Relative risks for comorbidities associated with myotonic dystrophy: A population-based analysis.

INTRODUCTION: A population-level relative risk assessment for comorbidities associated with myotonic dystrophy has not been performed. METHODS: In this study we utilized the Utah Population Database to identify patients with myotonic dystrophy in Utah according to ICD-9 coding. Comorbidity cases listed in the medical record were compared with those of the Utah population. RESULTS: Individuals with myotonic dystrophy were found to possess an increased risk of central and obstructive sleep apnea, hypothyroidism, and intellectual disability. The risk of cardiac conduction disorder is 60 times the population risk. CONCLUSIONS: This study provides a population-level relative risk assessment of comorbidities in myotonic dystrophy. This allows for improved counseling of patients regarding these increased risks.

Predictors of successful cardioversion with vernakalant in patients with recent-onset atrial fibrillation.

BACKGROUND: Vernakalant is a novel atrial-selective antiarrhythmic drug able to convert recent-onset atrial fibrillation (AF) with reportedly low proarrhythmic risk. Successful cardioversion predictors are largely unknown. We sought to evaluate clinical and electrocardiographic predictors of cardioversion of recent-onset AF with vernakalant. METHODS: Consecutive patients with AF ≤48 hours admitted for cardioversion with vernakalant (n = 113, median age 62 years, 69 male) were included. Sinus rhythm (SR) within 90 minutes after infusion start was considered to be successful cardioversion. Predictive values of demographics, concomitant therapy, comorbidities, and electrocardiographic parameters were assessed. Atrial fibrillatory rate (AFR), exponential decay, and mean fibrillatory wave amplitude were measured from surface ECG using QRST cancellation and time-frequency analysis. RESULTS: Cardioversion was achieved in 66% of patients. Conversion rate was higher in women than in men (80% vs 58%, P = 0.02) while none of other clinical characteristics, including index AF episode duration, could predict SR restoration. Female gender was predictive of vernakalant's effect in logistic regression analysis (OR = 2.82 95%CI 1.18-6.76, P = 0.020). There was no difference in AFR (350 ± 60 vs 348 ± 62 fibrillations per minute [fpm], P = 0.893), mean fibrillatory wave amplitude (86 ± 33 vs 88 ± 67 µV, P = 0.852), or exponential decay (1.30 ± 0.42 vs 1.35 ± 0.42, P = 0.376) between responders and nonresponders. CONCLUSIONS: Female gender is associated with a higher rate of SR restoration using intravenous (i.v.) vernakalant for recent-onset AF. ECG-derived indices of AF organization, which previous studies associated with effect of rhythm control interventions, did not predict vernakalant's effect.

[Lyme carditis]. / Borelioza serca.

Lyme disease is a multisystem infectious disease caused by the spirochete Borrelia burgdorferi. A steady increase in the number of cases is noticed both in Poland and Europe. Cardiac involvement in the course of borreliosis is relatively rare. It is estimated that it concerns about 0.5-10% of patients with Lyme disease. Cardiac involvement generally occurs in the early phase of illness. The most common manifestation of Lyme carditis are transient conduction abnormality, arrhythmias, myocarditis and pericarditis. The basic method of treatment Lyme carditis are antibiotics. The clinical course is usually benign. In most cases a complete recovery is observed. However, in a small proportion of patients dilated cardiomyopathy may occur. Furthermore, death from Lyme carditis has been reported. Lyme carditis remains a real diagnostic and therapeutic challenge for clinicians. Factors that can make the diagnosis difficult are: atypical clinical picture, negation of tick bite, the absence of erythema migrans, onset of symptoms outside the period of tick activity and negative serological results in the initial stage of the disease.

Cardiovascular abnormalities with single dose of tapentadol.

This case represents the development of dizziness, palpitation, tightness in chest, flushing, and tremor on consumption of a single dose of tapentadol (100 mg) for acute lower back pain. The patient was admitted in the intensive cardiac care unit for continuous monitoring. At admission, electrocardiogram showed tachycardia (140/min) along with ST segment elevation in second chest lead (V2). The patient was monitored and advised not to take further doses of tapentadol. He was discharged after 36 hours of admission. Tapentadol should be used cautiously in patients with cardiovascular diseases and receiving sympathomimetic drugs.

[Cardioprotective effect and mechanism of intensive lipid modulation on patients with coronary artery disease undergoing noncardiac surgery].

OBJECTIVE: To explore the protective effect and possible mechanism of intensive lipid modulation on the perioperative period of patients with stable coronary artery disease undergoing noncardiac surgery. METHODS: In the study, 60 patients with stable coronary artery disease undergoing elective noncardiac surgery were randomly divided into intensive lipid modulation group (n = 30) and conventional group (n = 30). In intensive lipid modulation group, the patients were given atorvastatin 40 mg every night before surgery, 80 mg 12 h before surgery, and 40 mg 2 h before surgery, and 40 mg every night after noncardiac surgery. In conventional group, the patients were given atorvastatin 20 mg every night before surgery and also after the surgery. The occurrence of perioperative major adverse cardiac events (including sudden cardiac death, acute myocardial infarction, unplanned revascularization) were compared in the two groups. Preoperative and 48 h postoperative changes of lipid levels and inflammatory markers were also compared in the two groups. RESULTS: In conventional group, one patient suffered myocardial infarction with acute anterior ST-segment elevation and was given emergency left anterior descending artery interventional reperfusion therapy, and 7 patients suffered asymptomatic myocardial infarction. In intensive lipid modulation group, one patient suffered asymptomatic myocardial infarction, and the incidence rate of perioperative acute myocardial infarction reduced significantly compared with conventional group (P < 0.05). There was no significant difference in preoperative and postoperative changes of lipid levels in the two groups (P > 0.05), and compared with conventional group, there was significantly lower levels of inflammatory markers in intensive lipid modulation group (P < 0.05). CONCLUSION: The intensive lipid modulation group significantly reduced the incidence of perioperative major adverse cardiac events especially asymptomatic myocardial infarction, and the inhibition of the inflammatory response may be one of the protective mechanisms, which still needs to be further confirmed by large multicenter randomized controlled clinical trials.

Ivabradine in the treatment of inappropriate sinus tachycardia in patients after successful radiofrequency catheter ablation of atrioventricular node slow pathway.

BACKGROUND: Inappropriate sinus tachycardia (IST) occurs relatively common after catheter ablation of slow pathway in patients with atrioventricular nodal reentrant tachycardia. The treatment of IST symptoms using ß-blockers or calcium channel-blockers are often noneffective or not well tolerated. Ivabradine is a new heart rate (HR)-decreasing agent inhibiting sinus node If current. The purpose of the study was to evaluate the efficacy and safety of ivabradine in patients with persistent and ß-blocker-resistant IST after successful radiofrequency (RF) ablation of atrioventricular node slow pathway. METHODS: We enrolled 14 patients (42 ± 11 years; 10 women) affected by IST after RF ablation. Holter monitoring, treadmill stress test, and IST symptoms assessment were performed at baseline and after first, and second month of the study. RESULTS: We observed significant reduction of mean resting HR after 30 and 60 days of ivabradine treatment compared to baseline (P < 0.001). 24-hour Holter monitoring showed a significant reduction of mean HR and mean HR during daily activity (P < 0.001). The study revealed significant improvement in exercise capacity during treadmill exercise test on ivabradine therapy (P < 0.001). Significantly lower incidence of IST-related symptoms were registered after administration of If current inhibitor. After 2 months of treatment no patients reported severe complaints assessed by means of European Heart Rhythm Association score. We did not observe severe side effects during therapy. CONCLUSION: Ivabradine is an effective treatment option to reduce HR and symptoms in patients with IST after RF ablation of atrioventricular node slow pathway. The therapy with ivabradine is well tolerated even with maximum daily dose.

Catheter ablation of an accessory pathway within the marshall vein in a patient with mechanical mitral valve.

A 37-year-old man, known case of mitral valve replacement, was referred for ablation. Meticulous mapping showed the earliest signal in the distal coronary sinus (CS). Endocardial ablation via transseptal approach failed to permanently ablate the accessory pathway. Similarly, ablation within the CS was unsuccessful. Finally, the mapping catheter was introduced into the vein of Marshall (VoM) and a very early signal was obtained. In the first 3 seconds of the radiofrequency energy application within the VoM, delta wave disappeared. During 1-year follow-up, the patient had no recurrence of the palpitations and electrocardiogram showed no delta wave.

Importance of superior vena cava isolation in successful ablation of persistent atrial fibrillation in patient with partial anomalous pulmonary vein.

Ectopic foci arising from pulmonary veins (PVs) are the predominant sources for the initiation and maintenance of atrial fibrillation (AF) in a vast majority of cases. However, ectopic foci also exist in the non-PV areas like superior vena cava (SVC) in 10-20% of the cases. We report the significance of SVC isolation in a patient with persistent AF and anomalous pulmonary venous connection of the right superior pulmonary vein into the SVC.

Unique preferential conduction within the isolated septal substrate in a patient with ventricular tachycardia complicated with non-ischemic dilated cardiomyopathy.

We describe the case of a 67-year-old woman with non-ischemic dilated cardiomyopathy who underwent successful radiofrequency catheter ablation for ventricular tachycardia (VT) originated from the isolated ventricular septal substrate. Pacemapping exhibited either left, identical to clinical VT, or right bundle branch block like wide QRS morphology. Time interval from the stimulus to QRS onset (St-QRS) was prolonged at the center of the substrate, while St-QRS at the border was shortened. Difference in the morphology of pacemapping was dependent on whether or not the pacing stimulus could propagate directly into the right ventricle due to the possible intramural conduction disturbance.

[12-lead ECG teletransmission in emergency medicine teams' actions]. / Teletransmisja 12-odprowadzeniowego zapisu EKG w dzialaniach zespolów ratownictwa medycznego.

INTRODUCTION: Sudden health-threatening conditions with cardiovascular aetiology constitute a great number of all interventions of emergency medicine teams. Diagnostic and therapeutic abilities of modern cardiology lead to the necessity of introducing diagnostic methods which enable effective pre-hospital diagnostics in patients with circulatory system diseases also in emergency medicine. The ECG teletransmissions performed by emergency medicine teams prior to hospitalization increase the accuracy of the diagnosis and thus improve the organization of medical transport of patients to the medical centres appropriate to their medical condition. MATERIAL AND METHODS: A 12-lead ECG teletransmission system and a system of teleconsultations was set up in September 2009 at the Voivodship Emergency Service and Medical Transport Station (WSPRiTS) "Meditrans" in Warsaw. The system consists of: emergency medicine teams and the Teletransmission Centre located in the Cardiac Department of WSPRiTS "Meditrans. The WSPRiTS "Meditrans" emergency medicine teams and helicopter emergency medicine teams performed standard ECGs at the place of the incident, sending them then via telephone to the Teletransmission Centre. Performing an ECG is recommended in the following cases: a pain in the chest, collapse and syncope, perceptible cardiac arrhythmia, dyspnoea and in any case when the head of the emergency medicine team (ZRM) took the decision to perform an ECG. The ECG record as well as the information about the patient supplied by the head of the team were analyzed by a consulting doctor on 24-hour duty at the receiving station. On basis of the received information the doctor from the Teletransmission Centre instructed the ZRM as to further procedure with the patient. There were 20117 ECG teletransmissions performed within the analyzed period. RESULTS: In the period between September 2009 and September 30th, 2012 there were 20 117 12-lead ECG teletransmissions performed, where 18139 (90.2%) were successful. 1978 (9.8%) were unsuccessful. 19 997 ECG transmissions were sent from WSPRiTS "Meditrans"ambulances and 120 by helicopter emergency teams. Women constituted 55% and men 45% of the investigated population of patients. The average age was 61 years. The average ECG transmission time was 7 minutes 10 seconds and did not extend the time of emergency medicine actions. The analysis of collected data revealed that ZRMs applied the teletransmission system particularly in cases others than acute coronary syndromes - 16 998 (93.7%) cases. The most frequent reasons to perform an ECG and consultation were pains in the chest - 23% cases, cardiac arrhythmias (18%) and collapses and syncope (13%). Among cardiac arrhythmias, arterial fibrillations (11%) were most often stated and in this group 79% cases were paroxysmal arrhythmias. During the 3 years 1141 cases of acute coronary syndromes were diagnosed in the pre-hospital period, what constituted only 6.3% of all teletransmissions. During a 9-month period 389 transports were carried out to primary health care centres from where the ECG records were then transferred to the Teletransmission Centre. In 117 cases (30%) the consultant changed the initial decision and patients were transported to other medical centres withour interventional cardiology departments. CONCLUSIONS: The system of ECG teletransmissions and consultations was appreciated by ZRMs and significantly supported their actions. The system should be supervised and coordinated by emergency medicine centres such as the Teletransmission Centre, Emergency Departments or Emergency Rooms. ECG teletransmissions make it possible to extend the paramedics and nurses' competences as regards emergency medical actions with patients with circulatory system diseases. The introduction of ECG teletransmissions from the place of the incident and the doctor's consultation have led to the optimization of transport of patients to appropriate in respect to their condition medical centres.

Ablation of atrioventricular nodal reentrant tachycardia in a patient with reversal of slow and fast pathways inputs into the atrioventricular node.

We report a case of atrioventricular nodal reentrant tachycardia (AVNRT) coexistent with His bundle anomaly and atrial septal defects. The His-bundle potential was recorded at the coronary sinus (CS) ostium. Fractionated atrial potentials and an A:V electrogram ratio 1:3 were recorded at the anterior septum of the tricuspid annulus approximately 2 cm from CS ostium. Radiofrequency catheter ablation at the anterior septum of the tricuspid annulus effectively eliminated AVNRT.

[Intraoperative interruption of an accessory pathway: is it always a long-term cure for arrhythmia?]. / Intraoperative Unterbrechung einer akzessorischen Leitungsbahn: Immer eine langfristige Heilung?

We report the case of a male patient who had undergone successful cardiac surgery about 20 years previously for a posteroseptal accessory pathway that caused almost incessant orthodromic AV reentrant tachycardia, but presented again recently with new onset cardiac arrhythmia. 3D mapping demonstrated scar-related reentrant tachycardia in the right atrium with a critical isthmus between the atriotomy scar and terminal crest, which could be successfully treated using irrigated-tip high-frequency catheter ablation.

The noncoronary cusp as a site for successful ablation of accessory pathways: electrogram characteristics in three cases.

Radiofrequency ablation is the treatment of choice to cure symptomatic patients with atrioventricular accessory pathways (APs). Septal APs are challenging because of the proximity of the normal conduction system. In some patients, despite aggressive lesion creation on the right anteroseptal region pathway, ablation is unsuccessful. We report 3 cases where the successful ablation site was in the noncoronary cusp of the aortic valve and discuss possible defining features of this variant of septal APs and an approach for successful ablation.

Ablation of right-sided accessory pathways with atrial insertion far from the tricuspid annulus using an electroanatomical mapping system.

BACKGROUND: It is difficult to ablate a right-sided accessory pathway (AP) with atrial insertion far from the tricuspid annulus (TA). We report our initial experience of ablating this rare AP by a 3-dimensional electroanatomical mapping system (CARTO). METHODS: From January of 2006 to April of 2008, 18 patients with right-sided APs who failed previous outside ablations were enrolled in this study. Retrograde AP conduction was mapped during pacing at the right ventricular apex by activation-mapping the right atrium (RA) using a 3-dimensional electroanatomical mapping system. AP atrial insertion was defined as the earliest retrograde atrial activations and successful ablation of the APs at this site. RESULTS: Among the 18 patients who had failed previous ablation, 10 patients (7 patients with right manifest APs and 3 patients with right conceal APs) had atrial insertions far from the TA. Of the 10 patients, the atrial insertions were found at the base of the RA appendage in 3 patients, at the high lateral RA in 5 patients, at the low lateral RA in other 2 patients. Ablation at the atrial insertions successfully abolished the AP conduction. The mean distance between the atrial insertion sites and the TA was 20.2 ± 2.7 mm. No patients reported recovered AP conduction or recurrent tachycardias after 6-month follow-up. CONCLUSIONS: The right-sided APs may have atrial insertion far from the TA. These uncommon variation of APs can be reliably identified and ablated using CARTO system.

Cardiac resynchronization therapy by ablation of right-anterolateral accessory pathway.

Ventricular preexcitation caused by right-sided accessory pathways can lead to abnormal septal motion patterns and may be associated with left ventricular (LV) dysfunction and heart failure, despite the lack of a clinical arrhythmia. Hence successful ablation of the accessory pathway abolishes not only preexcitation but also ventricular dyssynchrony in these patients. We describe a case of an asymptomatic 20-year-old male presenting with ventricular Type-B preexcitation combined with LV dysfunction. The individual risk of arrhythmic events was enhanced due to competitive sport activities of the patient and a short antegrade refractory period of the accessory pathway. Hence standard radiofrequency ablation of the right anterolateral accessory pathway was performed, despite no history of tachycardia. After successful accessory pathway ablation, normalization of LV size and function was demonstrated by echocardiography with a long-term follow-up of 4 years.

Idiopathic reentrant right ventricular outflow tract tachycardia with presystolic potential of central pathway.

A 12-year-old girl with recurrent palpitation due to idiopathic ventricular tachycardia (VT) with a left bundle branch block configuration and inferior axis was referred to our hospital. During the VT, a spiky presystolic potential (SP) was recorded at the septum of right ventricular outflow tract (RVOT) just below pulmonary valve. The SP was entrained with a decremental property by pacing from right ventricular apex. Concealed entrainment was observed by pacing where the SP was recorded. Delivery of radiofrequency current targeting the SP abolished the VT. The SP with the decremental property could represent the central pathway of this idiopathic RVOT reentrant VT.

Successful slow pathway ablation in a patient with persistent left superior vena cava.

Persistent left superior vena cava (PLSVC) is a rare vascular variant which can add difficulties to slow pathway (SP) ablation procedures because of the disturbed anatomy of the triangle of Koch. We describe a case of a successful SP ablation using an anatomical approach in a patient with PLSVC.

QRS alternans during idiopathic ventricular tachycardia originating from the right coronary cusp of the aorta.

A 77-year-old man underwent electrophysiological testing for idiopathic ventricular tachycardia (VT) with QRS alternans exhibiting a left bundle branch block and left inferior axis QRS morphology. Successful radiofrequency catheter ablation was achieved at the site of the earliest ventricular activation in the right coronary cusp. Pacing at this site reproduced an excellent pace map with QRS alternans. Pacing from other sites in the ventricular outflow tracts reproduced neither an excellent pace map nor QRS alternans. This case demonstrates that VT with a single origin and multiple exits in the aortic root may exhibit QRS alternans.

Acute success of cryoablation of left-sided accessory pathways: a single institution study.

OBJECTIVE: To compare the acute success and recurrence rate of cryoablation for left-sided accessory pathways (AP) with controls who underwent radiofrequency ablation (RFA) at the same institution. BACKGROUND: Catheter cryoablation of supraventricular tachycardia (SVT) is considered to be a safer alternative a compared with RFA. At our institution, cryoablation has become the primary interventional modality for all APs. The reported success rates of cryoablation for AP-mediated tachycardia have generally been less favorable than for RFA. However, the location of AP may influence cryoablation outcome. Furthermore, there are little data available on cryoablation of left-sided pathways. METHODS: A chart review was performed for all patients undergoing cryoablation between August 2005 and August 2007. Twenty-nine patients (mean age 13 years, range 6-18 years) were identified with SVT secondary to left-sided AP. The data collected included patient age, height, weight, date of procedure, mapping, ablation and procedure time, pathway location, success, and recurrence. Cryoablation was performed via a transseptal approach. Procedural success and recurrence rate were compared with our most recent 28 patients undergoing RFA ablation. RESULTS: Procedural success was achieved in 97% of patients in the cryoablation group, compared with 100% in the RFA control group. Recurrence rate in the cryoablation group was 1 of 24 (4.2%) patients compared with 4 of 28 (14%) patients in the RFA group over 12 months. CONCLUSION: Cryoablation can be safely and effectively used in the treatment of left-sided AP. Long-term outcomes remain to be seen.