Miguel Valderrábano - Academia.edu (original) (raw)

Papers by Miguel Valderrábano

Journal of Atrial Fibrillation, Feb 1, 2020

Marshall (VOM-EI) has been proposed as a potentially synergistic adjunctive therapeutic strategy ... more Marshall (VOM-EI) has been proposed as a potentially synergistic adjunctive therapeutic strategy for AF . The aim of this study is to investigate whether a VOM-EI translates into an improved rhythm control in paroxysmal AF, and whether the technique chosen for the PVI (RF or CB) has any influence when combined with a VOM-EI. Patients 44 to 82 years of age who had experienced multiple episodes of AF within the previous 6 months were consecutively enrolled in the study. Patients were excluded if their left atrium (LA) was >55 mm in diameter, or if there was evidence of any LA thrombus. Further exclusion criteria included unstable angina, myocardial infarctions within the previous 6 months, percutaneous transluminal coronary angioplasty within the previous 6 months, an ejection fraction of

Heart Rhythm, Mar 1, 2019

Background: Imaging guidance for left atrial appendage (LAA) closure (LAAC), conventionally consi... more Background: Imaging guidance for left atrial appendage (LAA) closure (LAAC), conventionally consists of transesophageal echocardiography (TEE) and fluoroscopy under general anesthesia (GA). Intracardiac echocardiography (ICE) can eliminate the need for GA, and expedite procedural logistics, and reduce the patient experience to a simple venous puncture. Objective: To define optimal ICE views and compare procedural parameters and cost of ICE vs TEE during LAAC with the Watchman device. Optimal ICE views of the LAA for Watchman implant were delineated using Carto-Sound and 3D rendition of the LAA in 6 patients. Procedural and financial parameters of 104 consecutive patients with standard indications for LAAC undergoing Watchman implant using ICE guidance through a single trans-septal puncture (n=53, 51%) were compared with those of TEEguided implants (n=51, 49%) in 3 centers. Results: Clinical characteristics were similar between the two groups. Total in-room, turnaround and fluoroscopy times were all shorter using ICE (p<0.05) under local anesthesia compared to the TEE group. Implant success was 100% in both groups without peri-device leaks or procedural complications. Follow-up TEE showed no significant peri-device leak in both groups. Total hospital charges for ICE with local anesthesia vs TEE were similar as were total hospital direct and indirect costs. Professional fees were significantly lower with ICE and local anesthesia than with TEE as the charge of anesthesia staff was avoided.

Heart Rhythm, Aug 1, 2012

Background-Treatment of perimitral flutter (PMF) requires bidirectional mitral isthmus (MI) block... more Background-Treatment of perimitral flutter (PMF) requires bidirectional mitral isthmus (MI) block, which can be difficult with radiofrequency ablation (RFA). The vein of Marshall (VOM) is located within the MI. Objective-To test whether VOM ethanol infusion could help achieve MI block. Methods-Perimitral conduction was studied in patients undergoing ablation of atrial fibrillation (AF). Group 1 included 50 patients with a previous AF ablation undergoing repeat ablation, 30 of which had had MI ablation. Spontaneous (8/50) or inducible PMF (21/50) was confirmed by activation mapping. Group 2 included 21 patients undergoing de novo VOM ethanol infusion. The VOM was cannulated with a quadripolar catheter for pacing and with an angioplasty balloon to deliver up to four 1mL infusions of 98% ethanol. Voltage maps were created before and after VOM ethanol. Bidirectional MI block was verified by differential pacing. RFA times required to achieve it were assessed. Results-In Group 1, VOM ethanol infusion acutely terminated PMF in 5/29 patients. RFA needed to achieve bidirectional MI block was 2.2±1.6 min. Presence of PMF or previous MI ablation did not affect RFA times. In Group 2, RFA needed to achieve bidirectional MI block was 2.0±1.6 min (p=NS). Five patients had bidirectional MI block achieved solely by VOM ethanol without RFA. In both groups, ablation after VOM ethanol was required in the annular aspect of the MI. There were no acute complications. ethanol infusion is useful in the treatment of PMF and assists in reliably achieving bidirectional MI block.

Methodist DeBakey cardiovascular journal, 2013

Ventricular tachyarrhythmias are common in patients with congestive heart failure. The clinical p... more Ventricular tachyarrhythmias are common in patients with congestive heart failure. The clinical presentation ranges from an asymptomatic incidental electrocardiographic finding to palpitations, syncope, and sudden cardiac death. Although implantable cardioverter defibrillators successfully prevent sudden cardiac death associated with ventricular fibrillation and ventricular tachycardia, recurrent implantable cardioverter defibrillators shocks remain a clinical management challenge. In this review, we discuss management strategies of ventricular tachycardia in congestive heart failure, including drug therapy, radiofrequency catheter ablation (RFCA), and recent RFCA advances.

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Heart Rhythm, Oct 1, 2012

Arteriosclerosis, Thrombosis, and Vascular Biology, 2015

Background: Clinical implications of detecting subclinical coronary artery disease (CAD) in patie... more Background: Clinical implications of detecting subclinical coronary artery disease (CAD) in patients with atrial fibrillation (AF) are unclear. Methods: A total of 430 AF patients (age 63 ± 10 y, 65% male, 62% hypertensive, 16% diabetic, 42% dyslipidemic) without known CAD undergoing pre-procedural CT for catheter ablation were included. We evaluated the change in: 1) numbers of patients with CACS-diagnosed CAD who could potentially be on statin. 2) CHA2DS2-VASc score after incorporating CACS>100 (related to increased risk of stroke) into the original definition of vascular diseases who could potentially be on anticoagulants. Results: 1) Prevalence of subclinical CAD (CACS>0) was 74% (319/430) and 25% (106/430) had CACS>100. There were 62% (267/430) who were not on statin. Of these patients, 71% (190/267) had subclinical CAD while 21% (34/163) of statin users had CACS of 0. 2) The median original CHA2DS2-VASc score was 2. After incorporating CACS>100 into the original sc...

Information about reprints can be found online at: Reprints: document. Answer Permissions and Rig... more Information about reprints can be found online at: Reprints: document. Answer Permissions and Rights Question andunder Services. Further information about this process is available in the permission is being requested is located, click Request Permissions in the middle column of the Web page Clearance Center, not the Editorial Office. Once the online version of the published article for which can be obtained via RightsLink, a service of the CopyrightCirculation: Arrhythmia and Electrophysiologyin Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions: by guest on April 28,

European Cardiology Review, 2021

In this review, the authors describe evolving alternative strategies for the management of AF, fo... more In this review, the authors describe evolving alternative strategies for the management of AF, focusing on non-invasive and percutaneous autonomic modulation. This modulation can be achieved – among other approaches – via tragus stimulation, renal denervation, cardiac afferent denervation, alcohol injection in the vein of Marshall, baroreceptor activation therapy and endocardial ganglionated plexi ablation. Although promising, these therapies are currently under investigation but could play a role in the treatment of AF in combination with conventional pulmonary vein isolation in the near future.

Surgical arrhythmia ablation techniques can achieve epicardial transmural lesions but require a c... more Surgical arrhythmia ablation techniques can achieve epicardial transmural lesions but require a combination of surgical access and endoscopic approaches. We sought to adapt a surgical ablation catheter to a percutaneous subxyphoid approach. The EpiSense nContact (Epi) is a surgical ablation catheter that contains a 3-cm ablation coil, an open irrigation system, and a suction mechanism to maintain tissue contact. Four sensing electrodes were added to the ablation coil to allow monitoring of electrograms. Six pigs were used for the study. A subxyphoid pericardial puncture was performed to advance a wire into the pericardial space. The subcutaneous tissue was dilated with a 165 cm angioplasty balloon to advance the Epi catheter into the pericardium without endoscopy or surgical tools. Manipulation was achieved by snaring and looping the wire over which the Epi catheter was advanced, or by positioning the wire across the transverse sinus to deliver atrial lesions. The catheter position ...

Methodist DeBakey Cardiovascular Journal, 2019

A 79-year-old man with an implantable cardiac defibrillator (ICD) experienced three ICD discharge... more A 79-year-old man with an implantable cardiac defibrillator (ICD) experienced three ICD discharges on the same day. The ICD had been implanted because of a history of ischemic cardiomyopathy with a previous, silent myocardial infarction (MI) and depressed ejection fraction (EF). He also had history of paroxysmal atrial fibrillation and hypertension. Prior to the ICD discharges he felt "uneasy," but did not faint. He decided to go to a local emergency department. The patient denied chest pain, dyspnea, or near syncope. He gave a history of a remote appropriate ICD discharge for sustained ventricular tachycardia (VT) and was currently taking amiodarone.

Methodist DeBakey Cardiovascular Journal, 2020

JACC: Clinical Electrophysiology, 2018

OBJECTIVES This study aimed: 1) to determine the voltage correlation between sinus rhythm (SR) an... more OBJECTIVES This study aimed: 1) to determine the voltage correlation between sinus rhythm (SR) and atrial fibrillation (AF)/atrial flutter (AFL) using multielectrode fast automated mapping; 2) to identify a bipolar voltage cutoff for scar and/ or low voltage areas (LVAs); and 3) to examine the reproducibility of voltage mapping in AF. BACKGROUND It is unclear if bipolar voltage cutoffs should be adjusted depending on the rhythm and/or area being mapped. METHODS High-density mapping was performed first in SR and afterward in induced AF/AFL. In some patients, 2 maps were performed during AF. Maps were combined to create a new one. Points of <1 mm difference were analyzed. Correlation was explored with scatterplots and agreement analysis was assessed with Bland-Altman plots. The generalized additive model was also applied. RESULTS A total of 2,002 paired-points were obtained. A cutoff of 0.35 mV in AFL predicted a sinus voltage of 0.5 mV (95% confidence interval [CI]: 0.12 to 2.02) and of 0.24 mV in AF (95% CI: 0.11 to 2.18; specificity [SP]: 0.94 and 0.96; sensitivity [SE]: 0.85 and 0.75, respectively). When generalized additive models were used, a cutoff of 0.38 mV was used for AFL for predicting a minimum value of 0.5 mV in SR (95% CI: 0.5 to 1.6; SP: 0.94, SE: 0.88) and of 0.31 mV for AF (95% CI: 0.5 to 1.2; SP: 0.95, SE: 0.82). With regard to AF maps, there was no change in the classification of any left atrial region other than the roof. CONCLUSIONS It is possible to establish new cutoffs for AFL and/or AF with acceptable validity in predicting a sinus voltage of <0.5 mV. Multielectrode fast automated mapping in AFL and/or AF seems to be reliable and reproducible when classifying LVAs. These observations have clinical implications for left atrial voltage distribution and in procedures in which scar distribution is used to guide pulmonary vein isolation and/or re-isolation. (J Am Coll Cardiol EP

Journal of atrial fibrillation

Left atrial appendage (LAA) exclusion strategies are increasingly utilized for stroke prevention ... more Left atrial appendage (LAA) exclusion strategies are increasingly utilized for stroke prevention in lieu of oral anticoagulants. Reductions in bleeding risk and long-term compliance issues bundled with comparable stroke prevention benefits have made these interventions increasingly attractive. Unfortunately, healthcare funding remains limited. Comparative cost economic analyses are therefore critical in optimizing resource allocation. In this review we seek to discourse the cost economics analysis of LAA exclusion over available therapeutic alternatives (warfarin and the new oral anticoagulants (NOACs)). .

Circulation, Nov 25, 2014

Introduction: The aim of this study was to examine prevalence, risk factors and impact on mortali... more Introduction: The aim of this study was to examine prevalence, risk factors and impact on mortality of new-onset atrial arrhythmia (AA) after isolated lung transplantation. Hypothesis: Occurence of postoperative AA is associated with lower survival after lung transplantation. Methods: This is a retrospective observational study of consecutive isolated lung transplant recipients. AA was defined as atrial fibrillation or atrial flutter. A total of 324 cases were identified. Patients with known history of AA were excluded (n=31). Logistic regression and Kaplan Meier analysis were utilized to evaluate potential risk factors and impact of AA on mortality. Results: The final cohort comprised of 293 cases. Mean age was 57 ±13 years. Primary lung pathologies were Obstructive diseases (26%; 77/293), Vascular diseases (2%; 6/293), Cystic fibrosis (7%; 21/293) and Restrictive diseases (65%; 189/293). Prevalence of AA post transplantation was 31 %(90/293) with a bimodal distribution of onset. The highest prevalence o...

JACC: Cardiovascular Imaging, 2016

OBJECTIVES The goal of this study was to evaluate the diagnostic performance of a comprehensive, ... more OBJECTIVES The goal of this study was to evaluate the diagnostic performance of a comprehensive, multicomponent cardiac magnetic resonance (CMR) study for assessment of left atrial (LA) and left atrial appendage (LAA) thrombus. BACKGROUND Pre-operative evaluation for pulmonary vein isolation (PVI) typically requires tomographic imaging to define pulmonary venous anatomy and transesophageal echocardiogram (TEE) to assess for the presence of LA/LAA thrombus. CMR is increasingly being used to define pulmonary venous anatomy before PVI. Limited data are available on the utility of a multicomponent CMR protocol in assessing LA/LAA thrombus. METHODS We studied patients who underwent multicomponent CMR for evaluation of pulmonary venous anatomy before PVI and underwent TEE within 7 days. LA and LAA thrombi were evaluated by using CMR as follows: 1) cine-CMR; 2) contrast-enhanced magnetic resonance angiography; and 3) equilibrium phase delayed enhancement (DE) CMR with a long inversion time (TI) of 600 ms (long TI DE-CMR). Components of the CMR study were evaluated for diagnostic performance for detection of LA or LAA thrombus using TEE as the reference standard. RESULTS During the study period, 261 patients were assessed. The median CHA 2 DS 2 VASc (congestive heart failure, hypertension, age $75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category) score was 2, and 73.6% of patients were undergoing anticoagulation therapy. CMR and TEE were performed within 1.3 AE 2.3 days. LA/LAA thrombi were discovered in 9 patients (3.5%) by using TEE. Among the CMR techniques performed, long TI DE-CMR had the highest diagnostic accuracy (99.2%), sensitivity (100%), and specificity (99.2%), followed by contrast-enhanced magnetic resonance angiography (accuracy 94.3%; sensitivity 66.7%; and specificity 95.2%) and cine-CMR (accuracy 91.6%; sensitivity 66.7%; and specificity 92.5%). CONCLUSIONS In patients referred for PVI, CMR could be a single complete diagnostic study for assessment of pulmonary venous anatomy as well as presence of LA/LAA thrombi, thus reducing the number of pre-operative tests before PVI. Long TI DE-CMR has the best diagnostic performance and should be used for the detection of LA/LAA thrombi.

The Journal of physiology, Jul 26, 2016

The autonomic nervous system regulates all aspects of normal cardiac function, and is recognized ... more The autonomic nervous system regulates all aspects of normal cardiac function, and is recognized to play a critical role in the pathophysiology of many cardiovascular diseases. As such, the value of neuroscience-based cardiovascular therapeutics is increasingly evident. This White Paper reviews the current state of understanding of human cardiac neuroanatomy, neurophysiology, pathophysiology in specific disease conditions, autonomic testing, risk stratification, and neuromodulatory strategies to mitigate the progression of cardiovascular diseases. This article is protected by copyright. All rights reserved.

Methodist DeBakey Cardiovascular Journal, 2013

The American journal of cardiology, Jan 28, 2015

The objective of this study was to examine prevalence and clinical implications of subclinical co... more The objective of this study was to examine prevalence and clinical implications of subclinical coronary artery disease (CAD) detected by coronary artery calcium score (CACS) testing in patients with atrial fibrillation (AF). CACS was assessed in patients without history of CAD undergoing catheter ablation of AF. Age- and gender-matched patients with normal sinus rhythm (NSR) presenting with chest pain served as controls. Predicted arterial age using the Multi-Ethnic Study of Atherosclerosis registry was also compared to the chronologic age. A total of 860 patients (430 AF and 430 NSR, age 63 ± 10 years, 65% men) were included. Subclinical CAD prevalence (CACS >0) was 74% (319 of 430) in the AF group. Compared to the patients with NSR, patients with AF had higher prevalence of Subclinical CAD (74% vs 63%; p <0.001). In multivariate analysis, AF was independently associated with Subclinical CAD (hazard ratio 1.60; p = 0.002) but only with persistent AF (hazard ratio 2.28; p <...

HeartRhythm Case Reports, 2015