Transvenous Before Surgical Hybrid Procedure.

BACKGROUND: Historically, persistent atrial fibrillation (PeAF) and long standing persistent atrial fibrillation (LSPeAF) have demonstrated limited clinical success despite hybrid approaches. OBJECTIVE: We describe our experience with the endocardial-before-epicardial approach defined by a comprehensive endovascular approach preceding and guiding the epicardial approach which includes an extensive posterior wall ablation. METHODS: 40 patients were followed over a 12 month period. The procedure was performed in a single center. Patients had a mean duration of atrial fibrillation of 6.0 ± 4.5 years with 22.5% having undergone prior ablations. Mean age was 61.7 ± 7.9 years with a mean left atrial volume of 131.5 ± 46.9 mL. The endovascular procedure remained uniform with antral pulmonary vein isolation, posterior left atrial roof and right atrial cavo-tricuspid isthmus (CTI) linear lesions with mapping and ablation of left atrial complex electrograms (CFAEs) and prior existing atrial arrhythmias. The epicardial procedure included a thorascopic approach with ganglionated plexus (GP) mapping and ablation, left atrial posterior wall ablation, directed CFAE ablation and left atrial appendage ligation. All patients received implantable cardiac monitoring. RESULTS: All 40 patients remained in sinus rhythm at their 12 month follow-up. During the monitoring period, episodes of paroxysmal atrial arrhythmias including fibrillation were documented, without persistence, after discontinuation of oral antiarrhythmic medications. CONCLUSION: The endo-before-epi approach resulted in improved management of persistent and long standing persistent atrial fibrillation over reported results for conventional approaches with no procedural complications, making this a promising option for the management of these arrhythmias.

Noninvasive risk stratification for sudden death in asymptomatic patients with Wolff-Parkinson-White syndrome.

Sudden cardiac death (SCD) as the first clinical manifestation of Wolff-Parkinson-White (WPW) syndrome is a well-documented, although rare occurrence. The incidence of SCD in patients with WPW ranges from 0% to 0.39% annually. Controversy exists regarding risk stratification for patients with preexcitation on surface electrocardiogram (ECG), particularly in those who are asymptomatic. This article focuses on the role of risk stratification using exercise and pharmacologic testing in patients with WPW pattern on ECG.

Coronary artery disease risk factors in patients with diastolic dysfunction.

Diastolic dysfunction (DD) is a common entity associated with advanced age and hypertension, often present in patients with ischemic heart disease. The correlation of DD and coronary artery disease (CAD) in asymptomatic young patients is not known. We sought to determine the prevalence of CAD risk factors in asymptomatic patients with DD. We present data from a retrospective chart review of CAD risk factors in asymptomatic patients diagnosed with DD during an echocardiograph examination. We screened all patients that had an echocardiographic examination at Lenox Hill Hospital from January 2004 until July 2007. DD was diagnosed if an impaired filling pattern with an E/A ratio less than one was noted on the mitral inflow pulse wave doppler. One-hundred and one patients met study criteria. Data regarding the presence of the following risk factors was collected: sex, hypertension, hyperlipidemia, smoking, diabetes, peripheral artery disease, and family history of CAD. The mean age of patients was 48 +/- 6; 50% were male. The most prevalent CAD risk factor in this group of patients with DD was hypertension (53%), followed by hyperlipidemia (31%) and diabetes (22%). These data can help identify those patients who are asymptomatic in terms of DD who may be at risk for the condition. These patients should undergo an echocardiograph examination in order to rule out presence of DD, even if symptoms are not present.