Introduction:
Radiofrequency catheter ablation of idiopathic ventricular arrhythmias originating in the para-Hisian region could be challenging because of a potential risk of iatrogenic ...atrioventricular block. Uncommonly, shift of the exit site during the ablation can be observed. Consequently, different approaches of radiofrequency catheter ablation of para-Hisian ventricular foci can be needed.
Case series presentation:
Three patients (2 males) underwent electroanatomical mapping and catheter ablation for idiopathic premature ventricular contractions originating near the His bundle. Patients underwent 24-h ECG Holter monitoring during follow-up. All patients had premature ventricular contractions with left bundle branch block morphology and inferior or horizontal axis. However, change of QRS morphology during ablation was observed, due to a change in the exit site. In two patients there was reduction of the arrhythmia burden after initially unsuccessful procedure. Mapping and ablation in the aortic root were needed in one patient. There were no complications.
Discussion:
Radiofrequency catheter ablation of para-Hisian ventricular arrhythmias is feasible and safe when performed cautiously. A change in the premature ventricular contractions' morphology and exit site during ablation may ensue; therefore, extensive mapping on both sides of the interventricular septum as well as in the aortic root may be warranted.
•Study covering 95 % of the performed EP procedures in Bulgaria was performed.•EP procedures were divided in 2 groups-catheter ablations and diagnostic EP studies.•Detailed complexity classification ...is proposed for ablations (simple or complex)
The implementation of diagnostic reference levels (DRLs) is an essential tool for optimisation of the routine practice, better management of patient exposure while maintaining sufficient image quality. National DRLs for electrophysiology (EP) procedures are not available in our country.
The main purpose of the study was to propose, for first time in Bulgaria, national DRLs (NDRLs) for EP studies and ablation procedures of two different levels of complexity. The proposed DRLs can be later used to establish NDRLs by the national authority with regulatory functions related to medical exposure.
A retrospective study was done with the three highest volume Bulgarian EP centers, where over 95% of all cardiac ablations were performed. Data were extracted from the electronic registry for invasive electrophysiology BG-EPHY. Independently of the proposed NDRLs, we also compared the air kerma-area product (KAP) between the participating centers for procedures of the same level of complexity.
The proposed NDRL in terms of KAP were: 5.2 Gy.cm2 for diagnostic EP studies, 25.5 Gy.cm2 for simple ablations, and 52.1 Gy.cm2 for complex ablations. There was a significant variation in KAP for procedures with the same degree of complexity within each center.
This study is the first to propose NDLRs for EP studies and ablation procedures of two levels of complexity in Bulgaria. The results identified EP procedures requiring further optimization of patient protection and provided a basis for future comparisons and standardization with further investigations on the topic. The proposed NDRLs are recommended to be used for better management of radiation exposure during EP procedures of different levels of complexity.
The deterioration of hepatorenal function due to worsening congestion is relatively common in acute heart failure and carries an independent adverse prognosis. In some patients, the risk of ...proarrhythmia is increased due to impaired drug metabolism. We described a patient with acute heart failure, polymorphic ventricular tachycardia (VT), and ventricular fibrillation episodes while receiving loading doses of amiodarone for atrial fibrillation. The occurrence of arrhythmia at the background therapy with a relatively safe antiarrhythmic drug in the settings of moderate cardiac, renal, and borderline liver functional impairment demonstrates that careful evaluation of liver and renal function is mandatory for the prevention of proarrhythmia.
To study the correlation between the sudden prolongations of the atrio-Hisian (AH) interval with ≥50 ms during burst and programmed atrial stimulation, and to define whether the AH jump during burst ...atrial pacing is a reliable diagnostic criterion for dual AV nodal physiology.
Retrospective data on 304 patients with preliminary ECG diagnosis of AV nodal reentrant tachycardia (AVNRT), confirmed during electrophysiological study, was analyzed for the presence of AH jump during burst and programmed atrial stimulation, and for correlation between the pacing modes for inducing the jump. Wilcoxon signed-ranks test and Spearman's bivariate correlation coefficient were applied, significant was P-value <0.05.
The population was aged 48.5 ± 15.7 (12-85) years; males were 38.5%. AH jump occurred during burst atrial pacing in 81% of the patients, and during programmed stimulation – in 78%, P = 0.366. In 63.2% AH jump was induced by both pacing modes; in 17.8% – only by burst pacing; in 14.8% – only by programmed pacing; in 4.2% there was no inducible jump. There was negative correlation between both pacing modes, ρ = –0.204, Р<0.001.
Burst and programmed atrial stimulation separately prove the presence of dual AV nodal physiology in 81 and 78% of the patients with AVNRT, respectively. There is negative correlation between the two pacing modes, allowing the combination of the two methods to prove diagnostic in 95.8% of the patients.
A 26-year-old woman with partial atrioventricular (AV) canal defect surgically closed with pericardial patch in a mode that the triangle of Koch had become part of the left atrium underwent ...successful slow pathway ablation for slow-fast AV nodal reentrant tachycardia. Transseptal approach was used because of the atypical post-operative anatomy. Transseptal catheter ablation of the slow pathway can be a reasonable and safe alternative in patients subjected to this type of operation.
...different approaches of radiofrequency catheter ablation of para-Hisian ventricular foci can be needed. Keywords catheter ablation, bundle of His, para-Hisian, premature ventricular contractions ...Абстракт Введение: Радиочастотная катетерная абляция желудочковых аритмий, возникающих в парагисиальной области, может быть сложной из-за потенциального риска ятрогенной атриовентрикулярной блокады. Редко наблюдается сдвиг в базовой линии абляции. Впоследствии могут потребоваться различные подходы к радиочастотной катетерной абляции парагисиальных желудочковых очагов. Представление серии клинических случаев: Трём пациентам (2 мужчин) провели электроанатомическое картирование и катетерную аблацию для идиопатических преждевременных сокращений желудочков, происходящих в пучке Гиса. Пациенты подвергались 24-часовому мониторированию холтеровского ЭКГ во время контроля. У всех пациентов были преждевременные сокращения желудочков с морфологией блока левого бедра и нижней или горизонтальной осью. Однако изменения морфологии QRS наблюдались во время абляции из-за изменения базовой линии. У двух пациентов было снижение аритмии после первоначально неудачной процедуры. Картирование и удаление корня аорты потребовались одному пациенту. Не возникло никаких осложнений. Обсуждение: Радиочастотная катетерная аблация парагисиальной внутрисосудистой аритмии возможна и безопасна при тщательном выполнении. Могут возникнуть изменения в морфологии преждевременных сокращений желудочков и в начальной точке во время абляции, и может быть оправдано обширное картирование с обеих сторон желудочкового барьера, а также корня аорты. Ключевые слова парагисиальный, пучок Гиса, преждевременные сокращения камеры, катетерная абляция INTRODUCTION Idiopathic ventricular arrhythmias (VAs) commonly present as symptomatic and drug-resistant ventricular ectopy or tachycardia and may cause a reduction of the left ventricular function.1 A few studies have demonstrated idiopathic VAs arising near the His bundle, which represented 3-9% of all idiopathic Vas.2-5 Ablation in this highly complex region could be challenging due to the potential risk of damage to the conduction system of the heart.6 The aim of this study was to show the relatively uncommon phenomenon of shift of the exit site and corresponding change of the QRS morphology during catheter ablation (CA), different CA approaches and short- and long-term results of radiofrequency (RF) CA of para-Hisian VAs. RESULTS Patient 1 is a 78-year-old man with ischemic heart disease, arterial hypertension, diabetes mellitus, sigmoid resection for cancer and anemia. In all patients, ECG showed LBBB morphology with inferior or horizontal axis, an R-wave in lead I, QS-wave in lead aVR, aVR-aVL polarity reversal and in the first case there was inferior leads discordance (positive/negative), all of which are specific for para-Hisian region.4,6,9,10 After a few RF applications, slight changes in PVCs morphology and exit site were observed and additional ablation at the new earliest site was needed.
The diagnosis of arrhythmogenic RV cardiomyopathy was accepted as definite. 1 A new coronary angiography did not show in-stent restenosis or new coronary lesions ( figure 2 G,H).
Focal right ventricular tachycardia is relatively uncommon. It usually arises from specific anatomic locations. A 59-year-old woman with a structurally normal heart and an automatic ...cardioverter-defibrillator implanted beforehand presented with drug-resistant incessant ventricular tachycardia for which 1786 anti-tachycardia pacing therapies and 119 shocks had been delivered. Electroanatomical mapping showed focal tachycardia originating from the acute margin of the right ventricle. Irrigated catheter ablation was performed successfully.
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