Symptomatic periesophageal vagal nerve injury by different energy sources during atrial fibrillation ablation

BackgroundSymptomatic gastric hypomotility (SGH) is a rare but major complication of atrial fibrillation (AF) ablation, but data on this are scarce.ObjectiveWe compared the clinical course of SGH occurring with different energy sources.MethodsThis multicenter study retrospectively collected the characteristics and clinical outcomes of patients with SGH after AF ablation.ResultsThe data of 93 patients (67.0 ± 11.2 years, 68 men, 52 paroxysmal AF) with SGH after AF ablation were collected from 23 cardiovascular centers. Left atrial (LA) ablation sets included pulmonary vein isolation (PVI) alone, a PVI plus a roof-line, and an LA posterior wall isolation in 42 (45.2%), 11 (11.8%), and 40 (43.0%) patients, respectively. LA ablation was performed by radiofrequency ablation, cryoballoon ablation, or both in 38 (40.8%), 38 (40.8%), and 17 (18.3%) patients, respectively. SGH diagnoses were confirmed at 2 (1–4) days post-procedure, and 28 (30.1%) patients required re-hospitalizations. Fasting was required in 81 (92.0%) patients for 4 (2.5–5) days; the total hospitalization duration was 11 [7–19.8] days. After conservative treatment, symptoms disappeared in 22.3% of patients at 1 month, 48.9% at 2 months, 57.6% at 3 months, 84.6% at 6 months, and 89.7% at 12 months, however, one patient required surgery after radiofrequency ablation. Symptoms persisted for >1-year post-procedure in 7 patients. The outcomes were similar regardless of the energy source and LA lesion set.ConclusionsThe clinical course of SGH was similar regardless of the energy source. The diagnosis was often delayed, and most recovered within 6 months, yet could persist for over 1 year in 10%

Association of Syncope and Atrioventricular Nodal Reentrant Tachycardia in a Patient with Brugada-type Electrocardiogram —Importance of Electrophysiologic Study in Differential Diagnosis of Wide QRS Tachycardia—

A 65-year-old man developed syncope following palpitation during an outdoor activity in the daytime. The 12-lead electrocardiogram (ECG) showed Brugada-type ST segment elevation. Holter ECG monitoring documented an episode of regular wide QRS tachycardia. During an electrophysiologic study (EPS), ventricular tachyarrhythmia was not induced. However, a common (slow-fast) type atrioventricular nodal reentrant tachycardia with aberrant ventricular conduction, which was the same configuration as the wide QRS tachycardia recorded by the Holter ECG monitoring, was induced. The patient has been asymptomatic for the 12-month follow-up after the successful slow pathway ablation. This patient reminds us of the importance of EPS in the differential diagnosis of a wide QRS tachycardia

Two Cases of Pilsicainide Intoxication showing the Brugada-type Electrocardiographic Findings and Incessant Wide QRS Tachycardia

We have experienced two patients with the Brugada-type electrocardiographic abnormalities and incessant wide QRS tachycardia (presumed ventricular tachycardia) induced by intoxication of a class IC antiarrhythmic drug pilsicainide. They were elderly men with impaired renal function. Plasma concentration of pilsicainide was elevated to a toxic level in both patients. After cessation of pilsicainide, incessant wide QRS tachycardia spontaneously subsided and intraventricular conduction delay with coved type ST segment elevation in V1 and V2 disappeared. In the elderly or patients with renal dysfunction, we should be very careful regarding dose adjustment of pilsicainide or it may be better to avoid using this drug

Clinical Efficacy of Bepridil for Class I Antiarrhythmic Drug-Induced Atrial Flutter in Patients with Paroxysmal Atrial Fibrillation

Background: Class I antiarrhythmic drugs can promote the organization of atrial fibrillation (AF) and sometimes converts AF into atrial flutter (AFL) concomitant with difficulty of rate control. We studied the usefulness of Bepridil, which exhibits a class III-like effect, for class I drug-induced AFL in patients with paroxysmal AF. Methods: The study population consisted of 17 consecutive patients (15 men, mean age 65 ± 8 years) with AFL converted from paroxysmal AF following oral treatment of class IA or IC antiarrhythmic agents including pilsicainide (n = 8), cibenzoline (n = 5), flecainide (n = 2), aprindine (n = 1), and propafenone with cibenzoline (n = 1). After the occurrence of AFL, class I drug was replaced by bepridil with a dose of 100–200 mg per day in all patients. Results: After the treatment with bepridil, 15 (88%) out of the 17 patients restored sinus rhythm after 1 to 68 days (average of 21 days). In 12 (80%) of the 15 patients, sinus rhythm was maintained for an average of 23.6 months (range of 1 to 62 months) follow-up period. Although torsade de pointes was not recognized, a marked QT prolongation (0.60 sec) was observed in one patient during the administration of bepridil at a daily dose of 200 mg. In this patient, QT interval was normalized (0.45 sec) after reduction of bepridil to 150 mg daily. Conclusion: Bepridil treatment may be safe and effective for class I drug-induced AFL in patients with paroxysmal AF to restore and maintain sinus rhythm as an alternative therapy for catheter ablation. However, the QT interval must be carefully monitored during this medication

Variations in cephalic vein venography for device implantation–Relationship to success rate of lead implantation

Introduction: Lead implantation using the cephalic vein (CV) cutdown technique has been well established, but is not always expected to achieve high success rates. We studied the relationship between preoperative CV venography and the success rate of lead implantation. Methods: Two hundred and twenty one CV venographies were performed in 205 patients (mean age 75 years, 113 males). Leads were inserted via the CV cutdown technique with a guidewire and sheath. Variations in CV venography included usage of the right and left CVs. The success rate of lead implantation was studied. Results: No major kink was observed in 71% of the right CV cases and 43% of the left CV cases. Leads were successfully implanted in over 90% of these patients. A major kink in the CV was found in 15% of the right CV cases and 34% of the left CV cases and successful lead implantation was around 80% in this population. The overall success rate tended to be higher for the right side (83%) than for the left side (71%). Conclusion: Severe kinks or variations in the CV that hinder lead manipulation were less frequent in the right CV. Therefore, a higher success rate of lead implantation by the cutdown technique is expected for the right CV