Differentiation of paroxysmal narrow QRS complex tachycardias using the 12-lead electrocardiogram.

OBJECTIVES: The purpose of this study was to evaluate the utility of the 12-lead electrocardiogram (ECG) for differentiating paroxysmal narrow QRS complex tachycardias. BACKGROUND: Previous studies evaluating the utility of the 12-lead ECG for differentiating paroxysmal supraventricular tachycardia types have shown conflicting results on the usefulness of some ECG criteria, and some criteria that are considered to be useful have never been formally evaluated. METHODS: Two hundred forty-two ECGs demonstrating paroxysmal narrow QRS complex (< 0.11 ms) tachycardia (rate > or = 120 beats/min) were analyzed. All ECGs were analyzed by an observer who had no knowledge of the mechanism of the tachycardia. RESULTS: There were 137 atrioventricular (AV) reciprocating tachycardias, 93 AV node reentrant tachycardias and 12 atrial tachycardias. Six criteria were found to be significantly different between tachycardia types by univariate analysis. A P wave separate from the QRS complex was observed more frequently in AV reciprocating tachycardia (68%) and atrial tachycardias (75%). A pseudo r' deflection in lead V1 and a pseudo S wave in the inferior leads were more common in AV node reentrant tachycardia (58% and 14%, respectively); QRS alternans was present more often during AV reciprocating tachycardia (27%). When a P wave was present, an RP/PR interval ratio > or = 1 was more common in atrial tachycardias (89%). During sinus rhythm, manifest pre-excitation was observed more often in patients with AV reciprocating tachycardia (45%). By multivariate analysis, the presence of a P wave separate from the QRS complex, pseudo r' deflection in lead V1, QRS alternans during tachycardia and the presence of pre-excitation during sinus rhythm were independent predictors of tachycardia type. These criteria correctly identified 86% of AV node reentrant tachycardias, 81% of AV reciprocating tachycardias and incorrectly assigned the tachycardia type in 19% of cases. CONCLUSIONS: Several features on the ECG are useful for differentiating supraventricular tachycardia type. However, approximately 20% of tachycardias may be incorrectly classified on the basis of analysis of the ECG; therefore, the ECG should not serve as the sole means for determining tachycardia mechanism.

Safety, feasibility and cost of outpatient radiofrequency catheter ablation of accessory atrioventricular connections.

OBJECTIVES: The purpose of this study was to evaluate prospectively the safety, feasibility and cost of performing radiofrequency catheter ablation of accessory atrioventricular (AV) connections on an outpatient basis in 137 cases. BACKGROUND: The efficacy and low complication rate of radiofrequency ablation as performed in the hospital suggested that it might be feasible to perform it on an outpatient basis. METHODS: In 100 cases (73%) performed between September 1, 1991 and April 20, 1992, patients met criteria for treatment as outpatients. Reasons for exclusion were age < 13 or > 70 years (4), anteroseptal location of the accessory AV connection (5 patients), obesity (> 30% of ideal body weight) (4 patients) or clinical indication for hospitalization (24 patients). Patients with only venous punctures had a recovery period of 3 h and those with arterial punctures had a recovery period of 6 h. There were 63 men and 32 women (5 patients underwent two ablation procedures > 1 month apart), with a mean age +/- SD of 36 +/- 13 years. The pathway was left-sided in 67 cases and right-sided or posteroseptal in 33. RESULTS: The procedure was successful in 97 of 100 cases, with a mean procedure duration of 99 +/- 42 min. In 70 cases the patient was discharged the day of ablation, and in 30 cases the patient required a short (< or = 18-h) overnight stay because the procedure was completed too late in the day for recovery in the outpatient facility. The mean duration of observation was 4.8 +/- 1.5 h for outpatients and 15 +/- 1.4 h for patients who underwent overnight hospitalization. At follow-up study, two patients had a clinically significant complication; both had a femoral artery pseudoaneurysm detected > or = 1 week after the procedure and both required surgical repair. Thirty consecutive patients (22 outpatients and 8 hospitalized overnight) undergoing catheter ablation after January 1, 1992 were chosen for a cost analysis. The mean cost of the procedure was $10,183 +/- $1,082. CONCLUSIONS: The majority of patients undergoing radiofrequency catheter ablation of an accessory AV connection can be treated safely on an outpatient basis.

Association between atrioventricular node reentrant tachycardia and inducible atrial flutter.

OBJECTIVES: The purpose of this study was to evaluate the inducibility of atrial flutter in patients with atrioventricular (AV) node reentrant tachycardia and to determine the effect of radio-frequency ablation of the slow AV node pathway on the inducibility of atrial flutter. BACKGROUND: Studies have shown that both AV node reentrant tachycardia and atrial flutter are reentrant arrhythmias having an area of slow conduction that is located in the low posterior right atrium near the ostium of the coronary sinus. METHODS: Ninety-one patients were prospectively evaluated using a standardized atrial pacing protocol. Three groups of patients were analyzed: 42 patients with inducible AV node reentrant tachycardia, 13 with a history of spontaneous atrial flutter and 36 control patients. A subgroup of 34 patients with AV node reentrant tachycardia who underwent successful radiofrequency ablation of the slow AV node pathway underwent atrial pacing again after ablation. RESULTS: Atrial flutter was more frequently inducible in patients with AV node reentrant tachycardia (88%) and in those with a history of atrial flutter (92%) than in control patients (36%) (p = 0.0001). There were no differences between the patient groups with respect to atrial effective refractory period, P wave duration or PA interval at the His position. Among the 34 patients with AV node reentrant tachycardia who underwent atrial pacing before and after radiofrequency ablation, there were 30 with atrial flutter and 4 with atrial fibrillation before ablation and 29 with atrial flutter and 5 with atrial fibrillation after ablation (p = NS). There was no difference in the duration of the induced atrial flutter before and after ablation. The mean atrial flutter cycle length before ablation (206 +/- 22 ms) was not different from that after ablation (196 +/- 20 ms) (p = NS). CONCLUSIONS: There is a strong association between AV node reentrant tachycardia and inducible atrial flutter, suggesting that there may be a common area of perinodal atrium participating in the two tachycardia circuits. However, radiofrequency ablation of the slow pathway of the AV node reentrant tachycardia circuit does not influence the inducibility of atrial flutter.

Repolarization abnormalities after catheter ablation of accessory atrioventricular connections with radiofrequency current.

The purpose of this study was to evaluate the serial changes in T wave configuration in patients undergoing successful radiofrequency catheter ablation of accessory atrioventricular (AV) connections. Twenty-nine consecutive patients with overt preexcitation and 16 patients with a concealed accessory atrioventricular (AV) connection were included. An electrocardiogram (ECG) was recorded before ablation and 15 min, 1 or 2 days and 1 and 3 months after ablation. Postablation T wave abnormalities occurred in 22 (76%) of the 29 patients who had overt pre-excitation but in none of the 16 patients with a concealed accessory AV connection. The T wave abnormalities were not related to myocardial necrosis or echocardiographic abnormalities. The ECG location and severity of T wave changes were dependent on the accessory AV connection location and degree of baseline pre-excitation, respectively. Fourteen of 19 patients with a posteriorly located AV connection (left, right or septal) had T wave inversion or flattening in the inferior leads and 3 patients had precordial T wave peaking. Two patients with an anteroseptal AV accessory connection had both inferior T wave inversion or flattening and precordial T wave peaking. Among seven patients with a manifest left lateral accessory AV connection, two had lateral T wave inversion or flattening and two had precordial T wave peaking. There was 95% concordance between the directional change of the T wave after ablation and the direction of the delta wave on the baseline ECG.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the cost of radiofrequency catheter modification of the atrioventricular node and medical therapy for drug-refractory atrioventricular node reentrant tachycardia.

The purpose of this study was to determine the charges for radiofrequency catheter modification of the atrioventricular (AV) node in 15 patients with symptomatic AV node reentrant tachycardia despite pharmacologic therapy and to compare these charges with the estimated charges for health care utilization by the same patients before the catheter procedure was performed. There were seven men and eight women with a mean age of 50 +/- 17 years. The mean duration and frequency of symptoms were 16 +/- 9 years and 4.5 +/- 6 episodes/month, respectively. Fourteen of the 15 patients required only one procedure for diagnosis and cure of AV node reentrant tachycardia and 1 patient required two sessions. All patients underwent electrophysiologic study before discharge from the hospital to confirm the short-term efficacy of the procedure. The mean duration of the hospital stay was 3 +/- 1.5 days and the mean total charge/patient expressed in 1991 dollars was $15,893 +/- $3,338 for catheter modification. These total charges consisted of hospital charges of $8,105 +/- $2,466 and physician charges of $7,788 +/- $971. All patients had a successful outcome and required no additional antiarrhythmic therapy. The estimated cost of health care utilization for these 15 patients before cure of AV node reentrant tachycardia was $7,651/patient per year. These estimated costs included charges incurred for emergency room visits, office visits, hospitalizations and antiarrhythmic drug therapy. In conclusion, the results of this study indicate that the annual health care costs incurred by patients who have symptomatic, drug-refractory paroxysmal supraventricular tachycardia caused by AV node reentry are substantial.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective, randomized comparison of conventional and high dose loading regimens of amiodarone in the treatment of ventricular tachycardia.

OBJECTIVES: The purpose of this prospective randomized study was to compare the electrophysiologic effects of conventional and high dose loading regimens of amiodarone in patients with sustained ventricular tachycardia. BACKGROUND: Uncontrolled studies in which patients have been treated with an oral loading dose of 2 to 4 g/day of amiodarone have suggested that, compared with a conventional loading dose, this dosing regimen results in more rapid control of spontaneous ventricular tachycardia and ventricular tachycardia induced by programmed stimulation. METHODS: Patients in whom sustained monomorphic ventricular tachycardia was inducible by programmed stimulation and who were refractory to class I antiarrhythmic medications were randomly assigned to receive either a conventional (n = 15) or a high (n = 17) loading dose of amiodarone. The conventional dose consisted of 600 mg twice a day for 10 days. The high dose regimen consisted of 50 mg/kg body weight per day on days 1 to 3, 30 mg/kg per day on days 4 and 5 and 600 mg twice a day on days 6 to 10. An electrophysiologic test was performed in the baseline state and after 3 and 10 days of therapy. An adequate response to amiodarone was defined as the inability to induce ventricular tachycardia or the ability to induce only relatively slow (cycle length > or = 350 ms) hemodynamically stable ventricular tachycardia. RESULTS: After 3 days of therapy, 2 of 14 patients who received the conventional loading dose and 6 of 15 patients who received the high dose loading regimen had an adequate response to amiodarone (p = 0.08). After 10 days of therapy, four patients in each group had an adequate response to amiodarone (p = NS). Three patients who received the high dose and one patient who received the conventional dose of amiodarone had an adequate response after 3 days of therapy but not after 10 days of therapy. There were significant increases in the sinus cycle length, atrioventricular block cycle length, ventricular effective refractory period and ventricular tachycardia cycle length after 3 and 10 days of therapy compared with baseline values regardless of the dosing regimen. The extent of the effects of amiodarone on these variables after 3 and 10 days of therapy was similar with both dosing regimens. CONCLUSIONS: The therapeutic and electrophysiologic effects of conventional and high dose loading regimens of amiodarone do not differ significantly after 3 or 10 days of therapy. High oral loading doses of amiodarone do not offer any significant clinical advantage over a conventional loading dose of amiodarone for controlling ventricular tachycardia induced by programmed stimulation.

Recognition and catheter ablation of subepicardial accessory pathways.

OBJECTIVES: The purpose of this study was to characterize left-sided accessory pathways that traverse the atrioventricular (AV) groove subepicardially and to describe results of radiofrequency catheter ablation within the coronary sinus in the patients studied. BACKGROUND: Radiofrequency catheter ablation has proved to be a safe and effective method for treatment of accessory pathways; however, subepicardial accessory pathways may account for some of the failures encountered during endocardial ablation. METHODS: The study group comprised 51 consecutive patients with a left-sided accessory pathway who were undergoing radio-frequency catheter ablation. Initially, the ablation catheter was introduced into a femoral artery and positioned on the ventricular aspect of the mitral annulus. If this endocardial approach was unsuccessful, the ablation catheter was introduced into the coronary sinus and energy applied at sites with shorter activation times than those recorded from the endocardium. RESULTS: Five (10%) of 51 patients with a left-sided accessory pathway could not have accessory pathway conduction interrupted with a median of 18 endocardial radiofrequency energy applications. Accessory pathway potentials were less frequent during endocardial mapping in these 5 patients than in the 46 patients whose accessory pathway was successfully ablated from the endocardial surface. All five of these patients later had successful ablation using one or two applications of radiofrequency energy from within the coronary sinus. Effective target site electrograms in the coronary sinus were characterized by an accessory pathway potential that was larger than the corresponding atrial or ventricular electrogram. There were no complications or recurrences after ablation within the coronary sinus. CONCLUSIONS: Some left-sided accessory pathways may be difficult to ablate from the endocardial surface because they traverse the AV groove subepicardially. The absence of an accessory pathway potential during endocardial mapping in combination with a relatively large accessory pathway potential within the coronary sinus may be a useful marker of a subepicardial pathway. In this select group of patients, radiofrequency catheter ablation from within the coronary sinus appears to enhance efficacy.

A prospective randomized comparison of direct current and radiofrequency ablation of the atrioventricular junction.

OBJECTIVES: The purpose of this study was to compare direct current and radiofrequency ablation of the atrioventricular (AV) junction in a prospective randomized fashion. BACKGROUND: Catheter ablation of the AV junction can be performed using either direct current shocks or radiofrequency energy. To date, these two techniques have never been compared prospectively or in a randomized study. METHODS: Forty patients with drug-refractory uncontrolled atrial fibrillation-flutter (38 patients) or inappropriate sinus tachycardia (2 patients) were randomly assigned to undergo direct current ablation (20 patients) using up to four shocks of 200 to 300 J or radiofrequency ablation (20 patients) using up to 15 applications of 16 to 25 W for 30 s. If complete AV block was not successfully induced, the ablation procedure was repeated using the alternate type of energy. A rate-responsive ventricular pacemaker was implanted in each patient. The intrinsic escape rhythm was evaluated 15 min, 2 days and 3, 6 and 12 months after ablation. RESULTS: Persistent complete AV block was successfully induced during the first ablation session in 13 (65%) of 20 patients randomly assigned to undergo direct current ablation, compared with 19 (95%) of 20 patients randomly assigned to undergo radiofrequency ablation (p < 0.05). Each patient whose first ablation attempt failed had a successful outcome with the alternate type of energy. The overall efficacy of radiofrequency ablation (26 [96%] of 27 patients) was significantly greater than that of direct current ablation (14 [67%] of 21 patients, p < 0.01). The duration of the direct current and radiofrequency ablation sessions did not differ significantly. The mean peak plasma creatine kinase MB fraction concentration was significantly higher after direct current ablation (58 +/- 29 IU/liter) than after radiofrequency ablation (2 +/- 2 IU/liter) (p < 0.001). An escape rhythm was present 15 min after ablation in an equal proportion of patients undergoing direct current and radiofrequency ablation (78% and 85%, respectively, p = 0.6). An escape rhythm was present in all patients 3, 6 and 12 months after ablation. The mean escape rhythm cycle length 15 min after direct current ablation (2,074 +/- 677 ms) was significantly longer than that 15 min after radiofrequency ablation (1,460 +/- 294 ms) (p < 0.05); however, the mean escape rhythm cycle lengths did not differ significantly at 2 days or 3, 6 or 12 months after ablation. Immediate arrhythmic complications did not occur after either procedure. One patient died suddenly 6.5 months after direct current ablation. CONCLUSIONS: Radiofrequency ablation of the AV junction is more efficacious and safer than direct current ablation and should be the preferred method for inducing complete AV block in patients who are appropriate candidates for ablation of AV conduction.

Randomized comparison of anatomic and electrogram mapping approaches to ablation of the slow pathway of atrioventricular node reentrant tachycardia.

OBJECTIVES: The purpose of this study was to prospectively compare in random fashion an anatomic and an electrogram mapping approach for ablation of the slow pathway of atrioventricular (AV) node reentrant tachycardia. BACKGROUND: Ablation of the slow pathway in patients with AV node reentrant tachycardia can be performed by using either an anatomic or an electrogram mapping approach to identify target sites for ablation. These two approaches have never been compared prospectively. METHODS: Fifty consecutive patients with typical AV node reentrant tachycardia were randomly assigned to undergo either an anatomic or an electrogram mapping approach for ablation of the slow AV node pathway. In 25 patients randomly assigned to the anatomic approach, sequential radiofrequency energy applications were delivered along the tricuspid annulus from the level of the coronary sinus ostium to the His bundle position. In 25 patients assigned to the electrogram mapping approach, target sites along the posteromedial tricuspid annulus near the coronary sinus ostium were sought where there was a multicomponent atrial electrogram or evidence of a possible slow pathway potential. If the initial approach was ineffective after 12 radiofrequency energy applications, the alternative approach was then used. RESULTS: The anatomic approach was effective in 21 (84%) of 25 patients, and the electrogram mapping approach was effective in all 25 patients (100%) randomly assigned to this technique (p = 0.1). The four patients with an ineffective anatomic approach had a successful outcome with the electrogram mapping approach. On the basis of intention to treat analysis, there were no significant differences between the electrogram mapping approach and the anatomic approach with respect to the time required for ablation (28 +/- 21 and 31 +/- 31 min, respectively, mean +/- SD, p = 0.7) duration of fluoroscopic exposure (27 +/- 20 and 27 +/- 18 min, respectively, p = 0.9) or mean number of radiofrequency applications delivered (6.3 +/- 3.9 vs. 7.2 +/- 8.0, p = 0.6). With both the anatomic and electrogram mapping approaches, the atrial electrogram duration and number of peaks in the atrial electrogram were significantly greater at successful target sites than at unsuccessful target sites. CONCLUSIONS: The anatomic and electrogram mapping approaches for ablation of the slow AV nodal pathway are comparable in efficacy and duration. If the anatomic approach is initially attempted and fails, the electrogram mapping approach may be successful at sites outside the areas targeted in the anatomic approach. With both the anatomic and electrogram mapping approaches, there are significant differences in the atrial electrogram configuration between successful and unsuccessful target sites.

Recurrence of conduction in accessory atrioventricular connections after initially successful radiofrequency catheter ablation.

The purpose of this study was to characterize the incidence and clinical features of accessory pathway recurrence after initially successful radiofrequency catheter ablation and to identify variables correlated with recurrence. Radiofrequency ablation was performed with a 7F deflectable tip catheter with a large (4 mm in length) distal electrode. Left-sided accessory pathways were approached through the left ventricle and right-sided pathways by way of the right atrium. Patients were included in the study if 1) they had an initially successful procedure, defined as the absence of accessory pathway conduction immediately after ablation, and 2) had undergone a 3-month follow-up electrophysiologic test or had documented recurrence of accessory pathway conduction. Accessory pathway conduction recurred after initially successful ablation in 16 (12%) of 130 patients. Almost half (7 of 16) of these recurrences were in the 1st 12 h after ablation, and the last occurred after 106 days. Return of delta waves on the electrocardiogram (ECG) or spontaneous paroxysmal supraventricular tachycardia was the initial indication of recurrence in 15 of the 16 patients. Two patients with manifest accessory pathways exhibited recurrence with exclusively concealed accessory pathway conduction. Accessory pathways ablated from the tricuspid anulus (right free wall or septal accessory pathways) had a much higher recurrence rate (24%) than did those on the mitral anulus (6%). Fourteen of 15 patients have had successful repeat accessory pathway ablation after the initial recurrence. After a mean follow-up period of 4 +/- 3 months, there have been no repeat recurrences of any of these accessory pathways. It is concluded that accessory pathway recurrence is infrequent after successful radiofrequency catheter ablation.(ABSTRACT TRUNCATED AT 250 WORDS)

Relation between efficacy of radiofrequency catheter ablation and site of origin of idiopathic ventricular tachycardia.

The results of radiofrequency catheter ablation of ventricular tachycardia (VT) in patients without structural heart disease are reported. Particular attention was focused on the relation between efficacy and the site of origin of the VT. Eighteen consecutive patients (5 women and 13 men; mean age 41 +/- 13 years) with idiopathic VT underwent catheter ablation using radiofrequency energy. Sites for radiofrequency energy delivery were selected on the basis of pace mapping. A follow-up electrophysiologic test was performed 1 to 3 months after the ablation procedure. Twenty VTs were induced. Radiofrequency catheter ablation was successful in eliminating all 10 VTs originating from the right ventricular outflow tract, and 5 of 10 from other sites in the left or right ventricle. There were no complications. The duration of ablation sessions was shorter, the frequency of identifying a site resulting in an identical pace map was higher, and the efficacy of catheter ablation was greater for VTs originating from the right ventricular outflow tract than for those from other locations. The results of this study demonstrate that radiofrequency catheter ablation of idiopathic VT is safe and effective. The efficacy of the procedure is dependent on the site of origin of the VT, with the efficacy being greater for VTs originating from the outflow tract of the right ventricle than for those from other locations.

Catheter ablation of atrial flutter using radiofrequency energy.

Sixteen patients with type I atrial flutter underwent an attempt at radiofrequency catheter ablation (8 women, 8 men, mean age 53 +/- 11 years). The primary criterion used to identify sites for radiofrequency energy delivery was the identification of a fractionated electrogram. Radiofrequency energy was delivered for 20 to 30 seconds. Radiofrequency catheter ablation was acutely successful in 13 patients and unsuccessful in 3. During a mean follow-up of 10 +/- 4 months, 9 of 13 patients with a successful acute result (69%) remained free of recurrent atrial flutter or atrial fibrillation. The ability to induce nonclinical types of atrial flutter was associated with an unsuccessful outcome. A greater proportion of electrograms recorded at successful sites demonstrated electrogram stability compared with unsuccessful ablation sites. None of the electrograms recorded at successful ablation sites were fractionated or had a double potential. This study demonstrates that radiofrequency catheter ablation of type I atrial flutter can be achieved safely.

A randomized comparison of the right- and left-sided approaches to ablation of the atrioventricular junction.

Radiofrequency ablation of the atrioventricular (AV) junction may be performed using either a right- or left-sided approach. This study prospectively compared the left-sided approach with persistent attempts from the right side in patients in whom initial radiofrequency applications on the right side were unsuccessful. Twenty-one of 54 patients did not have complete AV block induced after 3 right-sided radiofrequency applications. These 21 patients were randomly assigned to undergo either the left-sided approach (n = 10) or to undergo additional attempts from the right side (n = 11). The right-sided approach was performed by positioning the ablation catheter to record the largest possible atrial and His bundle electrograms. The left-sided approach was performed by positioning the ablation catheter along the left ventricular septum, where a His bundle potential was recorded. If either approach was not successful after an additional 17 radiofrequency applications, the alternative approach was then used. The AV junction was successfully ablated in all 10 patients randomized to the left-sided approach, but in only 6 of 11 patients randomized to persistent right-sided attempts (p < 0.05). The 5 patients in whom the AV junction was not successfully ablated using the right-sided approach underwent the left-sided approach and had a successful outcome after a mean of 1.2 +/- 0.4 radiofrequency applications. The left-sided approach required significantly fewer radiofrequency applications after randomization than the right-sided approach (3 +/- 3.4 vs 11 +/- 7.6, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of automated quantitative coronary angiography with caliper measurements of percent diameter stenosis.

Measurement of coronary artery stenosis is an invaluable tool in the study of coronary artery disease. Clinical trials and even day-to-day decision making should ideally be based on accurate and reproducible quantitative methods. Quantitative coronary angiography (QCA) using digital angiographic techniques has been shown to fulfill these requirements. Yet many laboratories have abandoned visual analysis in favor of the intermediate quantitative approach involving hand-held calipers. Thus, the purpose of this study was to determine the relation between QCA and the commonly used caliper measurements. Percent stenosis was assessed in 155 lesions using 3 techniques: QCA, caliper measures from a 35-mm cine viewer (cine) and caliper measures from a video display (CRT). Good overall correlation was noted among the 3 different techniques (r greater than or equal to 0.72). Both of the caliper methods underestimated QCA for stenosis greater than or equal to 75% (p less than or equal to 0.001) and overestimated stenosis less than 75% (p less than 0.05). Reproducibility assessed in 52 lesions by independent observers showed QCA to be superior (r = 0.95) to either of the caliper measurements (cine: r = 0.63; CRT: r = 0.73). Therefore, the commonly used caliper method is not an adequate substitute for QCA because overestimation of noncritical stenoses and underestimation of severe stenoses may occur and the measurements have poor reproducibility. These factors definitely preclude its use in rigorous clinical trials. Moreover, since they do not appear to overcome known deficiencies of visual analysis, caliper measurements for day-to-day clinical use must also be seriously questioned.

Intracardiac echocardiography to guide transseptal left heart catheterization for radiofrequency catheter ablation.

INTRODUCTION: The purpose of this study was to assess the feasibility and safety of intracardiac echocardiography to guide transseptal puncture for radiofrequency catheter ablation. METHODS AND RESULTS: Transcatheter intracardiac echocardiography (9 MHz) was utilized to guide transseptal puncture in 53 patients undergoing radiofrequency catheter ablation. The anatomy and relationship of intra- and extracardiac structures were visualized with the ultrasound transducer positioned at the fossa ovalis. The tip of the transseptal dilator and tenting of the fossa ovalis and the left atrial wall were simultaneously visualized in a single ultrasound image in all patients. With maximum tenting of the fossa ovalis, the mean distance from the fossa to the left atrial wall was 11.9 +/- 5.8 mm (range: 1.8 to 25.6 mm). In four patients (8%), the tented fossa ovalis abutted the left atrial wall and the transseptal dilator was redirected with ultrasound guidance. Puncture of the interatrial septum was achieved through the fossa ovalis in each patient and required a single attempt in 51 patients (96%). The mean number of punctures per patient was 1.1 +/- 0.4. The mean time to perform transseptal catheterization was 18.2 +/- 6.8 minutes. There were no complications. CONCLUSION: Intracardiac echocardiography delineated the anatomy of intra- and extracardiac structures not identified with fluoroscopy and simplified correct positioning of the transseptal dilator, puncture of the fossa ovalis, and cannulation of the left atrium in a timely and uncomplicated fashion.

Interference from a hand held radiofrequency remote control causing discharge of an implantable defibrillator.

A 46-year-old man with a history of sustained monomorphic ventricular tachycardia underwent an implantation of a third generation multiprogrammable implantable cardioverter defibrillator. One year post implant, while manipulating a remote control to a radiofrequency modulated toy car, the patient experienced a defibrillator discharge not preceded by an arrhythmia prodrome. Subsequent interrogation of the defibrillator revealed that a 34-joule shock had been delivered and had been preceded by RR intervals ranging from 141-406 msec, consistent with sensing lead noise. The remote control utilizes a 12-volt battery and has a carrier frequency of 75.95 MHz and a modulating frequency of 50 Hz. Evaluation of the remote control and defibrillator interaction revealed that the remote control was able to trigger tachyarrhythmia sensing and reproduce the clinical episode. Interference was present only when the remote control was within 8 cm of the pulse generator and at specific angles relative to the device and only when the antenna length was > 45 cm. Interference was eliminated when a ground wire was attached to the antenna and when an aluminium shield was placed between the pulse generator and the remote control. This case report suggests that patients with third generation multiprogrammable defibrillators should be cautioned against close contact with potential sources of electromagnetic interference, such as remote control units.

Inducibility of atrial fibrillation before and after radiofrequency catheter ablation of accessory atrioventricular connections.

INTRODUCTION: The purpose of this study was to evaluate the inducibility of atrial fibrillation in patients with an accessory atrioventricular connection (AAVC) and to determine if the inducibility of atrial fibrillation is altered after successful radiofrequency catheter ablation of the AAVC. METHODS AND RESULTS: Thirty-seven patients with an AAVC and 36 control patients were prospectively evaluated using a standardized atrial pacing protocol. The high right atrium was paced using a 25-beat drive train, 1.5-second intertrain pause, 10-mA pulse amplitude, and 2-msec pulse duration at cycle lengths of 250 to 100 msec, in 10-msec decrements. Pacing was performed twice at each cycle length. Thirty patients with an AAVC underwent repeat atrial overdrive pacing after successful radiofrequency ablation of the AAVC. Atrial fibrillation was induced in 26 (70%) patients with an AAVC and 22 (61%) controls (P = NS). Atrial flutter was induced in 11 (30%) patients with an AAVC and 13 (36%) controls (P = NS). The cumulative percentage of patients with atrial fibrillation/flutter induced at each pacing cycle length was the same in each group. There was no difference in the duration of atrial fibrillation/flutter between control patients and patients with an AAVC. Among the 30 patients who underwent repeat atrial overdrive pacing after radiofrequency ablation of an AAVC, there was no difference in the inducibility or duration of atrial fibrillation/atrial flutter after ablation compared to baseline. CONCLUSION: These findings indicate that the vulnerability of the atrium to fibrillate in response to atrial pacing is independent of the presence of an AAVC.