Olivier Deceuninck

Intravenous Adenosine to Predict Conduction Recurrence in Cavotricuspid Isthmus Early After Ablation of Typical Atrial Flutter: Myth or Reality?

Adenosine and Ablation of Typical Atrial Flutter. Introduction: Early recovery of conduction (ER) after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFl) occurs in approximately 10% of the patients. If not recognized, ER might lead to AFl recurrences. In this study, we hypothesized that intravenous adenosine (iADO) can be used to predict ER in the CTI immediately after RF ablation and distinguish functional block from the complete destruction of the CTI myocardium.

Massive Air Embolism After Central Venous Catheter Removal

A 66-year-old patient had a left central venous catheter in place for 8 days. The catheter, which had to be removed, was withdrawn while the patient was in a 180° supine position during a Valsalva maneuver, with positive pressure during removal. A massage at the site of puncture was performed for 3 minutes, and a compressive plaster was applied. Several minutes after removal, the patient, still supine, needed to cough. He immediately became sweaty and breathless, with progressive improvement after 5 to 10 minutes. However, after ≈20 minutes, the patient was still coughing and became more breathless and somnolent, with an O2 saturation of 93% …

Variable morphologies of preexcitation due to a concomitant Brugada pattern

Since the first publication of the Brugada syndrome in 1992 several variants of this ECG pattern have been described. We report a very unusual case of preexcitation with changing electrocardiographic morphologies which appeared to be an association of a variable Brugada pattern with a persistent antegrade preexcitation.

Integrity of the Ganglionated Plexi is Essential to Parasympathetic Innervation of the Atrioventricular Node by the Right Vagus Nervez

Radiofrequency isolation of pulmonary vein can be accompanied by transient sinus bradycardia or atrioventricular nodal (AVN) block, suggesting an influence on vagal cardiac innervation. However, the importance of the atrial fat pads in relation with the vagal innervation of AVN in humans remains largely unknown. The aim of this study was to evaluate the role of ganglionated plexi (GP) in the innervation of the AVN by the right vagus nerve.

Incidence of left atrial thrombus prior to catheter ablation of atrial fibrillation: Is it time for atrial cardiomyopathy evaluation?

To the Editor, We read with great interest the article by Gunawardene et al.1 We would like to add some commentaries about the presence of left atrial thrombus in anticoagulated patients with atrial fibrillation (AF) before pulmonary vein isolation. In this recently published article, the authors concluded that: “Preprocedural transesophageal echocardiography (TEE)maybedispensed in patients with a CHA2DS2-VASc score ≤1,” because “a cut off value for a CHA2DS2-VASc score of ≤1 has a 100% sensitivity for exclusion of left atrial appendage thrombus.” In some patients (“with an increase in the CHA2DS2-VASc score, a reduced LVEF of less than 30%, a history of nonparoxysmal AF, or presence of hypertrophic cardiomyopathy”), a “TEE should be performed leading to an individualized approach in this regard.” In another study of similar design,2 the authors obtained an identical result: A “CHA2DS2-VASc score<2has amaximal-negative predictive value for thepresenceof left atrial/left atrial appendage thrombi in anticoagulated patientswith AF planned for pulmonary vein isolation.” In addition, left atrial appendage thrombi were significantly associated with persistent AF (P = 0.002), heart failure (P < 0.001), diabetes mellitus (P = 0.017), spontaneous echo contrast (P < 0.001), and low left atrial appendage-peak emptying velocity (P< 0.001). Analyzing the literature quoted by Gunawardene et al.1 (table 7), we remarked that in our study with 681 patients, we found almost the same prevalence of left atrial/left atrial appendage thrombi before AF ablation (1% vs. 0.78%).2 Moreover, themost important thing is that in this population,we proposed an algorithm, making a distinction between paroxysmal and nonparoxysmal AF and the decision not to perform a TEEwas restricted to patientswithout heart disease.2 In these patients, the presence of left atrial/left atrial appendage seems to be not depending on an appropriate anticoagulation level3 or anticoagulation treatment type (with vitamin K or nonvitamin K antagonists),1 neither of clinical risk factors4 as CHA2DS2-VASc scores ≥2; history of nonparoxysmal AF; chronic heart failure, as well as nonclinical ones like4: dilated left atrium; hypertrophic cardiomyopathy; left atrial appendage morphology (≥3 left atrial appendage lobes), or the presence of sinus rhythm at the time of TEE. We agree that “an individual risk stratification on preablation TEE should be conducted for each patient prior to AF ablation, instead of making a generalized statement on whether preablation TEE is dispensable or not in all patients undergoing AF ablation.” Probably, it is time for an individualized approach in every patient with AF, appropriate anticoagulated or not, because left atrial fibrosis is the key. Hypercoagulability causes atrial fibrosis and promotes AF5 due to thrombogenic fibrotic atrial cardiomyopathy occurrence6; left atrial fibrosis induced by structural remodeling is associated with stroke risk.7 This vicious circle should be analyzed in each patient. Therefore, probably, it is time for atrial cardiomyopathy evaluation to understand the incidence of left atrial thrombus prior to catheter ablation of AF.

Decision of anticoagulation in patients with atrial fibrillation and low CHA2DS2-VASc score remains challenging

Atrial fibrillation is the most common cardiac rhythm disorder. The incidence and prevalence of atrial fibrillation increase with age. Atrial fibrillation causes high morbidity particularly due to systemic embolism. Several studies have reported that anticoagulation therapy using warfarin reduced 50% of the incidence of thromboembolism in atrial fibrillation patients. A number of scoring systems have been established to assess the risk of embolization in patients with non-valvular atrial fibrillation. In 2006, the guidelines of the ESC/ ACC/AHA recommended the use of the CHADS2 score system, which was replaced by the CHA2DS2-VASc score system in 2010 1. The CHA2DS2-VASc score system was developed as an extension of the CHADS2 score system, after the identification of additional stroke risk factors. The CHA2DS2-VASc score system is based on the presence of heart failure or an ejection fraction ≤ 35% (1 point), hypertension (1 point), age (1 point), diabetes (1 point), medical history of stroke or systemic embolism, (2 points), vascular diseases (1 point), and gender (1 point). The patients with a score of 0, 1, or > 1 have low, intermediate, and high stroke risk, respectively. Anticoagulation therapy is typically recommended for patients with a CHA2DS2-VASc score of > 1 unless Decision of anticoagulation in patients with atrial fibrillation and low CHA2DS2-VASc score remains challenging

Spontaneous migration of a nonfixed RV lead 3 weeks after implantation.

Figure 1. Migration of the right ventricular lead 3 weeks after initial implantation. 450 × 347 mm. initial postsurgery levels of both the atrial and ventricular leads were normal. However, 3 weeks after surgery the patient came back with presyncopal symptoms and left lateral thoracic pain. At that time, the atrial lead characteristics had not changed. Surprisingly, the ventricular lead did not capture the right ventricle anymore (threshold of stimulation >5V for 1 ms) and the detection level was undefinable. Impedance, however, was measured “as normal.” A chest X-ray (Fig. 1) confirmed the migration of the lead, surprisingly as far as the left rib-cage. A CT-scan (Fig. 2) was performed and demonstrated that the lead went through the RV apex, all the way into the left pleural cavity. This abnormal pathway for a lead led to small asymptomatic pleural and pericardic effusions. The RV lead was pulled back to RV apex under general anaesthesia and transesophageal echocardiography control without any complication. This unusual observation can best be explained by the absence of fixation of the lead to the pectoral muscle during the initial surgery.

Exercise intolerance due to sustained atrial bigeminy with short coupling interval.

Atrial bigeminy is a supraventricular arrhythmia rarely associated with severe symptoms. We report the case of a 22-year-old woman with no prior cardiac disease presenting with exercise intolerance since several months. No apparent heart disease other than a spontaneous conducted atrial bigeminy with a short coupling interval was found. At bicycle ergometric testing, symptoms occurred, because of an inadequate increase in pulse rate, due to sustained atrial bigeminy. At electrophysiological study, an ectopic atrial focus at the right atrial septum was successfully ablated.