[Surprising mechanism of highly symptomatic tachycardia in a young patient : Diagnosis and treatment]. / Überraschender Pathomechanismus hochsymptomatischer Tachykardien bei einem jugendlichen Patienten : Diagnostik und Therapie.

The diagnosis of paroxysmal tachycardia can be challenging in clinical practice because even with a typical patient history including palpitations, tachycardia, and an on/off phenomenon, 24 h Holter monitoring frequently fails to document the tachycardia. After unsuccessful 24 h Holter monitoring, we managed to document a very fast wide QRS complex tachycardia in a young patient by a mobile portable event monitor. Subsequent invasive electrophysiologic diagnostics followed by catheter ablation clarified the tachycardia mechanism and led to permanent elimination of the tachycardia.

Effect of transcoronary ablation of septal hypertrophy on clinical outcome in hypertrophic obstructive cardiomyopathy associated with atrial fibrillation.

BACKGROUND: Relatively few reports on the clinical impact of atrial fibrillation (AF) in hypertrophic obstructive cardiomyopathy (HOCM) are available. The aims of our study are to report the effect of transcoronary ablation of septal hypertrophy (TASH) on clinical outcome in HOCM associated with AF and to evaluate the influence of AF on symptoms and quality of life in HOCM. PATIENT AND METHODS: In 80 consecutive patients (38 f, mean age 56 +/- 17 years) with severely symptomatic HOCM referred for interventional treatment, we analyzed the prevalence of AF based on 240 Holter ECG recordings and patients' history, retrospectively. Symptoms, quality of life, number of hospital admissions and hemodynamic performance were obtained in all patients before and after TASH. Mortality was additionally investigated by letter and telephone contact. RESULTS: The overall prevalence of AF was 29%. Paroxysmal AF was detected in 17 pts (21.3%), persistent AF in 5 pts (6.3%). Only 1 pt (1.3%) suffered from permanent AF. Symptoms due to AF were present in 52.6% of the AF patients. Quality of life score was markedly improved after TASH (15.9 +/- 3.8 vs. 20.7 +/- 3.8, p < 0.001) with no difference between sinus rhythm and atrial fibrillation. However, hospital admissions were more frequent in the AF group (0.85 +/- 1.84 vs. 0.28 +/- 0.81, p = 0.03) in 32 +/- 13 months. AF patients suffered more often from syncope before TASH (30 +/- 70% vs. 10 +/- 30%, p = 0.008). Two patients with sinus rhythm at baseline died after 32 +/- 13 months from cardiovascular cause. CONCLUSIONS: Atrial fibrillation is the major cardiac arrhythmia in severe HOCM. The majority of AF patients demonstrate AF specific symptoms. The paroxysmal type of atrial fibrillation dominates by far. Both patients with and without atrial fibrillation showed similar quality of life with marked improvement after TASH.

Transcoronary ablation of septal hypertrophy for hypertrophic obstructive cardiomyopathy: feasibility, clinical benefit, and short term results in elderly patients.

OBJECTIVE: To evaluate symptomatic and haemodynamic results of transcoronary ablation of septal hypertrophy for hypertrophic obstructive cardiomyopathy in elderly patients. SETTING: Tertiary referral centre for patients with hypertrophic obstructive cardiomyopathy. DESIGN: Retrospective study of two groups of consecutive patients divided at a median age (59 years). PATIENTS: Transcoronary ablation of septal hypertrophy was compared for 80 patients (group 1) < 60 years of age and 77 patients (group 2) > or = 60 years of age. At baseline both groups were similar concerning the proportion of familial hypertrophic cardiomyopathy, concomitant moderate hypertension, prior syncope, left ventricular outflow obstruction, left ventricular end diastolic pressure, and left ventricular ejection fraction. Patients in group 2 had a lower interventricular septal thickness and more severe disease as measured by New York Heart Association (NYHA) functional class, exercise capacity, pulmonary artery mean pressure at workload, and cardiac index at peak exercise. RESULTS: Median follow up was seven months after transcoronary ablation of septal hypertrophy. Both groups had a significant and similar improvement in basal and provokable obstruction, septal thickness, NYHA functional class, exercise tolerance, peak oxygen consumption, and pulmonary artery mean pressure at workload. Significant differences, compared with the younger group, were a higher proportion of persistent total atrioventricular block (5% v 17%, p = 0.015) and a slight decrease in left ventricular ejection fraction (3 (12) v -6 (11)%, p = 0.001) in the elderly, despite a trend to a lower induced peak creatine kinase activity (596 (339) v 491 (331) U/l, p = 0.051). CONCLUSIONS: Short term results with transcoronary ablation of septal hypertrophy suggest that independent of a patient's age similar treatment strategies are justified in hypertrophic obstructive cardiomyopathy.

Transcoronary ablation of septal hypertrophy (TASH): a new treatment option for hypertrophic obstructive cardiomyopathy.

In 1991, our group started to develop a catheter interventional therapy for hypertrophic obstructive cardiomyopathy (HOCM). The new concept was proposed in 1994. It is based on the conventional PTCA technique with the aim of inducing an artificial myocardial infarction by instillation of 96% ethanol into the most proximally situated septal branch of the left anterior descending coronary artery. This leads to a subaortic contraction disorder with subsequent decrease of the intraventricular pressure gradient, shrinkage of the hypertrophied septal bulge and widening of the outflow tract ("therapeutic remodeling"). The subaortic defect is small and well demarcated as assessed by left ventricular angiography, transesophageal echocardiography and 18 F-glucose positron emission tomography. The term transcoronary ablation of septum hypertrophy (TASH) was suggested. Our patient cohort that now comprises 215 therapeutic procedures in 187 patients underwent a large variety of prospective studies (maximum follow-up 4.5 years) including invasive controls at regular intervals, investigation of hemodynamics at rest and at exercise, transesophageal and transthoracic echocardiography, Doppler echocardiography during bicycle exercise, electrophysiologic testing, Holter monitoring and measurement of myocardial metabolism and perfusion, assessment of microembolic events by transcranial Doppler sonography and histological examinations. This article gives an overview and reports our increasing experience in applying TASH. The following post-TASH findings were obtained: significant hemodynamic and clinical improvement at rest and at exercise, decrease of septum thickness, increase of outflow tract area and decrease of induced ventricular tachycardia. There were well-demarcated, histologically atypical subaortic myocardial defects, no microembolic events, abnormal early peak of infarct related enzymes, and no change of baroreflex sensitivity. Pre-/post-TASH evaluations of the patients should be based in particular on clinical symptoms correlated to the intraventricular gradient measured by bicycle exercise Doppler echocardiography and to outflow tract area as assessed by transesophageal echocardiography. Since 1994, as a roughly estimate, worldwide 1000 patients in 20 countries have been treated. According to published articles, abstract presentations and workshops, TASH consistently leads to a pronounced clinical and hemodynamic benefit for patients with HOCM. TASH has become an established technique. At least in centers with a high level of expertise, it is no longer experimental but a routinely performed alternative to surgical treatment for HOCM, i.e., the previous gold standard of therapy. Of course, patient outcome needs further careful clinical and prognostic evaluation. With respect to complications, TASH appears to be superior to surgery (transaortic septal myectomy) for HOCM. Like surgical treatment, TASH is currently indicated in critically ill patients with typical HOCM (subaortic form), who exhibit with drug refractory symptoms, including patients, who preferred DDD pacemaker therapy as a first therapeutic step but in whom this produced no subsequent clinical benefit.

[Typical AV nodal reentry tachycardia in 4 anterograde AV nodal pathways. Successful high frequency ablation of slow AV nodal pathways]. / Typische AV-Knoten-Reentry-Tachykardie bei vier antegrad leitenden AV-Knoten-Bahnen. Erfolgreiche Hochfrequenzablation der langsamen AV-Knoten-Bahnen.

CASE REPORT: A 26-year-old patient was referred to our department for electrophysiologic evaluation of recurrent paroxysmal tachycardias with narrow QRS-complexes (< 120 ms). Three jumps in the AV-nodal conduction curve were detected during programmed atrial extrastimulation in sinus rhythm and at a cycle length of 600 ms indicating of 4 antegrade conducting AV-nodal pathways. After intravenous application of orciprenaline an AV-nodal re-entrant-tachycardia (AVNRT) of the common type was induced with a cycle length of 290 ms. During tachycardia, antegrade conduction occurred via one of the slow conducting pathways, retrograde conduction via the fast pathway ("slow-fast"-AVNRT). Application of radiofrequency energy was able to ablate all slowly conducting AV-nodal pathways at one site in the infero-posterior region of Koch's triangle. During control stimulation with and without orciprenaline no AH-jump or inducible tachycardia was found. CONCLUSION: This case shows the rare finding of 4 antegrade AV-nodal pathways in a patient with the common type of AVNRT. Application of radiofrequency current was able to ablate all slow conducting AV-nodal pathways successfully.

[ACE inhibitor-associated interstitial lung infiltrates]. / ACE-Hemmer-assoziierte interstitielle Lungeninfiltrate.

HISTORY AND CLINICAL FINDINGS: A 60-year-old woman was prescribed Captopril, 37.5 mg daily, for severe left-ventricular dysfunction with associated mitral regurgitation. Left ventricular function improved markedly in the subsequent 6 months and the mean pulmonary capillary wedge pressure became normal. However, exertional dyspnoea unexpectedly did not improve but rather increased and she also developed severe dry cough. TESTS: The chest radiogram and computed tomography revealed multiple small interstitial infiltrates in both lungs without signs of congestion. Body plethysmography did not demonstrate any obstructive or restrictive ventilatory abnormalities. TREATMENT AND COURSE: When captopril was discontinued, the cough improved and the exertional dyspnoea quickly disappeared without any further treatment. All immunological tests, including those for antibodies against bird antigens and for antinuclear antibodies, were negative. The interstitial infiltrates had already markedly regressed 9 days after captopril had been discontinued and they had disappeared after 2 months. CONCLUSION: This case indicates that angiotensin-converting enzyme inhibitors should be considered as a cause of interstitial pulmonary infiltrates associated with dyspnoea.