Marcin Kuniewicz

Left atrial accessory appendages, diverticula, and left-sided septal pouch in multi-slice computed tomography. Association with atrial fibrillation and cerebrovascular accidents

BACKGROUND The aim of this study is to provide a morphometric description of the left-sided septal pouch (LSSP), left atrial accessory appendages, and diverticula using cardiac multi-slice computed tomography (MSCT) and to compare results between patient subgroups. METHODS Two hundred and ninety four patients (42.9% females) with a mean of 69.4±13.1years of age were investigated using MSCT. The presence of the LSSP, left atrial accessory appendages, and diverticula was evaluated. Multiple logistic regression analysis was performed to check whether the presence of additional left atrial structures is associated with increased risk of atrial fibrillation and cerebrovascular accidents. RESULTS At least one additional left atrial structure was present in 51.7% of patients. A single LSSP, left atrial diverticulum, and accessory appendage were present in 35.7%, 16.0%, and 4.1% of patients, respectively. After adjusting for other risk factors via multiple logistic regression, patients with LSSP are more likely to have atrial fibrillation (OR=2.00, 95% CI=1.14-3.48, p=0.01). The presence of a LSSP was found to be associated with an increased risk of transient ischemic attack using multiple logistic regression analysis after adjustment for other risk factors (OR=3.88, 95% CI=1.10-13.69, p=0.03). CONCLUSIONS In conclusion LSSPs, accessory appendages, and diverticula are highly prevalent anatomic structures within the left atrium, which could be easily identified by MSCT. The presence of LSSP is associated with increased risk for atrial fibrillation and transient ischemic attack.

Effectiveness of atrial versus atrioventricular pacing for sick sinus syndrome during long-term follow-up

BACKGROUND According to the current guidelines, atrioventricular (DDD) pacing is superior to atrial pacing (AAI) in the treatment of sick sinus syndrome (SSS). AIM To compare outcomes of AAI and DDD pacing in patients with SSS during long-term follow-up. METHODS We studied 809 patients, including 86 patients in the AAI group (57 women, mean age 65 ± 15 years) and 723 patients in the DDD group (406 women, mean age 71.5 ± 10 years). Evaluation of outcomes of AAI and DDD pacing in SSS was based on the analysis of medical records of patients who underwent pacemaker implantation. RESULTS Average duration of follow-up was 52 ± 25 months. In the AAI group, 63 of 86 patients remained without intervention. In the DDD group, 661 of 723 patients did not require surgical intervention. Overall, 105 patients died, including 13 in the AAI group and 92 in the DDD group (p = 0.4516). In the AAI group, a high degree atrioventricular block occurred on average after 46.3 ± 8.8 months and its incidence was estimated at 0.85% per year. Atrial fibrillation (AF) developed in 8 patients in the AAI group and 81 patients in the DDD group (p = 0.23). Among aetiological factors of an increased risk of developing AF, only the presence of tachycardia-bradycardia syndrome (hazard ratio [HR] 11.31) and the absence of antiarrhythmic therapy (HR 4.23) significantly increased the risk of AF. Urgent reoperation was needed in 23 patients in the AAI group and 62 patients in the DDD group (p < 0.01). Log-rank test analysis showed a significant effect of the development of AF on the risk of reoperation in this group (p = 0.0420). Lead-related complications were noted in 6 patients in the AAI group and 49 patients in the DDD group (p = 0.94). After 45 months, the risk of reoperation in the AAI group increased significantly due to a need for ventricular lead implantation. CONCLUSIONS 1. Atrial stimulation is safe in SSS but it may be associated with an increased risk of ventricular lead implantation if atrioventricular block or persistent AF with slow ventricular rate develops. 2. DDD and AAI groups did not differ significantly in terms of survival, development of persistent AF, and lead-related complications. 3. Tachycardia-bradycardia syndrome and the lack of antiarrhythmic treatment with beta-blocker and amiodarone increased the risk of persistent AF during long-term follow-up. 4. A higher rate of reoperations in patients with AAI systems, related mainly to development of persistent AF, especially after the fourth year of follow-up, may justify DDD system implantation in SSS.

Lead-related complications after DDD pacemaker implantation

BACKGROUND Pacing leads remain the weakest link in pacemaker systems despite advances in manufacturing technology. AIM The aim of the study was to assess the long-term pacing lead performance in an unselected real-life cohort following primary DDD pacing system implantation. METHODS A single-centre retrospective analysis of patients who underwent DDD pacing system implantation between October 1984 and December 2014 and were followed-up until August 2016 was conducted. The inclusion criterion was at least one follow-up visit after post-implant discharge. The performance of each atrial and ventricular lead implanted was evaluated during the follow-up period, and the incidence of, and predictive factors for, lead dislodgement and failure were analysed. RESULTS The data of 3771 patients and 24,431.8 patient-years of follow-up were analysed. The mean follow-up of patients was 77.7 ± 61.8 months. During the study period, 7887 transvenous atrial and right ventricular pacing leads were implanted. Lead dislodgement occurred in 94 (1.2%) leads (92 [2.4%] patients), perforation in 11 (0.1%) leads (10 [0.3%] patients), and lead failure in 329 (4.2%) leads (275 [7.3%] patients). Atrial lead position was a predictive factor for lead dislodgement, while age at implantation, polyurethane 80A insulation, subclavian vein access, unipolar lead construction, and lead manufacturer were multivariate predictors of lead failure. CONCLUSIONS Leads with polyurethane 80A insulation, unipolar construction, and those implanted via subclavian vein puncture exhibited the worst long-term performance.

Ortner’s syndrome after cryoballoon ablation

We present the case of a 54-year-old patient with hypertension, obesity (BMI, 31), paroxysmal atrial fibrillation EHRA class III B, a CHADSVASc score of 4, a HAS-BLED score of 2, a history of TIA, and an ineffective epicardial ablation for atrial fibrillation using the COBRA Fusion systemwith simultaneous ligation of the left atrial appendage 8 months prior. For the repeat ablation procedure, we selected cryoballoon ablation (Arctic Front Advance 28 mm). Using the Achieve diagnostic catheter, we identified potentials in the left superior pulmonary vein (LSPV) with no exit block. After contrast injection, ablation of the LSPVwas performed at − 58 °C until disappearance of pulmonary vein potentials in 30-s applications (cumulative time 150 s). The final result was complete pulmonary venous isolation together with exit and entrance block. During the procedure, the patient was sedated and anesthetized with midazolam and fentanyl. Hoarseness was observed in the early postoperative period. A laryngological examination revealed a left unilateral vocal fold paralysis. A 14day course of oral prednisone did not resolve the hoarseness. In the post-cryoballoon ablation heart CT with contrast, a scar was noted along the epicardial ablation with a change in the architecture of the roof of the left atrium (Fig. 1). After ineffective steroid therapy, we initiated a 10-week course of intramuscularly administeredMilgamma (vitamin B complex, cyanocobalamin 1 mg, pyridoxine 100 mg, and thiamine 100 mg). After 7 days of this therapy, the hoarseness resolved. At follow-up 4 months after the procedure, neither the atrial fibrillation nor the hoarseness has recurred. Ablation is an important and constantly developingmethod of treatment of atrial fibrillation (AF) [1]. Ablations using the COBRA Fusion system may be incomplete in the anteriorsuperior part of the LSPV due to fat thickness along the roofline [2]. LRLN injury was described once during RF ablation over the roof line in close relation to LSPV [3], but never before during cryoballoon ablation. Authors suggested deformation of the atrial wall by a stiff electrode could increase the likelihood of contact with the LRLN [3]. In our case, there was a post-lesion box change in the atrial architecture on the roof after the first ablation which could cause the same effect. This meant the LRLN was within a range of cryoenergy (− 58 °C) that was delivered in the LSPV. These circumstances support the diagnosis of iatrogenic Ortner’s syndrome, which was first described in 1897. Recovery from laryngeal nerve palsy after thermal damage might be spontaneous or with a late response to prednisone therapy, but the effectiveness in recovery after administration of vitamin B combination complex was interesting.

Rytm z szerokimi zespołami QRS — trudności diagnostyczne

In the case described we demonstrate the difficulty in interpreting the rhythm with wide QRS complex. The 25 year old patient with ventricular pre-excitation and periodically occurring rhythm with wide QRS complex, morphology meets the electrocardiographic (ECG) criteria for ventricular arrhythmias and in the absence of P waves. Initial difficulties in the interpretation of ECG were explained by electrophysiological study in which we demonstrate the supraventricular origin of rhythm conducted to the ventricles with pre-excitation. Radio frequency ablation of the accessory pathway reveals the periodically occurring low-atrial rhythm originating in the muscle of the coronary sinus. Very close proximity of the atrial rhythm and the accessory pathway resulted instant conduction of impulse to the ventricle and cause perfect imitation of ventricular rhythm. This case draws attention on the need to take account of none-sinus rhythm with ventricular preexcitation during diagnosis of rhythm with wide QRS complex.