Inducibilnost paroksizmalne fibrilacije atrija nakon krioablacije plućnih vena [Induction studies after cryoablation therapy for atrial fibrillation]

Aims: To analyze the clinical value of AF induction in patients treated by second generation CB for paroxysmal AF. Methods: Seventy patients underwent isoproterenol challenge after pulmonary vein isolation to assess AF induction and early PV reconnections (EPVR). Patients without EPVR were evaluated for premature atrial contraction (PAC) induction; atrial ectopy was considered frequent (PAC+) if >1/10 cycles or >6/min. After isoproterenol protocol, rapid atrial pacing (RAP) was performed. Results: AF induction by isoproterenol occurred only in 3/70 (4%) patients of whom 2/3 (66%) patients with an EPVR of a triggering vein. In the 62 patients without EPVR, PAC+ occurred in 17 patients (27%). RAP could induce AF in 23/70 (33%) patients. At a mean follow-up of 11.5 months, there were 11/70 (16%) AF recurrences. There was no significant difference in the AF recurrence rate in RAP inducible versus noninducible patients (log-rank p=0.33). A 41% recurrence rate (7/17 patients) was seen in the PAC+ group with significantly different AF-free survival for PAC+ vs PACpatients (log rank p < 0.0001). PAC+ was the only independent determinant to predict AF recurrence after multivariate analysis. Conclusion: PAC occurrence in response to isoproterenol could predict AF recurrence after PV isolation by CB, while RAP showed no prognostic implication

Ventricular extrasystole - induced cardiomyopathy.

Ventrikulske ekstrasistole (VES) česta su i načelno benigna pojava, osobito ako se radi o bolesniku sa strukturno zdravim srcem. 1998. godine objavljena je prva studija u kojoj je dokazano da medikamentozna supresija ekstrasistolije rezultira oporavkom funkcije lijeve klijetke u dilatacijskoj karidomiopatiji te je razvijen koncept VES inducirane kardiompatije (CMP). Sama pojavnost VES vrlo je velika u populaciji, raste s dobi, no točne podatke o incidenciji VES inducirane kardiomiopatije nemamo. Najvažniji čimbenik u razvoju ovog entiteta je "VES opterećenje»" no još se vode polemike oko točne definicije istog. Razvijeno je nekoliko životinjskih modela za rasvjetljavanje patofiziologije ove bolesti te se najvjerojatnije radi o funkcijskom poremećaju koji je u velikoj mjeri reverzibilan. U obradi ovih bolesnika potrebno je na sve dostupne načine detektirati sekundarne uzroke ekstrasistolije i kardiomiopatije, jer je VES inducirana CMP dijagnoza do koje dolazimo isključivanjem. Od terapijskih opcija na raspolaganju nam je medikamentozna terapija antiaritmicima te kateterska radiofrekventna (RF) ablacija. Randomizirane studije koje bi dale prednost jednoj od ovih opcija ne postoje. U posljednje vrijeme preferira se RF ablacija s vrlo dobrim razultatima u reverziji kardiomiopatije i s malom učestalosti komplikacija. U ovom trenutku, VES inducirana CMP još je prerijetko prepoznata kao uzrok neishemijske kardiomiopatije.Ventricular extrasystoles (PVC, Premature Ventricular Contraction) are a common and generally a benign phenomenon, especially in a patient with a structurally normal heart. The first study was published in 1998 which proved that medical suppression of extrasystole results in the recovery of the left ventricular function in dilatation cardiomyopathy, whereas the concept of PVC-induced cardiomyopathy (CMP) was developed. The incidence of PVCs itself is very large in population, rises with age, but we have no accurate data on the incidence of PVC-induced cardiomyopathy. The most important factor in the development of this disease is "PVC burden", but the exact definition thereof is still being discussed. Several animal models have been developed for elucidating the pathophysiology of this disease and it is probably a functional disorder that is largely reversible. In the treatment of these patients it is necessary to detect secondary causes of extrasystole and cardiomyopathy in all available ways; because the PVC-induced CMP is diagnosis of exclusion. Out of therapeutic options we have antiarrhythmic drug therapy and catheter radiofrequency (RF) ablation at disposal. There are no randomized studies that would prefer one of these options. RF ablation, with very good results in the reversion of cardiomyopathy and with a low incidence of complications, has been preferred lately. At this point, PVC-induced CMP is still too seldom recognized as a cause of non-ischemic cardiomyopathy

AV-block in patient with progressive muscle dystrophy – electrostimulation complications Case report

We report a case of total AV-block and paralytic ileus in 30-year old patient diagnosed with progressive muscular dystrophy 21 years ago. 30-year old male, diagnosed with progressive muscular dystrophy in 1998. has been in a wheelchair since 2002. Spondylodesis of thoracic spine was performed in 2005 due to scoliosis. Since 2014. patient has been using non-invasive mechanic ventilation due to respiratory failure. On 19th of February patient is diagnosed with obstructive ileus. Before the planned laparotomy, a total AV-block was diagnosed. Patient was transferred to the coronary care unit for temporary wire placement under ultrasound guidance. During the wire placement patient went to asystole, short resuscitation was performed and percutaneus pacing was placed. Interestingly percutaneus pacing did not result with voluntary muscular contractions due to severe muscle dystrophy. At last, endocardial pacing was successful and patient underwent laparotomy. Paralytic ileus was diagnosed. Postoperatively endocardial pacing was lost, again resuscitation was required along with percutaneus pacing. Therefore permanent DDDR pacemaker was implanted. Before implantation, on fluoroscopy temporary wire was visualized deep in pulmonary artery branch with multiple loops in right ventricle. This case report highlights the importance of x-ray guided endocardial lead placement in which less complications occure (RV-perforation, heart tamponade and in our case non-capture). In our case muscle weakness, respiratory failure, paralytic ileus, AV-block and treatment difficulties are all consequences of patient’s muscle dystrophy. Knowing that, it must be emphasized that knowledge of pathology of progressive muscle weakness is critical in various fields of clinical medicine

Young patient with dilatative cardiomyopathy and paroxysmal atrial fibrilation(PAF) – ablation therapy

We report a case of patient with dilatative cardiomyopathy, implanted cardioverter defibrillator with inapropriate shocks due to fast paroxysmal atrial fibrilation treated by cryoablation of pulmonary veins. A 43 year old man was diagnosed with acute heart failure (HF) and atrial fibrillation (AF) in 07.2016. At first, he was treated with diuretic and inotrope therapy and later on converted to sinus rhythm with amiodarone.Echocardiography showed dilatative cardiomyopathy with low ejection fraction of 20%. Coronarography ruled out ischemic disease. Spiroergometry established moderly decreased functional capacity, often irregular non-sustained ventricular tachycardia. Holter ECG showed a lot of episodes of atrial fibrillation. Single chamber cardioverter defibrillator (ICD) was implanted for primary prevention of sudden cardiac death. Later on patient presented with inappropriate ICD shocks due to fast AF despite amiodarone therapy. Therefore, pulmonary vein isolation (PVI) was indicated. 4/2018 TOE excluded LAA thrombus and successful cryoablation of all pulmonary veins was performed (Picture 1). After PVI, patient did not experience further AF symptoms which was confirmed in the ICD follow up (Picture 2). Complete reduction of AF burden was verified. Furthermore, HF symptoms improved and patient was in NYHA I-II class. Ultrasound confirmed positive remodeling of LV and EF increased to 40% with marked decrease of proBNP. Amiodarone therapy was abolished. Ablation of AF prevented further inadequate shocks of ICD and increased ejection fraction (EF) from 20% to 40%. Therefore, at least partly, heart failure was tachycardia mediated (tachycardiomiopathy). Ablation and reduction of AF burden in this case has direct mortality benefit

Electrical storm and catheter ablation of ventricular tachycardia days after left ventricular assist device implantation

Ventricular arrhythmias are common complication associated with left ventricular assist devices (LVAD). We present a challenging case of a 57-year-old male LVAD recipient who developed ventricular tachycardia refractory to antiarrhythmic drugs and device therapy in the early postoperative period and was eventually successfully treated with radiofrequency catheter ablation. Ventricular arrhythmias were successfully mapped, eliminated with ablation, and remained non-inducible. This case demonstrates that ventricular arrhythmia catheter ablation can be feasible, effective, and safe in LVAD recipients with a scar-related electrical storm even days after LVAD implantation. Although optimal treatment strategy in this patient population still needs to be defined, catheter ablation should be considered in LVAD recipients with ventricular arrhythmias refractory to antiarrhythmic drugs and device therapy representing a treatment of last resort