A13-6 Neurocardiogenic syncope in patients with dilated cardiomyopathy

EP Europace, Dec 2003

Aggelopoulou, N., Livanis, E.G., Kostopoulou, A., Leftheriotis, D., Flevari, P., Theodorakis, G.N., Kremastinos, D.T.H.

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A13-6 Neurocardiogenic syncope in patients with dilated cardiomyopathy

0 N. Aggelopoulou , E.G. Livanis, A. Kostopoulou, D. Leftheriotis, P. Flevari, G.N. Theodorakis, D.T.H. Kremastinos. 2nd Dept 1 D. Zysko, .I. Gajek. Department Wroclaw , Wroclaw , Poland 2 M. Scaglione , P. Didonna, D. Caponi, G. Azzaro, S. Leuzi, F. Fermis, G. Rossetti , M. Bocchiardo. Elechvphysiology Laboratory. Division 3 J.L. Merino , M. Abello, R. P&ado, M. Gnoatto , .I. Ruiz-Cmtador, M. Gonzalez-Vasserot, J.A. Sobrim. Hospital Universitario Ala Paz” , Madrid , Spain 4 A. Pastor, A. Nunez, A. Martin-Penato , C. Alonso, J.-C. Garcia, F.-G. Cosio. Cardiology Department. Hospital Universitario De Getafe tions after 30 minutes of supine rest and immediately after the syncope. The change of A D M concentration was expressed as ADM2IADMl. All the pts had 24.hour ECG bolter monitoring and heart rate variability analysis was performed for 2 minutes time period before NTG administration if the syncope occurred in active phase or 2 minutes period immediately before the syncope in the passive phase, not including the slowing of heart rate. The following HRV parameters were assessed:mRR, SDNN, rMSSD, TP, LF, HF and B calculated as LF,'HF. Results: The plasma level of A D M in group I decreased signiiicantly 31,9&33,6 vs 17,0&14,5 pg/ml (p<O,O5) and in group II increased signiiicantly 13,0&7,6 vs 27,4&13,0 pgiml @<0,05). - W SDNN RMSSD W ADM2 (PgW 17,0 +14,5 27,4 +13,0 The statistical analysis revealed significant correlation between the ADM2IADMl and phase of positive HU’IT (r=O,51 p<O,O2) (II- passive phase, I - active phase), and with LF (r=0,51, p<O,O5) and B parameter (r=0,52, p<O,O5). Conclusions: 1. There is a different type of neurohumoral response in the course of vasovagal syncope during the passive and active phase of the test. 2. The activation of sympathetic nervous system during gravitational stress correlates with the increase of A D M secretion. IAl 3 4 .I. Gajek, D. Zysko. Department Wroclaw, Wroclaw, Poland THE INFLUENCE OF HEAD-UP TILT TEST ON PLASMA ADRENOMEDULLIN CONCENTRATION IN PATIENTS WITH CARDIODEPRESSIVE VASOVAGAL SYNCOPE of Cardiology Medical University of Background: Adrenomedullin (ADM) is a potent vasodilator playing role in regulation of central hemodymmic. The concentration of plasma A D M in healthy persons increase under the influence of orthostatic stress. In patients with vasovagal syncope (VS) the changes in A D M concentration could be responsible either for syncope provocation or prevention. The aim of the study was to assess the influence of phase of the head-up tilt test (HU’ITJ in which the syncope occurred on the plasma concentration of ADM. Material and method: The study was performed in 23 patients (pts) with vasovagal syncope (17 w o m e n and 6 men), m e a n age 45,7&16,lyears, in w h o m the cardiodepressive vasovagal syncope during HU’IT according to the Italian protocol with nitroglycerine (NTG) prowcation was produced. In 6 pts VS occurred in the passive phase of tilt (group 1) and in 17 pts after NTG provocation (group 2). The head-up tilt test was performed according to ESC guidelines. The blood for A D M concentration was drawn after 30 min supine rest (ADM 1) and immediately after the syncope (ADM 2). A D M level was measured using radioimmunological method. The results are shown in table as mea&SD: 1,3+0,8 3,2+3,4 NS 2,7+1,3 1,6+1,5 <0,05 P <0,05 <0,05 In group 1 plasma level of A D M increased significantly after the HU’IT and in group 2 decreased significantly comparing to baseline values. The A D M concentration did not differ between the groups in baseline conditions and was signiiicantly higher after the syncope in group 1. Conclusions: 1. The excessive increase of A D M concentration during the passive phase of HU’IT could play the causative role in pathogen&s of VS occurring early during the HU’IT 2. In patients with VS after NTGprovocation the decrease of A D M concentration can be the result of hemodynamic changes in the presence of vasodilating drug and may be the mechanism that could prevent the syncope. IAl 3 5 SLOWING OF THE SINUS RHYTHM AND THE PAlTERN OF ACTIVATION OF THE SYMPATHETIC NERVOUS SYSTEM DURING HEAD-UP TILT TEST of Cardiology Medical University of The dysautonomic reaction and vasovagal syncope are the most frequently observed types of positive reaction to head-up tilt test (HU’IT. The widely accepted explanation of that reactions is the failure of the autonomic nervous system in dysautonomic and its ‘hyperactivity’ of reflex origin in vasovagal reaction. The slowing of heart rate during vasovagal reaction is commonly more abrupt because of the reflex mechanism. The aim of the study was to assess the activation of autonomic nervous system by means of heart rate variability (HRV) in the time period S-10 minutes after the positive HUTT and the ‘time of slowing’ as a novel parameter describing the course of HLJ’IT Material and methods: The study group consisted of 49 patients (pts) with positive HUTT according to Italian protocol with NTG provocation. In 32 pts vasovagal reaction was diagnosed (group I) and in 17 pts dysautonomic reaction was established (group II). The following parameters were analyzed: time of slowing of heart rate measured as the time from shortest to the longest RR interval and the time and frequency domain parameters of HRV in the 2 minutes time periods: immediately before and between S-10 minutes after the cessation of the HUTT In patients with vasovagal reaction the presence of pauses or escape rhythm was assessed. Results: There were no differences between the studied HRV parameters before the HU’IT The selected results of HRV parameters analysis after the HU’IT and ‘time of slowing’ are shown in the table: In patients with VVS RR pauses or junctional escape rhythm was present in 22 pts. In all studied patients significant negative correlation between time of slowing and the B HRV parameter (I=-0,41 p<O,OO5) was established. The time of slowing correlated with m R R before the HU’IT (r=0,29 p<O,O5). In the patients with dysautonomic reactions the time of slowing correlated only with B before HU’IT (r=O,59 p<O,O2). In the VVS group the time of slowing correlated with m R R before, rMSSD before, pNN50 before, m R R after the study and negatively with B after (I=-0,45 p<O,Ol) and the presence of pauses or escape rhythm (I=-0,44 p<O,O2). Group 1 Group11 P Time of slowing (s) Conclusion: Short time of slowing of heart rate reflecting abrupt vasovagal reaction is connected with signs of sympathetic nervous system activation in the period S-10 minutes after the HUTT NEUROCARDIOGENIC SYNCOPE IN PATIENTS WITH DILATED CARDIOMYOPATHY Background: The prevalence of neurocardiogenic syncope (NCS) in patients (pts) with dilated cardiomyopathy (DCM) is not well known. Due to overall systolic impairment and blunted baroreceptor sensitivity, central mechanisms may be the most important, if not exclusive, pathophysiologic mechanism of NCS in D C M pts. Clomipramine (CLOM) infusion during tilt test seems to be the most appropriate tool to investigate the pathophysiology of NCS in D C M pts, as it is the only challenge drug acting on the central nervous system and has been successfully tested in pts with NCS and preserved cardiac function. The purpose of the study was to investigate if the activation of central serotonergic mechanisms can provoke NCS in D C M pts. Methods: Fifteen pts with D C M and an AICD implanted in the past due to life threatening arrhythmias, (11 men, m e a n age 59.5&9.35 years), were studied. Three (20%) pts were in NYHA class I-II, 7 in class II (47%), and 5 in class III (33%). The m e a n EF was 33&6.1%, LVEDD 64.7&5.7 m m and LVESD 49&7.7 mm. Thirteen pts (874o) were treated with fi-blockers, 13 (87%) with ACE inhibitors, 9 (60%) with diuretics, 5 (33%) with a&rhythmic drugs and 2 (13%) with AT II inhibitors. Seven (47%) pts reported syncopal or presyncopal episodes 35.7&31.5 months after AICD implantation. Arrhythmic causes of syncope or presyncope were excluded by AICD interrogation. All pts underwent a CLOM tilt test after discontinuation of diuretics for 2 days. They were tilted at 60” for 20 min and 5 m g of CLOM were iv infused at the first 5 min of the test. Six pts (40%) had a positive response at the 11.5&5.6 min. The B20 type of positive response was cardioinhibitory in 2 pts and mixed in 4 pts. No differences were found in pts with positive and negative CLOM test in relation to age, EF, NYHA class and drug treatment (except for antiarrhythmia). All pts with positive CLOM test and only 1 with negative CLOM test reported syncope or presyncope. n Pts with syncopeof presyncope Positive test Conclusion: Central serotonergic activation is involved in the pathogenesis of NCS in DCM patients. The possibility that NCS is the cause of a syncopal episode should always be considered when assessing pts with DCM. A14. ABLATION O F ATRIAL F L U T T E R I Al 4 1 USE OF IRRIGATED RADIOFREQUENCY TIP CATHETERS IN ABLATION OF ATRIAL FLUTTER Z. Starek, L. Haman, Z. Csanadi, D. Herman. Fn USvAnq Republic, Fn Hradec Kralove, Czech Republic, University Hungary Fn Kralovske Vinohrady, Prague, Czech Republic, Brno, Czech Hospital, Szeged, Background: Radiofrequency ablation of common atrial flutter requires the creation of a complete transmural ablation line across cavotricuspid region to achieve bidirectional conduction block. Irrigated tip catheters facilitate rapid achievement of this block by creation larger and deeper lesions. The EASTHER registry was organized to collect data about the efficacy of the procedure in small and middle volume centm in Central and Eastern Europe, all using THERMOCOOL’ catheter technology. Methods: EASTHER is a prospective registry (April 2002 - February 2003). 133 consecutive patients (81.1% male, age 59.0*10.4 years, range 30-81 years) with common atria1 flutter were enrolled. Coincidence with atypical flutter was observed in 2.7%. Patients had a history of flutter of 31.0&53.6 months (range l-403) and concomitant AFib was observed in 42.9%. Stmchml heart disease was present in 38.9%. Amount of redo cases was 14%. RF energy was applied during 60 sec. in power-controlled mode at a setting between 40 to 50 W with an average flow rate of 19.0 mumin. Results: Acute success rate, defined as bi-directional block was achieved in 93.1%. Average number of RF applications was 12.0&7.0 (range 2-40) per procedure. Average delivered power varied between an minimum of 36.1&15.1 W till an maximum of 45.3&13.0 W, while the average maximum temperature observed at the same time was varied between 39.0&3.4”C and 45.4&4.O”C. Total procedure time was 100.1&42.7 min (range 20-280 min.) and fluoroscopy time was 15.8&9.6 min. (range 4 - 45 min.) Two serious adverse events were reported. These results are comparable with the literature data published. Conclusions: Irrigated tip catheters are effective and safe in ablation of common atria1 flutter. This technology helps to accelerate and facilitate achievement of bi-directional isthmus block. I Al 4 2 LIMITATIONS OF ABLATION CAVOTRICUSPID ISTHMUS AFTER ATRIAL FLUTTER LINES RECORDINGS BLOCK ASSESSMENT ABLATION FOR Background: Cm-tricuspid isthmus (CTI) block is the goal of typical atria1 flutter (FLTJ ablation. The study of the recorded potentials at the ablation line (AbL) has been proposed, accepting the presence of double potentials (DP) as a marker of block. We analysed the difficulty in the interpretation of DP recording at the Abl line after FLT Abl. Methods: 38 flutter ablation procedures were performed guided by anterior and septal right atrium (RA) activation sequence (AS) pacing from both sides of the AbL and by mapping the AbL 19 patients (P) with a complete study of DP including differential pacing (Dif P) m counter-clockwise and clockwise direction were selected for analysis. A 24-p& catheter allowed lo-12 simultaneous recordings from anterioriseptal RA and Dif P, and a bipolar catheter (2X4 mm) was used for ablation and recording in the CTI. Dif P was performed from low anterior and septal RA near the AbL, and from another level 1-2 cm above. CT1 block: descending pattern in the AS of the opposite RA pacing from both low anterior and septal RA. CT1 conduction: ascending pattern or fusion of activation front. Results: In 18 P, RA AS pacing both sides of the AbL showed bidirectional CT1 block appearance. DP study mapping the AbL were concordant and easy to assess in 15 P with a RA AS suggestive of counter-clockwise CT1 block, 10 P with a RA AS suggestive of clockwise CT1 block, DP study was complex and difficult to analyse even by Dif P, arising doubts of residual clockwise CT1 conduction. In these P, no FLT recurrences occurred after a mean follow-up of 29 month (range 11-48 m). The P with a bidirectional CT1 conduction pattern, the AS and AbL recordings were concordant, and FLT recurred at eighth month Conclusion: In FLT ablation, complexity of electrograms recorded from the CT1 in a quite number of patients, make difficult the study of DP, even with Dif P, being recommended its use combined with RA activation sequences during pacing. The use of a catheter covering septal RA eases the procedure. ATRIAL FLUTTER DUE TO REENTRY FOSSA OVALIS: REENTRANT CIRCUIT AND ABLATION AROUND THE DELINEATION Different reentrant circuits responsible for atypical atria1 flutter (AFTJ have been reported in the right atrium. However, information about circuit delineation and ablation approach of septal AFT is limited. Methods: Reentry around a septal obstacle was found the AFT mechanism at electrohysiological evaluation in 3 (2 females, ages of 64, 81, and 84 years) out of 124 patients with AFT. No patient had significant heart disease except for mild systemic hypertension. This mechanism of AFT presented clinically in all of them and had a cycle length of 205, 340, and 350 ms respectively. This AFT could be induced, entrained with fusion, and terminated by atria1 stimulation in all patients. Activation mapping around the fossa ovalis demonstrated double electrograms spanning through almost the entire AFT cycle length. Postpacing intervals following AFT entrainment by pacing around the fossa ovalis and the subeustaquian isthmus were similar (~20 ms) to or longer than the AFT cycle length respectively in all the patients. Reversal of rotation around the fossa ovalis resulting in AFT with a different activation sequence and similar cycle length to the clinical AFT was demonstrated in two patients. Sequential radiofrequency application from the fossa ovalis to the mid posterior wall of the right atrium, where low electrical activity was recorded prior ablation, terminated the AFT in two patients. Additional radiofrequency application from the fossa ovalis to the superior vena cava was performed in the remaining patient prior to AFT termination following a new radiofrequency application from the fossa ovalis to the right atrium posterior wall. Typical atria1 flutter, as other mechanism of AFT, could be induced in all the patients. Conclusions: Reentry around a septal obstacle, possibly the fossa ovalis, is a distinct mechanism responsible for no isthmus dependent atria1 flutter. This circuit can be ablated by radiofrequency application form the fossa ovalis to the posterior wall of the right atrium. ATYPICAL ATRIAL FLUTTER: USING NON FLUOROSCOPIC ABLATION 3D MAPPING RESULTS Aim: To evaluate the electrophysiological features of atypical atria1 flutter (AFI) and its response to radiofrequency catheter ablation. Methods: Twentyone patients (pts), 13 males and 8 females (mean age 47&25 yrs) with atypical drug refractory AFI, including amiodarone, underwent 3D electroanatomic mapping during clinical arrhythmia. RF ablation was performed using a 4 mm cooled tip catheter targeting conduction isthmuses. Results: The 3D mapping revealed macroreentrant circuits with one or more loops in all pts and allowed to identify isthmuses for ablation. In 6 pts the circuit was located in the left atrium while in the remaining 15 in the right atrium. Two pts presented functional reentry circuits while in the remaining pts the circuits were anatomical. The total number of circuits was 30 for 21 pts. The acute success was obtained in 20121 pts. The abolition of the conduction isthmuses determined arrhythmia interruption in 18121 pts. In two of the remaining 3 pts, AFI interruption was obtained ablating all the conduction isthmuses and was preceded by a change in morphology and cycle length of the arrhythmia. In the last pt the ablation of conduction isthmuses determined only the modification of the arrhythmia which stopped only after administration of flecainide iv. No acute or late complications were observed. During a mean follow up of 14&4 months there were no recurrences. All but one pts were free from ant&rhythmic drugs. Europace Supplements, Vol. 4, December 2003 B21

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Aggelopoulou, N., Livanis, E.G., Kostopoulou, A., Leftheriotis, D., Flevari, P., Theodorakis, G.N., Kremastinos, D.T.H.. A13-6 Neurocardiogenic syncope in patients with dilated cardiomyopathy, EP Europace, 2003, B20-B21, DOI: 10.1016/S1099-5129(03)91578-9