Kivanc Yalin

Gastroparesis as a Complication of Atrial Fibrillation Ablation

Percutaneous catheter ablation is a safe and effective treatment for symptomatic drug-resistant atrial fibrillation (AF). Gastroparesis is a little known complication of AF ablation. We aimed to evaluate the frequency of gastroparesis in the patients who underwent catheter ablation for AF by cryoballoon (CB) or radiofrequency (RF) and to define risk factors for gastroparesis. In all, 104 patients were treated with pulmonary vein (PV) isolation with 2 different technologies: CB in 58 patients (group 1) and open-irrigated tip RF catheter in 46 patients (group 2). Gastroparesis was seen in 7 cases (6 cases in group 1 and 1 case in group 2, respectively). The complaints related with gastroparesis began during the procedure in 4 of 6 patients of group 1. The other 3 patients admitted to our outpatient clinic with similar complaints within 72 to 96 hours after the procedure. For gastroparesis cases of group 1, mean minimal CB temperature on inferior PVs was lower and left atrium diameter was smaller. Management was conservative, and the patients have no residual symptoms at 6-month follow-up. The only patient still demonstrating residual symptoms during follow-up was in group 2. Although, clinically manifest gastroparesis is quite common with CB ablation, the process is generally reversible. However, damage may not be as reversible with RF ablation. In conclusion, during cryoablation, lower temperatures on inferior PVs and small left atrium size may be associated with increased risk of gastroparesis, and fluoroscopic guidance may be useful to avoid this complication.

Infarct characteristics by CMR identifies substrate for monomorphic VT in post-MI patients with relatively preserved systolic function and ns-VT.

The extent of peri‐infarct zone (PIZ) by contrast‐enhanced cardiac magnetic resonance (ce‐CMR) has been related to inducibility of ventricular arrhythmia in patients with ischemic cardiomyopathy. However, this relationship has not been established in postmyocardial infarction (post‐MI) patients with relatively reserved left ventricular (LV) systolic function yet. In this study, we investigated myocardial scar size and characteristics and its relationship with ventricular arrhythmia inducibility in patients with relatively preserved LV systolic function.

Electromechanical association: a subtle electrocardiogram artifact.

Artifacts on electrocardiogram (ECG) can simulate serious cardiac disorders. Although most common ECG artifacts can be easily recognized, in some exceptional situations, some patterns may hide pretty well even from experienced eyes. We recently reported an unusual ECG artifact caused by radial arterial impulse that closely imitates abnormal T wave. We now report 3 more examples and caught-in-the-act evidence of this subtle and dangerous artifact source.

Impact of transesophageal echocardiography during transseptal puncture on atrial fibrillation ablation

The aim of our study was to demonstrate the added value of routine transesophageal echocardiography (TEE) for correctly positioning the transseptal system in the fossa ovalis (FO), thus potentially preventing complications during fluoroscopy‐guided transseptal puncture (TP), and for assessing the optimal puncture site within the FO according to the expected procedure type.

Functional permanent 2:1 atrioventricular block treated with cardioneuroablation: Case report

A 54-year-old woman had undergone slow pathway ablation for AV nodal reentrant tachycardia 3 years ago. Before admission she had started to present with recurrent dizziness and syncope due to 2:1 AV block and was referred for pacemaker implantation. She was asymptomatic and had no signs of AV conduction abnormalities until 2 weeks ago. AV conduction abnormality resolved with atropine infusion until stage 2 of a treadmill exercise test. Electrophysiologic study showed suprahisian 2:1 AV block. After cardioneuroablation, the parameters of AV conduction normalized. Holter recordings were normal, and the patient was asymptomatic at the end of 12-month follow-up. Several clinical conditions comprise autonomic dysfunction by enhanced parasympathetic tone together with decreased sympathetic tone. Enhanced parasympathetic tone may cause sinus bradycardia or pauses, transient or permanent atrioventricular (AV) block, carotid sinus syndrome, or neurally mediated reflex syncope. Although the conduction system is not involved in these patients, they may present with serious symptoms. The parasympathetic postganglionic neuron body cell is located at the cardiac wall in the paracardiac ganglia. Cardioneuroablation is a little known technique for management of patients with excessive vagal activation. The technique is based on radiofrequency (RF) catheter ablation of autonomic connections in the 3 main ganglia around the heart.

Combined analysis of unipolar and bipolar voltage mapping identifies recurrences after unmappable scar-related ventricular tachycardia ablation

AIMS Scars causing ventricular tachycardia can extend deep to and beyond bipolar low-voltage areas (LVAs) and they may be a reason for endocardial ablation failure. Analysis of endocardial unipolar voltage maps has been used to detect scar transmurality and epicardial scar. We hypothesized that endocardial unipolar LVA around the overlying bipolar LVA may predict endocardial ablation recurrence in patients with structural heart disease undergoing substrate modification. METHODS AND RESULTS Twenty consecutive patients with structural heart disease (11 ischaemic and 9 non-ischaemic cardiomyopathy) and undergoing substrate modification due to unmappable ventricular tachycardia (VT) (18 males, 51 ± 11 age, LVEF: 36 ± 7%) were retrospectively reviewed. Bipolar LVA defined as <1.5 mV and unipolar LVA defined as <8.3 mV, respectively, on electro-anatomic mapping system. Peripheral unipolar LVA (pUni-LVA) surrounding bipolar LVA was measured and compared patients with and without VT recurrence at 6-month follow-up period. : Mean unipolar voltage and mean bipolar voltage was 6.26 ± 4.99 and 1.90 ± 2.30 mV, respectively. Bipolar voltage and unipolar voltage in corresponding points were correlated (r = 0.652, P = 0.0001). In all patients, unipolar LVAs were larger than the bipolar LVAs. Bipolar LVA (91.1 ± 93.5 vs. 87.5 ± 47.5 cm(2), P = 0.91) and unipolar LVA (148.1 ± 96.3 vs. 104.7 ± 44.2 cm(2), P = 0.21) were similar in patients with and without VT recurrence, respectively. Peripheral unipolar LVA was significantly larger in patients with VT recurrence than without (57.0 ± 40.4 vs. 17.2 ± 12.9 cm(2), P = 0.01). CONCLUSION In patients with structural heart disease and unmappable VT, pUni-LVA surrounding bipolar scar predicts recurrence of VT ablation. The results of this pilot study highlight the importance of intramural/epicardial substrate on endocardial VT ablation outcome.

Is achievement of pulmonary vein isolation the only effect of cryoballoon ablation in long-standing persistent atrial fibrillation?

A case of long-standing persistent atrial fibrillation (LPAF) that underwent hybrid treatment combining transvenous cryothermal and radiofrequency (RF) energy is described in the present report. Complex fractionated atrial electrogram (CFAE) maps before and after cryoablation revealed not only pulmonary vein isolation (PVI), but also a large antral ablation of CFAEs. Following cryoablation, a severe reduction in remote left atrial CFAE area was observed.

Successful ablation of an epicardial ventricular tachycardia by video-assisted thoracoscopy

A 19-year-old female was referred to us for monomorphic premature ventricular contraction (PVC) and non-sustained monomorphic ventricular tachycardia. The patient had undergone three endocardial (EN) and two combined EN and epicardial (EP) ablation attempts. The 12-lead ECG showed a PVC with an RBBB morphology …

Prediction of mid-term outcome after cryo-balloon ablation of atrial fibrillation using post-procedure high-sensitivity troponin level : cardiovascular topics

Objective High-sensitivity troponin I (hsTnI) assays lead to, among other things, improvement in the detection of myocardial injury and improved risk stratification of patients with atrial fibrillation (AF). The aim of this study was to investigate the association between post-procedure cardiac biomarkers and clinical outcome in patients undergoing cryo-balloon ablation (CA) for AF. Methods A total of 57 patients (mean age 55.1 ± 12.2 years, 50.9% female) with symptomatic paroxysmal AF underwent the CA procedure. Two hundred and twenty-eight pulmonary veins (PVs) were attempted for pulmonary vein isolation (PVI) with a second-generation cryo-balloon. hsTnI, CK-MB mass and myoglobin samples were prospectively obtained before and 24 hours after ablation. Result At a mean follow up of 214.6 ± 24.3 days, the probability of being arrhythmia free after a single procedure was 86%. Post-ablation hsTnI (p = 0.001), left atrial (LA) diameter (p = 0.002), duration of AF (p = 0.002), mean minimal temperature of the left superior pulmonary vein (p = 0.005), and age (p = 0.021) were associated with increased AF recurrence rate. On multivariate analysis, lower hsTnI level was the only independent predictor for AF recurrence (p = 0.012). Post-ablation hsTnI levels lower than 4.40 ng/ml predicted AF recurrence during follow up, with a sensitivity of 86% and a specificity of 96%. Conclusion It is well recognised that the PV antrum contributes to initiation and/or perpetuation of AF. A lower postablation hsTnI level may predict an increased AF recurrence rate, suggesting inadequate ablation of the PV antrum. This may be used as a non-invasive marker to predict the outcome of AF.

Selective right atrial cardioneuroablation in functional atrioventricular block.

We read the article with a great interest by Rivorola et al. 1 published recently in Europace Journal entitled ‘Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block’. In this case report, the authors have reported the consequence of cardioneuroablation procedure in a 38-year-old male with vagally mediated atrioventricular (AV) block during sleep. They targeted the endocardial regions with spectral characteristics of endocardial vagal …