Is long-term follow-up solely by imaging tests safe in non-operated pancreatic neuroendocrine tumors?

INTRODUCTION: the diagnosis of asymptomatic sporadic nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) has increased significantly due to the widespread use of high-resolution imaging tests, which is why the most appropriate management at the time of diagnosis is the subject of debate, as is how to follow-up patients. AIMS: the objective of this study was to analyze the frequency of imaging and endoscopic studies performed during long-term follow-up. METHODS: a retrospective review was performed of a database collected between January 2008 and December 2020 of patients with an incidental diagnosis of small NF-PNETs; follow-up was closed in March 2023. The imaging tests performed at the time of diagnosis and long-term follow-up were recorded. Growing less than 1 mm per year has not been considered as a worrisome feature. Follow-up was performed through imaging tests, considering endoscopic cytology for lesions with a faster grow rate. RESULTS: fifty-eight patients were included; the median age was 69 years. The initial mean size of the lesions studied was 12.79 mm (5-27). Follow-up was carried out only with computed tomography (CT) or magnetic resonance imaging (MRI). The initial size did not influence the behavior of the lesion in a statistically significant manner. Twenty-eight tumors (45 %) increased in size, with a growth equal to or less than 4 mm in 24 cases. The mean follow-up time was 82.41 months (12-164). No patient developed metastasis or died from PNET progression. CONCLUSIONS: the follow-up of neuroendocrine tumors of small size can be performed safely with only imaging tests.

Is long-term follow-up solely by imaging tests safe in non-operated pancreatic neuroendocrine tumors?

Introduction: the diagnosis of asymptomatic sporadic nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) has increased significantly due to the widespread use of high-resolution imaging tests, which is why the most appropriate management at the time of diagnosis is the subject of debate, as is how to follow-up patients. Aims: the objective of this study was to analyze the frequency of imaging and endoscopic studies performed during long-term follow-up. Methods: a retrospective review was performed of a database collected between January 2008 and December 2020 of patients with an incidental diagnosis of small NF-PNETs; follow-up was closed in March 2023. The imaging tests performed at the time of diagnosis and long-term follow-up were recorded. Growing less than 1 mm per year has not been considered as a worrisome feature. Follow-up was performed through imaging tests, considering endoscopic cytology for lesions with a faster grow rate. Results: fifty-eight patients were included; the median age was 69 years. The initial mean size of the lesions studied was 12.79 mm (5-27). Follow-up was carried out only with computed tomography (CT) or magnetic resonance imaging (MRI). The initial size did not influence the behavior of the lesion in a statistically significant manner. Twenty-eight tumors (45 %) increased in size, with a growth equal to or less than 4 mm in 24 cases. The mean follow-up time was 82.41 months (12-164). No patient developed metastasis or died from PNET progression. Conclusions: the follow-up of neuroendocrine tumors of small size can be performed safely with only imaging tests. (AU)

Multidrug-Resistant Bacterial Colonization and Infections in Large Retrospective Cohort of Mechanically Ventilated COVID-19 Patients1.

Few data are available on incidence of multidrug-resistant organism (MDRO) colonization and infections in mechanically ventilated patients, particularly during the COVID-19 pandemic. We retrospectively evaluated all patients admitted to the COVID-19 intensive care unit (ICU) of Hub Hospital in Milan, Italy, during October 2020‒May 2021. Microbiologic surveillance was standardized with active screening at admission and weekly during ICU stay. Of 435 patients, 88 (20.2%) had MDROs isolated ≤48 h after admission. Of the remaining patients, MDRO colonization was diagnosed in 173 (51.2%), MDRO infections in 95 (28.1%), and non-MDRO infections in 212 (62.7%). Non-MDRO infections occurred earlier than MDRO infections (6 days vs. 10 days; p<0.001). Previous exposure to antimicrobial drugs within the ICU was higher in MDRO patients than in non-MDRO patients (116/197 [58.9%] vs. 18/140 [12.9%]; p<0.001). Our findings might serve as warnings for future respiratory viral pandemics and call for increased measures of antimicrobial stewardship and infection control.

Treatment of Calcified Lesions Using a Dedicated Super-High Pressure Balloon: Multicenter Optical Coherence Tomography Registry.

BACKGROUND: Calcified lesions often lead to difficulty achieving optimal stent expansion. OPN non-compliant (NC) is a twin layer balloon with high rated burst pressure that may modify calcium effectively. METHODS: Retrospective, multicenter registry in patients undergoing optical coherence tomography (OCT) guided intervention with OPN NC. Superficial calcification with > 180o arc and > 0.5 mm thickness, and/or nodular calcification with > 90o arc were included. OCT was performed in all cases before and after OPN NC, and after intervention. Primary efficacy endpoints were frequency of expansion (EXP) ≥80 % of the mean reference lumen area and mean final EXP by OCT, and secondary endpoints were calcium fractures (CF), and EXP ≥90 %. RESULTS: 50 cases were included; 25 (50 %) superficial, and 25 (50 %) nodular. Calcium score of 4 in 42 (84 %) cases and 3 in 8 (16 %). OPN NC was used alone, or after other devices if further modification was needed, NC in 27 (54 %), cutting in 29 (58 %), scoring in 1 (2 %), IVL in 2 (4 %); or if non-crossable lesion, rotablation in 5 (10 %) cases. EXP ≥80 % was achieved in 40 (80 %) cases with mean final EXP post intervention of 85.7 % ± 8.9. CF were documented in 49 (98 %) cases; multiple in 37 (74 %). There were 1 flow limiting dissection requiring stent deployment and 3 non-cardiovascular related deaths in 6 months follow-up. No records of perforation, no-reflow or other major adverse events. CONCLUSION: Among patients with heavy calcified lesions undergoing OCT guided intervention with OPN NC, acceptable expansion was achieved in most cases without procedure related complications.

Executive summary of the consensus statement of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Spanish Society of Neurology (SEN), Spanish Society of Immunology (SEI), Spanish Society of Pediatric Infectology (SEIP), Spanish Society of Rheumatology (SER), and Spanish Academy of Dermatology and Venereology (AEDV), on the diagnosis, treatment and prevention of Lyme borreliosis.

The diagnosis of Lyme borreliosis (LB) is based on the epidemiological history, clinical manifestations and microbiological findings in the early disseminated and late phases of the disease. Related to this fact, microbiological diagnostic techniques have recently appeared. Far from facilitating the diagnosis and the clinical-therapeutic management of LB patients, they are generating confusion. Herein, experts and representatives of Spanish Scientific Societies [Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Spanish Society of Neurology (SEN), Spanish Society of Immunology (SEI), Spanish Society of Pediatric Infectology (SEIP), Spanish Society of Rheumatology (SER), and Spanish Academy of Dermatology and Venereology (AEDV)] exposed the executive summary after reviewing the epidemiology, clinical spectrum, available diagnostic techniques for the diagnosis of Borrelia burgdorferi infection, therapeutic and prevention options of LB. By consensus, recommendations for microbiological diagnosis are offered together with those supporting the therapeutic management and prophylaxis of infection.

Executive summary of the consensus statement of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Spanish Society of Neurology (SEN), Spanish Society of Immunology (SEI), Spanish Society of Pediatric Infectology (SEIP), Spanish Society of Rheumatology (SER), and Spanish Academy of Dermatology and Venereology (AEDV), on the diagnosis, treatment and prevention of Lyme borreliosis / Resumen ejecutivo del documento de consenso de la SEIMC, SEN, SEI, SEIP, SER y AEDV sobre el diagnóstico, tratamiento y prevención de la borreliosis de Lyme

The diagnosis of Lyme borreliosis (LB) is based on the epidemiological history, clinical manifestations and microbiological findings in the early disseminated and late phases of the disease. Related to this fact, microbiological diagnostic techniques have recently appeared. Far from facilitating the diagnosis and the clinical-therapeutic management of LB patients, they are generating confusion. Herein, experts and representatives of Spanish Scientific Societies [Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Spanish Society of Neurology (SEN), Spanish Society of Immunology (SEI), Spanish Society of Pediatric Infectology (SEIP), Spanish Society of Rheumatology (SER), and Spanish Academy of Dermatology and Venereology (AEDV)] exposed the executive summary after reviewing the epidemiology, clinical spectrum, available diagnostic techniques for the diagnosis of Borrelia burgdorferi infection, therapeutic and prevention options of LB. By consensus, recommendations for microbiological diagnosis are offered together with those supporting the therapeutic management and prophylaxis of infection.(AU)

El diagnóstico de la borreliosis de Lyme (BL) se basa en la historia epidemiológica, las manifestaciones clínicas y los hallazgos microbiológicos de las etapas temprana diseminada y tardía de la enfermedad. En relación a este hecho, han aparecido recientemente técnicas diagnósticas microbiológicas que, lejos de facilitar el diagnóstico y el manejo clínico-terapéutico de los pacientes con BL, están generando confusión. Por ello, los expertos y representantes de las sociedades científicas españolas [Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), Sociedad Española de Neurología (SEN), Sociedad Española de Inmunología (SEI), Sociedad Española de Infectología Pediátrica (SEIP), Sociedad Española de Reumatología (SER) y Academia Española de Dermatología y Venereología (AEDV)] han presentado el documento de síntesis tras revisar la epidemiología, el espectro clínico, las técnicas disponibles para el diagnóstico de la infección por Borrelia burgdorferi, así como las opciones terapéuticas y preventivas de BL. De manera consensuada, se ofrecen recomendaciones para el diagnóstico microbiológico, así como recomendaciones que respaldan el manejo terapéutico y la profilaxis de la infección.(AU)

Recurrent founder-event speciation across the Mediterranean likely shaped the species diversity and geographic distribution of the freshwater snail genus Mercuria Boeters, 1971 (Caenogastropoda: Hydrobiidae).

Dispersal is known to play an important role in shaping the diversity and geographic range of freshwater gastropods. Here, we used phylogenetic methods to test for the influence of dispersal and other biogeographic processes (such as vicariance) on the speciation and distribution patterns of Mercuria Boeters, 1971, a snail genus widely distributed in the western Palaearctic. The 25 extant species traditionally thought to comprise the genus, which were described mainly on the basis of morphology, have been recorded from lowland waters in both the Mediterranean and Atlantic river basins of Europe and North Africa. Using molecular phylogenies based on three gene fragments (COI, 16S rRNA and 28S rRNA) from 209 individuals, four molecular species delimitation methods and a shell characterization, we identified 14 putative species in our dataset, nine of which correspond to species classified by traditional taxonomy. Furthermore, biogeographical modelling favoured a scenario in which recurrent founder-event speciation since the late Miocene is the most probable process explaining the species diversity and distribution of the Mediterranean clades, whereas episodes of postglacial northward colonization from Iberian refugia by the species M.tachoensis may explain the current presence of the genus in Atlantic lowlands. The dispersal events inferred for Mercuria, probably promoted by multiple factors such as the changing connectivity of drainage basins driven by climate change or better access for avian dispersal vectors in lowlands, may explain the rare case among hydrobiids of a species-rich genus containing individual species with a large distribution area.

Synthesis and Characterization of Solvated Lanthanide Tris(trimethylsilyl)siloxides.

In an effort to develop precursors for the production of lanthanide silicate (LnSiOx) materials, the reactions of [Ln(NR2)3] (R = SiMe3) with three equivalents of tris(trimethylsilyl)silanol (H-OSi(SiMe3)3) or H-SST) in tetrahydrofuran (THF) were undertaken. The products were crystallographically characterized as [Ln(SST)3(THF)2] (where Ln = La, Ce, Pr, Nd, Sm, Eu, Gd, Tb, Dy, Ho, Er, Tm, Yb, and Lu). In general, these compounds are similar to the previously reported [Gd(SST)3(THF)2] complex, where each metal center of the monomeric species is found to adopt a trigonal bipyramidal (TBP; τ = av 0.95) geometry; however, the crystallographic structure solutions for these crystals invoke a much larger unit cell that reveals the complex disorder of the axial THF ligands. Using incompletely washed H-SST, the tetrahedrally (T-4) bound [Ln(SST)3(NEt3)] (Ln-NEt3 = Pr-NEt3, Ho-NEt3; NEt3 = triethylamine) compounds were isolated from the same reaction run in toluene. Rational syntheses of amine derivatives were realized by performing the same reaction with pure H-SST in toluene containing the appropriate amine and [Ln(NR2)3] with the final products identified as [Tm(SST)3(NEt3)] (Tm-NEt3) or [Tm(SST)3(NHPr2i)] (NHPr2i = di-iso-propylamine; Tm-NHPr2i). The products isolated from reactions undertaken in pyridine (py) were identified as [Ln(SST)3(py)2] (Ln-py = Ce-py, Eu-py, and Tm-py). The Ln-py structures exhibit the larger unit cell noted for the THF derivatives with each Ln adopting a TBP (τ = av 0.98) metal center possessing equatorial SST and axial py ligands. The same reaction run in toluene led to the isolation of [(η6-tol)Tm(SST)3] (Tm-tol). Multinuclear NMR (1H and 29Si) data support the retention of the solid-state structures of all of these compounds in solution. Photoluminescent measurements of Tb, Sm, Dy, and Eu were found to display emission and lifetime profiles in the visible range due to f-f transitions, consistent with trivalent lanthanide metal centers.

Immunosenescence, Immune Fitness and Vaccination Schedule in the Adult Respiratory Patient.

Immunosenescence is the gradual deterioration of the immune system caused by advancing age. It is associated with a reduced ability to respond to infections and develop long-term immune memory. It plays a key role in the development of respiratory diseases that are more common in older people, such as asthma, COPD, diffuse interstitial disease and respiratory infections in the elderly. We call immune fitness the establishment of lifestyle habits that can improve our immune capacity. We now know that good eating habits, good social relationships, not smoking, limiting alcohol consumption, exercising, controlling stress levels and establishing a proper vaccination programme can slow down the process of immunosenescence. Influenza and pneumococcal vaccines (PCV13 and PPSV23 conjugate) are well established in the adult vaccination schedule. The new pneumococcal vaccines PCV15 and PCV20 will help to extend protection against pneumococcal disease in adults. The vaccine against COVID-19 is currently the most useful tool to prevent the disease and reduce its pathogenicity. COPD patients and others with respiratory diseases may benefit from prevention of herpes zoster and Bordetella pertussis through vaccination. Respiratory syncytial virus (RSV) vaccine may be another vaccine to be added to the schedule, pending the results of its studies.

La inmunosenescencia es el deterioro gradual del sistema inmune provocado por el avance de la edad. Se asocia a una menor capacidad para responder a las infecciones y desarrollar memoria inmune a largo plazo. Es parte fundamental en el desarrollo de las enfermedades respiratorias más frecuentes en edades avanzadas, como el asma, la EPOC, la patología intersticial difusa y las infecciones respiratorias del anciano.Llamamos fitness inmunológico al establecimiento de unos hábitos de vida que puedan mejorar nuestra capacidad inmunitaria. Actualmente sabemos que tener buenos hábitos alimentarios, buenas relaciones sociales, no fumar, limitar el consumo de alcohol, hacer ejercicio, controlar los niveles de estrés y establecer un correcto programa de vacunación permiten ralentizar el proceso de inmunosenescencia.Las vacunas de la gripe y las antineumocócicas (la conjugada PCV13 y la PPSV23) están bien establecidas en el calendario vacunal del adulto. Las nuevas vacunas antineumocócicas PCV15 y PCV20 van a servir para ampliar la protección contra la enfermedad neumocócica en el adulto. La vacuna contra la COVID-19 es, en el momento actual, la herramienta más útil para prevenir la enfermedad y disminuir su patogenicidad. Los pacientes con EPOC y otros con enfermedades respiratorias podrían beneficiarse de la prevención del herpes zóster y Bordetella pertussis mediante la vacunación. La vacuna contra el virus respiratorio sincitial (VRS) puede ser otra de las siguientes que formen parte de este calendario, en espera de los resultados de sus estudios.

Vacunación antigripal: diferentes perspectivas para proteger más y mejor / Influenza vaccination: different perspectives for more and better protection

Objetivo: exponer los beneficios de la vacunación antigripal desde diferentes perspectivas y abordajes en base a la evidenciacientífica más actual y relevante.Método: se ha realizado una revisión de la literatura sobre algunas indicaciones de vacunación frente a gripe, como son:embarazada, población infantil, inmunosenescencia en las personas de edad avanzada y nuevos fármacos dirigidos a enfermedadesinflamatorias mediadas por el sistema inmune.Principales resultados: la vacunación de la embarazada logra un doble beneficio: evita complicaciones y hospitalizaciones en lagestante, y protege también al feto y al recién nacido en sus primeros meses de vida. Los niños desempeñan un papel fundamentalen la transmisión de la gripe, ya que son los principales diseminadores del virus en la comunidad. El envejecimiento se asociaa un mayor número y más gravedad de las infecciones, y una peor respuesta a las vacunas. En los pacientes con enfermedadesinflamatorias medidas por el sistema inmune se observa menor inmunogenicidad y efectividad vacunal.Conclusiones: la vacunación antigripal representa un reto para la Salud Pública española. Especialmente, el aumento de lalongevidad de los españoles y los avances en tecnologías sanitarias y nuevas terapias hace que el planteamiento de inversión ensalud a través de la vacunación cobre especial protagonismo e interés para las autoridades sanitarias.(AU)

Objective: to present the benefits of influenza vaccination from different perspectives and approaches based on the most currentand relevant scientific evidence.Methods: a review of the literature has been carried out on some indications for vaccination against influenza, such as: pregnantwomen, children, immunosenescence in the elderly and new drugs targeting immune-mediated inflammatory diseases.Main results: vaccination of pregnant women achieves a double benefit: it prevents complications and hospitalisations in pregnantwomen, and also protects the foetus and newborn in their first months of life. Children play a key role in influenza transmission,as they are the main spreaders of the virus in the community. Ageing is associated with a higher number and severity of infections,and a poorer response to vaccines. In patients with immune-mediated inflammatory diseases, lower immunogenicity and vaccineeffectiveness is observed.Conclusion: influenza vaccination represents a challenge for Spanish public health authority. In particular, the increase in thelongevity of Spanish people and the advances in health technologies and new therapies mean that the approach of investing inhealth through vaccination takes on special importance and interest for the health authorities.(AU)

Fístula carótida-yugular debido a trauma vascular con sierra de cadena. Enfoque diagnóstico y quirúrgico / Carotide-jugular fistula due to vascular trauma with chain saw. Diagnostic and surgical approach

INTRODUCCIÓN: el trauma carotídeo es una patología infrecuente pero generalmente devastadora, requiere un manejo diagnóstico y terapéutico oportuno. En los casos donde no hay inestabilidad hemodinámica o lesiones severas se puede incluir en el diagnóstico a la angiotomografía e incluso a la angiografía, que puede aportar datos fundamentales en el tratamiento. La cirugía convencional es de elección en muchos casos, determinada especialmente por las características de la lesión carotídea y por la disponibilidad de insumos endovasculares. CASO CLÍNICO: presentamos el caso de un paciente con lesión carotídea causada por un fragmento de sierra de cadena, que provocó una fístula carótido-subclavia. Se optó por la cirugía convencional que consistió en el cierre de la fístula y la angioplastia de la carótida interna con el uso de un parche en pantalón de safena mayor. DISCUSIÓN: el paciente se recuperó sin focalidades neurológicas

BACKGROUND: carotid trauma is an infrequent but generally devastating disease, requiring timely diagnostic and therapeutic management. In cases where there is no hemodynamic instability or severe injuries, angiotomography and even angiography can be included in the diagnosis, which can provide fundamental data in treatment. Conventional surgery is the choice in many cases, especially determined by the characteristics of the carotid lesion and by the availability of endovascular supplies. CASE REPORT: we present the case of a patient with a carotid lesion caused by a chainsaw fragment, which caused a carotid-subclavian fistula. Conventional surgery was chosen, which consisted of closing the fistula and angioplasty of the internal carotid with the use of a patch in the pants of the greater saphenous vein. DISCUSSION: the patient recovered without neurological focalities

[SEPAR Recommendations for COVID-19 Vaccination in Patients With Respiratory Diseases]. / Recomendaciones SEPAR sobre la vacuna COVID-19 en las enfermedades respiratorias.

The Spanish Society of Pneumonology and Thoracic Surgery (SEPAR) has elaborated this document of recommendations for COVID-19 vaccination in patients with respiratory diseases aimed to help healthcare personnel make decisions about how to act in case of COVID-19 vaccination in these patients.The recommendations have been developed by a group of experts in this field after reviewing the materials published up to March 7, 2021, the information provided by different scientific societies, drug agencies and the strategies of the governmental bodies up to this date.We can conclude that COVID-19 vaccines are not only safe and effective, but also prior in vulnerable patients with chronic respiratory diseases. In addition, an active involvement of healthcare professionals, who manage these diseases, in the vaccination strategy is the key to achieve good adherence and high vaccination coverage.

Organophosphorus-Modified Lanthanide Nitrates as Potential Actinide Oxide Aerosol Surrogates.

In search of suitable simulants for aerosol uranium waste products from Plutonium Uranium Redox Extraction (PUREX) process burns, a series of lanthanide nitrate hydrates ([Ln(κ2-NO3)3·nH2O]) were dissolved in the presence of tributylphosphate (O═P(O(CH2)3CH3)3) referred to as TBP) in kerosene or triphenylphosphate (O═P(O(C6H5) referred to as TPhP) in acetone. The crystal structure of the TPhP derivatives of the lanthanide nitrate series and uranium nitrate were solved as [Ln(κ2-NO3)3(TPhP)3] (Ln = La, Ce, Pr, Nd, Sm, Eu, Gd, Tb, Dy, Ho, Er, Tm, Yb, Lu) and [U(O)2(κ2-NO3)2(TPhP)2] (U), respectively. The lanthanide-TBP, Ln, and U were further characterized using FTIR spectroscopy, 31P NMR spectroscopy, thermogravimetric analysis, and X-ray fluorescence spectroscopy. Further, thermal treatment of the lanthanide-TBP, Ln, and U using a box furnace to mimic pyrolysis conditions was found by PXRD analyses to generate a phosphate phase [LnP3O9 or UP2O7) for all systems. The resultant nuclear waste fire contaminant particulates will impact both aerosol transport and toxicity assessments.

Trapped Intermediate of a Meerwein-Pondorf-Verley Reduction of Hydroxy Benzaldehyde to a Dialkoxide by Titanium Alkoxides.

A series of titanium alkoxides ([Ti(OR)4] (OR = OCH(CH3)2 (OPri), OC(CH3)3 (OBut), and OCH2C(CH3)3 (ONep)) were modified with a set of substituted hydroxyl-benzaldehydes [HO-BzA-Lx: x = 1, 2-hydroxybenzaldehyde (L = H), 2-hydroxy-3-methoxybenzaldehyde (OMe-3), 5-bromo-2-hydroxybenzaldehyde (Br-5), 2-hydroxy-5-nitrobenzaldehyde (NO2-5); x = 2, 3,5-di-tert-butyl-2-hydroxybenzaldehyde (But-3,5), 2-hydroxy-3,5-diiodobenzaldehyde (I-3,5)] in pyridine (py). Instead of the expected simple substitution, each of the HO-BzA-Lx modifiers were reduced to their respective diol [(py)(OR)2Ti(κ2(O,µ-O')(OC6H4-x(CH2O)-2)(L)x] (OR = OPri, x = 1, L = H (1a), OMe-3 (2a), Br-5 (3a·py), NO2-5 (4a·4py); x = 2, But-3,5 (5a), I-3,5 (6a), ONep; x = 1, L = H (1b), OMe-3 (2b), Br-5 (3b·py), NO2-5 (4b); x = 2, But-3,5 (5b), I-3,5 (6b·py)), as identified by single crystal X-ray studies. The 1H NMR spectral data were complex at room temperature but simplified at high temperatures (70 °C). Diffusion ordered spectroscopy (DOSY) NMR experiments indicated that 2a maintained the dinuclear structure in a solution independent of the temperature, whereas 2b appears to be monomeric over the same temperature range. On the basis of additional NMR studies, the mechanism of the reduction of the HO-BzA-Lx to the dioxide ligand was thought to occur by a Meerwein-Pondorf-Verley (MPV) mechanism. The structures of 1a-6b appear to be the intermediate dioxide products of the MPV reduction, which became "trapped" by the Lewis basic solvate.

High Density Mapping of Pre-Excitation 3D-Illustration of Anatomical Features.

While ablation of accessory pathways is usually performed without 3D mapping system, we present a case where high-density mapping helps in illustrating the anatomical features of epicardial and oblique AP connections.

The sawtooth EKG pattern of typical atrial flutter is not related to slow conduction velocity at the cavotricuspid isthmus.

INTRODUCTION: We hypothesized that very high-density mapping of typical atrial flutter (AFL) would facilitate a more complete understanding of its circuit. Such very high-density mapping was performed with the RhythmiaTM (Boston Scientific) mapping system using its 64 electrode basket catheter. METHODS AND RESULTS: Data were acquired from 13 patients in AFL. Functional anatomy of the right atrium (RA) was readily identified during mapping including the Crista Terminalis and Eustachian ridge. The leading edge of the activation wavefront was identified without interruption and its conduction velocity (CV) was calculated. CV was not different at the cavotricuspid isthmus (CTI) compared to the remainder of the RA (1.02 vs. 1.03 m/s, P = 0.93). The sawtooth pattern of the surface electrocardiogram (EKG) flutter waves was compared to the position of the dominant wavefront. The downslope of the surface EKG flutter waves represented on average 73% ± 9% of the total flutter cycle length. During the downslope, the activation wavefront traveled significantly further than during the upslope (182 ± 21 milliseconds vs. 68 ± 29 milliseconds, P < 0.0001) with no change in CV between the two phases (0.88 vs. 0.91 m/s, P = 0.79). CONCLUSION: CV at the CTI is not slower than other RA regions during typical AFL. The gradual downslope of the sawtooth EKG  is not due to slow conduction at the CTI suggesting that success of ablation at this site relates to anatomical properties rather than the presence of a "slow isthmus."

Cavotricuspid-Isthmus Dependent Flutter or Left-Sided Atrial Tachycardia?

A 52-year-old man with previous mitral valve replacement, cavotricuspid isthmus, and left-sided roof-line ablation for previous typical atrial flutter and tachycardia presented with recurrence of symptoms with an atrial tachycardia measuring 260 ms cycle length on electrocardiogram. Rhythmia electroanatomical mapping (Boston Scientific) was performed to understand the mechanism of arrhythmia and to guide ablative treatment.