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Curso de Atualização em Medicina Cardiovascular 2019
Reunião Anual Conjunta dos Grupos de Estudo de Cirurgia Cardíaca, Doenças Valvulares e Ecocardiografia da SPC
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01. History of Cardiology
02. Clinical Skills
03. Imaging
04. Arrhythmias, General
05. Atrial Fibrillation
06. Supraventricular Tachycardia (non-AF)
07. Syncope and Bradycardia
08. Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
09. Device Therapy
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21. Pulmonary Circulation, Pulmonary Embolism, Right Heart Failure
22. Aortic Disease
23. Peripheral Vascular and Cerebrovascular Disease
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26. Cardiovascular Surgery
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28. Risk Factors and Prevention
29. Rehabilitation and Sports Cardiology
30. Cardiovascular Disease in Special Populations
31. Pharmacology and Pharmacotherapy
32. Cardiovascular Nursing
33. e-Cardiology / Digital Health
34. Public Health and Health Economics
35. Research Methodology
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Complex left atrial tachycardias: where to block the mitral "isthmus"?
Session:
CO2 - Arritmias Supraventriculares
Speaker:
Gustavo Lima da Silva
Congress:
CPC 2019
Topic:
C. Arrhythmias and Device Therapy
Theme:
06. Supraventricular Tachycardia (non-AF)
Subtheme:
06.4 Supraventricular Tachycardia (non-AF) - Treatment
Session Type:
Comunicações Orais
FP Number:
---
Authors:
GUSTAVO SILVA; Inês Gonçalves; Afonso Nunes Ferreira; Pedro Silvério António; Nuno Cortez Dias; Luis Alves Carpinteiro; Fausto José Pinto; João Rodrigues De Sousa
Abstract
<p><strong>Introduction</strong>: Ablation of complex left atrial tachycardias (CLAT) is challenged by the heterogeneity of the underlying mechanisms, commonly with double circuits of diverse locations. The inferior mitral line (IML) is a classic element of the ablative strategy, aiming at blocking the perimitral circuits. However, the anatomical characteristics of the region (atrial muscle thickness and cooling by the adjacent circumflex artery) make ablation difficult, justifying the investigation of alternative strategies, such as anterior ML (AML), from a superior pulmonary vein to the anterior or anteroposterior region, of the mitral annulus.</p> <p><strong>Objective</strong>: To assess the pathophysiological relevance of anterior wall fibrosis in left atrial (LA) in the CLAT and the therapeutic potential of the pulmonary vein isolation (PVI) strategy and AML in the treatment of CLAT.</p> <p><strong>Methods</strong>: Prospective unicentric study of consecutive patients with CLAT undergoing electrophysiological study with high density three-dimensional mapping (<em>Carto 3</em>® or <em>Ensite Precision</em>®). The strategy consisted sequentially in: (1) map in bipolar voltage mode; (2) substrate analysis and location of low voltage areas <0.3mV; (3) interpretation of the arrhythmia mechanism by analyzing activation maps and Ripple™ (<em>Carto 3</em>®) or <em>SparkleMap™</em> (<em>Ensite Precision</em>®); (4) definition of the ablation strategy directed to the region of the circuit shared by the different <em>loops</em> and with lower speed of conduction; (5) line validation. We selected the cases in which the arrhythmia ended during the first set of radiofrequency ablation (RF), confirming the interpretation of the arrhythmia mechanism. According to the established mechanism, the therapeutic potential of AML was determined in the treatment of CLAT.</p> <p><strong>Results</strong>: 38 CLAT procedures were completed with RF application (n = 30, 60% men, 68 ± 9 years, 47% with structural heart disease and 53% submitted to IVP in the past). All patients had areas of low voltage in LA, particularly in the anterior wall (87%). The arrhythmia mechanism was macroreentrada in 77% of the CLAT and reentrant located in 33%. In the peri-mitral CLATs (n = 14), 50% presented a <em>single-loop</em> mechanism and the remaining <em>dual-loop</em>. Both IML and AML would have terminated <em>single-loop</em> arrhythmias, but the AML would terminate 57% of the <em>dual loop</em> cases, while the IML would have ended only 43%. In patients with CLAT not previously submitted to PVI, the performance of PVI and AML would terminate the arrhythmia in 79% of the cases. The strategy of IVP + LMI would be effective in only 63%.</p> <p><strong>Conclusion</strong>: Fibrosis in the anterior wall LA is prevalent, being the most frequent location of slow conduction isthmus. The arrhythmias raised thereby have often <em>dual-loop</em> mechanisms that can be treated with AML. Ablation of AML should be the preferred ablation strategy in patients with CLAT in whom peri-mitral involvement is detected</p>
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