Flecainide in Ventricular Arrhythmias: From Old Myths to New Perspectives

Flecainide is an IC antiarrhythmic drug (AAD) that received in 1984 Food and Drug Administration approval for the treatment of sustained ventricular tachycardia (VT) and subsequently for rhythm control of atrial fibrillation (AF). Currently, flecainide is mainly employed for sinus rhythm maintenance in AF and the treatment of idiopathic ventricular arrhythmias (IVA) in absence of ischaemic and structural heart disease on the basis of CAST data. Recent studies enrolling patients with different structural heart diseases demonstrated good effectiveness and safety profile of flecainide. The purpose of this review is to assess current evidence for appropriate and safe use of flecainide, 30 years after CAST data, in the light of new diagnostic and therapeutic tools in the field of ischaemic and non-ischaemic heart disease.

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The Changing Paradigm in the Treatment of Structural Heart Disease and the Need for the Interventional Imaging Specialist

Interventional Cardiology Review ◽

10.15420/icr.2016:12:2 ◽

2016 ◽

Vol 11 (2) ◽

pp. 135

Author(s):

Nina C Wunderlich ◽

Harald Küx ◽

Felix Kreidel ◽

Ralf Birkemeyer ◽

Robert J Siegel ◽

...

Keyword(s):

Heart Disease ◽

Heart Diseases ◽

Three Dimensional ◽

Structural Heart Disease ◽

Percutaneous Treatment ◽

Interventional Imaging ◽

Key Factor ◽

Structural Heart Diseases ◽

Specialist Standard ◽

Contrast Ventriculography

Percutaneous interventions in structural heart diseases are emerging rapidly. The variety of novel percutaneous treatment approaches and the increasing complexity of interventional procedures are associated with new challenges and demands on the imaging specialist. Standard catheterisation laboratory imaging modalities such as fluoroscopy and contrast ventriculography provide inadequate visualisation of the soft tissue or three-dimensional delineation of the heart. Consequently, additional advanced imaging technology is needed to diagnose and precisely identify structural heart diseases, to properly select patients for specific interventions and to support fluoroscopy in guiding procedures. As imaging expertise constitutes a key factor in the decision-making process and in the management of patients with structural heart disease, the sub-speciality of interventional imaging will likely develop out of an increased need for high-quality imaging.

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Structural heart disease

Drugs in Cardiology ◽

10.1093/med/9780199557462.003.0083 ◽

2010 ◽

pp. 175-190

Author(s):

Juan Carlos Kaski

Keyword(s):

Heart Disease ◽

Valvular Heart Disease ◽

Heart Diseases ◽

Structural Heart Disease ◽

Muscle Disease ◽

Structural Defects ◽

Common Causes ◽

Structural Heart Diseases ◽

Antithrombotic Management ◽

Valve Heart Disease

Valvular heart disease 176 Mitral stenosis 177 Mitral regurgitation 178 Mitral valve prolapse 179 Aortic stenosis 180 Aortic regurgitation 182 Tricuspid disease 184 Pulmonary valve disease 186 Antithrombotic management in valve heart disease 187 Cardiomyopathy 188 The most common causes of 1° structural defects in the heart are valvular heart disease, heart muscle disease (cardiomyopathy), and congenital structural heart diseases. Less commonly, 2° heart damage may be caused by infection....

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Electrophysiological predictors of ventricular tachycardia recurrence in patients with structural heart disease after combined endo-epicardial substrate catheter ablation

European Heart Journal ◽

10.1093/eurheartj/ehab724.0385 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

K A Simonova ◽

R B Tatarskiy ◽

A V Kamenev ◽

V S Orshanskaya ◽

V K Lebedeva ◽

...

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Catheter Ablation ◽

Cycle Length ◽

Low Voltage ◽

Heart Diseases ◽

Structural Heart Disease ◽

Substrate Modification ◽

Structural Heart Diseases ◽

Late Potential

Abstract Background Although there is a tremendous improvement in mapping and ablation techniques over the last decades, the recurrence rate of ventricular tachycardia (VT) in patients with structural heart diseases following endo-epicardial catheter ablation remains high. Purpose To determine predictors of VT recurrence in patients with structural heart disease after combined endo-epicardial radiofrequency (RF) VT ablation. Methods This prospective single-center study included 39 patients (34 men and 5 women, mean age 49.6±16.0 years), who underwent endo-epicardial mapping and ablation of the VT substrate. Etiology of structural heart diseases included: previous myocardial infarction (n=15); non-ischemic cardiomyopathy (n=24: 15 – arrhythmogenic right ventricular cardiomyopathy (ARVC), 6 – myocarditis, 3 – unspecified). First-line epicardial access was performed in 16 patients, as a second approach – in 23 subjects. We evaluated total ventricular myocardial areas, epi- and endocardial areas with bipolar low voltage (<1.5mV), scar area (bipolar <0.5mV), and unipolar low voltage (<5.0mV) and transient (<8.0mV) areas; areas of late potential registration were evaluated. Ratios of transient, low amplite and late-potential areas were calculated for endo- and epicardial surfaces, bipolar and unipolar maps. The following procedural electrophysiology characteristics were considered: inducibility of clinical VT, the number and morphology of induced VT, QRS width on sinus rhythm and VT, tachycardia cycle length, pseudo-delta wave extant and width, internal activation time, intrisicoud deflection time, and RS length. Clinical data such as echocardiography parameters, comorbidity and antiarrhythmic drug therapy were also taken into account. VT recurrences were documented using ICD/CRT-D interrogation, event ECG monitoring. Follow-up included mandatory visits at 6 and 12 months and unscheduled visits. Results Epicardial late potentials were registered in 69% of cases before ablation. Epicardial RF applications were delivered in 67% of patients; while only endocardial RF applications (including cases with intended epicardial substrate modification by endocardial ablation) were present in 28% cases. Non-inducibility of any VT plus abatement of local abnormal electrical activity was achieved in 32 (82%) of cases. The ratio epi/endo bipolar areas <0.5mV was much higher in patients with vs without VT recurrence at 6 months (4.3 (IQR: 2.5; 8.2) vs 0.75 (IQR:0.4; 1.6), P=0.001). A strong negative correlation was found between the induced VT cycle length and the ratio epi/endo bipolar areas <0.5mV: the shorter induced VT cycle length -the larger the area of the epicardial low voltage area (r=−0,52). Conclusion Regardless of epicardial substrate modification, patients with a larger epicardial low voltage area are more likely to have VT recurrence at 6 months after index ablation. A shorter induced VT cycle length is associated with a larger epicardial low-voltage area. FUNDunding Acknowledgement Type of funding sources: None.

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Three-dimensional echocardiography

ESC CardioMed ◽

10.1093/med/9780198784906.003.0088_update_001 ◽

2018 ◽

pp. 438-441

Author(s):

Francesco F. Faletra ◽

Laura A. Leo ◽

Tiziano Moccetti ◽

Mark J. Monaghan

Keyword(s):

Heart Disease ◽

Imaging System ◽

Heart Diseases ◽

Three Dimensional ◽

Structural Heart Disease ◽

Structural Heart Diseases ◽

Dimensional Echocardiography ◽

Three Dimensional Echocardiography ◽

Established Role

Three-dimensional echocardiography (3DE) certainly represents one of the major innovations of the last decades. Nowadays, 3DE has achieved a well-established role in many fields of cardiovascular diseases. This chapter discusses the contribution of 3DE towards a more precise quantitative assessment of cardiac chambers, in refining the diagnosis of structural heart diseases, and in guiding catheter-based structural heart disease procedures. The last section discusses the evolving role of a novel imaging system that specifically fuses fluoroscopy and two/three-dimensional echocardiography on one screen and represents a new exciting approach to image guidance for structural heart disease interventions.

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Three-dimensional echocardiography

10.1093/med/9780198784906.003.0088 ◽

2018 ◽

Author(s):

Francesco F. Faletra ◽

Laura A. Leo ◽

Tiziano Moccetti ◽

Mark J. Monaghan

Keyword(s):

Heart Disease ◽

Imaging System ◽

Heart Diseases ◽

Three Dimensional ◽

Structural Heart Disease ◽

Structural Heart Diseases ◽

Dimensional Echocardiography ◽

Three Dimensional Echocardiography ◽

Established Role

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The Place of Antiarrhythmic Drugs and Rhythm Control in the Treatment of Atrial Fibrillation

European Cardiology Review ◽

10.15420/ecr.2009.5.1.36 ◽

2009 ◽

Vol 5 (1) ◽

pp. 36

Author(s):

Philippe Chevalier ◽

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Antiarrhythmic Drugs ◽

Structural Heart Disease ◽

Rhythm Control ◽

Disease Course ◽

Drug Trials ◽

Cardiac Safety ◽

Selection Of

Atrial fibrillation (AF) is the most common arrhythmia, with incidence increasing with age and a ranging severity of symptoms. The arrhythmia, perpetuated from electrical, functional and structural remodelling by AF itself, can ultimately lead to increased morbidity and mortality. Emerging evidence appears to support the initiation of rhythm control, particularly early on in the disease course. Antiarrhythmic drugs have proved useful in inducing and maintaining cardioversion, but treatment varies depending on the degree of structural heart disease. Drug trials and selection of therapy have historically focused largely on cardiac safety. Class Ic drugs have demonstrated safety and efficacy in patients with little to no structural heart disease, yet their use continues to be superseded by the use of other drugs, especially amiodarone, which carries significant risks of extracardiac effects and end-organ toxicities. This article discusses the role of sinus rhythm control and antiarrhythmic drugs in AF, with an emphasis on patients exhibiting no or minimal structural heart disease and the importance of selecting an appropriate antiarrhythmic drug, taking into account arrhythmia burden, presence of concurrent cardiovascular disease and severity and, most importantly, the safety of the drug therapy.

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Vernakalant in Atrial Fibrillation: A Relatively New Weapon in the Armamentarium Against an Old Enemy

Drug Target Insights ◽

10.1177/1177392819861114 ◽

2019 ◽

Vol 13 ◽

pp. 117739281986111 ◽

Cited By ~ 3

Author(s):

Antoine Kossaify

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Structural Heart Disease ◽

Rhythm Control ◽

Disease Class ◽

Recent Onset ◽

Comprehensive Management ◽

Class Iib ◽

Pharmacological Cardioversion ◽

Onset Atrial Fibrillation

Atrial fibrillation is the most common sustained cardiac arrhythmia, and its prevalence is increasing with age; also it is associated with significant morbidity and mortality. Rhythm control is advised in recent-onset atrial fibrillation, and in highly symptomatic patients, also in young and active individuals. Moreover, rhythm control is associated with lower incidence of progression to permanent atrial fibrillation. Vernakalant is a relatively new anti-arrhythmic drug that showed efficacy and safety in recent-onset atrial fibrillation. Vernakalant is indicated in atrial fibrillation (⩽7 days) in patients with no heart disease (class I, level A) or in patients with mild or moderate structural heart disease (class IIb, level B). Moreover, Vernakalant may be considered for recent-onset atrial fibrillation (⩽3 days) post cardiac surgery (class IIb, level B). Although it is mainly indicated in patients with recent-onset atrial fibrillation and with no structural heart disease, it can be given in moderate stable cardiac disease as alternative to Amiodarone. Similarly to electrical cardioversion, pharmacological cardioversion requires a minimal evaluation and cardioversion should be included in a comprehensive management strategy for better outcome.

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340 Is catheter ablation of atrial fibrillation worthwhile in patients with congestive heart failure and concurrent structural heart disease?

EP Europace ◽

10.1016/s1099-5129(05)80201-6 ◽

2005 ◽

Vol 7 ◽

pp. 68-69

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Congestive Heart Failure ◽

Heart Disease ◽

Catheter Ablation ◽

Structural Heart Disease

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Monomorphic Ventricular Arrhythmias in Athletes

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2019.19.3 ◽

2019 ◽

Vol 8 (2) ◽

pp. 83-89 ◽

Cited By ~ 3

Author(s):

Jeffrey J Hsu ◽

Ali Nsair ◽

Jamil A Aboulhosn ◽

Tamara B Horwich ◽

Ravi H Dave ◽

...

Keyword(s):

Heart Disease ◽

Ventricular Arrhythmias ◽

Comprehensive Evaluation ◽

Arrhythmogenic Right Ventricular Cardiomyopathy ◽

Sports Participation ◽

Structural Heart Disease ◽

Competitive Sports ◽

Ventricular Cardiomyopathy ◽

Electrical Heart Disease ◽

Increase Risk

Ventricular arrhythmias are challenging to manage in athletes with concern for an elevated risk of sudden cardiac death (SCD) during sports competition. Monomorphic ventricular arrhythmias (MMVA), while often benign in athletes with a structurally normal heart, are also associated with a unique subset of idiopathic and malignant substrates that must be clearly defined. A comprehensive evaluation for structural and/or electrical heart disease is required in order to exclude cardiac conditions that increase risk of SCD with exercise, such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Unique issues for physicians who manage this population include navigating athletes through the decision of whether they can safely continue their chosen sport. In the absence of structural heart disease, therapies such as radiofrequency catheter ablation are very effective for certain arrhythmias and may allow for return to competitive sports participation. In this comprehensive review, we summarise the recommendations for evaluating and managing athletes with MMVA.

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Advanced interatrial block precedes atrial fibrillation and stroke. The prospective interatrial Block And Yearly EventS (BAYES) registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.0485 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Martinez-Selles ◽

R Elosua ◽

M Ibarrola ◽

M De Andres ◽

P Diez-Villanueva ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Sinus Rhythm ◽

Structural Heart Disease ◽

P Wave ◽

Wave Duration ◽

P Wave Duration ◽

Previous Diagnosis ◽

Surface Ecg ◽

Interatrial Block

Abstract Background Advanced interatrial block (IAB), prolonged and bimodal P waves in surface ECG inferior leads, is an unrecognized surrogate of atrial dysfunction and a trigger of atrial dysrhythmias, mainly atrial fibrillation (AF). Our aim was to prospectively assess whether advanced IAB in sinus rhythm precedes AF and stroke in elderly outpatients with structural heart disease, a group not previously studied. Methods Prospective observational registry that included outpatients aged ≥70 years with structural heart disease and no previous diagnosis of AF. Patients were divided into three groups according to P-wave characteristics. Results Among 556 individuals, 223 had normal P-wave (40.1%), 196 partial IAB (35.3%), and 137 advanced IAB (24.6%). After a median follow-up of 694 days; 93 patients (16.7%) developed AF, 30 stroke (5.4%), and 34 died (6.1%). Advanced IAB was independently associated with AF (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.7–5.1, p<0.001), stroke (HR 3.8, 95% CI 1.4–10.7, p=0.010), and AF/stroke (HR 2.6, 95% CI 1.5–4.4, p=0.001). P-wave duration (ms) was independently associated with AF (HR 1.05, 95% CI 1.03–1.07, p<0.001), AF/stroke (HR 1.04, 95% CI 1.02–1.06, p<0.001), and mortality (HR 1.04, 95% CI 1.00–1.08, p=0.021). Conclusions The presence of advanced IAB in sinus rhythm is a risk factor for AF and stroke in an elderly population with structural heart disease and no previous diagnosis of AF. P-wave duration was also associated with all-cause mortality. Figure. Age- and sex-adjusted linear and non-linear association between P-wave duration (msec) and atrial fibrillation (A), stroke (B), and atrial fibrillation or stroke (C) risk. Results of a generalized additive model with spline smoothing functions and 4 degrees of freedom. Figure 1. Kaplan-Meyer curves of survival free of atrial fibrillation (A), stroke (B) and atrial fibrillation or stroke (C) in patients with normal P-wave, partial interatrial block (IAB) and advanced IAB. Funding Acknowledgement Type of funding source: None

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