| Sumario: | ANTIARRHYTHMICS O001 EFFECTIVENESS AND SAFETY OF NEW CLASS III ANTIARRHYTHMIC AGENT NIFERIDILE IN PHARMACOLOGICAL CONVERSION OF PERSISTENT ATRIAL FIBRILLATION AND FLUTTER Yuricheva Y; Maykov E; Sokolov S; Golitsyn S; Mironov N; Beloshapko G; Yushmanova A; Rosenshtraukh L; Chazov E Russian Research Cardiology Centre The aim of our study was to evaluate the efficacy and safety of i.v. administered new class III antiarrhythmic agent niferidile in doses up to 30 mkg/kg in conversion of persistent atrial fibrillation (AF) and flutter (AFL) to sinus rhythm. 50 patients (33 male) without structural heart diseases, age 55 ± 12 years, with arrhythmia lasting 4,4 ± 4,2 months (2 weeks- 24 months) were included. Niferidile was administered as 3 bolus injections (10 mkg/kg each) performed with the 15-min interval. Conversion to sinus rhythm within 24 hours was achieved in 44 of the 50 patients: success rate of niferidile in dose of 10 mkg/kg was 54%, in dose of 20 mkg/ kg - 70%, and in dose of 30 mkg/ kg reached 88%. Niferidile was effective in all 11 patients with AFL and in 33 of 39 patients (85%) with AF. None of patients developed proarrhythmic effects such as «torsade de pointes». Conclusion: i.v. niferidile in doses up to 30 mkg/kg seems to be very effective (up to 88%) and safe for sinus rhythm restoration in patients with persistent AF and AFL. O002 ELECTROPHYSIOLOGIC AND ANTIARRHYTHMIC EFFECTS OF NEW CLASS III AGENT NIFERIDILE IN PATIENTS WITH PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIAS Mironov NYu; Golitsyn SP; Sokolov SF; Yuricheva YuA; Maikov EB; Shlevkov NB; Rosetstraukh LV; Chazov EI Russian cardiology research complex Background: According to preclinical studies Niferidile (Nf) is a novel potassium channel blocker that inhibits transient outward and delayed rectifier currents and increases effective refractory periods (ERP) more in atria, less in ventricles. High affinity of Nf to atrial myocardium predispose to high efficacy in patients with supraventricular arrhythmias and to low risk of ventricular arrhythmogenic action. Objectives: To evaluate electrophysiologic and antiarrhythmic effects of Nf in patients with paroxysmal supraventricular tachycardia (PSVT). Materials and Methods: Effects of Nf (20micrograms/kg intravenously) were studied in 22 patients (14 males) with PSVT (11 orthodromic tachycardia in WPW syndrome, 8 atrioventricular nodal reentrant tachycardia, 3 orthodromic tachycardia due to concealed bypass tract) during endocardial electrophysiological study (EPS). Termination of PSVT by Nf could be investigated in 16 patients and prevention of reinduction of PSVT by this drug - in 19 patients. Results: Nf terminated PSVT in 81.25% and prevented reinduction of PSVT in 75.95% of patients. Nf increased the ERP of right atrium (by 22.61%, p < 0.001), left atrium (by 21.55%, p < 0.001), right ventricle (by 14.02%, p < 0.05) and accessory pathways (anterogradely by 30.16%, p < 0.001; retrogradely by 33.6%, p < 0.001). Nf did not alter sinus node recovery time and atrioventricular conduction. Nf prolonged QT (by 21.3%, p < 0.01) and QTc (by 16.01%, p < 0.05) intervals without the evidence of proarrhythmic effect. Conclusions: Prolongation of ERP in cardiac tissues (mostly in atrials) is the main electrophysiologic effect of Nf. New drug demonstrated high antiarrhythmic efficacy and good safety profile in patients with PSVT. O003 PHARMACOLOGICAL TREATMENT OF PATIENTS WITH INAPPROPRIATE SINUS NODE TACHYCARDIA: BETA-BLOCKER OR IF-CHANNEL INHIBITOR? Borbola J; Abraham P; Foldesi Cs; Kardos A Hungarian Institute of Cardiology Inappropriate sinus-node tachycardia (IST) is a rare disease defined as increased heart rate at rest, and/or inadequate response to physical or emotional stress. In the last years 25 patients (23 women, 2 men, age: 18-57 (33) years) were treated with IST due to palpitations. Patients had no structural heart disease (LVEF: 65 ± 2%), TSH values were within normal limits, but resting heart rate were repeatedly high: 106 ± 3/min. The results of Holter recording (expressed as minimal-maximal and average heart rate/min) without medication showed high heart rate values: 58 ± 2 - 163 ± 3 - (96 ± 2)/min. The bicycle ergometry showed an average loading capacity of 120 ± 5 W (heart rate: control (C): 104 ± 4/min, top (T): 170 ± 6/min. The aim of the study was to compare the beta-blocker and ivabradine treatment in IST patients. The beta-blocker treatment (bisoprolol 5 mg/day) improved the high sinus node frequency spectrum both during Holter monitoring (54 ± 2 - 135 ± 4 - 81 ± 2/min, p < 0.0001) and during ergometry (120 ± 8 W; C: 86 ± 3; T: 145 ± 4/min; p < 0.05). The ivabradine therapy decreased the heart rate significantly and dose-dependently compared to the control values: ivabradine 5 mg b.i.d: 50 ± 2 - 131 ± 5 - 76 ± 2/min (p < 0.0001), ivabradine: (7.5 mg b.i.d.): 48 ± 1 - 130 ± 6 - 72 ± 2/min; p < 0.0001), and decreased the heart rate frequency during ergometry: ivabradine (2×5 mg/day: C: 83 ± 3; T: 137 ± 4/min (p < 0.05)), (2×7.5 mg/day: C: 77 ± 4; T: 137 ± 8/min (p < 0.05)). There was no change in the loading capacity. The ivabradine treatment was well tolerated, there was no sinus bradycardiac episode leading to treatment discontinuation. On the other hand, several side effects were noticed during beta-blocker therapy. Based on our clinical experiences, IST can be treated with the sinoatrial node modulator drug ivabradine successfully and safely. The ivabradine treatment might be considered as an alternative to the ablation of the sinoatrial node with the inherent risk of pacemaker implantation. ATRIAL FIBRILLATION ABLATION O004 ABLATION OF PAROXYSMAL AND PERSISTENT ATRIAL FIBRILLATION: 1-YEAR FOLLOW-UP THROUGH IMPLANTABLE ECG RECORDER Romanov A; Pokushalov E; Corbucci G; Shabanov V; Elesin D; Stenin I; Losik D State Research Institute of Circulation Pathology Introduction: The aim of this prospective observational study was to identify Responders to ablation through continuous subcutaneous monitoring for 1 year after ablation in patients with paroxysmal atrial fibrillation (PAF) or persistent AF (PersAF). Method: Patients with symptomatic drug refractory AF were enrolled. Real-time three-dimensional (3D) left atrium maps were reconstructed by using a nonfluoroscopic navigation system (CARTO, Biosense-Webster, USA). The ipsilateral left and right pulmonary veins (PVs) were encircled in 1 lesion line by circumferential PV isolation. All patients were implanted with Reveal XT (Medtronic Inc.) for continuous AF monitoring and data collected every month during the 12-month follow-up. Results: We enrolled 129 patients (56 ± 9 years, 102 males), all of whom were followed-up for 12 months after the last ablation procedure: 58 (45%) had a history of PersAF. After only 1 ablation procedure, 76 (59%) of the 129 patients were AF-free at 12-month: 48 out of 71 (68%) in the PAF group and 28 out of 58 (48%) in the PersAF group. After 1 or more ablation procedures, 94 (73%) of the 129 patients were AF-free 12 months after the last procedure: 57 out of 71 (80%) in the PAF group and 37 out of 58 (64%) in the PersAF group. Conclusion: Ablation is highly effective in treating AF, as assessed through detailed 1-year continuous monitoring: success rate is higher in PAF than in PersAF patients. The use of subcutaneous monitors is a valuable means of identifying responders and nonresponders, and can potentially guide antiarrhythmic and antithrombotic therapies. O005 FUNCTIONAL IMPROVEMENT IN ADVANCED HEART FAILURE AFTER MITRAL SURGERY IN PATIENTS UNDERGOING RADIOFREQUENCY ABLATION OF ATRIAL FIBRILLATION IS RELATED TO LONG TERM MANTAINANCE OF SINUS RHYTHM Rostagno C; Blanzola C; Sclafani G; Montesi GF; Braconi L; Stefano PL; Cardiologia Generale1, §Cardiochirurgia - AOU Careggi - Firenze Objective: Atrial fibrillation is associated with a higher mortality in patients with advanced heart failure, Persistence of AF after mitral valve (MV) surgery is associated with poorer hemodynamic improvement in comparison to resumption of sinus rhythm (SR). RF-maze associated with MV surgery is associated with a 60-70% long term persistence of SR. The aim of this prospective investigation was to evaluate the relation between persistence of SR and change of functional status in patients in patients with advanced NYHA class. Methods: 301 consecutive patients were treated by RF-maze with Medtronic CardioBlate® system associated with MV surgery between November 2001 and December 2007 and were followed up for an average period of 1450 days. 234 /301 were in advanced NYHA functional class (III-IV). Clinical examination, ECG and echocardiogram were evaluated at baseline and during follow-up (3 to 96 months). Results: At an average follow-up of 1450 days, 180/234 (77%) patients in preoperative NHYA class III-IV were alive. One hundred and twenty were in SR, while 60 remained in stable AF. In the two groups age was similar (mean 64.7 years in SR, 66.7 in AF) as mean AF duration (36 vs 39 months). Baseline LA diameter, left and right atrium area were greater in patients in whom AF persisted in comparison to those in SR. These last patients showed a more relevant remodelling of atrial chambers after surgery. Baseline mean NYHA class was 2.96 in SR and 3.13 in AF patients. At follow-up a significant functional improvement was found in SR patients (average NYHA class 1.31 vs 2.33, p < 0.003), associated with a significant decrease of calculated systolic pulmonary pressure. Conclusions: persistence of SR after AF ablation is associated with a significant functional improvement in comparison to patients who remain in AF. Persistent pulmonary hypertension after surgery may limit clinical improvement and contribute to maintenance of AF. O006 TRANSSEPTAL ACCESS AND ATRIAL FIBRILLATION ABLATION GUIDED BY INTRACARDIAC ECHO IN PATIENTS WITH ATRIAL SEPTAL CLOSURE DEVICES Santangeli P; Di Biase L; Burkhardt JD; Horton R; Sanchez J; Lakkireddy D; Bai R; Beheiry S; Hongo R; Natale A Texas Cardiac Arrhythmia Institute - St. David's Medical Center, Austin, TX Background: Percutaneous positioning of closure devices is a well-established treatment of atrial septal defects (ASD). These patients are at increased risk of developing atrial fibrillation (AF), and treatment by catheter ablation is underutilized due to the perceived difficulty of obtaining transseptal access in the presence of the closure device. We report the acute and long-term results of radiofrequency catheter ablation of AF in patients with ASD closure devices. Methods: Thirty-nine patients (age 54 ± 6 years, 72% males) with drug-refractory AF (33% paroxysmal, 51% persistent, 16% long-standing persistent) and ASD closure devices (82% Amplatzer®, 18% Cardioseal®) underwent radiofrequency catheter ablation. A double transseptal access guided by intracardiac echocardiography (ICE) was obtained in all patients. Results: In 35/39 (90%) patients the transseptal access was obtained in a portion of the native septum, while in 4/39 (10%) a direct access through the device was required. The latter group had a significantly longer time for achieving the double transseptal access (73.6 ± 1.1 min vs. 4.3 ± 0.4 min, p < 0.001), longer fluoroscopy time (122 ± 5 min vs. 80 ± 8 min, p < 0.001), and total procedure time (4.1 ± 0.2 hours vs. 3.1 ± 0.3 hours, p < 0.001). At a follow-up of 14 ± 4 months the overall success rate was 77% (85% in paroxysmal AF, 73% in non-paroxysmal AF). Transthoracic contrast-enhanced echocardiography with the Valsalva maneuver, performed between 3 and 6 months after the procedure, failed to detect shunt in all patients. Conclusions: Radiofrequency catheter ablation of AF is feasible, safe and effective in patients with ASD closure devices. Transseptal access can be obtained in portions of the native septum in the majority of the cases. Direct transseptal puncture of the device is feasible and safe, but it requires longer time for each transseptal access. O007 IMPACT OF RADIO-FREQUENCY CHARACTERISTICS ON ACUTE PULMONARY VEIN RECONNECTION AND CLINICAL OUTCOME AFTER PVAC ABLATION De Greef Y; Tavernier R; Schwagten B; De Keulenaer G; Stockman D; Duytschaever M Department of Cardiology, Antwerp Cardiovascular Institute Middelheim, Belgium Aim: To study the impact of radio-frequency (RF) characteristics on acute pulmonary vein reconnection (PVR) and outcome after PVAC ablation. A strategy of PV isolation with additional ablation of PVR (PVI + PVR) was compared to PVI-only. Methods: Eighty patients underwent PVAC-ablation: in 40 patients, PVI-only was performed; in another 40 patients adenosine and 1-hour waiting time were used to unmask and ablate PVR (PVI+PVR) after baseline PVI. Freedom of AF was compared at 12months. RF-characteristics of PVAC applications needed for baseline PVI were assessed. Results: There was no difference in clinical characteristics or baseline RF-profile between the 2 groups. In the PVI+PVR group, PVR was observed and ablated in 38 out of 160 veins (24%). Freedom of AF after PVI+PVR was higher compared to PVI-only (85% vs 65%, p < 0,05). Within the PVI group, when comparing patients with and without AF recurrence, percentage of PVAC applications with high T° but low power (>48°, <3W) was higher (28 ± 18% vs 11 ± 11%, p < 0,0001). When comparing PVs with and without PVR, the percentage of PVAC applications with high T° but low power was also higher (27 ± 13% vs 13 ± 15%, p < 0,0001). Conclusions: After PVAC-guided PVI, 24% of PVs exhibit acute PVR. Additional ablation of PVR is associated with improved clinical outcome. Acute PVR and recurrence of AF are characterised by a prior PVAC ablation with a considerable number of applications with high temperature but low power. If PVI is obtained with low power PVAC applications, a consistent use of adenosine and waiting time is required. O008 THE ROOF LINE DOES NOT INFLUENCE THE 12-MONTH SUCCESS OF CIRCUMFERENTIAL ABLATION OF THE PULMONARY VEINS: RESULTS OF A PROSPECTIVE RANDOMIZED STUDY. Arbelo E; Guiú E; Andreu D; Borras R; Berruezo A; Tolosana JM; Brugada J; Mont L Hospital Universitari Clínic, Thorax Institute, Barcelona, Spain Introduction: The isolation of the pulmonary veins (PV) for the treatment of atrial fibrillation (AF) is often associated to linear radiofrequency lesions within the left atrium (LA) in an effort to improve results. The aim of the study was to evaluate the contribution of the roof line in the mid-term success of AF ablation. Methods: We prospectively included patients (p) undergoing catheter ablation for AF. The PV isolation was performed by continuous circular lesions around ipsilateral PV, checking for conduction block with a circular multipolar catheter within the veins. Subsequently, p were randomized to no further ablation (CPVA-NoRL) versus an additional linear ablation at the roof of the LA (CPVA-RL) between the superior aspect of the circular lesions at the left and right PV). Follow-up was performed at 1, 3, 6 months after the procedure and every 6 months thereafter. After a 3 month blanking period, recurrence was defined as the occurrence of any arrhythmia of ≥30 seconds. Results: 140 patients (55 ± 11 years, 69% male, 35% hypertension, LA diametre 42 ± 6 mm, LVEF 62 ± 8%, 20% structural cardiomyopathy) undergoing AF ablation, were randomized. No significant differences were observed between the CPVA-NoRL vs. CPVA-RL groups in terms of LA diametre, presence of hypertension, structural cardiomyopathy nor any other arrhythmia predictor. After a first procedure of AF ablation, there was no significant difference in the arrhythmia-free survival curve between the two groups (72% in CPVA-RL vs. 78% in CPVA-NoRL at 12-months, log-rank p = 0,29). The incidence of LA macroreentrant tachycardias after a first procedure was 4,8% in the CPVA-RL group versus a 5,5% in the CPVA-NoRL one. Conclusion: The left atrial roof line does not improve mid-term results of the isolation of the pulmonary veins for the ablation of atrial fibrillation. O009 COMPLEXITY OF ATRIAL FIBRILLATION IN CHINESE IN ROUTINE DAILY PRACTICE: INSIGHTS FROM THE REALISEAF-TAIWAN REGISTRY Chiang CE; Wang KL; Naditch-Brule L; O'Neill J; Steg PG; RealiseAF registry General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan Purpose: Patients with atrial fibrillation (AF) have multiple co-morbidities and high cardiovascular risk. Most studies were carried out in Western countries, and there is a paucity of data from Chinese patients. The aim of this analysis was to describe clinical characteristics, risk factors, co-morbidities, and management strategies in Taiwanese patients in the RealiseAF registry. Methods: RealiseAF was a cross-sectional survey of 10,523 patients from 831 sites in 26 countries on 4 continents, with at least one AF episode documented by standard electrocardiogram or by Holter monitoring in the last 12 months. Participating physicians were randomly selected in 2009 from lists of office-/hospital-based cardiologists and internists. Results: Among 742 patients in Taiwan who were eligible for analysis, the mean (SD) age was 70.2 (11.8) years. More men (59.8%) than women were enrolled. Permanent AF was most common (51.7%), followed by paroxysmal (33.3%) and persistent (11.1%) AF. Cardiovascular risk factors and co-morbidities were very common: 72.9% had hypertension, 27.0% had diabetes, 40.7% had heart failure, 34.5% had coronary artery disease, 21.9% had cerebrovascular disease, and 38.8% had valvular heart disease. A rate-control strategy (67.8%) was more frequently undertaken than rhythm-control (24.5%). The majority of patients (85.2%) received at least one anti-arrhythmic drug, but 81.5% of patients had an EHRA AF classification ≥2. The mean (SD) CHADS2 score was 2.2 (1.4), and 65.1% had a CHADS2 score ≥2. However, only 31.8% of patients were receiving an oral anti-coagulant. Conclusions: AF patients in daily practice in Taiwan had multiple risk factors and co-morbidities, similar to those in Western countries. Patients were highly symptomatic despite the widespread use of anti-arrhythmic drugs. The risk of stroke was generally high, but the use of anti-coagulants was extremely inadequate. There is an apparent unmet need in AF treatment in Chinese patients. O010 IMPACT OF RADIOFREQUENCY CATHETER PULMONARY VEIN ISOLATION (PVI) ON TOTAL ATRIAL FIBRILLATION (AF) BURDEN IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION Urban L; Hlivak P; De Melis M; Garutti C; Corbucci G; Hatala R National Cardiovascular Institute, Slovak Medical University, Bratislava, Slovakia Background: Evaluation of success of radiofrequency catheter ablation (RFCA) in AF patients (pts) is largely based on symptoms reduction / abolition and on intermittent ECG recordings. Evaluation of the occurrence of AF by means of continuous ECG monitoring was rarely used until now. Aim: To quantify the total AF burden (AF%) in pts undergoing catheter PVI in the pre- and post-ablation period. AF% was defined as the percentage of the total monitoring time during which the patient was in AF. To this aim, continuous ECG monitoring was performed by means of implantable loop recorder (ILR, Reveal XT, Medtronic Inc., USA) in pts undergoing radiofrequency catheter ablation for paroxysmal AF. Patients and Methods: 52 pts (56 ± 9 years, 79% males) were prospectively enrolled in this study. All patients had the ILR implanted in stable sinus rhythm before RFCA (3 ± 2 months) and were followed-up for 9 months after RFCA. The initial 3 months were blanked and were not comprised in the analysis. All pts had paroxysmal AF for a mean of 6.4 ± 4.8 years, 47% of them had a history of >1 episode of persistent AF prior to ILR implantation, mean left atrial diameter was 44 ± 4 mm, LVEF% was 59 ± 6%. Their mean CHADS2 score was 1 ± 0.7. RFCA comprised point-by-point electroanatomically guided PVI only in 31 pts (60%), linear lesions were added in 21 (41%). Results:
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