Mahaim Tachycardia Induced Cardiomyopathy

We present the case report of a 22-year man, with incessant palpitations, chest pain, shortness of breath, and pulsations in his neck for the past 7 months. He was referred to the cardiology unit for workup of wide complex tachycardia (WCT). His echocardiography, 6 months earlier, had demonstrated severe left ventricular (LV) systolic dysfunction, severe global hypokinesia, mild tricuspid regurgitation (TR), and mild mitral regurgitation (MR) which resolved with medical therapy including beta-blockers. He underwent electrophysiological study, which revealed a decremental right sided atriofascicular pathway causing a WCT with left bundle branch block (LBBB) morphology and left axis deviation (LAD, Mahaim tachycardia). This was successfully ablated by radiofrequency ablation (RF) with abolition of the tachycardia. This case report highlights Mahaim tachycardia induced cardiomyopathy, a rare but curable cause of cardiomyopathy

Antidromic Atrioventricular Reentrant Tachycardia Dependent on a Unidirectional Left Anterior Accessory Pathway Mimicking Peri-mitral Ventricular Tachycardia: Successful Ablation via a Transseptal Approach

Antidromic atrioventricular reentrant tachycardia (aAVRT) is rare compared to orthodromic atrioventricular reentrant tachycardia (oAVRT). An aAVRT that is dependent on a unidirectional, decremental accessory pathway (AP) is even rarer. Idiopathic ventricular tachycardias (iVT) that have benign prognoses and respond well to medical therapy can be confused with aAVRTs dependent on APs having ventricular insertion sites close to the iVT focus and have a real risk of sudden death. The preferred approach of ablation for such tachycardias with anterograde conduction only is a retrograde aortic approach, which facilitates the mapping of the earliest ventricular activation during atrial pacing or tachycardia from the ventricular side. This, however, necessitates access to the arterial system with accompanying complications. We describe herein the case of a wide complex tachycardia, which was treated initially as VT with intravenous lidocaine. The baseline electrocardiogram (ECG) did not show preexcitation. An electrophysiology study (EPS) revealed a left anterior AP that conducted anterograde only. AVRT was easily inducible at a cycle length of 290 ms. Successful ablation was undertaken via the transseptal approach without recurrence

Is a post pacemaker implantation routine chest x ray necessary?

Introduction: The routine use of post pacemaker implantation chest X ray (CXR) to rule out pneumothorax and check lead position is a practice according to established protocols. Life time exposure to medical radiation is increasing. As the dose of radiation is cumulative it is vital to reduce radiation exposure. Methods: A retrospective study at the Aga Khan University hospital to assess the need for a post implantation CXR. All patients undergoing pacemaker implantation between October 2009 and December 2012 were included. The center had three implanting physicians. Results:A total number of 317 cases. Sixty seven percent were males, the mean age of the dual chamber (DC) group was 68.2 years, age range (22 to 91 years), and while for the single chamber pacemaker (SC) it was 70 years with age range 24 to 93 years. Except for one patient who had cephalic cut down, the rest underwent subclavian vein (SCV) puncture. The subclavian vein puncture was done under fluoroscopy. Pneumothorax occurred in 2 cases (0.63%). Both cases were during DC pacemaker implantation. Both cases required chest tube insertion. Acute lead displacement occurred in 5 cases (1.57%). The lead displacement occurred after the post procedure CXR as per protocol. These were all picked up by symptoms and pacemaker interrogation, where failure to capture and under-sensing was noted. Both pneumothorax patients had structural chest and lung abnormality; one had kyphoscoliosis, while the other had severe left apical lung fibrosis (pulmonary TB). Conclusion: Pneumothorax occurred in 0.63% of the cases which could be predicted pre procedure and the lead displacement occurred later and was picked up through device interrogation and symptoms. In the normal SCV puncture provided the pre-implantation CXR was normal and post implantation physical examination was normal a CXR did not add to the management. Keywords: PPM, complication, pneumothorax, lead displacemen