Roger Villuendas - Academia.edu (original) (raw)

Papers by Roger Villuendas

Research paper thumbnail of CE-452773-4 Anatomy of the Isthmus: Unraveling Tissue Composition of Ventricular Tachycardia Diastolic Pathway

Heart Rhythm, May 1, 2023

Research paper thumbnail of PO-628-06 Effect of Angiotensin Receptor Neprilysin Inhibitor and Empagliflozine on Ischemic Ventricular Tachycardia Substrate: A High-Density Mapping and Mri Study

Research paper thumbnail of Contemporary Yield of 24-hour Holter Monitoring: Role of Inter-Atrial Block Recognition

Journal of Atrial Fibrillation, Aug 1, 2019

Background The diagnostic yield of 24-hour ECG Holter monitoring (24H) is currently overcome by a... more Background The diagnostic yield of 24-hour ECG Holter monitoring (24H) is currently overcome by alternative ECG monitoring techniques and it needs to be optimized. The recognition of inter-atrial block (IAB) has emerged as a reliable indicator of patients at risk of atrial fibrillation relapses, and its role enhancing the yield of 24H is yet to be determined. We hypothesized that a presumably low yield of 24H may be ameliorated by means of incorporating the assessment for IAB. Methods We retrospectively analyzed 1017 consecutive 24H registers performed in a Multidisciplinary Integrated Health Care Institution, in which a restrictive definition of diagnostic 24H findings was used. A univariate and multivariate regression analysis served to determine the variables associated with a higher 24H's yield, including the requesting medical specialty, type of indication and a number of clinical, echocardiographic and ECG variables, including IAB. Results The mean age of our population was 62 ± 17 years (55% males). The majority of 24H were indicated from the Cardiology department (48%). The overall yield was 12.8%, higher for the assessment of the integrity of the electrical conduction system (26.1%) and poorer for the assessment of syncope (3.2%) and cryptogenic stroke (4.6%). The variables associated with higher diagnostic performance were indication from Cardiology (p < 0.001), IAB (p = 0.004), structural heart disease (p = 0.008) and chronic renal failure (p = 0.009). Patients ≤ 50 years old only retrieved a 7% yield. In the multivariate analysis, indication from Cardiology and IAB remained significant predictors of higher 24H's yield. In a secondary analysis including echocardiographic data, only identification of IAB remained statistically significant. Conclusions The recognition of IAB and the type of indication are major determinants of a higher 24H's diagnostic yield and may help to optimize the selection of candidates.

Research paper thumbnail of Trends in the use of electrical cardioversion for atrial fibrillation: influence of major trials and guidelines on clinical practice

BMC Cardiovascular Disorders, Jun 18, 2012

Background: The purpose of the present study was to assess the trends in the use of ECV following... more Background: The purpose of the present study was to assess the trends in the use of ECV following published studies that had compared rhythm and rate control strategies on atrial fibrillation (AF), and the recommendations included in the current clinical practice guidelines. Methods: The REVERCAT is a population-based assessment of the use of electrical cardioversion (ECV) in treating persistent AF in Catalonia (Spain). The initial survey was conducted in 2003 and the follow-up in 2010. Results: We observed a decrease of 9% in the absolute numbers of ECV performed (436 in 2003 vs. 397 in 2010). This is equivalent to 27% when considering population increases over this period. The patients treated with ECV in 2010 were younger, had a lower prevalence of previous embolism, a higher prevalence of diabetes, and increased body weight. Underlying heart disease factors indicated, in 2010, a higher proportion of NYHA ≥ II and left ventricular ejection fraction <30%. We observed a reduction in the number of ECV performed in 16 of the 27 (67%) participating hospitals. However, there was an increase of 14% in the number of procedures performed in tertiary hospitals, and was related to the increasing use of ECV as a bridge to AF ablation. Considering the initial number of patients treated with ECV, the rate of sinus rhythm at 3 months was almost unchanged (58% in 2003 vs. 57% in 2010; p = 0.9) despite the greater use of biphasic energy in 2010 and a similar prescription of anti-arrhythmic drugs. Conclusions: Although we observed a decrease in the number of ECVs performed over the 7 year period between the two studies, this technique remains a common option for treating patients with persistent AF. The change in the characteristics of candidate patients did not translate into better outcomes.

Research paper thumbnail of Previously Undetected Obstructive Sleep Apnea in Patients With New-Onset Atrial Fibrillation

American Journal of Cardiology, 2021

Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (... more Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (AF) control strategies. Continuous positive airway pressure (CPAP) may ameliorate arrhythmia control especially in early AF stages (new-onset AF). We investigated a practical screening strategy to determine the likelihood of CPAP indication in new-onset AF patients. Seventy-seven consecutive patients with new-onset (< 1 month) AF were prospectively evaluated. Of them, 4 were excluded due to previously diagnosed OSA. The remaining 73 (68% persistent AF) fulfilled the Epworth, Berlin and STOP-BANG questionnaires, an ambulatory polysomnography being performed thereafter in all them in order to determine the apnea-hipopnea index (AHI). CPAP was indicated following conventional criteria. The variables associated with the diagnosis of OSA, with the AHI value and with CPAP indication were investigated by means of descriptive, univariate and multivariate analysis. The prevalence of OSA of any degree and CPAP indication was 82% and 37%, respectively. The variables associated (p < 0.05) with a higher AHI were male gender, body mass index, obesity, hypertension and high-risk scoring at the Berlin and STOP-BANG questionnaires. In the multivariate analysis, the STOP-BANG scoring proved superior to conventional risk factors and became the only variable predicting CPAP indication (OR 4.5 [1.9 - 10.6]; p = 0.01), an optimized cutoff value of ≥ 4 being newly established (sensitivity/specificity 76/65%). In conclusion, in patients referred with new-onset AF we documented a high risk of OSA and of need for CPAP. A STOP-BANG scoring of ≥ 4 in our population was a practical screening alternative to direct polysomnography in this setting.

Research paper thumbnail of Impact of vein of Marshall ethanol infusion on left atrial function: an MRI study

Europace, May 24, 2023

Funding Acknowledgements: Type of funding sources: None. Background: Previous data suggested that... more Funding Acknowledgements: Type of funding sources: None. Background: Previous data suggested that left atrial (LA) function may be impaired by extensive atrial fibrillation (AF) ablation. Ethanol infusion of Vein of Marshall (EI-VOM) as an adjunctive therapy to pulmonary vein isolation is an emerging therapeutic strategy that has shown to improve efficacy in persistent AF ablation procedures and mitral isthmus line. The impact of EI-VOM scar formation on LA function has not been addressed. Purpose: To analyse the effect of EI-VOM on LA function, evaluated by magnetic resonance imaging (MRI) strain parameters. Methods: Twelve patients referred for de novo persistent AF or any repeat procedure were included. MRI was performed previous (baseline) and 3-month after AF ablation. MRI images were analyzed off-line with specialized post-processing software. LA volumes, LA strain parameters, including LA global longitudinal strain (GLS), LA reservoir (LASr), conduit (LAScd) and contractile (LASct) strain; LA ejection fraction (LAEF), LA passive emptying function (LAPEF) and LA active emptying function (LAAEF) were measured from SSFPs two-chamber cine sequences. Results: Two patients were excluded due to absence of VOM and failed ethanolization. Ten patients (83%) underwent both MRI studies (64 [55-71]years; 80% men; de novo ablation of persistent AF (50%)). Six patients received additional mitral isthmus line and three posterior wall isolation. Mean baseline indexed LA volume was 62.7ml/m2 [47-73].

Research paper thumbnail of From Atrial Fibrillation to Ventricular Fibrillation and Back

Circulation, Nov 24, 2015

Research paper thumbnail of Time to –30°C as a predictor of acute success during cryoablation in patients with atrial fibrillation

Cardiology Journal, Oct 25, 2021

Background: Freezing rate of second-generation cryoballoon (CB) is a biophysical parameter that c... more Background: Freezing rate of second-generation cryoballoon (CB) is a biophysical parameter that could assist pulmonary vein isolation. The aim of this study is to assess freezing rate (time to reach-30°C ([TT-30C]) as an early predictor of acute pulmonary vein isolation using the CB. Methods: Biophysical data from CB freeze applications within a multicenter, nationwide CB ablation registry were gathered. Successful application (SA), was defined as achieving durable intraprocedural vein isolation with time to isolation in under 60 s (SA-TTI<60) as achieving durable vein isolation in under 60 s. Logistic regressions were performed and predictive models were built for the data set. Results: 12,488 CB applications from 1,733 atrial fibrillation (AF) ablation procedures were included within 27 centers from a Spanish CB AF ablation registry. SA was achieved in 6,349 of 9,178 (69.2%) total freeze applications, and SA-TTI<60 was obtained in 2,673 of 4,784 (55.9%) freezes and electrogram monitoring was present. TT-30C was shorter in the SA group (33.4  9.2 vs 39.3  12.1 s; p < 0.001) and SA-TTI<60 group (31.8  7.6 vs. 38.5  11.5 s; p < 0.001). Also, a 10 s increase in TT-30C was associated with a 41% reduction in the odds for an SA (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.56-0.63) and a 57% reduction in the odds for achieving SA-TTI<60 (OR 0.43; 95% CI 0.39-0.49), when corrected for electrogram visualization, vein position, and application order. Conclusions: Time to reach-30°C is an early predictor of the quality of a CB application and can be used to guide the ablation procedure even in the absence of electrogram monitoring.

Research paper thumbnail of Cryoballoon Ablation for Persistent and Paroxysmal Atrial Fibrillation: Procedural Differences and Results from the Spanish Registry (RECABA)

Authorea (Authorea), Jul 2, 2021

Introduction: Cryoballoon ablation (CBA) has become a standard treatment for paroxysmal atrial fi... more Introduction: Cryoballoon ablation (CBA) has become a standard treatment for paroxysmal atrial fibrillation (PaAF) but limited data is available for outcomes in patients with persistent atrial fibrillation (PeAF). Methods: We analyzed the first 944 patients included in the Spanish Prospective Multi-center Observation Post-market Registry to compare characteristics and outcomes of patients undergoing CBA for PeAF versus PaAF. Results: A total of 944 patients (57.8±10.4 years; 70.1% male) with AF (27.9% persistent) were prospectively included from 25 centers. PeAF patients were more likely to have structural heart disease (67.7 vs 11.4%; p<0.001) and left atrium dilation (72.6 vs 43.3%; p<0.001). CBA of PeAF was less likely to be performed under general anesthesia (10.7 vs 22.2%; p<0.001), with an arterial line (32.2 vs 44.6%; p<0.001) and assisted transeptal puncture (11.9 vs 17.9%; p=0.025). During an application, PeAF patients had a longer time to-30°C (35.91±14.20 vs 34.93±12.87 sec; p=0.021) and a colder balloon nadir temperature during vein isolation (-35.04±9.58 vs-33.61±10.32ºC; p=0.004), but received fewer bonus freeze applications (30.7 vs 41.1%; p<0.001). There were no differences in acute pulmonary

Research paper thumbnail of Pseudoatrial Fibrillation during Pacemaker Interrogation: What is the Mechanism?

Pacing and Clinical Electrophysiology, Mar 19, 2013

Background: Normal pacemaker response to magnet and programmer is almost universal and helps to i... more Background: Normal pacemaker response to magnet and programmer is almost universal and helps to interpret basal rhythm. Methods and results: In this report, we report an undescribed atypical magnet response due to an internal cross-talk with atrial oversensing during a specific part of interrogation, simulating atrial fibrillation.

Research paper thumbnail of Ventricular fibrillation in a patient with Wolff‐Parkinson‐White syndrome unrelated to pre‐excited atrial fibrillation

Annals of Noninvasive Electrocardiology, May 29, 2019

Pre-excited atrial fibrillation (AF) with fast ventricular response leading to ventricular fibril... more Pre-excited atrial fibrillation (AF) with fast ventricular response leading to ventricular fibrillation (VF) is accepted as the arrhythmogenic mechanism of sudden cardiac death (SCD) in patients with Wolff-Parkinson-White (WPW) syndrome (Dreifus, Haiat, Watanabe, Arriaga, & Reitman, 1971). Ventricular pre-excitation is associated with an increased dispersion of the ventricular depolarization/repolarization and with early repolarization, although it remains unclear whether the repolarization's dispersion is proportional or not to the degree of pre-excitation (Balaji, Sokoloski, Case, & Gillette, 1998; Yagihara et al., 2012). A direct link between ventricular pre-excitation and incident VF unrelated with AF, however, has yet to be reported.

Research paper thumbnail of To the Editor— Interatrial block and atrial fibrillation: Invasive and noninvasive measurements may help to define the syndrome

Heart Rhythm, Nov 1, 2014

Research paper thumbnail of Left Atrial Geometry Improves Risk Prediction of Thromboembolic Events in Patients With Atrial Fibrillation

Journal of Cardiovascular Electrophysiology, May 13, 2016

LA Sphericity and Stroke Prediction. Background: Left atrial (LA) sphericity (LASP) is a new remo... more LA Sphericity and Stroke Prediction. Background: Left atrial (LA) sphericity (LASP) is a new remodeling parameter based on LA shape analysis, with independent predictive value for recurrence after atrial fibrillation (AF) ablation. Objectives: To evaluate the association between LASP and thromboembolic events (TE) in patients with AF. Methods: Twenty-nine AF patients and prior TE and 29 age-and gender-matched controls were included. LASP was calculated using a 3D-LA reconstruction. The LA appendage (LAA) volume and morphology were assessed. ROC curve analysis was performed for LASP, LA volume, LAA volume, and CHAD/CHA 2 D-VASc scores (Stroke 2-the grouping variable-was excluded). Results: Mean age of the study population was 61 ± 11 years (79.3% males, 53.4% hypertension, 8.6% diabetes). Patients with prior TE had higher LASP than those without (82.5 ± 3.3% vs. 80.2 ± 3.1%, P = 0.008); there were no differences in CHAD or CHA 2 D-VASc scores, LA volume, LAA volume, or LAA morphology. The C-statistic was higher for LASP (0.71) than for other tested variables (CHAD score = 0.58, CHA 2 D-VASc score = 0.59, LA volume = 0.50, LAA volume = 0.46; P < 0.01 for all vs. LASP). The best cutoff value for LASP was 83.6% (sensitivity 0.52, specificity 0.90). Logistic regression analysis showed predictive value for LASP (OR 1.26 per each 1% increase [1.85-52.20], P = 0.013), but not for clinical risk scores. The addition of LASP to the CHAD and CHA 2 D-VASc scores increased the predictive value over the risk scores alone (P = 0.004), and reclassified 45.5% of patients with CHAD = 0 (no anticoagulation indicated) to moderate-risk (anticoagulation indicated). Conclusion: LA sphericity is associated with prior TE in AF patients and improves the performance of the CHAD and CHA 2 D-VASc scores alone.

Research paper thumbnail of Negative SA-VA difference during entrainment of a supraventricular tachycardia: a new criterion for the diagnosis of focal atrial tachycardia

Research paper thumbnail of P1125 Safety and efficacy of ventricular tachycardia ablation during sinus rhythm in patients with structural heart disease

EP Europace, 2020

Funding Acknowledgements Project “PI-0057-2017”, funded by Junta de Andalucía and co-funded by Eu... more Funding Acknowledgements Project “PI-0057-2017”, funded by Junta de Andalucía and co-funded by European Union (ERDF/ESF, “Invesing in your future”) Background The best strategy for scar related ventricular tachycardia (VT) ablation is not yet established. Recently, the use of ventricular assist devices is being proposed to allow ablation during unstable VT. Purpose Analyze the results of a multicenter registry of substrate-guided VT ablation performed primarily during stable rhythm. Methods This prospective multicenter registry included 433 VT ablation procedures performed in 372 consecutive patients with structural heart disease undergoing VT ablation. Substrate ablation (scar dechanneling technique) during sinus rhythm without initial VT induction was the standard protocol. Any episode of sustained VT or appropriate ICD therapy was considered VT recurrence. Results Myocardial infarction was the arrhythmogenic substrate in 64% of patients. 90.5% of patients were male, mean age ...

Research paper thumbnail of Atrial tissue characterization by cardiac magnetic resonance and high-density mapping in patients with atrial fibrillation

EP Europace, 2021

Funding Acknowledgements Type of funding sources: None. BACKGROUND Left atrial fibrosis is a mark... more Funding Acknowledgements Type of funding sources: None. BACKGROUND Left atrial fibrosis is a marker of atrial disease and it has an important role in the pathophysiology of atrial fibrillation (AF). Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is an emerging tool to detect left atrial fibrosis. However, data on the correlation between LGE-CMR detected fibrosis and low voltage areas to define fibrotic tissue is scarce. PURPOSE To assess the correlation and degree of concordance between LGE-CMR and high-density bipolar voltage mapping for the identification of left atrial abnormal tissue. METHODS Seven patients scheduled for AF ablation (including first and redo procedures) underwent a preprocedural 1.5 Tesla LGE-CMR including left atrial 3D inversion-recovery steady-state free precession sequence (ECG and respiratory triggering) 20 minutes after the injection of 0.2 mmol/kg of gadobutrol. A high-density electroanatomical voltage mapping was acquired with a 16-elec...

Research paper thumbnail of Cardiac reparative therapy with adipose graft transposition procedure reduces slow conduction areas in a chronic myocardial infarction swine model

Europace, 2021

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Insituto... more Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Insituto de Salud Carlos III Cardiac regenerative therapy is a promising treatment for patients with ischemic heart disease, but there are some concerns on the potential increased risk of arrhythmic events following specific cell therapies. Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting in transposing a vascularized adipose flap from the autologous pericardium and placing it over the epicardial scar area and has demonstrated to reduce infarct size and improve the left ventricular ejection fraction in preclinical and human studies. Specific electrophysiological properties of the scar, (i.e. slow conduction velocity (CV)) have been identified as key features of ventricular tachycardia (VT) isthmuses. To assess the effect of the AGTP on VT inducibility and the electrophysiological properties of the post-MI scar with ultra-high density (UHD) mapping. A left c...

Research paper thumbnail of Atrioventricular Node Ablation to Enhance Resynchronization Therapy Response in a Patient With Complete Atrioventricular Block

JACC Case Reports, 2021

Up to one-third of patients who undergo cardiac resynchronization therapy do not obtain clinical ... more Up to one-third of patients who undergo cardiac resynchronization therapy do not obtain clinical benefit. A systematic approach can identify treatable causes in many nonresponding patients. We present a case of nonresponse to cardiac resynchronization therapy that resolved by ablation of the atrioventricular node in a patient with complete atrioventricular block. (Level of Difficulty: Advanced.)

Research paper thumbnail of Effect of adipose graft transposition procedure (AGTP) on the ischemic arrhythmogenic substrate: an MRI study in a swine model of chronic myocardial infraction

Europace, 2021

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Institut... more Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III Cardiac regenerative therapy is a promising treatment for patients with myocardial infarction (MI) and heart failure. Nevertheless, previous ex-vivo studies have raised concern on the potential increased risk of arrhythmic events following certain cell therapies. Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting in transposing a vascularized adipose flap from the autologous pericardium and placing it over the epicardial scar area and has demonstrated to reduce infarct size and improve the left ventricular ejection fraction in preclinical and human studies. To assess the effect of the AGTP on the post-MI scar composition and image-based ventricular tachycardia (VT) corridors detection by means of late gadolinium enhanced cardiac magnetic resonance (LGE-CMR). A left circumflex artery (first marginal branch) MI was induced in 9 Lan...

Research paper thumbnail of Cardiac reparative therapy with adipose graft transposition procedure (AGTP) improves electrophysiological remodeling of chronic myocardial infarction

European Heart Journal, 2021

Background Cardiac regeneration is a promising therapeutic option for patients with prior myocard... more Background Cardiac regeneration is a promising therapeutic option for patients with prior myocardial infarction (MI). Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting of the transposition of a vascularized adipose flap from the autologous pericardium over the epicardial scar area, which has shown to reduce the infarct size and improve the left ventricular function. Purpose To assess the impact of the AGTP on the electrophysiological remodeling of the post-MI scar by means of electrophysiological study (EPS), high density (HD) mapping, and 3D contrast-enhanced MRI (ceMRI). Methods A lateral MI was induced in 14 Landrace X Large White pigs by coil deployment at the first marginal branch of the circumflex artery. A 3D ceMRI, EPS and endocardial HD mapping were performed 2 (baseline) and 6 weeks post-MI (30 day post-treatment). Subjects were randomized to AGTP (n=8) or sham surgery (n=6) following baseline tests. Voltage and activation maps were bl...

Research paper thumbnail of CE-452773-4 Anatomy of the Isthmus: Unraveling Tissue Composition of Ventricular Tachycardia Diastolic Pathway

Heart Rhythm, May 1, 2023

Research paper thumbnail of PO-628-06 Effect of Angiotensin Receptor Neprilysin Inhibitor and Empagliflozine on Ischemic Ventricular Tachycardia Substrate: A High-Density Mapping and Mri Study

Research paper thumbnail of Contemporary Yield of 24-hour Holter Monitoring: Role of Inter-Atrial Block Recognition

Journal of Atrial Fibrillation, Aug 1, 2019

Background The diagnostic yield of 24-hour ECG Holter monitoring (24H) is currently overcome by a... more Background The diagnostic yield of 24-hour ECG Holter monitoring (24H) is currently overcome by alternative ECG monitoring techniques and it needs to be optimized. The recognition of inter-atrial block (IAB) has emerged as a reliable indicator of patients at risk of atrial fibrillation relapses, and its role enhancing the yield of 24H is yet to be determined. We hypothesized that a presumably low yield of 24H may be ameliorated by means of incorporating the assessment for IAB. Methods We retrospectively analyzed 1017 consecutive 24H registers performed in a Multidisciplinary Integrated Health Care Institution, in which a restrictive definition of diagnostic 24H findings was used. A univariate and multivariate regression analysis served to determine the variables associated with a higher 24H's yield, including the requesting medical specialty, type of indication and a number of clinical, echocardiographic and ECG variables, including IAB. Results The mean age of our population was 62 ± 17 years (55% males). The majority of 24H were indicated from the Cardiology department (48%). The overall yield was 12.8%, higher for the assessment of the integrity of the electrical conduction system (26.1%) and poorer for the assessment of syncope (3.2%) and cryptogenic stroke (4.6%). The variables associated with higher diagnostic performance were indication from Cardiology (p < 0.001), IAB (p = 0.004), structural heart disease (p = 0.008) and chronic renal failure (p = 0.009). Patients ≤ 50 years old only retrieved a 7% yield. In the multivariate analysis, indication from Cardiology and IAB remained significant predictors of higher 24H's yield. In a secondary analysis including echocardiographic data, only identification of IAB remained statistically significant. Conclusions The recognition of IAB and the type of indication are major determinants of a higher 24H's diagnostic yield and may help to optimize the selection of candidates.

Research paper thumbnail of Trends in the use of electrical cardioversion for atrial fibrillation: influence of major trials and guidelines on clinical practice

BMC Cardiovascular Disorders, Jun 18, 2012

Background: The purpose of the present study was to assess the trends in the use of ECV following... more Background: The purpose of the present study was to assess the trends in the use of ECV following published studies that had compared rhythm and rate control strategies on atrial fibrillation (AF), and the recommendations included in the current clinical practice guidelines. Methods: The REVERCAT is a population-based assessment of the use of electrical cardioversion (ECV) in treating persistent AF in Catalonia (Spain). The initial survey was conducted in 2003 and the follow-up in 2010. Results: We observed a decrease of 9% in the absolute numbers of ECV performed (436 in 2003 vs. 397 in 2010). This is equivalent to 27% when considering population increases over this period. The patients treated with ECV in 2010 were younger, had a lower prevalence of previous embolism, a higher prevalence of diabetes, and increased body weight. Underlying heart disease factors indicated, in 2010, a higher proportion of NYHA ≥ II and left ventricular ejection fraction <30%. We observed a reduction in the number of ECV performed in 16 of the 27 (67%) participating hospitals. However, there was an increase of 14% in the number of procedures performed in tertiary hospitals, and was related to the increasing use of ECV as a bridge to AF ablation. Considering the initial number of patients treated with ECV, the rate of sinus rhythm at 3 months was almost unchanged (58% in 2003 vs. 57% in 2010; p = 0.9) despite the greater use of biphasic energy in 2010 and a similar prescription of anti-arrhythmic drugs. Conclusions: Although we observed a decrease in the number of ECVs performed over the 7 year period between the two studies, this technique remains a common option for treating patients with persistent AF. The change in the characteristics of candidate patients did not translate into better outcomes.

Research paper thumbnail of Previously Undetected Obstructive Sleep Apnea in Patients With New-Onset Atrial Fibrillation

American Journal of Cardiology, 2021

Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (... more Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (AF) control strategies. Continuous positive airway pressure (CPAP) may ameliorate arrhythmia control especially in early AF stages (new-onset AF). We investigated a practical screening strategy to determine the likelihood of CPAP indication in new-onset AF patients. Seventy-seven consecutive patients with new-onset (< 1 month) AF were prospectively evaluated. Of them, 4 were excluded due to previously diagnosed OSA. The remaining 73 (68% persistent AF) fulfilled the Epworth, Berlin and STOP-BANG questionnaires, an ambulatory polysomnography being performed thereafter in all them in order to determine the apnea-hipopnea index (AHI). CPAP was indicated following conventional criteria. The variables associated with the diagnosis of OSA, with the AHI value and with CPAP indication were investigated by means of descriptive, univariate and multivariate analysis. The prevalence of OSA of any degree and CPAP indication was 82% and 37%, respectively. The variables associated (p < 0.05) with a higher AHI were male gender, body mass index, obesity, hypertension and high-risk scoring at the Berlin and STOP-BANG questionnaires. In the multivariate analysis, the STOP-BANG scoring proved superior to conventional risk factors and became the only variable predicting CPAP indication (OR 4.5 [1.9 - 10.6]; p = 0.01), an optimized cutoff value of ≥ 4 being newly established (sensitivity/specificity 76/65%). In conclusion, in patients referred with new-onset AF we documented a high risk of OSA and of need for CPAP. A STOP-BANG scoring of ≥ 4 in our population was a practical screening alternative to direct polysomnography in this setting.

Research paper thumbnail of Impact of vein of Marshall ethanol infusion on left atrial function: an MRI study

Europace, May 24, 2023

Funding Acknowledgements: Type of funding sources: None. Background: Previous data suggested that... more Funding Acknowledgements: Type of funding sources: None. Background: Previous data suggested that left atrial (LA) function may be impaired by extensive atrial fibrillation (AF) ablation. Ethanol infusion of Vein of Marshall (EI-VOM) as an adjunctive therapy to pulmonary vein isolation is an emerging therapeutic strategy that has shown to improve efficacy in persistent AF ablation procedures and mitral isthmus line. The impact of EI-VOM scar formation on LA function has not been addressed. Purpose: To analyse the effect of EI-VOM on LA function, evaluated by magnetic resonance imaging (MRI) strain parameters. Methods: Twelve patients referred for de novo persistent AF or any repeat procedure were included. MRI was performed previous (baseline) and 3-month after AF ablation. MRI images were analyzed off-line with specialized post-processing software. LA volumes, LA strain parameters, including LA global longitudinal strain (GLS), LA reservoir (LASr), conduit (LAScd) and contractile (LASct) strain; LA ejection fraction (LAEF), LA passive emptying function (LAPEF) and LA active emptying function (LAAEF) were measured from SSFPs two-chamber cine sequences. Results: Two patients were excluded due to absence of VOM and failed ethanolization. Ten patients (83%) underwent both MRI studies (64 [55-71]years; 80% men; de novo ablation of persistent AF (50%)). Six patients received additional mitral isthmus line and three posterior wall isolation. Mean baseline indexed LA volume was 62.7ml/m2 [47-73].

Research paper thumbnail of From Atrial Fibrillation to Ventricular Fibrillation and Back

Circulation, Nov 24, 2015

Research paper thumbnail of Time to –30°C as a predictor of acute success during cryoablation in patients with atrial fibrillation

Cardiology Journal, Oct 25, 2021

Background: Freezing rate of second-generation cryoballoon (CB) is a biophysical parameter that c... more Background: Freezing rate of second-generation cryoballoon (CB) is a biophysical parameter that could assist pulmonary vein isolation. The aim of this study is to assess freezing rate (time to reach-30°C ([TT-30C]) as an early predictor of acute pulmonary vein isolation using the CB. Methods: Biophysical data from CB freeze applications within a multicenter, nationwide CB ablation registry were gathered. Successful application (SA), was defined as achieving durable intraprocedural vein isolation with time to isolation in under 60 s (SA-TTI<60) as achieving durable vein isolation in under 60 s. Logistic regressions were performed and predictive models were built for the data set. Results: 12,488 CB applications from 1,733 atrial fibrillation (AF) ablation procedures were included within 27 centers from a Spanish CB AF ablation registry. SA was achieved in 6,349 of 9,178 (69.2%) total freeze applications, and SA-TTI<60 was obtained in 2,673 of 4,784 (55.9%) freezes and electrogram monitoring was present. TT-30C was shorter in the SA group (33.4  9.2 vs 39.3  12.1 s; p < 0.001) and SA-TTI<60 group (31.8  7.6 vs. 38.5  11.5 s; p < 0.001). Also, a 10 s increase in TT-30C was associated with a 41% reduction in the odds for an SA (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.56-0.63) and a 57% reduction in the odds for achieving SA-TTI<60 (OR 0.43; 95% CI 0.39-0.49), when corrected for electrogram visualization, vein position, and application order. Conclusions: Time to reach-30°C is an early predictor of the quality of a CB application and can be used to guide the ablation procedure even in the absence of electrogram monitoring.

Research paper thumbnail of Cryoballoon Ablation for Persistent and Paroxysmal Atrial Fibrillation: Procedural Differences and Results from the Spanish Registry (RECABA)

Authorea (Authorea), Jul 2, 2021

Introduction: Cryoballoon ablation (CBA) has become a standard treatment for paroxysmal atrial fi... more Introduction: Cryoballoon ablation (CBA) has become a standard treatment for paroxysmal atrial fibrillation (PaAF) but limited data is available for outcomes in patients with persistent atrial fibrillation (PeAF). Methods: We analyzed the first 944 patients included in the Spanish Prospective Multi-center Observation Post-market Registry to compare characteristics and outcomes of patients undergoing CBA for PeAF versus PaAF. Results: A total of 944 patients (57.8±10.4 years; 70.1% male) with AF (27.9% persistent) were prospectively included from 25 centers. PeAF patients were more likely to have structural heart disease (67.7 vs 11.4%; p<0.001) and left atrium dilation (72.6 vs 43.3%; p<0.001). CBA of PeAF was less likely to be performed under general anesthesia (10.7 vs 22.2%; p<0.001), with an arterial line (32.2 vs 44.6%; p<0.001) and assisted transeptal puncture (11.9 vs 17.9%; p=0.025). During an application, PeAF patients had a longer time to-30°C (35.91±14.20 vs 34.93±12.87 sec; p=0.021) and a colder balloon nadir temperature during vein isolation (-35.04±9.58 vs-33.61±10.32ºC; p=0.004), but received fewer bonus freeze applications (30.7 vs 41.1%; p<0.001). There were no differences in acute pulmonary

Research paper thumbnail of Pseudoatrial Fibrillation during Pacemaker Interrogation: What is the Mechanism?

Pacing and Clinical Electrophysiology, Mar 19, 2013

Background: Normal pacemaker response to magnet and programmer is almost universal and helps to i... more Background: Normal pacemaker response to magnet and programmer is almost universal and helps to interpret basal rhythm. Methods and results: In this report, we report an undescribed atypical magnet response due to an internal cross-talk with atrial oversensing during a specific part of interrogation, simulating atrial fibrillation.

Research paper thumbnail of Ventricular fibrillation in a patient with Wolff‐Parkinson‐White syndrome unrelated to pre‐excited atrial fibrillation

Annals of Noninvasive Electrocardiology, May 29, 2019

Pre-excited atrial fibrillation (AF) with fast ventricular response leading to ventricular fibril... more Pre-excited atrial fibrillation (AF) with fast ventricular response leading to ventricular fibrillation (VF) is accepted as the arrhythmogenic mechanism of sudden cardiac death (SCD) in patients with Wolff-Parkinson-White (WPW) syndrome (Dreifus, Haiat, Watanabe, Arriaga, & Reitman, 1971). Ventricular pre-excitation is associated with an increased dispersion of the ventricular depolarization/repolarization and with early repolarization, although it remains unclear whether the repolarization's dispersion is proportional or not to the degree of pre-excitation (Balaji, Sokoloski, Case, & Gillette, 1998; Yagihara et al., 2012). A direct link between ventricular pre-excitation and incident VF unrelated with AF, however, has yet to be reported.

Research paper thumbnail of To the Editor— Interatrial block and atrial fibrillation: Invasive and noninvasive measurements may help to define the syndrome

Heart Rhythm, Nov 1, 2014

Research paper thumbnail of Left Atrial Geometry Improves Risk Prediction of Thromboembolic Events in Patients With Atrial Fibrillation

Journal of Cardiovascular Electrophysiology, May 13, 2016

LA Sphericity and Stroke Prediction. Background: Left atrial (LA) sphericity (LASP) is a new remo... more LA Sphericity and Stroke Prediction. Background: Left atrial (LA) sphericity (LASP) is a new remodeling parameter based on LA shape analysis, with independent predictive value for recurrence after atrial fibrillation (AF) ablation. Objectives: To evaluate the association between LASP and thromboembolic events (TE) in patients with AF. Methods: Twenty-nine AF patients and prior TE and 29 age-and gender-matched controls were included. LASP was calculated using a 3D-LA reconstruction. The LA appendage (LAA) volume and morphology were assessed. ROC curve analysis was performed for LASP, LA volume, LAA volume, and CHAD/CHA 2 D-VASc scores (Stroke 2-the grouping variable-was excluded). Results: Mean age of the study population was 61 ± 11 years (79.3% males, 53.4% hypertension, 8.6% diabetes). Patients with prior TE had higher LASP than those without (82.5 ± 3.3% vs. 80.2 ± 3.1%, P = 0.008); there were no differences in CHAD or CHA 2 D-VASc scores, LA volume, LAA volume, or LAA morphology. The C-statistic was higher for LASP (0.71) than for other tested variables (CHAD score = 0.58, CHA 2 D-VASc score = 0.59, LA volume = 0.50, LAA volume = 0.46; P < 0.01 for all vs. LASP). The best cutoff value for LASP was 83.6% (sensitivity 0.52, specificity 0.90). Logistic regression analysis showed predictive value for LASP (OR 1.26 per each 1% increase [1.85-52.20], P = 0.013), but not for clinical risk scores. The addition of LASP to the CHAD and CHA 2 D-VASc scores increased the predictive value over the risk scores alone (P = 0.004), and reclassified 45.5% of patients with CHAD = 0 (no anticoagulation indicated) to moderate-risk (anticoagulation indicated). Conclusion: LA sphericity is associated with prior TE in AF patients and improves the performance of the CHAD and CHA 2 D-VASc scores alone.

Research paper thumbnail of Negative SA-VA difference during entrainment of a supraventricular tachycardia: a new criterion for the diagnosis of focal atrial tachycardia

Research paper thumbnail of P1125 Safety and efficacy of ventricular tachycardia ablation during sinus rhythm in patients with structural heart disease

EP Europace, 2020

Funding Acknowledgements Project “PI-0057-2017”, funded by Junta de Andalucía and co-funded by Eu... more Funding Acknowledgements Project “PI-0057-2017”, funded by Junta de Andalucía and co-funded by European Union (ERDF/ESF, “Invesing in your future”) Background The best strategy for scar related ventricular tachycardia (VT) ablation is not yet established. Recently, the use of ventricular assist devices is being proposed to allow ablation during unstable VT. Purpose Analyze the results of a multicenter registry of substrate-guided VT ablation performed primarily during stable rhythm. Methods This prospective multicenter registry included 433 VT ablation procedures performed in 372 consecutive patients with structural heart disease undergoing VT ablation. Substrate ablation (scar dechanneling technique) during sinus rhythm without initial VT induction was the standard protocol. Any episode of sustained VT or appropriate ICD therapy was considered VT recurrence. Results Myocardial infarction was the arrhythmogenic substrate in 64% of patients. 90.5% of patients were male, mean age ...

Research paper thumbnail of Atrial tissue characterization by cardiac magnetic resonance and high-density mapping in patients with atrial fibrillation

EP Europace, 2021

Funding Acknowledgements Type of funding sources: None. BACKGROUND Left atrial fibrosis is a mark... more Funding Acknowledgements Type of funding sources: None. BACKGROUND Left atrial fibrosis is a marker of atrial disease and it has an important role in the pathophysiology of atrial fibrillation (AF). Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is an emerging tool to detect left atrial fibrosis. However, data on the correlation between LGE-CMR detected fibrosis and low voltage areas to define fibrotic tissue is scarce. PURPOSE To assess the correlation and degree of concordance between LGE-CMR and high-density bipolar voltage mapping for the identification of left atrial abnormal tissue. METHODS Seven patients scheduled for AF ablation (including first and redo procedures) underwent a preprocedural 1.5 Tesla LGE-CMR including left atrial 3D inversion-recovery steady-state free precession sequence (ECG and respiratory triggering) 20 minutes after the injection of 0.2 mmol/kg of gadobutrol. A high-density electroanatomical voltage mapping was acquired with a 16-elec...

Research paper thumbnail of Cardiac reparative therapy with adipose graft transposition procedure reduces slow conduction areas in a chronic myocardial infarction swine model

Europace, 2021

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Insituto... more Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Insituto de Salud Carlos III Cardiac regenerative therapy is a promising treatment for patients with ischemic heart disease, but there are some concerns on the potential increased risk of arrhythmic events following specific cell therapies. Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting in transposing a vascularized adipose flap from the autologous pericardium and placing it over the epicardial scar area and has demonstrated to reduce infarct size and improve the left ventricular ejection fraction in preclinical and human studies. Specific electrophysiological properties of the scar, (i.e. slow conduction velocity (CV)) have been identified as key features of ventricular tachycardia (VT) isthmuses. To assess the effect of the AGTP on VT inducibility and the electrophysiological properties of the post-MI scar with ultra-high density (UHD) mapping. A left c...

Research paper thumbnail of Atrioventricular Node Ablation to Enhance Resynchronization Therapy Response in a Patient With Complete Atrioventricular Block

JACC Case Reports, 2021

Up to one-third of patients who undergo cardiac resynchronization therapy do not obtain clinical ... more Up to one-third of patients who undergo cardiac resynchronization therapy do not obtain clinical benefit. A systematic approach can identify treatable causes in many nonresponding patients. We present a case of nonresponse to cardiac resynchronization therapy that resolved by ablation of the atrioventricular node in a patient with complete atrioventricular block. (Level of Difficulty: Advanced.)

Research paper thumbnail of Effect of adipose graft transposition procedure (AGTP) on the ischemic arrhythmogenic substrate: an MRI study in a swine model of chronic myocardial infraction

Europace, 2021

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Institut... more Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III Cardiac regenerative therapy is a promising treatment for patients with myocardial infarction (MI) and heart failure. Nevertheless, previous ex-vivo studies have raised concern on the potential increased risk of arrhythmic events following certain cell therapies. Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting in transposing a vascularized adipose flap from the autologous pericardium and placing it over the epicardial scar area and has demonstrated to reduce infarct size and improve the left ventricular ejection fraction in preclinical and human studies. To assess the effect of the AGTP on the post-MI scar composition and image-based ventricular tachycardia (VT) corridors detection by means of late gadolinium enhanced cardiac magnetic resonance (LGE-CMR). A left circumflex artery (first marginal branch) MI was induced in 9 Lan...

Research paper thumbnail of Cardiac reparative therapy with adipose graft transposition procedure (AGTP) improves electrophysiological remodeling of chronic myocardial infarction

European Heart Journal, 2021

Background Cardiac regeneration is a promising therapeutic option for patients with prior myocard... more Background Cardiac regeneration is a promising therapeutic option for patients with prior myocardial infarction (MI). Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting of the transposition of a vascularized adipose flap from the autologous pericardium over the epicardial scar area, which has shown to reduce the infarct size and improve the left ventricular function. Purpose To assess the impact of the AGTP on the electrophysiological remodeling of the post-MI scar by means of electrophysiological study (EPS), high density (HD) mapping, and 3D contrast-enhanced MRI (ceMRI). Methods A lateral MI was induced in 14 Landrace X Large White pigs by coil deployment at the first marginal branch of the circumflex artery. A 3D ceMRI, EPS and endocardial HD mapping were performed 2 (baseline) and 6 weeks post-MI (30 day post-treatment). Subjects were randomized to AGTP (n=8) or sham surgery (n=6) following baseline tests. Voltage and activation maps were bl...