Tamás Tahin

Ablation of the Epicardial Substrate in the Right Ventricular Outflow Tract in a Patient With Brugada Syndrome Refusing Implantable Cardioverter Defibrillator Therapy

Brugada syndrome is associated with a high risk of sudden cardiac death. Currently, the cornerstone of therapy is implantation of an implantable cardioverter defibrillator (ICD). Recently, a novel approach to preventively ablate the substrate located in the anterior epicardial region of the right ventricular outflow tract showed promising results by reducing the number of ventricular fibrillation episodes in patients with ICD. Here we report on a patient with Brugada syndrome who refused ICD therapy in whom a successful epicardial right ventricular outflow tract substrate ablation was performed. In some special cases, ablation therapy might be considered as the sole therapeutic option for these patients.

Electroanatomical mapping systems in catheter ablation of cardiac arrhythmias

Due to the recent technical development of the past years, most cardiac electrophysiological laboratories are equipped with computer-based electroanatomical mapping systems that precisely describe both the temporal and spatial characteristics of cardiac activation. This development has also been driven by the need for increased accuracy in arrhythmia localization as required for catheter ablation. Computer-based electroanatomical mapping systems are able to reconstruct cardiac anatomy and provide a straightforward representation of chamber activation. These systems capture and display details of intracardiac physiology and mark the site of interventions. Nowadays, several mapping technologies are available in the electrophysiological labs: CARTO XP, EnSite NavX and Array, Real-time Position Management. In this paper we aim to briefly present the principal technological and practical characteristics of these mapping systems regarding eligibility, ability and limitations. The development of computer-based mapping technologies is also discussed in detail, since future systems will be able to display any parametric process including vectors, strains, contraction patterns etc., a wide variety of physiologic parameters beyond activation times and voltage. Using electroanatomical mapping systems, the specific recording of both anatomy and physiology has contributed substantially to the expansion of ablation to atypical atrial flutters, ventricular tachycardia, congenital heart-disease-related arrhythmias and atrial fibrillation. While the technology is already facilitating, the obvious down-side to this technological explosion is cost. Subsequent studies will be needed, however, to show that this translates into improved outcomes and cost savings.

Successful direct thrombin inhibitor treatment of a left atrial appendage thrombus developed under rivaroxaban therapy

Absztrakt A szerzők a 62 eves, rivaroxabannal antikoagulalt ferfi betegnel perzisztens pitvarfibrillacio miatt pulmonalisvena-izolaciot terveztek. A preoperativ transoesophagealis echokardiografia soran bal pitvari fulcsethrombus jelenletet mutattak ki. Thrombophilia iranyaban vegzett vizsgalataik alapjan a beteg heterozigotanak bizonyult metilen-tetrahidrofolat-reduktaz-genmutaciora. Felteteleztek, hogy ebben az esetben a direkt trombininhibitor hatekonyabb antithromboticus hatassal birhat, ezert dabigatranra valtottak. Ket honapnyi direkt trombininhibitor kezeles es folsavpotlas mellett a thrombus feloldodott. A szerzők kiemelik, hogy pitvarfibrillalo betegnel adekvat rivaroxabanterapia mellett is kialakulhat bal pitvari fulcsethrombus. Jelen eset felveti annak a lehetőseget, hogy a metilen-tetrahidrofolat-reduktaz-genmutacio csokkentheti a Xa faktor inhibitorok hatekonysagat. Az esettanulmany alapjan dabigatranra valo csere hatekony lehet a bal pitvari fulcsethrombusok feloldasaban. Orv. Hetil., 2016, ...The authors present the history of a 62-year-old man on continuous rivaroxaban therapy who was scheduled for pulmonary vein isolation due to persistent atrial fibrillation. Preoperative transesophageal echocardiography detected the presence of left atrial appendage thrombus. Thrombophilia tests showed that the patient was heterozygous carrier of the methylene-tetrahydrofolate reductase gene mutation. The authors hypothesized that a direct thrombin inhibitor might exert a more appropriate effect against thrombosis in this case and, therefore, a switch to dabigatran was performed. After two months of anticoagulation with the direct thrombin inhibitor and folic acid supplementation the thrombus resolved. The authors underline that thrombus formation may develop in atrial fibrillation even if the patient is adequately treated with rivaroxaban. This case suggests, that methylene-tetrahydrofolate reductase gene mutation may modulate the efficacy of direct Xa factor inhibitors. According to this case history, dabigatran may be an effective therapeutic option in resolving established thrombus.

Rivaroxabankezelés mellett kialakult bal pitvari fülcsethrombus sikeres kezelése direkt trombininhibitorral

Absztrakt A szerzők a 62 eves, rivaroxabannal antikoagulalt ferfi betegnel perzisztens pitvarfibrillacio miatt pulmonalisvena-izolaciot terveztek. A preoperativ transoesophagealis echokardiografia soran bal pitvari fulcsethrombus jelenletet mutattak ki. Thrombophilia iranyaban vegzett vizsgalataik alapjan a beteg heterozigotanak bizonyult metilen-tetrahidrofolat-reduktaz-genmutaciora. Felteteleztek, hogy ebben az esetben a direkt trombininhibitor hatekonyabb antithromboticus hatassal birhat, ezert dabigatranra valtottak. Ket honapnyi direkt trombininhibitor kezeles es folsavpotlas mellett a thrombus feloldodott. A szerzők kiemelik, hogy pitvarfibrillalo betegnel adekvat rivaroxabanterapia mellett is kialakulhat bal pitvari fulcsethrombus. Jelen eset felveti annak a lehetőseget, hogy a metilen-tetrahidrofolat-reduktaz-genmutacio csokkentheti a Xa faktor inhibitorok hatekonysagat. Az esettanulmany alapjan dabigatranra valo csere hatekony lehet a bal pitvari fulcsethrombusok feloldasaban. Orv. Hetil., 2016, ...The authors present the history of a 62-year-old man on continuous rivaroxaban therapy who was scheduled for pulmonary vein isolation due to persistent atrial fibrillation. Preoperative transesophageal echocardiography detected the presence of left atrial appendage thrombus. Thrombophilia tests showed that the patient was heterozygous carrier of the methylene-tetrahydrofolate reductase gene mutation. The authors hypothesized that a direct thrombin inhibitor might exert a more appropriate effect against thrombosis in this case and, therefore, a switch to dabigatran was performed. After two months of anticoagulation with the direct thrombin inhibitor and folic acid supplementation the thrombus resolved. The authors underline that thrombus formation may develop in atrial fibrillation even if the patient is adequately treated with rivaroxaban. This case suggests, that methylene-tetrahydrofolate reductase gene mutation may modulate the efficacy of direct Xa factor inhibitors. According to this case history, dabigatran may be an effective therapeutic option in resolving established thrombus.

Ablation of premature ventricular complexes originating from the left ventricular outflow tract using a novel automated pace-mapping software

Abstract Pace-mapping is an important tool during the ablation of premature ventricular complexes (PVCs) or ventricular tachycardia. The automated pace mapping system software (PaSo module, CARTO XP v9, Biosense/Webster) allows direct comparisons between paced ECGs and the acquired PVC ECG during ablation in a reasonable time. We report our experience with the automated pace mapping system during the ablation of PVCs in the left ventricular outflow tract (LVOT). A 67-year-old male patient was referred to our Department because of recurrent resting atypical chest pain. A 12 lead ECG showed frequent PVCs with LVOT morphology and a 24-hour Holter ECG revealed, that 31% of the total beats were monomorphic PVCs. We decided to perform a radiofrequency catheter ablation. After recording an electroanatomic and an activation map during PVCs, pace-mapping was performed with the PaSo module of the CARTO system. The best percent match area (89.0%) was found in the LVOT, where we performed multiple ablations and PVCs ...

Quality of life measured with EuroQol-five dimensions questionnaire predicts long-term mortality, response, and reverse remodelling in cardiac resynchronization therapy patients

Abstract Aims There are previous studies on quality of life (QoL) in cardiac resynchronization therapy (CRT) patients; however, there are no data with the short EuroQol-five dimensions (EQ-5D) questionnaire predicting outcomes. We aimed to assess the predictive role of baseline QoL and QoL change at 6 months after CRT with EQ-5D on 5-year mortality and response. Methods and results In our prospective follow-up study, 130 heart failure (HF) patients undergoing CRT were enrolled. Clinical evaluation, echocardiography, and EQ-5D were performed at baseline and at 6 months of follow–up, continued to 5 years. Primary endpoint was all-cause mortality at 5 years. Secondary endpoints were (i) clinical response with at least one class improvement in New York Heart Association without HF hospitalization and (ii) reverse remodelling with 15% reduction in left ventricular end-systolic volume at 6 months. Fifty-four (41.5%) patients died during 5 years, 85 (65.3%) clinical responders were identified, and 63 patients (48.5%) had reverse remodelling. Baseline issues with mobility were associated with lower response [odds ratio (OR) 0.36, 95% confidence interval (CI) 0.16–0.84; P = 0.018]. Lack of reverse remodelling correlated with self-care issues at baseline (OR 0.10, 95% CI 0.01–0.94; P = 0.04). Furthermore, self-care difficulties [hazard ratio (HR) 2.39, 95% CI 1.17–4.86; P = 0.01) or more anxiety (HR 1.51, 95% CI 1.00–2.26; P = 0.04) predicted worse long-term survival. At 6 months, mobility (HR 3.95, 95% CI 1.89–8.20; P < 0.001), self-care (HR 7.69, 95% CI 2.23–25.9; P = 0.001), or ≥ 10% visual analogue scale (VAS) (HR 2.24, 95% CI 1.27–3.94; P = 0.005) improvement anticipated better survival at 5 years. Conclusion EuroQol-five dimension is a simple method assessing QoL in CRT population. Mobility issues at baseline are associated with lower clinical response, whereas self-care issues predict lack of reverse remodelling. Problems with mobility or anxiety before CRT and persistent issues with mobility, self-care, and VAS scale at 6 months predict adverse outcome.

Minimal Invasive Left Ventricular Lead Repositioning is Safe and Effective in Distal Left Ventricular Lead Positions: LEFT VENTRICULAR ELECTRODE REPOSITIONING PROCEDURES

Treatment of left ventricular electrode dislocation and phrenic nerve stimulation remains an issue in the era of new electrode designs.

Successful Catheter Ablation of Right Atrial Tachycardia After Bilateral Lung Transplantation.

A 47-year-old woman underwent bilateral lung transplantation for pulmonary fibrosis in June of 2013. The early postoperative period was complicated by continuous atrial arrhythmias that proved unresponsive to antiarrhythmic agents (propafenon and bisoprolol). Therefore, in February 2014, we performed an electrophysiological study after adequate antibiotic and antimycotic prophylaxis. During the procedure, the clinical tachycardia was easily inducible with burst atrial pacing and programmed atrial extrastimuli. Tachycardia cycle length varied between 380 ms and 420 ms, and A-A-V response after ventricular burst pacing suggested atrial tachycardia. Entrainment mapping from the area of early activation failed to demonstrate reentry as the underlying mechanism of the tachycardia, thus ectopic atrial tachycardia was diagnosed. Electroanatomical mapping was performed with ENSITE NavX system (Endocardial Solutions Inc.) during ongoing arrhythmia (Figure ​(Figure1).1). Activation map showed that earliest activation was in the right atrium, corresponding to a scar of the extracorporeal membrane oxigenator (ECMO) cannula during lung transplantation. To avoid paralysis of the diaphragm, we paced the high right atrial region with high energy to demonstrate and mark the location of right phrenic nerve. Subsequently, we performed RF ablation with 3.5 mm irrigated tip catheter (AlCath Flux Blue G eXtra) using 40 W energy and 43°C temperature limit. After the application of one RF ablation at the site of earliest activation (ablation time 46 seconds), the arrhythmia stopped immediately and was no longer inducible even after administration of isoproterenol. The total procedure time was 75 minutes with a fluoroscopy time of 2.3 minutes. No procedural complications occurred. Outpatient visits and 24-hour Holter electrocardiogram monitoring were scheduled every 3 months. The patient was free of symptoms and arrhythmia episodes without any antiarrhythmic medication during the 9-month follow-up period. FIGURE 1 Left side: 12 lead surface electrocardiogram (paper speed 100 mm/sec) and intracardiac electrocardiogram (ablation catheter and coronary sinus catheter) during ongoing arrhythmia. Cycle length is changing from beat to beat. The local activation recorded ... Atrial tachyarrhythmias are frequent after lung transplantation but the incidence of right atrial tachycardia is very low. Most commonly atrial fibrillation is observed in the early postoperative period and left atrial tachycardia occurs later in time.1-4 Right atrial tachycardia might also be associated to the operation, during which an ECMO is implanted with cannulation of the right atrium and aorta. Damaging the anterior part of the high right atrium during this step might be the ground of arrhythmia substrate formation. To the best of our knowledge, our case represents the first successful ablation of right atrial tachycardia after lung transplantation due to scarring of a passagere cannula of ECMO. Ablation of typical right atrial flutter and left atrial tachycardias originating from the donor pulmonary veins has been reported previously.1-4 Atrial ablation in lung transplant recipients is rarely performed, in contrast to heart transplant recipients, where ablation of atrial arrhythmias has repeatedly been reported and arrhythmias are dominantly originating from the right atrium.5

Atrial Arrhythmias After AF Ablation: Challenge for the Next Decade?

The significance of atrial fibrillation is increasing, and also the impact of atrial fibrillation (AF) ablation procedures. After any ablation method, the chance to develop other atrial tachyarrhythmias is between 3 and 50 %. In this chapter the different AF ablation techniques, the pathophysiology of the atrial tachycardias, those diagnostic steps, and therapeutic possibilities are reviewed.

When to go epicardially during ventricular tachycardia ablation Role of surface electrocardiogram

Early recognition of ventricular tachycardias (VTs) with epicardial circuits is crucial. Surface electrocardiogram (ECG) suggesting an epicardial origin could guide ablation procedures and increase success rates. A 35-year-old female patient with VT treated by combined epicardial and endocardial ablation approach is presented in this report, and the role of surface electrocardiogram and timing of epicardial access is discussed.