Simultaneous angiographic imaging of ipsilateral pulmonary veins for catheter ablation of atrial fibrillation.

Various imaging techniques are nowadays in clinical use to obtain important information about pulmonary vein (PV) anatomy in patients undergoing catheter ablation of atrial fibrillation (AF). Although some controversy exists about the optimal approach for catheter ablation of AF in recent times, knowledge of the individual left atrial-PV anatomy remains a basic feature of the different ablational techniques. Angiographic delineation of PV ostia has become an integral part of the PV isolation procedure, mainly in order to avoid potentially harmful PV stenosis. Selective venography with angiocatheters is well documented and widely available but has its own limitations, particularly with respect to visualization of the atriovenous junctions. The present report summarizes the usefulness, safety and feasibility of a new angiographic technique for simultaneous imaging of ipsilateral PVs applicable during catheter ablation of AF. Electrophysiologically guided segmental PV isolation was accomplished in 31 patients mostly with paroxysmal atrial fibrillation, who experienced significant clinical improvement during a followup of 17 +/- 15 months. The angiographic technique was effective for assessment of the individual anatomy including common ostia and supernumerary veins which can be easily missed by selective venography. Variant PV ostia were identified in about 20% of patients; particularly the presence of a left common trunk was challenging for the segmental ablation strategy. Angiographic detection of variant PV anatomy was comparable to visualization with computer tomography performed at 4-months follow-up. Finally, this type of angiographic imaging performed at the time of catheter ablation may help to reduce the risk of significant PV stenosis.

Autonomic epilepsy--the influence of epileptic discharges on heart rate and rhythm.

PURPOSE: To study cardiac alterations (changes in heart rate and cardiac arrhythmias) at the transition from the pre-ictal to the ictal state during focal epileptic seizures. METHODS: We assessed ECG changes during 92 seizures recorded with scalp EEG in 30 patients and 35 seizures in 11 patients evaluated with subdural strip and/or grid electrodes. Consecutive RR intervals were analyzed with a newly developed mathematical model for a total of 90 seconds (60 seconds pre-ictal, 30 seconds ictal). RESULTS: We found an ictal tachycardia (heart rate increase > 10 bpm) in 82.5% of seizures, and an ictal bradycardia (heart rate decrease > 10 bpm) in 3.3% of seizures. Bradycardia was only observed in seizures of frontal lobe origin. Heart rate changes occurred several seconds prior to EEG seizure onset on scalp-EEG in 76.1% of seizures, but also prior to EEG seizure onset on invasive EEG in 45.7% of seizures. Early tachycardia occurred significantly more often in temporal than in frontal lobe origin seizures. We found no significant effect of the side of seizure onset on both the quality and quantity of ictal heart rate changes. The occurrence of an aura or of awakening prior to the seizure had no influence on peri-ictal heart rate changes. Low risk cardiac arrhythmias were more frequently observed in frontal lobe origin seizures. CONCLUSIONS: Epileptic discharges directly influence portions of the central autonomic network, within a brain area too small or too deep to be detected on EEG, most likely deep mesial structures such as the amygdala or portions of the hippocampus. The potential clinical applications of our results include (1) automatic seizure detection, (2) differentiation between seizures of temporal and frontal lobe origin, (3) detection of peri-ictal cardiac arrhythmias, and (4) clarification of SUDS (sudden unexplained death syndrome) in epilepsy.