Multi atrial maco-re-entry circuits in adults with repaired congenital heart disease: entrainment mapping combined with three-dimensional electroanatomic mapping.

OBJECTIVES: We sought to characterize re-entry circuits causing intra-atrial re-entrant tachycardias (IARTs) late after the repair of congenital heart disease (CHD) and to define an approach for mapping and ablation, combining anatomy, activation sequence data and entrainment mapping. BACKGROUND: The development of IARTs after repair of CHD is difficult to manage and ablate due to complex anatomy, variable re-entry circuit locations and the frequent co-existence of multiple circuits. METHODS: Forty-seven re-entry circuits were mapped in 20 patients with recurrent IARTs refractory to medical therapy. In the first group (n = 7), ablation was guided by entrainment mapping. In the second group (n = 13), entrainment mapping was combined with a three-dimensional electroanatomic mapping system to precisely localize the scar-related boundaries of re-entry circuits and to reconstruct the activation pattern. RESULTS: Three types of right atrial macro-re-entrant circuits were identified: those related to a lateral right atriotomy scar (19 IARTs), the Eustachian isthmus (18 IARTs) or an atrial septal patch (8 IARTs). Two IARTs originated in the left atrium. Radiofrequency (RF) lesions were applied to transect critical isthmuses in the right atrium. In three patients, the combined mapping approach identified a narrow isthmuses in the lateral atrium, where the first RF lesion interrupted the circuit; the remaining circuits were interrupted by a series of RF lesions across a broader path. Overall, 38 (81%) of 47 IARTs were successfully ablated. During follow-up ranging from 3 to 46 months, 16 (80%) of 20 patients remained free of recurrence. Success was similar in the first 7 (group 1) and last 13 patients (group 2), but fluoroscopy time decreased from 60 +/- 30 to 24 +/- 9 min/procedure, probably related to the increasing experience and ability to monitor catheter position non-fluoroscopically. CONCLUSIONS: Entrainment mapping combined with three-dimensional electroanatomic mapping allows delineation of complex re-entry circuits and critical isthmuses as targets for ablation. Radiofrequency catheter ablation is a reasonable option for treatment of IARTs related to repair of CHD.

Entrainment mapping and radiofrequency catheter ablation of ventricular tachycardia in right ventricular dysplasia.

OBJECTIVES: The purpose of this study was to determine if entrainment mapping techniques and predictors of successful ablation sites previously tested in coronary artery disease can be applied to ventricular tachycardia (VT) in arrhythmogenic right ventricular dysplasia (ARVD). BACKGROUND: VT in ARVD has not been well characterized. Reentry circuits in areas of abnormal myocardium are the likely cause, but these circuits have not been well defined. METHODS: Mapping of 19 VTs in 5 patients with ARVD was performed. At 58 sites pacing entrained VT and radiofrequency current (RF) was applied to assess acute termination of VT. RESULTS: Sites classified as exits, central/proximal, inner loop, outer loop, remote bystander and adjacent bystander were identified by entrainment criteria. The reentrant circuit sites were clustered predominantly around the tricuspid annulus and in the right ventricular outflow tract (RVOT). RF ablation acutely terminated VT at 13 sites or 22% of the applications. Of the 19 VTs, eight were rendered noninducible and three were modified to a longer cycle length. In 2 patients ablation at a single site abolished two VTs. CONCLUSION: VT in ARVD shows many of the characteristics of VT due to myocardial infarction. Entrainment mapping techniques can be used to characterize reentry circuits in ARVD. The use of entrainment mapping to guide ablation is feasible.

Radiofrequency catheter ablation of ventricular tachycardia late after myocardial infarction.

Radiofrequency catheter ablation is a promising method for controlling ventricular tachycardia (VT) due to prior myocardial infarction. Limitations of mapping and ablation techniques have largely restricted its use to selected patients who have hemodynamically tolerated sustained monomorphic VT that allows catheter mapping. Multiple monomorphologies of VT, which are usually present, often complicate the ablation procedure and interpretation of ablation effects. Ablation is generally restricted to experienced centers and is usually reserved for patients who have failed other therapies. Despite these difficulties, successful ablation can be life-saving in patients with incessant VT and can markedly improve quality of life with frequent shocks from implantable defibrillators.

Antiarrhythmic drug therapy in the management of atrial fibrillation.

Antiarrhythmic drugs have been used for the acute conversion of atrial fibrillation to sinus rhythm, as well as for the long-term maintenance of sinus rhythm. In recent years, concerns regarding antiarrhythmic drug efficacy as well as safety have prompted a re-examination of the indications for antiarrhythmic therapy in patients with atrial fibrillation. This review will focus on the safety and efficacy of antiarrhythmic therapy in the acute and chronic management of patients with atrial fibrillation.

The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia.

OBJECTIVES: We sought to determine the prognostic value of the admission electrocardiogram (ECG) in patients with unstable angina and non-Q wave myocardial infarction (MI). BACKGROUND: Although the ECG is the most widely used test for evaluating patients with unstable angina and non-Q wave MI, little prospective information is available on its value in predicting outcome in the current era of aggressive medical and interventional therapy. METHODS: ECGs with the qualifying episode of pain were analyzed in patients enrolled in the Thrombolysis in Myocardial Ischemia (TIMI) III Registry, a prospective study of patients admitted to the hospital with unstable angina or non-Q wave MI. RESULTS: New ST segment deviation > or = 1 mm was present in 14.3% of 1,416 enrolled patients, isolated T wave inversion in 21.9% and left bundle branch block (LBBB) in 9.0%. By 1-year follow-up, death or MI occurred in 11% of patients with > or = 1 mm ST segment deviation compared with 6.8% of patients with new, isolated T wave inversion and 8.2% of those with no ECG changes (p < 0.001 when comparing ST with no ST segment deviation). Two other high risk groups were identified: those with only 0.5-mm ST segment deviation and those with LBBB, whose rates of death or MI by 1 year were 16.3% and 22.9%, respectively. On multivariate analysis, ST segment deviation of either > or = 1 mm or > or = 0.5 mm remained independent predictors of death or MI by 1 year. CONCLUSIONS: The admission ECG is very useful in risk stratifying patients with non-Q wave MI. The new criteria of not only > or = 1-mm ST segment deviation but also > or = 0.5-mm ST segment deviation or LBBB identify high risk patients, whereas T wave inversion does not add to the clinical history in predicting outcome.

Removal of the protruding retention wire via a femoral approach while leaving the active-fixation atrial "J" lead in situ: a technique for the management of class III atrial "J" leads.

The Telectronics Accufix Atrial "J" pacing lead poses a mechanical risk to patients of retention wire fracture and protrusion. Standard lead extraction techniques include percutaneous approaches, which are associated with significant risk of morbidity and mortality, and open procedures, which necessitate thoracotomy. In nine patients referred with Class III retention wire fractures, attempts were made to snare the protruding retention wire from a femoral approach using snare devices and bioptomes. In six cases, the retention wire was successfully removed, leaving the lead body in place. In four patients with lead function that was able to be evaluated, the atrial lead remained functional after the procedure. There were no complications. Snare removal of the protruding retention wire via a femoral approach should be considered as an option in the management of patients with Class III Accufix leads.