Severe headache, seizures and supraventricular tachycardia in a 33-year-old Filipino male with confirmed COVID-19: A case report

@#COVID-19 primarily presents as a pulmonary problem, ranging from mild respiratory illness to fatal acute respiratory distress syndrome. Most common manifestations are fever (89%) and cough (72%), while headache and arrhythmia are found in 28% and 17%, respectively. We aim to present a confirmed COVID-19 case presenting with both neurologic and cardiac manifestations. A 33-year-old Filipino male nurse initially consulted at the emergency room due to progressive diffuse headache, with associated localized seizures progressing to generalized tonic clonic seizure and arrhythmia. He had no coryza, cough, sore throat, and diarrhea. He was previously well and had no known co-morbidities or direct exposure to confirmed COVID-19 patients. Physical examination showed elevated blood pressure, tachycardia, and sensory and motor deficits in the left upper and lower extremities. Pertinent diagnostic test results included the detection of SARS-CoV-2 viral RNA via RT-PCR. Imaging studies demonstrated cortical venous thrombosis with hemorrhagic venous infarction in the right parietal lobe. Ground glass appearance on the middle lobe of the left lung was also evident. ECG showed supraventricular tachycardia. Prothrombin time, activated partial thromboplastin time, and D-dimer were all within the normal limits. Carotid massage was done. He was treated with anti-epileptics, anticoagulants, antiarrhythmics, antivirals, antibiotics, and supportive management. During the hospital stay, his symptoms resolved; he was discharged after 21 days. Follow-up done after 3 weeks revealed no recurrence of severe headache, seizure, or tachycardia. It is theorized that an interplay exists between ACE-2 tropism, systemic inflammation, cytokine storm, and hypoxemia in the background of COVID-19 infection. These mechanisms may lead to thrombosis and arrhythmia resulting to neurologic derangements and myocardial injury. Underlying mechanisms make the cerebro-cardiovascular systems vulnerable to the coronavirus disease 2019 infection. COVID-19 should therefore be part of the differential diagnoses in patients presenting with headache, seizures, and arrhythmias.

Enterocolitis necrosante posterior a evento aislado de taquicardia supraventricular: reporte de un caso de presentación neonatal atípica / Necrotizing enterocolitis after an isolated event of supraventricular tachycardia. Case report of atypical neonatal presentation

La taquicardia supraventricular (TSV) es la principal taquiarritmia en el recién nacido (RN) que requiere una resolución urgente. Por su parte, la enterocolitis necrosante (ECN) es la emergencia gastrointestinal más común que afecta principalmente a RN prematuros. Aunque estas se reconocen como patologías distintas, la bibliografía sugiere que los episodios de TSV pueden predisponer a los pacientes a la ECN a través de alteraciones en el flujo sanguíneo mesentérico y una disminución de la perfusión tisular. Se presenta aquí el caso clínico de un neonato prematuro que desarrolló un cuadro de ECN luego de un evento aislado de TSV con bajo gasto cardíaco

Supraventricular tachycardia (SVT) is the main tachyarrhythmia in the newborn (NB) that requires urgent resolution. Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency that mainly affects premature infants. Although these conditions are recognized as distinct pathologies, literature reports suggest that episodes of SVT may predispose patients to NEC secondary to disturbances in mesenteric blood flow and a decrease in tissue perfusion. We present here the clinical case of a premature neonate who developed NEC after an isolated SVT event with low cardiac output

Catheter Ablation in Neonate with Heart Failure Due to Incessant Atrioventricular Reentrant Tachycardia

Abstract The atrioventricular (AV) reentrant tachycardia (AVRT) is the most common cause of supraventricular tachycardia (SVT) in the young pediatric population. Some newborns might present with congestive heart failure and require interventional treatment. Catheter ablation in small infants (<6 months and <5 kg) is still poorly performed and controversial due to high complications rate in this group of patients.1 We report a case of a 28 days old infant (3,5 kg) with a drug-refractory left accessory pathway mediated tachycardia and severe hemodynamic compromise, who underwent catheter ablation. Radiofrequency ablation should be part of the therapeutic arsenal in a context of drug-resistant supraventricular tachycardia with hemodynamic compromise, despite the greater risks of complications in this special population.

Validação de um Algoritmo Simples para Detecção de Taquicardia Ventricular no Eletrocardiograma / Validation of a Simple Electrocardiographic Algorithm for Detection of Ventricular Tachycardia

Resumo Fundamento O diagnóstico diferencial de taquicardia de QRS largo, entre taquicardia ventricular (TV) ou taquicardia supraventricular com condução aberrante (TSV-A) é algumas vezes difícil de ser feito na sala de emergência. Objetivo Avaliar a acurácia de um algoritmo novo e simples para a detecção de TV no eletrocardiograma (ECG) em pacientes com taquicardia de QRS largo. Métodos ECGs de 12 derivações para detecção de taquicardia de QRS largo foram obtidos prospectivamente de 120 pacientes durante estudo eletrofisiológico. Seis médicos com diferentes experiências analisaram os ECGs, e fizeram o diagnóstico com base no algoritmo D12V16, que envolve a análise da polaridade predominante do complexo QRS nas derivações I, II, V1 e V6. O diagnóstico foi comparado com os obtidos pelo algoritmo tradicional de Brugada e pelo estudo eletrofisiológico, o qual é considerado padrão ouro. Adotou-se um nível de significância de 5% (p<0,05) nas análises estatísticas. Resultados De acordo com o estudo eletrofisiológico, 82 ECGs eram de TV e 38 de TSV-A. Doenças cardíacas estruturais estavam presentes em 71 (86,6%) dos pacientes com TV e em oito (21,1%) com TSV-A. O algoritmo de Brugada teve uma maior sensibilidade global (87,2%), enquanto o algoritmo D12V16 apresentou maior especificidade global (85,1%) para TV. Tanto o algoritmo D12V16 como o de Brugada apresentou um alto valor preditivo positivo (90,9% vs. 85,8%, respectivamente) e acurácia similar (73,8% vs. 81,4%, respectivamente) para o diagnóstico de TV. Nos avaliadores experientes, a acurácia foi maior utilizando o algoritmo de Brugada que o algoritmo D12V16, mas a acurácia dos dois algoritmos foi similar segundo os avaliadores menos experientes. Conclusão O algoritmo simplificado pode ser um método útil para reconhecer TV no ECG, principalmente para médicos menos experientes. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Abstract Background The differential diagnosis of wide QRS complex tachycardia (WCT) between ventricular tachycardia (VT) or supraventricular tachycardia with aberrant conduction (SVT-A) is sometimes difficult in the emergency room. Objective The aim of this study was to evaluate the accuracy of a new simple electrocardiographic algorithm to recognize VT in patients with wide complex tachycardia. Methods The 12-lead electrocardiograms (ECG) for WCT were prospectively obtained from 120 patients during electrophysiological study. Six physicians with different expertise analyzed the electrocardiographic recordings, and made the diagnosis based on the D12V16 algorithm, that involves the analysis of the predominant polarity of QRS in leads I, II, V1 and V6. The diagnosis was compared with that made using the traditional Brugada algorithm and the "gold-standard" electrophysiological study. Statistical analyses were performed with a significance level of 5% (p<0.05). Results According to the EPS study, 82 ECG recordings were VT and 38 SVT-A. Structural heart diseases were present in 71 (86.6%) patients with VT and in 8 (21.1%) with SVT-A. The Brugada algorithm had higher global sensitivity (87.2%), and the D12V16 algorithm had higher global specificity (85.1%) for VT. Both D12V16 and Brugada's algorithms presented a high positive predictive value (90.9% vs 85.8%, respectively) and similar accuracy (73.8% vs 81.4%, respectively) for the diagnosis of VT. Experienced evaluators were more accurate using Brugada algorithm than the D12V16 algorithm, but the accuracy of both algorithms was similar according to less experienced examiners. Conclusion The simplified algorithm may be a useful method to recognize VT in the ECG, especially for less experienced doctors. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Ablação por Cateter de Taquicardia Atrial Focal com Ativação Precoce Próxima ao Feixe de His, a Partir da Cúspide Aórtica não Coronária / Catheter Ablation of Focal Atrial Tachycardia with Early Activation Close to the His-Bundle from the Non Coronary Aortic Cusp

Resumo Fundamento A ablação da taquicardia atrial (TA) com local de ativação mais precoce próxima ao feixe de His é um desafio, devido ao risco de bloqueio de AV completo por sua proximidade ao sistema de His-Purkinje (SHP). Uma alternativa para minimizar esse risco é posicionar o cateter na cúspide não coronária (CNC), que é anatomicamente contígua à região para-Hissiana. Objetivos O objetivo deste estudo foi fazer uma revisão de literatura e avaliar as características eletrofisiológicas, a segurança e o índice de sucesso de aplicação de radiofrequência (RF) por cateter na CNC para o tratamento de TA para-Hissiana em uma série de casos. Métodos Avaliamos retrospectivamente dez pacientes (Idade: 36±10 anos) que foram encaminhados para ablação de taquicardia paroxística supraventricular (TPSV) e haviam sido diagnosticados com TA focal para-Hissiana confirmada por manobras eletrofisiológicas clássicas. Para a análise estatística, um P valor d <0.05 foi considerado estatisticamente significativo. Resultados A ativação atrial mais precoce na posição His foi de 28±12ms da onda P, e a CNC foi 3±2ms antes da posição His, sem evidência de potencial His em todos os pacientes. Foi aplicada RF à CNC (cateter de ponta de 4-mm; 30W, 55°C) e a taquicardia foi interrompida em 5±3s sem aumento no intervalo PR ou evidência de um ritmo juncional. Os testes eletrofisiológicos não induziram novamente a taquicardia em 9/10 pacientes. Não houve complicações em nenhum procedimento. Durante o período de acompanhamento de 30 ± 12 meses, nenhum paciente apresentou recorrência de taquicardia. Conclusão O tratamento percutâneo de TA para-Hissiana por meio de CNC é uma estratégia segura e eficiente, tornando-se uma opção interessante para o tratamento de arritmia complexa. (Arq Bras Cardiol. 2021; 116(1):119-126)

Abstract Background Atrial tachycardia (AT) ablation with earliest activation site close to the His-Bundle is a challenge due to the risk of complete AV block by its proximity to His-Purkinje system (HPS). An alternative to minimize this risk is to position the catheter on the non-coronary cusp (NCC), which is anatomically contiguous to the para-Hisian region. Objectives The aim of this study was to perform a literature review and evaluate the electrophysiological characteristics, safety, and success rate of catheter-based radiofrequency (RF) delivery in the NCC for the treatment of para-Hisian AT in a case series. Methods This study performed a retrospective evaluation of ten patients (Age: 36±10 y-o) who had been referred for SVT ablation and presented a diagnosis of para-Hisian focal AT confirmed by classical electrophysiological maneuvers. For statistical analysis, a p-value of <0.05 was considered statistically significant. Results The earliest atrial activation at the His position was 28±12ms from the P wave and at the NCC was 3±2ms earlier than His position, without evidence of His potential in all patients. RF was applied on the NCC (4-mm-tip catheter; 30W, 55ºC), and the tachycardia was interrupted in 5±3s with no increase in the PR interval or evidence of junctional rhythm. Electrophysiological tests did not reinduce tachycardia in 9/10 of patients. There were no complications in all procedures. During the 30 ± 12 months follow-up, no patient presented tachycardia recurrence. Conclusion The percutaneous treatment of para-Hisian AT through the NCC is an effective and safe strategy, which represents an interesting option for the treatment of this complex arrhythmia. (Arq Bras Cardiol. 2021; 116(1):119-126)

Disincronía ventricular inducida por fármacos y taquicardiomiopatía en un neonate / Drug-induced ventricular dissynchrony and tachycardiomyopathy in a newborn

Resumen La disfunción ventricular secundaria a disincronía eléctrica y mecánica es una complicación de la estimulación ventricular desde el ápex del ventrículo derecho. No existen informes de disincronía secundaria a los efectos de fármacos antiarrítmicos. Se presenta el caso de una niña de 10 días de vida con taquicardia supraventricular incesante que se internó en terapia intensiva neonatal. Se inició tratamiento con propranolol por vía oral y ante la persistencia de la taquicardia se agregó amiodarona endovenosa. La paciente estuvo predominantemente en taquicardia con frecuencias cardíacas entre 200 y 290 latidos por minuto durante una semana a pesar del tratamiento instaurado. La función ventricular fue normal en los ecocardiogramas realizados. Se agregó flecainida por vía oral al esquema de tratamiento y luego de 24 horas presentó una taquicardia más lenta con QRS ancho e imagen de bloqueo completo de rama izquierda. Un nuevo ecocardiograma evidenció deterioro de la función ventricular izquierda e insuficiencia mitral moderada lo que motivó la suspensión de la flecainida y el propranolol. A las 24 horas de la suspensión se observó la normalización de la función ventricular a pesar de la persistencia de episodios intermitentes de taquicardia. Se reinició el propranolol logrando el control de la taquicardia. La presencia de disincronía ventricular generada por el bloqueo de rama izquierda secundario al tratamiento farmacológico con flecainida constituye una novedosa explicación posible para el desarrollo de disfunción ventricular.

Abstract Ventricular dysfunction secondary to electrical and mechanical dyssynchrony in chronic right ventricular apical pacing is a well-recognized complication. There are no previous reports of pharmacologically induced dyssynchrony. A 10-day old infant with incessant supraventricular tachycardia was admitted to the neonatal intensive care unit. Therapy with oral propranolol was initiated and due to persistence of tachycardia intravenous amiodarone was administered. The patient remained predominantly in tachycardia with heart rates between 200-290 beats per minute for a week with serial echocardiograms showing preserved ventricular function. Oral flecainide was started. After 24 hours of treatment the patient developed a slower incessant wide QRS with a left bundle branch block pattern. The echocardiogram showed deterioration of left ventricular systolic function and moderate mitral regurgitation. Flecainide and propranolol were discontinued. The QRS complex narrowed and despite intermittent breakthroughs of supraventricular tachycardia, ventricular function normalized. Propranolol was restarted to achieve definitive control of the tachycardia. The presence of ventricular dyssynchrony generated by the left bundle branch block pattern secondary to pharmacological treatment with flecainide is a novel possible explanation for the development of ventricular dysfunction.

Assessment of the hemogram parameters in patients with paroxysmal supraventricular tachycardia: a retrospective study

SUMMARY OBJECTIVE: Inflammation has been suggested as a potential mechanism in the pathogenesis of arrhythmia. Hemogram parameters such as monocyte count to high-density lipoprotein cholesterol ratio (MHR), neutrophil/lymphocyte ratio (NLR), and monocyte/lymphocyte ratio (MLR) have been considered to be markers of inflammation and new cardiovascular risk predictors. This retrospective study aimed to investigate the relationship between MHR, NLR, and MLR in patients with paroxysmal supraventricular tachycardia (PSVT). METHODS: A retrospective study conducted at a university hospital in Bolu, Turkey, between 2017 and 2019. Our study included 196 patients who underwent electrophysiological study (EPS) due to palpitation or documented PSVT on electrocardiography (ECG). Patients having documented atrioventricular nodal re-entrant tachycardia (AVNRT) on ECG or inducible AVNRT on EPS were included in the PSVT group (n=130), and patients with palpitation but without inducible arrhythmia on EPS (n=66) were included in the control group. Routine biochemical and hemogram tests were performed before the EPS procedure. RESULTS: When hemogram parameters were compared, there was no statistically significant difference in MHR values [0.010 (0.001-0.030) vs 0.010 (0.001-0.020) p =0.67]. Additionally, both NLR [2.21(0.74-11.36) vs 1.98(0.72-24.87) p=0.13] and MLR [0.25 (0.03-1.05) vs 0.24(0.07-1.39) p=0.41] were not statistically significant between the two groups. CONCLUSION: There is no significant difference in PSVT patients regarding hemogram parameters including white blood cell subtypes, MLR, NLR, and MHR. Therefore the evaluation of hemogram parameters may not be clinically relevant for PSVT patients.

RESUMO OBJETIVO: A inflamação tem sido sugerida como um mecanismo potencial na patogênese da arritmia. Parâmetros do hemograma, como contagem de monócitos e razão de colesterol lipoproteína de alta densidade (MHP), proporção de neutrófilos / linfócitos (NLP) e proporção de monócitos / linfócitos (MLR), foram considerados marcadores de inflamação e novos preditores de risco cardiovascular. Este estudo retrospectivo teve como objetivo investigar a relação entre MHP, NLP e MLP em pacientes com taquicardia paroxística supraventricular (PSVT). MÉTODOS: Estudo retrospectivo realizado em um hospital universitário em Bolu, Turquia, entre 2017 e 2019. Nosso estudo incluiu 196 pacientes submetidos a estudo eletrofisiológico (EPS) devido a palpitações ou PSVT documentada na eletrocardiografia (ECG). Os pacientes com taquicardia nodal atrioventricular reentrante (AVNRT) no ECG ou AVNRT indutível no EPS foram incluídos no grupo PSVT (n = 130) e os pacientes com palpitações sem arritmia induzível no EPS (n = 66) foram incluídos no grupo controle. Testes bioquímicos e de hemograma de rotina foram realizados antes do procedimento de EPS. RESULTADOS: Quando os parâmetros do hemograma foram comparados, não houve diferença estatisticamente significante nos valores de MHP (0,010 (0,001-0,030) vs 0,010 (0,001-0,020) p = 0,67). Além disso, tanto o NLP (2,21 (0,74-11,36) vs 1,98 (0,72-24,87) p = 0,13) quanto o MLP (0,25 (0,03-1,05) vs 0,24 (0,07-1,39) p = 0,41) não foram estatisticamente significantes entre os dois grupos. CONCLUSÃO: Não há diferença significativa nos pacientes com PSVT em relação aos parâmetros do hemograma, incluindo os subtipos de glóbulos brancos, MHP, NLP e MHP. Portanto, a avaliação dos parâmetros do hemograma pode não ser clinicamente relevante para pacientes com PSVT.

Experiencia en el uso de propranolol para el tratamiento de la taquicardia supraventricular en pacientes menores de un año / Experience using propranolol for the management of supraventricular tachycardia in patients younger than 1 year

Objetivo. Evaluar los resultados y efectos adversos de la terapia con propranolol en menores de un año con taquicardia supraventricular. Población y métodos. Menores de 1 año con taquicardia supraventricular documentada, que recibieron tratamiento y prevención con propranolol por vía oral. Se analizaron sexo y edad, cardiopatía congénita asociada, pre excitación ventricular en el electrocardiograma basal, recurrencia intratratamiento y efectos adversos. Resultados. Se identificaron 107 pacientes. El primer episodio de taquicardia supraventricular ocurrió a una edad mediana de 190 días. En 10 pacientes, se observó cardiopatía congénita asociada. El 23,3 % presentó pre excitación ventricular en el electrocardiograma basal. El rango de la dosis de propranolol fue de 2 a 5 mg/kg/día. En el 30,8 %, se observó recurrencia intratratamiento. En 2 pacientes, se suspendió la medicación por efectos adversos graves. Conclusión. El propranolol evitó la recurrencia en el 70 % de los casos. En 2 pacientes, fue necesario suspenderlo por efectos adversos graves

Objective. To assess the results and adverse events of propranolol therapy in infants younger than 1 year with supraventricular tachycardia. Population and methods. Infants younger than 1 year with documented supraventricular tachycardia who received oral treatment and prophylaxis with propranolol. Sex and age, associated congenital heart disease, ventricular preexcitation in the base line electrocardiogram, on-treatment recurrence, and adverse events were analyzed. Results. A total of 107 patients were identified. The first supraventricular tachycardia event occurred at a median age of 190 days. Associated congenital heart disease was observed in 10 patients. Ventricular preexcitation in the baseline electrocardiogram was detected in 23.3 %. Propranolol dose ranged from 2 to 5 mg/kg/day. On-treatment recurrence was observed in 30.8 %. Medication was discontinued in 2 patients due to severe adverse events. Conclusion. Propranolol prevented recurrence in 70 % of cases. It was discontinued in 2 patients due to severe adverse events.

Enfoque en el diagnóstico diferencial de las taquicardias paroxísticas supraventriculares en el Laboratorio de electrofisiología / Differential diagnosis of paroxysmal supraventricular tachycardia at the electrophysiology laboratory

Resumen: Las taquicardias paroxísticas supraventriculares son arritmias frecuentes y producen importante morbilidad. El estudio electrofisiológico permite hacer el diagnóstico su mecanismo para luego realizar la ablación. El diagnóstico no siempre es sencillo y se debe recurrir a múltiples observaciones y maniobras para alcanzarlo. En la siguiente revisión se discuten los principales criterios usados para el diagnóstico del mecanismo de estas taquicardias durante un estudio electrofisiológico.

Abstract: Paroxysmal supraventricular tachycardias are frequently observed arrhythmias associated to significant morbidity. Electrophysiological study allows the diagnosis of the mechanisms underlying the arrhythmia leading toblation. The diagnosis is not always easy and multiple observations and maneuvers are required to uncover it. In the following review, the main criteria used to diagnose the mechanisms of these tachycardias during an electrophysiological study are discussed.

Resultado del tratamiento en pacientes sometidos a ablación percutánea por arritmias supraventriculares en la ciudad de Cuenca, periodo abril 2013- julio 2018 / Treatment outcome of percutaneous ablation in patients with supraventricular arrhythmias in Cuenca, April 2013- July 2018

INTRODUCCIÓN: Las taquicardias supraventriculares son comunes en la práctica clínica, a pesar de tener buen pronóstico, puede afectar significativamente la calidad de vida de los pacientes. El tratamiento médico no da como resultado la ausencia total de la arritmia, por lo que la terapia por ablación se ha convertido en el tratamiento de elección en muchos de los casos por su alto índice de éxito brindando una solución definitiva. El objetivo de este estudio es determinar la frecuencia de presentación de las principales taquicardias supraventriculares, distribuidas por edad y sexo, la frecuencia de éxito de la ablación percutánea y los factores relacionados con el mismo y la frecuencia de las complicaciones presentadas. MATERIALES Y MÉTODOS: Se realizó un estudio descriptivo transversal y de correlación, que incluyó 156 con diagnóstico de taquicardia supraventricular y ablacionados en los cinco centros hospitalarios en donde se realizó el procedimiento, basándonos en los registros clínicos de los mismos. RESULTADOS: De los 156 pacientes, 51.9% fueron mujeres y 48.1% hombres, con edades comprendidas entre los 10 y 80 años de edad. Las arritmias reportadas fueron taquicardia de reentrada nodal, taquicardia reentrante auriculoventricular y flutter auricular, de estas la más frecuente fue la taquicardia por reentrada auriculoventricular. El éxito global del tratamiento fue del 93.5%, sin reportar complicaciones, los factores relacionados estudiados no presentaron asociación estadísticamente significativa. CONCLUSIÓN: El tratamiento por ablación tuvo un alto porcentaje de éxito y una tasa nula de complicaciones, esto es un indicador tanto de eficacia como seguridad de este procedimiento.(au)

BACKGROUND: Supraventricular tachycardia is commonly diagnosed in clinical practice, despite having a good prognosis, it can significantly affect the patient's life quality. Pharmacological treatment does not result in the total absence of the arrhythmia, which is why ablation therapy has become the treatment of choice, due to its high success rate, and for offering a definitive solution. The aim of this study was to determine the frequency of each supraventricular tachycardia type, according to age and sex, the rate of success of percutaneous ablation and its related factors, and the frequency of complications due to the procedure. METHODS: A cross-sectional, descriptive, correlational study was conducted, including 156 patients diagnosed with supraventricular tachycardia and ablated, from five hospitals where the procedure was performed, based on their clinical records. RESULTS: From the 156 patients in this study, 51.9% were women and 48.1% men, the age ranged between 10 and 80 years. The most commonly reported arrhythmias were nodal reentrant tachycardia, atrioventricular reentrant tachycardia and atrial flutter, being the atrioventricular reentrant tachycardia the most frequent of all. The global success rate was 93.5%, no complications were reported, and none of the studied factors had significant statistical association with the success rate. CONCLUSION: Ablation treatment had a high success rate, with cero complications in this study, demonstrating the efficacy and safety of the procedure.(au)

Ablação Por Cateter Sem Uso de Fluoroscopia Para Tratamento de Fibrilação Atrial e Arritmias Atriais: Eficácia e Segurança / Catheter Ablation for Treatment of Atrial Fibrillation and Supraventricular Arrhythmias Without Fluoroscopy Use: Acute Efficacy and Safety

Resumo Fundamento O uso da radiação ionizante em procedimentos médicos está associado a riscos significativos à saúde dos pacientes e da equipe de saúde. Objetivos Avaliar a segurança e a eficácia aguda da ablação por cateter para tratamento da fibrilação atrial (FA) e arritmias supraventriculares (SVTs), utilizando uma abordagem exclusivamente não fluoroscópica, guiada por eco intracardíaco (ICE) e mapeamento 3D. Métodos 95 pts (idade média 60 ± 18 anos, 61% do sexo masculino) programados para ablação de FA (69 pts, 45 FA paroxística e 24 FA persistente) ou SVTs (26 pts - 14 reentrada nodal, 6 Wolf-Parkinson-White [WPW], 5 flutter atrial direito [AD], 1 taquicardia atrial). Nove pacientes (9,5%) tinham marcapasso definitivo ou dispositivos de ressincronização com desfibrilador. Dois sistemas de mapeamento eletroanatômico foram utilizados - CARTO (65%) e NAVx (35%), bem como cateteres de ICE disponíveis - Acunav e ViewFlex. Resultados O isolamento das veias pulmonares (VPs), bem como todos os outros alvos que precisavam de ablação em ambos os átrios, foram alcançados e adequadamente visualizados. Não foram observados derrames pericárdicos, complicações trombóticas ou outras intercorrências nesta série. Punções transseptais difíceis (19 pacientes - 20%) foram realizadas sem fluoroscopia em todos os casos. Não foi utilizada fluoroscopia de backup, e nenhum vestuário de chumbo foi necessário. Avaliações detalhadas dos marcapassos após o procedimento não mostraram nenhum dano aos eletrodos, deslocamentos ou mudanças de limiar. Conclusões Uma estratégia de ablação por cateter sem uso de radiação para FA e outras arritmias atriais é segura e eficaz quando guiada pela utilização adequada do ICE e do mapeamento 3D. Diversos sítios em ambos os átrios podem ser alcançados e adequadamente ablacionados sem a necessidade de fluoroscopia de backup. Não foram observadas complicações. (Arq Bras Cardiol. 2020; 114(6):1015-1026)

Abstract Background The use of ionizing radiation in medical procedures is associated with significant health risks for patients and the health care team. Objectives Evaluate the safety and acute efficacy of ablation for atrial fibrillation (AF) and supraventricular arrhythmias (SVTs) using an exclusively non-fluoroscopic approach guided by intracardiac echo (ICE) and 3D-mapping. Methods 95 pts (mean age 60 ± 18 years, 61% male) scheduled for AF Ablation (69 pts, 45 paroxysmal AF and 24 persistent AF) or non-AF SVT (26 pts - 14 AV node reentry, 6 WPW, 5 right atrial (RA) flutters, 1 atrial tachycardia) underwent zero fluoro procedures. Nine patients (9.5%) had permanent pacemakers or defibrillator resynchronization (CRT-D) devices. Both CARTO (65%) and NAVx (35%) mapping systems were used, as well as Acunav and ViewFlex ICE catheters. Results Pulmonary vein isolation (PVI), as well as all other targets that needed ablation in both atria were reached and adequately visualized. No pericardial effusions, thrombotic complications or other difficulties were seen in these series. Difficult transseptal puncture (19 patients - 20%) was managed without fluoroscopy in all cases. No backup fluoroscopy was used, and no lead apparel was needed. Pacemaker interrogations after the procedure did not show any lead damage, dislocation, or threshold changes. Conclusions A radiation-free (fluoroless) catheter ablation strategy for AF and other atrial arrhythmias is acutely safe and effective when guided by adequate ICE and 3D-mapping utilization. Multiple different bi-atrial sites were reached and adequately ablated without the need for backup fluoroscopy. No complications were seen. (Arq Bras Cardiol. 2020; 114(6):1015-1026)

Diagnóstico diferencial de las taquicardias de complejo ancho: un desafío permanente / Wide QRS tachycardia: a diagnostic challenge

El diagnóstico electrocardiográfico correcto de la causa de una taquicardia de complejo QRS ancho (TCA) es fundamental, ya que tanto el manejo, como el pronóstico del paciente, es diferente según su etiología, y define el estudio que debemos realizar. Numerosos criterios y algoritmos han sido descritos para diferenciar el origen de estas taquicardias. Sin embargo, muchos de estos son complejos y difíciles de aplicar para el médico menos experimentado. Esto es particularmente importante en los servicios de emergencia, donde se necesita una definición rápida que permita un manejo agudo apropiado. En la presente revisión analizamos los diferentes mecanismos de las TCA y los principales criterios diagnósticos en el ECG, reforzando, especialmente, aquellos de aplicación rápida y de alto rendimiento diagnóstico.

The correct electrocardiographic diagnosis of the cause of a wide QRS complex tachycardia (WCT) is essential since both management and prognosis of the patient. The correct electrocardiographic diagnosis of the cause of a wide QRS complex tachycardia (WCT) is essential since both management and prognosis is different according to its etiology and defines the study that we should perform. Numerous criteria and algorithms have been described to differentiate the origin of these tachycardias. However, many of these are complex and difficult to apply to the less experienced doctor. This is particularly important in emergency rooms, where a rapid definition is needed to allow proper therapy. In this review we analyze the different mechanisms of WCT and the main EKG diagnostic criteria, emphasizing those which can be applied rapidly and have high diagnostic value.

Current Status of Researches on Atrial Tachycardia Occurred after Atrial Fibrillation Catheter Ablation / 中国医疗器械杂志

Atrial fibrillation is the most common persistent arrhythmia in the clinic. It affects a wide range of populations with high incidence, morbidity and mortality. Clinical studies have shown that ablation is one of the best means for the treatment of atrial fibrillation. However, after receiving ablation, some patients may experience atrial tachycardia and thus feel even deteriorated feelings. Understanding the predicting factors, electrophysiological mechanisms, and differential diagnosis and treatment strategies for post-ablation atrial tachycardia is essential for reducing the incidence and for the management of post-ablation atrial tachycardia. Therefore, we summarize the research progress of the above-mentioned aspects, and correspondingly proposes further research directions.

Severe headache, seizures and supraventricular Tachycardia in a 33-year-old Filipino male with confirmed COVID-19: A case report

@#COVID-19 primarily presents as a pulmonary problem, ranging from mild respiratory illness to fatal acute respiratory distress syndrome. Most common manifestations are fever (89%) and cough (72%), while headache and arrhythmia are found in 28% and 17%, respectively. We aim to present a confirmed COVID-19 case presenting with both neurologic and cardiac manifestations. A 33-year-old Filipino male nurse initially consulted at the emergency room due to progressive diffuse headache, with associated localized seizures progressing to generalized tonic clonic seizure and arrhythmia. He had no coryza, cough, sore throat, and diarrhea. He was previously well and had no known co-morbidities or direct exposure to confirmed COVID-19 patients. Physical examination showed elevated blood pressure, tachycardia, and sensory and motor deficits in the left upper and lower extremities. Pertinent diagnostic test results included the detection of SARS-CoV-2 viral RNA via RT-PCR. Imaging studies demonstrated cortical venous thrombosis with hemorrhagic venous infarction in the right parietal lobe. Ground glass appearance on the middle lobe of the left lung was also evident. ECG showed supraventricular tachycardia. Prothrombin time, activated partial thromboplastin time, and D-dimer were all within the normal limits. Carotid massage was done. He was treated with anti-epileptics, anticoagulants, antiarrhythmics, antivirals, antibiotics, and supportive management. During the hospital stay, his symptoms resolved; he was discharged after 21 days. Follow-up done after 3 weeks revealed no recurrence of severe headache, seizure, or tachycardia. It is theorized that an interplay exists between ACE-2 tropism, systemic inflammation, cytokine storm, and hypoxemia in the background of COVID-19 infection. These mechanisms may lead to thrombosis and arrhythmia resulting to neurologic derangements and myocardial injury. Underlying mechanisms make the cerebro-cardiovascular systems vulnerable to the coronavirus disease 2019 infection. COVID-19 should therefore be part of the differential diagnoses in patients presenting with headache, seizures, and arrhythmias.

Crioablación en taquicardia ortodrómica por vía accesoria oculta parahisiana: caso clínico y revisión de la literatura / Crioablation of orthodromic supraventricular tachycardia win an occult accessory pathway

Abstract An 18-year-old woman with recurrent tachycardia was shown to have orthodromic supraventricular tachycardia through an antero-septal occult pathway near the His. Cryoablation was selected to avoid A-V block. The accesory pathway was finally interrupted after 360 sec of cryoablation. No recurrence was documented after a 12 month follow-up

Bloqueo de rama alternante en una taquicardia supraventricular: ¿Cuál es el mecanismo subyacente? / Alternating bundle branch block in a supraventricular tachycardia: Which is the mechanism ?

El bloqueo de rama funcional durante una taquicardia supraventricular puede ser observado con longitudes de ciclo cortas y representa una respuesta fisiológica del sistema de conducción intraventricular por la existencia de conducción nodal auriculo ventricular acelerada. Presentamos el caso de un paciente joven con taquicardia reentrante aurículo-ventricular ortodrómica y bloqueo de rama alternante. Esta respuesta infrecuente se explica por el hallazgo obtenido durante el estudio electrofisiológico. Una conducción nodal aurículo-ventricular acelerada produce un frente de onda que despolariza las ramas durante sus períodos refractarios. Una vez que ocurrió el bloqueo en una de las ramas, dicho bloqueo persistió debido al fenómeno de linking, que es por conducción oculta retrógrada repetitiva de la rama contralateral. Después de la ablación transcatéter de una vía accesoria oculta lateral izquierda, el marcapaseo auricular rápido a la misma longitud de ciclo de la taquicardia, reprodujo la misma aberrancia observada durante la taquicardia. Este procedimiento demostró que el bloqueo de rama funcional fue debido a la longitud de ciclo corto y no a la presencia de una vía accesoria aurículo-ventricular.

Functional bundle branch block during a supraventricular tachycardia can be observed with shorter cycle lengths and represent a physiologic response by the specialized intraventricular conduction system to accelerated AV nodal conduction. The present case corresponds to a young patient with exercise induced orthodromic A-V reentrant tachycardia and alternating bundle branch block. This unusual response is explained by the finding obtained during the electrophysiology study. An accelerated AV nodal conduction made the depolarizing wave front reach the bundle branches during their refractory period. Once block in one bundle was stablished, block persisted due to the linking phenomenon that is repetitive retrograde concealed conduction from the contralateral bundle. After catheter ablation of a concealed left-sided accessory A-V pathway, rapid atrial pacing at the same cycle length of the tachycardia reproduced the same aberrancies observed during tachycardia. This response proved that functional bundle branch block is due to the short cycle length and not the presence of an accessory A-V pathway.

Assessing Accuracy of Wrist-Worn Wearable Devices in Measurement of Paroxysmal Supraventricular Tachycardia Heart Rate

BACKGROUND AND OBJECTIVES: Wrist-worn wearable devices provide heart rate (HR) monitoring function via photoplethysmography technology. Recently, these devices have been used by patients to measure the HR when palpitation occurs, but few validation studies of these instruments have been conducted. We assessed the accuracy of these devices for measuring a HR. METHODS: This study enrolled 51 consecutive patients with a history of paroxysmal supraventricular tachyarrhythmia (SVT) or paroxysmal palpitations who were scheduled to undergo an electrophysiological study (EPS). Three devices were assessed: Apple Watch Series 2 (Apple), Samsung Galaxy Gear S3 (Galaxy), and Fitbit Charge 2 (Fitbit). Patients were randomly assigned to wear 2 different devices. The HR at baseline and induced SVT were measured during the EPS. After successful ablation of SVT, HR measurements was also done during atrial and ventricular pacing study. RESULTS: The mean patient age was 44.4±16.6 years and 27 patients were male (53%). The accuracy (within ±5 beats per minute [bpm] of an electrocardiogram [ECG] measurement) of the baseline HR measurements was 100%, 100%, and 94%, for Apple, Galaxy, and Fitbit, respectively. The HR during induced SVT ranged from 108 bpm to 228 bpm and the accuracy (within ±10 bpm of an ECG) was 100%, 90%, and 87% for the Apple, Galaxy, and Fitbit, respectively. During pacing study, accuracy of these devices was also acceptable but tended to decrease as the HR increased, and showed differences between the devices. CONCLUSIONS: Wrist-worn wearable devices accurately measure baseline and induced SVT HR. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0002282