Julián Villacastín

ICCC Catalan Institute of Cardiovascular Sciences, Barcino, Catalonia, Spain

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Publications (74)368.09 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Since most sudden cardiac death victims show neither symptoms before the event nor other singns or risk factors that would have identified them as a high risk population before their cardiac arrest, emergency out-of-hospital medical services must be improved in order to obtain a higher survival in these patients. Early defibrillation is an essential part of the chain of survival that also includes the early identification of the victim, activation of the emergency medical system, immediate arrival of trained personnel who can perform basic cardiopulmonary resuscitation and early initiation of advanced cardiac life support that would raise the survival rate for sudden cardiac arrest victims. Many studies have demonstrated the enormous importance of early defibrillation in patients with a cardiac arrest due to ventricular fibrillation. The most important predictor of survival in these individuals is the time that elapses until electric defibrillation, the longer the time to defbrillation the lower the number of patients who are eventually discharged. Multiple studies have demonstrated that automatic external defibrillation will reduce the time elapsed to defibrillation and thus improve survival. For these reason, public access defibrillation to allow the use of automatic external defibrillators by minimally trained members of the lay public, has received increasing interest on the part of a groving number of companies, cities or countries. The automatic external defibrillaton, as performed by a lay person is being investigated. The liberalization of its application, if is demonstrated to be effective, will need to be accompanied by legal measures to endorse it and appropriate health education, probably during secondary education.
    Revista Española de Cardiología. 07/2013; 53(6):851–865.
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    ABSTRACT: Although advances in the management of acute myocardial infarction have resulted in a decline in long-term risk of sudden death, it continues to be high in certain subsets of patients. Thus, it is important to identify and treat these patients. Left ventricular ejection fraction less than 0.40, frequent premature ventricular ectopy on Holter monitoring, late potentials on signal-averaged electrocardiogram, impaired heart rate variability, abnormal baroreflex sensitivity and inducible sustained monomorphic ventricular tachycardia during electrophysiological study are predictors of sudden death and arrhythmic events. Although the negative predictive value of each factor is high, the positive predictive accuracy is low. Several tests can be combined to obtain higher positive predictive values. In fact, in some studies combined noninvasive tests have been used to select patients for ventricular stimulation study. Some preventive treatment can be applied in these patients. Available data do not justify prophylactic therapy with amiodarone in high-risk survivors of acute myocardial infarction. Sudden death and total mortality have been significantly reduced in postinfarction patients by longterm beta blockade. Hence, beta blockers should be given to all patients with acute myocardial infarction who do not have contraindications to their use. The MADIT study has shown the beneficial effect of implantable cardioverter defibrillator in reducing mortality in patients with prior myocardial infarction, an ejection fraction less than 0.36, asymptomatic nonsustained ventricular tachycardia, and inducible sustained ventricular tachycardia, unsuppressable by procainamide. Besides, several studies are under way to evaluate the prophylactic use of implantable defibrillator for improving survival in high-risk patients.
    Revista Española de Cardiología. 07/2013; 53(3):440–462.
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    ABSTRACT: Echocardiographic optimization of the VV interval may improve CRT response, but it is time-consuming and not routinely performed. The aim of this study was to compare the response to cardiac resynchronization therapy (CRT) when the interventricular pacing (VV) interval was optimized by tissue Doppler imaging (TDI) to CRT response when it was optimized following QRS width criteria. The study included 156 consecutive CRT patients with severe heart failure and left bundle-branch block configuration. Atrioventricular interval was selected according to a pulsed Doppler assessment, and VV optimization was randomly assigned to echocardiography (ECHO group, n = 78) or electrocardiography (ECG group, n = 78). Optimal VV was defined for the ECHO group as producing the best LV intraventricular synchrony according to TDI displacement curves and for the ECG group as resulting in the narrowest QRS measured from the earliest deflection. At 6-month follow-up, percentage of echocardiographic responders (defined as neither death nor heart transplantation and a LV end-systolic volume reduction >10%) was higher in the ECG optimized group (50.0% vs 67.9%; P = 0.023), whereas clinical response (defined as neither death nor heart transplantation and >10% improvement in the 6-minute walking test) was similar in both groups (71.8% vs 73.1%; P = 0.858). VV optimization based on QRS width obtained a higher percentage of responders in terms of LV reverse remodeling compared to the TDI method.
    Journal of Cardiovascular Electrophysiology 06/2011; 22(10):1129-34. · 3.48 Impact Factor
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    ABSTRACT:   Some observations support the existence of epicardial connections (ECs) between ipsilateral pulmonary veins (vein to vein ECs [VVECs]), and we have observed venoatrial ECs inserted at distance from the pulmonary vein ostium (vein to atrium ECs [VAECs]). Our aim was to determine the prevalence of ECs and their relevance for pulmonary vein isolation. We studied 100 consecutive patients with drug-refractory atrial fibrillation who underwent ostial pulmonary vein isolation by cooled radiofrequency catheter ablation. A VVEC was identified if pulmonary vein pacing activated the ipsilateral vein before the atrium, requiring ablation of both venous ostia to isolate either pulmonary vein. A VAEC was identified if pacing produced atrial breakthrough located at distance from the venous ostium, requiring extraostial ablation to isolate the pulmonary vein. Patients with ECs (20%) were younger (P = 0.02) and had a higher prevalence of structural heart disease (P = 0.01) than patients without ECs. VVECs and VAECs were identified in 32 pulmonary veins (10%) and VAECs in 10 veins (3%). Veins with ECs had a higher rate of early recurrence of conduction following isolation (29% vs 11%; P = 0.01). Twenty percent of patients with atrial fibrillation had ECs resistant to ostial ablation in one or more pulmonary veins. Isolating veins with ECs may require a different ablation approach. These connections are associated with an increased rate of early recurrence of conduction. (J Cardiovasc Electrophysiol, Vol. 22, pp. 149-159, February 2011).
    Journal of Cardiovascular Electrophysiology 02/2011; 22(2):149-59. · 3.48 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) ablation efficacy varies according to patients' clinical characteristics. Although the association of obstructive sleep apnoea (OSA) and AF is well established, data on AF ablation efficacy in OSA are scarce. The aim of this study was to clarify the effect of OSA on the outcome of AF ablation. A series of 174 consecutive patients without polysomnography submitted to circumferential pulmonary vein ablation were included in the study. All patients were assessed by Berlin Questionnaire (BQ) and underwent an echocardiogram and a clinical evaluation. Patients with a high BQ score, indicating high risk for OSA, participated in a sleep study. Diagnoses were classified according to the apnoea-hypoapnoea index (AHI) as mild (AHI < 10/h), non-severe (AHI < 30/h), or severe (AHI >or= 30/h) OSA. Follow-up consisted of outpatient visits and 24 or 48 h Holter monitoring at 1, 4, and 7 months, and every 6 months thereafter. Any episode of AF or left atrial (LA) flutter was considered recurrence. Fifty-one (29.3%) patients had high BQ scores. The sleep study showed that 17 (9.8%) and 25 (14.4%) of these patients had non-severe and severe OSA, respectively. One-year arrhythmia-free probability after a single ablation procedure was 48.5% in patients with low risk for OSA (low BQ score or AHI < 10/h), 30.4% in the non-severe OSA group (10 < AHI < 30/h) and 14.3% in the severe OSA group (AHI >or= 30). Anteroposterior LA diameter [hazard ratio (HR) = 1.046, 95% confidence interval (CI): 1.005-1.089; P = 0.029] and severe OSA (HR = 1.870, 95% CI: 1.106-3.161; P = 0.019) were the independent predictors of arrhythmia recurrence. In patients with AF ablation, the presence of severe OSA is an independent predictor for AF ablation failure.
    Europace 08/2010; 12(8):1084-9. · 2.77 Impact Factor
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    ABSTRACT: The effect of conventional i.v. anaesthetic agents on atrial fibrillation (AF) dynamics has not been fully addressed. We aim to evaluate whether the most frequently used intravenous anaesthetic agent, propofol, modifies AF organization parameters. Multiple and simultaneous intraatrial bipolar recordings from 27 patients in AF were analyzed before and after infusing a propofol bolus. Signal organization parameters were determined using time and frequency domain analysis. Non-linear analysis was also performed to determine signal entropy. Linear analysis showed that AF becomes more organized in right atrial recordings after infusing propofol, increasing interelectrode correlation (difference of 0.017 +/- 0.005), with the contrary effect on the left atrial dipoles (difference of -0.015 +/- 0.009, p = 0.008). Entropy analysis showed similar findings, achieving a statistical significance of p = 0.001 with Shannon Entropy.
    Medical & Biological Engineering 12/2008; 47(3):333-41. · 1.76 Impact Factor
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    ABSTRACT: Currently, selection of the ablation catheter for pulmonary vein (PV) isolation is a matter of choice. To evaluate the efficiency of cooled ablation for PV isolation. A prospective randomised trial was carried out comparing the time required to disconnect each targeted PV using cooled ablation (open irrigation at 15 ml/min, group A) or standard temperature-controlled 4 mm tip catheter ablation (group B). The ablation parameter limit settings were 45 degrees C, 35 (5) W in group A, and 55 degrees C, 35 (5) W in group B. Thirty-six patients referred for a first atrial fibrillation (AF) ablation procedure were randomised to group A or group B (18 patients in each group). There were no significant differences in baseline characteristics between the groups. Bidirectional block was achieved in 61/61 PVs from group A (100%) and 59/61 PVs from group B (97%); p = NS. Time to PV disconnection was significantly shorter in group A than in group B (median (25th-75th centiles) 14 (5-28) min vs 19 (14-32) min, respectively; p = 0.003). Five asymptomatic PV stenoses were identified by MRI, all in group B (p = 0.05). After 1-year minimum follow-up, AF recurrences were less frequently documented in patients treated with cooled ablation (6% vs 33%; p = 0.05). Cooled ablation is more efficient than standard ablation in achieving PV isolation. Results obtained from this study also suggest a potential benefit of clinical efficacy and safety from cooled ablation, which should be further evaluated in larger clinical trials.
    Heart (British Cardiac Society) 01/2008; 95(3):203-9. · 5.01 Impact Factor
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    ABSTRACT: We report a case of a 43 year old man from Spain, who has been diagnosed with Naxos disease. It is a hereditary disorder characterized by palmoplantar keratoderma, woolly hair and cardiomyopathy, which has been associated with a mutation in plakoglobin encoding gene in chromosome 17q21. In the patient, the direct sequencing of the plakoglobin gene discarded TG deletion at 2157 characteristic of Naxos disease. Analysis of the reported desmoplakin mutations associated with Carvajal Syndrome, another ARVC disease, that it is also accompanied with a skin and hair disorder, also failed to reveal mutations in desmoplakin gene. These results suggest the existence of other causative genes and/or other putative sites in desmoplakin/plakoglobin encoding genes than those recently published.
    International journal of cardiology 06/2007; 118(2):275-7. · 6.18 Impact Factor
  • Europace 03/2007; 9(2):119-20. · 2.77 Impact Factor
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    ABSTRACT: Contemporary atrial pacemakers incorporate pacing modes for treating atrial arrhythmias. Because atrial fibrillation in the right atrium can exhibit an organized pattern, it can be difficult to differentiate from atrial flutter. We assessed criteria for discriminating between atrial flutter and organized atrial fibrillation when using a bipolar electrode in the right atrium. Simultaneous bipolar electrograms of the right and left atria were obtained in 45 patients: Group I comprised 15 patients with atypical flutter, Group II comprised 15 with typical flutter, and Group III, 15 with organized atrial fibrillation in the right atrium. The mean cycle length and the mean variation in cycle length observed over 15 seconds in electrograms of the right atrium were recorded. The mean cycle length was longer in Groups I and II than in Group III (232 [21] ms and 234 [24] ms, respectively, versus 183 [16] ms; P< .001). The mean variation in cycle length was less in Groups I and II than in Group III (16 [7] ms and 13 [4] ms, respectively, versus 22 [7] ms; P< .01). A cycle length > or =203 ms discriminated atrial flutter from atrial fibrillation with a sensitivity of 97% and a specificity of 87%. A cycle length variation < or =18 ms discriminated atrial flutter from atrial fibrillation with a sensitivity of 70% and a specificity of 80%. Cycle length was better than the variation in cycle length for differentiating atrial flutter from organized atrial fibrillation.
    Revista Espa de Cardiologia 03/2007; 60(2):104-9. · 3.20 Impact Factor
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    ABSTRACT: It is unclear whether atrial fibrillation (AF) drivers in humans are focal or reentrant. To test the hypothesis that functional reentry is involved in human AF maintenance, we determined the effects of adenosine infusion on local dominant frequency (DF) at different atrial sites. By increasing inward rectifier potassium channel conductance, adenosine would increase DF of reentrant drivers but decrease it in the case of a focal mechanism. Thirty-three patients were studied during AF (21 paroxysmal, 12 persistent) using recordings from each pulmonary vein-left atrial junction (PV-LAJ), high right atrium, and coronary sinus. DFs were determined during baseline and peak adenosine effect. In paroxysmal AF, adenosine increased maximal DF at each region compared with baseline (PV-LAJ, 8.03+/-2.2 versus 5.7+/-0.8; high right atrium, 7+/-2.2 versus 5.4+/-0.7; coronary sinus, 6.6+/-1.1 versus 5.3+/-0.7 Hz; P=0.001) and increased the left-to-right DF gradient (P=0.007). In contrast, in persistent AF, adenosine increased DF only in the high right atrium (8.33+/-1.1 versus 6.8+/-1.2 Hz; P=0.004). In 4 paroxysmal AF patients, real-time DF mapping of the left atrium identified the highest DF sites near the PV-LAJ, where adenosine induced an increase in DF (6.7+/-0.29 versus 4.96+/-0.26 Hz; P=0.008). Finally, simulations demonstrate that the frequency of reentrant drivers accelerates proportionally to the adenosine-modulated inward rectifier potassium current. Adenosine accelerates drivers and increases frequency differently in paroxysmal compared with persistent human AF. The results strongly suggest that AF is maintained by reentrant sources, most likely located at the PV-LAJ in paroxysmal AF, whereas non-PV locations are more likely in persistent AF.
    Circulation 01/2007; 114(23):2434-42. · 15.20 Impact Factor
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    ABSTRACT: Introduction and objectives Contemporary atrial pacemakers incorporate pacing modes for treating atrial arrhythmias. Because atrial fibrillation in the right atrium can exhibit an organized pattern, it can be difficult to differentiate from atrial flutter. We assessed criteria for discriminating between atrial flutter and organized atrial fibrillation when using a bipolar electrode in the right atrium. Methods Simultaneous bipolar electrograms of the right and left atria were obtained in 45 patients: Group I comprised 15 patients with atypical flutter, Group II comprised 15 with typical flutter, and Group III, 15 with organized atrial fibrillation in the right atrium. The mean cycle length and the mean variation in cycle length observed over 15 seconds in electrograms of the right atrium were recorded. Results The mean cycle length was longer in Groups I and II than in Group III (232 [21] ms and 234 [24] ms, respectively, versus 183 [16] ms; P<.001). The mean variation in cycle length was less in Groups I and II than in Group III (16 [7] ms and 13 [4] ms, respectively, versus 22 [7] ms; P<.01). A cycle length ≥203 ms discriminated atrial flutter from atrial fibrillation with a sensitivity of 97% and a specificity of 87%. A cycle length variation ≤18 ms discriminated atrial flutter from atrial fibrillation with a sensitivity of 70% and a specificity of 80%. Conclusions Cycle length was better than the variation in cycle length for differentiating atrial flutter from organized atrial fibrillation.
    Revista Espanola De Cardiologia - REV ESPAN CARDIOL. 01/2007; 60(2):104-109.
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    ABSTRACT: Findings from animal studies and small series of patients support the greater safety of cryoenergy over radiofrequency in the ablation of arrhythmic substrates near the AV node. The purpose of this study was to systematically evaluate the electrophysiologic effects of successive cryoenergy applications to the human AV node in order to better define the safety margin of cryothermal ablation. In 15 patients referred for AV nodal ablation, 94 cryomapping and 105 cryoablation applications were delivered through a 6-mm-tip cryothermal ablation catheter (Freezor Xtra, CryoCath) at predefined sites of the triangle of Koch. Temporary effects on AV conduction were observed in 18 (19%) cryomapping and 38 (36%) cryoablation applications. Persistent effects were observed in 9 (9%) cryoablation applications. Persistent effects were associated with cryoablation at the superior third of the triangle of Koch (P = .05), nadir tip temperature < or = -79 degrees C (P = .007), and effect onset time < or =15 seconds (P = .03). Temperature and effect onset time remained statistically significant after multivariate adjustment (P = .01 and .02, respectively). Overall, persistent complete AV block was achieved with cryoenergy in only one patient. In two additional patients, AV conduction remained modified. In the remaining patients, persistent complete AV block was achieved with radiofrequency (median one application per patient). The low rate of persistent AV conduction impairment observed with attempts to cryoablate the AV node supports a great safety margin of perinodal cryothermal ablation.
    Heart Rhythm 10/2006; 3(10):1189-95. · 5.05 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) may be triggered by ectopic beats originating in sleeves of atrial myocardium entering the pulmonary veins (PVs). PV isolation by means of circumferential ostial or atrial radiofrequency ablation is an effective but also a difficult and long procedure, requiring extensive applications that can have serious potential complications. Our objective was to examine pathological effects of PV beta-radiation, particularly the ability to destroy PV myocardial sleeves without inducing PV stenosis and other unwanted effects, in order to establish its potential feasibility for the treatment of AF. Ten minipigs were studied. A phosphorus-32 source wire centered within a 2.5-mm diameter balloon catheter (Galileo III Intravascular Radiotherapy System, Guidant, Santa Clara, CA, USA) was used to deliver beta-radiation to the superior wall of the right PV trunk. Pathological analysis was performed either immediately after ablation (2 pigs) or 81 +/- 27 days later (8 pigs). Acute effects of PV beta-radiation consisted of endothelial denudation covered by white thrombus, elastic lamina disruption, and PV sleeve necrosis. Late effects consisted of mild focal neointimal hyperplasia that reduced the PV luminal area by only 1.3 +/- 1.8%, elastic lamina thickening, and PV sleeve fibrosis. Four of these 8 PVs were completely re-endothelized. Lesions were transmural in 6 of 10 radiated PVs and segmental, involving 28 +/- 7% of the right PV perimeter. Intravascular beta-radiation can induce transmural necrosis and fibrosis of PV myocardial sleeves without PV stenosis and other unwanted effects, which supports a potential usefulness of this energy source in the treatment of AF.
    Journal of Cardiovascular Electrophysiology 07/2006; 17(6):662-9. · 3.48 Impact Factor
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    ABSTRACT: The identification and ablation of atrial ectopic foci could complement the conventional empirical pulmonary vein approach and may increase the success rate of atrial fibrillation ablation. Although both adenosine and isoproterenol infusion have been reported to induce ectopics, no clear findings on their use during ablation have been published. Our aim was to investigate the utility of these two pharmacologic maneuvers in patients referred for atrial fibrillation ablation. The effects of adenosine infusion, isoproterenol infusion, or both were evaluated in 53 patients with refractory atrial fibrillation referred for ablation. Patients were in sinus rhythm during evaluation. Administration of adenosine or isoproterenol induced atrial arrhythmias in 46 patients (87%). Arrhythmia inducibility was similar in those with paroxysmal and those with persistent atrial fibrillation (87% and 86%, respectively). Atrial ectopics alone were induced in 31 patients (65%), atrial tachycardia in four (8%), and atrial fibrillation in 13 (27%). In 10 patients (19%), ectopic foci were located outside the pulmonary veins and subsequently underwent ablation. In 32 of the 46 patients with inducible arrhythmias, only the induced ectopic foci were ablated (mean 1.4 [0.6] targets per patient). The long-term success rate of first procedures was 66%. Adenosine and isoproterenol infusion induced atrial ectopics in most patients with drug-refractory atrial fibrillation while they were in sinus rhythm. In almost 20%, the ectopic foci were located outside the pulmonary veins. The effectiveness of induced ectopic-guided ablation observed in our patient series supports the clinical utility of this approach.
    Revista Espa de Cardiologia 07/2006; 59(6):559-66. · 3.20 Impact Factor
  • Journal of Cardiovascular Electrophysiology 04/2006; 17(3):325-7. · 3.48 Impact Factor
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    ABSTRACT: Dietary n-3 or omega-3 polyunsaturated fatty acids show promise as preventive therapy for cardiovascular disease, offering a safe and effective means of reducing sudden death. Oily fish is the main dietary source of omega-3 polyunsaturated fatty acid. In recent years, the anti-arrhythmic effects of polyunsaturated fatty acids have been extensively investigated. Several mechanisms that could explain these antiarrhythmic effects have been proposed and have been investigated. However, to date, no definitive mechanism has been identified. This review summarizes the epidemiological data supporting the use of omega-3 fatty acids in this context, the preclinical and clinical evidence revealed by animal and human studies, and current hypotheses about the antiarrhythmic mechanism of this class of polyunsaturated fatty acid.
    Revista Española de Cardiología Suplementos 01/2006; 6:38-51.
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    ABSTRACT: Introduction and objectives The identification and ablation of atrial ectopic foci could complement the conventional empirical pulmonary vein approach and may increase the success rate of atrial fibrillation ablation. Although both adenosine and isoproterenol infusion have been reported to induce ectopics, no clear findings on their use during ablation have been published. Our aim was to investigate the utility of these two pharmacologic maneuvers in patients referred for atrial fibrillation ablation. Methods The effects of adenosine infusion, isoproterenol infusion, or both were evaluated in 53 patients with refractory atrial fibrillation referred for ablation. Patients were in sinus rhythm during evaluation. Results Administration of adenosine or isoproterenol induced atrial arrhythmias in 46 patients (87%). Arrhythmia inducibility was similar in those with paroxysmal and those with persistent atrial fibrillation (87% and 86%, respectively). Atrial ectopics alone were induced in 31 patients (65%), atrial tachycardia in four (8%), and atrial fibrillation in 13 (27%). In 10 patients (19%), ectopic foci were located outside the pulmonary veins and subsequently underwent ablation. In 32 of the 46 patients with inducible arrhythmias, only the induced ectopic foci were ablated (mean 1.4 [0.6] targets per patient). The long-term success rate of first procedures was 66%. Conclusions Adenosine and isoproterenol infusion induced atrial ectopics in most patients with drugrefractory atrial fibrillation while they were in sinus rhythm. In almost 20%, the ectopic foci were located outside the pulmonary veins. The effectiveness of induced ectopicguided ablation observed in our patient series supports the clinical utility of this approach.
    Revista Espanola De Cardiologia - REV ESPAN CARDIOL. 01/2006; 59(6):559-566.
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    ABSTRACT: A key point in atrial fibrillation (AF) ablation is the ability to identify the pulmonary vein (PVs) and locate their ostia. The purpose of this study was to assess the error margin of PV identification and ostia location in the absence of previous PV imaging. This study was performed in patients referred for catheter ablation of AF. PVs were reconstructed before ablation using the CARTO system. The operator tagged the superior and inferior edges of the PV ostia before and after examining the corresponding PV angiograms. The distances between the tagged PV ostia were measured using CARTO software. A total of 105 location estimations of 54 PVs were analyzed. The location of PV ostia without angiography deviated from the angiographic PV ostia by a median of 13 mm (95% confidence interval = 11-14 mm; P < .0001). In 84 of the 105 estimations (80%), wrong tagging was performed inside the PV. A multiple logistic regression revealed that, at sites displaying PV potentials, the left atrial potential amplitude was an independent predictor of location at the angiographic PV ostium (odds ratio 24 [95% confidence interval = 3.7-227] per 1-mV increase). Receiver operator characteristic analysis set the optimal cutoff level at 0.7 mV. Use of this criterion improved the accuracy of PV ostium location by 4 mm (95% confidence interval = 1-6 mm; P = .005). Attempts at PV identification and ostia location in the absence of previous PV imaging are subject to a broad error margin.
    Heart Rhythm 10/2005; 2(10):1082-9. · 5.05 Impact Factor
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    ABSTRACT: Prosthetic valves may make ventricular access difficult in radiofrequency catheter ablation. This case report describes an optimized atrial transseptal approach to access the ventricle in a patient with left ventricular tachycardia and a mechanical prosthetic aortic valve.
    Revista Espa de Cardiologia 07/2005; 58(6):756-8. · 3.20 Impact Factor

Publication Stats

660 Citations
368.09 Total Impact Points

Institutions

  • 2004–2011
    • ICCC Catalan Institute of Cardiovascular Sciences
      Barcino, Catalonia, Spain
  • 2002–2011
    • Hospital Clínico San Carlos
      • Servicio de Cardiología
      Madrid, Madrid, Spain
  • 1992–2002
    • Hospital General Universitario Gregorio Marañón
      • • Department of Cardiology
      • • Clinical Electrophysiology Laboratory
      Madrid, Madrid, Spain
  • 1997
    • Hospital de Basurto
      Bilbo, Basque Country, Spain