studies, and it was not possible to measure inflow and outflow temperature, being not possible to define heat transfer capacity. However, as presented before, as there was a higher RF power in group III we can infer that we achieved some cooling on the esophagus-atrium interface. Tsuchiya and cols showed a reduction in luminal esophageal temperature using an esophageal balloon with irrigation flow similar to our study.5We strongly agree with the authors that a higher flow of irrigation and consequential higher temperature reduction could be more protective, especially using power-controlled RF applications. Additionally, we think that esophageal cooling strategies are a promising strategy to avoid severe esophageal lesions, especially with contact sensor, power-controlled RF applications, allowing more effective atrial lesions close to the esophagus, thus improving AF ablation results. References 1. Shah S, Mercado Montoya M, Zagrodzky J, Kulstad E. Letter to the Editor regarding the paper "Comparative study of strategies to prevent esophageal and periesophageal injury during atrial fibrillation ablation". Journal of Cardiovascular Electrophysiology. 2020.2. de Oliveira BD, Oyama H, Hardy CA, et al. Comparative study of strategies to prevent esophageal and periesophageal injury during atrial fibrillation ablation. J Cardiovasc Electrophysiol. 2020;31(4):924-933.3. Montoya MM, Mickelsen S, Clark B, et al. Protecting the esophagus from thermal injury during radiofrequency ablation with an esophageal cooling device. J Atr Fibrillation. 2019;11(5):2110.4. Scanavacca MI, Neto S, Pisani CF, et al. Cooled intra-esophageal balloon to prevent thermal injury of esophageal wall during radiofrequency ablation. Heart rhythm. 2007;4(5):S117.5. Tsuchiya T, Ashikaga K, Nakagawa S, Hayashida K, Kugimiya H. Atrial fibrillation ablation with esophageal cooling with a cooled water-irrigated intraesophageal balloon: a pilot study. J Cardiovasc Electrophysiol. 2007;18(2):145-150.

Regular radiofrequency (RF) catheter ablation is not encouraged during pregnancy, owing to radiation exposure and the uncertainties about the maternal and fetal health, being postponed to the postpartum period. However, the intervention may be indispensable in pregnant women with severe drug-resistant tachyarrhythmia. In such cases, catheter ablation without fluoroscopy is recommended. The aim of this case report is to describe a successful atrial tachycardia catheter ablation on the non-coronary cusp, during pregnancy, and without fluoroscopy.

Aims To develop quality indicators (QIs) that may be used to evaluate the quality of care and outcomes for adults with atrial fibrillation (AF). Methods and results We followed the ESC methodology for QI development. This methodology involved (i) the identification of the domains of AF care for the diagnosis and management of AF (by a group of experts including members of the ESC Clinical Practice Guidelines Task Force for AF); (ii) the construction of candidate QIs (including a systematic review of the literature); and (iii) the selection of the final set of QIs (using a modified Delphi method). Six domains of care for the diagnosis and management of AF were identified: (i) Patient assessment (baseline and follow-up), (ii) Anticoagulation therapy, (iii) Rate control strategy, (iv) Rhythm control strategy, (v) Risk factor management, and (vi) Outcomes measures, including patient-reported outcome measures (PROMs). In total, 17 main and 17 secondary QIs, which covered all six domains of care for the diagnosis and management of AF, were selected. The outcome domain included measures on the consequences and treatment of AF, as well as PROMs. Conclusion This document defines six domains of AF care (patient assessment, anticoagulation, rate control, rhythm control, risk factor management, and outcomes), and provides 17 main and 17 secondary QIs for the diagnosis and management of AF. It is anticipated that implementation of these QIs will improve the quality of AF care.

Resumo O manejo de dispositivos cardíacos eletrônicos implantáveis de pacientes que evoluem a óbito tem sido motivo de controvérsia. Em nosso meio, não há recomendações uniformes, estando baseadas exclusivamente em protocolos institucionais e em costumes regionais. Quando o cadáver é submetido para cremação, além de outros cuidados, recomenda-se a retirada do dispositivo devido ao risco de explosão e dano do equipamento crematório. Principalmente no contexto da pandemia causada pelo SARS-Cov-2, a orientação e organização de unidades hospitalares e serviços funerários é imprescindível para minimizar o fluxo de pessoas em contato com fluidos corporais de indivíduos falecidos por COVID-19. Nesse sentido, a Sociedade Brasileira de Arritmias Cardíacas elaborou este documento com orientações práticas, tendo como base publicações internacionais e recomendação emitida pelo Conselho Federal de Medicina do Brasil.

Background Left atrial appendage (LAA) occlusion is an alternative therapy for atrial fibrillation patients who have high embolic risk and contraindications to anticoagulant therapy. Objective To evaluate the feasibility, safety, and mid-term outcomes of percutaneous LAA occlusion, including device-related thrombosis. Methods Sixty consecutive patients who had undergone percutaneous LAA occlusion with AMPLATZER™ Amulet™ device from September 2015 to March 2018 were enrolled. Patients were followed for 21 ± 15 months (median - 20 months, interquartile range - 9 to 27 months). The postprocedural assessment was done at the 1st, 6th, and 12th month. Patients were clinically evaluated, and transesophageal echocardiography was performed at each visit. We evaluated the condition of normality of variables using the Kolmogorov-Smirnov test. P-values < 0.05 were statistically significant. Results The most common indication for the procedure was major bleeding with anticoagulants (n: 53, 88.3%). The procedure was completed successfully in 59 (98.3%) patients. Periprocedural mortality was observed in one patient. Postprocedural antiplatelet treatment was planned as dual or single antiplatelet therapy or low-dose anticoagulant therapy in 52 (88.1%), 2 (3.4%), and 5 (8.5%) patients, respectively. We found no clinically significant cerebrovascular events, device-related thrombus, or embolization in any patient during the follow-up. Two (3.4 %) patients presented significant peri-device leak (>3 mm) at the 1st month evaluation, which disappeared at the 12th month follow-up. Conclusion We concluded that LAA occlusion using the Amulet™ LAA occluder can be performed with high procedural success and acceptable outcomes.

Introduction: Catheter ablation of the parahisian accessory pathways (PHAP) has been established as the definitive therapy for this type of arrhythmia. However, the PHAP proximity to the normal atrioventricular conduction system makes the procedure technically challenging. Here, we have reported a case series of 20 patients with PHAP who underwent aortic access ablation to evaluate the safety and efficacy of this approach in the PHAP ablation. Methods and results: The ablation through the aortic cusps was the successful approach in 13 of 20 (65%) of the cases. In 11 patients, the aortic approach was the initial strategy for ablation, and the accessory pathway was eliminated in seven (63.6%) of them. The aortic approach followed a failed right-sided attempt in nine patients. In six (66.7%) patients, the ablation was successful with the aortic approach. The only independent predictor for the successful ablation with each approach was the earliest ventricular activation before delta wave (predelta time) and a right-sided earliest ventricular activation of more than 23 ms had high sensitivity and specificity for right-sided success. Systematically using the two strategies (right and left approaches), the ablation of the PHAP was successful in 18 (90%) patients. Conclusion: The aortic approach seems to be a safe and effective strategy for the ablation of PHAP. It can be used when the right-sided approach fails or even considered as an initial strategy when the predelta time is less than 23 ms in the right septal region. When combining the right- and left-sided approaches, the success rate is high. We believe that the retrograde aortic approach remains a key tool for this challenging ablation.

A 58-year-old male patient with Chagas disease and multiple ICD therapies was referred for ablation, although as the electroanatomical mapping was not available, we performed the guided by electrophysiologic and fluoroscopic mapping. Epicardial and endocardial abnormal potentials were eliminated and VT was not induced anymore.

A 22-year-old patient a right lateral accessory pathway and three prior failures, was successfully ablated from the epicardial surface. Due to respiratory movement catheter instability, ablation was succeeded with the aid of apnea.

A 49-years-old female with Chagas cardiomyopathy and multiple ICD therapies was referred for catheter ablation. Epicardial and endocardial scar mapping was performed using a multieletrode catheter showing very delayed potentials on the inferior-basal portion of the scar. Then substrate modification resulted in VT non-inducibility.

Catheter ablation has become a cornerstone of therapy in the management of patients with atrial fibrillation (AF). Thermal energy generated in the left atrium (LA) during ablation has the potential to damage adjacent structures. The most feared and rare complication in these ablations is atrial-esophageal fistula (AEF) result from the thermal injury to the esophagus due to the proximity to the LA, with potential catastrophic outcome. This review focuses on the diagnosis and management of AEF after catheter ablation for AF, including preventive measures to avoid esophageal lesions. Symptoms of AEF are often vague and nonspecific, sometimes asymptomatic until they present with fistula or perforation, making the diagnosis somewhat challenging. The esophagogastroduodenoscopy is the gold standard for early detection of esophageal lesions related to AF ablation. Chest CT with oral and intravenous contrast is preferred when there is suspicion of perforation. The use of an esophageal temperature probe during ablation to monitoring esophageal temperature, associated with mechanical displacement of the esophagus, may be feasible to prevent thermal esophageal lesions and enabling adequate energy delivery to the posterior wall of the LA. Prophylactic use of proton pump inhibitors after AF ablation is accepted to be effective and justified as preventive treatment. AEF is an unpredictable complication. Be aware of these complications in the follow-up of patients after AF ablation can lead to the early recognition to start treatment, including surgical repair, as soon as possible to prevent the fatal outcome.

1. Epidemiologia da Parada Cardiorrespiratoria e Apresentacao da Diretriz […] Atualizacao da Diretriz de Ressuscitacao Cardiopulmonar e Cuidados Cardiovasculares de Emergencia da Sociedade Brasileira de Cardiologia – 2019

Background:Ventricular and supraventricular premature complexes (PC) are frequent and usually symptomatic. According to a previous study, magnesium pidolate (MgP) administration to symptomatic patients can improve the PC density and symptoms.Objective:To assess the late follow-up of that clinical intervention in patients treated with MgP or placebo.Methods:In the first phase of the study, 90 symptomatic and consecutive patients with PC were randomized (double-blind) to receive either MgP or placebo for 30 days. Monthly follow-up visits were conducted for 15 months to assess symptoms and control electrolytes. 24-hour Holter was performed twice, regardless of symptoms, or whenever symptoms were present. In the second phase of the study, relapsing patients, who had received MgP or placebo (crossing-over) in the first phase, were treated with MgP according to the same protocol.Results:Of the 45 patients initially treated with MgP, 17 (37.8%) relapsed during the 15-month follow-up, and the relapse time varied. Relapsing patients treated again had a statistically significant reduction in the PC density of 138.25/hour (p < 0.001). The crossing-over patients reduced it by 247/hour (p < 0.001). Patients who did not relapse, had a low PC frequency (3 PC/hour). Retreated patients had a 76.5% improvement in symptom, and crossing-over patients, 71.4%.Conclusion:Some patients on MgP had relapse of symptoms and PC, indicating that MgP is neither a definitive nor a curative treatment for late follow-up. However, improvement in the PC frequency and symptoms was observed in the second phase of treatment, similar to the response in the first phase of treatment. Fundamento:Extrassístoles (ES) ventriculares e supraventriculares são frequentes e muitas vezes sintomáticas. Segundo estudo prévio, a administração de pidolato de magnésio (PMg) a pacientes sintomáticos pode resultar na melhora da densidade das ES e dos sintomas relacionados.Objetivo:Avaliar os resultados dessa intervenção clínica inicial no seguimento tardio de pacientes recebendo PMg ou placebo.Métodos:Noventa pacientes com ES, sintomáticos e consecutivos foram randomizados (duplo-cego) para receber PMg ou placebo por 30 dias. Visitas mensais de seguimento (15 meses) foram realizadas para avaliar a sintomatologia e controlar eletrólitos. O Holter de 24 horas foi realizado sempre que sintomáticos, ou duas vezes, independentemente dos sintomas. Na segunda fase do estudo, os pacientes cujos sintomas recidivassem, seja do grupo PMg ou placebo (crossing over), receberam PMg seguindo-se o mesmo protocolo.Resultados:Dos 45 pacientes que receberam inicialmente o PMg, 17 (37,8%) apresentaram recidiva dos sintomas em tempo variável nos 15 meses. Os pacientes com recidiva e tratados uma segunda vez apresentaram redução estatisticamente significante na densidade de ES de 138,25/hora (p < 0,001). Os pacientes de crossing reduziram em 247/hora (p < 0,001). Nos pacientes que não apresentaram recidiva, a frequência de ES foi baixa (3 ES/hora). A melhora dos sintomas foi de 76,5% nos retratados e de 71,4% nos de crossing.Conclusão:Houve recorrência de sintomas e das ES em alguns pacientes que usaram PMg, deixando claro não ser essa uma forma de tratamento definitivo ou curativo no seguimento tardio. Contudo, houve também melhora na frequência de ES e de sintomas em uma segunda etapa de tratamento, semelhante à resposta na primeira etapa.