Ventricular Dyssynchrony Patterns in Left Bundle Branch Block, With and Without Heart Failure

Background: Assessment of ventricular dyssynchrony in patients with heart failure is used for selecting candidates for cardiac resynchronization therapy (CRT). The patterns of regional distribution of dyssynchrony in a population with LBBB with and without heart failure have not been well delineated. This aspect forms the object of the study.Methods: Tissue Doppler Imaging (TDI) data of consecutive patients with heart failure and LBBB (Group A) was compared with those with LBBB and normal LV function (Group B). All patients had standard 2D-echocardigraphic examination and TDI. Tissue velocity curves obtained by placing sample volumes in opposing basal and mid segments of septal, lateral, inferior, anterior and posterior walls were analyzed. Inter ventricular dyssynchrony (IVD) was assessed by the difference between aortic and pulmonary pre ejection intervals. LV dyssynchrony (LVD) was assessed by the difference in times to peak velocity. A delay of ≥ 40 msec was considered significant for presence of IVD and LVD.Results: There were 103 patients in Group A and 25 in Group B. The mean QRS duration and PR intervals respectively were 146 ± 25 vs. 152±20 msec and 182± 47 vs. 165±36 msec. (p=NS) LVEF in the 2 groups were (32 ± 6 % vs. 61± 11%; p< 0.01). Prevalence of dyssynchrony in the HF group compared to Group B was 72% vs. 16%, (P<0.01). Lateral wall dyssynchrony in the 2 groups was 37% vs. 0% (p< 0.01) while septal dyssynchrony was 16% vs. 16% (p- NS).Conclusions: 72% of heart failure patients with LBBB have documented dyssynchrony on TDI, which has a heterogeneous regional distribution. Dyssynchrony may be seen in LBBB and normal hearts but it is does not involve the lateral wall. Septal dyssynchrony in heart failure patients may not have the same significance as lateral wall delay

Successful Catheter Ablation of Persistent Electrical Storm late Post Myocardial Infarction by Targeting Purkinje Arborization Triggers

Drug refractory ventricular tachycardia (VT) occurring as a storm after acute myocardial infarction has grave prognosis. We report a case of a middle-aged lady who presented with drug refractory VT that lead to persistent electrical storm two weeks after an anterior wall myocardial infarction. She underwent a successful catheter ablation of VT followed a few days later by implantation of an AICD. Catheter ablation of the VT could control the persistent electrical storm and the patient was free from a recurrence of VT at three month follow up

Succesful Radiofrequency Ablation of Atrial Tachycardia Arising From Within the Coronary Venous Sinus

Focal atrial tachycardia (AT) though a relatively uncommon cause of supraventricular tachycardia is difficult to control with antiarrythmic drugs. With the advent of radiofrequency ablation (RFA), this form of tachycardia can be treated with high long-term success [1]. These foci tend to cluster at specific anatomic locations. In the right atrium, these foci occur along the crista terminalis, the tricuspid annulus, the ostium of the coronary sinus and the perinodal region. In the left atrium, foci occur predominantly at the pulmonary vein ostia and less commonly at the mitral annulus, the left atrial appendage, and the left side of interatrial septum [2-6]. We report the electrophysiological characteristics and ablation procedure of a focal atrial tachycardia which was arising from deep within the coronary sinus

Substrate Based Ablation of Ventricular Tachycardia Through An Epicardial Approach

Ventricular tachycardia (VT) occurring late after myocardial infarction is often due to reentry circuit in the peri-infarct zone. The circuit is usually located in the sub-endocardium, though subepicardial substrates are known. Activation mapping during VT to identify target regions for ablation can be difficult if VT is non inducible or poorly tolerated. In the latter, a substrate based approach of mapping during sinus rhythm in conjunction with pace mapping helps to define the reentry circuit and select target sites for ablation in majority of patients with hemodynamically unstable VT. Percutaneous epicardial catheter ablation has been attempted as an approach where ablation by a conventional endocardial access has been unsuccessful. We report a case of post myocardial infarction scar VT which could be successfully ablated with a substrate based approach from the epicardial aspect

Long QT syndrome- a genetic insight

Long QT syndrome is a rare arrhythmogenic disorder characterized by a prolongation of the QT interval on Electrocardiogram (ECG) with a propensity to ventricular tachyarrhythmia, leading to syncope, cardiac arrest or sudden death. It is regarded as the “Rosetta Stone” for studying the genetic basis of ventricular arrhythmogenesis. It is caused mainly due to mutations in sodium and potassium channel genes or in the genes involved in the signal transduction pathway. Molecular, genetic and functional studies revealed the impliction of about 13 genes in this disorder. Studies have also revealed the variation in mutations in different ethnic groups, thus necessitating a complete genetic analysis in all the known ethnic groups of the world. This would help to develop personalized medicine, molecular diagnosis, risk stratification, establish a genotype-phenotype correlation, to find the epidemiological variables responsible for the etiology of the disease and identify the possible mode of inheritance

Silent cerebral lesions following catheter ablation for atrial fibrillation:a state-of-the-art review

Atrial fibrillation is associated with neurocognitive comorbidities such as stroke and dementia. Evidence suggests that rhythm control-especially if implemented early-may reduce the risk of cognitive decline. Catheter ablation is highly efficacious for restoring sinus rhythm in the setting of atrial fibrillation; however, ablation within the left atrium has been shown to result in MRI-detected silent cerebral lesions. In this state-of-the-art review article, we discuss the balance of risk between left atrial ablation and rhythm control. We highlight suggestions to lower the risk, as well as the evidence behind newer forms of ablation such as very high power short duration radiofrequency ablation and pulsed field ablation

Clinical Picture Of Arrhythmogenic Right Ventricular Dysplasia / Cardiomyopathy Patients From Indian Origin

Objective: Among the inherited cardiomyopathies, Arrhythmogenic right ventricular dysplasia/cardiomyopathy is unique with a peculiar pathology of fibro-fatty replacement. Studies have been carried out all over the world and several groups have reported clinical heterogeneity in manifestation of ARVD/C related symptoms. Present study is an attempt to identify the clinical profile of ARVD/C patients from Asian Indian origin.Methods: 31 patients in the span of three years were diagnosed with ARVD/C. Diagnosis was based on proposed task force criteria.Results: The mean age at diagnosis was 32.9 ± 16.4 years with slight tilt in male to female ratio (1.46). About 80% cases had palpitations, syncope in 45.16% and dyspnea in 22.5%, whereas 16% of patients were asymptomatic. About 50% of patients revealed a family history of confirmed ARVD/C or sudden death of a family member without any known cause. ECG showed T-wave inversion in about 60% cases, prolongation of QRS was observed in 20% cases. RV dilatation was observed in 80% of patients and 66.7% showed systolic dysfunction. RV free wall motion abnormalities were found in 33% patients. Most of the early onset cases with less than 30 years of age showed family history indicative of ARVD/C. Familial study in three patients indicated early onset of condition in younger generations in two families. Conclusion: ARVD/C in India shows relatively early age at onset when compared with other Asian populations with more than half of patients showing the disease below the age of 30 years. History in most of the early onset cases revealed family history indicating strong genetic influence

Catheter ablation of ventricular tachycardia: strategies to improve outcomes

Catheter ablation of ventricular arrhythmias has evolved considerably since it was first described more than 3 decades ago. Advancements in understanding the underlying substrate, utilizing pre-procedural imaging, and evolving ablation techniques have improved the outcomes of catheter ablation. Ensuring safety and efficacy during catheter ablation requires adequate planning, including analysis of the 12 lead ECG and appropriate pre-procedural imaging. Defining the underlying arrhythmogenic substrate and disease eitology allow for the developed of tailored ablation strategies, especially for patients with non-ischemic cardiomyopathies. During ablation, the type of anesthesia can affect VT induction, the quality of the electro-anatomic map, and the stability of the catheter during ablation. For high risk patients, appropriate selection of hemodynamic support can increase the success of VT ablation. For patients in whom VT is hemodynamically unstable or difficult to induce, substrate modification strategies can aid in safe and successful ablation. Recently, there has been an several advancements in substrate mapping strategies that can be used to identify and differentiate local late potentials. The incorporation of high-definition mapping and contact-sense technologies have both had incremental benefits on the success of ablation procedures. It is crucial to harness newer technology and ablation strategies with the highest level of peri-procedural safety to achieve optimal long-term outcomes in patients undergoing VT ablation

Atrial natriuretic peptide gene - a potential biomarker for Long QT syndrome

This study highlights the possible implication of NPPA (natriuretic peptide precursor A) gene in the etiology of Long QT syndrome (LQTS) by population-based as well as familial study. Three SNPs of NPPA- C-664G, C1363A and T1766C were examined by molecular analyses in LQTS, controls and first degree relatives (FDRs). This study revealed a possible association of 1364 C>A SNP ‘C’ allele with LQTS (p = 0.0013). All three SNPs were in tight linkage disequilibrium. The familial study highlights the association of NPPA SNP with cLQTS and implicating it as a potential biomarker in South Indian population

KvLQT1 and KCNE1 K+ channel gene polymorphisms in long QT syndrome

Long QT Syndrome (LQTS), a disorder of the cardiac repolarization process with prolongation of the QT interval (QTc &#8805;0.46 seconds), is an ion-channelopathy. Mutations in either KCNQ1 or KCNE1 genes are susceptible to LQTS. Hence, screening of KCNQ1 and KCNE1 genes is taken up to evaluate the genetic correlation of these genes in Long QT patients of Indian origin. A total of 33 Long QT Syndrome patients and 100 healthy subjects were enrolled for the present study. PCR-SSCP protocol was utilised for screening of KCNQ1 and KCNE1 genes followed by In-silico and statistical analysis. The clinical profile of the Long QT syndrome patients in our study revealed a higher percentage of females with the mean age also being higher in females when compared to males. The two variations (S546S and IVS13+36A&#62;G) in KCNQ1 and the S38G polymorphism in KCNE1 gene were identified and their association with Long QT syndrome is being reported for the first time in Indian population. S546S is located in the KCNQ1 C terminus close to this domain and IVS13+36A&#62;G is located in the intronic region in close proximity to the coding region for C-terminal domain; these may therefore affect the functional protein through non-assembly. S38G leads to a substitution of serine to glycine at 38th amino acid position (S38G) in the transmembrane domain of KCNE1. Our study reports compound heterozygosity/genetic compound ofS546S and IVS13+36A&#62;G of KCNQ1 gene. Haplotype frequencies and linkage disequilibrium analysis revealed a significant association between the three biomarkers. Compound heterozygosity of the polymorphisms influence downstream signalling and KCNQ1-KCNE1 interactions