Cesare Storti

Apelin plasma levels predict arrhythmia recurrence in patients with persistent atrial fibrillation.

Low levels of the regulatory peptide apelin have been reported in patients with lone atrial fibrillation (AF). We evaluate the potential utility of assessing apelin plasma levels as a predictor of AF recurrence in individuals presenting for electrical cardioversion. Plasma levels of apelin, brain natriuretic peptide (BNP) and high-sensitivity C-reactive protein were measured in 93 patients, with persistent AF before successful external electrical cardioversion. Significantly lower apelin plasma levels were found in patients with AF recurrence as respect to population with persistence of sinus rhythm during a six months follow-up. The hazard increased with duration of AF, left atrial dimension, BNP concentrations. Subjects with apelin levels below the median had a hazard ratio of 3.1 of arrhythmia recurrence with respect to those with high apelin levels (p< 0.05). A significant difference in BNP levels was found between patients with and without AF recurrence during the follow-up. After adjusting for potential confounders, both BNP and apelin retained their statistical significance as independent predictors of arrhythmia recurrence. Patients with both low apelin and elevated BNP had a worse prognosis compared with those with either low apelin or elevated BNP alone. Low plasma apelin levels before external electrical cardioversion are an independent prognostic factor for arrhythmia recurrence in patients with AF treated with antiarrhythmic drugs. Apelin may be of particular value for the identification of high-risk patients in addition to BNP.

Fast pathway ablation in a patient with iterative atrioventricular nodal reentrant tachycardia and prolonged PR interval

A safe approach to radiofrequency catheter ablation is still unclear and not well defined in patients with AV nodal reentrant tachycardia and prolonged PR interval. In our study, a patient with iterative AV nodal reentrant tachycardia and prolonged PR interval underwent fast pathway radiofrequency catheter ablation. By mapping Kochs triangle, the earliest retrograde atrial activation area was localized. Radiofrequency energy was delivered here with the interruption of tachycardia with no complications.

Efficacy and safety of the second generation cryoballoon ablation for the treatment of paroxysmal atrial fibrillation in patients over 75 years: a comparison with a younger cohort

Aims In this double centre, retrospective study, we aimed to analyse the 1-year efficacy and safety of cryoballoon ablation (CB-A) in patients older than 75 years compared with those younger than 75-years old. Methods and results Fifty-three consecutive patients aged 75 years or older with drug-resistant paroxysmal AF (PAF) who underwent pulmonary vein isolation (PVI) by the means of second generation CB-A, were compared with 106 patients aged <75 years. The mean age in the study group (>75 years) was 78.19 ± 2.7 years and 58.97 ± 8.5 in the control group. At 1-year follow-up the global success rate was 83.6% and did not significantly differ between older (10/53) and younger patients (16/106) (81.1 vs. 84.9%, P = 0.54). Transient phrenic nerve palsy was the most common complication which occurred in eight patients in the younger group and in three in the older group (7.5 vs. 5.7%, respectively, P = 0.66). Conclusions The results of our study showed that CB-A for the treatment of PAF is a feasible and safe procedure in elderly patients, with similar success and complications rates when compared with a younger population.

Single freeze per vein strategy with the second-generation cryoballoon for atrial fibrillation: a propensity score-matched study between 180- and 240-s application time in a large cohort of patients

Aims The single-freeze strategy using the second-generation cryoballoon (CB-A, Arctic Front Advance, Medtronic, Minneapolis, MN, USA) has been reported to be as effective as the recommended double-freeze approach in several single-centre studies. In this retrospective, international, multicentre study, we compare the 3-min single-freeze strategy with the 4-min single-freeze strategy. Methods and results Four hundred and thirty-two patients having undergone pulmonary vein isolation (PVI) by means of CB-A using a single-freeze strategy were considered for this analysis. A cohort of patients who were treated with a 3-min strategy (Group 1) was compared with a propensity score-matched cohort of patients who underwent a 4-min strategy (Group 2). Pulmonary vein isolation was successfully achieved in all the veins using the 28-mm CB-A. The procedural and fluoroscopy times were lower in Group 1 (67.8 ± 17 vs. 73.8 ± 26.3, P < 0.05; 14.9 ± 7.8 vs. 24.2 ± 10.6 min, P < 0.05). The most frequent complication was PNP, with no difference between the two groups (P = 0.67). After a mean follow-up of 13 ± 8 months, taking into consideration a blanking period of 3 months, 85.6% of patients in Group 1 and 87% of patients in Group 2 were free from arrhythmia recurrence at final follow-up (P = 0.67). Conclusion There is no difference in acute success, rate of complications, and freedom from atrial fibrillation recurrences during the follow-up between 3-min and 4-min per vein freeze strategies. The procedural and fluoroscopy times were significantly shorter in 3-min per vein strategy.

Spontaneous incessant AV reentrant tachycardia related to left bundle branch block and concealed left-sided accessory AV pathway.

Incessant Tachycardia in WPW Syndrome. Three patients in whom permanent AV reentrant tachycardia became the clinical manifestation of Wolff‐Parkinson‐White syndrome are described. The substrate for the arrhythmia was created by coexistence of a concealed left‐sided accessory pathway and an ipsilateral bundle branch block. Pharmacology therapy in all three patients failed to control the tachycardia, which in two cases led to severe left ventricular failure. After successful radio frequency ablation of the accessory pathway (in two) or A V junction (in one), left ventricular function gradually returned to normal.

Vasospasm of the right coronary artery associated with syncope and bradyarrhythmias diagnosed by loop recorder examination

It is well known that coronary spasm and atherosclerotic lesions are closely related. When the vasospastic episode involves the right coronary artery, ischaemia-related bradyarrhythmias can occur. This phenomenon has been attributed both to the ischaemia of the atrioventricular (AV) node secondary to impaired blood flow via the AV nodal artery and to the Bezold–Jarisch reflex due to an increased vagal tone secondary to ischaemia. We report a case of recurrent syncopes associated with bradyarrhythmias due to vasospasm of the right coronary artery diagnosed by the loop recorder examination.

A particular case of transient ST elevation during cryoballoon ablation of atrial fibrillation

Introduction The cryoballoon (CB) technology nowadays represents a valid alternative to the radiofrequency for pulmonary vein (PV) isolation. Transient ST elevation has been reported as a rare adverse event occurring during atrial fibrillation (AF) ablation and is mostly related to air embolism during contrast injection. However, the present case describes the occurrence of ST elevation during CB ablation secondary to the proximity of a venous bypass graft for the distal right coronary artery to the ostium of left inferior pulmonary vein (LIPV).

Ablation of Antero-Septal and Intermediate Septal Accessory Pathways: How Safe Is It? How Can One Minimize the Risk of AV Block?

The current goal of radiofrequency catheter ablation of supraventricular tachycardias is to cure a large cohort of patients with a primary success rate close to 100% and a complication and recurrence rate close to 0%. In this setting, the ablation of the atrioventricular (A-V) accessory pathway in the triangle of Koch may still represent a grey area, since the strict anatomical relationship between the bypass tract and the A-V node-His bundle may affect the feasibility and safety of the procedure. Consequently, the only rationale for successful ablation with no complication in this area relies on the assumption that the accessory pathway is more sensitive to radiofrequency energy delivery than the normal A-V conduction system [1]. The risk of damaging the normal A-V conduction pathway and of inducing a complete A-V block requiring a permanent pacemaker has been pointed out by both early [2, 3] and recent [4–6] reports, although successful and safe ablation has been described in limited series of cases [7, 8], even with “para-hissian” accessory pathways [1]. Moreover, in the risk/benefit ratio of ablation of by-pass tracts in the Koch’s triangle one must consider not only failure and the risk of permanent complete A-V block, but also the theoretical possibility of creating an incessant reentrant circuit by partially damaging both the accessory pathway and the A-V node conduction.

“Incisional” Reentrant Atrial Tachycardia: How to Prevent and Treat It?

Patients submitted to cardiac surgery for correction of congenital or acquired heart diseases may subsequently experience several types of atrial tachyarrhythmias [1–4]. Most of these are macroreentrant atrial tachycardias strictly related to the presence of scars, prosthetic materials, or conduits and have therefore been named “incisional” or “scar-related” atrial tachycardias. Although their electrocardiographic characteristics may resemble those of atrial flutter, slight differences in P wave morphology and tachycardia cycle length are present and should be identified in order to formulate the correct diagnosis. “Incisional” atrial tachycardia may occur at widely variable times after the operation, most frequently in patients submitted to septal atrial defect repair and Fontan or Mustard procedures for tricuspid atresia or great vessel transposition correction, respectively. The true prevalence of these arrhythmias is unknown; small retrospective series reported a prevalence of 32–57% after the Fontan procedure [4, 6, 7] and about 15% after the Mustard operation [3, 8].

Prolonged or Failed Attempts at RF Ablation of Accessory Pathways: What Are the Causes?

In 1997 almost the entire population with arrhythmias related to the presence of an anomalous AV pathway (AP) is treated successfully by radiofrequency catheter ablation (RF-CA) without excessive difficulty, but in some cases a very prolonged procedure or a second session or both are required to obtain a successful outcome [1].