Association of left atrial enlargement and increased left ventricular wall thickness with arrhythmia recurrence after cryoballoon ablation for atrial fibrillation.

BACKGROUND: Left atrial enlargement (LAE) predicts atrial fibrillation (AF) recurrence after cryoballoon-based pulmonary vein isolation (CB). Increased left ventricular wall thickness (LVWT) is pathophysiologically associated with LAE and atrial arrhythmias. AIMS: To assess effect of increased LVWT on long-term outcomes of CB depending on coexistence of LAE. METHODS: LAE was defined using either echocardiography ( > 48 cm³/m²) or multislice computer tomography (MSCT, ≥63 cm³/m²). Increased LVWT was echocardiographic septal/posterior wall thickness > 10 mm in males and > 9 mm in females. All patients achieved 2-year follow-up. RESULTS: Of 250 patients (median [interquartile range, IQR] age of 61 [49.0-67.3] years; 30% female) with AF (40% non-paroxysmal), 66.5% had hypertension, and 27.2% underwent redo procedure. MSCT was done in 76%. During follow-up of 24.5 (IQR, 6.0-31.00) months the clinical success rate was 72%, despite 46% of patients having arrhythmia recurrence. Arrhythmia recurrence risk was increased by LAE and increased LVWT (hazard ratio [HR], 1.801; P = 0.002 and HR, 1.495; P = 0.036; respectively). The highest arrhythmia recurrence (61.9% at 2 years) was among patients with LAE and increased LVWT (33.6% of patients); intermediate (41.8%) among patients with isolated LAE; and lowest among patients with isolated increased LVWT or patients without LAE or increased LVWT (36.8% and 35.2% respectively, P = 0.004). After adjustment for body mass index (BMI), paroxysmal AF, CHA2DS2-VASc score, clinically-significant valvular heart disease, and cardiomyopathy, patients with LAE and concomitant increased LVWT diagnosis had a 1.8-times increased risk of arrhythmia recurrence (HR, 1.784; 95% confidence interval [CI], 1.017-3.130; P = 0.043). CONCLUSION: Joint occurrence of LAE and increased LVWT is associated with the highest rate of arrhythmia recurrence after CB for AF.

Association between the acquisition of antibodies against Lyme disease and the risk of atrial arrhythmias.

INTRODUCTION: The impact of antibodies against Borrelia burgdorferi (BB) on the occurrence of cardiac arrhythmias in patients without typical symptoms of Lyme disease (LD) is largely unknown. OBJECTIVES: We aimed to assess the risk of atrial fibrillation (AF) and other atrial arrhythmias (AAs) in patients who tested positive for anti-LD antibodies. PATIENTS AND METHODS: We included consecutive patients referred for the diagnosis and treatment of AAs who had no history of erythema migrans or other symptoms of LD. The presence of anti-BB antibodies (immunoglobulin [Ig] M and IgG) was assessed in each patient, and the diagnostic workup of cardiac arrhythmias was performed. RESULTS: Of the 527 patients enrolled in the study, 292 (55%) were diagnosed with AAs, and we detected BB antibodies in 131 individuals (24.8%). The patients with a serological history of Borrelia infection were older (mean [SD], 55.6 [15.7] vs 50.3 [18.6] years; P = 0.01), had a higher probability of developing AF or other supraventricular arrhythmias (SAs) (66.4% vs 51.8%; P = 0.03), and had elevated levels of N­terminal pro-B ­type natriuretic peptide (NT­proBNP) (58% vs 47.5%; P = 0.04). We also found an as-sociation between the occurrence of AF and other SAs in patients with anti-BB antibodies and elevated NT­proBNP values, and the risk of AAs in these patients increased almost 3­fold (P = 0.01). CONCLUSION: Our data indicated an association between the exposure to Borrelia infection and the risk for AF and other AAs in the patients with elevated levels of NT­proBNP, suggesting the need for a more efficacious diagnostic approach to patients with SAs, especially in LD­endemic regions.

[Ortodromic atrio-ventricular reentrant tachycardia with functional left bundle branch block morphology - differential diagnosis of wide complex tachycardia based on case report]. / Czestoskurcz przedsionkowo−komorowyortodromowy z czynnosciowym blokiemlewej odnogi peczka Hisa ­ róznicowaniemechanizmów czestoskurczu z szerokimizespolami QRS na podstawie opisu przypadku.

We present a case of 18 year-old man, without structural heart disease, who suffered from regular and irregular palpitations. ECG was normal during sinus rhythm, and showed LBBB morphology during tachycardia (220/min). Programmable pacing from CS induced sustained atrial fibrillation with normal and wide QRS (LBBB-like, RBBB-like) and minimal RR interval 270 ms. We found and ablate concealed left free wall accessory pathway. During 1-year observation patient stayed asymptomatic.

A combination of quinidine/mexiletine reduces arrhythmia in dilated cardiomyopathy in two patients with R814W SCN5A mutation.

SCN5A gene mutations are described in 2% of patients with dilated cardiomyopathy (DCM) and different rhythm disturbances, including multifocal ectopic Purkinje-related premature contractions. Recent data indicate that sodium channel blockers are particularly effective monotherapy in carriers of the R222Q SCN5A variant. Our purpose is to describe the effectiveness of antiarrhythmic treatment in a family with genetically determined arrhythmogenic DCM associated with the R814W variant in the SCN5A gene. We examined a family with arrhythmogenic DCM (multifocal ectopic Purkinje-related premature contractions phenotype, atrial tachyarrhythmias, automatism, and conduction disorders) and described antiarrhythmic treatment efficacy in heart failure symptoms reduction and myocardial function improvement. We found a heterozygotic mutation R814W in SCN5A by whole exome sequencing in the proband and confirmed its presence in all affected subjects. There were two sudden cardiac deaths and one heart transplantation among first-degree relatives. The 58-year-old father and his 37-year-old daughter had full spectrum of symptoms associated with R814W SCN5A mutation. Both had implanted cardioverter defibrillator. In the father, adding mexiletine to quinidine therapy reduced ventricular arrhythmia (50-60% â†’ 6-8% of whole rhythm) and reverted long-standing atrial fibrillation to sinus rhythm. In the daughter, mexiletine and overdrive pacing were effective in ventricular arrhythmia reduction (25% â†’ 0.01%). Because of a growing number of atrial fibrillation recurrences, a reduced dose of quinidine (subsequently flecainide) was added, resulting in arrhythmia significant reduction. In both cases, antiarrhythmic effectiveness correlated with clinical improvement. In SCN5A R814W-associated DCM, a combination of Class I antiarrhythmics and overdrive pacing is an effective treatment of severe ventricular and atrial arrhythmias.

[Sixty four-slice computed tomography unmasked unexpected source of atrial arrythmias--a case report]. / Wielorzedowa spiralna tomografia komputerowa ujawnia nieoczekiwane zródlo przedsionkowych zaburzen rytmu - opis przypadku.

We describe a 23-year-old man with drug refractory, left atrial arrhythmias (paroxysmal atrial tachycardia, runs, pairs and single extra beats) in the area of remnant of left upper pulmonary vein ostium (in fact, this vein). The superior drained into vena innominata/vena cava superior. The patient underwent three unsuccessful catheter ablations in another center. Computed tomography scan of left atrium and pulmonary veins revealed this rare congenital anomaly. This information was crucial to perform successful ablation in the area of remnant and distinguish left atrial appendage from the remnant area. During 6 month follow-up the patient remained free of arrhythmia.

Ablation of atrial tachyarrhythmias late after surgical correction of tetralogy of Fallot: long-term follow-up.

BACKGROUND: After the surgical correction of tetralogy of Fallot, surgical scars and natural obstacles form pathways capable of supporting an atrial tachyarrhythmia (AT). Radiofrequency (RF) ablation is effective, although the few studies published on this topic had relatively short follow-up periods. AIM: The aims of the study were to evaluate the acute and long-term effects of RF ablation of AT and examine the charac-teristics of arrhythmia recurrence. METHODS: Tetralogy of Fallot patients (n = 16, age 44.7 ± 10.7 years) referred for ablation of ATs, appearing 25.7 ± 9.6 years after repair, were studied. RESULTS: Twenty-five ATs were ablated, including 16 cavo-tricuspid isthmus atrial flutters (CTI-AFLs) and nine intraatrial reentrant tachycardia (IART). In one patient with paroxysmal atrial fibrillation (PAF), pulmonary vein isolation was also performed. Ten patients had permanent, and six had paroxysmal arrhythmia prior to the first ablation. Four patients had PAF. Regardless of the type of first ablated arrhythmia, all 16 patients required CTI-AFL ablation. The effectiveness of the first RF ablation reached 88%. The acute efficacy of RF ablation was 100% for CTI-AFL and 78% for IART. Long-term follow-up was possible in 15 out of 16 patients (mean follow-up 68.8 ± 36.6 months). Four patients were free of sustained arrhythmia, nine (60%) had AF. After the last RF ablation, an episode suggestive of CTI-AFL/IART was documented only in one patient. CONCLUSIONS: Ablation of CTI-AFL/IART in tetralogy of Fallot patients is safe and effective. AF was observed in most patients during the long-term follow-up. Regardless of the type of the first ablated arrhythmia, all patients required CTI-AFL ablation.

Risk factors of atrial fibrillation recurrence despite successful radiofrequency ablation of accessory pathway: At 11 years of follow-up.

BACKGROUND: Previous reports on patients with radiofrequency catheter ablation (RFCA) of accessory pathway (AP) and atrial fibrillation (AF) include only short follow-up periods. The aim of this study was to analyze predictors of recurrence of AF in patients after successful RFCA of APs over long term follow-up periods. METHODS: Of the 1,007 patients who underwent non-pharmacological treatment of APs (between the years 1993-2008), data of 100 consecutive patients were retrospectively analyzed (75 men, mean age 43.6 ± 14.7), with the longest period of follow-up (mean 11.3 ± 3.5 years) after successful RFCA of AP. In Group 1, there were 72 patients (54 men, mean age 40.66 ± 13.85 years) without documented episodes of AF after RFCA of AP. Group 2 consisted of 28 patients (21 men, mean age 50.79 ± 14.49 years) with AF episodes despite successful elimination of AP. RESULTS: In univariate analysis, patients from Group 1 were significantly younger at the time of abla-tion than patients from Group 2 (40.66 ± 13.85 vs. 50.79 ± 14.49 years; p = 0.002), had shorter his¬tory of AF episodes (4.11 ± 4.07 vs. 8.25 ± 7.50 years; p = 0.024) and had less frequently documented atrial tachycardia (AT) prior to ablation (3.39 vs. 20.00% years; p = 0.022). In multivariate analysis, the history of AF in years (p = 0.043), was an independent risk factor for AF recurrences. CONCLUSIONS: Older patient age, longer history of AF and AT prior to RFCA of APs identified a sub-group of patients who required additional treatment. In the multivariate analysis, the history of AF in years (p = 0.043) was a risk factor for AF recurrence.

Radiofrequency catheter ablation of accessory pathways in patients with Ebstein's anomaly: At 8 years of follow-up.

BACKGROUND: Data regarding long-term follow-up of radiofrequency catheter ablation (RFCA) of accessory pathways (APs) in patients with Ebstein's anomaly (EA) are limited. The procedures are challenging due to multiple or wide APs. METHODS: Analysis was performed on clinical and periprocedural data of patients with EA referred to the centre in order to perform catheter ablation of AP. The group consisted of 22 patients (female 40.9%, mean age 33.6 ± 19.1 years). The follow-up utilized electrocardiogram and Holter monitoring. RESULTS: Twenty-two patients had 33 accessory pathways (8 patients had multiple APs, 11 patients broad AP). Twenty-nine different arrhythmias were ablated: 20 orthodromic atrioventricular reciprocating tachycardia (O-AVRT), 5 antidromic atrioventricular reciprocating tachycardia (A-AVRT), 3 slow/ fast atrioventricular nodal reentry tachycardia (s/f AVNRT) and 1 cavotricuspid-isthmus-dependent atrial flutter (CTI-AFL). In 3 (13.6%) patients multiple ablation targets for RFCA ablation were observed. The acute procedural success rate after the first RFCA performed was: 100% for AVNRT, 77.3% for APs and 50.0% for CTI-AFL ablation. Follow-up (mean 95.7 ± 49.8 months) was completed in 86.4% of patients. One patient had paroxysmal atrial fibrillation not targeted during ablation. One patient died due to heart failure 12 years after RFCA. Three patients who underwent RFCA of accessory pathways in the mid-1990s were lost in follow-up. CONCLUSIONS: Radiofrequency ablation in patients with EA is challenging but safe and have a high short-term as well as long-term success rate.

Impact of different re-stenting strategies on expansion of a drug-eluting stent implanted to treat bare-metal stent restenosis.

We used intravascular ultrasound (IVUS) to compare the expansion of drug-eluting stents (DES) implanted to treat bare-metal stent (BMS) restenosis after 3 common re-stenting strategies. A total of 80 consecutive BMS restenotic targets were re-stented either directly (n = 30, group 1) or after low-pressure (<8 atm) pre-dilation with an undersize regular balloon (n = 16, group 2) or after high-pressure (>12 atm) pre-dilation with a semicompliant balloon the same or greater diameter as the original BMS diameter (n = 34, group 3). More patients from groups 2 and 3 had diabetes mellitus. The targets in group 1 were more proximal and focal. Lesions from groups 2 and 3 were more severe. The size and deployment pressure of the DESs and the achieved angiographic results were all similar. The post-intervention minimum stent area and the percentage of expansion of DES (minimum stent area/distal reference lumen area x 100%) were, however, both significantly larger in group 3 (6.4 +/- 1.5 mm(2) in group 3 vs 5.6 +/- 1.6 mm(2) in group 1 vs 4.4 +/- 1.4 mm(2) in group 2, p <0.001; and 88 +/- 30% in group 3 vs 74 +/- 14% in group 1 vs 73 +/- 23% in group 2, p = 0.021). A post-intervention minimum stent area <5.0 mm(2) was seen in only 3 lesions in group 3 (8.8%) versus 14 in group 1 (46.7%) and 11 in group 2 (68.8%; adjusted odds ratio 0.11, 95% confidence interval 0.03 to 0.38, p <0.001). Overall, the acute lumen gain was mainly from BMS re-expansion; however, the BMS volume increased the most in group 3 (p <0.001). In conclusion, high-pressure pre-dilation leads to superior post-intervention expansion of DESs implanted to treat BMS restenosis, regardless of the original expansion because of the greater BMS re-expansion.