A Twenty-Year Follow-Up of Adults with Ebstein Anomaly with Special Focus on Supraventricular Arrhythmias, Supraventricular Arrhythmias and Effectiveness of Catheter Ablation in 20-Year Follow-Up of Adults with Ebstein Anomaly.

Background: Ebstein anomaly (EA) is a rare congenital heart disease characterized by the apical displacement of the tricuspid leaflets, creating an enlarged functional right atrium. Supraventricular arrhythmias (SVA) are common, and catheter ablation remains challenging. SVA is considered a risk factor for sudden cardiac death in this population. Still, there are very few real-life data on the impact of SVA treated invasively or conservatively on a patient's prognosis. We aimed to analyze the incidence of SVA in adults with EA, evaluate the effectiveness of catheter ablation, and analyze the impact of SVA and catheter ablation on survival in this population. Methods and results: 71 pts (median age 53 years; range 24-84 years) with EA were evaluated retrospectively from 1988 to 2020. Forty patients (56.3%) had SVA, and eighteen of them (45.0%) required at least one catheter ablation (35 procedures in total). Indications for ablation were mostly intra-atrial reentrant tachycardia (IART) and atrioventricular reentrant tachycardia (AVRT) (14 pts [77.8% and 9 pts [50.0%], respectively. IART and AVRT coexisted in nine pts. One patient suffered from persistent atrial fibrillation. Procedural effectiveness was reported in 28 (80%) cases; over a longer follow-up (mean 12.6 ± 5.4 years), only eight (44.4%) patients were completely free from SVA after the first ablation. In total, 10 patients (14%) died due to cardiovascular events. There was no difference in survival between patients with or without SVA (p = 0.9) and between ablated and non-ablated EA individuals (p = 0.89). Conclusions: Supraventricular arrhythmia is frequent in adults with Ebstein anomaly. Patients often require more than one catheter ablation but eventually become free from arrhythmias. The imaging parameters assessed by echocardiography or cardiac magnetic resonance do not seem to be associated with ablation outcomes. The impact of supraventricular arrhythmia itself or treatment with radiofrequency ablation is questionable and should be thoroughly investigated in this population.

Prominent crista terminalis mimicking a right atrial mass: a systematic literature review and meta-analysis.

The crista terminalis is an anatomical structure localized on the posterolateral wall of the right atrium (RA). We performed a systematic review of the literature and meta-analysis concerning cases of unusual prominent crista terminalis mimicking RA mass. Moreover, we described the differential diagnosis of cardiac masses with the use of echocardiography, computed tomography, and cardiac magnetic resonance (CMR). We also emphasize the potential importance of this structure in electrophysiological procedures, including its role in exaggerated arrhythmias. Prominent crista terminalis may be a potential obstacle during invasive cardiac procedures or catheter ablation target. In analyzed cases, the crista terminalis was often erroneously interpreted as pathologic and at first confused with a thrombus or tumor during transthoracic echocardiography examination. The correct final diagnoses were mostly made with used transesophageal echocardiography or CMR. The most important imaging findings suggestive of prominent crista terminalis rather than tumor were a similar echogenicity/intensity with adjacent myocardium, the location on posterolateral wall of the RA, the phasic change in size, and no enhancement after contrast injection. We describe up to date and detailed imaging features for the differential diagnostics of selected intracardiac masses using various imaging techniques, including multimodality cardiac imaging. Familiarity with the anatomy and the imaging findings of the prominent crista terminalis will reduce misdiagnosis and avoid additional tests and unwarranted clinical interventions, while in patients considered for invasive cardiac procedures it might increase their efficacy and safety.

[Development of catheter ablation of supraventricular tachycardias with special consideration of contributions from German engineers and electrophysiologists]. / Entwicklung der Katheterablation supraventrikulärer Tachykardien unter besonderer Berücksichtigung der Beiträge deutscher Ingenieure und Elektrophysiologen.

The development and clinical implementation of catheter ablation of supraventricular tachycardia is one of the outstanding achievements of modern cardiovascular treatment. Over a period of less than 40 years, a curative and safe treatment strategy for almost all forms of atrial arrhythmias has been developed and implemented. German electrophysiologists and engineers have made a significant contribution to this truly outstanding success story in modern medicine. Their contributions should be appropriately acknowledged because without them, the development of ablation technology and its worldwide dissemination would not have been possible. Both the technological contributions and the medical-electrophysiological contributions were at the absolute forefront of worldwide developments and have made a significant contribution to the fact that today more than 500,000 patients with symptomatic and/or threatening cardiac arrhythmias can be successfully treated every year by use of catheter ablation. We would like to thank them all for their achievements.

Evaluation of troponin I serum levels in patients with arrhythmias with and without coronary artery disease.

BACKGROUND: Elevated levels of cardiac enzymes in the blood are an indicator of ongoing cardiac ischemia. Persistent tachycardia may lead to myocardial ischemia due to oxygen supply-demand mismatch. OBJECTIVES: We sought to evaluate the probability of underlying coronary artery disease (CAD) in patients with symptomatic supraventricular (SVT) or ventricular tachyarrhythmias (VT) based on cardiac enzyme level fluctuation. MATERIALS AND METHODS: Troponin I (TNI) levels were measured twice and coronary angiography was also performed in patients without a history of cardiovascular disease and symptomatic SVT or VT. RESULTS: Of the 114 (group A: CAD (n = 40), group B: no CAD (n = 74)) patients eligible for the study, 34 patients in group A and 64 patients in group B had SVT, while 6 patients in group A and 10 patients in group B had VT. All patients with underlying CAD developed a significantly elevated TNI level compared to baseline, irrespective of arrhythmia type (2.02 ± 7.98 ng/ml vs. 5.64 ± 13.38, p = 0.031). In patients without CAD, TNI level was not significantly elevated compared to the baseline level, irrespective of arrhythmia type (0.34 ± 1.38 ng/ml vs. 0.48 ± 1.48 ng/ml, p = 0.158). Most patients with normal TNI levels (46 of 47 patients; 98 %) had SVT. CAD was present in 13 of 47 patients (27 %) with tachycardia, despite normal TNI levels. CONCLUSIONS: Elevated TNI levels are not helpful to discriminate between SVT and VT. An increase in TNI level in repeated blood sampling can help identify patients with higher probability of underlying CAD. Patients with VT demonstrated higher increases in TNI levels, compared to patients with SVT.

Reports of Symptoms Associated with Supraventricular Arrhythmias as a Serious Adverse Drug Reaction in the Spanish Pharmacovigilance Database.

This study aimed to determine the type of drugs reported as suspected of causing severe supraventricular arrhythmias from the Spanish Human Pharmacovigilance System database. A total of 1053 reports were analysed, of which 526 (50%) were on men and 516 (49%) were on women. The most affected age group was the over-65s, with 593 reports (56%). Of the 1613 drugs, those belonging to the cardiovascular system (ATC Group C) were the most numerous (414 reports, 26%), with digoxin being the most frequent drug (49 reports, 12%). Other common groups were antiinfectives for systemic use (ATC Group J; 306 reports, 19%), antineoplastic and immunomodulating agents (ATC Group L; 198 reports, 12%), and nervous system drugs (ATC Group N; 185 reports, 11%). The most common supraventricular arrhythmia was atrial fibrillation (561 reports, 51%). Regarding outcomes, 730 (66%) patients recovered, 76 (7%) did not recover, 25 (3%) recovered but with sequelae, and 23 (2%) resulted in death. This study revealed that certain drugs have reported to be associated more frequently to supraventricular arrhythmias as serious adverse reactions, especially in the older population. Proper clinical management and effective strategies to ensure medication appropriateness should always be considered to improve patient safety when prescribing drugs.

Managing arrhythmia in cardiac resynchronisation therapy.

Arrhythmia is an extremely common finding in patients receiving cardiac resynchronisation therapy (CRT). Despite this, in the majority of randomised trials testing CRT efficacy, patients with a recent history of arrhythmia were excluded. Most of our knowledge into the management of arrhythmia in CRT is therefore based on arrhythmia trials in the heart failure (HF) population, rather than from trials dedicated to the CRT population. However, unique to CRT patients is the aim to reach as close to 100% biventricular pacing (BVP) as possible, with HF outcomes greatly influenced by relatively small changes in pacing percentage. Thus, in comparison to the average HF patient, there is an even greater incentive for controlling arrhythmia, to achieve minimal interference with the effective delivery of BVP. In this review, we examine both atrial and ventricular arrhythmias, addressing their impact on CRT, and discuss the available evidence regarding optimal arrhythmia management in this patient group. We review pharmacological and procedural-based approaches, and lastly explore novel ways of harnessing device data to guide treatment of arrhythmia in CRT.

Appearances of Premature Atrial and Ventricular Contractions After Switching From Brand Name to Generic Cibenzoline.

In antiarrhythmic drugs, the therapeutic window is narrower than in other drugs. Brand name and generic drugs do not use the same inactive ingredients and binder substances. We report a 78-year-old male patient who had been treated for asymptomatic atrial fibrillation and atrial/ventricular premature contractions. Brand name cibenzoline had completely suppressed all arrhythmias. When the medication was changed to the generic drug, the patient showed frequent palpitations and arrhythmias. After restarting the brand-name drug, the arrhythmias were completely suppressed again. These results showed clear differences between brand name and generic cibenzoline in a specific patient. This report is the first case to describe the diminished effectiveness of generic oral cibenzoline.

A Focus on the Right Atrium: Right Atrial Diverticulum and Atrial Flutter.

We report a case of a 70-year-old woman who presented for a cavotricuspid isthmus atrial flutter ablation that was aborted prematurely. On subsequent imaging, she was discovered to have a right atrial diverticulum, which was present on prior imaging but not reported, likely due to unfamiliarity with the entity. (Level of Difficulty: Intermediate.).

Flecainide in clinical practice.

Flecainide, similar to encainide and propafenone, is IC class antiarrhythmic, inhibiting Nav1.5 sodium channels in heart muscle cells and modulates cardiac conduction. Despite its over 40-year presence in clinical practice, strong evidence and well-known safety profile, flecainide distribution in Europe has not always been equal. In Poland, the drug has been available in pharmacies only since October this year, and previously it had to be imported on request. Flecainide can be used successfully in both the acute and chronic treatment of cardiac arrhythmias. The main indication for flecainide is the treatment of paroxysmal supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, atrioventricular re-entrant tachycardia and ventricular arrhythmias in patients without structural heart disease. Beyond that, it may be used in some supraventricular tachycardia in children and for sustained fetal tachycardia. Many studies indicate its efficacy comparable to or better than previously used drugs such as propafenone and amiodarone, depending on the indication. This review aims to highlight the most important clinical uses of flecainide in the light of the latest scientific evidence and to provide an overview of the practical aspects of treatment, including indications, off-label use, contraindications, areas of use, monitoring of treatment and most common complications, taking into account special populations: children and pregnant women.

Lessons from timing of ablation therapy for multi-drug refractory gestational atrial tachycardia with abruptio placentae: a case report.

Background: Supraventricular tachycardia poses a clinical challenge during pregnancy, particularly if refractory to antiarrhythmic medications. Performing catheter ablation during pregnancy necessitates careful risk benefit analysis for both the mother and foetus, especially with left-sided ablations that may require post-procedural systemic anticoagulation. Case summary: We describe a case of a 31-year-old pregnant woman with refractory atrial tachycardia which failed a multi-antiarrhythmic drug regimen and ultimately developed abruptio placentae, requiring a carefully staged ablation approach for definitive treatment. Discussion: This case highlights the importance of taking into consideration the risks of post-procedural anticoagulation in the event of clinical complications in pregnancy such as abruptio placentae and coordinating carefully with gynaecologists to optimize maternal and foetal outcomes. Here, careful risk stratification was paramount to successfully navigate through the management of her atrial tachycardia while ensuring foetal viability.

Myocardial Infarction by a Myocardial Bridge in the LAD Combined With Atrioventricular Re-Entrant Supraventricular Tachycardia.

We present the case of a patient who presented with palpitations and was found to have atrioventricular re-entrant tachycardia with unusually elevated cardiac biomarkers. A coronary computed tomographic angiography showed a myocardial left anterior descending artery bridge; an accessory pathway was ablated, and cardiac magnetic resonance revealed anteroseptal myocardial infarction resulting from hypoperfusion during tachycardia caused by the left anterior descending artery myocardial bridge. (Level of Difficulty: Intermediate.).

Treatment of Symptomatic Functional Atrioventricular Block by Cardioneuroablation as an Alternative to Pacemaker Implantation.

A woman with recurrent presyncope caused by a functional atrioventricular (AV) block after meals, with limiting symptoms, underwent cardioneuroablation and AV node vagal denervation without pacemaker implantation. Normal AV conduction was recovered with complete abolishment of symptoms. (Level of Difficulty: Advanced.).

Diagnostic Role of Incidental Premature Contractions During Doppler Echocardiography.

Cardiac sonographers often perceive premature beats as a limiting factor during echocardiography because they alter filling and contractility, and loops recorded during or after a premature contraction are often discarded. Here we present 2 cases in which the incidental occurrence of premature beats on Doppler echocardiography contributed to the diagnosis. (Level of Difficulty: Intermediate.).

The Influence of Environmental Air Pollution on Ventricular Arrhythmias: A Scoping Review.

INTRODUCTION: Exposure to air pollution is a recognised risk factor for cardiovascular disease and has been associated with supraventricular arrhythmias. The effect of air pollution on ventricular arrhythmias is less clear. This scoping review assessed the effects of particulate and gaseous air pollutants on the incidence of ventricular arrhythmias. METHODS: MEDLINE and EMBASE databases were searched for studies assessing the effects of air pollutants on ventricular tachycardia and ventricular fibrillation. These pollutants were particulate matter (PM) 2.5, PM10, Nitrogen Dioxide (NO2), Carbon Monoxide (CO), Sulphur Dioxide (SO2), and Ozone (O3). RESULTS: This review identified 27 studies: nine in individuals with implantable cardioverter defibrillators, five in those with ischaemic heart disease, and 13 in the general population. Those with ischaemic heart disease appear to have the strongest association with ventricular arrhythmias in both gaseous and particulate pollution, with all three studies assessing the effects of PM2.5 demonstrating some association with ventricular arrythmia. Results in the general and ICD population were less consistent. CONCLUSION: Individuals with ischaemic heart disease may be at an increased risk of ventricular arrhythmias following exposure to air pollution.

Prevalence, Management, and Outcome of Atrial Fibrillation and Other Supraventricular Arrhythmias in COVID-19 Patients.

COVID-19 mainly affects the respiratory system but has been correlated with cardiovascular manifestations such as myocarditis, heart failure, acute coronary syndromes, and arrhythmias. Cardiac arrhythmias are the second most frequent complication affecting about 30% of patients. Several mechanisms may lead to an increased risk of cardiac arrhythmias during COVID-19 infection, ranging from direct myocardial damage to extracardiac involvement. The aim of this review is to describe the role of COVID-19 in the pathogenesis of cardiac arrhythmias and provide a comprehensive guidance for their monitoring and management.

Comparison of in-hospital outcomes of patients undergoing catheter ablation for typical versus atypical atrial flutter.

BACKGROUND: Catheter ablation (CA) is indicated as definitive therapy for patients with either typical or atypical atrial flutter (TAFlutter and AAFlutter, respectively) which is unresponsive to medical therapy. There is a paucity of data regarding in-hospital outcomes of patients undergoing CA. METHODS: Retrospective study using the NIS to identify patients ≥18 years who underwent CA between 2015 and 2017. Individuals were identified using ICD-10-CM/PCS for TAFlutter, AAFlutter, and CA. RESULTS: A total of 17,390 patients underwent CA for Aflutter (33% AAFlutter and 67% TAFlutter). The TAFlutter group was younger (mean 65.9 years vs. 67.2 years), with less females (30% vs. 43%, p ≤ 0.001 for both) compared to the AAFlutter group. The TAFlutter group had a higher rate of diabetes, tobacco use, obesity, and chronic obstructive pulmonary disease (p ≤ 0.001 for all). The AAFlutter cohort had increased prior strokes and atrial fibrillation (p ≤ 0.001 for both). The mean CHA2DS2-VASc score was found to be 2.3 in AAFlutter compared to 2.1 in TAFlutter (p ≤ 0.001). There were significantly higher proportions of thromboembolic events, transfusions, and longer length of stay in the TAFlutter group (p ≤ 0.001 for all) with the AAFlutter group having significantly higher rates of cardioversion, implantation of cardiac devices, and increased hospital charges (p ≤ 0.001 for all); no significant difference was found in mortality after controlling for comorbidities. CONCLUSIONS: We found higher complication rates in CA for patients with TAFlutter, but no difference in in-hospital all-cause mortality. Variation in CA depending upon the mechanism of AFlutter may underlie these differences, and warrant further study.

Vanishing Cardiac Tumor by Chemotherapy in a Patient With Diffuse Large B-Cell Lymphoma.

A 70-year-old Japanese man presented with a massive cardiac tumor associated with diffuse large B-cell lymphoma. Standard chemotherapy resulted in complete remission and the cardiac tumor disappeared. (Level of Difficulty: Intermediate.).