Jakub Baran

Intracardiac Echocardiography for Detection of Thrombus in the Left Atrial Appendage: Comparison with Transesophageal Echocardiography in Patients Undergoing Ablation for Atrial Fibrillation. The Action-Ice I Study

Background—Transesophageal echocardiography (TEE) is the gold standard for the exclusion of thrombi in the left atrial appendage (LAA) before ablation for atrial fibrillation. Intracardiac echocardiography (ICE) is used to assist atrial fibrillation ablation; however, it can also be used for LAA imaging. The aim of our study was to determine whether ICE could replace TEE and to identify the optimal ICE placement for LAA visualization. Methods and Results—Seventy-six consecutive patients (56 men; mean age, 55±9.6 years) scheduled for atrial fibrillation ablation underwent TEE before the procedure and LAA assessment by ICE. An 8F AcuNav probe was introduced into right atrium, pulmonary artery, and coronary sinus. LAA structure was analyzed by the echocardiographer and electrophysiologist who were blinded to the results of TEE. ICE probe was positioned in the right atrium in all patients, in the pulmonary artery in 64 of 74 (86%) patients, and in the coronary sinus in 49 of 74 (66%) patients. The LAA was properly visualized in 56 of 64 (87.5%) patients from the pulmonary artery versus 13 of 49 (26%) patients from the coronary sinus (P<0.001). From the right atrium, the whole LAA cavity could not be seen in any patient. In those patients in whom LAA was visualized properly by ICE, a perfect agreement between ICE and TEE was obtained (both techniques detected LAA thrombus in 2 patients and excluded LAA thrombus in the remaining patients). Conclusions—ICE can be used safely and effectively for the evaluation of LAA in patients undergoing atrial fibrillation ablation. ICE imaging from pulmonary artery is accurate for LAA visualization. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01371279.

“Rescue” ablation of electrical storm in arrhythmogenic right ventricular cardiomyopathy in pregnancy

BackgroundRadiofrequency ablation (RFCA) became a treatment of choice in patients with recurrent ventricular tachycardia, ventricular fibrillation, and appropriate interventions of implanted cardioverter-defibrillator (ICD), however, electrical storm (ES) ablation in a pregnant woman has not yet been reported.Case presentationWe describe a case of a successful rescue ablation of recurrent ES in a 26-year-old Caucasian woman during her first pregnancy (23rd week). The arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) was diagnosed 3 years earlier and several drugs as well as 2 ablations failed to control recurrences of ventricular tachycardia. RFCA was performed on the day of the third electric storm. The use of electroanatomic mapping allowed very low X-ray exposure, and after applications in the right ventricular outflow tract, arrhythmia disappeared. Three months after ablation, a healthy girl was delivered without any complications. During twelve-month follow-up there was no recurrence of ventricular tachycardia or ICD interventions.ConclusionsThis case documents the first successful RFCA during ES due to recurrent unstable ventricular arrhythmias in a patient with ARVD/C in pregnancy. Current guidelines recommend metoprolol, sotalol and intravenous amiodarone for prevention of recurrent ventricular tachycardia in pregnancy, however, RFCA should be considered as a therapeutic option in selected cases. The use of 3D navigating system and near zero X-ray approach is associated with minimal radiation exposure for mother and fetus as well as low risk of procedural complication.

Antazoline for rapid termination of atrial fibrillation during ablation of accessory pathways

BACKGROUND AND AIM To assess safety and efficacy of antazoline for termination of atrial fibrillation (AF) occurring during ablation of accessory pathways (AP). METHODS We analyzed electrophysiological mechanism of antazoline (changes in A-A interval) and the percentage of pre-excited QRS complexes before and after antazoline administration. The total dose administered and the time from the start of injection to sinus rhythm restoration were also measured. RESULTS Out of consecutive 290 patients with Wolff-Parkinson-White syndrome undergoing radiofrequency (RF) ablation, 12 (4.1%) (4 females, mean age 36 ± 20 years) developed sustained AF which did not stop spontaneously within 10 min, and antazoline in 100 mg repeated boluses was administered. In all 12 patients the drug restored sinus rhythm after a mean of 425 ± 365 s (range 43-1245 s) using a mean cumulative dose of 176 ± 114 mg (range 25-400 mg). The drug slightly prolonged R-R intervals during AF (from 383 ± 106 to 410 ± 70 ms) and reduced the percentage of fully pre-excited QRS complexes (from 35% to 26%). Intracardiac recordings showed gradual increase in A-A intervals, as well as regularization and decreasing fractionation of atrial activity following drug injection (mean A-A interval of 162 ± 30 ms at baseline vs. 226 ± 26 ms shortly before sinus rhythm restoration, p < 0.001). AP was not completely blocked in any patient which enabled continuation of ablation. CONCLUSIONS Antazoline safely and rapidly converts AF into sinus rhythm during ablation of AP. The drug does not block AP completely, enabling continuation of ablation. The drug converting AF into more organized atrial activity (atrial flutter/tachycardia) before sinus rhythm resumption.

Application of a novel liquid chromatography/tandem mass spectrometry method for the determination of antazoline in human plasma: Result of ELEPHANT-I [ELEctrophysiological, pharmacokinetic and hemodynamic effects of PHenazolinum (ANTazoline mesylate)] human pharmacokinetic study.

Antazoline is a first-generation antihistaminic agent with antiarrhythmic quinidine-like properties. In some countries, it is widely used for termination of cardiac arrhythmias, especially atrial fibrillation (AF). However, no human pharmacokinetic studies have been conducted with intravenous antazoline. The aim of our study was to develop and validate a novel liquid chromatography/tandem mass spectrometry (LC-MS/MS) method for the determination of antazoline in human plasma: the ELEPHANT-I [ELEctrophysiological, pharmacokinetic and hemodynamic effects of PHenazolinum (ANTazoline mesylate)] human pharmacokinetic study. Antazoline was extracted from plasma using liquid-liquid extraction. The concentration of the analyte was measured by LC-MS/MS with xylometazoline as an internal standard. The method was validated for linearity, precision, accuracy, stability (freeze/thaw stability, stability in autosampler, short and long term stability), dilution integrity and matrix effect. The analyzed validation criteria were fulfilled. The method was applied to a pharmacokinetic study involving 10 healthy volunteers. Following a single intravenous dose of antazoline mesylate (100 mg), the plasma concentration profile showed a relative fast elimination with a terminal elimination half-life of 2.29 h. A relatively high volume of distribution was observed (Vss=315 L). The values of mean residence time (MRT∞), area under the curve (AUC∞) and clearance were 3.45 h, 0.91 mg h L(-1) and 80.5 L h(-1), respectively. One volunteer showed significant differences in pharmacokinetic parameters. In conclusion, the proposed new LC-MS/MS method was successfully used for the first time for the determination of antazoline in human plasma.

Antazoline—insights into drug-induced electrocardiographic and hemodynamic effects: Results of the ELEPHANT II substudy

Antazoline is an old antihistaminic and new antiarrhythmic agent with unknown mechanisms of action which recently has been shown to effectively terminate atrial fibrillation. The aim of study was to examine the effects of antazoline on hemodynamic and ECG parameters.

Rivaroxaban twice daily for lysis of left atrial appendage thrombus: a potential new therapeutic option.

430 8 weeks, the patient underwent the second TEE, which excluded the presence of the LAA thrombus (FIGURE 1B). Moreover, on the day before ablation, intracardiac echocardiography was performed and confirmed no thrombus in the LAA (FIGURE 1C). Blood samples were taken during both treatment regimens 3, 12, and 24 hours after the morning dose of rivaroxaban to measure the activity of the anti-Xa factor. We used the anti-factor Xa chromogenic method (Diagnostica Stago, Asnières-surSeine, France), with the therapeutic range of plasma rivaroxaban levels between 20 and 500 ng/ml, which is sufficient to define the therapeutic level of rivaroxaban during its administration. The measurements showed a markedly higher activity of anti-Xa factor at the studied time points during treatment with rivaroxaban, 15 mg twice daily, compared with a standard dose of 20 mg once daily (FIGURE 1D). No bleeding complications occurred. In the available literature, there are single case reports demonstrating the efficacy of the recommended once-daily dose of rivaroxaban in dissolving LAA thrombi.3,4 An ongoing multicenter study5 evaluates the efficacy of oral rivaroxaban (once daily) in dissolving an LAA thrombus in patients with nonvalvular AF. However, there are patients in whom the thrombus persists despite therapy. Rivaroxaban is a direct factor Xa inhibitor used in the treatment and prevention of thromboembolic events. In patients with atrial fibrillation (AF), a single daily dose is recommended,1 whereas in those with acute deep vein thrombosis or pulmonary embolism, rivaroxaban should be used twice daily for 3 weeks. Considering the relatively short half-life of rivaroxaban (7–11 hours) and rare but known cases of a persistent thrombus in the left atrial appendage (LAA) despite the use of rivaroxaban once daily,2 the question arises of whether some patients with AF should receive the drug twice daily. We present a case of a 45-year-old obese man with hypertension and persistent AF with a CHA2DS2-VASc score of 1 and a HAS-BLED score of 0, who was admitted to our center for AF ablation. The patient had been on chronic therapy with rivaroxaban (20 mg once daily), β-blockers, and angiotensin-converting enzyme inhibitors. Routine preablation transesophageal echocardiography (TEE) revealed a thrombus in the LAA (FIGURE 1A), and ablation was postponed. The patient entered the ongoing Riva-Twice study (approved by a local ethics committee; No. 49/PB/2015), and the dose of rivaroxaban was increased to 15 mg twice daily. After Correspondence to: Roman Piotrowski, MD, Oddział Kardiologii, Centrum Medyczne Kształcenia Podyplomowego, Szpital Grochowski, ul. Grenadierow 51/59, 04-073 Warszawa, Poland, phone: +48 22 51 52 757, e-mail: rpiotrow@op.pl Received: April 14, 2016. Revision accepted: May 13, 2016. Published online: June 15, 2016. Conflict of interests: none declared. Pol Arch Med Wewn. 2016; 126 (6): 430-431 doi:10.20452/pamw.3435 Copyright by Medycyna Praktyczna, Kraków 2016 CLINICAL IMAGE

Cryoballoon ablation for atrial fibrillation – is cryoenergy applied only to the pulmonary vein ostium?

This case report shows that cryoablation of pulmonary veins (PV) may occasionally result in deeper lesions than expected and collateral damage in spite of proper ostial positioning of cryoballoon. The use of intracardiac vascular ultrasound and repeated computed tomography enabled detailed examination of these findings.

Intracardiac echocardiography for verification for left atrial appendage thrombus presence detected by transesophageal echocardiography: the ActionICE II study

Transesophageal echocardiography (TEE) remains the gold standard for exclusion of left atrial appendage (LAA) thrombus in patients scheduled for direct electrical cardioversion (DEC) or atrial fibrillation (AF) ablation. Recently, intracardiac echocardiography (ICE) of the pulmonary artery (PA) has been shown to provide excellent LAA images and to be useful in verification of equivocal TEE findings.

A novel technique for iatrogenic pseudoaneurysm obliteration with ultrasound-guided thrombin foam injection

BACKGROUND Iatrogenic pseudoaneurysms (IPA) are treated with ultrasound-guided thrombin injections (UGTI). We describe a novel technique for IPA repair that applies UGTI with thrombin foam (UGTFI). METHODS AND RESULTS Successful obliteration of 6 IPAs (IPA without a neck, n = 5; with a neck, n = 1) in 6 patients (2 males, aged 68 ± 1 years, 4 females, aged 59 ± 11 years) was performed by using UGTFI. The dose of administered thrombin was 25-75 IU. No microembolization phenomenon and no serious clinical complications were observed. CONCLUSIONS Treatment of IPA with UGTFI may reduce the embolization rate, risk of IPA cavity thrombin leakage, required drug dose. Use of the thrombin foam could be the next step in the development of the UGTI, particularly in the treatment of IPA without a neck.

Noninvasive assessment of left atrial fibrosis. Correlation between echocardiography, biomarkers, and electroanatomical mapping

Left atrial (LA) fibrosis promotes atrial fibrillation (AF), may predict poor radiofrequency catheter ablation (RFCA) outcome, and may be assessed invasively using electroanatomical mapping (EAM). Speckle tracking echocardiography (STE) enables quantitative assessment of LA function. The aim was to assess the relationship between LA fibrosis derived from EAM and LA echocardiographic parameters as well as biomarkers of fibrosis in patients with AF.