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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; von Hafe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> present data on a series of patients with well documented Brugada syndrome &#40;BrS&#41; who were screened as possible candidates for implantation of a subcutaneous implantable cardioverter-defibrillator &#40;S-ICD&#41;&#46; As detailed in the study&#44; and as required by the manufacturer of the device&#44; patients considered for an S-ICD have to fulfill certain electrocardiographic &#40;ECG&#41; criteria based on a specific analysis tool&#46; Basically&#44; a good sensing signal with good discrimination between depolarization &#40;QRS complex&#41; and repolarization &#40;ST segment-T wave&#41; is required in order to identify potential arrhythmias&#44; but also to avoid oversensing&#44; particularly T-wave oversensing&#44; that may result in a false positive arrhythmia diagnosis and in inappropriate shocks&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The problem of T-wave oversensing in BrS is a well-known phenomenon that goes back to the very beginning of the description of this disease&#46; Historical patients were documented in the past to have required implantation of left ventricular epicardial leads because of T-wave oversensing at many right ventricular endocavitary locations &#40;unpublished data&#41;&#46; These patients prompted the development of new algorithms for endo- and epicardial systems to avoid T-wave oversensing&#46; Use of dynamic sensing thresholds and T-wave suppression algorithms have resulted in the virtual disappearance of this problem for endocavitary systems&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As also pointed out by von Hafe et al&#46;&#44; a significant proportion of patients with BrS immediately fail to qualify for safe implantation of a S-ICD&#46; This percentage has been as high as 30&#37; in some studies<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> and was 14&#37; in von Hafe et al&#46;&#8217;s series&#46; When their patients underwent exercise testing and ECG qualification for an S-ICD was repeated after exercise&#44; the proportion of patients not qualifying for an S-ICD increased to one in three&#46; These observations are extremely important because an S-ICD can theoretically reduce the number of complications associated with endocavitary leads&#46; However&#44; these advantages come with some drawbacks&#44; like the lack of antitachycardia pacing that may be useful to avoid a shock in the 4&#37; of patients with BrS suffering from pace-terminable monomorphic ventricular tachycardia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> A second drawback of S-ICDs is the lack of antibradycardia pacing&#46; Conduction disturbances and sick sinus syndrome are common in BrS and also have a very negative prognostic impact&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Correction of these bradyarrhythmia episodes may be one of the reasons that patients with BrS do not present more syncopal episodes after transvenous ICD implantation&#46; An important subset of patients with BrS suffer from atrial fibrillation that may be completely asymptomatic&#46; Atrial fibrillation is an important prognostic issue in BrS because of its complications&#44; including embolization&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> and as a potential cause of inappropriate shocks &#40;14&#37; of patients in the series by Sarkozy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a>&#41;&#46; Correct identification of atrial fibrillation requires atrial sensing&#44; something not available with an S-ICD&#46; Thus&#44; while we are all very much in favor of the theoretical advantages of an S-ICD in BrS compared to endocavitary systems&#44; the available data do not seem to support the S-ICD as the best option&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As complications of endocavitary leads have invariably been related to the number of leads implanted&#44; reducing the number of leads while maintaining the advantages of atrial sensing and ventricular antitachycardia and antibradycardia pacing seems to be the best option at present&#46; Single-pass endocavitary leads with A and V sensing and V pacing have been available for some time&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> In combination with T-wave suppression algorithms and remote monitoring&#44; they have been shown to offer the best solution not only in BrS but in a wide variety of diseases&#44; offering the best therapies while avoiding unnecessary complications&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study by von Hafe et al&#46; is an important one because it tackles the problem of ECG variability in BrS&#46; If for any reason an S-ICD is considered in a patient with BrS there is no doubt that ECG candidacy testing at rest and after exercise has to become part of the routine assessment before S-ICD implantation&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pedro Brugada is a consultant for Biotronik&#46;</p></span></span>"
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The variability of the electrocardiogram in Brugada syndrome: Implications for subcutaneous implantable cardioverter-defibrillator candidacy
A variabilidade do ECG na síndrome de Brugada: implicações na seleção de candidatos a CDI subcutâneo
Pedro Brugada
Cardiovascular Division, UZ Brussel, Brussels, Belgium
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; von Hafe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> present data on a series of patients with well documented Brugada syndrome &#40;BrS&#41; who were screened as possible candidates for implantation of a subcutaneous implantable cardioverter-defibrillator &#40;S-ICD&#41;&#46; As detailed in the study&#44; and as required by the manufacturer of the device&#44; patients considered for an S-ICD have to fulfill certain electrocardiographic &#40;ECG&#41; criteria based on a specific analysis tool&#46; Basically&#44; a good sensing signal with good discrimination between depolarization &#40;QRS complex&#41; and repolarization &#40;ST segment-T wave&#41; is required in order to identify potential arrhythmias&#44; but also to avoid oversensing&#44; particularly T-wave oversensing&#44; that may result in a false positive arrhythmia diagnosis and in inappropriate shocks&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The problem of T-wave oversensing in BrS is a well-known phenomenon that goes back to the very beginning of the description of this disease&#46; Historical patients were documented in the past to have required implantation of left ventricular epicardial leads because of T-wave oversensing at many right ventricular endocavitary locations &#40;unpublished data&#41;&#46; These patients prompted the development of new algorithms for endo- and epicardial systems to avoid T-wave oversensing&#46; Use of dynamic sensing thresholds and T-wave suppression algorithms have resulted in the virtual disappearance of this problem for endocavitary systems&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As also pointed out by von Hafe et al&#46;&#44; a significant proportion of patients with BrS immediately fail to qualify for safe implantation of a S-ICD&#46; This percentage has been as high as 30&#37; in some studies<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> and was 14&#37; in von Hafe et al&#46;&#8217;s series&#46; When their patients underwent exercise testing and ECG qualification for an S-ICD was repeated after exercise&#44; the proportion of patients not qualifying for an S-ICD increased to one in three&#46; These observations are extremely important because an S-ICD can theoretically reduce the number of complications associated with endocavitary leads&#46; However&#44; these advantages come with some drawbacks&#44; like the lack of antitachycardia pacing that may be useful to avoid a shock in the 4&#37; of patients with BrS suffering from pace-terminable monomorphic ventricular tachycardia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> A second drawback of S-ICDs is the lack of antibradycardia pacing&#46; Conduction disturbances and sick sinus syndrome are common in BrS and also have a very negative prognostic impact&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Correction of these bradyarrhythmia episodes may be one of the reasons that patients with BrS do not present more syncopal episodes after transvenous ICD implantation&#46; An important subset of patients with BrS suffer from atrial fibrillation that may be completely asymptomatic&#46; Atrial fibrillation is an important prognostic issue in BrS because of its complications&#44; including embolization&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> and as a potential cause of inappropriate shocks &#40;14&#37; of patients in the series by Sarkozy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a>&#41;&#46; Correct identification of atrial fibrillation requires atrial sensing&#44; something not available with an S-ICD&#46; Thus&#44; while we are all very much in favor of the theoretical advantages of an S-ICD in BrS compared to endocavitary systems&#44; the available data do not seem to support the S-ICD as the best option&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As complications of endocavitary leads have invariably been related to the number of leads implanted&#44; reducing the number of leads while maintaining the advantages of atrial sensing and ventricular antitachycardia and antibradycardia pacing seems to be the best option at present&#46; Single-pass endocavitary leads with A and V sensing and V pacing have been available for some time&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> In combination with T-wave suppression algorithms and remote monitoring&#44; they have been shown to offer the best solution not only in BrS but in a wide variety of diseases&#44; offering the best therapies while avoiding unnecessary complications&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study by von Hafe et al&#46; is an important one because it tackles the problem of ECG variability in BrS&#46; If for any reason an S-ICD is considered in a patient with BrS there is no doubt that ECG candidacy testing at rest and after exercise has to become part of the routine assessment before S-ICD implantation&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pedro Brugada is a consultant for Biotronik&#46;</p></span></span>"
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