Real-time cardiovascular magnetic resonance-guided radiofrequency ablation: A comprehensive review.

Cardiac magnetic resonance (CMR) imaging could enable major advantages when guiding in real-time cardiac electrophysiology procedures offering high-resolution anatomy, arrhythmia substrate, and ablation lesion visualization in the absence of ionizing radiation. Over the last decade, technologies and platforms for performing electrophysiology procedures in a CMR environment have been developed. However, performing procedures outside the conventional fluoroscopic laboratory posed technical, practical and safety concerns. The development of magnetic resonance imaging compatible ablation systems, the recording of high-quality electrograms despite significant electromagnetic interference and reliable methods for catheter visualization and lesion assessment are the main limiting factors. The first human reports, in order to establish a procedural workflow, have rationally focused on the relatively simple typical atrial flutter ablation and have shown that CMR-guided cavotricuspid isthmus ablation represents a valid alternative to conventional ablation. Potential expansion to other more complex arrhythmias, especially ventricular tachycardia and atrial fibrillation, would be of essential impact, taking into consideration the widespread use of substrate-based strategies. Importantly, all limitations need to be solved before application of CMR-guided ablation in a broad clinical setting.

Transient conduction disturbances acutely after pulsed-field cavotricuspid isthmus ablation: a case report.

Background: Cavotricuspid isthmus pulsed-field ablation has been recently described to be safely performed despite initial reports on coronary arterial spasm while conduction disturbances as a complication of cavotricuspid isthmus ablation are rare and have been reported exclusively for radiofrequency catheter ablation. Case summary: A 64-year-old female patient with mechanical prosthetic valves underwent atrial fibrillation ablation using the pentaspline pulsed-field ablation catheter. At the end of the uneventful pulmonary vein isolation, an atrial tachycardia depended to the cavotricuspid isthmus occurred. A single pulsed-field application at the cavotricuspid isthmus resulted in right bundle branch block combined with posterior fascicular hemiblock and PR prolongation that resolved spontaneously within 12 h. Discussion: This is the first report of transient conduction disturbances as a complication of cavotricuspid isthmus pulsed-field ablation. Although the underlying mechanism, either single or miscellaneous, was not verified, this case highlights that caution should be taken when the pentaspline pulsed-field ablation catheter is used for cavotricuspid isthmus ablation.

Left Axillary Access for Transcatheter Aortic Valve Implantation in a Patient With Two Dependent Internal Mammary Artery Grafts and a Permanent Left-Sided Implanted Pacemaker.

Transfemoral access has been established as the gold standard approach for the majority of patients undergoing transcatheter aortic valve implantation (TAVI). However, in cases with anatomical difficulties or severely diffused peripheral arterial disease, alternative vascular access may be considered such as the transaxillary approach. We present the case of a 92-year-old gentleman with exertional dyspnea due to severe symptomatic aortic stenosis and a history of peripheral femoro-femoral bypass surgery, coronary arterial bypass surgery and a permanent dual-chamber left-side implanted pacemaker. Due to the high surgical risk and the severe anatomical difficulties, the method of TAVI using the left axillary approach was opted. A 14-F vascular sheath was inserted with surgical cutdown and with fluoroscopic guidance while small injections of contrast confirmed the non-occlusive position and the patency of the left internal mammary artery (LIMA) graft. A stiff guidewire was used to cross the heavily calcified aortic valve and subsequently was placed into the left ventricle. Balloon aortic valvuloplasty was performed followed by a successful TAVI with no significant aortic regurgitation or paravalvular leak. The patient recuperated uneventfully and was discharged after 72 h. Axillary access for TAVI is a feasible option for high-risk patients with extended peripheral arteriopathy. To our knowledge this is the first case report describing the implantation of a newer type of intra-annular self-expanding valve platform in a nonagenarian patient with severe comorbidities and such a remarkable history of multiple previous interventions in the selected access site. Meticulous upfront strategy planning and efficient collaboration between specialties is of outmost importance in hybrid procedures for favorable clinical outcomes, especially in cases with challenging anatomies.

Amplified sinus-P-wave analysis predicts outcomes of cryoballoon ablation in patients with persistent and long-standing persistent atrial fibrillation: A multicentre study.

Introduction: Outcomes of catheter ablation for non-paroxysmal atrial fibrillation (AF) remain suboptimal. Non-invasive stratification of patients based on the presence of atrial cardiomyopathy (ACM) could allow to identify the best responders to pulmonary vein isolation (PVI). Methods: Observational multicentre retrospective study in patients undergoing cryoballoon-PVI for non-paroxysmal AF. The duration of amplified P-wave (APW) was measured from a digitally recorded 12-lead electrocardiogram during the procedure. If patients were in AF, direct-current cardioversion was performed to allow APW measurement in sinus rhythm. An APW cut-off of 150 ms was used to identify patients with significant ACM. We assessed freedom from arrhythmia recurrence at long-term follow-up in patients with APW ≥ 150 ms vs. APW < 150 ms. Results: We included 295 patients (mean age 62.3 ± 10.6), of whom 193 (65.4%) suffered from persistent AF and the remaining 102 (34.6%) from long-standing persistent AF. One-hundred-forty-two patients (50.2%) experienced arrhythmia recurrence during a mean follow-up of 793 ± 604 days. Patients with APW ≥ 150 ms had a significantly higher recurrence rate post ablation compared to those with APW < 150 ms (57.0% vs. 41.6%; log-rank p < 0.001). On a multivariable Cox-regression analysis, APW≥150 ms was the only independent predictor of arrhythmia recurrence post ablation (HR 2.03 CI95% 1.28-3.21; p = 0.002). Conclusion: APW duration predicts arrhythmia recurrence post cryoballoon-PVI in persistent and long-standing persistent AF. An APW cut-off of 150 ms allows to identify patients with significant ACM who have worse outcomes post PVI. Analysis of APW represents an easy, non-invasive and highly reproducible diagnostic tool which allows to identify patients who are the most likely to benefit from PVI-only approach.

Cardiac amyloidosis presenting with coronary artery embolization.

Amyloid light-chain (AL) amyloidosis is a multisystemic disease. Among its clinical manifestations, vein and arterial thromboembolic events are included. We report the unusual case of a 57-year-old female patient with AL amyloidosis presenting with an ST segment elevation myocardial infarction due to coronary artery embolization (CE). The patient reported a history of exertional dyspnoea along with episodes of haemoptysis for the last few months. Her coronary angiography demonstrated embolization of the distal segment of the left anterior descending artery. The main findings of her cardiac ultrasound included concentric left ventricular hypertrophy, mildly impaired left ventricular systolic function, left atrium enlargement and a restrictive-like filling pattern, while her chest computed tomography (CT) demonstrated bilateral pleural effusions. Cardiac magnetic resonance imaging that was performed afterwards, indicated areas of microvascular infarction, a small apex infarct and findings compatible with possible amyloidosis, a diagnosis that was confirmed later by fat tissue biopsy. Patient was referred for an oncology consultation, started therapy with direct oral anticoagulants, angiotensin converting enzyme inhibitor, statins and anti-plasma cell therapy. She has been improving since then and has been free of cardiovascular events for a follow-up period of 12 months. Cardiologists ought to be aware of amyloidosis as a rare but possible cause of coronary embolization, while close collaboration with oncologists is required for the establishment of the correct diagnosis.

Vascular Inflammation and Cardiovascular Burden in Metastatic Breast Cancer Female Patients Receiving Hormonal Treatment and CDK 4/6 Inhibitors or Everolimus.

Background: Chemotherapy regimens for breast cancer treatment can promote vascular dysfunction and lead to high cardiovascular risk. Purpose: To investigate the cardiovascular burden and vascular inflammation in metastatic breast cancer patients receiving CDK 4/6 inhibitors or everolimus in addition to standard hormonal treatment. Methods: 22 consecutive female patients with metastatic breast cancer were enrolled. Relative wall thickness (RWT) and left ventricle mass (LVM) measurements by transthoracic echocardiography were obtained followed by 24-h ambulatory blood pressure monitoring, and 18F-fluorodeoxyglucose positron-emission tomography/computed tomography imaging. Uptake of the radiotracer in the aortic wall was estimated as tissue-to-background ratio (TBR). Each patient was assessed for the aforementioned parameters before the initiation and after 6 months of treatment. Results: At follow up, patients assigned to CDK 4/6 treatment demonstrated increased 24-h systolic blood pressure (SBP) (p = 0.004), daytime SBP (p = 0.004) and night time SBP (p = 0.012) (Group effect). The 24-h mean arterial pressure measurements were also higher in CDK 4/6 population, in comparison to everolimus that displayed firm values (Group effect- p = 0.035, Interaction effect-p = 0.023). Additionally, 24 h diastolic blood pressure recordings in CDK 4/6 therapy were higher opposed to everolimus that remained consistent (Interaction effect- p = 0.010). In CDK 4/6 group, TBR aorta also increased significantly, whereas TBR values in everolimus remained stable (Interaction effect-p = 0.049). Both therapeutic regimens displayed statistically significant damaging effect to RWT and LVM. Conclusion: CDK 4/6 inhibitors and hormonal treatment can lead to increased vascular inflammation, and higher blood pressure compared to the combination of everolimus and hormonal treatment. Moreover, both treatment strategies promoted left ventricle remodeling.

Illuminating the Marshall: novel techniques highlighted in an atrial tachycardia case report.

BACKGROUND: Electroanatomic mapping is usually required in order to obtain a precise diagnosis and guide the ablation of atrial tachycardias (ATs) after ablation for atrial fibrillation (AF). However, epicardial connections may limit the interpretation of the endocardial activation sequence as well as the efficacy of endocardial radiofrequency ablation. CASE SUMMARY: A 53-year-old man with history of AF ablation 2 years ago was admitted for ablation of a recurrent AT (cycle length 275 ms). Ultra-high-density mapping with the Rhythmia™ system revealed a challenging activation map with two focal points of early activation in the left atrium. The use of an advanced mapping software allowed the rapid reanalysis and reannotation of the activation map and suggested epicardial involvement of the Marshall bundle (MB). Subsequent ethanol infusion in the vein of Marshall (VOM) immediately terminated the tachycardia. Six months post-ablation, the patient had no recurrence of arrhythmias. DISCUSSION: This case highlights the role of novel diagnostic and treatment methods in the management of a post-AF ablation AT. By developments in cardiac mapping systems, the rapid editing of a high-density activation map and clarification of the arrhythmia origin can be facilitated overcoming the limitations of conventional techniques. Moreover, ethanol infusion in the VOM was shown to be an effective alternative method in the management of MB-related tachycardias.

Activated Clotting Time as a Marker of Inflammation in Hospitalized Patients.

Inflammation and coagulation pathways are implicated in circulatory disease, but their interaction has not been completely deciphered yet. In this study, we investigated the association of coagulation and inflammation indices (activated clotting time [ACT], C-reactive protein, neutrophils) in hospitalized patients. Blood samples were drawn from consecutive patients at admission and at 48 hours for the assessment of the aforementioned parameters (n = 63). Healthy controls matched for sex and age were also examined (n = 39). Activated clotting time positively correlated with CRP on admission (r = 0.354, P = .005), while the correlation was more robust on the second day (r = 0.775, P < .001). Activated clotting time was significantly more prolonged in patients with abnormal CRP or abnormal absolute neutrophil count compared to patients with normal inflammatory markers (U = 55.0, P < .001 and U = 310.5, P = .035, respectively). At 48 hours, a positive relationship was observed between ACT and relative percentage of neutrophils (r = 0.358, P = .004). These findings suggest a link between ACT and inflammation indices for the first time in humans. Further research is needed to determine whether these interrelations can be used to improve patient management.

Electrical Storm: Current Evidence, Clinical Implications, and Future Perspectives.

PURPOSE OF REVIEW: Electrical storm (ES) is a life-threatening medical emergency of repetitive episodes of sustained ventricular arrhythmias within a short period. Its occurrence is associated with poor short- and long-term survival, even in patients with implantable cardioverter defibrillators (ICD). Management of ES is challenging and mainly based on retrospective studies. This article reviews the existing literature on ES, presents the available data regarding its management, and proposes a new algorithm based on current evidence. RECENT FINDINGS: Recent research could modify the management of ES supporting the role of non-selective ß1 and ß2 blockade and the early intervention with catheter ablation as well as strengthening the role of cardiac sympathetic denervation. A multipronged approach should be considered for the management of ES including identification and correction of reversible causes, ICD reprogramming, drug therapy (beta-blockers-especially non-selective ones-and other anti-arrhythmic drugs) and non-pharmacologic therapies such as catheter ablation and techniques of neuroaxial modulation. Although current data suggest early aggressive management, further research is required to clarify the optimal order and combination of therapies for the prevention of future events.

Late T-wave inversion following resolution of non-ischemic acute pulmonary edema.

Electrocardiographic (ECG) changes occurring several hours after the onset of acute cardiogenic pulmonary edema have been seldom described. The proposed explanatory mechanisms are various and not fairly established. In the absence of significant coronary artery disease, these ECG abnormalities could be attributed to mechanisms implicated in coronary microcirculatory dysfunction.

A Recalcitrant Electrical Storm and Implantable Defibrillator Exhaustion: Treatment Implications According to and Beyond Guidelines.

A 60-year-old patient presented with recalcitrant electrical storm (ES). Mild sedation and initial antiarrhythmic combination of esmolol and amiodarone did not affect the intensity of ES, which resulted in battery exhaustion. Oral propranolol in addition to intravenous amiodarone might be preferred in hemodynamically stable patients before interventional therapies. (Level of Difficulty: Intermediate.).

The TyG Index as a Marker of Subclinical Atherosclerosis and Arterial Stiffness in Lean and Overweight Postmenopausal Women.

BACKGROUND: The present study aims to examine the association of the metabolic syndrome (MS) as well as of the triglyceride-glucose index (TyG-Index), a novel marker of insulin resistance, with subclinical atherosclerosis in a cohort of postmenopausal women, stratified according to their body mass index. METHODS: A total of 473 informed-consenting, non-diabetic postmenopausal women, without overt cardiovascular disease, were included in this study. We aimed to compare the association between structural and functional indices of subclinical atherosclerosis (i.e. carotid artery intima-media thickness (IMT), flow-mediated dilation of the brachial artery, pulse wave velocity (PWV)) with the TyG-index or MS, separately for lean and overweight/obese women. RESULTS: The TyG-Index correlated significantly with carotid IMT (r=0.155, p=0.012) and PWV (r=0.157, p=0.013) only in the group of lean women. Multivariate analysis showed that subclinical atherosclerosis was predicted by MS, in the overweight/obese group (OR=2.517, 95% CI: 1.078-5.878, p=0.033), and by the TyG-Index the lean group (OR=3.119, 95% CI: 1.187-8.194, p<0.001). Using a TyG-Index cut-off value of 8.0 in the lean subpopulation, women above the cut-off had 44.1% prevalence of subclinical atherosclerosis compared to 29.4% in women below the cut-off (p=0.043). CONCLUSIONS: The TyG-Index is associated with carotid atherosclerosis and arterial stiffness mainly in lean postmenopausal women, while the MS serves as a better predictor of subclinical atherosclerosis in overweight/obese women. The TyG-Index may prove a useful marker for identifying high-risk women in the normal-weight postmenopausal population.

Pericardial cyst: An unusual cause of chest pain.

Pericardial cysts are uncommon paracardiac lesions, usually located within the right cardiophrenic space. They usually do not cause symptoms and are detected by chance. Chest X-ray, echocardiography, and chest computed tomography or magnetic resonance imaging are useful diagnostic tools. We report a case of a man with symptomatic pericardial cysts of unusual location, review the literature, and discuss the diagnostic approach and treatment options. .

One-hand chest compression and hands-off time in single-lay rescuer CPR-a manikin study.

PURPOSE: To evaluate the effect of one-hand chest compression while continuously maintaining an open airway (OCOA) on rescue breath-associated hands-off time (RAHO) during single-lay rescuer cardiopulmonary resuscitation (CPR). METHODS: In this study, 193 CPR/automated external defibrillator certified lay rescuers were randomly allocated into 2 groups and were tested in a standard scenario using a mannequin. In control group (group A), the participants provided standard CPR. In group B, OCOA was performed by placing the heel of the strong hand in the center of the mannequin's chest while maintaining an open airway using the other hand. RESULTS: Mean RAHO was statistically significantly different between the two groups (group A: 8.38 ± 1.97 vs group B: 7.71 ± 2.43, P = .008). Only 13 (13.5%) group A and 25 (25.8%) group B providers ventilated the manikin with tidal volumes of 500 to 600 mL, while most participants caused hyperventilation. Although there were no significant differences in mean tidal volume between the groups, stomach inflation was greater in group A (< .001). Chest compressions were deeper in group A (P < .001), while chest recoil was significantly better in group B. In group B, there was a positive correlation between body mass index and compression depth (group A, P = .423; group B, P < .001). CONCLUSIONS: In our study, OCOA resulted in shorter RAHO and less stomach inflation. Our results indicate that the airway should be maintained open during chest compressions, regardless of the technique. Larger studies are needed for the full clarification of OCOA.