Open Window Mapping of Accessory Pathways: A Literature Review and Practical Guide.

Catheter ablation is the treatment of choice for patients with symptomatic accessory pathways (APs) causing recurrent atrioventricular reciprocating tachycardia or in situations where APs conduct rapidly, posing a risk of sudden cardiac death. Conventional AP mapping relies on point-by-point assessment of local electrograms looking closely for pathway electrograms or early atrial or ventricular electrograms, which may be challenging and time consuming. Recently, open window mapping (OWM) using 3D navigational systems has emerged as a novel technique to help localise and ablate APs. OWM has significant advantages over conventional point-by-point mapping techniques. The purpose of this review is to summarise the currently available literature on the OWM technique and to highlight the technical aspects and mapping considerations for OWM, including specific cases demonstrating its utility.

Watchful Waiting in Aortic Stenosis: The Problem of Acute Decompensation.

BACKGROUND: Acute decompensation with heart failure, angina, or syncope may be the first indication of undiagnosed aortic stenosis, but should be uncommon when the disorder is known and managed by watchful waiting. There is a lack of information on the proportion of patients with acute decompensated aortic stenosis with and without a prior diagnosis and their outcomes. METHODS: We examined the records of patients with aortic stenosis (International Classification of Diseases code 135.0) admitted to 3 UK hospitals between January 2015 and January 2016. We determined the number of admissions with acute decompensation and the proportion in whom aortic stenosis was and was not previously known. The characteristics and outcomes in the 2 groups were compared. RESULTS: Of 684 patients with aortic stenosis, 543 (79%; 95% confidence interval [CI], 76-82) were elective admissions and 141 (21%; 95% CI, 18-24) were emergencies with acute decompensation; 86 of 141 patients (61%; 95% CI, 52-69) with known aortic stenosis were under watchful waiting and 55 of 141 patients (39%; 95% CI, 31-48) did not have a prior diagnosis. In-hospital mortality was 16% versus 13%, respectively (P = .48). There were no statistically significant differences in characteristics or clinical presentation between the 2 groups (P > .1 for all comparisons). CONCLUSIONS: Approximately 1 in 5 patients admitted to the hospital with aortic stenosis have life-threatening complications due to their disorder. More than half of such patients are actively monitored for aortic stenosis before admission, exposing shortcomings of the watchful waiting management strategy. Measures to identify symptomatic patients earlier and shorten the time between symptom onset and surgery have the potential to substantially reduce morbidity and mortality.

Prevalence of DNA-confirmed familial hypercholesterolaemia in young patients with myocardial infarction.

PURPOSE: To report the prevalence of DNA-confirmed Familial Hypercholesterolaemia (FH) in young patients with acute myocardial infarction, the relative contribution of smoking and diabetes and to compare these rates with those in the general population. METHODS: A pilot clinical service was established to diagnose FH in young patients (≤50 years) with myocardial infarction at a London hospital. Over 23 months, 231 such patients, underwent testing for 48 common FH-mutations and whole exon LDLR gene deletions and duplications. Patients with total cholesterol levels ≥7.0 mmol/L, additionally, underwent full sequencing of the LDLR gene. Smoking and diabetes history were recorded. The prevalence of FH, smoking and diabetes were determined and compared with the prevalence in age and sex matched controls from published surveys. RESULTS: The prevalence of DNA-confirmed FH was 1.3% (95% confidence interval 0.3%-3.8%) compared with 0.2% (0.17%-0.23%) in the general population (p=0.012). Observed prevalence rates for smoking and diabetes were 57% (50.3%-63.6%) and 13.4% (9.2%-18.6%) respectively in patients, compared with expected rates of 25% (23.9%-26.2%) and 4.6% (4.1%-5.2%) in the general population (p<0.001 for both comparisons). CONCLUSION: FH is an important cause of premature myocardial infarction but it accounts for only a small proportion of all such events. The endemic risk factors, smoking and diabetes, far exceed FH in patients with acute myocardial infarction aged 50 or less. Consideration should be given to extending the use of statins and blood pressure drugs to a younger group of smokers and diabetics, who are excluded from treatment by conventional prevention strategies.

Novel low density lipoprotein receptor variant linked to early onset acute myocardial infarction in a patient with familial hypercholesterolaemia.

A novel LDL-receptor gene variant was found responsible for previously undetected familial hypercholesterolaemia and acute myocardial infarction in a young man.

Frequency of gall bladder carcinoma in patients with acute and chronic cholecystitis.

BACKGROUND: Gallbladder carcinoma is a relatively uncommon neoplasm which is more common in the seventh decade of life compared to that of cholelithiasis which is in the fourth decade. The objective of the study was to determine the frequency of carcinoma gall bladder in cases of acute and chronic cholecystitis particularly with reference to cholelithiasis. METHODS: This cross-sectional observational study was done in the department of Surgery at Fauji Foundation Hospital, Rawalpindi from 1st January, 2009 till 3 1st October, 2011. All 310 cholecystectomies performed during this period were included in this study. The specimens collected were macroscopically examined and sent for histopathology. All the reports were reviewed and the results recorded. RESULTS: Out of 310 cases, 27 (8.7%) had acute cholecystitis and 280 (91.2%) were chronic cholecystitis. 3 specimens got autolysed and therefore excluded from the study. 290 cases had cholelithiasis. 2 out of 290 calculous cases were found to have coexistent carcinoma gall bladder proven on histopathology. CONCLUSION: Frequency of carcinoma gallbladder associated with cholelithiasis discovered incidentally after cholecystectomy is very low in our patients.