Idiopathic ventricular outflow tract arrhythmias from the great cardiac vein: challenges and risks of catheter ablation.

INTRODUCTION: Catheter ablation for idiopathic ventricular arrhythmia is well established but epicardial origin, proximity to coronary arteries, and limited accessibility may complicate ablation from the venous system in particular from the great cardiac vein (GCV). METHODS: Between April 2009 and October 2010 14 patients (56 ± 15 years; 9 male) out of a total group of 117 patients with idiopathic outflow tract tachycardias were included undergoing ablation for idiopathic VT or premature ventricular contractions (PVC) originating from GCV. All patients in whom the PVC arose from the GCV were subject to the study. In these patients angiography of the left coronary system was performed with the ablation catheter at the site of earliest activation. RESULTS: Successful ablation was performed in 6/14 (43%) and long-term success was achieved in 5/14 (36%) patients. In 4/14 patients (28.6%) ablation was not performed. In another 4 patients (26.7%), ablation did not abolish the PVC/VT. In the majority, the anatomical proximity to the left coronary system prohibited effective RF application. In 3 patients RF application resulted in a coronary spasm with complete regression as revealed in repeat coronary angiography. CONCLUSION: A relevant proportion idiopathic VT/PVC can safely be ablated from the GCV without significant permanent coronary artery stenosis after RF application. Our data furthermore demonstrate that damage to the coronary artery system is likely to be transient.

[Catheter ablation for atrial fibrillation: clinically established or still an experimental method].

Interventional treatment for atrial fibrillation has been introduced as a therapeutic option since the pulmonary veins (PV) have been discovered as the dominant sources of paroxysmal atrial fibrillation (PAF). Elimination of PV conduction is the initial goal during catheter ablation in this setting. The success rate after the initial procedure varies between 60 and 85 %, with more than 80 % after subsequent interventions. Supported by the current guidelines, interventional treatment of AF is indicated in case of symptomatic arrhythmias refractory to antiarrhythmic treatment. The introduction of the combined, stepwise approach has been another important breakthrough with regard to the treatment of chronic persistent atrial fibrillation (CAF). This strategy includes the combination of all conventional ablation strategies (PV isolation, ablation of complex fractionated atrial electrograms, linear ablation) with the goal of AF termination. The first procedure for CAF treatment is quite frequently also only the first step towards stable sinus rhythm with a favourable outcome after AF termination (> 80 % sinus rhythm). In more than half of the patients predominantly other atrial arrhythmias than AF have to be targeted in a second procedure. This approach is currently under clinical investigation and so far not "clinically established" due to the fact that it is a quite time consuming and challenging procedure even in experienced centres. Future studies may help to identify predictors for procedure failure (e.g. LA size, AF duration, atrial cycle length, spectral analysis) in order to improve patient selection. Additionally, it has to be underscored, that in paroxysmal atrial fibrillation the relatively high recurrence rate after the first procedure still is the subject of further investigations. This aspect might be improved by the introduction of novel strategies (i.e. testing of concealed PV conduction after ablation with adenosine) or new technologies (i.e. robotic navigation) for PAF ablation.

[Surface ECG presentation and intracardiac electrogram characteristics of uncommon supraventricular tachycardia entities]. / Differenzialdiagnose ungewöhnlicher Elektrogramme - vom Oberflächen-EKG zur elektrophysiologischen Diagnose.

The vast majority of patients with supraventricular tachycardias present with specific 12-lead surface ECG characteristics allowing the diagnosis of the underlying mechanisms prior to the invasive electrophysiological study. However, an accurate diagnosis remains challenging in a subset of patients, even when using well-established stimulation maneuvers and sophisticated conventional mapping methods. Thus, the aim of the present manuscript is to describe some cases with uncommon entities of supraventricular tachycardias where the combined interpretation of 12-lead ECG presentation and invasive electrophysiological characteristics revealed the correct diagnoses.

[Surgical treatment of multivisceral intra-abdominal recurrences and metastases]. / Traitement opératoire des récidives et métastases intra-abdominales multiviscérales.

From 1988 to 1990, 467 patients were operated a total of 850 times for malignant intra-abdominal tumours. Analysis of these 850 operations revealed that 205 were performed for recurrences with or without metastasis and 59 were performed for metastasis. The operations for recurrences were elective in 158 cases and consisted of 86 local radical procedures and 72 non-radical procedures. 47 operations for recurrences were performed as emergency procedures and were non-radical in 45 cases. With 55 of 59 operations for metastasis the majority of these operations was performed electively and locally radical. The majority for metastases were performed electively and were locally radical. The majority of life-threatening emergency situations were controlled (129 of 141 operations, 92%) and two-thirds of these patients left hospital with a satisfactory quality of life (Karnofsky index > 50 in 83 of the 141 operations). Consequently, repeated operations and the combination of surgery with adjuvant therapy can control malignant disease for several years with a satisfactory quality of life.