Electrocardiographic modifications induced by breast implants.

BACKGROUND: Echocardiography realization can be challenging in the presence of breasts implants (BI). It is less known if electrocardiograms (ECG) may be modified in the presence of BI. METHODS: ECG from women with BI (and without any known cardiac structural disease) were sent and analyzed by two experienced electrophysiologists (EP1 and EP2) who were blinded and completely unaware of the context of the patients (Group 1). ECG from a control matched-group of female women without BI (Group 2) were also blindly sent for analysis. RESULTS: ECG were collected from 28 women with BI (42 ± 8 years) without any acute medical condition. A proportion of 42% of the ECG were considered abnormal by EP1 and 46% by EP2. The abnormalities were for EP1: negative T waves (5), ST depression in inferolateral leads (2), absence of R wave progression from V1 to V4 (4), left ventricular (LV) hypertrophy (1), long QT(1), early repolarization (1), short PR (1); For EP2: negative T waves (6), ST depression in inferolateral leads (2), absence of R wave progression from V1 to V4 (4), LV hypertrophy(3), long QT (1), early repolarization (1). ECG from group 2 were considered abnormal in only 1 patient (5%) for EP1, and normal in all for EP2 (P = 0.0002 between the groups). CONCLUSIONS: ECG from women with BI were considered abnormal in 42% to 46% of the cases by expert readers. ECG interpretation can thus be misleading in these women.

A comparison between multipolar mapping and conventional mapping of atrial tachycardias in the context of atrial fibrillation ablation.

BACKGROUND: Activation mapping can be challenging and time-consuming in patients with multiple atrial tachycardias (ATs). AIMS: To compare multielectrode mapping using a dedicated mapping catheter - PentaRay (Biosense Webster Inc.) - and the conventional technique for mapping ATs in the context of atrial fibrillation (AF) ablation. METHODS: All procedures where PentaRay mapping of AT were used - after or during persistent AF ablation - were analysed. These were compared to a historical group - using conventional mapping. RESULTS: A mean of 449±520 points within 14±6min were acquired per AT in the PentaRay group (n=17) versus 42±18 points (P<0.0001) within 33±25min (P=0.04) in the conventional group (n=17). All 25 AT isthmuses were easily identified and ablated in the PentaRay group (100%) versus 20/23 (87%) in the conventional group (P=0.056). The ablation time was shorter in the PentaRay group (760±540 vs 1347±962 s; P=0.037). However, procedure and fluoroscopy times were not significantly different between the PentaRay and conventional groups: 253±77 vs 267±73min (P=0.80) and 13.1±8.0min vs 15.1±10.0min (P=0.98), respectively. Recurrence occurred in less patients in the PentaRay group (0 vs 23.5%; P=0.033) during a mean follow-up of nearly 1 year. CONCLUSION: In patients with multiple ATs, multielectrode PentaRay mapping was faster than the conventional technique, with less radiofrequency delivery and a better mid-term outcome.

Radiofrequency catheter ablation of atrial fibrillation: Electrical modification suggesting transmurality is faster achieved with remote magnetic catheter in comparison with contact force use.

BACKGROUND: Remote magnetic navigation (RMN) and contact force (CF) sensing catheters are available technologies for radiofrequency (RF) catheter ablation of atrial fibrillation (AF). Our purpose was to compare time to electrogram (EGM) modification suggesting transmural lesions between RMN and CF-guided AF ablation. METHODS AND RESULTS: A total of 1,008 RF applications were analyzed in 21 patients undergoing RMN (n = 11) or CF-guided ablation (n = 10) for paroxysmal AF. All procedures were performed in sinus rhythm during general anesthesia. Time to EGM modification was measured until transmurality criteria were fulfilled: (1) complete disappearance of R if initial QR morphology; (2) diminution > 75% of R if initial QRS morphology; (3) complete disappearance of R' of initial RSR' morphology. Impedance drop as well as force time integral (FTI) were also assessed for each application. Mean CF at the beginning of each RF application in the CF group was 11 ± 2 g and mean FTI per application was 488 ± 163 gs. Time to EGM modification was significantly shorter in the RMN group (4.52 ± 0.1 seconds vs. 5.6 ± 0.09 seconds; P < 0.00001). There was no significant difference between other procedural parameters. CONCLUSION: Remote magnetic AF ablation is associated with faster EGM modification suggesting transmurality than optimized CF and FTI-guided catheter ablation.

Pacemakers implantation and radiofrequency catheter ablation procedures during medical missions in Morocco: an 8-year experience.

AIMS: Radiofrequency catheter ablation (RFCA) for arrhythmias in the context of short-term medical missions (MM) in a developing country has not been reported so far. We describe here our experience with RFCA and pacemaker implantation in Morocco with a fully portable electrophysiological (EP) system under the auspice of the Monaco-Morocco Cardiology Association. METHODS AND RESULTS: Since November 2007, two to three MM (mean duration 4 days including transportation) per year were conducted (including two physicians and one nurse from Monaco) and were alternately located in Marrakech, Fes, Agadir, Casablanca, Rabat, Essaouira, and Oujda. All patients' files were sent by local teams and/or referring Moroccan cardiologists before MM. Each case was discussed with the Monaco EP team before the MM. Pacemakers and leads were donated by companies (Sorin Group, Medtronic, Saint-Jude Medical). The EP system (EP Tracer, CardioTek) as well as diagnostic/ablation catheters were brought for RFCA procedures. After the procedures, follow-up was performed by local teams. Procedures took place in gynaecological or orthopaedic operating room, or, when available, in the interventional cardiology cathlab. Thirty-one RFCA were performed during 11 MM (atrioventricular node re-entrant tachycardia = 12; atrioventricular re-entrant tachycardia/Mahaïm fibre = 15; typical atrial flutter = 3; ventricular ectopy = 1). Acute success was 93.5% for RFCA. Two major RFCA-related complications occurred (air embolism and complete atrioventricular block). No complication was related to pacemaker implantations (n = 44; mean 4 pacemakers per mission). CONCLUSION: Radiofrequency catheter ablation for arrhythmias in developing countries is technically challenging but feasible, despite technical and cultural difficulties.

Non-contrast cardiac resynchronization therapy implantation is feasible in case of renal insufficiency.

PURPOSE: Renal insufficiency (RI) is frequent in patients eligible for cardiac resynchronization therapy (CRT) and may be worsened by the use of contrast agents. We sought to determine the feasibility of CRT implantation without contrast injection in patients with contraindication to iodine. METHODS: Patients eligible for CRT and presenting with RI were prospectively included (non-contrast NC group). A contemporary control group (CG) of CRT patients with contrast injection was used for comparison. An over-the-wire coronary sinus (CS) lead with an angled distal tip was selected for this "blind harpooning" technique. RESULTS: Seventeen patients in the NC group were included (78 ± 7 years). Serum creatinine was 208 ± 86 µmol/L (glomerular filtration rate 33 ± 15 mL/min/1.73 m(2)). CG included 25 patients (70 ± 7 years, serum creatinine 85 ± 21 µmol/L). CRT implantation was successful in 16/17 patients (94.1 %) without contrast injection. The mean procedure and fluoroscopy times were similar in the two groups: 146 ± 29 in the NC group versus 153 ± 25 min (p = 0.57) and 25 ± 12 in the NC group versus 23 ± 16 min (p = 0.7) respectively. The mean CS lead implantation time was 36 ± 19 (NC group) versus 39 ± 15 min (p = 0.64). No major procedure-related complications were observed in both groups. CONCLUSION: CRT implantation is feasible in the majority of the cases (94.1 %) without contrast injection and without lengthening the procedure time in patients with RI.

Remotely controlled steerable sheath improves result and procedural parameters of atrial fibrillation ablation with magnetic navigation.

AIMS: The magnetic navigation (MN) system may be coupled with a new advancement system that fully controls both the catheter and a robotic deflectable sheath (RSh) or with a fixed-curve sheath and a catheter-only advancement system (CAS). We aimed to compare these approaches for atrial fibrillation (AF) ablation. METHODS AND RESULTS: Atrial fibrillation ablation patients (45, 23 paroxysmal and 22 persistent) performed with MN-RSh (RSh group) were compared with a control group (37, 18 paroxysmal and19 persistent) performed with MN-CAS (CAS group). Setup duration was measured from the procedure's start to operator transfer to control room. Ablation step duration was defined as the time from the beginning of the first radiofrequency (RF) pulse to the end of the last one and was separately acquired for the left and the right pulmonary vein (PV) pairs. Clinical characteristics, left atrial size, and AF-type distribution were similar between the groups. Setup duration as well as mapping times was also similar. Ablation step duration for the left PVs was similar, but was shorter for the right PVs in RSh group (46 ± 9 vs. 63 ± 12 min, P < 0.0001). Radiofrequency delivery time (34 ± 9 vs. 40 ± 11 min, P = 0.007) and procedure duration (227 ± 36 vs. 254 ± 62 min, P = 0.01) were shorter in RSh group. No complication occurred in RSh group. During follow-up, there were five recurrences (11%) in RSh group and 11 (29%) in CAS group (P = 0.027). CONCLUSION: The use of the RSh for AF ablation with MN is safe and improves outcome. Right PV isolation is faster, RF delivery time and procedure time are reduced.

General anesthesia is not superior to local anesthesia for remote magnetic ablation of atrial fibrillation.

BACKGROUND: Remote magnetic navigation is an emerging technology for atrial fibrillation (AF) ablation. General anesthesia (GA) has shown to be superior to local anesthesia (LA) for manual AF ablation in terms of catheter stability and lesion formation. We aimed at comparing GA with LA for remote magnetic AF ablation procedures. METHODS: All patients eligible for a remote magnetic ablation of AF were included in this study. Ninety patients (70% of the patients were male; age: 60 ± 10 years; CHA2 DS2 -VASC : 1.6 ± 1.2; paroxysmal AF: 60%, persistent AF: 40%), including 45 patients with GA, and 45 patients with LA were enrolled consecutively. RESULTS: There was no significant difference in total procedure time between the two groups (237 ± 50 minutes in the GA group vs 240 ± 61 minutes in the LA group; P = 0.84). Fluoroscopy time was significantly increased in the GA group (14.6 ± 6 minutes vs 11.6 ± 6 minutes, P = 0.018). Ablation time was not different between the two groups (2,320 ± 984 seconds in the GA group vs 2,055 ± 1,023 seconds in the LA group; P = 0.25). After a mean follow-up of 1 year (including repeat procedures), 39/45 patients (86.6%) within the GA group were free from recurrences versus 40/45 patients (88.8%) in the LA group (P = 0.74) without antiarrhythmic drugs. CONCLUSION: For remote magnetic AF ablation, procedures under LA have similar results to GA in terms of efficacy and safety after 1-year follow-up.

Ultrasound-guided venous puncture in electrophysiological procedures: a safe method, rapidly learned.

BACKGROUND: We sought to determine the feasibility and learning curve associated with systematic use of real-time ultrasound-guided venous puncture (UGVP) in patients undergoing electrophysiological (EP) procedures. METHODS: Four operators performed UGVP in consecutive patients undergoing EP procedures (group I). Puncture time was defined as the time from ultrasound (US) visualization of the femoral vein to the insertion of all sheaths. A learning curve as defined by UGVP evolution over the time was established for each operator. This population was compared to an historical group of patients in whom venous puncture was performed without US (group II). RESULTS: A total of 150 patients per group were included. UGVP was successfully achieved in all patients. Mean time for 2.8 ± 0.7 sheaths per patient insertion was 280 ± 151 seconds in group I. There was one minor vascular complication (VC) out of 150 patients (0.66%) without major VC in group I as compared with group II (2% major VC and 4.6% minor VC; P < 0.05). UGVP time reached a plateau at the sixth patient-case for each operator; thus, learning curve was estimated to six patients. CONCLUSION: UGVP is a short learning curve technique, significantly associated with a low incidence of minor VCs. This study supports wide use of UGVP in patients undergoing EP procedures.

Safe right bundle branch block pattern during permanent right ventricular pacing: a case report.

We present the case of a 72-year-old male who underwent a permanent transvenous DDD pacemaker implantation for symptomatic complete heart block. The postoperative surface electrocardiogram (ECG) revealed a right bundle branch block (RBBB) pacing pattern with transition in lead V3 and left bundle branch block (LBBB) in D1, suggesting a malpositioned ventricular lead in the left heart. Malposition of a lead was ruled out by chest X-ray and echocardiogram confirming apical right ventricular pacing. After a literature review, a surface ECG maneuver, by placing leads V1 and V2 one intercostal space lower, restored the usual patterns of paced LBBB pattern. We discuss the literature concerning safe-paced RBBB.

Silent embolization of an Amplatzer septal occluder into the left ventricular outflow tract requiring emergent surgical retrieval.

Percutaneous closure of secundum atrial septal defect is an established safe alternative to surgery with rare complications and high primary success rate. This procedure can be complicated by early or late device embolizations. We report an asymptomatic delayed nonobstructive embolization of an amplatzer septal occluder (ASO) into the left ventricle outflow tract detected by routine transthoracic echocardiography 1 week after implantation, which required emergent surgical retrieval in a stable patient.