Laila González-Melchor

Permanent junctional reciprocating tachycardia in a patient with an atypically located accessory pathway in the left lateral mitral annulus.

Permanent junctional reciprocating tachycardia (PJRT) is an uncommon form of atrioventricular reentrant tachycardia due to an accessory pathway characterized by slow and decremental retrograde conduction. The majority of accessory pathways in PJRT are located in the posteroseptal zone. Few cases of atypical location have been described. We report a case of PJRT in a 72-year-old woman in whom the accessory pathway was located in the left lateral region and treated by radiofrequency catheter ablation.

ECG, October 2018

1. Probably, given the axis change, QRS width, and RS interval, this is ventricular tachycardia. 2. Based on the baseline intraventricular conduction disorder, the R wave peak time in lead II (< 50 ms) and the presence of RS complexes in precordial leads (V5 and V6), the patient may have aberrantly conducted supraventricular tachycardia. 3. Based on the presence of a Q wave in the aVR lead > 40 ms (Vereckei criterion) and baseline electrocardiogram, this is probably ventricular tachycardia. 4. All are incorrect.

Acute and long-term outcomes of simultaneous atrioventricular node ablation and leadless pacemaker implantation

Leadless pacemaker (LDP) allows implantation using a femoral approach. This access could be utilized for conventional atrioventricular nodal ablation (AVNA). It could facilitate unifying the two procedural components. Data regarding its feasibility and long‐term outcomes remain lacking. We aim to evaluate the feasibility and long‐term outcomes of sequential LDP and AVNA.

Ablation of atrial fibrillation in patients with Brugada syndrome: A systematic review of the literature

Supraventricular arrhythmias are common in Brugada syndrome (BS), and notoriously difficult to manage with medical therapy secondary to associated risks. Pulmonary vein isolation (PVI) is often utilized instead, but its outcomes in this population are not well‐known. We aim to provide a holistic evaluation of interventional treatment for Atrial fibrillation (AF) in the BS population. Electronic databases Medline, Embase, Cinahl, Cochrane, and Scopus were systematically searched for publications between 01/01/1995 and 12/31/2017. Studies were screened based on predefined inclusion and exclusion criteria. A total of 49 patients with BS and AF were included. Age range from 28.8 to 64 years, and 77.5% were male. 38 patients were implanted with implantable cardioverter‐defibrillators (ICD) at baseline, and of them, 39% suffered inappropriate shocks for rapid AF. 34/49 (69%) of patients achieved remission following a single PVI procedure. Of the remaining, 13 patients underwent one or more repeat ablation procedures. Overall, 45/49 (91.8%) of patients remained in remission during long‐term follow‐up after one or more PVI procedures in the absence of antiarrhythmic drug (AAD) therapy. Postablation, no patients suffered inappropriate ICD shock. Furthermore, no major complications secondary to PVI occurred in any patient. AF ablation achieves acute and long‐term success in the vast majority of patients. It is effective in preventing inappropriate ICD therapy secondary to rapid AF. Complication rates of PVI in BS are low. Thus, in light of the risks of AADs and risk of inappropriate ICD shocks in the BS population, catheter ablation could represent an appropriate first‐line therapy for paroxysmal atrial fibrillation in BS patients.

Cardiac resynchronization therapy outcomes in patients under nonoptimal medical therapy

Cardiac resynchronization therapy (CRT) is indicated in symptomatic heart failure (HF) patients after achieving optimal medical therapy (OMT). However, many patients may not be under OMT when the CRT device is implanted. Here, we evaluate the long‐term benefits of CRT in symptomatic HF patients receiving or not OMT.

Prognostic value of nutrition status in the response of cardiac resynchronization therapy

Background Cardiac resynchronization therapy (CRT) is indicated in symptomatic heart failure (HF) patients after achieving optimal medical therapy. However, there are still a large percentage of patients who do not respond to CRT. Malnutrition is a frequent comorbidity in patients with HF, and it is associated with a poorer prognosis. Here, we evaluate the nutritional status of patients assessed by Controlling Nutritional Status (CONUT) score and its association with structural remodeling and cardiovascular events. Methods We investigated the effect of CONUT on HF/death in 302 consecutive patients with a CRT device implanted between 2005 and 2015 in a single tertiary center. We categorized the patients into three groups: normal nutritional status (CONUT 0–1), mild malnutrition (CONUT 2–4) and moderate-severe malnutrition (CONUT ≥ 5). Changes in nutritional status were assessed in patients with mild-to-severe malnutrition prior to CRT. Results One hundred and forty-eight patients exhibited normal nutritional status (49.0%), 99 patients exhibited mild malnutrition (32.8%) and 55 patients exhibited moderate-severe malnutrition (18.2%). CONUT scores of at least 2 were associated with higher risk of HF/death compared with CONUT 0–1. Significant left ventricular (LV) reverse remodeling was noted in patients with better nutritional status. In addition, those malnutrition patients at baseline that improved nutritional state exhibited fewer HF/death events at follow-up. Conclusion CONUT score prior to CRT was an independent risk factor of death/HF and was correlated with LV reverse remodeling. Improvements in CONUT score during long-term follow-up were associated with a reduction in the rate of HF/death.

Case reportPermanent junctional reciprocating tachycardia in a patient with an atypically located accessory pathway in the left lateral mitral annulusTaquicardia juncional permanente reciprocante numa doente com via acessória de localização atípica no anel mitral lateral esquerdo

Permanent junctional reciprocating tachycardia (PJRT) is an uncommon form of atrioventricular reentrant tachycardia due to an accessory pathway characterized by slow and decremental retrograde conduction. The majority of accessory pathways in PJRT are located in the posteroseptal zone. Few cases of atypical location have been described. We report a case of PJRT in a 72-year-old woman in whom the accessory pathway was located in the left lateral region and treated by radiofrequency catheter ablation.

Epicardial mapping and ablation of the right ventricle substrate during flecainide testing in Brugada syndrome

Brugada syndrome (BrS) is characterized by ST-segment elevation in right precordial leads on 12-lead electrocardiogram (ECG) with associated sudden cardiac death because of ventricular fibrillation (VF). The ECGmanifestations of this syndrome are often dynamic or concealed and may be unmasked or modulated by sodium channel blockers, febrile state, vagotonic agents, α-adrenergic agonists, β-adrenergic blockers, a combination of glucose and insulin, hypoand hyperkalemia, alcohol or cocaine toxicity, and tricyclic antidepressants, as well as other medical drugs. In symptomatic patients the implantation of an implantable cardioverter-defibrillator (ICD) is recommended, with or without medical treatment, with the purpose of reduction of the ionic imbalance at the end of phase 1 of action potential, inhibitors of potassium outward currents (ito), or drugs that increase calcium currents (ICaL). In 2011 Nademanee et al published a case series of 9 symptomatic patients with BrS who had recurrent VF episodes and ICD discharges who underwent epicardial ablation of the right ventricular outflow tract (RVOT). As Sacher et al discovered later and then published by Boyle and Shivkumar, in this location low voltages with prolonged duration and fractionated late potentials were found, and preliminary studies have shown an absence of clinical recurrence after the procedure of 78% in a 20-month follow-up.