Safety and efficacy of a nurse-led elective cardioversion with etomidate for atrial arrhythmia in a tertiary hospital.

Management of cardiac arrhythmias often requires direct current cardioversion (DCC) to restore sinus rhythm. This intervention varies greatly between countries and hospitals, mostly regarding the organization of an elective DCC, and the choice of the sedation. The aim of this study is to assess the safety and efficacy of an elective DCC performed in a cardiology day hospital, led by trained nurses, and using intravenous Etomidate as sedation. We performed a retrospective cohort study at a single tertiary hospital in Belgium. Data were collected from January 2017 to October 2020. A total of 788 electrical cardioversions were performed on 574 patients from 2017 to 2020. Age was 70.9 ± 10 years. Restoration of sinus rhythm was obtained in 89.5% of the patients. One (0.1%) patient experienced ischemic stroke within 24 h, despite adequate anticoagulation. There were 4 (0.5%) cases of transient sinus arrest requiring atropine. Three patients (0.4%) experienced respiratory depression, requiring bag-mask ventilation but not oro-tracheal intubation. There were no cases of hypotension. No periprocedural death was reported. In conclusion, an elective electrical cardioversion performed and led by trained nurses, using Etomidate as sedation, appears to be both safe and effective.

An atypical evolution of tako-tsubo cardiomyopathy.

An 83-year-old woman with a possible history of myocardial infarction presented with acute chest pain and dyspnoea. The electrocardiogram showed no signs of acute coronary syndrome, but Q waves in the anteroseptal leads. The blood tests showed an important elevation of troponin T level. Emergency coronary angiography revealed normal epicardial arteries, but the left ventriculogram demonstrated anterior akinesis and ballooning with normal apical and basal function. An atypical takotsubo cardiomyopathy was suspected and the patient received beta blocker and ACE inhibitor treatment. Two days later the echocardiogram evolved to a classical pattern of apical ballooning with normalization on the follow-up examination 5 weeks from the acute episode. To our knowledge, this is the first case report describing an evolving pattern of wall motion abnormality from an anterior wall ballooning to an apical form.

Is there a potential benefit to increased irrigation channels during radiofrequency ablation? Results from a two-center prospective randomized study.

INTRODUCTION: Open irrigation during radiofrequency (RF) application allows a higher power delivery in the setting of temperature-controlled ablation, without causing blood clots. This study sought to evaluate the clinical value of the additional 6 supplementary channels at the proximal catheter tip compared to a standard irrigated RF catheter with 6 conventional channels present at the distal tip only. METHODS AND RESULTS: Ninety-five consecutive patients were prospectively randomized to cavotricuspid isthmus ablation using an 3.5 mm tip ablation catheter with 6 distal irrigation channels (6C; 48 patients) or an 4 mm tip ablation catheter with 12 irrigation channels (12C; 47 patients) disposed at the distal (6 channels) and proximal (6 additional channels) catheter tip. There was no significant difference between the 12C and the 6C irrigated-tip catheter concerning the total procedural duration, the RF duration, the fluoroscopic duration, and the amount of irrigation. Conversely, there were significantly more patients who experienced at least one steam pop while using the 12C as compared to the 6C irrigated-tip catheter (0% vs 13%, respectively, P = 0.018). CONCLUSION: The addition of proximal irrigation holes at the catheter tip do not facilitate lesion formation during RF ablation, but significantly increases the risk of steam pop. This is probably the consequence of an increase distortion of the temperature feedback.

Complicated forms of tachycardia-mediated cardiomyopathy associated with idiopathic left ventricular tachycardia.

Idiopathic left ventricular tachycardia is an infrequent form of ventricular tachycardia associated with a structurally normal heart. The prognosis is usually benign; however, sustained cases have been reported. In this report, we describe two cases of persistent idiopathic left ventricular tachycardia complicated by tachycardia-mediated cardiomyopathy. In the first case, the patient developed a right ventricular thrombus with subsequent pulmonary embolism. In the second case, the patient developed acute pulmonary edema. Both cases were cured by catheter ablation.

Ease of using a dedicated percutaneous closure device after inadvertent cannulation of the subclavian artery: case report.

Inadvertent puncture of the subclavian artery is a relatively frequent and potentially disastrous complication of attempted central venous access. Due to its noncompressible location, accidental subclavian arterial cannulation may result in hemorrhage as the sheath is removed. We report a new case of successful percutaneous closure of the subclavian artery which had been inadvertently cannulated, using a closure device based on a collagen plug (Angio-Seal, St. Jude Medical). This was performed in a patient who had received maximal antiplatelet and anticoagulation therapies because of prior coronary stenting in the context of cardiogenic shock. There was no prior angiographic assessment, as arterial puncture was presumed to have been distal to the right common artery and vertebral arteries. No complications were observed in this high-risk patient, suggesting that this technique could be used once the procedure has been evaluated prospectively.

Multidetector 16-slice CT scan evaluation of cavotricuspid isthmus anatomy before radiofrequency ablation.

INTRODUCTION: The anatomy of the cavotricuspid isthmus (CTI) is an important determinant of the ease of radiofrequency ablation. We evaluated the anatomy of the region with a multidetector 16-slice computed tomography (CT) scan and correlated this with subsequent procedural difficulty. METHODS: Twenty-nine patients (mean age 64 +/- 15 years) with typical atrial flutter or paroxysmal atrial fibrillation underwent ablation of the CTI. A multidetector 16-slice CT scan with contrast injection was performed in all before the procedure. RESULTS: The CTI showed marked variability as evidenced by the following measurements: length (8.2 to 32.2 mm), width (26 to 56.5 mm), depth (0 to 11 mm), thickness (0.2 to 7.5 mm), the angle between the inferior vena cava and the CTI (59.9 to 129.5 degrees ), and the length of the Eustachian valve (4.8 to 26.1 mm) present in 72% of patients. The appearance of the CTI was classified as follows into three categories: concave (72%), flat (17%), or with a sub-Eustachian recess (28%). Procedures were classified as difficult in case of failure to achieve bidirectional block or if radiofrequency duration was greater than 99% confidence interval. In the multivariate analysis, a significant correlation was present between the thickness of the CTI and procedural difficulty (p = 0.0005). CONCLUSIONS: The multidetector 16-slice CT scan with contrast injection accurately evaluates the anatomy of the CTI. The only independent anatomic parameter that predicts a more difficult procedure is the thickness of the CTI.