The anatomy of the atrioventricular nodal artery: A meta-analysis with implications for cardiothoracic surgery and ablation procedures.

The objective of the present meta-analysis was to evaluate recent and applicable data regarding the location and variation of the atrioventricular nodal artery (AVNA) in relation to adjacent structures. In order to minimize postoperative risks and maintain physiological anastomosis for proper cardiac function, understanding such possible variations of vascularization of the AV node is of immense importance prior to cardiothoracic surgery as well as ablations. In order to perform this meta-analysis, a systematic search was conducted in which all articles regarding, or at least mentioning, the anatomy of the AVNA was searched. In general, the results were based on 3919 patients. AVNA was found to originate only from the RCA in 82.41% (95% CI: 79.46%-85.18%). The pooled prevalence of AVNA originating only from LCA was found to be 15.25% (95% CI: 12.71%-17.97%). The mean length of AVNA was found to be 22.64 mm (SE = 1.60). The mean maximal diameter of AVNA at its origin was found to be 1.40 mm (SE = 0.14). In conclusion, we believe that this is the most accurate and up-to-date study regarding the highly variable anatomy of the AVNA. The AVNA was found to originate most commonly from the RCA (82.41%). Furthermore, the AVNA was found to most commonly have no (52.46%) or only one branch (33.74%). It is hoped that the results of the present meta-analysis will be helpful for physicians performing cardiothoracic or ablation procedures.

Compound motor action potentials in transient and persistent phrenic nerve injury - metanalysis.

BACKGROUND: The right phrenic nerve is vulnerable to injury (PNI) during cryoballoon ablation (CBA) isolation of the right pulmonary veins. The complication can be transient or persistent. The reported incidence of PNI fluctuates from 4.73% to 24.7% depending on changes over time, CBA generation, and selected protective methods. M e t h o d s: Through September 2019, a database search was performed on MEDLINE, EMBASE, and Cochrane Database. In the selected articles, the references were also extensively searched. The study provides a comprehensive meta-analysis of the overall prevalence of PNI, assesses the transient to persistent PNI ratio, the outcome of using compound motor action potentials (CMAP), and estimated average time to nerve recovery. R e s u l t s: From 2008 to 2019, 10,341 records from 48 trials were included. Out of 783 PNI retrieved from the studies, 589 (5.7%) and 194 (1.9%) were persistent. CMAP caused a significant reduction in the risk of persistent PNI from 2.3% to 1.1% (p = 0.05; odds ratio [OR] 2.13) in all CBA groups. The mean time to PNI recovery extended beyond the hospital discharge was significantly shorter in CMAP group at three months on average versus non CMAP at six months (p = 0.012). CMAP (in contrast to non-CMAP procedures) detects PNI earlier from 4 to 16 sec (p <0.05; I2 = 74.53%) and 3 to 9o (p <0.05; I2 = 97.24%) earlier. C o n c l u s i o n s: Right PNI extending beyond hospitalization is a relatively rare complication. CMAP use causes a significant decrease in the risk of prolonged injury and shortens the time to recovery.

[Atrial flutter in cardiology practice]. / Trzepotanie przedsionków w praktyce kardiologa.

Atrial flutter (AFL) is one of the most common arrhythmias present in clinical practice, both for the GPs and cardiologist practice. After atrial fibrillation (AF) is second the most common supraventricular arrhythmia. This usually occurs along the cavo-tricuspid isthmus of the right atrium though atrial flutter can originate from the left atrium as well. As AFL is rarely susceptible to pharmacotherapy, that is why, the guidelines of the European and American Cardiology Societies suggest non-pharmacological treatment - an ablation, which is a "gold standard". Due to the reentrant nature of atrial flutter, it is often possible to ablate the circuit that causes atrial flutter with radiofrequency catheter ablation. Catheter ablation is considered to be a first-line treatment method for many people with typical atrial flutter due to its high rate of success (>90%) and low incidence of complications. This is done in the cardiac electrophysiology lab by causing a ridge of scar tissue in the cavo-tricuspid isthmus that crosses the path of the circuit that causes atrial flutter. Eliminating conduction through the isthmus prevents reentry, and if successful, prevents the recurrence of the atrial flutter. Atrial fibrillation often occurs after catheter ablation for atrial flutter. We present an up to date overview of the most important information about AFL based on the available literature.

Morphology of the Vieussens valve and its imaging in cardiac multislice computed tomography.

INTRODUCTION: To deliver accurate morphological descriptions of the Vieussens valve (VV) and to investigate whether this structure could be visualized using standard contrast-enhanced electrocardiogram-gated multislice computed tomography (MSCT). METHODS: A total of 145 human autopsied hearts and 114 cardiac MSCT scans were examined. RESULTS: The VV was observed in both study groups, however, the detection rate was significantly worse in the MSCT examination (18.4% in MSCT vs 62.1% in cadavers, P < .0001). The VV height was larger in MSCT patients (2.8 ± 1.2 vs 5.4 ± 1.7 mm; P < .0001). No significant difference was found in the measured distance between the VV and the coronary sinus ostium between the two separate subgroups (27.3 ± 9.5 vs 24.4 ± 5.8 mm; P = .18). In autopsied material the most frequent valve location was the anterior wall of the coronary sinus (43.3%); the same was observed in MSCT scans (71.4%). CONCLUSION: The VV is a common heart structure, present in over 60% of humans, located mainly on the anterior and superior circuit of the coronary sinus, with relatively high morphological variability. Large VVs, which pose a significant obstacle in catheterization procedures, may be visualized using standard-protocol contrast-enhanced cardiac MSCT.

Electrode ingrowths revealed during cadaveric dissection of a 5y old implanted pacemaker - the case report.

Increasing numbers of implanted cardiovascular electronic devices, results in a need for lead extractions, which has increased to an annual volume of over 10,000 worldwide. We present a cadaveric dissection body with a single chamber pacemaker implanted 5y before death.

Sphenoid bone and its sinus - anatomo-clinical review of the literature including application to FESS.

Authors paid attention to anatomy and clinical implications which are associated with the variations of the sphenoid sinus. We discuss also anatomical structure of the sphenoid bone implementing clinical application of this bone to different invasive and miniinvasive procedures (i.e. FESS).

[Reasons of recurrence and subjective arrhythmia feelings after successful RF AVNRT ablation].

Aim of the study was analysis of electrophysiological and clinical parameters related to increasement of recurrence risk of AVNRT and subjective heart feelings after successful RF ablation. Materials and methods: Retrospective analysis was made among patients after successful RF AVNRT ablation. Study group was 93 patients (F=63), mean age 46.7+15.9 (from 18 to 80y). Electrophysiological and physical parameters achieved during electrophysiological study was analysed. Using telephone monitoring and question survey patients were divided into 3 subgroups A ­ without symptoms, B ­ with subjective arrhythmia feelings and C with documented arrhythmia recurrence. Results: 6.4% patients (n=6) had documented arrhythmia recurrence AVNRT (subgroup C); women 100% (n=6), mean age 43.5±14 years. 43% of patients (n=40) after successful RF ablation had subjective feelings of heart palpitations of a different kind (subgroup B); women 68% (n=32), mean age 42.8±14 years. 51% (n=47) of patients didn't feel any arrhythmia (subgroup A); women 64% (n=36), mean age 50.7±17 years. Conclusions: Factors related to increased risk of arrhythmia recurrence was: atypical forms of tachycardia, shorter tachycardia cycle, slow pathway modification, low mean power during RF ablation. Among patients without documented arrhythmia recurrence: lower age, higher time from the beginning arrhythmia until ablation procedure and Wenckebach Point cycle length shorter predispose to inadequate subjective arrhythmia feelings after successful RF ablation.

Human coronary sinus - from Galen to modern times.

Based on the review of the current literature and our own experiences we reviewed the literature paying most attention to human venous coronary system with special respect to coronary sinus - the largest vein of the heart. Many details still remain obscure, although most of modern procedures require deep anatomical knowledge on cardiac veins. Many of developmental remarks are still not clear, regarded to development of the vessels of the heart in association with origin of heart conductive system.

Syndrome of canal of Guyon - definition, diagnosis, treatment and complication.

Syndrome of canal of Guyon is the second after carpal tunnel syndrome, compression syndrome in the wrist. Opposite to median nerve compression, ulnar nerve compression is not very popular. However it impairs functioning of the hand even more than median nerve lesion. Authors deal with definition, possible diagnostic methods, treatment and most frequent complication.

Morphometric parameters of human coronary sinus - based on study of 80 human hearts.

The study was carried out on 80 human hearts (64 male and 16 female). The whole material has been divided into 4 groups: I - aged 19-40; II - aged 41-50; III - aged 51-60 and IV - aged 61-70. The venous vascular bed of 80 hearts was injected through the coronary sinus with Duracryl plus (Spofa Dental, Czech Republic) and next corroded. Thus obtained specimens were measured using electronic caliper (MAU-a E 0-150, Horex, Poland). The length of the coronary sinus varied from 15-50 mm (with the mean value of 30 mm in male hearts and 25 mm in female hearts). The caliber of the vessels varied from 7-13 mm. The length of the coronary sinus is not age-dependent, however it is longer in male than female hearts. Generally the caliber of male coronary sinus is bigger than in the female, although it isn't statistically significant.

Application of Duracryl plus for preparation of corrosion casts of venous coronary tree of human heart.

Duracryl Plus is a synthetic resin, self-polymerizing copolymer of methyl methacrylate and acrylate, which is widely used in dental practice. The aim of this study was to apply it to fill the venous vascular beds of human hearts to obtain corrosion cast ready to describe wanted parameters of venous coronary vessels.

Morphology of tributaries of coronary sinus in humans - corrosion casting study.

The study was carried out on 80 human hearts obtained during autopsies. The vascular beds were filled with synthetic resin and next corroded. In all 80 hearts we have been found both: great, middle and small cardiac veins. In two out of 80 hearts we did not find oblique vein of the left atrium. Posterior vein of the left ventricle was double in four hearts. Right marginal vein was found in 5 hearts, left marginal vein was seen in 9 hearts. We also compared the dimensions of all of the above mentioned tributaries of the coronary sinus.

Inferior tibiofibular joint (tibiofibular syndesmosis) - own studies and review of the literature.

The study was carried out on 50 human lower legs obtained during autopsies. The anatomy of the joint was studied using classical anatomical description methods. Based also on literature we have reviewed the current knowledge on the inferior tibiofibular joint.

Anatomy of Guyon's canal - a systematic review.

Carpal tunnel syndrome is the first on the list of peripheral nerve lesions in the upper limb. Most of the anatomical facts about this syndrome are widely known. The Guyoun's canal is the second reason for compression syndrome in the wrist. Anatomy of this is region still remains controversial. This is why authors tried to compile some latest findings accompanied by their own observation, and added some clinical notes, which might be useful both for orthopedic surgeons and well as for representatives of basic sciences.

Morphology of human sinoatrial node and its surrounding right atrial muscle in the global obesity pandemic-does fat matter?

Introduction: The sinus node (SN) is the main pacemaker site of the heart, located in the upper right atrium at the junction of the superior vena cava and right atrium. The precise morphology of the SN in the human heart remains relatively unclear especially the SN microscopical anatomy in the hearts of aged and obese individuals. In this study, the histology of the SN with surrounding right atrial (RA) muscle was analyzed from young non-obese, aged non-obese, aged obese and young obese individuals. The impacts of aging and obesity on fibrosis, apoptosis and cellular hypertrophy were investigated in the SN and RA. Moreover, the impact of obesity on P wave morphology in ECG was also analyzed to determine the speed and conduction of the impulse generated by the SN. Methods: Human SN/RA specimens were dissected from 23 post-mortem hearts (preserved in 4% formaldehyde solution), under Polish local ethical rules. The SN/RA tissue blocks were embedded in paraffin and histologically stained with Masson's Trichrome. High and low-magnification images were taken, and analysis was done for appropriate statistical tests on Prism (GraphPad, USA). 12-lead ECGs from 14 patients under Polish local ethical rules were obtained. The P wave morphologies from lead II, lead III and lead aVF were analyzed. Results: Compared to the surrounding RA, the SN in all four groups has significantly more connective tissue (P ≤ 0.05) (young non-obese individuals, aged non-obese individuals, aged obese individuals and young obese individuals) and significantly smaller nodal cells (P ≤ 0.05) (young non-obese individuals, aged non-obese individuals, aged obese individuals, young obese individuals). In aging, overall, there was a significant increase in fibrosis, apoptosis, and cellular hypertrophy in the SN (P ≤ 0.05) and RA (P ≤ 0.05). Obesity did not further exacerbate fibrosis but caused a further increase in cellular hypertrophy (SN P ≤ 0.05, RA P ≤ 0.05), especially in young obese individuals. However, there was more infiltrating fat within the SN and RA bundles in obesity. Compared to the young non-obese individuals, the young obese individuals showed decreased P wave amplitude and P wave slope in aVF lead. Discussion: Aging and obesity are two risk factors for extensive fibrosis and cellular hypertrophy in SN and RA. Obesity exacerbates the morphological alterations, especially hypertrophy of nodal and atrial myocytes. These morphological alterations might lead to functional alterations and eventually cause cardiovascular diseases, such as SN dysfunction, atrial fibrillation, bradycardia, and heart failure.

Angioarchitecture of uterine cervical leiomyomata - a SEM study.

AIM: he main goal of this study was assessment of vascular structure of cervical uterine leiomyomata. MATERIALS AND METHODS: The study was carried out on ten human uteri collected upon autopsy. Vessels were injected with synthetic resin, next corroded and coated with gold, finally observed using scanning electron microscope. RESULTS: Most of cervical fibroids were observed in the middle third of the wall of cervix. They were surrounded by relatively dense 'vascular capsule'. consisted of flattened vein, arterioles and capillaries. CONCLUSIONS: Structure of cervical uterine leiomyomata was similar to those observed in initial stage of growth of myometrial fibroids.

Blood vessels of the intratumoral septa in uterine leiomyomata.

The angioarchitecture of fibroid intratumoral septa was studied using 32 uteri obtained during necropsies of the females aged between 35-57. The whole vascular bed of 16 uteri was injected with synthetic resin Mercox CL-2R and then the uteri were corroded in potassium hydroxide. Next 16 uteri were injected with acrylic emulsion, Liquitex R. Their vascular bed was studied using immunohistochemistry for von Willebrandt's factor. Immunohistochemistry allowed to visualize the vessels within the intratumoral septa, while SEM allowed to differentiate the vessels, which were mainly the venules and the veins. Apart from the veins the intratumoral septa were consisted of small arteries and capillaries.

Radiofrequency catheter ablation of ventricular tachycardia using combined endocardial techniques in patients with structural heart disease improves procedural effectiveness and reduces arrhythmia episodes.

BACKGROUND: Evidence indicates that radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) in patients with structural heart disease (SHD) is safe and effective. However, arrhythmia recurrence is still relatively high, and the optimal procedural strategy is unclear. In clinical practice, several combinations of mapping and ablation techniques are used to improve VT ablation efficacy. AIM: The study aimed to evaluate and provide evidence on the efficiency and safety of a systematized combination of VT ablation (mapping) techniques in patients with SHD. METHODS: From 2016 to 2019, 47 patients (54 procedures) with SHD (89% heart failure, 94% ischemic heart disease, 37% VT storm) who underwent RFCA of VT were retrospectively analyzed from a group of 58 consecutive patients. During RFCA of VT, different combinations of three techniques, activation mapping (AM), pace mapping (PM), and substrate-based mapping (SbM), were used. The procedures were performed using the CARTO® 3 (Biosense Webster Inc., Diamond Bar, CA, US) electro-anatomical mapping system. RESULTS: During a median (interquartile range [IQR]) follow-up of 25.5 months (11.75-52.25), VT-free survival after ablation was 68.5% (n = 37/54 procedures). Acute procedural success was achieved in 85% (n = 46/54 procedures). The number of induced VT morphologies, induction of non-clinical or non-sustained VT after ablation, and fewer VT mapping techniques used during the procedure were related to decreasing VT-free survival. CONCLUSIONS: VT ablation strategy based on systemic use of combined techniques is effective and safe in long-term follow-up of patients with SHD.

Permanent single-chamber atrial pacing: an obsolete or viable alternative to dual-chamber pacing in selected patients with sinus node disease?

INTRODUCTION: Single atrial stimulation (AAI) has been commonly used for permanent pacing in sick sinus syndrome and significant bradycardia. OBJECTIVE: The study aimed to evaluate long­term AAI pacing and to identify timing and reasons for pacing mode change. PATIENTS AND METHODS: Retrospectively, we included 207 patients (60% women) with initial AAI pacing, who were followed­up for an average of 12 years. RESULTS: At the time of death or loss to follow­up, 71 patients (34.3%) had unchanged AAI pacing mode. The reason for an upgrade of the pacing system was development of atrial fibrillation (AF) in 43 patients (20.78%) and atrioventricular block (AVB) in 34 patients (16.4%). The cumulative ratio for a pacemaker upgrade reoperation reached 2.77 per 100 patient­years of the follow­up. Cumulative ventricular pacing below 10% after an upgrade to dual­chamber pacemaker was observed in 28.6% of the patients. Younger age at implant was the leading independent predictor of the change to dual­chamber simulation (hazard ratio, 1.98; 95% CI, 1.976-1.988; P = 0.001). There were 11 (5%) lead malfunctions that required reoperation. Subclavian vein occlusion was noted in 9 upgrade procedures (11%). One cardiac device-related infection was observed. CONCLUSIONS: The reliability of AAI pacing decreases with each year of observation due to development of AF and AVB. However, in the current era of effective AF treatment, the advantages of AAI pacemakers, such as lower incidence of lead malfunction, venous occlusion, and infection, as compared with dual-chamber pacemakers, may make AAI pacemakers a viable option.

Contact Force-Sensing versus Standard Catheters in Non-Fluoroscopic Radiofrequency Catheter Ablation of Idiopathic Outflow Tract Ventricular Arrhythmias.

BACKGROUND: Adequate contact between the catheter tip and tissue is important for optimal lesion formation and, in some procedures, it has been associated with improved effectiveness and safety. We evaluated the potential benefits of contact force-sensing (CFS) catheters during non-fluoroscopic radiofrequency catheter ablation (NF-RFCA) of idiopathic ventricular arrhythmias (VAs) originating from outflow tracts (OTs). METHODS: A group of 102 patients who underwent NF-RFCA (CARTO, Biosense Webster Inc., Irvine, CA, USA) of VAs from OTs between 2014 to 2018 was retrospectively analyzed. RESULTS: We included 52 (50.9%) patients in whom NF-RFCA was performed using CFS catheters and 50 (49.1%) who were ablated using standard catheters. Arrhythmias were localized in the right and left OT in 70 (68.6%) and 32 (31.4%) patients, respectively. The RFCA acute success rate was 96.1% (n = 98) and long-term success during a minimum 12-month follow-up (mean 51.3 ± 21.6 months) was 85.3% (n = 87), with no difference between CFS and standard catheters. There was no difference in complications rate between CFS (n = 1) and standard catheter (n = 2) ablations. CONCLUSIONS: There is no additional advantage of CFS catheters use over standard catheters during NF-RFCA of OT-VAs in terms of procedural effectiveness and safety.