Catheter Ablation of Atrial Tachycardia after Pulmonary Vein Isolation in a Patient with Common Ostium of Inferior Pulmonary Veins: Case Report.

Background and Objectives: Atrial fibrillation (AF), a prevalent cardiac arrhythmia, significantly impacts the quality of life of those affected. The preferred treatment for symptomatic AF, particularly when pharmacological methods fall short, is catheter ablation with pulmonary vein isolation (PVI). While common pulmonary vein (PV) anatomical variants, such as the right accessory pulmonary vein and the common ostium of left pulmonary veins (LCPV), have been studied extensively, their impact on the long-term outcome of PVI is known to be minimal. However, data on less common anomalies, like the common ostium of the left and right inferior pulmonary vein (CIPV), remain scarce in the medical literature. This report aims to shed light on the challenges and outcomes of catheter ablation in a patient with a rare CIPV anomaly. By presenting this case, we contribute to the limited knowledge about the management of such unique anatomical variations in AF treatment and discuss the importance of individualized treatment approaches. Case Presentation: We present a case involving a 56-year-old male diagnosed with AF in 2018. Initial PVI treatment was successful, but the patient experienced symptom recurrence after three years. A preprocedural CT scan before the second ablation revealed a CIPV anomaly. During the repeat procedure, a right superior pulmonary vein (RSPV) reisolation was performed due to identified gaps in the previous ablation line. Post-procedure, the patient maintained a sinus rhythm and reported no further symptoms. Conclusions: This case highlights the importance of recognizing rare PV anatomies like CIPV in the effective management of AF. Tailored ablation strategies, accounting for unique anatomical conditions, can lead to successful long-term outcomes, reinforcing the need for personalized approaches in AF treatment, especially in cases involving complex anatomical variations.

Coronary Artery Occlusion Detection Using 3-Lead ECG System Suitable for Credit Card-Size Personal Device Integration.

Background: Early coronary occlusion detection by portable personal device with limited number of electrocardiographic (ECG) leads might shorten symptom-to-balloon time in acute coronary syndromes. Objectives: The purpose of this study was to compare the accuracy of coronary occlusion detection using vectorcardgiographic analysis of a near-orthogonal 3-lead ECG configuration suitable for credit card-size personal device integration with automated and human 12 lead ECG interpretation. Methods: The 12-lead ECGs with 3 additional leads ("abc") using 2 arm and 2 left parasternal electrodes were recorded in 66 patients undergoing percutaneous coronary intervention prior to ("baseline", n = 66), immediately before ("preinflation", n = 66), and after 90-second balloon coronary occlusion ("inflation", n = 120). Performance of computer-measured ST-segment shift on vectorcardgiographic loops constructed from "abc" and 12 leads, standard 12-lead ECG, and consensus human interpretation in coronary occlusion detection were compared in "comparative" and "spot" modes (with/without reference to "baseline") using areas under ROC curves (AUC), reliability, and sensitivity/specificity analysis. Results: Comparative "abc"-derived ST-segment shift was similar to two 12-lead methods (vector/traditional) in detecting balloon coronary occlusion (AUC = 0.95, 0.96, and 0.97, respectively, P = NS). Spot "abc" and 12-lead measurements (AUC = 0.72, 0.77, 0.68, respectively, P = NS) demonstrated poorer performance (P < 0.01 vs comparative measurements). Reliability analysis demonstrated comparative automated measurements in "good" agreement with reference (preinflation/inflation), while comparative human interpretation was in "moderate" range. Spot automated and human reading showed "poor" agreement. Conclusions: Vectorcardiographic ST-segment analysis using baseline comparison of 3-lead ECG system suitable for credit card-size personal device integration is similar to established 12-lead ECG methods in detecting balloon coronary occlusion.

Contractile reserve assessed by dobutamine test identifies super-responders to cardiac resynchronization therapy.

INTRODUCTION: In this study, we sought to determine whether myocardial contractile reserve (CR) assessed by dobutamine stress echocardiography (DSE) can identify patients who experience nearly complete normalization of left ventricular (LV) function after the implantation of a cardiac resynchronization therapy (CRT) pacemaker. MATERIAL AND METHODS: The study group consisted of 55 consecutive patients with non-ischemic dilated cardiomyopathy, LV ejection fraction (LVEF) < 35%, and prolonged QRS complex duration, who were scheduled for CRT pacemaker implantation. The DSE (20 µg/kg/min) was performed in all patients. The CR assessment was based on a change in the wall motion score index (ΔWMSI) and ΔLVEF during DSE. Super-response was defined as an increase in LVEF to > 50% and reduction in left ventricular end-systolic dimension to < 40 mm 12 months following the CRT implantation. RESULTS: A total of 7 patients (12.7%) were identified as super-responders to CRT. When compared to non-super-responders, these patients had significantly higher values of the dobutamine-induced change in ΔWMSI (1.031 ±0.120 vs. 0.49 ±0.371, p < 0.01), and ΔEF (17.9 ±2.2 vs. 8.8 ±6.2, p < 0.01). Receiver operating characteristic analysis showed that dobutamine-induced changes in ΔWMSI ≥ 0.7 and ≥ 14% for ΔEF are the best discriminators for a super-response. Patients with ΔWMSI ≥ 0.7 and ΔEF ≥ 14% are significantly less often hospitalized (p < 0.01) for worsening of heart failure during 28.5 ±3.0 months of the follow-up. CONCLUSIONS: Contractile reserve assessed by DSE can identify patients with dilated cardiomyopathy who are likely to experience near normalization of LV function following CRT.

Pulmonary vein isolation supported by MRI-derived 3D-augmented biplane fluoroscopy: a feasibility study and a quantitative analysis of the accuracy of the technique.

BACKGROUND: Despite the advancement of technology in electroanatomic mapping systems (EAMS), fluoroscopy remains a necessary, basic imaging modality for electrophysiology procedures. We present a feasibility study of new software that enables 3D-augmented fluoroscopy in biplane catheterization laboratories for planning and guidance of pulmonary vein isolation (PVI). The computer-assisted overlay registration accuracy was assessed in a clinical setting using an automatic calculation of overlay projection geometry that was derived from hardware sensors in C-arms, detectors, and patient table. METHODS: Consecutive patients (n = 89) underwent left atrium (LA) magnetic resonance imaging MRI scan prior to PVI. Ideal ablation lines encircling the ipsilateral pulmonary veins (PVs) at antral level were drawn onto the segmented LA surface. The 3D-model was superimposed onto biplane fluoroscopy and matched with angiographies of LA and PVs. Three-dimensional-overlay projection geometry was automatically calculated from C-arm, detectors, and table sensors. Accuracy of technique was assessed as alignment of MRI-derived 3D overlay and angiographic LA/PV anatomy. Integrity of registered overlay was quantified using landmark measurements. RESULTS: Alignment offsets were 1.3 ± 1.5 mm in left PV, 1.2 ± 1.5 mm in right PV, and 1.1 ± 1.4 mm in LA roof region. Bravais-Pearson correlation of the landmark measurements was r = 0.978 (s < 0.01), mean offset between landmark distance measurements was 1.4 ± 0.78 mm. Average time needed for overlay registration was 9.5 ± 3.5 seconds. CONCLUSIONS: MRI-derived 3D-augmented fluoroscopy demonstrated a high level of accuracy when compared with LA/PV angiography. The new system could be especially useful to guide procedures not supported by EAMS, such as cryotechnique PVI.

Wireless remote monitoring of reconstructed 12-lead ECGs after ablation for atrial fibrillation using a hand-held device.

OBJECTIVE: Atrial fibrillation (AF) surveillance using a wireless handheld monitor capable of 12-lead electrocardiogram reconstruction was performed, and arrhythmia detection rate was compared with serial Holter monitoring. METHODS: Twenty-five patients were monitored after an AF ablation procedure using the hand-held monitor for 2 months immediately after and then for 1 month approximately 6 months postablation. All patients underwent 12-lead 24-hour Holter monitoring at 1, 2, and 6 months postablation. RESULTS: During months 1-2, 425 of 2942 hand-held monitor transmissions from 21 of 25 patients showed AF/atrial flutter (Afl). The frequency of detected arrhythmias decreased by month 6 to 85/1128 (P < .01) in 15 of 23 patients. Holter monitoring diagnosed AF/Afl in 8 of 25 and 7 of 23 patients at months 1-2 and month 6, respectively (P < .01 compared with wireless hand-held monitor). Af/Afl diagnosis by wireless monitoring preceded Holter detection by an average of 24 days. CONCLUSIONS: Wireless monitoring with 12-lead electrocardiogram reconstruction demonstrated reliable AF/Afl detection that was more sensitive than serial 12-lead 24-hour Holter monitoring.

Wireless monitoring of reconstructed 12-lead ECG in atrial fibrillation patients enables differential diagnosis of recurrent arrhythmias.

UNLABELLED: Differential diagnosis of symptomatic events in post-ablation atrial fibrillation (AF) patients (pts) is important; in particular, accurate, reliable detection of AF or atrial flutter (AFL) is essential. However, existing remote monitoring devices usually require attached leads and are not suitable for prolonged monitoring; moreover, most do not provide sufficient information to assess atrial activity, since they generally monitor only 1-3 ECG leads and rely on RR interval variability for AF diagnosis. A new hand-held, wireless, symptom-activated event monitor (CardioBip; CB) does not require attached leads and hence can be conveniently used for extended periods. Moreover, CB provides data that enables remote reconstruction of full 12-lead ECG data including atrial signal information. We hypothesized that these CB features would enable accurate remote differential diagnosis of symptomatic arrhythmias in post-ablation AF pts. METHODS: 21 pts who underwent catheter ablation for AF were instructed to make a CB transmission (TX) whenever palpitations, lightheadedness, or similar symptoms occurred, and at multiple times daily when asymptomatic, during a 60 day post-ablation time period. CB transmissions (TXs) were analyzed blindly by 2 expert readers, with differences adjudicated by consensus. RESULTS: 7 pts had no symptomatic episodes during the monitoring period. 14 of 21 pts had symptomatic events and made a total of 1699 TX, 164 of which were during symptoms. TX quality was acceptable for rhythm diagnosis and atrial activity in 96%. 118 TX from 10 symptomatic pts showed AF (96 TX from 10 pts) or AFL (22 TX from 3 pts), and 46 TX from 9 pts showed frequent PACs or PVCs. No other arrhythmias were detected. Five pts made symptomatic TX during AF/AFL and also during PACs/PVCs. CONCLUSIONS: Use of CB during symptomatic episodes enabled detection and differential diagnosis of symptomatic arrhythmias. The ability of CB to provide accurate reconstruction of 12 L ECGs including atrial activity, combined with its ease of use, makes it suitable for long-term surveillance for recurrent AF in post-ablation patients.

Wireless remote monitoring of atrial fibrillation using reconstructed 12-lead ECGs.

UNLABELLED: Remote surveillance is important for patients with atrial fibrillation (AF). Atrial signal recognition with conventional monitoring devices is difficult; remote AF detection is predominantly accomplished by R-R interval analysis. Twelve lead ECG (12L) displays atrial activity and remains the gold standard for AF diagnosis. CardioBip is a portable wireless patient-activated event monitor providing signal reconstruction of a 12L waveform (12CB) using 5 leads and patient-specific transformation matrices. We hypothesized that atrial signal analysis with 12CB can detect atrial activity and improve AF detection. METHODS: 18 patients with AF undergoing DC cardioversion (CV) were studied. Separate 12-lead P and QRS patient-specific transformation matrices were created at baseline AF. Multiple wireless 12CB transmissions were performed 3-7 days before and up to 2 weeks after CV. Rhythm was confirmed with 12-lead ECGs (12L). In SR the number of leads with visible P waves (atrial signal > 0.05 mV), and P wave polarity were analyzed. In AF, the number of leads with AF signal were compared (fibrillatory [f] waves >0.025 mV). RESULTS: Fourteen of 18 patients successfully cardioverted to SR and 4 failed; thus, 14 SR and 22 AF transmissions were analyzed. SR P wave was visible on 141/168 leads on 12L and 137/168 on 12CB (126 true pos [TP] and 11 false pos [FP] relative to 12L; p=0.26). In 126 leads with P waves in both 12L and 12CB, the methods agreed on P wave polarity in 125. In AF, F waves were visible in 178/264 leads on 12L and 189/264 leads on 12CB (144 TP, 45 FP; p=0.27). All 5 AF relapses were successfully detected by 12CB based on atrial activity. CONCLUSION: 12CB is not inferior to 12L in detecting atrial signal in SR and AF, and shows excellent potential for remote wireless monitoring of AF patients.

[Implantable cardioverter-defibrillator oversensing due to electric shock].

INTRODUCTION: We described the first case of oversensing due to electric shock in Serbia, in a 54-year-old man who had implantable cardioverter-defibrillator (ICD). CASE OUTLINE: In July 2002, the patient had acute anteroseptal myocardial infarction and ventricular fibrillation (VF) which was terminated with six defibrillation shocks of 360 J. Coronary angiography revealed 30% stenosis of circumflex artery, the left anterior descending coronary artery was recanalized and the right coronary artery was without stenosis. Left ventricular ejection fraction was 20%. In December 2003, an electrophysiology study was performed and ventricular tachycardia (VT) was induced and terminated with 200 J defibrillation shock. Single chamber ICD Medtronic Gem III VR was implanted in January 2004 and defibrillation threshold was 12 J. The patient was followed up during three years every three months and there were no VT/VF episodes and VT/VF therapies. In December 2007, the patient experienced electric shock through the fork while he was making barbecue on the electric grill. ICD recognized this event in VF zone (oversensing) and delivered defibrillation shock of 18 J. The electrogram of the episode showed ventricular sensing--intrinsic sinus rhythm with electric shock potentials which were misidentified as VF. After charge time of 3.16 seconds, ICD delivered defibrillation shock and sinus rhythm was still present. CONCLUSION: Oversensing of ICD has different aetiology and the most common cause is supraventricular tachyarrhythmia.

[Brugada syndrome--a brand new case].

BACKGROUND: Brugada syndrome (BS) is a disorder characterized by syncope or sudden death associated with one of several electrocardiographic (ECG) patterns characterized by incomplete right bundle branch block and ST elevation in the anterior precordial leads. Patients with BS are prone to develop ventricular tachyarrhythmias that may lead to syncope, cardiac arrest, or sudden cardiac death. CASE REPORT: A 58-year-old woman is the first described case of Brugada syndrome in Serbia with intermittent typical changes in basic electrocardiography (ECG): ST segment elevation in the precordial chest leads like dome or coved--major form or type I. For the last 27 years the patient had suffered of palpitations and dizziness, without syncopal events. Her sister had died suddenly during the night in sleep. During 24-hour Holter monitoring the patient had ventricular premature beats during the night with R/T phenomenon and during the recovery phase of exercise testing had rare premature ventricular beats as the consequence of parasympatethic stimulation. Late potentials were positive. Echocardiography revealed left ventricular ejection fraction of 60%. We performed coronary angiography and epicardial coronary arteries were without significant stenosis and structural heart disease was excluded. In the bigining of the electrophysiological study ECG was normal, and after administration of Propaphenon i.v. Brugada syndrome unmasked with appearance of type I ECG pattern. A programed ventricular stimulation induced non sustained ventricular tachycardia. One-chamber implantable cardioverter defibrillator was implanted and the patient was treated with a combination od amiodarone and metoprolol per os. After one-year folow-up, there were no episodes of ventricular tachycardia and ventricular fibrillation. CONCLUSION: Brugada syndrome is a myocardial disorder which prognosis and therapy are related to presence of ventricular fibrillation or ventricular tachycardia. Electrophysiologicaly induced malignant ventricular disorders class I are indication for implantation of cardioverter defibrilator, as also occurred in presented patient.

Effects of atropine and pirenzepine on heart rate turbulence.

BACKGROUND: It has been shown that mortality risk in patients after myocardial infarction could be estimated by heart rate turbulence (HRT), a short-term change in heart rate after ventricular premature beat (VPB), presumably caused by baroreceptor mechanism. We sought to determine whether pharmacological blockade with atropine, or augmentation of vagal tone with pirenzepine given in small doses would influence HRT. METHODS: In 30 patients with normal echocardiogram, and without signs or symptoms of coronary artery disease, after electrophysiologic examination or radiofrequency ablation for supraventricular arrhythmias was completed, turbulence onset (TO) and turbulence slope (TS) in basal state, after 1.3 mg IV pirenzepine and finally, after atropine in dose of 0.04 mg/kg of body weight were compared. RESULTS: As assessed by Friedman ANOVA test both pirenzepine and atropine caused a significant change in both TO (P < 0.01) and TS (P < 0.01). The mean basal TO of -3.6 +/- 2.9%, changed after pirenzepine to -5.99 +/- 5.6% (P < 0.01), and after atropine it changed to -3.3 +/- 18.1% (P < 0.01). The mean basal TS of 18.6 +/- 10.1 ms/R-R interval increased after pirenzepine to 26.8 +/- 19.9 ms/R-R interval (P < 0.05), and decreased after atropine to 1.2 +/- 0.8 ms/R-R interval (P < 0.01). Mean cycle length increased after pirenzepine from 706.8 +/- 106.8 to 830 +/- 151.9 ms (P < 0.01), and decreased after atropine to 454.2 +/- 58.1 ms (P < 0.01). CONCLUSION: A conclusion could be drawn that vagomymetic manipulation with intravenous pirenzepine increases HRT; vagal blockade with atropine decreases HRT. This finding suggests that a normal vagal innervation of heart is a prerequisite for the phenomenon of HRT.

[Learning curve in performing radiofrequency ablation of accessory pathways in patients with Wolf-Parkinson-White syndrome].

INTRODUCTION: This study examines the effect of operator experience on radiofrequency ablation (RFA) of accessory pathways success rate in patients with Wolff-Parkinson-White (WPW) syndrome. MATERIAL AND METHODS: The first 100 consecutive patients with WPW syndrome treated by radiofrequency ablation at our Clinic, were divided into group A (first 50 patients) and group B (the following 50 patients). Various parameters were compared between these 2 groups. RESULTS: The success rate in group A was 69% and in group B 92%, p < 0.01. There were 6 patients with recurrent WPW syndrome, after 3 months of follow-up, 5 were from group A and 1 from group B, p < 0.05. Significantly more applications of radiofrequency energy were delivered in group A (10.0 +/- 4.8 in group A and 6.2 +/- 3.1 in group B, p < 0.05). Two patients from group A presented with complications: one had intermittent complete AV-block, and the other pericardial effusion. CONCLUSION: This study shows a clear learning curve in performing RFA of accessory pathways in patients with WPW syndrome.

[Location of accessory pathways and its radiofrequency ablation in Wolf-Parkinson-White syndrome].

INTRODUCTION: Radiofrequency ablation (RFA) of accessory pathways (AP) is the first line therapy in symptomatic patients with preexcitation syndrome, resistant to medical therapy. OBJECTIVE: To evaluate the influence of AP location on RFA effectiveness. METHOD: The study compared RFA results of AP located on the left side, right side, and in septal area of the heart in the first 101 consecutive patients treated at Dedinje Cardiovascular Institute in Belgrade. RESULTS: There was no significant difference between the right-, left- and septal-AP in relation to primary success rates (66.7%, 84.3%, 73.7%, respectively, p = 0.285), recurrence rates (12.5%, 6.97%, 14.3%, p = 0.591), and final success rates (66%, 84.3%, 78.9%, p = 0.37). Maximally achieved interface temperature was lowest at right-sided AP (49.8 +/- 1.9 degrees C) as compared to the left (53.0 +/- 3.5 degrees C) or septal AP (52.9 +/- 3.0 degrees C) (p < 0.01). Fluoroscopy time did not differ significantly (p = 0.062), while total procedure time and the number of applied RF pulses was higher in the left-sided AP as compared to other two (104.6 +/- 44.9 for the left, 98.9 +/- 47.5 for the right and 80.7 +/- 39.8 minutes for the septal AP, p < 0.05; 11.0 +/- 8.8 pulses for the left, 6.5 +/- 3.8 for the right and 6.4 +/- 5.0 for septal AP, p < 0.01). Two major complications developed: one third-degree AV block after ablation of midseptal AP, and one pericardial effusion without tamponade, with spontaneous regression. CONCLUSION: The success rate of RFA of the right-, left- and septal-AP was similar. Heating of the tissue was weakest during RFA of the right-sided AP.

Usefulness of atrial fibrillation burden as a predictor for success of pulmonary vein isolation.

BACKGROUND: The definition of symptomatic improvement after pulmonary vein isolation (PVI) is controversial. We assessed primarily the usefulness and predictive accuracy (PA) of AF (atrial fibrillation) burden (AFB) within the first 3 months after the procedure as an early predictor for curative success as well as reduction of symptoms. METHODS: We studied 100 pts (62 men, mean age: 54 +/- 9 years, LVEF: 57 +/- 9%, paroxysmal AF, 85, persistent AF, 15) who underwent PVI. RF ablation was used in 63 patients. The combination of cryoablation and RF (Hybrid therapy) was used in the remaining 37 patients, in 19 patients of whom additionally linear lesions were performed. All patients were followed up 3 months after PVI (the blanking period) and every 3 months thereafter. The significance of early recurrence of AF (ERAF) was separately analyzed for RF and for hybrid therapy arm. Quality of life (QoL) was assessed using the physical composite summary score (PCS) and mental composite summary score (MCS). AFB was dichotomized at: 0, 0.5, 1, 6, 12, and 24 hours. RESULTS: ANOVA revealed significant differences between PCS at baseline and after PVI in patients without recurrence and with those with postablation AFB <12 hours. There was no difference between PCS in patients with AFB > or =12 hours within a 3 months interval and PCS at baseline. ERAF occurred in 35% of patients (16 patients, AFB > or =12 hours). Symptomatic ERAF occurred in 29 patients (17 patients AFB > or =12 hours). After the blanking period, documented AF recurrence was found in 50 patients (17 patients, AFB > or =12 hour). Symptomatic late recurrence was found in 47 patients (31 patients with AFB > or =12 hours). Absence of ERAF was revealed to be predictive for long-term success and symptomatic ERAF was found to be predictive for symptomatic AF recurrence (P <0.0001). CONCLUSION: AF recurrence with AFB > or =12 hours within 3 months is associated with a missed improvement of QoL. Symptomatic ERAF predicts recurrence independently of therapy.