Slow pathway catheter ablation of atrioventricular nodal re-entrant tachycardia guided by electroanatomical mapping: a randomized comparison to the conventional approach.

BACKGROUND: Electroanatomical mapping may be expected to improve safety, efficiency and efficacy of selective slow pathway ablation for atrioventricular nodal re-entrant tachycardia (AVNRT). The goal of this prospective randomized study was to compare the efficiency of conventional fluoroscopic and electroanatomical mapping in guiding catheter ablation of AVNRT. METHODS AND RESULTS: Following induction of typical AVNRT, 20 consecutive patients were randomized to either conventional fluoroscopic or electroanatomical (CARTO) mapping to guide slow pathway ablation using a 4mm electrode. Endpoints for ablation were non-inducibility and no more than a single AV nodal echo on aggressive retesting. Acute procedural success was 100% in both groups, with no complications. Although there were no differences in time taken for pre- and post-ablation electrophysiological evaluations, in the electroanatomical group the ablation portion of the procedure showed a substantial reduction in duration (12.6+/-6.8 vs 35.9+/-18.3 min; P< 0.001) and fluoroscopic exposure (0.7+/-0.5 vs 9.6+/-5.0 min; P< 0.001) compared with the fluoroscopic group, reflected in reduced total procedure time (83.6+/-23.6 vs 114+/-19.3 min; P=0.008) and total fluoroscopic exposure (4.2+/-1.4 vs 15.9+/-6.4 min; P< 0.001). Electroanatomical mapping was associated with a lower number (2.7+/-1.6 vs 5+/-2.8; P=0.018), duration (165.3+/-181.6 vs 341+/-177.7s; P=0.013), and total energy delivery (24.3+/-3.1 vs 28.7+/-4.5 watts; P=0.042) of RF applications. There were no acute or long-term (8.9+/-2.2 month) complications or arrhythmia recurrence in either group. CONCLUSIONS: While both conventional and non-fluoroscopic electroanatomical mapping are associated with excellent results in guiding ablation of typical AVNRT, the latter offers significantly shorter procedure and fluoroscopy times, improving the efficiency of the procedure and reducing X-ray exposure.

Clinical significance of syncope in the electrophysiologic study versus electrocardiographic monitoring (ESVEM) trial. The ESVEM Investigators.

BACKGROUND: Syncope may portend risk of death, but which patients with syncope are at high risk remains unclear. OBJECTIVE: The ESVEM trial, a multicenter randomized prospective trial, provided the opportunity to compare mortality rates of patients enrolled with syncope to those enrolled with spontaneous ventricular arrhythmias. METHODS: Patients enrolled in the ESVEM trial presenting with syncope alone (25 patients) or in combination with ventricular tachycardia (24 patients) were compared with patients with spontaneous ventricular tachycardia alone (332 patients) or ventricular fibrillation (105 patients). All patients had ventricular tachyarrhythmias induced at electrophysiology testing of >/=10 premature ventricular complexes per hour on Holter monitor. RESULTS: Of all patients randomly assigned, arrhythmic death and total mortality rates were the same for those with syncope alone, with ventricular tachycardia and syncope, with ventricular tachycardia alone, or with ventricular fibrillation. At 1 year, arrhythmic and total mortality rate for all patients was 21% and 24%, respectively; for patients with syncope alone, 30% and 29%, respectively (P = NS). At 4 years, arrhythmic death and total mortality rate for all patients was 33% and 42%, respectively; for patients with syncope alone, 37% and 42%, respectively (P = NS). CONCLUSION: Syncope, associated with induced ventricular tachyarrhythmias at electrophysiologic testing, indicates high risk for death, similar to that of patients with documented spontaneous ventricular tachyarrhythmias.

Teletronics 330-801 atrial lead extraction via the subclavian approach.

BACKGROUND: The Telectronics 330-801 atrial J (801) lead was recalled after reports implicated lead fracture/retention wire protrusion in patient mortality and morbidity. Recent reports suggest that 801 lead extraction may be associated with substantial morbidity and, possibly, excess mortality. We hypothesized that the 801 lead could be extracted using the subclavian approach with a high success rate and acceptable morbidity. METHODS: We analyzed the clinical outcomes in 60 consecutive patients who underwent 801 lead extraction. RESULTS: Sixty patients (34 women) with a mean age of 67 +/- 14.8 years had 18 class I, 13 class II, and 29 class III fractures. The lead age was 39 +/- 17 months. The subclavian approach was successful in 58 of 60 patients (96%). Complications, three major and eight minor, occurred in 10 of 60 patients (16%). All complications were successfully treated. There were no deaths. Only concurrent ventricular lead extraction was associated with complications (p = 0.008 by Fisher's exact test). CONCLUSIONS: Telectronics 801 leads can be successfully extracted using the subclavian approach with acceptable short-term morbidity, low mortality, and excellent long-term results.

Post-traumatic pseudoaneurysm of the ascending aorta--an incidental finding two decades later.

Traumatic rupture of the aorta following blunt trauma is a well described entity. Rupture of the ascending aorta is frequently associated with concomitant cardiac damage and immediate death with few long-term survivors described in the literature. A case of traumatic pseudoaneurysm of the ascending aorta discovered two decades after the initial injury is reported.