Haemorrhagic cerebral air embolism from an atrio-oesophageal fistula following atrial fibrillation ablation.

We report the case of a man found unconscious three weeks following atrial fibrillation (AF) ablation. Cranial and thoracic imaging demonstrated multiple areas of pneumo-embolic infarction secondary to an atrio-oesophageal fistula (AEF). AEF is a recognised, but rare, complication of AF ablation.(1-8) Early recognition is critical as the mortality is 100% without surgical intervention. We consider the postulated mechanisms of AEF formation, the spectrum of clinical presentation, investigations and treatment.

Automated analysis of atrial late gadolinium enhancement imaging that correlates with endocardial voltage and clinical outcomes: a 2-center study.

BACKGROUND: For late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) assessment of atrial scar to guide management and targeting of ablation in atrial fibrillation (AF), an objective, reproducible method of identifying atrial scar is required. OBJECTIVE: To describe an automated method for operator-independent quantification of LGE that correlates with colocated endocardial voltage and clinical outcomes. METHODS: LGE CMR imaging was performed at 2 centers, before and 3 months after pulmonary vein isolation for paroxysmal AF (n = 50). A left atrial (LA) surface scar map was constructed by using automated software, expressing intensity as multiples of standard deviation (SD) above blood pool mean. Twenty-one patients underwent endocardial voltage mapping at the time of pulmonary vein isolation (11 were redo procedures). Scar maps and voltage maps were spatially registered to the same magnetic resonance angiography (MRA) segmentation. RESULTS: The LGE levels of 3, 4, and 5SDs above blood pool mean were associated with progressively lower bipolar voltages compared to the preceding enhancement level (0.85 ± 0.33, 0.50 ± 0.22, and 0.38 ± 0.28 mV; P = .002, P < .001, and P = .048, respectively). The proportion of atrial surface area classified as scar (ie, >3 SD above blood pool mean) on preablation scans was greater in patients with postablation AF recurrence than those without recurrence (6.6% ± 6.7% vs 3.5% ± 3.0%, P = .032). The LA volume >102 mL was associated with a significantly greater proportion of LA scar (6.4% ± 5.9% vs 3.4% ± 2.2%; P = .007). CONCLUSIONS: LA scar quantified automatically by a simple objective method correlates with colocated endocardial voltage. Greater preablation scar is associated with LA dilatation and AF recurrence.

Use of Ivabradine in Postural Orthostatic Tachycardia Syndrome.

Postural orthostatic tachycardia syndrome (POTS) is characterized by inappropriate increase in heart rate on assuming upright position from a supine position without a necessary drop in blood pressure. Etiology of this condition is complex and multifactorial. Autonomic dysfunction,[1] hypovolemia,[2] hyper responsiveness of beta adrenergic receptors[3] with associated elevations of plasma norepinephrine levels have been implicated as underlying pathophysiologic mechanisms. Beta blockers have previously been used to treat this condition. Ivabradine which selectively inhibits If ion current in the sino atrial node, has been reported to be useful in patients with POTS.[4,5] We present one further such case of POTS successfully treated by Ivabradine.