Efficacy of low energy rectilinear biphasic cardioversion for regular atrial tachyarrhythmias

Background: External, rectilinear biphasic cardioversion (RBC), as against monophasic cardioversion, requires lower energy and has been documented to be more effective in restoring sinus rhythm in atrial fibrillation (AF). There is, however, limited data on the optimal protocol of low energy RBC in atrial flutter (AFl) and regular atrial tachyarrhythmias (AT). Methods and results: A prospective, single-center study was conducted, wherein 50 consecutive patients (mean age: 70.8 &#177; 8.7; 24 males) undergoing cardioversion of persistent or paroxysmal AFl or AT were randomized into two protocols of subsequent RBC shocks: 1) 10 J, 20 J, 50 J, 100 J, 200 J or 2) 20 J, 50 J, 100 J, 200 J. Initial energy was effective in 9/28 (32%) patients using Protocol 1 and in 12/22 (52%) patients using Protocol 2 (NS). In 9/12 patients with pacemakers, energy of 10 J or 20 J restored sinus or atrial-paced rhythm. Mean cumulative energy and number of shocks was 67 &#177; 70 J vs 64 &#177; 62 J (NS) and 2.0 &#177; 0.8 vs 1.6 &#177; 0.7 (p = 0.05) for both protocols, respectively. Mean successful energy was higher for AFl patients than for AT patients 66 &#177; 49 J vs 30 &#177; 19 J, p < 0.04. In approximately 25% of patients, conversion of AFl/AT into AF was observed after initial energy. Conclusions: Low energy RBC is effective in 32-52% of patients with AFl/AT. Energy of 50 J is effective in 73% of patients and should be recommended as an initial energy in regular AT. Low energy RBC may be especially indicated in patients with pacemakers. (Cardiol J 2011; 18, 1: 33-38

Antazoline for rapid termination of atrial fibrillation during ablation of accessory pathways

Background and aim: To assess safety and efficacy of antazoline for termination of atrial fibrillation (AF) occurring during ablation of accessory pathways (AP).Methods: We analyzed electrophysiological mechanism of antazoline (changes in A-A interval) and the percentage of pre-excited QRS complexes before and after antazoline administration. The total dose administered and the time from the start of injection to sinus rhythm restoration were also measured.Results: Out of consecutive 290 patients with Wolff-Parkinson-White syndrome undergoing radiofrequency (RF) ablation, 12 (4.1%) (4 females, mean age 36 ± 20 years) developed sustained AF which did not stop spontaneously within 10 min, and antazoline in 100 mg repeated boluses was administered. In all 12 patients the drug restored sinus rhythm after a mean of 425 ± 365 s (range 43–1245 s) using a mean cumulative dose of 176 ± 114 mg (range 25–400 mg). The drug slightly prolonged R-R intervals during AF (from 383 ± 106 to 410 ± 70 ms) and reduced the percentage of fully pre-excited QRS complexes (from 35% to 26%). Intracardiac recordings showed gradual increase in A-A intervals, as well as regularization and decreasing fractionation of atrial activity following drug injection (mean A-A interval of 162 ± 30 ms at baseline vs. 226 ± 26 ms shortly before sinus rhythm restoration, p &lt; 0.001). AP was not completely blocked in any patient which enabled continuation of ablation.Conclusions: Antazoline safely and rapidly converts AF into sinus rhythm during ablation of AP. The drug does not block AP completely, enabling continuation of ablation. The drug converting AF into more organized atrial activity (atrial flutter/tachycardia) before sinus rhythm resumption.

Long-term follow-up and comparison of techniques in radiofrequency ablation of ventricular arrhythmias originating from the aortic cusps (AVATAR Registry)

Introduction: Radiofrequency ablation (RFA) of outflow tract ventricular arrhythmia (VA) that originates from the aortic cusps can be challenging. Data on long-term efficacy and safety as well as optimal technique after aortic cusp ablation have not previously been reported. Objectives: This aim of the study was to determine the short- and long-term outcomes after RFA of aortic cusp VA, and to evaluate aortic valve injuries according to echocardiographic screening. Patients and methods: This was a prospective multicenter registry (AVATAR, Aortic Cusp Ventricular Arrhythmias: Long Term Safety and Outcome from a Multicenter Prospective Ablation Registry) study. A total of 103 patients at a mean age of 56 years (34–64) from the “Electra” Registry (2005–2017) undergoing RFA of aortic cusps VA were enrolled. The following 3 ablation techniques were used: zero-fluoroscopy (ZF; electroanatomical mapping [EAM] without fluoroscopy), EAM with fluoroscopy, and conventional fluoroscopy-based RFA. Data on clinical history, complications after RFA, echocardiography, and 24-hour Holter monitoring were collected. The follow-up was 12 months or longer. Results: There were no major acute cardiac complications after RFA. In one case, a vascular access complication required surgery. The median (interquartile range [IQR]) procedure time was 75 minutes (IQR, 58–95), median follow-up, 32 months (IQR, 12–70). Acute and long-term procedural success rates were 93% and 86%, respectively. The long-term RFA outcomes were observed in ZF technique (88%), EAM with fluoroscopy (86%), and conventional RFA (82%), without differences. During long-term follow-up, no abnormalities were found within the aortic root. Conclusions: Ablation of VA within the aortic cusps is safe and effective in long-term follow-up. The ZF approach is feasible, although it requires greater expertise and more imaging modalities

Elektrokardiogram miesiąca Czynny rytm pozazatokowy ze sprawnym przewodzeniem wstecznym blokującym aktywność węzła zatokowego

U 49-letniego chorego w EKG stwierdzono rytm zatokowy miarowy 80/min z zespołami QRS o morfologii niezupełnego bloku prawej odnogi pęczka Hisa (nRBBB), bez zaburzeń przewodzenia przedsionkowo-komorowego (p-k) oraz z częstymi wstawkami rytmu o częstotliwości 75/min, o zespołach QRS 120 ms, o morfologii niezupełnego bloku lewej odnogi pęczka Hisa (nLBBB) z przewodzeniem wstecznym. Czynny rytm rozpoczynają pobudzenia przedwczesne przewiedzione wstecznie, blokujące aktywność węzła zatokowego. Po ustąpieniu przewodzenia wstecznego powraca rytm zatokowy. W kontrolnym badaniu EKG podczas leczenia beta-adrenolitykiem stwierdzono bradykardię zatokową 50/min, zakłóconą pojedynczą ekstrasystolią o morfologii zespołów QRS jak w czynnym rytmie w pierwszym EKG. W zespołach QRS lub tuż przed nimi widoczne są załamki P pochodzenia zatokowego

Izolacja okrężna żył płucnych u chorego z napadowym migotaniem przedsionków przy użyciu systemu High Density Mesh Ablator (HDMA) - pierwsze polskie doświadczenie

We present a case of a 49 year-old man without structural heart disease who suffered from frequent episodes of atrial fibrillation. We performed pulmonary vein isolation using a new system High-Density Mesh Ablation. All four pulmonary veins were isolated and during an 8-month follow-up period no arrhythmia recurrences were noted. Kardiol Pol 2010; 68, 11: 1295-129

Idiopatyczne objawowe przedwczesne skurcze dodatkowe komorowe: krótko&#8722; i długoterminowa ocena skuteczności leczenia antyarytmicznego i ablacji

Background: There is little data on the long-term efficacy of antiarrhythmic drugs (AADs) and radiofrequency catheter ablation (RFCA) in patients with symptomatic premature ventricular complexes (PVCs) and no organic heart disease. Aim: To evaluate the short- and long-term efficacy and tolerance of AAD therapy and RFCA in patients with idiopathic PVCs. Methods: This was a prospective, crossover, open-label study performed in 84 consecutive patients (mean age 47 &#177; 15 years; 60% women) with symptomatic idiopathic PVCs (mean PVCs/24 h, 13,768 &#177; 9,424; range 1,693&#8211;42,687). Patients were treated for 2&#8211;3 weeks with metoprolol, propafenone or verapamil. Then patients were referred for RFCA, if they had drug intolerance, inefficacy or did not wish to have prolonged AAD treatment. Results: The most efficacious agent was propafenone, followed by verapamil, and then metoprolol [35 (42%), 13 (15%) and eight (10%) responders, respectively, p < 0.01 vs propafenone]. Only responders to drug treatment had a significant reduction in symptom severity (Visual Analogue Scale score: 6.2 &#177; 1.4 vs 2.7 &#177; 2.0, p < 0.001). After AAD, 50 (60%) patients underwent RFCA. During long-term follow-up (48 &#177; 10 months), RFCA (mean 1.2 procedures/patient) was effective in 44/50 (88%) patients. Of the 34 remaining patients, 21 remained on effective AAD, 6 patients remained on ineffective AAD, and 7 patients were taken off AADs therapy due to spontaneous remission of PVCs or a decrease in symptom severity. Conclusions: Short-term treatment with propafenone was more effective than verapamil or metoprolol in suppressing idiopathic PVCs. However, optimal benefit was achieved with RFCA, which was effective and safe during long-term follow-up.Wstęp: Wiedza na temat długoterminowej skuteczności leków antyarytmicznych (AADs) i przezskórnej ablacji prądem o wysokiej częstotliwości (RFCA) u pacjentów z objawowymi przedwczesnymi skurczami dodatkowymi (PVCs) bez organicznej choroby serca jest ograniczona. Cel: Celem pracy była ocena krótko- i długoterminowej skuteczności oraz tolerancji leczenia AADs i RFCA u chorych z idiopatycznymi PVCs. Metody: Do prospektywnego, otwartego badania typu krzyżowego włączono 84 kolejnych chorych (średni wiek 47 &#177; 15 lat; 60% kobiet) z objawowymi idiopatycznymi PVCs (średnia liczba PVCs/24 h 13,768 &#177; 9,424; zakres: 1,693&#8211;42,687). Chorzy byli leczeni w sposób losowy przez 2&#8211;3 tygodnie metoprololem, propafenonem i werapamilem. Następnie pacjentów kierowano na zabieg RFCA, jeśli stwierdzono u nich nieskuteczność, nietolerancję lub niechęć do długoterminowego leczenia AADs. Wyniki: W obserwacji krótkotermnowej najskuteczniejszym lekiem był propafenon, a w dalszej kolejności werapamil i metoprolol [35 (42%), 13 (15%) i 8 (10%) chorych uznanych za responders, kolejno, p < 0,01 v. propafenon]. Tylko u pacjentów zakwalifikowanych jako AADs responders osiągnięto istotną redukcję nasilenia objawów arytmii (Visual Analog Scale: 6,2 &#177; 1,4 v. 2,7 &#177; 2,0; p < 0,001). Po próbie doboru farmakoterapii 50 (60%) osób poddano RFCA. Podczas obserwacji długoterminowej (48 &#177; 10 miesięcy) RFCA (średnio 1,2 procedury/chorego) była skuteczna u 44/50 (88%) chorych. Spośród pozostałych 34 pacjentów 21 chorych było skutecznie leczonych AADs, 6 było leczonych AADs nieskutecznie, a u 7 chorych zrezygnowano z terapii AADs z powodu spontanicznej remisji PVCs lub istotnego zmniejszenia nasilenia objawów PVCs. Wnioski: Krótkoterminowe leczenie propafenonem jest skuteczniejsze niż werapamilem i metoprololem w redukcji liczby oraz objawów idiopatycznych PVCs, jednak optymalny efekt długoterminowy odnoszą chorzy poddani zabiegowi ablacji