Mihaela Grecu

Radiofrequency Catheter Ablation of an Incessant Supraventricular Tachycardia in a Premature Neonate

BRUGADA, J., et al.: Radiofrequency Catheter Ablation of an Incessant Supraventricular Tachycardia in a Premature Neonate. A 32‐week, premature neonate with incessant supraventricular tachycardia and hemodynamic compromise who failed to respond to antenatal and postnatal antiarrhythmic therapy underwent successful radiofrequency catheter ablation (RCA) of a concealed left free‐wall accessory pathway when the infant was 4‐days‐old and weighed only 1,840 grams. At follow‐up performed 60 days after the procedure, the infant remained free of any drug, in sinus rhythm, and in normal hemodynamic condition.

Abnormal Atrioventricular Node Conduction and Atrioventricular Nodal Reentrant Tachycardia in Patients Older Versus Younger Than 65 Years of Age

Study Objective: We examined the possible role of atrioventricular node (AVN) conduction abnormalities as a cause of AVN reentrant tachycardia (RT) in patients >65 years of age.

Complication due to entrapment in the Chiari apparatus

A 58-year-old man was scheduled for typical atrial flutter ablation. During placement of the duodecapolar catheter, its tip was entrapped near …

Outcome in patients with diabetes mellitus undergoing isolated surgical aortic valve replacement

Background: The risk scoring systems used in cardiac surgery (including EuroSCORE II) include only insulin-dependent diabetes. Diabetes mellitus (DM) is a marker of poor prognosis after surgical myocardial revascularization, but its impact in patients with isolated surgical aortic valve replacement (SAVR) has not been well established. Aim: We aimed to analyze differences in outcomes and surgical risk in patients with and without type 2 DM (T2DM), which underwent SAVR. Material and methods: We included retrospectively the patients hospitalized for SAVR between January 2000 and June 2014 in Cardiovascular Surgery Unit of Cardiovascular Diseases Institute. Preoperative parameters and early postoperative outcome in patients with and without T2DM were compared. Results: A number of 1191 patients were included (65.4±13 years; 67.8% men); 144 (12.07%) out of those were with T2DM. Biological prostheses were performed in 22% of patients. Mean age was higher in T2DM group (p=0.005). The mean EuroSCORE II risk score was 5.49±0.63 in T2DM and 4.89±0.17 in non-T2DM patients (p=0.579). In these 2 groups, preoperative left ventricular systolic function was comparable. Mean values of cardiopulmonary bypass time were 137.88±5.71 minutes in T2DM, 149.48±4.8 minutes in non-T2DM patients (p=0.714). The need of inotropic therapy was an important predictor for postoperative evolution (6±2 days in non-T2DM and 15±4 days in T2DM; p=0.008). Conclusions: Patients with T2DM undergoing SAVR have a non-significantly higher operative risk score comparing with non-T2DM patients. In spite of this, T2DM seems to be a risk factor that could worsen the postoperative outcome, by requiring prolonged inotropic treatment.

Sick sinus syndrome - a case report of paroxysmal supraventricular tachycardia due to atrioventricular node re-entry

Sick sinus syndrome encompasses a variety of EKG manifestations consisting of atrial bradyarrhythmias and tachyarrhythmias, alternating bradyarrhythmias and tachyarrhythmias as in tachycardia-bradycardia syndrome. Supraventricular tachyarrhythmias that can occur include atrial flutter, atrial fibrillation, atrial tachycardia and paroxysmal supraventricular tachycardia, although there is no direct causal relation between paroxysmal supraventricular tachycardia and sinus node disease. Atrioventricular node re-entry is a common cause of paroxysmal supraventricular tachycardia episodes. We present the case of a 70 year old female, hospitalized for atypical chest pain and dizziness when walking. The EKG on admission showed sinus bradyarrhythmia, anterior fascicular block, atrial and ventricular extrasystoles. During the hospitalization the patient presented an episode of palpitations, narrow complex tachycardia being registered on the EKG, with no response to the Valsalva maneuver or intravenous beta blocker. The tachyarrhythmia ceased spontaneously after one hour. 24 hour Holter EKG was performed and confirmed sinus node dysfunction. The electrophysiological study identified paroxysmal supraventricular tachycardia due to atrioventricular nodal re-entrant tachycardia, which was successfully treated by ablating the slow intranodal pathway. Therefore, in a case of sick sinus syndrome when the patient’s symptoms cannot be attributed to the bradycardia, but to the tachyarrythmic episodes, it is often most efficient to treat the patients paroxysmal supraventricular tachycardia by radiofrequency ablation, rather than using cardiac pacing.

Diagnosis and management of a wide QRS regular tachycardia

In spite of the available clinical and electrocardiographic criteria for the differential diagnosis of wide QRS complex tachycardias, distinguishing orthodromic supraventricular tachycardias is still a challenge. We present a case of a 63-year old patient admitted in our clinic after experiencing two episodes of syncope. Echocardiography showed left ventricular hypertrophy, grade 1 diastolic dysfunction and left atrial enlargement. A Holter monitoring revealed episodes of atrial fibrillation and paroxysmal narrow QRS tachycardia alternating with wide QRS tachycardia (170-180 bpm). During an electrophysiology study we induced self-limiting orthodromic supraventricular tachycardias with narrow and left bundle branch block patterns. Retrograde mapping near the mitral annulus identified a concealed accessory posteroseptal by-pass tract which was successfully ablated. After the procedure the patient developed atrial flutter and atrial fibrillation with rapid ventricular response (196 beats per minute) with a 3.9 s post-tachycardia pause. The patient underwent implantation of a cardiac pacemaker which allowed us to start antiarrhythmic treatment with amiodarone. This case shows that occult accessory posteroseptal by-pass tracts can have a late-onset presentation in a 63-year old male and explains why latent rhythm disturbances require a step-by-step medical approach.

Vague nerve stimulation in chronic heart failure: is it worth it?

In heart failure the major pathophysiology changes are enhanced sympathetic nervous system activity and reduced parasympathetic activation. Despite advances in pharmacologic treatment and interventional therapies such as implantable devices, mortality and morbidity in patients with advanced heart failure is still higher. In the last three decades the novel interventional and device-based therapies aim to restore cardiac autonomic balance by neuromodulation. Chronic vague nerve stimulation (VNS) is a neuromodulator method proposed as a new potential therapy in patients with heart failure. Results of preclinical animal studies and early clinical trials have demonstrated the safety and efficacy of this therapy in heart failure. Although a favorable long-term safety profile was found in human, improvements in the efficacy endpoints in patients with heart failure by VNS are controversially, as demonstrated by one of the largest recently published trial. Despite that VNS does not reduce left ventricular end-systolic volume index, the rate of death or heart failure events in chronic heart failure patients, this new treatment improved quality of life, NYHA functional class, and 6-min walking distance. Large randomized clinical studies are necessary to evaluate the clinical role of this new therapeutic approach in chronic heart failure.

Complex management of electrical storm in a patient with non-ischemic dilated cardiomyopathy

Electrical storm represents a major clinical emergency characterized by electrical heart instability with several recurrent episodes of ventricular arrhythmias over a short period of time. We present the case of a 67-year old male, hypertensive, diabetic who was referred to the cardiology department after a resuscitated cardiac arrest through sustained ventricular tachycardia. The echocardiography revealed a severe aspect of dilated cardiomyopathy and fibrotic aspect of inferior-posterior wall of the left ventricle. The ischemic coronary cause has been ruled out by coronary computed tomography. An implantable cardioverter defibrillator (ICD) was implanted. One day after, the electrical storm and hemodynamically stability worsened requiring high dosage of amiodarone, putting therapies of ICD on “off” and the intubation of the patient. Taking all into account, an urgent electrophysiological study was performed and led to complex radiofrequency catheter ablation of the substrate of the lateral, medium-ventricular wall. Afterwards, the electrical storm did not reappear, the ICD therapies were put on “on” and the patient was rapidly extubated, being discharged with pharmacological recommendations, the milestone being the anti-arrhythmic treatment. Though the treatment of electrical storm is complex but still unclearly defined, we emphasize the need of applying all the therapeutical measures and having a prompt response to this life-threatening condition.

Wide complex tachycardia – diagnostic and therapeutic challenges

Dilated cardiomyopathy is associated with ventricular arrhythmias and with an increased risk of sudden cardiac death. In these cases, wide complex tachyarrhythmias are frequently a diagnostic challenge. The efficiency of antiarrhythmic drug therapy is limited and often the implantation of a cardiac defibrillator is required. We hereby present the case of a 68 year old male patient known with dilated cardiomyopathy, who experienced a syncopal episode as the clinical expression of a wide complex tachycardia. The recorded electrocardiogram identified ventricular tachycardia originated in the right ventricle or in the interventricular septum. The electrocardiograms recorded before and after the syncopal episode showed a major left bundle-branch block and a first degree atrioventricular block. 24-hour Holter ECG monitoring detected ventricular tachycardia originating in the left ventricle. The etiology of the dilated cardiomyopathy, arrhythmias and conduction abnormalities could not be identified. During the electrophysiological study, no sustained supraventricular or ventricular tachyarrhythmias were triggered. The pharmacological treatment has been optimized and a cardiac defibrillator was implanted. The particularity of this case consists in the presence of multiple rhythm disturbances originating both in the left and right ventricle, in a patient with idiopathic dilated cardiomyopathy and conduction disturbances at several levels.

Minimally invasive epicardial posterior left atrial wall isolation: technique and results

Atrial fibrillation (AF) is the most frequent arrhythmia in clinical practice. Catheter and surgical ablation has emerged as an alternative to maintain sinus rhythm and to avoid long-term AF complications. An ablation technique aims to target the triggers and the substrate of AF to prevent initiation and perpetuation of this arrhythmia. Surgical ablation is the gold standard in AF ablation; it has the best results in maintaining sinus rhythm in patients with persistent AF. Epicardial posterior left atrial wall isolation by right monolateral thoracoscopic approach is a minim invasive surgical technique that aims to eliminate major ganglionated plexi isolation influence on atrial myocardium in addition to pulmonary vein isolation. The exclusion of the left atrial posterior wall, including the pulmonary veins (considered as triggers or initiators) could be completed with an additional isolation/destruction of the adjacent major ganglionated plexi (considered as substrate modifiers) including the complex interconnection neural network which could add to influence the persistence of AF. Different hybrid surgical ablation lesions sets were developed, usually in a manner less than the full Cox-Maze IV lesion set. They are performed epicardially via minimally invasive (non-sternotomy) approaches without cardiopulmonary bypass, followed by catheter-based endocardial mapping, and if necessary additional ablation lines. The results of these innovative techniques are promising in persistent and long persistent AF. Epicardial right monolateral thoracoscopic approach to isolate the pulmonary vein and the major ganglionated plexi isolation in symptomatic refractory persistent AF patients is feasible and efficient.