Pressure-Guided cryoablation of pulmonary veins in atrial fibrillation: A fast and effective strategy.

BACKGROUND: Cryoballoon ablation of atrial fibrillation (AF) involves successful electrical pulmonary vein isolation (PVI). Pulmonary vein (PV) ostial occlusion with cryoballoon is classically assessed using PV angiography. A pressure-guided technique to assess ostial occlusion has been evaluated in small cohorts with mixed results. We evaluated the efficacy of this pressure-guided PVI technique and its impact on reducing contrast and fluoroscopy time as compared to the traditional approach. METHODS: We evaluated patients with paroxysmal AF, who underwent cryoballoon PVI. Patients prior to January 20th, 2013 underwent confirmation of PV occlusion by angiography only. Patients ablated after this time had PV occlusion initially determined by pressure monitoring and further confirmed by contrast injection into the PV in most cases (Pressure-guided PVI). Differences in the volume of contrast used and fluoroscopy time were evaluated. RESULTS: 46 patients had pressure-guided PVI and29 patients had occlusion of PV confirmed by angiography alone. Pressure-guided PVI was 99.5% successful in ablating AF, which was non-inferior to traditional method of PV isolation. This technique used an average of 8cc of contrast and 21.5min of fluoroscopy time, which was significantly less than the contrast amount used, and fluoroscopy time with angiographic isolation of PV. CONCLUSION: Pressure-guided PVI is an effective method for cryoablation of AF. This method not only significantly reduces the volume of contrast used but also decreases the fluoroscopy without compromising the success of PVI.

Bradycardia during Transradial Cardiac Catheterization due to Catheter Manipulation: Resolved by Catheter Removal.

Purpose. To report the resolution of bradycardia encountered during transradial cardiac catheterization through the catheter pullback technique in two cases. Case Report. A 62-year-old male and an 81-year-old male underwent coronary angiogram to evaluate for coronary artery disease and as a result of positive stress test, respectively. Upon engagement of the FL 3.5 catheter into the ascending aorta through the transradial approach, the first case developed bradycardia with a heart rate of 39 beats per minute. The second case developed profound bradycardia with a heart rate of 25 beats per minute upon insertion of the 5 Fr FL 3.5 catheter near the right brachiocephalic trunk through the right radial access. Conclusion. Bradycardia can be subsided by removal of the catheter during catheter manipulation in patients undergoing transradial coronary angiogram if there is a suspicion of excessive stretching of aortic arch receptors and/or carotid sinus receptors.

An Unusual Presentation of an Unusual Disease: Spontaneous Pneumomediastinum.

We report a case of spontaneous pneumomediastinum with unusual clinical presentation. The most common symptoms of spontaneous mediastinum are chest pain and shortness of breath. Our patient presented with neck swelling and change in voice, an unusual presentation for spontaneous pneumothorax. A 30-year-old previously healthy man presented with complaints of neck swelling and hoarseness of voice beginning after an intense coughing spell. He had no other complaints. He denied any trauma to the chest, nausea, vomiting, recent air travel, scuba diving or recreational drug use. His vital signs were stable with an O2 saturation of 97 percent on room air. Chest examination was remarkable for palpable crepitus over lower neck as well as bilateral upper and mid anterior chest. Chest radiograph as well as chest computed tomography (CT) demonstarted a massive pneumomediastinum with free air dissecting throughout the soft tissues of the neck. The patient was admitted for observation. Neck swelling and hoarseness of voice resolved in less than 24 hours with conservative management of cough. He was discharged without incident. Spontaneous pneumomediastinum is an uncommon, self-limiting condition in which air is present in the mediastinum with no obvious precipitating factor. Cough, inhaled drugs, physical exercise, labor, and diabetic ketoacidosis have been reported to trigger spontaneous pneumomediastinum. Our patient developed the condition after an intense coughing spell following smoking cessation. CT scan is considered gold standard for the diagnosis. Spontaneous pneumomediastinum is characterized by spontaneous recovery and can be treated with short period of observation and symptomatic management.