Outcomes of cardiac perforation complicating catheter ablation of ventricular arrhythmias

Background-Cardiac perforation is a recognized complication of catheter ablation procedures, most commonly encountered during ablation of atrial fibrillation. The study aims to investigate the incidence, management, and hospital outcomes of cardiac perforation complicating catheter ablation for ventricular arrhythmias. Methods and Results-Consecutive patients undergoing catheter ablation for ventricular arrhythmias at a tertiary referral center were included in this retrospective analysis. Of 1152 consecutive catheter ablation procedures in 892 patients over 12 years, 11 procedures (1.0%) were complicated by ventricular perforation. Emergent pericardial drainage and surgical repair were required in 10 (91%) and 6 (55%) cases, respectively. No perforation was apparent in patients with prior cardiac surgery. More than half of the perforations (6 of 11) occurred in the context of steam pops during radiofrequency ablation and were more likely to require surgical repair (P=0.07). Intra-aortic balloon counterpulsation, left ventricular assist device, and biventricular assist device were used in 2 patients, 1 patient, and 1 patient, respectively. Of 6 cases in which the site of perforation could be determined at cardiac surgery, 5 were in the right ventricle (4 outflow tract, 1 free wall) and only 1 was located in the left ventricle. All patients survived to discharge. Conclusions-Ventricular perforation and tamponade occurs in 1% of ventricular ablation procedures and in this series, occurred only in patients without a history of prior cardiac surgery. More than half the patients required surgical repair. Perforation is often associated with steam pops and emergent surgical repair is often required when perforation occurs after a steam pop. © 2011 American Heart Association, Inc

Resetting criteria during ventricular overdrive pacing successfully differentiate orthodromic reentrant tachycardia from atrioventricular nodal reentrant tachycardia despite interobserver disagreement concerning QRS fusion

Background The beginning of ventricular overdrive pacing (VOP) during supraventricular tachycardia (SVT) accurately distinguishes orthodromic reentrant tachycardia (ORT) from atrioventricular nodal reentrant tachycardia (AVNRT) even when pacing terminates tachycardia. Tachycardia resetting most often occurs during this transition zone (TZ) of QRS fusion in ORT and after this TZ in AVNRT. The end of the TZ is marked by the first beat with a stable QRS morphology but is a subjective assessment. Disagreement concerning this beat may change tachycardia diagnosis. Objective The purpose of this study was to assess interobserver agreement for identifying the TZ and whether disagreement affected diagnosis. Methods Seventy-nine consecutive patients with inducible ORT and AVNRT were included. Resetting of tachycardia was evaluated by (1) atrial timing perturbation and (2) fixed stimulationatrial activation timing (SA). Two blinded observers identified the end of the TZ and used the two resetting criteria to establish a diagnosis. Diagnostic results were compared with standard criteria for SVT diagnosis. The diagnosis was considered correct if both electrophysiologists\u27 TZ assessment resulted in a correct diagnosis. Results Agreement on the TZ occurred in 80% (148/186) of VOP trains. In ORT patients, tachycardia resetting occurred during the TZ and correctly diagnosed ORT based on atrial timing perturbation and fixed SA in 91% and 98% of VOP trains, respectively. In AVNRT patients, tachycardia resetting occurred after the TZ and correctly diagnosed AVNRT based on atrial timing perturbation and fixed SA in 93% and 94% of VOP trains, respectively. Conclusion Resetting criteria used during the VOP TZ accurately differentiate between ORT and AVNRT despite interobserver disagreement concerning identification of the TZ. © 2011 Heart Rhythm Society

Bisphosphonate-related osteonecrosis of the jaw: An overview

Bisphosphonates are widely used in the management of metastatic disease to bone and in diseases of altered bone turnover. Recently, multiple-case series and retrospective studies have established a relationship between necrotic bone lesions localized to the jaw and the use of chronic bisphosphonate therapy. This condition has been named bisphosphonate-related osteonecrosis of the jaw (BRONJ). To evaluate the potential risks associated with this new and emerging complication, stage-specific management strategies and guidelines have been developed. In view of the widespread use of chronic bisphosphonate therapy, the observation of an associated risk of osteonecrosis of the jaw should alert practitioners to monitor for this previously unrecognized complication and to reevaluate the indications for and the duration of bisphosphonate therapy in patients with osteopenia/osteoporosis and cancer. Morbidity associated with BRONJ might be prevented or reduced by implementing prevention strategies and establishing early diagnostic procedures. The current widespread use of bisphosphonates as an inhibitor of bone resorption is directly attributable to their efficacy in improving the quality of life for patients with metastatic bone cancer, osteoporosis, and Paget\u27s disease. © 2010 New York Academy of Sciences

Peripheral artery disease. Part 1: Clinical evaluation and noninvasive diagnosis

Peripheral artery disease (PAD) is a marker of systemic atherosclerosis. Most patients with PAD also have concomitant coronary artery disease (CAD), and a large burden of morbidity and mortality in patients with PAD is related to myocardial infarction, ischemic stroke, and cardiovascular death. PAD patients without clinical evidence of CAD have the same relative risk of death from cardiac or cerebrovascular causes as those diagnosed with prior CAD, consistent with the systemic nature of the disease. The same risk factors that contribute to CAD and cerebrovascular disease also lead to the development of PAD. Because of the high prevalence of asymptomatic disease and because only a small percentage of PAD patients present with classic claudication, PAD is frequently underdiagnosed and thus undertreated. Health care providers may have difficulty differentiating PAD from other diseases affecting the limb, such as arthritis, spinal stenosis or venous disease. In Part 1 of this Review, we explain the epidemiology of and risk factors for PAD, and discuss the clinical presentation and diagnostic evaluation of patients with this condition. © 2011 Macmillan Publishers Limited. All rights reserved

Interim Prosthetic Phase of Multidisciplinary Management of Cleidocranial Dysplasia: The Bronx Approach

This case report presents treatment of two patients with the usual characteristics of Cleidocranial Dysostosis. A multidisciplinary approach using the disciplines of prosthodontics, orthodontics, and oral surgery was effected. Exfoliation of the patient\u27s deciduous teeth and failure of permanent anterior tooth eruption led to emotional, social, and self-esteem issues in both patients. Due to the psychosocial issues confronting these two patients, esthetics was addressed prior to active intervention with orthodontics and after some surgical intervention. The use of two interim overdenture prostheses with magnetic retention is described. © 2011 by The American College of Prosthodontists