Haemorrhagic cerebral air embolism from an atrio-oesophageal fistula following atrial fibrillation ablation.

We report the case of a man found unconscious three weeks following atrial fibrillation (AF) ablation. Cranial and thoracic imaging demonstrated multiple areas of pneumo-embolic infarction secondary to an atrio-oesophageal fistula (AEF). AEF is a recognised, but rare, complication of AF ablation.(1-8) Early recognition is critical as the mortality is 100% without surgical intervention. We consider the postulated mechanisms of AEF formation, the spectrum of clinical presentation, investigations and treatment.

Adenocarcinoma of the small bowel.

Cancer of the small bowel is a rare entity but its incidence is rising. Historically, outcome is poor despite apparent curative resection. At present surgery remains the only treatment modality of proven benefit in the management of this disease. Recent data would suggest 5-year survival rates in the order of 40-50% at all sites of small bowel cancer. To improve upon this, earlier diagnosis with a high index of suspicion and multicentre adjuvant therapy trials are required.

Automated analysis of atrial late gadolinium enhancement imaging that correlates with endocardial voltage and clinical outcomes: a 2-center study.

BACKGROUND: For late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) assessment of atrial scar to guide management and targeting of ablation in atrial fibrillation (AF), an objective, reproducible method of identifying atrial scar is required. OBJECTIVE: To describe an automated method for operator-independent quantification of LGE that correlates with colocated endocardial voltage and clinical outcomes. METHODS: LGE CMR imaging was performed at 2 centers, before and 3 months after pulmonary vein isolation for paroxysmal AF (n = 50). A left atrial (LA) surface scar map was constructed by using automated software, expressing intensity as multiples of standard deviation (SD) above blood pool mean. Twenty-one patients underwent endocardial voltage mapping at the time of pulmonary vein isolation (11 were redo procedures). Scar maps and voltage maps were spatially registered to the same magnetic resonance angiography (MRA) segmentation. RESULTS: The LGE levels of 3, 4, and 5SDs above blood pool mean were associated with progressively lower bipolar voltages compared to the preceding enhancement level (0.85 ± 0.33, 0.50 ± 0.22, and 0.38 ± 0.28 mV; P = .002, P < .001, and P = .048, respectively). The proportion of atrial surface area classified as scar (ie, >3 SD above blood pool mean) on preablation scans was greater in patients with postablation AF recurrence than those without recurrence (6.6% ± 6.7% vs 3.5% ± 3.0%, P = .032). The LA volume >102 mL was associated with a significantly greater proportion of LA scar (6.4% ± 5.9% vs 3.4% ± 2.2%; P = .007). CONCLUSIONS: LA scar quantified automatically by a simple objective method correlates with colocated endocardial voltage. Greater preablation scar is associated with LA dilatation and AF recurrence.

Outcomes of elderly patients aged 80 and over with symptomatic, severe aortic stenosis: impact of patient's choice of refusing aortic valve replacement on survival.

BACKGROUND: Aortic valve replacement (AVR) can be performed safely in selected elderly patients with aortic stenosis (AS). However, the survival benefits of AVR over conservative treatment have not been convincingly demonstrated in AS patients aged above 80. AIM: To investigate the outcomes of patients aged 80 and over with symptomatic, severe AS and by analyzing the effects of patient's choice in either agreeing or refusing to undergo AVR, determine the survival benefits afforded by AVR. DESIGN: Cohort study. METHODS: Subjects aged 80 and over with severe symptomatic AS, diagnosed between 2001 and 2006 were segregated into three groups: subjects who underwent AVR (Group A); patients who were fit for AVR but declined surgery due to personal choice (Group B) and those who were not fit for surgery and were managed conservatively (Group C). Follow-up was conducted by out-patient attendances, review of medical records and telephone interviews. The primary endpoint was all-cause mortality. RESULTS: A total of 103 patients (86.0 +/- 4.2 years, 41% male) were identified and no patient was lost during follow-up. In Group A (n = 17), all 15 patients who underwent AVR were alive after 3.6 +/- 1.4 years follow-up and 2 died whilst awaiting AVR. Seventy-four percent of Group B (n = 24) and 76% of Group C (n = 62) died during follow-up. Group A had significantly better survival than B and C. (P < 0.01) Amongst patients fit for AVR with similar operative risks (Groups A and B), refusal to undergo surgery (hazard ratio 12.61, P = 0.001) was the only predictor of mortality in a multivariate model. CONCLUSION: For elderly AS patients fit for surgery, the patient's decision to refuse AVR is associated with a >12-fold increase in mortality risk. These findings have significant implications for informed decision-making when managing the fit, elderly patient with AS.

Role of electrophysiological study and ablation in the management of recurrent atrial flutter associated with haemodynamic compromise in a critically ill patient.

Atrial flutter is a common arrhythmia. In the critical care setting, the arrhythmia may present in any patient, but it is most commonly seen in patients with impaired ventricular function, valvular disease, atrial dilatation or after cardiac surgery. We present a 68-year-old lady with recurrent poorly tolerated atrial flutter that was resistant to multiple pharmacological interventions and complicated by cardiogenic shock following direct current cardioversion. The flutter was successfully cured with radiofrequency ablation and was followed by an immediate improvement in her haemodynamic status. We review the management of acute atrial flutter and discuss the role of electrophysiologically guided ablation.

Short and long-term outcome of pancreatic surgery in a district general hospital.

Pancreatic surgery is a formidable undertaking with historically high mortality and poor prognosis for periampullary lesions. This has led to recommendations that all pancreatic surgery should be performed in specialist centres. There is no doubt from large series that a low mortality can be achieved in these centres, but there has been no direct comparison between results from these specialist centres and district general hospitals with an interest in pancreatic disease. We present a retrospective, seven-year experience with a 3% 30 day mortality, 39% morbidity and 14 month median survival for malignant disease. Comparison with the UK survey of specialist pancreatic units shows that pancreatic surgery can be safely performed in the setting of a district general hospital with low morbidity and mortality, and good long-term outcome.