Andrzej Głowniak

Analysis of ventricular late potentials in signal-averaged ECG of people with epilepsy.

Purpose:  There has been growing interest in cardiac disturbances in epilepsy patients and their etiologic role in the context of sudden death. Ventricular late potentials (VLPs) recorded on signal‐averaged electrocardiography (SAECG) reflects delayed ventricular depolarization and identifies the structural or functional substrate for the ventricular tachycardia in the reentry mechanism. Therefore, abnormal SAECG poses the potential of identifying patients at increased risk of malignant ventricular arrhythmias and sudden cardiac death. The aim of this exploratory study was to screen epilepsy patients who were treated with established doses of antiepileptic drugs (AEDs) on the presence of VLPs.

Pacemaker lead extraction and recapture of venous access: technical problems arising from extensive venous obstruction.

We report the case of the extraction of 18 year-old leads in a patient with a DDD pacemaker, and chronic obstruction of the left subclavian and innominate veins coexisting with extensive stenoses in the upper caval vein. After removal of pacing leads, angiographic guidewires were introduced via the Byrd dilatators and new pacing leads introduced with the use of long sheaths originally dedicated for transvenous left ventricular leads implantation. With this case, we discuss the problems arising during reimplantation of pacing leads in patients with chronic venous occlusion.

The effect of a single dialysis session on spatial QRS-T angle in haemodialysis patients

BACKGROUND Abnormal values of the spatial angle between the directions of ventricular depolarization and repolarization (QRS-T) reflect the action potential inhomogeneities and predict cardiac events and mortality in various patient groups. The study was designed to (i) compare QRS-T in haemodialysis (HD) patients and healthy subjects, (ii) assess the influence of HD on QRS-T and (iii) evaluate the possible associations between QRS-T and echocardiography, haemodynamic as well as biochemical parameters. METHODS The angular differences between the maximum spatial QRS and T vectors were measured in 73 HD patients and in 57 controls. QRS-T in patients was estimated pre- and post-dialysis together with the evaluation of blood chemistry and haemodynamic parameters. RESULTS Pre-dialysis QRS-T was higher compared with controls (30.18 ± 9.84 and 13.65 ± 7.23, respectively; P < 0.001). HD induced an increase of QRS-T (41.09 ± 11.74; P < 0.001). Pre-dialysis QRS-T adjusted for left ventricular mass index correlated with troponin T (r = 0.398, P = 0.001) and HDL (r = -0.270, P = 0.043). The differences between pre- and post-dialysis (Δ) QRS-T correlated with Δ potassium (r = 0.453, P < 0.001), Δ calcium (r = -0.309, P = 0.011) and Δ stroke index (SI; r = 0.311, P = 0.017). On multivariate analysis, troponin T was found to be an independent predictor of pre-dialysis QRS-T, whereas independent predictors of the HD-induced increase in QRS-T were potassium and cardiac index changes. CONCLUSIONS QRS-T is high in HD patients. HD enhances the inhomogeneities of action potential. Pre-dialysis QRS-T is mainly associated with troponin T elevation. HD-induced increase in QRS-T is mainly associated with potassium and SI changes. The possible clinical importance of the higher QRS-T in HD patients remains to be confirmed in further studies.

Acute left main coronary artery occlusion following inadvertent delivery of radiofrequency energy during ventricular tachycardia ablation successfully treated by rescue angioplasty with stenting: A two-year follow-up

Radiofrequency catheter ablation (RFCA) is a treatment mode in patients with recurrent, symptomatic, ventricular arrhythmias. A rare but potentially life-threatening complication of RFCA includes injury to the coronary arteries, which leads to acute occlusion and myocardial infarction. In the few reported cases, the most frequently affected vessel has been the left main coronary artery. We present the case of a 28 year-old female. During the RFCA procedure, an acute occlusion of the left main coronary artery occurred, which was treated successfully with emergency angioplasty.

Iodine-123 metaiodobenzylguanidine myocardial imaging in haemodialysed patients asymptomatic for coronary artery disease: a preliminary report.

AimThe aim of this study was to evaluate the usefulness of iodine-123 metaiodobenzylguanidine (123I-mIBG) myocardial scintigraphy in the detection of cardiac sympathetic neuropathy in haemodialysed patients without relevant cardiovascular symptoms. Materials and methodsA group of 20 haemodialysed patients were examined. The stress/rest myocardial perfusion scintigraphy by gated single-photon emission computed tomography was performed. Cardiac sympathetic functions were evaluated by single-photon emission computed tomography and planar 123I-mIBG myocardial scintigraphy and also by 24-h Holter study, with heart rate variability (HRV) and signal-averaged electrocardiogram analysis of ventricular late potentials. Semiquantitative analysis of 123I-mIBG myocardial uptake was expressed as routine heart/mediastinum ratio (HMR) 15 [early (eHMR)] and 240 min [delayed (dHMR)] after administration and washout rate (WOR). ResultsMyocardial perfusion scintigraphy showed normal values of all parameters, but semiquantitative 123I-mIBG cardiac imaging assessment indicated low values of HMR (eHMR 1.87±0.27; dHMR 1.74±0.25) and high values of WOR (31.38±9.49) compared with normal values. In 10 patients (50%) ventricular late potential was determined, and in these patients mean values of dHMR came up to 1.59±0.20. The mean value of HRV came up to 88.40±16.05 and significant correlations were found between HRV and eHMR (P=0.01) and dHMR (P=0.007). Conclusion 123I-mIBG scintigraphy can detect very early stages of cardiac sympathetic dysfunction. Low values of HMR and high values of WOR suggest an impaired cardiac adrenergic system in patients without any relevant symptoms of heart failure. Low values of HRV may confirm cardiac autonomic neuropathy.

Extraction of a 17-year-old pacing lead chronically dislocated into the liver vein.

In most cases of lead-dependent infective endocarditis total system removal is the treatment of choice (1-4). The main complications of the extraction procedure include damage to the wall of the heart or major vessels (5,6). We report a case of a 59-year-old man with chronic AF implanted with a ventricular demand (VVI) pacemaker, referred to our center because of symptoms of local pocket infection. Seventeen years earlier the patient was implanted with a ventricular lead, which was found broken on ligature 5 years following implantation. He was then implanted with a new ventricular lead, with the old one left dislocated into liver vein. After the next pacemaker re-implantation 7 months ago, the patient developed symptoms of local pocket infection, and phlebography revealed chronic obstruction of left subclavian and brachiocephalic veins. At admission, transesophageal echocardiography (TEE) revealed vegetation (10x10mm) on the ventricular aspect of the septal tricuspid valve leaflet. After consultation with a cardiosurgeon we decided to perform transvenous lead extraction with full cardiosurgical stand-by. When the pacemaker pocket was opened symptoms of local infection were revealed. Swabs were taken and we then removed the pacemaker and, subsequently, the active ventricular lead with the use of Byrd dilatators. The attempt to liberate the proximal part of the old lead from the liver vein (Fig. 2A, B) with the use of a pigtail catheter introduced via the right jugular vein was unsuccessful. The following attempt was made with the loop of angiographic guide wire (Fig. 2C, D, E). The lead was looped by the guidewire introduced via the pigtail catheter, and the distal part of the guidewire was fixed by a Dotter basket (Fig. 2E, F) Manual traction applied to the guidewire liberated the ingrown part of the lead (Fig. 3A, B) and it progressed into the inferior vena cava (IVC), where it was caught by a Dotter basket (Fig. 3C, D). We subsequently liberated the distal tip of the lead with a 13F sheath (Fig. 3E, F) and removed it along with a small part of ventricular myocardium. There were no complications for the procedure. Considering the pocket infection and sufficient intrinsic rhythm, reimplantation was postponed. Four days after the procedure the patient, in good overall condition, was transferred to a district hospital. Opinions concerning the approach to inactive pacing leads are contradictory. New Heart Rhythm Society (HRS) consensus (4) moves toward this problem; howJV A _1 1_ 10 03 Fig. 1 External pocket view (A), the course of both leads (B); obstruction of left subclavian and brachiocephalic veins (C).