Intra- and Postprocedural Management of Coronary Artery Perforation During Percutaneous Coronary Intervention.

Background: Little is known regarding the postprocedural management of coronary artery perforation (CAP). Methods and Results: The characteristics, outcomes, and management of 115 CAP cases among 13,453 patients undergoing percutaneous coronary intervention (PCI) between 2001 and 2017 at Miyazaki Medical Association Hospital were analyzed retrospectively. The incidence of CAP was 0.85% (25 [0.19%] coronary ruptures [CRs], 90 [0.67%] wire perforations [WPs]). The most prevalent causes of CRs and WPs were rotational atherectomy (36.0%) and polymer-jacketed wires (41.1%), respectively. Fifty-two percent of CRs were treated using prolonged balloon inflation, whereas 50% of WPs were treated through embolization. Immediate and delayed cardiac tamponade (CT) occurred in 20% and 24% of CRs, respectively, and in 2.2% and 10% of WPs, respectively. The mean (±SD) right atrial pressure (RAP) during delayed CT in the CR and WP groups was 16.0±1.2 and 14.0±3.0 mmHg, respectively. New-onset atrial fibrillation developed in 24.0% and 11.1% of patients in the CR and WP groups, respectively, whereas late-onset coronary artery aneurysm (CAA) occurred in 24.0% and 0% of patients, respectively. One-year mortality rates in patients with immediate and delayed CT were 28.6% and 20.0%, respectively. Conclusions: Special attention should be paid to delayed CT, new-onset atrial fibrillation, and late-onset CAA after CAP treatment. Continuous monitoring of RAP after CAP during PCI may be useful for the early detection of delayed CT.

A case report of atrial fibrillation in a patient with heparin resistance associated with an antithrombin III deficiency successfully treated by radiofrequency catheter ablation using a direct thrombin inhibitor.

BACKGROUND: Pulmonary vein antrum isolation has proven to be a useful strategy for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) worldwide. Anticoagulation therapies are necessary to avoid thromboembolic events before, during, and after RFCA of AF. During the RFCA procedure for AF, it is recommended that the activated coagulation time be maintained between 300 s and 400 s using heparin as an anticoagulation therapy. CASE SUMMARY: An 81-year-old man with symptomatic and drug-refractory paroxysmal AF underwent RFCA. We found that he had a severe heparin resistance during the RFCA procedure, and heparin had little effect on him. Thus, a direct thrombin inhibitor, Argatroban Hydrate®, was used instead of heparin for anticoagulation therapy during the procedure. Finally, the AF was successfully treated by RFCA without any complications. With a post-procedural inspection, we found that he had a Type-1 antithrombin III (AT-III) deficiency. DISCUSSION: Atrial fibrillation is the most common clinical arrhythmia and is associated with significant clinical morbidity and increased mortality. An AT-III deficiency is a well-known autosomal dominant hereditary disease and congenital blood coagulation abnormality occurring in about 1:500-5000 live births that may sometimes cause thrombophilia. Thus, the physicians may occasionally come across patients with an AT-III deficiency in real-world clinical practice, even though they have no history of thrombophilia. Argatroban Hydrate® may be effective and feasible for anticoagulation therapy during the RFCA procedure of AF in patients with heparin resistance such as in this present case.

Radiofrequency catheter ablation of premature ventricular contractions from near the His-bundle.

OBJECTIVE: This study aimed to investigate the effects of radiofrequency catheter ablation (RFCA) and clinical and electrophysiological characteristics in symptomatic patients with premature ventricular contractions (PVCs) from near the His-bundle (His-PVCs). METHODS: The patient characteristics, prevalence of complications with any life style related disease (ALSRD) including hypertension, dyslipidemia, or diabetes mellitus, and/or cardiovascular disease (CVD) including coronary artery disease, cerebrovascular disease, renal dysfunction, or cardiomyopathy, clinical status, frequency of PVCs evaluated by 24hour Holter monitoring, echocardiography including the left ventricular diastolic dysfunction (LVDD) parameters, and electrophysiological findings were evaluated in 14 consecutive symptomatic patients with His-PVCs. RESULTS: The prevalence of males, being elderly and/or slightly obese, current and/or history of smoking, ALSRD or CVD related complications, and LVDD probably resulting from ALSRD and/or CVD complications were higher in patients with His-PVCs. RFCA of His-PVCs steadily decreased the PVC frequency and improved the systolic function, LV dilation, and clinical status, but not the LVDD. There was a significant relationship between the accordance rate of the QRS polarity between sinus rhythm and His-PVCs and the distance between the successful ablation site and His-bundle. CONCLUSION: The analysis of the QRS duration and accordance rate of the QRS polarity between sinus rhythm and His-PVCs before the RFCA may help to determine the distance between the origin of the PVCs and His-bundle. Further, the appropriate ablation catheter may be selected during the RFCA procedure. Finally, RFCA may be one of the most effective, feasible, and safest therapies for symptomatic patients with His-PVCs.

Paroxysmal Atrial Fibrillation in Patients Successfully Treated by Radiofrequency Catheter Ablation with Severely Compression, Lateral Displacement, and Clockwise Rotation of Their Hearts due to Severe Pectus Excavatum.

Two cases with severe pectus excavatum and symptomatic atrial fibrillation (AF) underwent radiofrequency catheter ablation (RFCA). Their chest X-ray and computed tomography (CT) findings revealed lateral displacement and clockwise rotation of their hearts, and severe right atrial and mild right ventricular compression against the sternum, but no left atrium compression against the spinal column. The procedure was therefore carefully performed under guidance with CT, intra-cardiac echography, atriography, and a three-dimensions mapping system. Finally, the AF was successfully treated by RFCA without any complications. These findings underscore the importance of understanding cases of abnormal anatomy and carefully designing a strategy before performing any procedure.

A case of paroxysmal atrial fibrillation in a patient successfully treated by radiofrequency catheter ablation with a severely right-sided dislocation of the heart after a total right lung excision.

A 72-year-old woman with symptomatic and drug-refractory paroxysmal atrial fibrillation (AF) underwent radiofrequency catheter ablation (RFCA). She had a history of a total right lung excision. Her chest X-ray and computed tomography (CT) revealed a severely sight-sided dislocation of the heart. Thus, the procedure was carefully performed under guidance of a CT, intracardiac echogram, atriography, and 3D mapping system. Finally, the AF was successfully treated by RFCA without any complications.

Clinical benefits of deep sedation with a supraglottic airway while monitoring the bispectral index during catheter ablation of atrial fibrillation.

BACKGROUND: Pulmonary vein antrum isolation (PVAI) under sedation has proven to be a useful strategy for catheter ablation of atrial fibrillation (AF). METHODS: To evaluate the clinical benefits of respiratory management using supraglottic airways (SGAs) under deep sedation while monitoring the bispectral (BIS) index during the PVAI and the durations from admission to the catheterization room to starting the radiofrequency energy delivery (Time α), and from starting the radiofrequency energy delivery to completion of the PVAI (Time ß), X-ray time, frequency of dislocations of the three-dimensional maps (D3DM), procedure-related complications, and proportion of an AF-free rate 15 months after the PVAI (PAFFR) in patients who received deep sedation without SGAs (Group A: n=48) and those with SGAs (Group B: n=51) were evaluated. RESULTS: There were no significant differences in patient characteristics, Time α (77±3 versus 78±2 min; p=0.816), complications of cardiac tamponade (2% versus 2%; p=0.966), or PAFFR (81% versus 88%; p=0.313) between the two groups. However, the Time ß (84±4 versus 67±3; p=0.001), X-ray time (53±2 versus 34±2; p<0.001), and minor complications of nasal bleeding (25% versus 0%; p=0.001) were significantly shorter and lower in Group B than in Group A, in accordance with a reduction in the hypoxia (15% versus 0%; p=0.007) and D3DM (31% versus 8%; p=0.003). CONCLUSIONS: These results may demonstrate the clinical benefits of deep sedation with SGAs while monitoring the BIS index without any hypoxia during PVAI in patients with AF.

Inappropriate Sinus Tachycardia Diagnosed and Treated as Depression Successfully Treated by Radiofrequency Catheter Ablation.

We experienced a man in his 20s with inappropriate sinus tachycardia (IST) initially diagnosed and treated as depression who was steadily treated with radiofrequency catheter ablation (RFCA) using an EnSite™ system. The patient has remained well without any symptoms or medications, including antidepressants, for two years since the RFCA. To avoid missing IST and treating it as an emotional problem and/or mental illness such as depression, physicians - including cardiologists - should be aware of these conditions when examining patients with multiple and incapacitating complaints including palpitations and general fatigue and/or tachycardia, especially characterized by an elevated resting heart rate or a disproportionate increase in the heart rate with minimal exertion.

A case of premature ventricular complexes/ventricular tachycardia from the left ventricular outflow tract successfully ablated from the distal great cardiac vein.

We experienced a 41-year-old male with premature ventricular complexes/ventricular tachycardia from the left coronary cusp and distal great cardiac vein of the left ventricular outflow tract successfully treated by radiofrequency catheter ablation utilizing a 3D mapping system (EnSiteNavX/Velocity™ Cardiac Mapping System, St. Jude Medical, St. Paul, MN, USA) without any complications. .