Technical advances in health care have improved patient survival and quality of life, but are not devoid of complications.
We present the case of a 74-year-old woman with a history of hypertensive ...heart disease with preserved systolic function, atrial fibrillation and dyslipidemia. She had a DDDR pacemaker implanted in 2005 due to symptomatic complete atrioventricular block.
The patient reported progressive fatigue, weakness, ascites with abdominal discomfort, and lower limb edema, accompanied by non-specific hepatic cholestasis on biochemical testing. Abdominal ultrasound revealed homogeneous hepatomegaly and dilatation of the inferior vena cava and upper hepatic veins, suggestive of congestive hepatopathy.
Echocardiography revealed tricuspid regurgitation progressively worsening over the previous four years and dilatation and progressive dysfunction of the right ventricle, with preserved left ventricular function. The transesophageal echocardiogram revealed severe tricuspid regurgitation with flail septal leaflet and marked dilatation of the tricuspid annulus due to mechanical interference of the pacemaker lead, which was adhering to the septal leaflet. Minimally invasive surgical treatment was performed with partial resection of the leaflet, placement of a tricuspid annuloplasty ring and replacement of the pacemaker lead.
Regression of the congestive symptoms was observed, and the postoperative echocardiogram showed the tricuspid annuloplasty ring with no evidence of stenosis and only slightly dilated right chambers with moderate pulmonary hypertension. Six months after the procedure, the patient suffered an acute neurological event and died.
O progresso técnico associado aos cuidados de saúde tem permitido uma melhoria da sobrevida e da qualidade de vida dos doentes, não sendo, no entanto, isento de complicações.
Apresenta-se o caso de uma doente de 74 anos, com história de cardiopatia hipertensiva com função sistólica preservada, fibrilhação auricular e dislipidemia. Era portadora de pacemaker DDDR desde 2005 por bloqueio auriculo-ventricular completo sintomático.
Referia quadro arrastado de agravamento progressivo de cansaço, astenia, ascite com epigastralgia, e edema dos membros inferiores, acompanhado de colestase hepática bioquímica inespecífica. A ecografia abdominal revelou hepatomegalia homogénea e dilatação das veias cava inferior e supra-hepáticas, sugestivos de hepatite de estase.
Apresentava, ecocardiograficamente, insuficiência tricúspide em agravamento progressivo nos últimos 4 anos, com dilatação e disfunção progressiva do ventrículo direito, mantendo função ventricular esquerda preservada. O ecocardiograma transesofágico revelou regurgitação tricúspide major por flail leaflet do folheto septal, com dilatação marcada do anel valvular, em relação com efeito mecânico do electrocatéter de pacemaker, que se encontrava aderente ao folheto septal. Optou-se por tratamento cirúrgico minimamente invasivo, com ressecção parcial do folheto, colocação de anel tricúspide e recolocação do electrocatéter de pacing no ventrículo direito.
Observou-se regressão dos sintomas de congestão, objetivando-se o anel protésico tricúspide sem evidência de estenose e cavidades direitas apenas ligeiramente dilatadas, com hipertensão pulmonar moderada. Cerca de seis meses após o procedimento, a doente sofreu um evento neurológico agudo, com evolução desfavorável, tendo vindo a falecer.
Primary malignant cardiac tumors, particularly lymphoma, are rare entities. Cardiac involvement or metastization of the heart from neoplasia located elsewhere are more frequently found. We present ...the case of a 79-year-old patient admitted with heart failure symptoms with a 3-week evolution. Evaluation led to the identification of a cardiac tumor with unusual clinical presentation and with a rapid and fatal evolution. Pathologic analysis identified a B-cell non-Hodgkin lymphoma.
The association between atrial fibrillation (AF) and mitral valve disease is frequent. Isolation of the pulmonary veins by radiofrequency energy applications performed intraoperatively has been ...proposed for patients with AF in whom mitral valve surgery has been indicated. Balloon mitral valvuloplasty is currently the preferred procedure for patients with mitral stenosis and a favorable valve anatomy.
To evaluate the short- and long-term results of percutaneous pulmonary vein isolation for the treatment of AF in patients with mitral stenosis undergoing balloon mitral valvuloplasty.
Five patients (four male and one female, age 43 +/- 4 years) underwent balloon mitral valvuloplasty concomitant with pulmonary vein isolation between August 1996 and February 1997. These patients had permanent AF, diagnosed 31 +/- 12 months previously; their mitral valve area was 1.0 +/- 0.25 cm2 and their left atria measured 54 +/- 5 mm. Balloon mitral valvuloplasty was performed via a transseptal approach, and then four ablation lines were created in the left atrial posterior wall to encircle all four pulmonary veins. Radiofrequency applications lasted 45 seconds each, and aimed at a maximum preset temperature of 65 degrees C. Electrical cardioversion was performed at the end of the procedure.
Mitral valve area increased 1.0 +/- 0.3 cm2 after valvuloplasty. The number of radiofrequency applications per patient was 37 +/- 3, and the average duration of the entire treatment was 131 +/- 28 minutes. Fluoroscopy time averaged 32 +/- 12 minutes. All patients were discharged in sinus rhythm, and mitral flow Doppler evaluation at one month showed a biphasic pattern in all cases, with the A wave measuring 70 +/- 15 cm/sec. Three patients maintained sinus rhythm at five-year follow-up. Of these patients, one had developed a left atrial flutter at four-year follow-up and underwent ablation. The remaining two patients presented AF at five year follow-up.
Percutaneous isolation of the pulmonary veins concomitant with balloon mitral valvuloplasty had suppressed AF in 60% of patients by five-year follow-up.
There are currently two techniques for percutaneous electrical isolation of the pulmonary veins (PV): anatomical isolation and electrical disconnection. The aim of the present study was to assess the ...continuity and circumferential extension of the radiofrequency applications necessary for PV electrical disconnection in order to evaluate the differences between this technique and anatomical isolation.
We studied 9 patients with paroxysmal atrial fibrillation who underwent PV electrical disconnection. The electrophysiologic study was performed with a decapolar circular catheter (Lasso) introduced in the PV ostia and a mapping and ablation catheter (CARTO). Ablation was performed following the activation sequence of PV potentials. Using the CARTO system we evaluated the number of applications, their distribution in quadrants, and the maximum distance between contiguous and opposite RF applications. We assessed the number of veins with circumferential applications. The number of applications and maximum distance between contiguous applications were compared to the maximum distance between opposite applications.
A total of 26 PV were isolated, including 9 right superior, 5 right inferior, 6 left superior and 6 left inferior. On average more than 10 applications were necessary, with a heterogeneous distribution. In 80.8% of the PVs the maximum distance between contiguous application was less than 1 cm and maximum distance between opposite application were highest in the right superior PV and lowest in the right inferior PV. The applications were circumferential in 80.8% of the disconnections. The number of RF applications was significantly higher in PVs with greater distances between opposite applications (correlation coefficient 0.51; p=0.008). No relation was found between maximum distances in contiguous and opposite applications (correlation coefficient r=0.13; p=NS).
Electrical disconnection was achieved in the great majority of cases with circumferential applications, similarly to anatomical isolation. However, the heterogeneous distribution of the applications implies the existence of areas that need a greater number of applications and that can only be identified during electrophysiologic study. Therefore, rather than two aspects of the same treatment for atrial fibrillation, electrical disconnection and anatomical isolation complement each other in the achievement of effective PV isolation.
Ectopies from the pulmonary veins may cause paroxysmal atrial fibrillation and their discrete ablation may be curative. In the absence of focal activity during the procedure, identification of target ...sites with conventional techniques is difficult. We investigated the feasibility of non-contact mapping (EnSite) for identification and successful ablation of pulmonary vein foci in such cases.
We studied 7 patients with idiopathic paroxysmal atrial fibrillation referred for percutaneous ablation and not presenting spontaneous or inducible atrial premature beats during the procedure. An EnSite balloon catheter and an ablation catheter (NaviStar) were placed inside the left atrium. The ablation catheter was also used for electroanatomic mapping (CARTO) of specific sites. Multiphasic pulmonary vein potentials were detected on virtual electrograms and tagged on the non-contact map and confirmed with conventional mapping. The procedural endpoint was elimination or dissociation of the multiphasic potential. Non-contact mapping identified 13 foci of multiphasic potentials in the seven patients (5 foci were initially identified by EnSite), and discrete ablation suppressed 9 of them (69%). Six months later, 4 of the 5 patients in whom all foci were suppressed remain asymptomatic, in sinus rhythm, under no medication.
In patients with paroxysmal atrial fibrillation and no ectopic activity during electrophysiological study virtual electrograms may complement conventional techniques in detecting hidden pulmonary vein foci and may be used to evaluate ablation efficacy.
To evaluate electrophysiological changes after bilateral pulmonary vein isolation in patients undergoing mitral valve surgery and to relate the clinical outcome at 1-year follow-up with the results ...of the postoperative electrophysiological study.
Prospective study of patients with atrial fibrillation undergoing bilateral pulmonary vein isolation using radiofrequency energy and concomitant mitral valve surgery. Pulmonary vein isolation was performed with a heptapolar catheter. Each set of up to 7 simultaneous applications aimed at a maximal duration of one minute and a maximal preset temperature of 70 degrees C. Energy delivery (< 150 watts) was controlled by thermosensors located on each electrode. Before hospital discharge, all patients presenting sinus rhythm underwent an electrophysiological study, using epicardial pacing wires placed during surgery. Isolated areas were compared to the non-isolated left atrium with respect to electrogram amplitudes and atrial capture thresholds. At one-year follow up, cardiac rhythm was assessed in all patients and correlated with the results of the postoperative electrophysioloical study.
The study population consisted of 20 patients with mitral valve disease (mean age 59 +/- 11 years), chronic atrial fibrillation present for 0.5 to 18 years and dilated left atria (55 +/- 11 mm assessed by M-mode echocardiography). The radiofrequency procedure added, on average, 7 minutes (3 to 17) to the duration of the mitral valve surgery. No patient died or suffered surgical complications. Eleven patients presented sinus rhythm before hospital discharge. The electrogram amplitude inside the isolated zones was less than 25% of that in nonisolated areas (0.3 +/- 0.2 mV versus 2.1 +/- 1.7 mV, p = 0.002). Atrial capture thresholds were significantly higher for the isolated areas (13.5 +/- 9.3 mA versus 8.5 +/- 4.0 mA; p < 0.05). At one-year follow-up, nine patients maintained atrial fibrillation, nine remained in sinus rhythm and two lost sinus rhythm to atrial fibrillation. In both these patients, the reduction in electrogram amplitude inside the isolated zones was similar to that of the remaining patients discharged in sinus rhythm. However, postoperative electrophysiological studies in these patients showed that atrial capture thresholds for isolated areas had not increased significantly (8 mA and 6 mA, respectively).
Rhythm at discharge after bilateral pulmonary vein isolation tends to remain at one-year follow up. Radiofrequency-induced modifications in electrogram amplitudes may be less important than increases in pacing thresholds of isolated zones with respect to maintenance of sinus rhythm.
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