Late elimination of challenging idiopathic ventricular arrhythmias originating from left ventricular summit by anatomical ablation.

Ablation of premature ventricular complexes (PVCs) originating from left ventricular outflow tract (LVOT)/left ventricular summit (LVS) is challenging with considerable rate of failure. Recently, in a novel approach to ablation of these arrythmias, application of radiofrequency energy to anatomically opposite sites of presumed origin of arrythmia, has been associated with moderate procedure success. Although late elimination of PVCs that are persistent following an ablation procedure has been previously reported, this observation has not been studied sufficiently. In this report, firstly, we present three cases of lately eliminated LVS PVCs, then, we discuss possible mechanism of this observation and conclude that after an initial failed attempt of anatomic ablation, operators may choose a period of watchful waiting before attempting a redo procedure.

Effect of radiofrequency on epicardial myocardium after ablation of ventricular arrhythmias from within coronary sinus.

BACKGROUND: Radiofrequency (RF) ablation of idiopathic ventricular arrhythmias (IVA) from the coronary venous system (CVS) has been increasingly performed, but real effect of ablation lesions from CVS on epicardial myocardium has not been studied. OBJECTIVE: To compare effects of RF delivered inside the distal CVS during ablation of IVAs originating from left ventricular summit (LVS) with IVAs ablated from right ventricular outflow tract (RVOT) using cardiac magnetic resonance imaging (CMRI). METHODS: Twenty consecutive patients with IVAs who underwent acutely successful RF ablation at initial appropriate sites, i.e., distal CVS (Group 1, n = 10) or RVOT (Group 2; n = 10) were enrolled. Detailed contrast-enhanced CMRI of each patient was performed 3 months later. Presence and location of scars, distance of CVS to epicardial ventricular myocardium were measured and analyzed. RESULTS: Group 1 consisted of 10 and Group 2 consisted of 10 patients. Three months after the ablation, only three patients in Group 1 had detectable late gadolinium enhancement (LGE) on CMRI while nine out of 10 patients in Group 2 had evident LGE on CMRI (P: 0.02). The mean distance of distal CVS to epicardial anterobasal myocardium was measured to be 8.8 ± 1.6 mm in Group 1. In three cases that had detectable scar on superior anterobasal LV epicardium, the mean distance was 7.4 ± 1.1 mm. CONCLUSIONS: RF delivery inside the CVS is less likely to produce detectable LGE on CMRI compared to RVOT. This may partially explain less than ideal long-term results after ablation of LVS IVAs from within the great cardiac vein/anterior interventricular vein.

Ablation of parahisian premature ventricular extrasystoles by subtricuspid retrograde approach using inverted catheter technique: back to the anatomy.

This report illustrates a feasible and anatomical solution aiming to improve the success and decrease the possible hazards such as atrioventricular block during ablation of parahisian PVCs. We tried to illustrate the specific anatomy pertaining parahisian region and to explain a retrograde subvalvular catheter technique to overcome these procedural obstacles.

Total blush score: a new index for the assessment of microvascular perfusion in idiopathic dilated cardiomyopathy.

BACKGROUND: The aim of this study was to evaluate tissue-level perfusion in patients with idiopathic dilated cardiomyopathy (IDC), using the myocardial blush grade technique. METHOD: The study population consisted of 26 prospectively enrolled IDC patients (15 women and 11 men; mean age, 59+/-8.8 years) and 26 control subjects (11 women and 15 men; mean age, 54.9+/-10.6 years), whose angiographic films were technically adequate for myocardial blush grade analysis. After grading, we measured total blush score (TBS) for both groups. TBS was determined as the sum of the blush grades of each coronary territory. RESULTS: A total of 156 coronary territories in both groups were assessed. Average of TBS was significantly lower in patients with IDC than in control group (7.6+/-1.2 vs. 8.8+/-0.4; P<0.0001). The TBS significantly and inversely correlated with New York Heart Association class, heart rate, left ventricular end-systolic dimension, and left ventricular end-diastolic pressure, and positively correlated with left ventricular ejection fraction (r=-0.76, P<0.001; r=-0.61, P=0.001; r=-0.77, P<0.0001; r=-0.68, P<0.0001; and r=0.67, P<0.0001, respectively). CONCLUSION: In IDC, decreased TBS might be assumed to be a surrogate marker for a diseased microvascular network in the catheterization laboratory. The relationship between reduced TBS and IDC severity suggests that this index might have prognostic significance.

The association of elevated white blood cell count and C-reactive protein with endothelial dysfunction in cardiac syndrome X.

BACKGROUND: The aim of the study is to evaluate the association of inflammatory markers with endothelial function in syndrome X. METHODS: The study population consisted of 59 prospectively enrolled patients (28 women and 31 men; mean age, 50.29 +/- 6.48 years) and 51 healty control subjects (18 women and 33 men; mean age, 51.04 +/- 7.25 years). High-sensitive CRP (hs-CRP), white blood cell (WBC) count and its subtypes [neutrophil (N), lymphocyte (L) and monocyte (M)] were measured in each subject. Endothelial function was assessed with the brachial artery flow-mediated dilatation (FMD) technique. RESULTS: WBC counts and hs-CRP levels were significantly higher in patients who had syndrome X than in control subjects (7.53 +/- 1.52 x 10(9) cells/L versus 6.21 +/- 1.17 x 10(9) cells/L, P = 0.0001, and 3.11 +/- 0.63 mg/L versus 2.68 +/- 0.76 mg/L, P = 0.002, respectively). Neutrophil count and N/L ratio was significantly increased in syndrome X when compared with the control subjects (5.14 +/- 1.10 x 10(9) cells/L versus 4.11 +/- 0.76 x 10(9) cells/L, P = 0.0001 and 2.75 +/- 1.06 versus 2.37 +/- 0.65, P = 0.02, repectively). Other subtype counts were similar between the groups. FMD was impaired significantly in patients who had syndrome X in comparison with the control subjects (5.71 +/- 4.08% versus 16.02 +/- 4.13%, P = 0.0001). There was a significant correlation between hs-CRP levels and FMD measurements (r = -0.44; P = 0.0001). Furthermore, the correlation between WBC count and FMD measurements were also significant (r = -0.48; P = 0.0001). CONCLUSIONS: The present study showed that hs-CRP and WBC count were higher in patients with syndrome X than in control subjects. Furthermore, endothelial function was impaired significantly in patients with syndrome X.The increased levels of hs-CRP and WBC count may suggest that these markers may be used in clinical practice for the assessment of the inflammatory status of the endothelium in syndrome X.

The effect of high-dose aspirin pre-treatment on the incidence of myonecrosis following elective coronary stenting.

BACKGROUND: Inadequate platelet response to aspirin is associated with increased incidence of peri-procedural myonecrosis. Antiplatelet activity of aspirin can be improved by increasing the dose. High-dose aspirin pre-treatment, therefore, may reduce the incidence of myonecrosis post stenting. METHODS AND RESULTS: Two-hundred patients taking 75-325 mg daily doses of aspirin for at least 2 weeks were randomized for addition or no addition of 500 mg aspirin before elective coronary stenting (aspirin 500 group, n=100 and control group, n=100). Primary endpoint was the occurrence of peri-procedural myonecrosis defined as creatine kinase-myocardial band (CK-MB) elevation of >1x upper limits of normal (ULN). Aspirin 500 patients were significantly younger and more likely to have family history of coronary artery disease, but less likely to have received statins than controls. Elevation of CK-MB was observed in 29% of aspirin 500 patients and 15% of controls (p=0.017). The incidence of non-Q wave myocardial infarction (CK-MB elevation of >3xULN) tended to be higher in the aspirin 500 group than in the control group (5% versus 0%, p=0.059). Multivariate analysis identified baseline aspirin dose (OR: 1.006; 95% CI: 1.002-1.010; p=0.004), aspirin 500 mg treatment (OR: 2.5; 95% CI: 1.2-5.5; p=0.021) and baseline CK-MB level (OR: 1.4; 95% CI: 1.1-1.7; p=0.012) as independent predictors of CK-MB elevation after coronary stenting. CONCLUSION: For patients taking daily low-dose aspirin therapy, supplementation with high-dose aspirin before elective coronary stenting does not reduce, but may increase the incidence of peri-procedural myonecrosis.