Browsing by Author "Francisco, A. R."
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- Association of circulating levels of collagen turnover biomarkers with the phenotype in a population with sarcomeric hypertrophic cardiomyopathyPublication . Brito, D. A.; Pedro, M. M. Mendes; Calisto, C.; Pires, R.; Moldovan, O.; Silva, D.; Francisco, A. R.; Guimarães, T.; Pinto, Fausto J.; Madeira, H. C.Background and aim: In patients (pts) with sarcomeric hypertrophic cardiomyopathy (sHCM) and left ventricular hypertrophy (LVH), cardiac fibrosis and diastolic dysfunction are typical features. Studies suggest that collagen turnover (ColT) is increased in sHCM, but its clinical significance and relationship with cardiac LVH and function is doubtful. In order to address this question, we evaluated the association of circulating levels of biomarkers of ColT (bioColT) with clinical, morphological and functional echocardiographic (echo) features. Methods: Thirty nine sHCM pts (49±17y, 54% female) major echo criteria and positive genotype, nondilated left ventricle (LV) and preserved ejection fraction were enrolled, after exclusion of conditions that might influence circulating levels of bioColT. On the same day, clinical evaluation, ECG, echo study and laboratorial tests (including measurement of 6 bioColT related to collagen synthesis and degradation PICP, PIIINP, CITP, MMP1, MMP9 and TIMP) were performed. Associations were looked for between bioColT and: 1) structural and functional parameters and indices of systolic and diastolic function evaluated by echo/tissue Doppler imaging; 2) current NYHA functional class, hospitalization due to sHCM and nonsustained ventricular tachycardia (NSVT) on Holter, during the preceding year. Associations were considered statistically significant if p<0.05. Results: Controlling for age and body mass index, TIMP1 levels (a measure of tissue inhibition of collagentype 1 degradation) correlated with LV mass index (LVMI; r=0.49), septal thickness (ST; r=0.43), maximal wall thickness (MWT; r=0.44), LVWT score (r=0.44), lateral E' (r=−0.49), septal E/E' (r=0.55), and lateral E/E' (r=0.64); and CITP (a measure of collagentype I degradation) levels correlated with LVMI (r=0.38), ST (r=0.36), MWT (r=0.38), LVWT score (r=0.37) and lateral E' (r=−0.45). No correlations were found between PICP or other bioColT levels and echodata. Only TIMP1 levels were significantly increased in the presence of symptoms and hospitalizations (p=0.031). None bioColT was associated with the occurrence of NSVT on Holter. Conclusions: In pts with sHCM and LVH, collagen turnover is active, and acts in favor of a predominance of inhibition of collagen degradation over collagen degradation. Both, TIMP1 and CITP levels were associated with the degree and extension of LVH, but only TIMP1 levels were also positively associated with echoindices of diastolic dysfunction, left ventricular filling pressures and morbidity. Therefore, it appears in this series to be the biomarker of choice amongst ColT biomarkers, for future research.
- Difference of late potentials detected by signal-averaged ECG in patients with spontaneous or drug-induced type 1 electrocardiogram pattern of Brugada syndromePublication . Agostinho, J. A. Ribeiro; António, P.; Dias, N. Cortez; Silva, G. Lima da; Guimarães, T.; Francisco, A. R.; Gonçalves, I.; Paixão, A.; Paiva, S.; Carpiteiro, L.; Pinto, Fausto J.; Sousa, J. deIntroduction: Brugada syndrome (BrS) patients (pts) with spontaneous type 1 electrocardiographic (ECG) pattern (sT1ECGp) have a greater arrhythmic risk compared to those with fleicainide-induced type 1 ECG pattern (iT1ECGp). However, when the analysis is restricted to asymptomatic pts, the type 1 spontaneous pattern loses its independent prognostic value. Late potentials (LP) obtained by signal-averaged ECG (SA-ECG) are associated with regions of delayed myocardial depolarization and consequent abnormal electrical conduction. There is a higher prevalence of LP obtained by SA-ECG in pts with BrS and their detection showed a strong prognostic predictor value in several studies. Objective: To evaluate the presence of LP by SA-ECG in pts with BrS and assess differences between patients with spontaneous or drug-induced type 1 ECG pattern. Methods: This was a single-center prospective study of consecutive pts diagnosed with BrS, including sT1ECGp and iT1ECGp. The patients were submitted to SA-ECG study to detect LP, with determination of the duration of filtered QRS (fQRS), root-mean-square voltage of the terminal 40ms of the filtered QRS (RMS40) and the duration of low-amplitude signal (<40 μV) in the terminal part of the filtered QRS complex (LAS40), using conventional and right modified leads. The presence of LP was considered positive when ≥2 of the following were present: fQRS ≥114 ms, RMS40 <20 μV or LAS40 ≥38ms. The results were displayed using medians and interquartile ranges, obtained using the Mann-Whitney test. Results: The presence of LP by SA-ECG was studied in 29 pts (75.9% male, mean age 44±12 years), 18 with sT1ECGp and 11 iT1ECGp. Only 3 pts (10.3%) had symptoms related with BrS (unexplained syncope) and none had documented malignant ventricular arrhythmias. Known or potential pathogenic mutations were identified in 5 pts (17.2%). The presence or absence of LP showed no statistically significant difference according to clinical, electrocardiographic or genetic characteristics of the pts. However, in conventional leads, pts with sT1ECGp showed significantly higher values of fQRS and lower values of RMS40 [fQRS 108 (103–112) vs. 97 (89–103), p=0.016; RMS40 19 (10–22) vs. 22 (16–40), p=0.028]. In addition, in modified right leads, pts with sT1ECGp had significantly higher values of fQRS, lower RMS40 and longer LAS40 [fQRS 108 (101 -111) vs. 98 (89–102), p=0.0005; RMS40 15 (11–21) vs. 25 (18–33), p=0.007; LAS40 41 (34–49) vs. 31 (28- 39), p=0.007]. Conclusion: Patients with the spontaneous type 1 electrocardiographic (ECG) pattern revealed a higher detection of late potentials, which may partially explain the higher arrhythmogenic risk classically described in this subgroup of BrS patients.
- Implantation of ICD and CRT-D in the elderly population : will it be a limiting factor?Publication . Ricardo, I. Aguiar; Dias, Nuno Cortez; Marques, P.; Magalhães, A.; Gonçalves, I.; Agostinho, J.; Silva, G. Lima da; Guimarães, T.; Santos, I.; Francisco, A. R.; Bernardes, A.; Costa, H. C.; Carpinteiro, L.; Pinto, J. Fausto; Sousa, J. deIntroduction: Implantable cardioverter defibrillator (ICD) and cardiac resynchronization (CRT-D) implantation in elderly patients is effective in preventing sudden death, although limited by the natural shorter life expectancy. The different device brands present very variable survival estimates and it has been discussed the availability of less expensive, less longevity generators for the elderly population. Purpose: To determine if the expected survival rate in the elderly patient population (≥75 years) should influence the selection of the desired longevity of the devices. Methods: A retrospective single-center study of consecutive patients who underwent implantation of ICD or CRT-D after November 1995. The mean survival of patients undergoing 1st implant or generator replacement at an advanced age (≥75 years) was evaluated and compared to the effective longevity of the generators. Cumulative survival analyzes using the Kaplan Meier method were used. Results: A total of 1312 cardiac devices were implanted, of which 163 generators in elderly patients (53% CDI and 47% CRT-D). Of these, 77% corresponded to the 1st implant. The median survival after implantation of the elderly patients was 6.8 years, not differing according to the type of device (Log-rank P = NS). The median longevity of CDI generators was 6.9 years, in line with the expected survival of elderly patients. Conversely, the median CRT-D longevity was 5.8 years, lower than the average survival of the elderly. For this reason, 21% of these CRT-D carriers were subsequently subjected to generator replacement, due to battery exhaustion. Conclusion: The effective longevity of ICDs is in agreement with an expected survival of elderly patients, for which it will not make sense to provide generators of shortened longevity for this population. The effective longevity of the CRTs is lower than the survival expectancy of the treatments, so that, paradoxically, generators with increased longevity should be favored.
- One stent versus two stents for distal LM PCI: insights from the experience of a high volume centerPublication . Santos, R.; Menezes, Miguel Nobre; Carrilho-Ferreira, Pedro; Calhaz-Jorge, Carlos; Francisco, A. R.; Oliveira, Eduardo Infante de; Duarte, J.; Cardoso, P.; Torres, D.; Aguiar-Ricardo, Inês; Rigueira, Joana; Rodrigues, Tiago; Ferreira, Afonso Nunes; Pinto, Fausto J.; Canas da Silva, PedroDistal left main (LM) PCIremains a challenge. One of the most debated issues is whether to use a single vs 2 stent provisional strategy. While most studies and guidelines favour a single stent strategy, the recent DK-CRUSH V trial has shown better results with a 2 stent strategy.
- Prognostic impact of invasive hemodynamic evaluation in patients with pulmonary arterial hypertensionPublication . Ricardo, I. Aguiar; Plácido, R.; Gonçalves, I.; Agostinho, J.; Silva, G. Lima da; Menezes, M. Nobre; Francisco, A. R.; Santos, R.; Ferreira, A.; Guimarães, T.; Martins, S. Robalo; Pinto, J. FaustoIntroduction: Invasive hemodynamic evaluation is a fundamental diagnostic method in patients with pulmonary hypertension (PH). However, its prognostic value in this group of patients is not fully established. Purpose: To assess the prognostic impact of hemodynamic parameters of right catheterization in patients with PH. Methods: Prospective observational study of patients with PH undergoing right and left catheterization for diagnostic confirmation and functional evaluation during vasoreactivity test. Only patients with mean pulmonary arterial pressure (PAP) >25 mmHg considered not secondary to left heart disease were included. A basal evaluation of the conventional hemodynamic parameters, left and right ventricular function indexes, pulmonary and systemic vascular resistance indexes were performed and they were re-evaluated during vasoreactivity test. The parametres were analysed and related with overall mortality and with cardiac death or hospitalization during clinical follow-up by Multivariate regression analysis of Cox. Results: A total of 68 patients were included (71% females, mean age 53±17 years), 81% of whom were from group 1 (NICE) and 15% from group IV. The mean value of mean pulmonary artery pressure was 47±16mmHg and mean right atrial pressure was 11±7mmHg. During a median follow-up of 34 months, 7 patients (10%) died and 25 (37%) were hospitalized for heart failure. Of all hemodynamic parameters, the only independent predictor of mortality was the mean right atrial pressure, for each 1mmHg rise, mortality risk increased by 12% (hazard ratio (HR): 1, 12; 95% CI 1.02–1.23; p=0.018) and the risk of death or hospitalization for cardiac causes was 17% (HR: 1.17, 95% CI: 1.00–1.37, P=0.050). The prognosis was not influenced by the demonstration of pulmonary arterial vasoreactivity, magnitude of PAP elevation or pulmonary vascular resistance. Conclusion: In patients with PH, invasive hemodynamic evaluation offers an addictional value in prognostic stratification. In particular, measurement of mean right atrial pressure has been shown to be an independent predictor of mortality. On the other hand, other parameters such as pulmonary arterial vasoreactivity, although important in the definition of the therapeutic strategy, did not have an impact on the risk of death or hospitalization.
- Utility of pace-matching mapping in the ablation of idiopathic ventricular tachyarrhythmiasPublication . Gonçalves, I. S. S.; Silva, G. L.; Agostinho, J. R.; Guimarães, T.; Francisco, A. R.; Ricardo, I. A.; Rigueira, J.; Quaresma, J.; Barreiros, C.; Dias, Nuno Cortez; Carpinteiro, L.; Sousa, J.Introduction: The electroanatomical mapping of idiopathic ventricular tachyarrhythmias (iVT) - premature ventricular contractions (PVC) and idiopathic ventricular tachycardia (VT) - is dependent on the recording of spontaneous PVC or induction of the clinical VT during the procedure to obtain the iVT activation map. The presence of infrequent and non-inducible iVT may preclude ablation. Pace-matching (PM) mapping of the anatomical region on interest, using the PaSo™ algorithm, may allow to circumvent this limitation. Purpose: Determination of the utility of the PaSo™pace-matching mapping for iVT ablation Methods: A single-center retrospective study was made, with inclusion of consecutive patients undergoing iVT ablation between October 2013 and October 2016. It was collected electroanatomical data, including the highest correlation obtained by PM (PaSo™). Success of the procedure was assessed (defined as the elimination of spontaneous PVC during the electrophysiological study and non-inducible iVT at the end) and the ability of the PaSo™ pace-matching mapping to guide effective ablation was determined. Results: 29 patients were studied (62.1% women, mean age 52.8±14.7 years). 65.5% presented symptomatic frequent PVC and 34.5% VT. The most frequent anatomic origin was the right ventricular outflow tract (58.6%), followed by the left coronary cusp (20.7%), mitro-aortic continuity (13.8%) and papillary muscles (6.9%). The ablation was successful (PVC elimination during the procedure) in 75.9% of the cases. In 79.3% of the cases it was possible to obtain an activation map; in 20.7% (6 cases) it was only possible to obtain a pace-matching map, because ocurred suppression of PVC during the procedure, and success was achieved in 5 of these cases. There was no relationship between success and anatomical region of origin of the iVT. The mean value of the better pace-matching correlation was 94.45% ± 3.95%, being significantly higher when the zone of interest was located in the right ventricle (95.71±3.23 vs. 92.68±4.3, p=0.04). There was a positive and significant association between the PaSo™ correlation value and success (r=0.554; p=0.007). Significantly higher correlations were observed in successful ablations [95.9% vs 92%; p=0.006), and the PaSo™ correlation value was a good predictor of success (AUC: 0.874, 95% CI 0.74–1.0, p=0.003). The pace-matching threshold of 93.55% predicted ablation success with 86.4% sensitivity and 85.7% specificity. Conclusion: In patients with iVT, pace-matching mapping provides a suitable method for performing ablation procedure, and it is essential in patients where spontaneous suppression of PVC occurs during the procedure. The achievement of a pace-matching correlation>93.55% conveniently identifies the dysrhythmic focus, allowing increasing of ablation success.