Treatment of accidental puncture of the left subclavian artery and ongoing haemorrhage with vascular stenting.

A man in his 60s was admitted for radiofrequency catheter ablation (RFCA) as a treatment for atrial fibrillation. A decapolar catheter (Synaptic Medical, Beijing, China) was inserted into the coronary sinus via the left subclavian vein. Two hours after RFCA, the patient presented new symptoms of cough, mild haemoptysis, mild dyspnoea and mild chest discomfort. Contrast-enhanced CT showed a mediastinal haematoma with contrast medium extravasation at the interlobular fissure outside the parietal pleura and mild-moderate pericardial effusion. Active left subclavian artery bleeding, rather than venous bleeding due to superior vena cava perforation, was finally diagnosed. Ongoing haemorrhage conservative treatment with red cell concentrate and intravenous fluid (normal saline) replacement may lead to compression of the mediastinum, and a covered stent was used to treat this iatrogenic complication.

The underrecognized and neglected compact atrioventricular nodal potential: clinical significance for preventing atrioventricular block during so-called slow pathway radiofrequency ablation.

BACKGROUND: The radiofrequency (RF) ablation target may be located at the compact atrioventricular node (AVN) region during so-called slow pathway (SP) RF ablation, potentially leading to transient or permanent atrioventricular block (AVB). However, related data are rare. METHODS: Among 715 index consecutive patients who underwent RF ablation for atrioventricular nodal re-entry tachycardia, 17 patients subsequently experienced transient or permanent AVB and were included in this retrospective observational study. RESULTS: Among the 17 patients, two patients (11.8%) developed transient first-degree AVB, four patients (23.5%) developed transient second-degree AVB, seven patients (41.2%) developed transient third-degree AVB, and four patients (23.5%) developed permanent third-degree AVB. During baseline sinus rhythm before the start of RF ablation, no His-bundle potential was recorded from the RF ablation catheter. During the so-called SP RF ablation that led to transient or permanent AVB, junctional rhythm with ventriculoatrial (VA) conduction block followed by subsequent AVB was observed in 14 of 17 patients (82.4%), and a low-amplitude, low-frequency hump-shaped atrial potential was recorded before the start of RF ablation in 7 of the 17 patients (41.2%). Direct AVB occurred in 3 of the 17 patients (17.6%), and a low-amplitude, low-frequency hump-shaped atrial potential was recorded before the start of RF ablation in all 3 patients. CONCLUSIONS: The low-amplitude, low-frequency hump-shaped atrial potential recorded at the so-called SP region may reflect the electrogram of compact AVN activation, and RF ablation to this site heralds impending AVB even when a His-bundle potential is not recorded.

Vitamin D protects intestines from liver cirrhosis-induced inflammation and oxidative stress by inhibiting the TLR4/MyD88/NF-κB signaling pathway.

Liver cirrhosis affects the structures and physiological functions of the intestine. Our previous study revealed that liver injury inhibited 25-hydroxylation of vitamin D (25(OH)-VD). The aim of this study was to investigate the roles and mechanisms of vitamin D in liver cirrhosis-induced intestinal injury. The rat liver cirrhosis model was established through the administration of carbon tetrachloride (CCl4) for 8 weeks. Hematoxylin-eosin staining was performed to unveil the intestinal injury induced by liver cirrhosis. Enzyme-linked immunosorbent and reverse transcription PCR (RT-PCR) analysis were used to determine the levels of 25(OH)-VD, vitamin D receptor, Cytochrome P450 24A1 (CYP24A1), and α-defensin 5 (DEFA5) in rat and human serum of liver cirrhosis. Furthermore, liver cirrhosis rats were treated with low-dose (500 IU/kg) and high-dose (2,000 IU/kg) vitamin D intraperitoneally. The expression levels of TLR4/MyD88/NF-κB signaling pathway were evaluated by RT-PCR and Western blot. In conclusion, we determined the deficiency of vitamin D and down-regulation of DEFA5 and intestinal damage induced by liver cirrhosis. Moreover, vitamin D effectively inhibited liver cirrhosis-induced intestinal inflammation and oxidative stress through the TLR4/MyD88/NF-κB pathway. Vitamin D might be a promising therapeutic strategy for future treatment of liver-induced intestinal injury.

Monitoring Spike Potential and Abrupt Impedance Rise with Concomitant Temperature/Contact Force Change for Timely Detection of the Occurrence of "Silent" or "Nonaudible" Steam Pop.

Aim: Steam pop (SP) during radiofrequency catheter ablation (RFCA) for pulmonary vein isolation (PVI) may cause cardiac perforation, which may require drainage and emergent thoracotomy or even lead to death. Data investigating the timely detection of the occurrence of "silent" or "nonaudible" SP events are limited. Methods and Results: A total of 516 consecutive atrial fibrillation (AF) patients who underwent index PVI were included in this retrospective observational study. The duration, power, impedance, temperature, and contact force (CF) of RFCA were continually monitored and recorded throughout the procedure. A total of 15 (2.9%) audible SP events occurred in 14 patients; 2 of the patients developed pericardial tamponade, 1 patient underwent drainage, and 1 patient underwent emergent thoracotomy. The time from RFCA initiation to the occurrence of audible SP was 19.4 ± 6.9 s. Abrupt temperature change occurred in 13 (86.7%) of the 15 SP events, of which 8 (53.3%) exhibited an abrupt temperature rise of 2.3 ± 1.0°C, 5 (33.3%) exhibited an abrupt temperature drop of 2.3 ± 1.3°C, and 2 (13.3%) exhibited no discernible temperature change. Conclusions: In conclusion, simultaneously recorded spike potentials and abrupt impedance rise with concomitant temperature and/or CF change could be a feasible method for the timely detection of the occurrence of audible, "silent," or "nonaudible" SP events, particularly in regions where the risk of perforation may be of concern.

Electrocardiographic and electrophysiological characteristics of idiopathic ventricular arrhythmias with acute successful ablation at the left ventricular basal inferoseptum recess near the mitral annulus.

PURPOSE: We sought to clarify the electrocardiographic and electrophysiological characteristics of ventricular arrhythmias (VAs), including idiopathic ventricular tachycardia (VT) and premature ventricular contractions (PVCs), with acute successful radiofrequency catheter ablation (RFCA) at the left ventricular basal inferoseptum recess near the mitral annulus (LV-BIS-MA). METHODS: Twenty-five patients with acute successful RFCA at the LV-BIS-MA were included in this study. RESULTS: The S-wave amplitudes on lead III during VAs were 1.54 ± 0.38 mV, significantly larger than those on lead II (0.55 ± 0.19 mV) and aVF (1.04 ± 0.31 mV) (P < 0.01). Precordial R/S > 1 transition before lead V2 and S-waves in lead V6 was recorded in 100% and 48.0% of patients, respectively. The earliest bipolar activation preceded the QRS onset by 32.3 ± 11.5 ms. Pace mapping demonstrated perfect QRS morphology matching in only 56.0% of patients. The RFCA start-to-effect time was 10.2 ± 5.8 seconds (s) in 21 patients (84.0%). In the remaining 4 patients (16.0%), the mean duration of successful RFCA was not well determined due to the infrequent presence of clinical VAs during ablation. The trans-septal approach was utilized in all 25 cases. Intra-cardiac echocardiography (ICE) showed that the ablation catheter tip was underneath the anterior leaflet of the mitral valve via the reversed C-curve technique. Early (within 3 days) and late (1 year) recurrence rates were 4.0% (one patient) and 12.0% (three patients), respectively. No complications during RFCA or at the 1-year follow-up. CONCLUSIONS: LV-BIS-MA VAs are a subgroup of idiopathic VAs with distinctive ECG and EP features. RFCA via a trans-septal approach using a reversed C-curve technique is effective for better identification and targeting of the areas of VAs origin, and ICE showed that the ablation catheter tip was underneath the anterior leaflet of the mitral valve.

Electrocardiographic and electrophysiological characteristics of idiopathic ventricular arrhythmias with acute successful ablation at the superior portion of the mitral annulus.

BACKGROUND: We sought to identify the electrocardiographic and electrophysiological characteristics of ventricular arrhythmias (VAs), including idiopathic ventricular tachycardia (VT) and premature ventricular contractions (PVCs), with acute successful radiofrequency catheter ablation (RFCA) at the superior portion of the mitral annulus (SP-MA). METHODS AND RESULTS: Among 437 consecutive patients who presented with VAs for RFCA, twenty-six patients with acute successful RFCA at the SP-MA were included in this study. The ratio of the amplitude of the first positive peak (if present) versus the nadir in the unipolar electrogram (EGM) was 0.00-0.03 (0.00) at the acute successful RFCA site. The time interval between the QRS onset and the maximum descending slope (D-Max) in the unipolar EGM (QRS-Uni) was 18.8 ± 13.6 ms. With bipolar mapping, the ventricular QRS (V-QRS) interval was 3.75-17.3 (11) ms, 6 (23.1%) patients showed the earliest V-QRS interval of 0 ms, and the other 20 patients (76.9%) showed a V-QRS interval of 10-54 ms. The RFCA start-to-effect time was 14.1 ± 7.2 s in 23 patients (88.5%). In the remaining 3 patients (11.5%), the mean duration of successful RFCA was not well defined due to the infrequent nature of clinical VAs during RFCA. Early (within 3 days) and late (1-year) recurrence rates were 23.1% (6 patients) and 26.9% (7 patients), respectively. VAs disappeared 3 days later due to delayed RFCA efficacy in 2 patients (7.7%). No complications occurred during the RFCA procedure or the one-year follow-up. CONCLUSIONS: SP-MA VAs are a rare but distinct subgroup of VAs. Bipolar and unipolar EGM features can help to determine the optimal RFCA site, and the QRS-Uni interval may serve as a marker that could be used to guide RFCA.

Intraprocedural Conversion Efficacy of Intravenous Nifekalant Administration for Persistent Atrial Fibrillation after Pulmonary Vein Isolation.

The aim of this study was to prospectively assess the efficacy, safety, and predictive effect of intravenous nifekalant administration for persistent atrial fibrillation (PerAF) after pulmonary vein isolation (PVI) with second-generation cryoballoon ablation (CBA) on 1-year atrial tachyarrhythmia (ATa) -free survival by examining the pharmacological conversion rate.One hundred and two drug-refractory, consecutive PerAF patients undergoing PVI were enrolled in this prospective observational study. After PVI, nifekalant (50 mg) was given followed by 30 minutes of observation and no further intervention. PerAF was successfully converted to sinus rhythm (SR) in 60 patients (58.8%) after a median time of 7.75 (4.13-12) minutes (group N). In the remaining 42 patients (41.2%) (group C), PerAF was successfully converted to SR by external electrical cardioversion. Nonsustained ventricular tachycardia occurred in 1 patient in group N. The left atrial volume (LAV) in group C was larger than that in group N (128.2 ± 28.2 versus 111.8 ± 24.5 mL, P = 0.002). Phrenic nerve injury occurred in 4 of 102 patients (3.9%). No other complications occurred during the procedure or within the 1-year follow-up period. At the 1-year follow-up, after a 3-month blanking period (BP), ATa-free survival during 1-year follow-up in group C was significantly lower than that in group N (50.0% versus 71.7%, P = 0.026), and the overall ATa-free survival rate was 62.7%. Two patients in group C and 4 patients in group N underwent a second procedure with radiofrequency catheter ablation. Multivariate Cox regression analysis demonstrated that unsuccessful conversion to SR (P = 0.025), ATa relapse during the BP (P = 0.000), and larger LAV (P = 0.016) were independent predictors of ATa recurrence at the 1-year follow-up.In conclusion, at the 1-year follow-up, the ATa-free survival rate after PVI with CBA for PerAF patients was 62.7%, and successful conversion to SR with nifekalant could serve as a clinical predictor of reduced ATa recurrence.