Dual AV Nodal Nonreentrant Tachycardia Resulting in Inappropriate ICD Therapy in a Patient with Cardiac Sarcoidosis.

Dual atrioventricular nodal nonreentrant tachycardia (DAVNNT) occurs due to concurrent antegrade conduction over fast and slow atrioventricular nodal pathways and is treated by slow pathway modification. We describe a unique case of a patient with cardiac sarcoidosis who received inappropriate ICD shocks for DAVNNT. Atrial and ventricular device electrograms satisfied both rate and V>A criteria for ventricular tachycardia. We postulate that alterations in refractoriness and conduction as is seen in cardiac sarcoidosis (CS) may have contributed to occurrence of DAVNNT.

A case of combined pulmonary vein isolation (PVI) and watchman implant through hepatic vein in a patient with interrupted inferior vena cava (IVC).

This case report describes a successful procedure involving pulmonary vein isolation (PVI) and left atrial appendage (LAA) closure with a watchman device in a 78-year-old male with atrial fibrillation and an interrupted inferior vena cava. Due to the vascular anomaly, a transhepatic approach was used, which proved successful.

Treatment of atrial fibrillation in hypertrophic cardiomyopathy.

Atrial Fibrillation (AF) is present in 5 percent of hypertrophic cardiomyopathy (HCM) patients at the time of diagnosis. Ostial pulmonary vein (PV) diameter is increased in patients with AF as well as hypertensive patients. These findings support the theory that the cascade of events leading to diastolic dysfunction might predispose a person to AF by stretching the PVs. This mechanism is likely relevant to AF in HCM as well. The recognition that AF often times arises from the PVs has led to innovation of ablation techniques that target this zone to electrically isolate the PVs from the left atrium (LA). Anticoagulation is the cornerstone of AF treatment. Additional AF treatment in HCM patients depends on the initial decision regarding need for surgical intervention, whether or not AF is permanent, and the severity of symptoms in patients with non-permanent AF. If surgery is planned, correction of the arrhythmia with MAZE procedure, which isolates the arrhythmogenic foci, at the time of myectomy is an option to consider. The goal in HCM patients with permanent AF is to control the heart rate whether by chronic medications or through ablate + pace procedure. Based on the severity of symptoms, HCM patients with non-permanent AF will be treated with either the rate control strategy (b-blockers/calcium channel blocker) or the rhythm control strategy (PV ablation, antiarrhythmic drugs, or radiofrequency ablation of the LA). This is because adverse effects of antiarrhythmics and complications after invasive procedures are justifiable only in HCM patients who experience severe symptoms.

Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction.

Small, single-center studies suggest that catheter ablation of atrial fibrillation (AF) can improve ventricular function and reduce symptoms in patients with left ventricular (LV) dysfunction. However, ablation has not been compared with a pharmacologic strategy for AF. The authors evaluated patients with AF and symptomatic LV dysfunction (ejection fraction < or =45%) referred for pulmonary vein isolation (PVI). They compared these patients with a matched cohort treated medically for AF and LV dysfunction via a retrospective case-control method. Fifteen patients (14 men, 56+/-11 years, 10 [67%] paroxysmal AF) with AF for 4+/-3 years underwent PVI. Baseline ejection fraction was 37%+/-6% and New York Heart Association (NYHA) class was 2.0+/-1.0. Fifteen controls (13 men, 63+/-14 years, 11 [73%] paroxysmal AF) with AF for 5+/-4 years were treated medically for AF. Baseline ejection fraction was 34%+/-11% and NYHA class was 2.0+/-0.7. The groups were similar in all respects. During a follow-up of 16+/-13 months after complete PVI, ejection fraction improved (P=.001) to 50%+/-13% and normalized in 8 patients (53%). NYHA class improved to 1.3+/-0.5 (P=.01). In the medically treated group, after follow-up of 16+/-12 months, no improvement in ejection fraction (36%+/-12%) or NYHA class (1.8+/-0.7) was seen. Compared with pharmacologic therapy, PVI significantly improved LV function and NYHA class in patients with AF and symptomatic LV dysfunction. These provocative findings provide potent rationale for a randomized clinical trial comparing ablation with pharmacologic therapy.

Carcinoma of the prostate presenting as a painful parotid mass with mandibular invasion: a case report.

Prostate cancer metastatic to the parotid gland is exceedingly rare, as only 10 cases have been previously reported in the literature. Symptoms may mimic a parotid infection or suggest a primary parotid tumor. We report a new case of carcinoma of the prostate metastatic to the parotid. The tumor was painful and had invaded the mandible. Fine-needle aspiration of the mass and immunohistochemical staining for prostate-specific antigen confirmed the diagnosis. The patient died 1 month later of an unrelated cause.

Supraclavicular lymph node: incidence of unsuspected metastatic prostate cancer.

An uncommon presentation of prostate carcinoma to the supraclavicular lymph nodes is herein reviewed. With prompt diagnosis and treatment, patient survival can be extended. A high index of suspicion is necessary to make the diagnosis. The clinical features of four cases involving metastatic prostate carcinoma will be discussed.