Ongoing substrate-driven atrial fibrillation "boxed" in the left atrial posterior wall with ablation: a case report.

Patients undergoing valve surgery for rheumatic heart disease are expected to develop significant atrial arrhythmogenic substrates outside of the pulmonary veins, which sometimes require complex ablation techniques for the treatment of symptomatic arrhythmias. We describe, herein, the case of a 76-year-old male undergoing endocardial ablation for the treatment of symptomatic persistent atrial fibrillation which developed after aortic and mitral valve replacement with a simultaneous tricuspid ring annuloplasty. Following pulmonary vein isolation, the patient's atrial fibrillation was converted into cavotricuspid isthmus-dependent atrial flutter. After a successful cavotricuspid isthmus ablation, the arrhythmia reverted back to a left atrial tachyarrhythmia originating from the posterior wall. A linear left atrial lesion led to the electrical isolation of a large area, which included the posterior wall, as well as the containment of the ongoing fibrillatory activity, while sinus rhythm was restored in the rest of the atria. In conclusion, successful left atrial posterior wall isolation can be achieved in the setting of severe scarring due to previous atriotomy by creating a linear lesion on the atrial roof, in conjunction with pulmonary vein isolation, sparing the patient from requiring bottom-line ablation, and avoiding possible esophageal injury. Such compartmentalization of the left atrium may effectively contain local fibrillatory activity, while allowing for the restoration of sinus rhythm.

Endocardial, epicardial, and right atrial approach for catheter ablation of premature ventricular contractions from the inferoseptal process of the left ventricle.

Background: Inferoseptal process of the left ventricle (ISP-LV) might be a source of idiopathic ventricular arrhythmias. In these cases, ectopic foci are accessible from the LV endocardium, epicardially from the middle cardiac vein as well as from the right atrium (RA). This study reports a series of patients with premature ventricular contractions (PVCs) arising from the ISP-LV that were successfully ablated following access from different structures. Methods and Results: Five patients (4 males, age 61 ± 12.8 years) with PVCs arising from the ISP-LV were successfully ablated using three different approaches for ablation-endocardial, epicardial (through coronary sinus or its branches), and RA approaches. Endocardial LV mapping, RA, and coronary sinus (CS) mapping were performed in all five cases. PVCs demonstrated RBBB or LBBB-like morphology and left superior axis. The three patients ablated endocardially had a maximum deflection index (MDI) of 0.36, 0.43, and 0.54, whereas in the remaining 2 patients, MDI was 0.57 and both demonstrated QS morphology in the inferior leads. Local activation time at the successful ablation site was 35 ± 8.9 (26-55) msec pre-QRS. Pacemapping at the successful ablation site resulted in a good (11/12) or perfect (12/12) QRS match in all cases. Three of the patients demonstrated frequent monomorphic PVCs of another morphology suggesting a remote exit site. All patients remained arrhythmia-free after a mean follow-up of 21 ± 15 (6-36) months. Conclusion: Successful ablation of PVCs from ISP-LV may require access from the CS or even RA apart from LV endocardial approach. Not infrequently patients demonstrate additional PVC foci.

Catheter ablation of typical atrial flutter with the superior approach in a patient with inferior vena cava interruption.

Inferior vena cava (IVC) interruption is a rare condition that might pose difficulties during typical flutter ablation. When azygos vein continuation is present ablation via the femoral route could be performed. In the absence of azygos vein continuation, typical atrial flutter ablation via a superior approach from the SVC is feasible.

Is everything clear about Tako-tsubo syndrome?

INTRODUCTION: Tako-tsubo syndrome is a novel cardio-vascular disease affecting predominantly postmenopausal women exposed to unexpected strong emotional or physical stress, in the absence of significant coronary heart disease. It is characterized by acute onset of severe chest pain and/or acute left ventricular failure, ECG-changes, typical left ventricular angiographic findings, good prognosis and positive resolution of the morphological and clinical manifestations. First described in 1990 in Japan by Sato, Tako-tsubo cardiomyopathy is characterized by transient contractile abnormalities of the left ventricle, causing typical left ventricular apical ballooning at end-systole with concomitant compensatory basal hyperkinesia. There are also atypical forms, presenting with left ventricular systolic dysfunction which affects the mid-portions of the left ventricle. The etiology of the disease still remains unclear. Many theories have been put forward about the potential underlying pathophysiological mechanisms that may trigger this syndrome among which are the theory of catecholamine excess, the theory of multivessel coronary vasospasm, the ischemic theory, and the theory of microvascular dysfunction and dynamic left ventricular gradient induced by elevated circulating catecholamine levels. Adequate management of Tako-tsubo syndrome demands immediate preparation for coronary angiography. Once the diagnosis is made, treatment is primarily symptomatic and includes monitoring for complications. Patients with Tako-tsubo syndrome most frequently develop acute LV failure, pulmonary edema, rhythm and conductive disturbances and apical thrombosis. Treatment is symptomatic and includes administration of diuretics, vasodilators and mechanical support of circulation with intra-aortic balloon counterpulsation.