Attila Makai

Favorable Early Outcome of Carotid Artery Stenting Without Protection Devices

Background and Purpose— Protection devices are increasingly used in carotid artery stenting. However, no randomized trial has been conducted to evaluate the efficacy of such devices, and arguments have also been formulated against their routine use. We set out to investigate the complication rates associated with carotid artery stenting performed without protection devices. Applicability of covered stents in the carotid system was also evaluated. Methods— Between January 2001 and July 2003, 245 consecutive patients (260 hemispheres) underwent carotid artery stenting. No protection devices were applied. Covered stents were implanted in 31 (12.1%) cases. The incidence of complications during the intervention and the subsequent 30-day follow-up period was recorded. Results— The technical success rate was 98.8%. One postprocedural nonneurological death (0.4%) occurred. Neurological complications (inclusive of transient ischemic attacks) were observed in 14 cases (5.4%). The rate of major complications (death, major stroke, and myocardial infarction) was 1.6% among the symptomatic and 1.5% among the asymptomatic cases. The rate of minor strokes was 3.2% in the symptomatic and 1.5% in the asymptomatic group. Of the neurological complications, 64.3% occurred postprocedurally. No ipsilateral neurological complications were detected in the subgroup treated with covered stents. Conclusions— Carotid artery stenting without protection devices appears to be safe. Most of the neurological complications could not have been prevented with protection devices, because they occurred after the intervention. The application of covered stents may reduce the rate of embolization-related complications in the periprocedural period.

Acute and chronic effects of vinpocetine on cerebral hemodynamics and neuropsychological performance in multi-infarct patients

A double‐blind, prospective, randomized, placebo‐controlled clinical trial was carried out to test the acute and long‐term hemodynamical and beneficial cognitive effects of the vasoactive agent vinpocetine on patients suffering from multiple cerebral infarcts by means of functional transcranial Doppler examinations and by neuropsychological tests. Twenty‐six patients (17 men, 9 women) with multiple cerebral infarctions, aged between 50 and 83 years (mean age ± SD = 63.4 ± 9.39 years) were examined, 14 of whom received vinpocetine and 12 placebo. The functional transcranial Doppler included breath‐holding tests, finger movement, word fluency, and picture‐discrimination tasks. Twenty‐five patients were assessed by neuropsychological battery. No serious side effect was found in the vinpocetine group. The flow velocities were significantly lower in the acute phase after breath holding in the vinpocetine group than in the placebo group. Three months later, the vinpocetine patients did not show any significant worsening in digit span backward test, while the placebo group did. No other significant differences in the neuropsychological test could be detected between the treatment and the placebo groups. Longer lasting and higher dosage of vinpocetine therapy is suggested to prove its potential effect.

Ablation of Posteroseptal and Left Posterior Accessory Pathways Guided by Left Atrium–Coronary Sinus Musculature Activation Sequence

Introduction: While some posteroseptal and left posterior accessory pathways (APs) can be ablated on the tricuspid annulus or within the coronary venous system, others require a left‐sided approach. “Fragmented” or double potentials are frequently recorded in the coronary sinus (CS), with a smaller, blunt component from left atrial (LA) myocardium, and a larger, sharp signal from the CS musculature.

Parasympathetic nervous system activity predicts mood repair use and its effectiveness among adolescents with and without histories of major depression.

Depressive disorders that onset in the juvenile years have been linked to far-reaching adverse consequences, making it imperative to elucidate key mechanisms and contributory factors. Excessive use of regulatory responses that exacerbate sadness (maladaptive mood repair) or insufficient use of regulatory responses that reduce it (adaptive mood repair) may reflect behavioral mechanisms of depression risk. Cardiac vagal control, indexed by patterns of respiratory sinus arrhythmia (RSA), has received attention as a putative physiological risk factor for depression. Although mood repair and RSA are related, the nature of this relationship is not well characterized in the context of depression risk. Therefore, we tested alternative models of the relationships between RSA patterns (at rest and in response to a sad film), trait mood repair, and the effectiveness of a mood repair response in the laboratory (state mood repair) among adolescents with depression histories (n = 210) and emotionally healthy peers (n = 161). In our data, a mediation model best explained the association between the key constructs: Adolescents with normative RSA patterns exhibited lower levels of depression and trait maladaptive mood repair, and benefited more from instructed (state) mood repair in the laboratory. By contrast, adolescents with atypical RSA patterns exhibited higher levels of depression and dispositional maladaptive mood repair, which, in turn, mediated the relations of RSA patterns and depression symptoms. Atypical RSA patterns also predicted reduced benefits from laboratory mood repair.

Randomized Trial of Intracardiac Echocardiography During Cavotricuspid Isthmus Ablation

Randomized Trial of ICE During CTI Ablation. Introduction: Despite a high success rate, radio‐frequency ablation (RFA) of the cavotricuspid isthmus (CTI) can be unusually challenging in some cases. We postulated that visualization of the CTI with intracardiac echocardiography (ICE) could maximize the succes rate, decrease the procedure and ablation time, and minimize the radiation exposure.

Ventricular location of a part of the right atrial isthmus after tricuspid valve replacement for Ebstein’s anomaly: a challenge for atrial flutter ablation

We report the case of a patient with atrial flutter late after tricuspid valve replacement for Ebstein’s anomaly. Computed tomographic angiography revealed that coronary sinus ostium and part of the right atrial isthmus were located on the ventricular side of the valve ring due to the specific surgical approach in this condition. Based on the results of electroanatomic mapping and entrainment, the arrhythmia was found to be cavotricuspid isthmus dependent clockwise atrial flutter. Completion of the isthmus line required ablation lesions across the artificial valve. When these were delivered the arrhythmia terminated and isthmus block was achieved. Due to arrhythmia recurrence a redo procedure was performed which demonstrated conduction recovery in the ventricular part of the cavotricuspid isthmus. Intracardiac ultrasound-guided ablation successfully eliminated conduction across the isthmus with subsequent freedom from arrhythmia on follow up.

Electrogram analysis at the His bundle region and the proximal coronary sinus as a tool to predict left atrial origin of focal atrial tachycardias

AIMS Early activation at the His bundle (HB) region or proximal coronary sinus (CS) during focal atrial tachycardias (FATs) often necessitates biatrial mapping. Analysis of CS electrograms (EGMs) consisting of a near-field (N) component from CS musculature and a far-field (F) component from left atrial (LA) myocardium can uncover LA activation preceding right atrial (RA) activation. A similar pattern might be observed at the HB. METHODS AND RESULTS Eight patients underwent RA and LA pacing testing the hypothesis that N and F components originating from the RA and LA septum are present in the HB atrial EGM (Pacing group). In this group N preceded F (N-F sequence) in all, while F preceded N (F-N sequence) in seven of eight patients during RA and LA pacing, respectively. Twenty-seven patients with FAT demonstrating earliest activation at the HB or proximal CS during limited RA mapping were also studied (FAT group). Two observers analysed the EGMs at the earliest site during FAT. They found an N-F sequence in 17 (94%) and 16 (89%) of 18 RA FAT and an F-N sequence in seven (78%) and eight (89%) of nine LA FAT, respectively. The F-N sequence predicted the need for LA access with a sensitivity of 78 and 89% and a specificity of 94 and 89%. CONCLUSION Near-field and F components from RA and LA activation can be identified in the HB atrial EGM. Earliest atrial EGM analysis at the HB or CS can predict the need for LA access during FAT ablation.

Post-incisional right atrial tachycardia eliminated by a single radiofrequency lesion

A 75-year-old female, 16 years after operation for a left atrial myxoma using a transseptal left atrial approach, underwent an electrophysiology study and electroanatomic mapping using the CARTO® system for atrial flutter (AFL). Electrophysiology study revealed a clockwise cavotricuspid isthmus (CTI) dependent AFL (Fig. 1). This arrhythmia terminated during CTI ablation (Fig. 2) and after further ablation CTI block was established. During repeated stimulation another AFL with a cycle length (CL) of 350 ms was induced (Fig. 3). Entrainment of this tachycardia from the CS (Fig. 4) yielded a long post-pacing interval (PPI), while from the right atrial lateral wall (yellow dot on the CARTO map) the PPI equaled the tachycardia CL (Fig. 5). A CARTO activation map was created of the right atrium (RA) and revealed a long line of double potentials (blue dots) extending along the lateral wall of the RA, corresponding to an atriotomy incision. The activation front of the AFL circulated around this line and a narrow isthmus was noted between the cranial end of the line and the tricuspid annulus. A single radiofrequency pulse delivered at this site (red dot) with an irrigated tip ablation catheter terminated the AFL (Fig. 6) and rendered it non-inducible. J Interv Card Electrophysiol (2007) 19:73–76 DOI 10.1007/s10840-007-9141-x

Converging methods in the assessment of sympathetic baroreflex sensitivity

AIMS Abnormalities of the sympathetic baroreflex regulation are documented in various diseases. The recording of sympathetic nerve activity allows for the calculation of baroreflex gain but this is not available in practice. A non-invasive method based on blood pressure during the late phases of Valsalva manoeuvre (VM) was proposed. Sympathetic gain could be calculated from the pressure fluctuations following ventricular extrasystole or non-sustained ventricular tachycardia (NSVT). METHODS AND RESULTS We assessed both indices in 25 subjects with no significant cardiovascular disease. VM was performed at 40 mmHg for 12 s. Paced NSVT consisted of five to six cycles. The sympathetic gains were determined based on the recovery of mean arterial pressure (MAP, mmHg/s). The maximum slope of five consecutive MAP elevations occurring within a 15-cycle period after NSVT was calculated. This MAP turbulence slope (MAP(TS)) was expressed in mmHg/cycle. Five patients were excluded because of unacceptable VM. VM-derived sympathetic gain (SBRS(vals)) and the NSVT-derived gain (SBRS(NSVT)) correlated closely (R = 0.86, P < 0.001). Their mean difference was 3.2 +/- 4.8 mmHg. Both SBRS(vals) and SBRS(NSVT) correlated closely with MAP(TS) (R = 0.77, P < 0.001 and R = 0.86, P < 0.001, respectively). CONCLUSION The sympathetically mediated arterial pressure recovery is an analogous process following both VM and NSVT. SBRS(NSVT) or MAP(TS) may be useful in the assessment of patients with implanted antiarrhythmic devices.

Primary cardiac angiosarcoma: A case report

Cardiac angiosarcomas are the most common primary malignant cardiac tumors in adults. The diagnosis is often delayed due to nonspecific clinical symptoms at presentation. The cornerstones of diagnosis are echocardiography and the histological evaluation of the cardiac biopsy. The knowledge on the treatment is limited; the outcomes of chemotherapy, radiotherapy, complete surgical removal, and heart transplantation are controversial. We report a 38‐year‐old woman with a primary heart tumor which infiltrated the right atrial wall and the pericardium and caused pericardial effusion. Angiosarcoma was verified histologically. The surgical excision could not be radical, and the patient died 3 months from diagnosis.