Ordinary AV Nodal Reentry Tachycardia-Unusual Ablation: A Case Report and Review of the Literature.

A 72-year-old woman was referred to us with typical symptoms of paroxysmal supraventricular tachycardia for electrophysiological diagnostics and catheter ablation. During the first session of catheter ablation, a probing of the right ventricle was not successful. Therefore, an angiography of the central veins was performed. A rare anatomical variation with atresia of the inferior vena cava below the hepatic veins with azygos persistence was detected. The blood of the lower half of the body was drained via the dilated azygos into the superior vena cava; the blood of the liver veins enters into the right atrium directly. By atypical catheter placement over the azygos vein in the right ventricle and coronary sinus, an AV nodal reentry tachycardia (AVNRT) could be confirmed as the mechanism of tachycardia. However, a stable position of the ablation catheter could not be achieved by the femoral approach, so the successful AV node modulation with ablation of the slow pathway was performed via jugular access.

Efficacy of temperature-guided cryoballoon ablation without using real-time recordings - 12-Month follow-up.

BACKGROUND: We sought to evaluate a temperature-guided approach of cryoballoon (CB) ablation without visualization of real-time recordings. METHODS AND RESULTS: We analysed 166 patients (34.9% female, 60 ±â€¯11 years) with paroxysmal or short-term persistent atrial fibrillation (AF). Comorbidities included diabetes mellitus (n = 28), coronary artery disease (n = 24), hypertension (n = 122), previous stroke or TIA > 3 months (n = 12). Cryoablation of the pulmonary veins (PV) was performed using first-generation (n = 78) and second-generation CB (n = 88). Two 5-minute freezes were performed for the first-generation and two 4-minute freezes for the second-generation CB with the intention to achieve a temperature drop below -40 °C. At 12-month follow-up, we observed overall freedom from AF in 92 patients (56.6%, mean time to AF recurrence 3.4 ±â€¯2.9 months). There was a significant difference in freedom from AF between first-generation CB (45%) and second-generation CB (67%; p < 0.005). Complications were groin hematoma (4.8%) and phrenic nerve palsy (PVP) (2.4%). PVP disappeared after 12 months in all patients. Three patients developed cardiac tamponade (1.8%) that resolved without further sequelae after pericardiocentesis. Multivariate analysis revealed that only the achieved temperature in the right inferior PV (RIPV) was a predictor of long-term freedom from AF (OR 0.9; p = 0.014). Female gender was a predictor of AF recurrence (OR 6.1; p = 0.022). CONCLUSION: Temperature-guided CB ablation without real-time recordings is feasible and safe without reducing the efficacy if second-generation CB is used. Deep nadir temperatures especially in the RIPV are necessary for long term-success.

Renal denervation as a second-line option in a patient with electrical storm resistant to medical treatment and conventional radiofrequency catheter ablation.

Electrical storm (ES) represents a critical state of electrical instability. We describe a patient with coronary artery disease, mechanical aortic valve replacement, and reduced left ventricular function with recurrent ICD shocks. Despite medical treatment with beta-blocker and amiodarone, and after successful ablation of different VT morphologies in combination with substrate modification, ES could not be controlled. We performed renal denervation (RDN) to reduce arrhythmic burden. Thereafter, patient remained free from sustained and non-sustained VTs at 6-month follow-up. RDN is an effective second-line treatment option in patients in whom conventional catheter ablation and medical treatment failed to control the VTs.

Predictors of future arrhythmic events in patients with unexplained syncope.

AIMS: The purpose of this study was to examine the usefulness of implantable loop recorders (ILRs) for symptom-rhythm correlation and to identify predictors of future arrhythmic events. PATIENTS AND METHODS: In our dual-centre study, we analysed ILR data of 189 patients (mean age 67.4 ± 15.2 years, 114 male) with unexplained syncope (single syncope 21 patients, recurrent 168 patients, traumatic injury 43 patients). Patients had severe comorbidities such as hypertension (n = 127), coronary artery disease (n = 31), diabetes mellitus (n = 33) and chronic renal insufficiency (n = 18). The median ILR usage was 29 months (M), with a range between 1 and 46 M. RESULTS: Forty-nine (26%) patients experienced syncope during the study, with a median of 8 M to first recurrence of syncope. In 43 patients, pacemaker implantation was performed because of sinus node disease (n = 29), high-degree AV-block (n = 6) or atrial fibrillation with slow ventricular rate (n = 8). In five patients, an ICD was implanted because of documented ventricular tachycardia (n = 4) or left ventricular ejection fraction <35% (n = 1). One patient received ablation of the cavotricuspid isthmus because of documented atrial flutter. Concerning the clinical course, in five patients explantation of the ILR was necessary due to pocket infection. Three patients died due to non-cardiac causes. Logistic regression analysis revealed that older patients had a significantly higher risk for future arrhythmic events (OR 1.3, p = .039). CONCLUSIONS: ILR monitoring is effective in indicating causes of unexplained syncope by providing symptom-rhythm associations. Only age was a predictor of future arrhythmic events. The mortality in patients with unexplained syncope was very low.

[Acute chest pain and new ECG changes in pacemaker patients : A clinical challenge]. / Akuter Thoraxschmerz in Verbindung mit neuen EKG-Veränderungen bei Schrittmacherpatienten : Eine klinische Herausforderung.

We report the case of a 82-year-old woman who was admitted to our institution with acute chest pain, nausea, and vomiting. Because of atrial fibrillation with intermittent bradycardia, a single-chamber pacemaker was implanted 4 years ago. The initial 12-lead ECG showed atrial fibrillation with a heart rate of 70 bpm, narrow QRS, and T­wave inversions in the inferolateral leads. Coronary artery disease was excluded by immediate cardiac catheterization. A subsequent ECG three hours later showed a ventricular paced rhythm. During the subsequent clinical course, cardiac injury markers remained normal. However, serum amylase and lipase levels were 5 times above the normal range. According to these clinical findings, acute pancreatitis was the most likely diagnosis. Abdominal ultrasound excluded pancreatic necrosis and gallstones. Initial treatment consists of fasting, pain control, and intravenous fluids with resolution of symptoms after a few days. The patient could be discharged 7 days later. In conclusion, the observed ECG findings in combination with chest pain are suggestive for myocardial ischemia mandating immediate cardiac catheterization. However, acute pancreatitis might present with the aforementioned ECG changes and symptoms. The case was further complicated by a distinct electrocardiographic memory effect due to intermittent ventricular pacing.

ST-segment Elevation Following Cardioversion of Atrial Fibrillation in the Emergency Department: Unmasked Myocardial Infarction due to Left Main Coronary Artery Plaque Rupture or Unspecific Finding?

Atrial fibrillation (AF) is a frequent reason for emergency department visits. According to current guidelines either rate- or rhythm-control are acceptable therapeutic options in such situations. In this report, we present the complicated clinical course of a patient with AF and a rapid ventricular response. Because of paroxysmal AF, the patient was on chronic oral anticoagulation therapy with warfarin. Pharmacological treatment was ineffective to control ventricular rate, and immediate synchronized electrical cardioversion was performed. One hour later, the patient complained of chest pain in combination with marked ST-segment elevation in the anterior leads. Cardiac catheterization with optical coherence tomography disclosed plaque rupture in the left main coronary artery without other significant stenosis. Stent implantation was performed successfully. During the course of the hospital stay, the patient remained asymptomatic and the ST-segment elevations resolved. However, despite treatment with amiodarone it was not possible to keep the patient permanently in sinus rhythm. Therefore, a biventricular pacemaker was implanted and AV node ablation performed.

Toxic Epidermal Necrolysis During Dronedarone Treatment: First Report of a Severe Serious Adverse Event Of A New Antiarrhythmic Drug.

A 77-year-old female patient with symptomatic atrial fibrillation with fast ventricular rate despite conventional antiarrhythmic therapy was treated with dronedarone. Five days later, she developed a maculopapulous exanthema and small flaccid blisters, which spread over the common integument predominantly located on the dorsal trunk. Over few days, the patient showed a severe epidermal necrolysis of approximately 30 % of the body area and ultimately died in multiorgan failure. Here, we report a rare case of toxic epidermal necrolysis during treatment with dronedarone leading to patient death.

Renal denervation with cryoenergy as second-line option is effective in the treatment of resistant hypertension in non-responders to radiofrequency ablation.

AIMS: Renal denervation (RDN) with radiofrequency (RF) is being used to treat resistant hypertension (rHTN). As 15-30% of treated patients are non-responders to RDN, we investigated whether RDN with cryoenergy can serve as a second-line option. METHODS AND RESULTS: Ten non-responder patients (mean age 55 years, six male) with rHTN were treated with cryoenergy for RDN. In order to qualify as non-responders, patients had to show systolic 24 hr ambulatory BP (ABP) ≥150 mmHg (median ABP 183/102 mmHg, median office- based BP [OBP] 191/108 mmHg) despite treatment with ≥4 different antihypertensive drugs (mean 6), and further not show a reduction of systolic ABP ≥10 mmHg at ≥3 months after RDN with RF. The three/six/12-month follow-up (FU) comprised clinical and biochemical evaluation, OBP and ABP measurement. Additionally, at six months, duplex sonography was performed. Cryoablation with a 7 Fr cryoablation catheter (Freezor® Xtra; Medtronic, Minneapolis, MN, USA) was performed in all patients without complications (four applications in both renal arteries, every four minutes, temperature -75°C). At three, six, and 12 months we found a reduction in systolic OBP of -41/-47/-61 mmHg (n=10/7/6; p=0.044 for all), diastolic OBP of -18/-14/-34 mmHg, systolic ABP of -38/-35/-52 mmHg (n=9/7/6, p=0.014 for all), and diastolic ABP of -20/-13/-18 mmHg (p=0.043 for all), respectively. During FU, no complications occurred and the renal function remained unchanged. CONCLUSIONS: The significant reduction in systolic OBP and ABP observed qualifies RDN with cryoenergy as an effective second-line therapeutic option in non- responders to RDN with RF.

First clinical manifestation of Brugada syndrome during pregnancy.

The role of hormonal changes during pregnancy in Brugada syndrome is unknown. Only rare case reports of Brugada syndrome during pregnancy have been published. In this article, we describe a patient with first clinical manifestation of Brugada syndrome during pregnancy. The definitive diagnosis could only be achieved by drug challenge with ajmaline after childbirth because the spontaneous typical Brugada-like pattern was absent. Elevated hormone levels during pregnancy may increase the risk for arrhythmias in particular cases.

Unmasked superoparaseptal pathway conduction due to atrial fibrillation in a patient with left ventricular dysfunction. Rapid recovery after successful radiofrequency ablation.

We report the case of a 56-year-old woman with newly diagnosed atrial fibrillation (AF) and severe left ventricular (LV) dysfunction caused by rapid conduction via an accessory pathway (AP), mimicking left bundle branch block, as the first clinical manifestation of Wolff-Parkinson-White (WPW) syndrome. Electrical cardioversion of the AF revealed a short PR interval and a delta wave, which was positive in leads I, II, aVL, and V2 and negative in lead V1 with a transition zone between V1 and V2. Radiofrequency catheter ablation of a superoparaseptal pathway was accompanied by rapid recovery from LV systolic dysfunction.

Renal denervation in the treatment of drug-resistant hypertension: current knowledge and future perspectives.

Resistant hypertension remains a challenging issue even for modern medicine. Therefore, research is focusing on the development of new technologies to optimize the treatment of this condition. It has been demonstrated that the dysfunction of the sympathetic nervous system is crucial in the development and maintenance of advanced stages of hypertension. Based on these findings, clinical trials have recently shown that catheter-based percutaneous renal denervation therapy is safe and effective in the treatment of resistant hypertension. This review discusses the current scientific knowledge of renal denervation therapy in resistant hypertension, including the different methods that have been described in the literature so far, as well as limitations of the available data. Furthermore, new potential targets for this fascinating therapy will be addressed.

Catheter-based renal denervation for drug-resistant hypertension by using a standard electrophysiology catheter.

AIMS: The endovascular application of low-dose radiofrequency (RF) energy to the renal arteries results in effective ablation of sympathetic nerve fibres leading to a significant lowering of blood pressure (BP). This study aims to examine the feasibility and safety of renal denervation by the use of a standard electrophysiology (EP) catheter. METHODS AND RESULTS: Twelve patients (mean age 62±14 years, nine male) with drug resistant hypertension despite medical treatment with at least four antihypertensive drugs underwent renal denervation by using a standard steerable RF ablation catheter with a 7 Fr diameter (Marinr®; Medtronic Inc., Minneapolis, MN, USA). Low-power RF applications have been applied along the length of both renal arteries, consecutively. Assessment of 24 hour ambulatory BP was done at baseline, at one, and at three months following RF ablation. The mean reduction of 24 hour ambulatory BP was -11/-7 mmHg at one month and -24/-14 mmHg at three months (p<0.01 for systolic and p<0.03 for diastolic blood pressure) with unchanged medication. No vascular complications have been observed in the short-term follow-up. The renal function as assessed by serum creatinine and proteinuria remained unchanged from baseline. CONCLUSIONS: Our preliminary results indicate that the use of a standard RF ablation catheter is feasible and safe for sympathetic renal denervation as shown by a significant lowering of mean 24 hour ambulatory BP in comparison to baseline during short-term follow-up. Whether the use of a standard EP catheter for sympathetic renal denervation indeed improves the long-term outcome in resistant hypertension, however, remains to be investigated.