Case of Takotsubo cardiomyopathy after tooth extraction – Unusual trigger of a rare syndrome

AbstractWe describe a case of Takotsubo cardiomyopathy in a 75-year-old woman after an elective extraction of 10 teeth of the lower jaw using bilateral mandibular anesthesia. The patient complained of shortness of breath and chest pain after 24h. Coronary angiography showed smooth normal coronary arteries with thrombolysis in myocardial infarction III flow. Left ventriculography demonstrated apical ballooning. Three months later, the patient is symptom-free, with normal left ventricular function.We assume that the complex and robust procedures in dentistry together with a systemic absorption of epinephrine are sufficient triggers for the development of Takotsubo cardiomyopathy. In our case, we advocate an external catecholamine exposure rather than an internal catecholamine excess. We need more vigilance when assessing such patients.<Learning objective: We describe a stress-induced cardiomyopathy with late symptom development despite an uncomplicated tooth extraction. There was only one case of Takotsubo cardiomyopathy with acute symptoms described in the literature, although after complicated tooth extraction. It could be interesting for physicians that the complex and robust procedures in dentistry together with a systemic absorption of epinephrine are sufficient triggers for the development of Takotsubo cardiomyopathy.

Transseptal puncture without fluoroscopy using a radiofrequency needle: A case series

Background: The non-fluoroscopy approach with the use of a three-dimensional (3D) navigation system is increasingly recognized as a future technology in the treatment of arrhythmias. However, there are a limited number of articles published concerning transseptal puncture without the use of fluoroscopy.Methods: Presented in this paper is the first series of patients (n = 10) that have undergone transseptal puncture without the use of fluoroscopy under transesophageal echocardiography control using a radiofrequency transseptal needle and a 3D navigation system.Results: All patients were treated without complications. In 6 patients, re-pulmonary vein isolation was performed. In 5 cases, linear ablation of the left atrium for treatment of left atrial macro re-entry tachycardia was provided. In 2 patients, focal atrial tachycardia was treated, 1 patient underwent cavo tricuspidal isthmus (CTI) ablation and 1 patient, re-CTI ablation. The ablation of complex fragmented atrial electrograms was done in 2 patients. In 1 case, right atrial macro re-entry tachycardia was treated.Conclusions: Transseptal puncture without using fluoroscopy is safe and effective when using a radiofrequency needle, a 3D navigation system and transesophageal echocardiograph

Posterior wall substrate modification using optimized and contiguous lesions in patients with atrial fibrillation

Background: Radiofrequency (RF) linear ablation at the left atrial (LA) roof and bottom to isolate the LA posterior wall using contiguous and optimized RF lesions was evaluated. Achieving isolation of the LA posterior wall is challenging as two continuous linear lesion sets are necessary.Methods: Forty consecutive patients with symptomatic atrial fibrillation (AF) and arrhythmia substrates affecting the LA posterior wall underwent posterior wall isolation by linear lesions across the roof and bottom. The cohort was divided into two groups: group 1 (20 patients) linear ablation guided by contact force (CF) only; group 2 (20 patients) guided by ablation index (AI) and interlesion distance.Results: Bidirectional block across the LA roof and bottom was achieved in 40/40 patients. Additional endocardial RF applications in 5 patients from group 1 vs. 3 patients from group 2 resulted in posterior wall isolation in all patients. Procedure duration was almost equal in both groups. CF and AI were significantly higher in group 2 for the roof line, whereas no statistical difference was found for the bottom line. AI-guided LA posterior wall isolation led to a significantly lower maximum temperature increase. The mean AI value as well as the mean value for catheter-to-tissue CF for the roof line were significantly higher when AI-guided ablation was performed. Standard deviation in group 2 showed a remarkably lower dispersion.Conclusions: Ablation index guided posterior wall isolation for substrate modification is safe and effective. AI guided application of the posterior box lesion allows improved lesion formation

First clinical experience using the DiamondTemp catheter and a novel omnipolar high-resolution mapping system for atrial fibrillation ablation

Background: The DiamondTemp (DT) radiofrequency ablation (RFA) catheter has been introduced as a new tool for atrial fibrillation (AF) ablation. The new technology allows for temperature-controlled irrigated ablation and real-time lesion assessment. Recently, the EnSite X mapping system became commercially available allowing for omnipolar and ultra-high-resolution mapping. We aimed to assess the feasibility of the new DT RFA catheter in performing AF ablation procedures in conjunction with the novel EnSite X system under routine clinical conditions. Methods: We analyzed data from 10 consecutive patients who underwent AF ablation using the DT RFA guided by EnSite X. Procedural data and short-term follow-up were assessed as well as potential technical issues. Results: Nine out of 10 patients underwent de-novo pulmonary vein isolation (PVI), and one patient underwent repeat ablation. First-pass isolation was observed in 7/10 patients. Total procedure duration (skin-to-skin) was 88.9 ± 30.1 min, and left atrium dwell time was 70 ± 22.3 min. The mean number of RF applications needed for PVI and additional ablation was 70.52 ± 26.70. The HD Grid SE mapping catheter was utilized in 8 patients and the Advisor SE in 2 patients. Bidirectional block of the applied lines was achieved in all patients. No steam pops were observed, and no intraprocedural complications occurred. Conclusions: This first clinical series demonstrated that temperature-controlled irrigated ablation in combination with the novel omnipolar and high-resolution mapping system resulted in rapid, efficient, and durable lesion formation under routine clinical conditions. Randomized controlled trials are needed to elucidate the impact on lesion formation, long-term outcomes, and reproducibility of our initial findings

The individual relationship between atrial fibrillation sources from CARTOFINDER mapping and atrial cardiomyopathy: the catch me if you can trial

Background Targeting individual sources identified during atrial fibrillation (AF) has been used as an ablation strategy with varying results. Objective Aim of this study was to evaluate the relationship between regions of interest (ROIs) from CARTOFINDER (CF) mapping and atrial cardiomyopathy from late gadolinium enhancement (LGE) cardiovascular magnetic resonance imaging (CMR). Methods Twenty consecutive patients underwent index catheter ablation for persistent AF (PERS AF). Pre-processed LGE CMR images were merged with the results from CF mapping to visualize harboring regions for focal and rotational activities. Atrial cardiomyopathy was classified based on the four Utah stages. Results Procedural success was achieved in all patients (n = 20, 100%). LGE CMR revealed an intermediate amount of 21.41% ± 6.32% for LA fibrosis. ROIs were identified in all patients (mean no ROIs per patient n = 416.45 ± 204.57). A tendency towards a positive correlation between the total amount of atrial cardiomyopathy and the total number of ROIs per patient (regression coefficient, β = 10.86, p = .15) was observed. The degree of fibrosis and the presence of ROIs per segment showed no consistent spatial correlation (posterior: β = 0.36, p-value (p) = .24; anterior: β = −0.08, p = .54; lateral: β = 0.31, p = 39; septal: β = −0.12; p = .66; right PVs: β = 0.34, p = .27; left PVs: β = 0.07, p = .79; LAA: β = −0.91, p = .12). 12 months AF-free survival was 70% (n = 14) after ablation. Conclusion The presence of ROIs from CF mapping was not directly associated with the extent and location of fibrosis. Further studies evaluating the relationship between focal and rotational activity and atrial cardiomyopathy are mandatory

Foodborne Botulism in the Republic of Georgia

In the Republic of Georgia, high rates of foodborne botulism are largely caused by home-preserved vegetables

Spread of Clostridium botulinum in the soils of Georgia

ObjectiveThe main focus of this study was to study the spread of botulism inGeorgia and the biological characteristics of the strains ofClostridiumbotulinumisolated from territories in the country.IntroductionAccumulation ofC. botulinumin soil occurs through excretion ofbacterial spores from the intestines of humans, animals, birds andfish. In Georgia, during the winter season, the population consumeshomemade vegetable preserves, which are made of locally produced(as well as imported) vegetables. Historical surveys confirmed that thepresence ofC. botulinumin the soil is widespread. Some researchersconsiderC. botulinuma characteristic component of soil flora.MethodsSoil samples were collected from areas, where from 2001-2002cases of botulism caused by homemade vegetable preserves (producedfrom vegetables cultivated in those areas) were registered. Soilsamples were collected from Kakheti, Shida Kartli, Kvemo Kartli,Samtkhe-Javakheti, and Samegrelo regions. Standard bacteriologyand PCR were used to confirm the presence ofC. botulinumfrom soilsamples. Separation of strains and their examination was conducted inaccordance with the scheme provided by the CDC Atlanta ReferenceLaboratory (USA), which was later tested by NCDC. Toxigenicityand toxin production of strains were tested using a biotest on whitemice.ResultsIn total, 258 soil samples were tested, from which, 40 (15.5%)cultures ofC. botulinumtype B were obtained. Toxigenicity andtoxin production were confirmed through biotests. These resultsconfirm the presence ofC. botulinumin agricultural lands, whichcauses contamination of vegetables cultivated on those lands, whichare used for the preparation of homemade preserves, causing botulismin humans.ConclusionsFor the purpose of finding solutions to botulism, it is essentialto verify the ecology of the pathogen through establishing theprevalence of bacteria in different soil types. It was shown that someareas of Georgia, where vegetable growing is greatly developed, andwhich, are the main sources of crops, are highly contaminated withC. botulinum. In Georgia, land used for agriculture is contaminatedwithC. botulinum.C. botulinumtype B was isolated from 40 culturesobtained from 258 soil samples, which represents contamination in15.5% of sampled areas. These results suggest that vegetables andmelons may be highly contaminated as well. All cases ofC. botulinumin humans that were researched were connected to homemade cannedvegetables

Spread of Clostridium botulinum in the soils of Georgia

ObjectiveThe main focus of this study was to study the spread of botulism inGeorgia and the biological characteristics of the strains ofClostridiumbotulinumisolated from territories in the country.IntroductionAccumulation ofC. botulinumin soil occurs through excretion ofbacterial spores from the intestines of humans, animals, birds andfish. In Georgia, during the winter season, the population consumeshomemade vegetable preserves, which are made of locally produced(as well as imported) vegetables. Historical surveys confirmed that thepresence ofC. botulinumin the soil is widespread. Some researchersconsiderC. botulinuma characteristic component of soil flora.MethodsSoil samples were collected from areas, where from 2001-2002cases of botulism caused by homemade vegetable preserves (producedfrom vegetables cultivated in those areas) were registered. Soilsamples were collected from Kakheti, Shida Kartli, Kvemo Kartli,Samtkhe-Javakheti, and Samegrelo regions. Standard bacteriologyand PCR were used to confirm the presence ofC. botulinumfrom soilsamples. Separation of strains and their examination was conducted inaccordance with the scheme provided by the CDC Atlanta ReferenceLaboratory (USA), which was later tested by NCDC. Toxigenicityand toxin production of strains were tested using a biotest on whitemice.ResultsIn total, 258 soil samples were tested, from which, 40 (15.5%)cultures ofC. botulinumtype B were obtained. Toxigenicity andtoxin production were confirmed through biotests. These resultsconfirm the presence ofC. botulinumin agricultural lands, whichcauses contamination of vegetables cultivated on those lands, whichare used for the preparation of homemade preserves, causing botulismin humans.ConclusionsFor the purpose of finding solutions to botulism, it is essentialto verify the ecology of the pathogen through establishing theprevalence of bacteria in different soil types. It was shown that someareas of Georgia, where vegetable growing is greatly developed, andwhich, are the main sources of crops, are highly contaminated withC. botulinum. In Georgia, land used for agriculture is contaminatedwithC. botulinum.C. botulinumtype B was isolated from 40 culturesobtained from 258 soil samples, which represents contamination in15.5% of sampled areas. These results suggest that vegetables andmelons may be highly contaminated as well. All cases ofC. botulinumin humans that were researched were connected to homemade cannedvegetables