Case report
Epicardial ablation for prevention of ventricular fibrillation in a patient with Brugada Syndrome
Ablação epicárdica para prevenção da fibrilhação ventricular em doente com síndrome de Brugada
Nuno Cortez-Diasa,b,
, Rui Plácidoa,b, Liliana Martaa,c, Ana Bernardesa, Sílvia Sobrala, Luís Carpinteiroa,b, João de Sousaa,b
Corresponding author
a Unidade de Arritmologia Invasiva, Serviço de Cardiologia, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
b Clínica Universitária de Cardiologia, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
c Serviço de Cardiologia, Hospital Distrital de Santarém, Santarém, Portugal
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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "João" "apellidos" => "de Sousa" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidade de Arritmologia Invasiva, Serviço de Cardiologia, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Clínica Universitária de Cardiologia, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital Distrital de Santarém, Santarém, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ablação epicárdica para prevenção da fibrilhação ventricular em doente com síndrome de Brugada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 986 "Ancho" => 2507 "Tamanyo" => 260306 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">12-Lead electrocardiogram showing bifascicular block (complete right bundle branch block and left anterior hemiblock), type 1 Brugada pattern (with coved ST elevation in V1–V4, terminating in inverted T wave), long QT interval (522 ms, corrected QT 568 ms) and isolated ventricular extrasystole with left bundle branch block morphology and inferior axis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">It is now over twenty years since Pedro and Josep Brugada first described the association between primary ventricular fibrillation (VF) and an electrocardiographic pattern of right bundle branch block with coved ST-segment elevation in the right precordial leads in individuals with no structural heart disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Since then, there has been major progress towards better understanding of the genetic and pathophysiological mechanisms of Brugada syndrome, particularly the hypothesis of a voltage gradient between the endocardium and the epicardium during depolarization as the mechanism behind the electrocardiographic abnormalities and associated ventricular arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The fact that electrocardiographic abnormalities were observed in the right precordial leads, and thus originating in the right ventricular outflow tract (RVOT), soon raised the suspicion that this was the origin of arrhythmias in these patients. However, initial attempts at endocardial mapping of this region failed to identify the arrhythmic substrate. Various cases were reported in the literature in which endocardial ablation was attempted to prevent recurrence of VF in patients with Brugada syndrome and frequent ventricular extrasystoles originating in the RVOT.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> Nevertheless, such an approach has important limitations, given that frequent ventricular extrasystoles are not common in these patients, making them difficult to map.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nademanee et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> recently described epicardial ablation of areas of delayed depolarization located in the anterior RVOT in Brugada syndrome. This study was a landmark in increasing knowledge of the pathophysiology of the syndrome, as well as providing evidence for an apparently effective therapeutic approach.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 60-year-old woman had a history of frequent syncopal episodes for the past 10 years, unrelated to exertion or posture and usually preceded by dizziness and palpitations. Five years previously, she had suffered respiratory arrest during sleep, with generalized tonic-clonic movements. Four years ago, one of her sons suffered sudden death at the age of 39, which prompted investigation of the family. This revealed type 1 Brugada electrocardiographic pattern in the patient and another son, and both received an implantable cardioverter-defibrillator (ICD) in May 2009.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Direct sequencing of the SCN5A gene identified no pathogenic mutation. The polymorphisms c.87A>G (p.Ala29Ala) and c.3183A>G (p.Glu1061Glu) in homozygosity and c.5457T>C (p.Asp1819Asp) in heterozygosity, previously described as non-pathogenic variants, were identified.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Frequent recurrences of polymorphic ventricular tachycardia (VT) were subsequently documented coinciding with syncopal episodes, and three appropriate shocks for VF. The frequency of arrhythmic events increased progressively, despite quinidine therapy up to the maximum tolerated dose of 400 mg/day. In the six months prior to the ablation procedure, the patient had a mean of five episodes (4–8) of polymorphic VT/VF per month.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In July 2013, still under quinidine therapy, the patient underwent electrophysiological study. She presented sinus rhythm, with bifascicular block (complete right bundle branch block and left anterior hemiblock) and type 1 Brugada repolarization abnormalities in the right precordial leads and in the frontal plane leads DII, DIII and aVR (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Occasional monomorphic ventricular extrasystoles were documented, with left bundle branch morphology, inferior axis, and QRS transition in V4, the frequency of which decreased spontaneously during the exam. During programmed ventricular stimulation, only self-limited runs of polymorphic VT (lasting up to 7 s) were induced, without VF being triggered.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Endocardial mapping of the right ventricle was then performed in sinus rhythm, using the CARTO 3 system (Biosense Webster, Diamond Bar, CA) with an irrigated catheter (Thermocool SF, Biosense Webster). No low-voltage areas were identified, nor zones with local electrograms prolonged beyond the end of the QRS complex (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Epicardial access was obtained through subxiphoid puncture under fluoroscopic guidance, and a 9F introducer connected to a passive drainage system was inserted. High-density epicardial electroanatomical mapping of the right ventricle (304 points) and left ventricular (LV) anterior, lateral and posterior walls was performed. Voltage mapping showed normal epicardial voltages in both the left ventricle and RVOT (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Mapping of the duration of the bipolar electrogram showed that this ended during the QRS complex in all LV regions mapped. By contrast, the bipolar electrogram terminated after the end of the QRS complex in the entire right ventricular anterior wall, and an area measuring 6.9 cm<span class="elsevierStyleSup">2</span> was identified in the anterior region of the RVOT, with fractionated potentials lasting up to 370 ms and up to 216 ms after the end of the surface QRS (<a class="elsevierStyleCrossRefs" href="#fig0015">Figures 3 and 4</a>, and Video 1). Although the electrograms in this area showed mainly normal voltages, the fractionated and delayed components presented reduced voltage (<1 mV). The marked prolongation of epicardial depolarization contrasted with normal depolarization in the corresponding endocardial region (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a> and Video 2).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Radiofrequency energy, in power control mode with energy output set to 35 W, was applied epicardially in the anterior RVOT over the entire area with delayed termination of local electrograms. The total duration of applications was 34 min (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>). This resulted in elimination of the fractionated potentials and a slight reduction in repolarization abnormalities in V2–V3, but the Brugada pattern remained on the surface electrocardiogram (ECG). The programmed ventricular stimulation protocol was repeated, which induced runs of polymorphic VT of similar duration to that before ablation, without triggering VF.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In the 48 hours following ablation, frequent, predominantly monomorphic, ventricular extrasystoles persisted, with no other arrhythmic events. The patient was discharged medicated with propranolol 30 mg/day, quinidine therapy having been discontinued.</p><p id="par0055" class="elsevierStylePara elsevierViewall">She was asymptomatic at six-month clinical assessment and reported no palpitations, fainting or syncopal episodes; no ventricular arrhythmias had been detected by the ICD. Holter monitoring recorded only 48 dimorphic and isolated ventricular extrasystoles. The electrocardiogram 43 days after ablation revealed persistence of right bundle branch block, but with significant changes in repolarization and no evidence of the previous Brugada pattern (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The clinical spectrum of Brugada syndrome is wide, ranging from asymptomatic to sudden cardiac death due to VF, which may occur late and be the first manifestation of the disease. Other common manifestations are syncope, seizures and nocturnal gasping, due to self-limited episodes of polymorphic VT/VF. Until recently, the only effective treatment for prevention of sudden death was implantation of an ICD, which is recommended in high-risk patients such as symptomatic individuals and those who have survived previous arrhythmic events.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However, there is a high long-term incidence of complications, which occur in up to a third of cases, the most common being inappropriate shocks.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a> In addition, although ICDs are effective in treating episodes of VF, they cannot prevent them and therefore do not improve patients’ quality of life. In patients with frequent episodes, as in the case presented, the only option is quinidine,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> a potent I<span class="elsevierStyleInf">to</span> blocker, but this drug frequently has adverse effects that make it difficult to titrate, as in our patient. Moreover, she continued to suffer frequent ventricular arrhythmias that significantly affected her quality of life, and so the decision was made to attempt ablation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">There have been various small studies of less than 10 patients<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a> and case reports<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> of ablation to prevent VF in patients with Brugada syndrome. The initial strategy was focal endocardial ablation of ventricular extrasystoles,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> which are assumed to be a major trigger for ventricular arrhythmias in these patients. The origin of the ventricular extrasystoles was identified in different regions of the RVOT and local application of radiofrequency energy had varying success in preventing recurrence. This approach has important limitations due to the sporadic nature of ventricular extrasystoles, which are often not detected during electrophysiological study, as well as the possible coexistence of ventricular extrasystoles of different morphologies and origins with no pathophysiological significance. Notably, the first case described of a Brugada electrocardiographic pattern being eliminated as a result of radiofrequency ablation was of a patient in whom the absence of ventricular extrasystoles during the exam meant that pace mapping was required, followed by ablation of a large area, which suggests that extensive modification of the substrate may be curative in these patients.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In 2007, Morita et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> studied radiofrequency ablation for the treatment of ventricular arrhythmias in an animal model of Brugada syndrome. Although the approach adopted still focused on ablation of ventricular extrasystoles, this work also highlighted the pathophysiological importance of the epicardium. The authors found that the appearance of the Brugada pattern coincided with the development of heterogeneity in the morphology and duration of epicardial action potentials, with no alterations in endocardial recordings. Ventricular extrasystoles were subsequently documented, with multiple foci distributed over a large area of the epicardium (6.1±1.4 cm<span class="elsevierStyleSup">2</span>), ending in polymorphic VT. They demonstrated that epicardial (but not endocardial) application of radiofrequency energy prevented recurrence of these tachyarrhythmias. However, and in agreement with clinical observations, they pointed out that in order to achieve this effect ablation over a wide area was necessary, extensively modifying the substrate.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In a pioneering study in 2011, Nademanee et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> performed endocardial and epicardial mapping of the RVOT in nine patients with Brugada syndrome and frequent episodes of VF. As in the case presented, there were no alterations in voltage or duration of electrograms in the endocardium, but areas with abnormal potentials were identified in the anterior wall of the RVOT, characterized by low voltages (≤1 mV), fractionation and long duration (>80 ms), lasting well beyond the end of the surface QRS. In that study, the authors mapped the duration of the local bipolar electrogram, while we opted to map the time to the end of the bipolar electrogram, using the surface electrocardiogram as the reference and adjusting the lower edge of the region of interest on the map to the end of the QRS (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B). Re-analyzing the map employing their method produced similar results (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>C). Nademanee et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> found that epicardial ablation of the area of abnormal potentials resulted in normalization of the Brugada pattern in seven of the nine patients, during follow-up in three of them, as in our patient. None of the patients had recurrence of polymorphic VT/VF, as in the case presented.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The type 1 Brugada repolarization abnormalities observed in our patient were not only in the right precordial leads but also in aVR and inferior leads. It has recently been reported that the presence of such alterations in the frontal plane leads is a strong predictor of risk in patients with Brugada syndrome.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The present case also illustrates the unpredictable nature of ventricular extrasystoles as a target for ablation in this syndrome. Although our patient had frequent monomorphic ventricular extrasystoles of a morphology consistent with RVOT origin, these disappeared spontaneously during electrophysiological study, probably due to sedation; isoprenaline, commonly used to increase the incidence of extrasystoles, was not used since it is known to have an anti-arrhythmic effect in Brugada syndrome. It is also worth noting the seeming inconsistency between the long-term efficacy of substrate modification, as reflected in the disappearance of the Brugada electrocardiographic pattern and prevention of ventricular arrhythmias, and its apparent ineffectiveness in eliminating ventricular extrasystoles in the short term. Electrocardiographic monitoring during the 48 hours following ablation showed that monomorphic ventricular extrasystoles reappeared after the exam and remained constant during this period. This prompted institution of propranolol, despite discontinuation of quinidine therapy. No ventricular extrasystoles were documented on follow-up assessment, and so propranolol was also discontinued.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally, it is important to recognize that epicardial ablation to modify the electrophysiological substrate may have its limitations. It has recently been observed that prolongation of electrograms in the RVOT is dynamic. In a patient with a history of VF but without spontaneous type 1 Brugada pattern, epicardial mapping of the RVOT identified a low-voltage area with fractionated potentials. Subsequently, during administration of ajmaline, the appearance of a type 1 pattern on the ECG coincided with progressive prolongation of local electrograms.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The dynamic nature of depolarization abnormalities in the epicardium in patients with Brugada syndrome makes it difficult to determine how extensive substrate modification has to be to achieve clinical efficacy, or even a cure. Furthermore, a study using non-contact mapping (EnSite 3000), in which the location of the epicardial substrate was extrapolated from analysis of unipolar endocardial virtual electrograms, suggested that prolongation of depolarization beyond the end of the surface QRS could originate at sites in the RVOT that are not accessible via the epicardium, such as the septal region.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Since follow-up in the case presented is still short, it is impossible to draw definitive conclusions as to the efficacy of the procedure. However, the disappearance of the Brugada pattern and the absence of any arrhythmic events in a patient in whom these had been extremely frequent suggests that epicardial ablation of abnormal, fractionated and prolonged potentials in the RVOT was effective as well as safe.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres350687" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec332245" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres350688" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec332244" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-08" "fechaAceptado" => "2014-01-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec332245" "palabras" => array:5 [ 0 => "Brugada syndrome" 1 => "Catheter ablation" 2 => "Epicardial ablation" 3 => "Electrophysiology" 4 => "Mapping" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec332244" "palabras" => array:5 [ 0 => "Síndrome de Brugada" 1 => "Ablação por cateter" 2 => "Ablação epicárdica" 3 => "Eletrofisiologia" 4 => "Mapeamento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present the case of a 60-year-old woman with Brugada syndrome, permanent type 1 electrocardiographic pattern, who had previously received an implantable cardioverter-defibrillator. She suffered frequent syncopal episodes and multiple appropriate shocks (around five per month) due to polymorphic ventricular tachycardia/ventricular fibrillation, refractory to quinidine therapy. Combined epicardial and endocardial electroanatomical mapping was performed with a view to substrate ablation. An area of abnormal fractionated electrograms, lasting up to 370 ms and up to 216 ms after the end of the surface QRS, was identified in the epicardium in the lower anterior part of the right ventricular outflow tract. Extensive epicardial ablation of this area, which eliminated the fractionated electrograms, led to the disappearance of the Brugada electrocardiographic pattern six weeks after ablation. Despite discontinuation of quinidine, no further ventricular arrhythmias occurred during follow-up, which is still of short duration.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">É apresentado o caso de uma doente de 60 anos com síndrome de Brugada, padrão tipo 1 permanente, portadora de cardioversor-desfibrilhador, com episódios frequentes de síncope por taquicardia ventricular polimórfica/fibrilhação ventricular (cerca de cinco por mês), refratários à terapêutica com quinidina e com múltiplos choques apropriados. Foi efetuado mapeamento eletroanatómico endocárdico e epicárdico do ventrículo direito, em ritmo sinusal, confirmando-se a presença de uma área epicárdica na região anterior da câmara de saída ventricular direita com eletrogramas anómalos, fracionados e de longa duração (até 370 ms), que se prolongavam até 216 ms após o término do QRS de superfície. A ablação epicárdica alargada dessa área, com abolição dos eletrogramas anómalos, conduziu ao desaparecimento do padrão de Brugada na reavaliação eletrocardiográfica efetuada às seis semanas. Apesar da suspensão da terapêutica com quinidina, não ocorreram novas disritmias ventriculares, durante o seguimento, ainda de curta duração.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cortez-Dias N, Plácido R, Marta L, et al. Ablação epicárdica para prevenção da fibrilhação ventricular em doente com síndrome de Brugada. Rev Port Cardiol. 2014;33:305.e1–305.e7.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0120" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 986 "Ancho" => 2507 "Tamanyo" => 260306 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">12-Lead electrocardiogram showing bifascicular block (complete right bundle branch block and left anterior hemiblock), type 1 Brugada pattern (with coved ST elevation in V1–V4, terminating in inverted T wave), long QT interval (522 ms, corrected QT 568 ms) and isolated ventricular extrasystole with left bundle branch block morphology and inferior axis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1028 "Ancho" => 2507 "Tamanyo" => 189561 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Endocardial maps of the right ventricle. Mapping of time to end of local bipolar electrogram in anteroposterior view (A) and right lateral view (B): activation of the endocardial regions ends during the surface QRS (in red), which ended 127 ms after the map reference. Mapping of bipolar voltage in anteroposterior view (C) and right lateral view (D): all endocardial regions of the right ventricle show normal voltage (>1.5 mV) (in pink).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1174 "Ancho" => 3007 "Tamanyo" => 195592 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Epicardial maps in anteroposterior views: (A) mapping of bipolar voltage, showing normal voltage (>1.5 mV, in pink) in all epicardial regions of the left ventricle and right ventricular outflow tract (regions with lower voltage correspond to pulmonary and tricuspid valve planes; voltage in the epicardial apical region was not assessed); (B) mapping of time to end of the local bipolar electrogram; and (C) mapping of the duration of the local bipolar electrogram. The electrograms recorded in the left ventricle were of normal duration and ended during the surface QRS. An area measuring 6.9 cm<span class="elsevierStyleSup">2</span> was identified in the anterior region of the right ventricular outflow tract with fractionated potentials (light pink dots), of long duration (up to 370 ms) and lasting up to 216 ms after the end of the QRS.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1458 "Ancho" => 3007 "Tamanyo" => 245622 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Endo-epicardial dispersion of action potential duration in the anterior region of the right ventricular outflow tract: (A) bipolar and unipolar electrograms of the epicardium (MAP-Epi) and endocardium (MAP-Endo) recorded in contiguous sites, shown in right profile views on the endocardial (B) and epicardial (C) maps of the right ventricle. The marked prolongation of epicardial depolarization (duration 330 ms, lasting up to 216 ms after the end of the QRS) contrasts with the normal duration of depolarization in the corresponding endocardial region (102 ms).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1451 "Ancho" => 1632 "Tamanyo" => 133662 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Radiofrequency energy applications on the epicardial side of the anterior region of the right ventricular outflow tract, covering the area with prolonged action potentials.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 2708 "Ancho" => 1632 "Tamanyo" => 535671 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Comparison of surface electrocardiograms before and after ablation. LICS: left intercostal space; RICS: right intercostal space.</p>" ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 2038528 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] 7 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1636616 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Right bundle branch block persistent ST segment elevation and sudden cardiac death: A distinct clinical and electrocardiographic syndrome: A multicenter report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 5 | 11 |
| 2024 October | 31 | 28 | 59 |
| 2024 September | 39 | 26 | 65 |
| 2024 August | 44 | 31 | 75 |
| 2024 July | 26 | 29 | 55 |
| 2024 June | 38 | 18 | 56 |
| 2024 May | 43 | 17 | 60 |
| 2024 April | 33 | 23 | 56 |
| 2024 March | 44 | 20 | 64 |
| 2024 February | 33 | 34 | 67 |
| 2024 January | 35 | 34 | 69 |
| 2023 December | 33 | 26 | 59 |
| 2023 November | 31 | 20 | 51 |
| 2023 October | 24 | 12 | 36 |
| 2023 September | 33 | 22 | 55 |
| 2023 August | 25 | 13 | 38 |
| 2023 July | 46 | 16 | 62 |
| 2023 June | 37 | 14 | 51 |
| 2023 May | 45 | 23 | 68 |
| 2023 April | 34 | 7 | 41 |
| 2023 March | 45 | 18 | 63 |
| 2023 February | 35 | 23 | 58 |
| 2023 January | 39 | 19 | 58 |
| 2022 December | 47 | 25 | 72 |
| 2022 November | 63 | 32 | 95 |
| 2022 October | 33 | 15 | 48 |
| 2022 September | 30 | 29 | 59 |
| 2022 August | 32 | 31 | 63 |
| 2022 July | 38 | 29 | 67 |
| 2022 June | 33 | 18 | 51 |
| 2022 May | 56 | 35 | 91 |
| 2022 April | 45 | 24 | 69 |
| 2022 March | 34 | 28 | 62 |
| 2022 February | 31 | 23 | 54 |
| 2022 January | 50 | 22 | 72 |
| 2021 December | 36 | 24 | 60 |
| 2021 November | 49 | 38 | 87 |
| 2021 October | 56 | 45 | 101 |
| 2021 September | 37 | 24 | 61 |
| 2021 August | 51 | 37 | 88 |
| 2021 July | 45 | 20 | 65 |
| 2021 June | 30 | 17 | 47 |
| 2021 May | 34 | 34 | 68 |
| 2021 April | 68 | 33 | 101 |
| 2021 March | 46 | 17 | 63 |
| 2021 February | 111 | 15 | 126 |
| 2021 January | 52 | 13 | 65 |
| 2020 December | 46 | 12 | 58 |
| 2020 November | 47 | 13 | 60 |
| 2020 October | 38 | 15 | 53 |
| 2020 September | 45 | 15 | 60 |
| 2020 August | 15 | 5 | 20 |
| 2020 July | 55 | 5 | 60 |
| 2020 June | 62 | 8 | 70 |
| 2020 May | 49 | 8 | 57 |
| 2020 April | 53 | 5 | 58 |
| 2020 March | 53 | 6 | 59 |
| 2020 February | 115 | 30 | 145 |
| 2020 January | 49 | 12 | 61 |
| 2019 December | 32 | 1 | 33 |
| 2019 November | 42 | 3 | 45 |
| 2019 October | 44 | 4 | 48 |
| 2019 September | 42 | 12 | 54 |
| 2019 August | 53 | 6 | 59 |
| 2019 July | 43 | 15 | 58 |
| 2019 June | 29 | 6 | 35 |
| 2019 May | 54 | 9 | 63 |
| 2019 April | 25 | 12 | 37 |
| 2019 March | 57 | 11 | 68 |
| 2019 February | 89 | 7 | 96 |
| 2019 January | 60 | 8 | 68 |
| 2018 December | 73 | 13 | 86 |
| 2018 November | 147 | 8 | 155 |
| 2018 October | 394 | 30 | 424 |
| 2018 September | 134 | 16 | 150 |
| 2018 August | 84 | 12 | 96 |
| 2018 July | 48 | 8 | 56 |
| 2018 June | 71 | 12 | 83 |
| 2018 May | 80 | 15 | 95 |
| 2018 April | 106 | 7 | 113 |
| 2018 March | 102 | 6 | 108 |
| 2018 February | 127 | 7 | 134 |
| 2018 January | 110 | 8 | 118 |
| 2017 December | 154 | 9 | 163 |
| 2017 November | 74 | 7 | 81 |
| 2017 October | 42 | 15 | 57 |
| 2017 September | 45 | 19 | 64 |
| 2017 August | 53 | 22 | 75 |
| 2017 July | 67 | 18 | 85 |
| 2017 June | 43 | 9 | 52 |
| 2017 May | 69 | 12 | 81 |
| 2017 April | 49 | 6 | 55 |
| 2017 March | 64 | 23 | 87 |
| 2017 February | 76 | 6 | 82 |
| 2017 January | 60 | 5 | 65 |
| 2016 December | 71 | 11 | 82 |
| 2016 November | 49 | 13 | 62 |
| 2016 October | 82 | 13 | 95 |
| 2016 September | 69 | 9 | 78 |
| 2016 August | 27 | 3 | 30 |
| 2016 July | 31 | 3 | 34 |
| 2016 June | 17 | 4 | 21 |
| 2016 May | 20 | 9 | 29 |
| 2016 April | 77 | 1 | 78 |
| 2016 March | 99 | 15 | 114 |
| 2016 February | 121 | 30 | 151 |
| 2016 January | 140 | 27 | 167 |
| 2015 December | 115 | 10 | 125 |
| 2015 November | 99 | 16 | 115 |
| 2015 October | 118 | 19 | 137 |
| 2015 September | 99 | 26 | 125 |
| 2015 August | 93 | 18 | 111 |
| 2015 July | 97 | 14 | 111 |
| 2015 June | 73 | 17 | 90 |
| 2015 May | 83 | 15 | 98 |
| 2015 April | 76 | 11 | 87 |
| 2015 March | 73 | 10 | 83 |
| 2015 February | 62 | 12 | 74 |
| 2015 January | 71 | 14 | 85 |
| 2014 December | 95 | 16 | 111 |
| 2014 November | 67 | 18 | 85 |
| 2014 October | 79 | 17 | 96 |
| 2014 September | 85 | 18 | 103 |
| 2014 August | 76 | 19 | 95 |
| 2014 July | 104 | 42 | 146 |
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