JOURNAL OF CARDIAC ARRHYTHMIAS

What are the characteristics and results of Tilt Tests in the elderly?

Ana Gabriela Ponte Farias — 2024-05-06

Introduction: The elderly have several causes of syncope or pre-syncope. The importance of the Tilt Test (TT) has been questioned in this population. However, dysautonomic causes are common in these age groups, having an impact on morbidity and mortality. Objective: Compare the results of the TT between the age groups of the elderly (>=60 years) and the non-elderly. Methods: Crosssectional study carried out between 2016-2021. We used the Mann-Whitney and Chi-square tests, with a p-value < 5% considered significant. The protocols used were Westminster or Italian. Results: We analyzed 2364 tilt tests, 61.7% female, aged 51.1 (31-71) years. Positivity was 32.6%, 37.2% with sensitization (p < 0.0001). In the elderly group (EG), there were 958 tests (40.5%) and 1381 (58.4%) in the non-elderly (NEG). EG positivity was 270 (28.0%), lower than NEG with 524 (37.43%) (p < 0.01). Positivity with sensitization in EG was 195 (20.35%) x 403(29.18%) in NEG (p<0.001). In EG, 50 patients (5.22%) had a dysautonomic response and in NEG, there were 10 (0.72%) (p < 0.001). Complications were 4.2% EG x 2.6% NEG ( p= 0.03). Conclusion: The TT in the elderly showed a lower incidence of positivity in the passive and sensitization phases compared to the non-elderly. Vasovagal causes were the most frequent causes in the elderly, had a higher incidence of dysautonomic responses, fewer prodromes and a higher rate of complications, however without severity.

Microbes and their Role in Atrial Fibrillation: A Literature Review

Saira Rafaqat — 2023-11-07

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia observed in clinical practice. The gut microbiota (GM) and their byproducts have the potential to activate the autonomic nervous system, which plays a crucial role in the development and maintenance of AF. Recent hypotheses suggest that bacterial infections, such as Helicobacter pylori and Chlamydia pneumonia might play a role in the development of AF. The emerging evidence suggested that certain patients might develop AF due to bacterial infections. AF patients exhibited a significant increase in species richness and diversity. Specifically, opportunistic pathogenic bacteria such as Klebsiella, Haemophilus, Streptococcus and Enterococcus were significantly higher, while symbiotic bacteria such as Agathobacter and Butyrivibrio were significantly lower in AF patients. Likewise, the development of AF has been linked to infections caused by viruses that have an affinity for the heart. Chronic hepatitis C virus infection appears to be linked to an elevated risk of incidental AF, likely due to the shared underlying pathology of chronic inflammation. Numerous studies have explored the arrhythmogenic effects of SARS-CoV-2, particularly its impact on mortality and its association with AF. Influenza infection was found to be significantly linked to the development of AF, resulting in an 18% increased risk. However, in cases where AF is present and dengue infection is suspected, it is advisable to exercise caution when considering the use of anticoagulants, ensuring that specific serological tests have excluded the presence of this infection.

Parahisian Stimulation Through Unusual Vascular Access - Case Report

Carlos Robério Mendes — 2024-03-07

Introduction: To report the case of a patient with a total atrioventricular block with significant ventricular dysfunction whose pacemaker implantation and physiological stimulation occurred through the iliac vein due to tortuosities in other vessels that prevented the procedure. Method: Information was obtained by reviewing the medical records, interviewing the patient, photographing the diagnostic methods to which the patient was submitted, and reviewing the literature. Conclusion: The reported case and published publications bring to light the discussion of pacemaker implantation sites and physiological stimulation in a complex situation that, although it occurs in a minority of cases, when well it is capable of obtaining satisfactory results.

The Tilt Test in the Assessment of Syncope and Pre-syncope. Effective and safe? Analysis of a Series of 2364 Patients over 6 Years

Eduardo Augusto Quidute Arrais Rocha — 2024-02-26

The tilt table test (TT) provides relevant information about individual susceptibility to neuro-mediated hypotension and bradycardia. Its importance has been questioned. In this work, we analyze the results and safety of TT in the investigation of syncope, presyncope or postural dizziness. Cross-sectional study, with TT exams performed by specialists in cardiac arrhythmias, in the period 2016-2021, in a syncope unit. Analyzes were performed using the Mann-Whitney test, multiple logistic regression, with a significant p value <0.05. The protocols used were Westminster or Italian protocol. There were 2364 TT performed, 61.7% female, aged 51.1 (31-71) years. The positivity rate was 32.6%, 37.2% with pharmacological sensitization (p< 0.01). For the investigation of syncope, positivity was 34.2% (477) x 30.65% (285) for other symptoms (p<0.001), while evaluating syncope and presyncope together the difference was 37.55% (623) x 20.9% (139) for other symptoms (p<0.001). Positivity was higher in males (p<0.01; OR=1.40(1.16-1.69)), in sensitized tests (p<0.01;2.01(1.64-2, 38)), in patients with early orthostatic hypotension (OH) with symptoms (p <0.01; 9.68(4.13-27.44)). The complication rate was 3.29%, but without severity. The TT remains an important and safe methodology in clinical practice for the investigation of patients with suspected neurally mediated syndromes.

The Role of Different Components of Metabolic Syndrome in the Pathogenesis of Atrial Fibrillation

Saira Rafaqat — 2024-11-28

Metabolic syndrome (MetS) goes by various aliases such as dysmetabolic syndrome, syndrome X, and insulin resistance syndrome. Dysmetabolic syndromes indicate factors that pose risks for the onset of cardiovascular diseases and type 2 diabetes, making it a rapidly escalating global health concern. Atrial Fibrillation (AF) disrupts the heart’s electrical system, manifesting as dysrhythmias and arrhythmias with irregular heartbeats. This condition significantly amplifies worldwide mortality and morbidity rates. The principal hazard associated with metabolic syndrome is cardiovascular disease. Notably, metabolic syndrome plays a pivotal role in the genesis of AF, as numerous studies have highlighted the fundamental connection between the two. This review underscores that the distinct components of metabolic syndrome – hypertension, diabetes, obesity, and dyslipidemia – actively participate in the pathophysiology of AF development and progression through atrial remodeling, involving both structural and electrical modifications.

Naphazoline poisoning associated with bradycardia and persistent hypertension: Case report

Marcelo Vitola Dreckmann — 2024-12-17

Naphazoline (NA) is an α-adrenergic agonist derived from imidazoline. Due to its vasoconstrictor action, it is widely used as a nasal decongestant with a rapid onset of action. It presents few studies on its side effects, with most case studies of accidental ingestion in children under two years of age. We report a case on the relationship between NA intoxication and symptomatic bradycardia, reversed after administration of intravenous Naloxone, in a young adult patient.

Impact of preoperative persistent or permanent atrial fibrillation on inhospital mortality after coronary artery bypass graft surgery

Marcela da Cunha Sales — 2024-03-21

Introduction: Atrial fibrillation (AF) is an arrhythmia that has a well-established impact on cardiovascular and cerebrovascular morbidity and mortality. However, the role of this arrhythmia plays on surgical risk remains uncertain. Objective: to evaluate the impact of preoperative persistent or permanent AF on in-hospital mortality after isolated coronary artery bypass graft surgery (CABG). Methods: prospective cohort with 2,377 patients submitted to isolated CABG between January 2014 and December 2021. Sixty-two variables, including baseline factors, operative characteristics, and outcomes, were analyzed. Patients were divided into two study groups: No preoperative AF (n=2,287) and preoperative persistent or permanent AF (N=90). The comparison between the groups was performed initially by descriptive and univariate analysis. Subsequently, the analysis of mortality predictors was performed using binary logistic regression - multivariate adjusted analysis. Results: patients with preoperative AF were older, had a higher prevalence of pulmonary hypertension and anemia, had lower ejection fraction and had higher surgical risk scores when compared with patients with no history of atrial fibrillation. The in-hospital death was more frequent in patients with a history of AF (3.2% vs 8.9%, P=0.010). Through the multivariate analysis, it was possible to verify that preoperative AF is independently associated with the occurrence of in-hospital mortality after CABG (OR 2.68; 95% CI 1.21-5.94, P=0.015). Conclusion: Preoperative persistent or permanent AF has been shown to have a significant impact on in-hospital mortality rates after CABG even after adjusted multivariate analysis, being an independent risk predictor for the occurrence of postoperative death.

Torsades de Pointes induced by propofol in a patient with Wolff Parkinson White Syndrome: Case report

Anna Luiza Souza — 2024-12-17

We describe a clinical case of a 57-year-old female patient with Wolf Parkinson White Syndrome, who, during anesthetic induction with propofol for ablation of the accessory pathway, presented polymorphic ventricular arrhythmia, specifically Torsades de Pointes.

Inferior Vena Cava Agenesis: an incidental diagnosis during electrophysiological study

Sérgio Ferreira de Ferreira Filho — 2024-10-03

Inferior Vena Cava Agenesis (IVCA) is a rare congenital anomaly occurring in 0.0005% to 1% of the general population. Although often asymptomatic, IVCA significantly increases the risk of serious thromboembolic events, including chronic venous insufficiency, pulmonary thromboembolism, and deep vein thrombosis (DVT). This study investigates the incidence and clinical implications of IVCA discovered incidentally during electrophysiological studies (EPS) at the Instituto de Cardiologia do Rio Grande do Sul over the past 27 years. A cross-sectional review of 13,194 EPS reports from January 1997 to July 2024 identified 12 cases (0.09%) of incidentally diagnosed IVCA. Of the patients in question, 66.7% were female, with a mean age of 44.6 years. One patient had a history of complex heart disease, and arrhythmia induction was a potential outcome in 66.7% of cases. Atrioventricular node reentry tachycardia (AVNRT) was the most common arrhythmia observed. Catheterization of the right heart chambers via the azygos system was feasible in 83.3% of cases. One patient experienced deep vein thrombosis and pulmonary thromboembolism post-procedure, which was managed with anticoagulation. The study highlights the importance of recognizing IVCA during EPS as it can impact catheterization techniques and procedural outcomes. Although IVCA is a rare occurrence, it should be considered as a potential cause of difficulties encountered during catheterization procedures, and alternative access methods should be prepared. This awareness is crucial for preventing complications and ensuring effective treatment of cardiac arrhythmias.

Comparison of one-patch and standard 12-lead electrocardiogram

Zachary Townsend — 2024-09-06

Pre-connected and positioned patch devices have attempted to simplify the electrocardiogram (ECG) testing process. However, these devices have not been extensively tested and compared with standard ECG systems. The purpose of this study was to compare a novel patch-based ECG device with a standard 12-lead ECG system in order to determine clinical equivalence. Study participants underwent two consecutive ECG tests in a randomized fashion. ECG measurements (heart rate, PR, RR, QRS, QT intervals) were compared between the standard 12-lead ECG and the one-patch ECG. Paired t-test analysis was used for the comparisons conducted using GraphPad Prism. A total of 30 participants underwent the ECG testing (80% female; mean age 35 ± 16 years). One participant presented with first degree AV Block. All other participants were in normal sinus rhythm/sinus arrhythmia. There were no statistically significant differences identified in heart rate, PR interval, RR interval, QRS interval, and QT interval (p > 0.05) between the one-patch ECG and standard 12-lead ECG. These findings suggest that one-patch devices may provide equivalent ECG measurements compared with conventional 12-lead systems. Given the advantages of a one-patch, pre-positioned ECG system, this technology shows promising potential for cardiovascular screening.

Electrical stimulation in special clinical situations

Lenises de Paula van der Steld — 2024-07-22

Introduction: Neuromodulation is an approach used to treat diseases that are refractory to clinical treatments by employing electrical and chemical stimulation techniques, especially in cardiac, neurological, and psychiatric disorders. Objective: This study aims to provide an overview of the latest developments in neuromodulation therapies that use electrical stimulation. Methods and results: The present study describes the most common neuromodulation techniques. Neuroplasticity is used to adjust the ions and neural excitability in response to central and peripheral nervous system stimulation. The spinal cord, dorsal root, and gastric stimulations are effective treatments for neuropathies, chronic pain, muscle spasticity, epilepsy, depression, cluster headaches, heart failure, and gastroparesis symptoms. Deep brain stimulation and invasive cortical stimulation are medical procedures used selectively to treat Parkinson’s disease, dystonia, obsessive-compulsive disorder, and chronic pain. Barostimulation therapy is beneficial in controlling refractory hypertension, reducing the risk of cardiovascular events, and improving overall quality of life. Repetitive Transcranial Magnetic Stimulation is a recommended treatment option for fibromyalgia, neuropathic pain, chronic headaches, treatment-resistant depression, generalized anxiety disorders, schizophrenia, and attention deficit disorder. While controlling obesity shows promise in regulating appetite and promoting satiety, more research is needed to understand the safety and efficacy of these therapies in various groups. Conclusion: Neuromodulation devices hold promise for treating diseases that do not respond to clinical treatments. Additional clinical trials and studies are required to understand it fully.

Right atrial appendage accessory pathway causing pseudo-refractory atrioventricular reentrant tachycardia

Lucas Hollanda Oliveira — 2024-11-21

Catheter ablation is the first-line therapy for symptomatic atrioventricular reentrant tachycardia (AVRT). Pseudo-refractory AVRT may stem from misdiagnosis, use of inadequate ablation methods, or the presence of additional concealed or unusual located pathways that initiate or sustain the tachycardia. We present a case of right atrial appendage accessory pathway—a rare and overlooked cause of AVRT—to illustrate the importance of raising suspicion for this condition when standard mapping and ablation around the tricuspid valve annulus fail to eliminate pathway conduction. Furthermore, we present a straightforward, effective approach for localizing the pathway site and safely performing irrigated ablation at the base of the right atrial appendage.

Evolution of Cardiac Arrythmia Management by Catheter Ablation in Tanzania

Yona Gandye — 2024-05-21

In Tanzania, despite the expansion of cardiovascular management through the expansion of health system infrastructure to combat cardiovascular diseases, radiofrequency ablation of cardiac arrhythmias remains a major challenge as the current management with catheter ablation is inaccessible to the majority. Several limitations for developing invasive arrhythmia care are identified: lack of manpower, healthcare resources, health systems challenges, high cost of consumables, healthcare financing challenges and limited antiarrhythmic medications. The proposed solutions to address the unmet are: inauguration of a domestic arrhythmia society with dedicated prioritized academic programs, advocacy for training in the cost-effective conventional approach to arrhythmia ablation, reducing irrational claim deduction from insurers and regulation of central medical store policy, calling the Ministry of Health to implement insurance accreditation of radiofrequency ablation in Tanzania, sensitize the government to offer motivation to candidates pursuing electrophysiology career, the government through the Ministry of Health and education to transform the current training infrastructure to meet current academic needs including radiofrequency ablation services, the creation of training partnerships within Africa to improve local electrophysiology expertise. Radiofrequency ablation using a conventional approach, which is cost-effective, can be adopted to ensure service availability in Tanzania and the Sub-Sahara region. A unique responsibility lies within the government and financers to reinforce the efforts to implement these recommendations and achieve the medical tourism policy in Tanzania.

Atrioventricular Nodal Reentrant Tachycardia in Kartagener’s Syndrome

Christian Moreno Luize — 2024-05-24

Single case report of a middle-aged patient with Kartagener’s syndrome who experienced recurrent paroxysmal supraventricular tachycardia. Despite optimized beta-blocker therapy, only cardioversion in emergency departments provided symptomatic relief. The unique electrocardiographic features of this condition and their significance in transaortic electrophysiological studies for diagnosis and treatment are highlighted.

Proposal for a pacemaker implant technique with minimum radiation exposure

Mário Augusto Cray da Costa — 2024-10-31

Objective: To describe a standardized technique for implanting a pacemaker to reduce the time of surgery and radiation exposure and to demonstrate the results in a series of patients. Methods: Through descriptive and cross-sectional statistics, 109 patients undergoing dual-chamber (DDD) and single-chamber (VVI) pacemaker implantation were evaluated, using a standardized technical approach used in the cardiac surgery service of Santa Casa de Misericórdia of Ponta Grossa-PR, Brazil, from November 2016 to November 2019. Clinical aspects, implant indication, implant times, and radiation time were studied. The technique was described, and its most relevant aspects were discussed. Results: 68.81% of the pacemakers were DDD and the surgical time ranged from 11’22’’ to 34’43’’, with a median of 18’15’’. In these cases, the fluoroscopy time ranged from 34’’ to 5’10’’, with a mean of 1’42’’ and a 16.9 mGy median amount of radiation. The time to implant the VVI pacemaker ranged from 12’ to 42’, with a median of 17’12’’. The fluoroscopy time ranged from 26’’ to 6’25’’, with a mean of 1’41’’ and the median amount of radiation was 13.6 mGy. Conclusion: The technique proved to be agile, safe, with low fluoroscopy times and small amount of radiation. There were no postoperative complications. However, few studies were found for comparison.