Background: Chagas' cardiomyopathy is one important cause of heart failure in Latin America. Ventricular dyssynchrony may be a factor of decompensation in the course of this disease, but there are no data on its prevalence and its main prognostic implications yet.

We present a case of a young boy who had an implantable cadrioverter defibrillator implanted for refractory syncope and cathecolaminergic polymorphic ventricular tachycardia (CPVT). The patient underwent an electrical storm with multiple shocks and serious compromise of quality of life and risk. The pharmacological options are discussed as well as the strategies of managing ventricular arrhythmias in CPVT.

SUMMARY BACKGROUND: Cardiac resynchronization therapy (CRT) is a therapeutic modality for patients with heart failure (HF). The effectiveness of this treatment for event reduction is based on clinical trials where the population of patients with Chagas' disease (DC) is underrepresented. OBJECTIVE: To evaluate the prognosis after CRT of a population in which CD is an endemic cause of HF. METHODS: A retrospective cohort conducted between January 2015 and December 2016 that included patients with HF and left ventricular ejection fraction (LVEF) of less than 35% and undergoing CRT. Clinical and demographic data were collected to search for predictors for the combined outcome of death or hospitalization for HF at one year after CRT implantation. RESULTS: Fifty-four patients were evaluated, and 13 (24.1%) presented CD as the etiology of HF. The mean LVEF was 26.2± 6.1%, and 36 (66.7%) patients presented functional class III or IV HF. After the mean follow-up of 15 (±6,9) months, 17 (32.1%) patients presented the combined outcome. In the univariate analysis, CD was associated with the combined event when compared to other etiologies of HF, 8 (47%) vs. 9 (13,5%), RR: 3,91 CI: 1,46–10,45, p=0,007, as well as lower values of LVEF. In the multivariate analysis, CD and LVEF remained independent risk factors for the combined outcome. CONCLUSION: In a population of HF patients undergoing CRT, CD was independently associated with mortality and hospitalization for HF.

Nota: Estas diretrizes se prestam a informar e não a substituir o julgamento clínico do médico que, em última análise, deve determinar o tratamento apropriado para seus pacientes.

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A estimulação direta do sistema de condução foi idealizada na década de 70, porém, o procedimento só se tornou factível e reprodutível com o desenvolvimento de ferra-mentas específicas. A qualidade da estimulação obtida depende de fatores como: nível anatômico do sistema His-Purkinje alcançado; captura muscular concomitante ou não e resposta eletrocardiográfica obtida. A estimulação do sistema de condução envolve a captura do feixe de His ou do ramo esquerdo e seus fascículos, podendo ser seletiva (S) ou não seletiva (NS), na dependência de ausência ou presença, respectivamente, de captura simultânea do miocárdio ventricular adjacente. Diante das atuais evidências, a estimulação direta do sistema de condução pode ser considerada uma alternativa aos pacientes com bradicardia e indicação para implante de marcapasso, evitando-se os efeitos indesejáveis do dissincronismo ventricular causado pela estimulação tradicional de ventrículo direito (VD) como, também, uma alternativa à estimulação biventricular para terapia de ressincronização cardíaca (TRC). Apesar de promover ativação ventricular fisiológica, a estimulação do feixe de His apresenta algumas limitações anatômicas e funcionais além da incapacidade de corrigir a doença distal do sistema de condução, enquanto a estimulação do ramo esquerdo fornece limiares mais baixos e estáveis, além de corrigir as doenças de condução, sendo capaz de promover sincronismo intraventricular equivalente à estimulação direta do feixe de His e, por esses motivos, sua aplicação vem se ampliando largamente. Embora os dados ainda sejam limitados e grandes estudos prospectivos para avaliação de segurança e eficácia a longo prazo sejam necessários, os resultados são favoráveis à essa modalidade de estimulação.

We describe the case of a 62-year-old patient who returned for evaluation nine months after receiving an implantable cardioverter-defibrillator (ICD) with signs of delayed right ventricular (RV) perforation. The clinical signs that allowed the diagnosis of this late presentation to be achieved are discussed herein, as well as the conduct and the frequency of this complication in the literature.

Background There is limited prospective real-world evidence of patients with atrial fibrillation (AF) in Latin America. Methods The rationale and design of the study were previously published (1). Briefly, RECALL was the first nationwide prospective study of patients in Brazil with known atrial fibrillation. A total of 4,585 patients were included among 89 sites from April 2012 to August 2019. All patients were followed for one year by the protocol. Patient characteristics, medications under use and clinical outcomes during the follow-up were collected. Results From the total of patients enrolled, 41 were excluded from the analysis since they did not have a confirmed diagnosis of atrial fibrillation. The median age was 70 (61–78) years, 46% were women and the majority of the cases were permanent AF (53,8%). The mean CHA2DS2VASc was 3.2±1.6 and the median HASBLED was 2 [2–3]. The most common risk factor was arterial hypertension (77.9%). The median heart rate was 74 [65–85] and the mean ejection fraction was 52.2±2.6 (%). Only 4.4% of patients had history of previous ablation and 30.4% were using anti-arrhythmic. At baseline, 22.0% did not use anticoagulants (Figure 1) and 9.1% did not use any antithrombotic therapy. The most common anticoagulant was vitamin K antagonist – VKA (62.6%) while the remaining 37.4% were direct oral anticoagulants. The main reasons for not using an oral anticoagulant were physician judgment's (low risk of stroke – 24.6%) and difficult to control (14.7%) or perform INR (9.9%) while patient preference and adverse event represented respectively 5.3% and 4.1%, respectively. Only 42.5% of the INRs at baseline were between 2 and 3. During follow-up, the use of anticoagulants and INR in the therapeutic range increased to 87.1% and 59.1%, respectively. In one year, 17.8% of patients were hospitalized due to atrial fibrillation. At 1 year, the rates of death, stroke, systemic embolism and major bleeding were 5.76 [5.12–6.47], 2.77 [2.32–3.32] 1.01 [0.75–1.36], 2.21 [1.81–2.70], respectively. Among VKA users, the rate of mortality and bleeding was higher in the group with time in therapeutic range below 60% (Figure 2). Conclusion RECALL represents the largest prospective registry of patients with atrial fibrillation in Latin America. Our findings highlight important gaps in the treatment of patients which can inform clinical practice and help to guide future interventions to improve the care of these patients. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Brazilian Society of Cardiology