Nearly Fatal Torsade de Pointes with Sotalol

A 75-year-old woman with paroxysmal atrial fibrillation (AF) experienced recurrent seizures at home. Holter monitoring (each line 50 sec) showed repetitive runs of torsade de pointes (TdP), degenerating into ventricular fibrillation and ventricular tachycardia (VT). Abrupt asytole heralded end of electrical activity and life. Amazingly, 6 min after cardiac arrest a slow ventricular escape rhythm arose spontaneously without resuscitation. At baseline, repolarisation was markedly prolonged (QTc>660 msec) and ventricular bigeminy triggered short bursts of TdP after „long-short” sequences. No hypokalemia or renal dysfunction was present. Following intensive treatment (sedation, magnesium iv, acceleration of heart rate) the patient recovered without neurological deficit. Except left ventricular hypertrophy and incomplete left bundle branch block the results of angiography, electrophysiological study and ajmaline test were normal. There was no family history of sudden death. Months ago a cardioversion attempt with ibutilide triggered polymorphic VT. Therapy with metoprolol (95 mg/day) was discontinued due to poor efficacy of rhythm control. Thus, sotalol (240 mg/day) was initiated in-hospital without signs of QT prolongation within 4 days (QT 416, QTc 432 msec). However, two weeks later the patient presented with an “idiosyncratic” proarrhythmic response to sotalol (IKr-blocking drug) and a life-threatening arrhythmia.1 There is growing evidence that drug-induced long QT syndrome (LQTS) may be due to "silent" mutations on LQT genes.2,3 Although not proven by molecular analysis, our case seems to resemble a subclinical, inherited form of LQTS that makes the patient vulnerable to the QT-prolonging effects of a variety of cardiac and noncardiac drugs. The concept of “repolarization reserve” suggests that any factor that impairs the repolarizing currents renders TdP very likely when IKr-blocking drugs are used. Avoiding torsadogenic drugs should basically prevent recurrence of TdP. However, an implantable cardioverter-defibrillator was placed for safety reasons.4 During a follow-up of more than two years a few non-sustained episodes occurred, the longest, a short-coupled polymorphic VT lasted for 25 beats resulting in a diverted shock.

Lower Body Mass Index and Atrial Fibrillation as Independent Predictors for Mortality in Patients with Implantable Cardioverter Defibrillator

Aim: To evaluate risk factors related to total mortality in an unselected population of patients implanted with a cardioverter defibrillator. Methods: Survival analysis was performed retrospectively investigating the records of 77 consecutive patients implanted with defibrillators (median 67 years, range 38-83 years; 63 men). All patients were followed regularly in 3-month intervals. The cause of mortality was assessed clinically, including post-mortem examination of device to assess possible arrhythmogenic death. Predictors were assessed by Kaplan-Meier analysis with log-rank tests and by Cox regression analysis (proportional hazards). Results: Defibrillator recipients had a mean (±SD) ejection fraction of 34±13%, left ventricular end-diastolic dimension (LVEDD) of 6.24±0.8 cm, QRS duration of 129±34 ms, and body mass index (BMI) of 26.4±4.3 kg/m². Atrial fibrillation was present in 32 patients, paroxysmal fibrillation in 23, and permanent fibrillation in 9 patients. The estimate of mean survival time for all patients was 51.5 (95% CI 46.6-56.5) months. During the study period 11/77 (14%) patients died. Mean follow-up time was 24.5 months (range 0.2-60.7) for survivors and 7.6 months (range 1.5-42) for non-survivors. Independent predictors of mortality were the NYHA class (P=0.004), BMI≤26 kg/m² (P=0.024), presence of paroxysmal or permanent atrial fibrillation (P=0.014), and absence of arterial hypertension (P=0.010). LVEDD showed a weak significant effect on survival (P=0.049)

Original articleHigh incidence of tachyarrhythmias detected by an implantable loop recorder in patients with unexplained syncope

Background: Syncope is a complex clinical syndrome that may be challenging with respect to a definite diagnosis. The implantable loop recorder (ILR) is a useful tool to define but also to exclude an arrhythmic aetiology. Aim: To investigate the causes of recurrent syncope or near-syncope with respect to underlying arrhythmias in non-selected consecutive patients monitored with an ILR. Methods: A retrospective study was conducted including 55 patients (34 men, 21 women; age 60±19 years) with unexplained syncope who received an ILR for prolonged monitoring at our institution between April 1998 and October 2006. Results: Forty (73%) patients had a recurrence of syncope or near-syncope. Structural heart disease was present in 18 (33%) patients, 4 of them having an ejection fractionWstęp: Omdlenie jest złożonym zespołem klinicznym, a wykrycie przyczyny utrat przytomności może być trudne. Implantowany pętlowy rejestrator arytmii (ILR) jest użytecznym narzędziem do potwierdzenia lub wykluczenia arytmii serca jako przyczyny omdlenia. Cel: Ustalenie przyczyny omdleń lub stanów przedomdleniowych za pomocą rejestracji EKG urządzeniem ILR w grupie kolejnych chorych. Metodyka: Retrospektywne badanie objęło 55 chorych (34 mężczyzn, 21 kobiet, średni wiek 60±19 lat) z niewyjaśnionym omdleniem, u których w naszej klinice implantowano ILR pomiędzy kwietniem 1998 a październikiem 2006 r. Wyniki: Nawrót omdlenia lub stanu przedomdleniowego wystąpił u 40 (73%) chorych. Organiczną chorobę serca stwierdzono u 18 (33%) chorych, spośród których 4 miało frakcję wyrzutową lewej komor

Wpływ długości cieśni trójdzielno-żylnej na całkowitą energię prądu o wysokiej częstotliwości stosowanego w trzepotaniu prawego przedsionka

Background and aim: The complexity and success rate of right atrial flutter ablation is highly dependent on anatomical structures. Methods: The study comprised 35 consecutive patients (33–77 years old; 30 men) who underwent ablation of typical atrial flutter. The linear ablation line was measured offline as a surrogate for the cavotricuspid isthmus (CTI) length with the help of a three-dimensional mapping and navigation system (Ensite™). Biophysical parameters, such as total radiofrequency (RF) energy and time of the ablation procedure, were analysed to test the hypothesis that any of these variables show a correlation with the length of the ablation line. Results: Bidirectional isthmus block was achieved in all cases. The isthmus length had a mean value of 32 ± 12 mm with a range of 14–57 mm. The linear regression between the CTI length and the total RF energy was not significant. There was no significant difference in energy (32.281 ± 25.587 vs. 37.136 ± 24.250 W-s, p = NS) or in the total ablation time (759 ± 646 vs. 802 ± 533 s, p = NS) between the group with short (< 29 mm; n = 17) vs. long CTI (≥ 29 mm, n = 18). When comparing different ablation technologies, total RF energy delivered with 8-mm catheter technol­ogy (group I) was significantly lower than in patients with cross over from 8-mm to cooled ablation technology (group III) (29.615 ± 12.331 vs. 62.674 ± 28.735 W-s, p = 0.01). The same was true for the comparison between cooled ablation technology (group II) and group III (19.879 ± 13.669 vs. 62.674 ± 28.735 W-s, p = 0.002). Conclusions: The length of the CTI as measured with help of a three-dimensional mapping system may reflect only a weak indicator for the complexity of flutter ablation procedures. The thickness of musculature and specific anatomy of the CTI seem to be the main challenges in performing a linear ablation to achieve bidirectional block.Wstęp i cel: Stopień trudności i odsetek pozytywnych wyników ablacji w trzepotaniu prawego przedsionka zależy od wa­runków anatomicznych. Metody: Do badania włączono 35 kolejnych pacjentów (33–77 lat; 30 mężczyzn), których poddano ablacji z powodu typowego trzepotania przedsionków. Linię ablacji zmierzono w trybie offline jako wartość zastępczą długości ujścia trójdzielno-żylnego (CTI) za pomocą systemu do trójwymiarowego mapowania i nawigacji (Ensite™). Parametry biofizyczne, takie jak całkowita energia prądu o wysokiej częstotliwosci (RF) i czas ablacji analizowano w celu sprawdzenia, czy którakolwiek z tych zmiennych wykazuje korelację z długością linii ablacji. Wyniki: We wszystkich przypadkach uzyskano dwukierunkowy blok cieśni. Średnia długość cieśni wynosiła 32 ± 12 mm, zakres — 14–57 mm. Analiza regresji liniowej wykazała, że zależność między długością CTI i całkowitą energią RF była nieistotna statystycznie. Nie stwierdzono znamiennej różnicy dotyczącej energii (32,281 ± 25,587 vs. 37,136 ± 24,250 W-s, p = NS) oraz czasu ablacji (759 ± 646 vs. 802 ± 533 s, p = NS) między grupami z krótką (< 29 mm; n = 17) i długą CTI (≥ 29 mm, n = 18). Porównując różne technologie stosowane do ablacji, wykazano, że całkowita energia RF dostarczona za pomocą 8-milimetrowego cewnika (grupa I) była istotnie niższa niż u pacjentów, u których stosowano najpierw technologię 8-milimetrowego cewnika, a następnie ablację chłodzonymi elektrodami (grupa III) (29,615 ± 12,331 vs. 62,674 ± 28,735 W-s, p = 0,01). Podobną zależność stwierdzono, porównując osoby poddane ablacji chłodzonymi elektrodami (grupa II) z grupą III (19,879 ± 13,669 vs. 62,674 ± 28,735 W-s, p = 0,002). Wnioski: Długość CTI mierzona za pomocą systemu do trójwymiarowego mapowania jest słabym wskaźnikiem złożoności zabiegów ablacji w trzepotaniu przedsionków. Grubość tkanki mięśniowej i określone cechy anatomiczne CTI stanowią najważniejsze problemy w trakcie zabiegu liniowej ablacji w celu uzyskania dwukierunkowego bloku

Association between vascular cell adhesion molecule 1 and atrial fibrillation

IMPORTANCE Accumulating evidence links inflammation and atrial fibrillation (AF).OBJECTIVE To assess whether markers of systemic and atrial inflammation are associated with incident AF in the general population.DESIGN, SETTING, AND PARTICIPANTS The Bruneck Study is a prospective, population-based cohort study with a 20-year follow-up (n = 909). The population included a random sample of the general community aged 40 to 79 years. Levels of 13 inflammation markers were measured at baseline in 1990. Findings were replicated in a case-control sample nested within the prospective Salzburg Atherosclerosis Prevention Program in Subjects at High Individual Risk (SAPHIR) study (n = 1770). Data analysis was performed from February to May 2016.EXPOSURES Levels of 13 inflammation markers.MAIN OUTCOMES AND MEASURES Incident AF over a 20-year follow-up period in the Bruneck Study.RESULTS Of the 909 participants included in the Bruneck Study, mean [SD] age was 58.8 (11.4) years and 448 (49.3%) were women. Among the 880 participants free of prevalent AF (n = 29) at baseline, 117 developed AF during the 20-year follow-up period (incidence rate, 8.2; 95% CI, 6.8-9.6 per 1000 person-years). The levels of soluble vascular cell adhesion molecule 1 (VCAM-1) and osteoprotegerin were significantly associated with incident AF (hazard ratio [HR], 1.49; 95% CI, 1.26-1.78; and 1.46; 95% CI, 1.25-1.69, respectively; P <.001 with Bonferroni correction for both), but osteoprotegerin lost significance after age and sex adjustment (HR, 1.05; 95% CI, 0.87-1.27; P >.99 with Bonferroni correction). Matrix metalloproteinase 9, metalloproteinase inhibitor 1, monocyte chemoattractant protein-1, P-selectin, fibrinogen, receptor activator of nuclear factor-.B ligand, high-sensitivity C-reactive protein, adiponectin, leptin, soluble intercellular adhesion molecule 1, and E-selectin all fell short of significance (after Bonferroni correction in unadjusted and age-and sex-adjusted analyses). The HR for a 1-SD higher soluble VCAM-1 level was 1.34 (95% CI, 1.11-1.62; Bonferroni-corrected P =.03) in a multivariable model. The association was of a dose-response type, at least as strong as that obtained for N-terminal pro-B-type natriuretic peptide (multivariable HR for a 1-SD higher N-terminal pro-B-type natriuretic peptide level, 1.15; 95% CI, 1.04-1.26), internally consistent in various subgroups, and successfully replicated in the SAPHIR Study (age-and sex-adjusted, and multivariable odds ratios for a 1-SD higher soluble VCAM-1 level, 1.91; 95% CI, 1.24-2.96, P =.003; and 2.59; 95% CI, 1.45-4.60; P =.001).CONCLUSIONS AND RELEVANCE Levels of soluble VCAM-1, but not other inflammation markers, are significantly associated with new-onset AF in the general community. Future studies should address whether soluble VCAM-1 is capable of improving AF risk classification beyond the information provided by standard risk scores