Showing papers in "Interventional Cardiology in 2016"

Hypertension risk factors who underwent dobutamine stress echocardiography

Abstract: Objectives and methods: The present report aims to identify the hypertension risk factors who underwent Dobutamine stress echocardiography (DSE) (558 heart patients), based on the routine secondary data set (UCLA Statistics Web Site) without any specific setting. Joint generalized linear statistical gamma models are used. Results: The present identified statistical significant hypertension risk factors from three blood pressure (basal, systolic, and maximum) analyses are the following: basal heart rate (bhr) (P<0.0001), double product (DP) of basal blood pressure and heart rate (basedp) (P<0.0001), peak heart rate (pkhr) (P<0.0001), DP of peak heart rate & systolic blood pressure (dp) (P<0.0001), dobutamine dose (dose) (P=0.0268), maximum heart rate (maxhr) (P<0.0001), percent maximum predicted heart rate (pctM-phr) (P=0.0312), DP on maximum dobutamine dose and blood pressure (dpmaxdo) (P<0.0001), age (P=0.0048), chest pain (P=0.0505), resting wall motion abnormality on echocardiogram (restwma) (P<0.0001), positive stress echocardiogram (posSE) (P=0.0002), new myocardial infraction (newMI) (P<0.0001), recent angioplasty (newPTCA) (P=0.0252), recent bypass surgery (newCABG) (P=0.0482), history of hypertension (hxofHT) (P=0.0541), history of coronary artery bypass surgery (hxofCABG) (P=0.0529), any event (P=0.0289), and base line electrocardiogram diagnosis (ecg) (P=0.0312). Conclusions: Impacts of heart conditions, biochemical parameters, dobutamine dose and many others on hypertension have been identified based on probabilistic modeling. Most of the present findings and their effects are almost new in the hypertension literature.

The FAME Trials: Impact on Clinical Decision Making.

Abstract: Careful and stepwise evaluation of the fractional flow reserve (FFR) index has been performed over the years, culminating in the landmark Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) and Fractional Flow Reserve-Guided Percutaneous Coronary Intervention Plus Optimal Medical Treatment Versus Optimal Medical Treatment Alone in Patients with Stable Coronary Artery Disease (FAME II) trials. Findings from these studies demonstrated unequivocally the overall inadequacy of angiography versus FFR to correctly assess stenosis severity. Thus, proof of concept and clinical applicability was established beyond debate and will be discussed here.

Computational fluid dynamic analysis of calcified coronary plaques: correlation between hemodynamic changes and cardiac image analysis based on left coronary bifurcation angle and lumen assessments

Abstract: The purpose of this study was to determine the relationship between left coronary bifurcation angle and significant coronary stenosis with use of coronary CT angiography (CCTA)-generated computational fluid dynamics (CFD) analysis when compared to the CCTA analysis of coronary lumen stenosis with invasive coronary angiography (ICA) as the reference method. Eleven patients with calcified plaques at the left coronary artery tree who underwent CCTA and ICA examinations were included in the study. CFD simulation of left coronary models was performed to analyse hemodynamic changes including wall shear stress, wall pressure and flow velocity. The mean bifurcation angle was measured 83.3 ± 17.1o and 83.3 ± 17.0o on CCTA and ICA, respectively, with no significant difference (p=0.99). Of 15 significant stenosis at left anterior descending (LAD) and left circumflex (LCx) on CCTA, only 3 of them were confirmed to be >50% stenosis on ICA. Wall shear stress was noted to increase in the LAD and LCx models with significant stenosis and wider angulation (>80o), but remained no change in most of the other coronary models with no significant stenosis and narrower angulation. Wall pressured was decreased at the significant stenotic lesions, while flow velocity was increased with flow turbulence at the post-stenotic sites. This study further clarifies the direct correlation between left coronary bifurcation angle and significant stenosis, with angulation measurement being more accurate than lumen assessment for diagnosing significant stenosis.

Persistence of Oral Anticoagulants in Japanese Patients with Atrial Fibrillation:Non-Vitamin K Antagonist Oral Anticoagulant versus Warfarin

Abstract: Atrial fibrillation (AF) is the most common form of tachyarrhythmia and a well-known stroke risk. [1-4]. Many studies have demonstrated that vitamin K antagonists such as warfarin reduce the incidence of stroke in AF patients [4,5]. In a “real world” setting, however, a US cohort study showed that one-fourth of patients initiating warfarin for the first time for AF discontinued treatment within the first year [6]. Adherence to long-term anticoagulation therapy is a key for the prevention of stroke in at-risk AF patients. Since the approval of dabigatran by the U.S. Food and Drug Administration (FDA) in 2010, and in Japan in 2011, non-vitamin K antagonist oral anticoagulants (NOACs) have appeared in clinical practice. Large-scale randomized clinical trials (RCTs) assessing their application have shown NOACs to be as safe and effective as warfarin in patients with non-valvular AF (NVAF). Adherence to medication in RCTs is often high because selected patients are enrolled in these studies and patient adherence is attentively monitored [7].

Pre-implantation genetic diagnosis (pgd) for heart disease determined by genetic factors

Abstract: The application of PGD has currently been extended to an increasing number of common disorders with genetic predisposition, including inherited heart disease, the prevention and treatment of which presents an important challenge. The major problem is that no pre-clinical diagnosis and preventive management exists, with high risk of premature or sudden death. We previously described the first series of 18 PGD cycles for 5 different inherited cardiac diseases, and showed feasibility and extremely high utility of preventing inheritance of genes predisposing to these conditions. The present paper summarizes the cumulative experience of 51 PGD cycles for 14 cardiac diseases, determined by 23 different gene mutations. This resulted in the embryo transfer in 44 of 51 PGD cycles, yielding 29 (66%) unaffected pregnancies and birth of 27 healthy, disease predisposition free children. This is the world’s largest PGD experience, demonstrating important clinical implications of PGD for preventing inheritance of predisposing genes for heart disease, as practical means for avoiding the risk of mortality or premature or sudden death in offspring of couples carrying a heart disease predisposing genes.

Changes in left ventricular global and regional longitudinal strain during right ventricular pacing

Abstract: Background: LV strain and functions may be altered by Right ventricular apical pacing (RVAP). Right ventricular Septal pacing (RVSP) might be a better alternative. The detrimental effect of RV pacing may be mediated by regional LV impairment. Objectives: Our study aimed to demonstrate the short term impacts of right ventricular (RV) apical and septal pacing on Left ventricular (LV) regional and global longitudinal strain (GLS) in patients with preserved ejection fraction (EF). Methods: 62 patients indicated for permanent pacemaker implantation and preserved LV systolic function were included. Dual chamber pacemakers were implanted in all patients. Patients were divided into 2 groups according to RV lead position: group A (RVAP, n = 32) and group B (RVSP, n = 30). Patients were examined at baseline and after 6 months of implantation for LV systolic functions, global and regional strain by echocardiography and 2D speckle tracking echocardiography. Results: Paced-QRS duration was significantly shorter in group B compared to group A patients (P value 0.02). Regarding ventricular strain, there were no statistically significant difference between both groups at baseline measurements in comparisons of GLS, relative apical longitudinal strain (rALS) and regional longitudinal strain (RLS) (P value of >0.05). In contrast there was statistically significant difference between both groups appeared in results of GLS (P value of 0.01) at 6 months. In addition, regional longitudinal strain in septal, apical and rALS were affected after 6 months with P value of 0.02, 0.03 and 0.03 respectively. Conclusion: RVAP appears to worsen global longitudinal strain more than RVSP, and the resultant decrease in apical strain is most correlated region to decrease in GLS.

Anticoagulation with rivaroxaban after ultrasound-assisted catheter-directed thrombolysis in patients with intermediate highrisk pulmonary embolism a case series

Abstract: Background: The optimal treatment for intermediate-high risk pulmonary embolism (PE) is still unclear and challenging. A new method for this entity is ultrasound-assisted catheter directed thrombolysis (USAT). The use of non-vitamin K antagonist anticoagulants (NOAC) is currently not recommended after thrombolysis. In our case series we tried to evaluate the efficacy and safety of NOAC treatment shortly after USAT. Methods and findings: We report five patients with intermediate-high risk pulmonary embolism who were successfully treated with rivaroxaban as post-procedural anticoagulation after USAT. The treatment was tolerated well with rapid clinical improvement and almost complete normalisation of right heart function (reduction of mean right to left ventricular (RV/LV) ratio from 1.22 (range 1.07-1.24) at baseline to 0.87 (range 0.76-1.07) three days after thrombolysis (p = 0.016). We observed one GUSTO moderate bleeding episode and a transient rise in creatinine in one patient, but no other adverse events. After 2.4 days (range 2-4 days), patients were switched from unfractionated heparin to rivaroxaban. Follow up-visit after three months showed normalisation of right heart function (RV/LV ratio 0.69 (range 0.65-0.81), no recurrent thrombotic events and no additional bleeding episodes. Conclusion: In our experience, USAT followed by post-procedural anticoagulation with rivaroxaban appears to be an effective treatment of intermediate-high risk pulmonary embolism.

The safety and efficacy of sotalol in the management of acute atrial fibrillation: a retrospective case control study

Abstract: Objective: The European Society of Cardiology, American Heart Association and the American College of Cardiology guidelines on atrial fibrillation (AF) 2006 state that Sotalol should not be used in acute AF. We assessed the safety and efficacy of sotalol in acute AF when compared to other anti-arrhythmic drugs (ADD). Methods: A single centre retrospective observational study on 300 patients admitted with acute AF over a 12 months period. Study drugs used were sotalol, amiodarone, flecainide, propafenone or disopyramide for rhythm control. Digoxin, beta blockers, verapamil, diltiazem were prescribed for rate control. Rates of cardioversion to sinus rhythm, readmission rates due to AF, all cause readmissions, mortality rates due to sudden cardiac death and all-cause mortality was recorded over a 2 year follow up period. For paired data, the Wilcoxon matched-pairs signed- ranks or paired t-test were used. For unpaired data, Fisher’s exact test was used. Results: 120 patients were discharged on sotalol. The mean total dose used was 169.2 mg daily. Cardioversion to sinus rhythm on discharge occurred in 68% in the rhythm control group versus 42% for rate control group (p<0.001). Sotalol had a significantly higher cardioversion rate regardless of the dose when compared to amiodarone (p=0.036) however, there were similar readmission rates for AF. Four patients died acutely in hospital, none were on sotalol. Compared to all drugs sotalol had the lowest mortality rates (p=0.001). Mortality rates were lower in patients who received the higher dose of sotalol; 7.4% for patients who received a total of 320 mg daily versus 11.8% in those who received 160 mg daily. Conclusion: Sotalol is as safe and effective as other anti-arrhythmic drugs; in fact it was significantly more effective than amiodarone in this cohort. All AAD\\\\\\\\\\\\\\\'s demonstrated a significant improvement in cardioversion rates and a significantly lower mortality rate than rate controlling drugs.

Vasovagal syncope in 2016: the current state of the faint

Abstract: The evolving definition of syncope The term “syncope” suggests a clinical and intuitively grasped picture, yet it has been inconsistently and infrequently defined in the literature. Table 1 review some of the syncope definitions over the past couple decades. Originally, syncope was defined as a transient state of unconsciousness characterized by spontaneous recovery, or recovery in a supine position [1]. This definition was developed for research purposes to describe tilt table test outcomes, and was not intended for clinical use. Subsequently, the European Society of Cardiology (ESC) published their first guidelines for the management of syncope in 2001, which were updated in 2004 [2]. The ESC defined syncope as a transient loss of consciousness attributable to global cerebral hypoperfusion, and characterized by rapid onset, brevity, and spontaneous recovery. In 2009, the ESC published their updated guidelines for the diagnosis and management of syncope [3]. One significant update was highlighting the definition of syncope in the broader context of transient loss of consciousness (T-LOC). The term T-LOC was coined to encompass all disorders characterized by a selflimited loss of consciousness, irrespective of mechanism. For example, T-LOC includes syncope, epileptic seizures, psychogenic pseudosyncope, and other miscellaneous causes. Syncope is differentiated from other forms of T-LOC due to its unique pathophysiology of transient global cerebral hypoperfusion. The ESC definition of syncope provided a more specific and pathophysiological basis for the diagnosis of syncope, and sought to clarify the confusion with the broader T-LOC umbrella. While a laudable effort, the inclusion of “global cerebral hypoperfusion” in the definition proved challenging for clinicians to apply during their initial encounter with afflicted patients. The definition could only be applied strictly with the demonstration of cerebral hypoperfusion, again leaving clinicians without a widely applicable working definition. In September 2013, a multispecialty workshop of North American and European syncope experts met in Gargnano, Italy with the aim of obtaining consensus on the optimal evaluation and management of syncope patients in the emergency department. The Gargnano consensus conference removed the physiologic criterion for syncope, and substituted a criterion that would exclude other causes of loss of consciousness [4]. Syncope was defined as “a transient loss of consciousness, associated with inability to maintain the postural tone and with immediate spontaneous and complete recovery, associated with clinical features suggestive of specific forms of syncope (e.g. vasovagal, orthostatic, cardiac); or the absence of clinical features specific for another form of transient loss of consciousness such as epileptic seizure, hypoglycemia, or trauma”. This was a practical, feasible approach that after vigorous debate met agreement by cardiologists, neurologists, internists, family Derek S Chew, Satish R Raj and Robert S Sheldon*

Typical atrioventricular nodal reentrant and orthodromic atrioventricular tachycardias: electrocardiographic, electrophysiological diagnosis and treatment

Abstract: Paroxysmal supraventricular tachycardias with narrow QRS are defined as rhythms originating from above the His bundle, heart rate higher 100 bpm and QRS complex of less than 120 ms in adults or less than 90 ms in children. They present a prevalence of up to 8/1000 individuals. The main presentations of these regular tachycardias are atrioventricular nodal re-entrant tachycardia and orthodromic atrioventricular reentrant tachycardia due to an accessory pathway. These tachycardias present morbidity, with symptoms such as palpitations, dyspnea, chest pain, syncope, polyuria, and can be a cause of sudden cardiac death. Thus, their clinical and electrocardiographic diagnoses are the first step in the approach and treatment of the patient. This review will discuss the clinical aspects, electrocardiographic, electrophysiological diagnosis and treatment options in the acute phase and long-term management, in addition to nonpharmacological treatment.

Radiofrequency catheter ablation of ventricular tachycardia in structural heart disease: singleteam experience with follow-up upto 5 years

Abstract: Introduction: Catheter ablation of ventricular tachycardia (VT) in structural heart disease has significantly evolved over the past few decades. We present our experience of VT ablation in such patients over last five years. Methods and Results: Out of 38 cases of VT ablation in patients with structural heart disease done during last five years, 18 had chronic myocardial scar, 2 had recent myocardial infarction, 1 dilated cardiomyopathy and 17 ARVD/C. Substrate modifications was performed as first step in majority of patients by using 3D electroanatomical system (NavX, St. Jude Medical, USA). VT induction was tried after substrate modification. End point of ablation was non-inducibility of all VTs. Failure of RFA was seen in no patient. Partial success of RFA was seen in 2 and in 36 (95%) the procedure was fully successful. Fifteen patients already had an ICD implanted whereas 20 patients underwent ICD implantation after the procedure. Median Follow-up available is for 38 months. Four patients had recurrence of VT identified by the ICD. No patient had sudden cardiac death. One patient of ARVD/C had progressive RV failure. Conclusion: VT ablation in patients with underlying structural heart disease significantly reduces the recurrence of VT episodes. It plays an important role in reducing the number of ICD therapies.

Impact of nocturnal oxygen therapy for central sleep apnea syndrome on nocturnalpremature ventricular contractions

Abstract: We report here a case of central sleep apnea syndrome associated with frequent nocturnal premature ventricular contractions (PVCs) that were successfully eliminated using nocturnal oxygen therapy. He was admitted to our hospital for chest discomfort during the night. The symptoms frequently woke him up during sleep. His electrocardiogram (ECG) showed sinus rhythm accompanied by PVCs. The 24 hour ambulatory ECG detected frequent PVCs during the night (more than 1000 beats/hour). Additionally, polysomnography demonstrated severe central sleep apnea syndrome, the so-called Cheyne-Stokes respirations (apnea-hypopnea index 48/ hour). He received oxygen at a rate of 2 liter/min only during sleep. After nocturnal nasal oxygen therapy, the PVCs became significantly fewer and his symptoms disappeared. This case report suggests the possibility of an impact of oxygen inhalation during sleep in patients with central SAS on the prevention of ventricular arrhythmias during both the daytime and night. However, further well-established randomized, controlled studies are needed to confirm these effects.

Heterogeneity of clinical syndromes related to loss of function mutations in KCNJ2

Abstract: Ionic current abnormalities related to both inherited and acquired arrhythmia syndromes cause sudden cardiac death [1,2]. In the heart, ionic current IK1 maintains the resting membrane potential and augments terminal repolarization of the action potential [3]. Three inward rectifier channels contribute to cardiac IK1, but the dominant component is carried by Kir2.1, encoded by KCNJ2. The importance of this protein is emphasized by the association KCNJ2 mutations and various inherited arrhythmia syndromes, such as Andersen-Tawil Syndrome (ATS1), Short QT Syndrome 3, and Catecholaminergic Polymorphic Ventricular Tachycardia 3 [4-6]. The loss of IK1 may lead to arrhythmias by action potential prolongation and subsequent development of early after-depolarization (EAD) and the fatal ventricular arrhythmia Torsade de pointes. Importantly, IK1 has also been shown to be down regulated in heart failure (HF) and contributes to the acquired long QT and sudden cardiac death in this disease [7,8]. Critical to understanding the pathogenesis of arrhythmia development related to abnormal IK1 is the determination of the biophysical mechanisms by which mutations in KCNJ2 affect Kir2.1 function. Here we review the known and hypothesized mechanisms of Kir2.1 channel dysfunction as it relates to varied clinical syndromes.

Sub-acute anterior myocardial infarction due to the discontinuation of warfarin in a patient with aortic valve prosthesis: what is the best treatment

Abstract: Acute myocardial infarction (MI) is a common entity in patients due to the atherosclerotic plaque rupture or coronary embolism. We present a patient who had a mechanical aortic valve and was admitted to the hospital for a sub-acute anterior ST elevation myocardial infarction due to the discontinuation of warfarin. In case of persistent thrombus formation despite aggressive antithrombotic and anticoagulant therapy, thrombus aspiration, angioplasty and stenting should be preferred rather than conservative approach.

Role of 2-dimensional speckle tracking echocardiography in diagnosis of coronary artery stenosis instable angina pectoris patients

Abstract: Background and methods: In this work, 120 patients suspected of having stable angina pectoris were included. They were presented for evaluation of chest pain and to whom clinical evaluation, echocardiography, nuclear scanning and coronary angiography were done. They were classified into group (A) 40 control patients considered as a control group with normal coronaries, and group (B) 80 patients with significant CAD.   Results: The study showed that regarding the Echo. Parameters, there were statistically significant difference between the 2 groups regarding the A wave, E/A ration, DT, Em and E/EM. Also regarding SLSS and GLS 17 and GLS 12 as well as SLSr, GLSr 17 and GLSr 12. Significant difference was present regarding number of vessels affected in regard to GLS 12, GLSr 12 and GLSr 17. In comparison with the results of MPI, there was a positive correlation between the number of segments affected in MPI and GLS 12 and GLSr 12. A statistically significant correlation was also found between the 17 segments in MPI and SLSS and SLSr parameters.   Conclusion: Myocardial strain by speckle tracking is superior to conventional Echo. Parameters measurements of global and segmental LS using 2DSE and it is a more sensitive tool in the identification of WMA at rest than visual analysis and that support its use to risk stratify atherosclerotic CAD. It may help in identifying which coronary artery is affected.

Epicardial adiposopathy and atrial fibrillation

Abstract: Kocyigit and colleagues reported a study to investigate the association between epicardial adipose tissue (EAT) thickness and AF recurrence after cryoballoon-based pulmonary vein isolation (PVI). A total of 249 patients (55.6 ± 10.7 years; 48.2% male; 18.5% persistent AF were followed-up for 29 months (8 months-48 months). AF after the ablation procedure was 75.9% at a median follow-up of 29 months.

The importance of cardiopulmonary arrest registry

Abstract: Since 1991, the International Liaison Committee on Resuscitation (ILCOR) applies registry templates to register cardiopulmonary arrest events and the treatment given to the patient in every case. This information is registered in a database that is useful to improve the cardiopulmonary resuscitation guidelines. For this reason, the ILCOR has introduced some changes to the registry template in several occasions, in order to obtain better results. The information collected on the registry templates is also useful for an epidemiological approach to the cardiopulmonary arrest. Unfortunately, this template is whether not applied or not correctly applied in many countries. The changes on the ILCOR’s registry aim to facilitate the filling of the form. National and Local Health Services must implement its use, since it will allow to improve CA information all over the world.

Cardiovascular diseases: what else should cardiologists know?

Abstract: Cardiovascular diseases remain the main cause of death worldwide. More than 17 million people die annually from cardiovascular diseases (CVD), therefore the World Health Organization (WHO) launched on September 22, 2016 a new initiative to tackle the global threat of CVD, including heart attacks and strokes. Recently a close attention was paid on the retinal microvasculature and it\\\'s visualization in patients with CVD. The retina is the only place in whole human organism, where are visible vessels of alive person, reflecting early changes in other organs. Taken into account aforementioned we believe that cardiologists should be aware of valuable diagnostic potential of retinal examination, as it could help to detect early stages of disease comparing with assessment of CVD risk by coronary angiography.

Coronary artery steal syndrome in patient after coronary arteries by-pass surgery and left subclavian artery stenting-is the maintenance of a patent internal mammary artery still necessary?

Abstract: The use of the left internal mammary artery (LIMA) is preferred for the revascularization of a stenosed or occluded left anterior descending artery (LAD). Occlusion or stenosis of proximal part of the left subclavian artery (LSA) could induce reverse blood flow in LIMA called coronary subclavian steal syndrome (CSSS) and should be revascularized before coronary artery bypass grafting (CABG) surgery with LIMA. If restenosis of previously stented LSA occurs after CABG surgery with LIMA another revascularization is inevitable. However, the revascularization of LSA could reveal that increased blood pressure in LAD persistent through years due to present CSSS could substantially influence blood pressure change in coronary arteries and LIMA graft. This phenomenon can raise the question if it is necessary to maintain patent LIMA-LAD graft.

Failure of ventricular capture and pacemaker exit block secondary to moderate hyperkalemia

Abstract: An 81-year-old woman was admitted to our institution with bradycardia, weakness and presyncope. At admission physical examination revealed a pulse rate of 42 per minute, blood pressure of 95 / 50 mmHg, and an oxygen saturation of 93 % on room air. The interrogation of the device showed a correct ventricular sensing and a threshold for ventricular pacing of 6.5 V at 1 ms pulse width. Analytic test showed a creatinine 3.78 mg / dl, Urea 187 mg / dl, sodium 133 mEq / L, potassium 6.2 mEq / L, and pH 7.37. Our patient showed a moderate acute hyperkalemia, which caused pacemaker exit block and capture failure.

Long-term clinical outcomes up to 7- year results of intracoronary stand-alone bolus administration of eptifibatide during coronary intervention (ice) study

Abstract: Objectives: This study evaluated the immediate, intermediate and 7-year results of intracoronary (IC) eptifibatide administration during percutaneous coronary intervention (PCI). Background: Several studies tested intravenous (IV) bolus and continuous administration of eptifibatide during PCI. However, limited data is available considering giving eptifibatide as IC bolus alone during PCI. Methods: Clinical outcomes of 376 patients who received coronary stent(s) + eptifibatide by three applications during PCI and were followed up for over 84 months. Group A (119 patients) had IC eptifibatide bolus only; group B (119 patients) had IC bolus and IV infusion and group C (138 patients) had IV bolus + infusion. The standard two boluses of eptifibatide 180 mcg/kg were given either via IC or IV route and only groups B and C received IV infusion at 2 mcg/kg/min for 18-24 hours. Results: There were 256 males and 120 females, mean age 57 ± 11. Among them 52% were diabetics. The 6, 12, 24, 84-month cumulative composite endpoint of death and myocardial infraction (MI) was lower in group A (2.5%) compared to group C (10.8%, OR 4.3, p = 0.029), and group-B (5.8%, OR 2.6, p = 0.17). Compared to group-A, target vessel revascularization (TVR) was three fold in group-C (OR 3.3, p = 0.001) and two-fold in group-B (OR 2.0, p = 0.061). Bleeding was significantly higher in Group-C (OR 5.4, p < 0.0001) and Group-B (OR 3.4, p = 0.007) compared to Group-A. Re-hospitalization was significantly lower in group A (10.9%) compared to group B (16.8%) and group C (28%) (P =0.0009). Conclusion: The IC bolus alone application of eptifibatide may be safer and superior to the IV route, and continuous infusion may not be necessary. Large-scale prospective randomized trials are needed to further validate these findings.

Electrophysiological recognition of an atrio-ventricular mahaim fibre pathway

Abstract: Mahaim fibres are cardiac accessory bundles which can cause dangerous tachyarrhythmias. Despite their first description being many y ears ago, their recognition and diagnosis still proves difficult. The electrocardiographic features of Mahaim pathways are subtle and shared with other accessory pathways; as such, an electrophysiology study must be used to diagnose this pathway. Even then, it is often a process of elimination which leads to the eventual diagnosis. Here, I will present the case of a young woman with a peculiar history who was ultimately diagnosed with a Mahaim fibre pathway. Using this case, I will describe the key electrophysiological features and the treatment of the Mahaim fibre pathway.

Khan-Malek anomaly-two cases of a never reported accessory coronary artery

Abstract: We report two cases of an unusual accessory coronary artery arising from the left coronary cusp and traveling over the superior epicardial aspect of the left ventricle parallel to the left main coronary (LM) and the left anterior descending artery (LAD).

Tachycardia with wide QRS complex on a cocaine dependent patient: not everything is what it seems

Abstract: Introduction: Ventricular arrhythmias related to cocaine may not respond to antiarrhythmic drugs and may need treatment with radiofrequency ablation. Case presentation: In this case we describe a 33-year-old man that presented to the emergency room complaining of chest discomfort and slight palpitations predominantly in the precordium, starting for 1 hour ago. The patient reports rare episodes of non tachycardic palpitations in the past, short-lived. He denied syncope or pre- syncope and did not show low output objective signs. After exams, he was diagnosed with sustained ventricular tachycardia confirmed by all used electrocardiographic criteria; the emergency medical team chose to use intravenous amiodarone, which reverted the arrhythmia. The patient was hospitalized, and continued intravenous amiodarone, sedation with benzodiazepines and 24-hour continuous monitoring electrocardiographic (Holter) were conducted. Amiodarone was suspended and was initiated oral diltiazem 80 mg in 8/8 hours. We requested a cardiac nuclear magnetic resonance image that showed normal perfusion and contractility, the absence of delayed enhancement, mild hypertrophy of the basal septum and lack of arrhythmogenic substrate. Electrophysiological study (EPS) was performed. Conclusion: During the EPS, the ECG at baseline was normal. The programmed electrical stimulation induced atrioventricular nodal reentrant tachycardia (AVNRT) with aberrant conduction. The ablation of the slow pathway was successful, and the patient did not present new tachycardia episodes.

No dual antiplatelet therapy in atrial fibrillation

Abstract: Managing atrial fibrillation is common in daily practice and an important part of this management is deciding over the embolism prevention strategy. Oral anticoagulants (warfarin, acenocumarol, apixaban, rivaroxaban or dabigatran) and antiplatelets (acetylsalicylic acid or clopidogrel) are the two groups of drugs used to prevent embolism events. To choose wisely CHA2DS2-VASc embolism risk scale aids in making this decision. But, is dual antiplatelet therapy, acetylsalicylic acid plus clopidogrel, a correct option in embolism prevention in atrial fibrillation?

AF classification and ablation strategy: time for a new paradigm

Abstract: Catheter ablation for symptomatic atrial fibrillation has emerged as a successful therapy for patients with medically refractive atrial fibrillation. Nearly uniform superior shortand long-term success rates compared with antiarrhythmic medications have prompted recent guideline changes that suggest ablation can be considered before use of pharmacologic therapies [1]. Traditionally, ablation strategies for AF have been divided into either pulmonary vein isolation (PVI) alone or PVI and substrate ablation. The trigger alone strategy has been the primary strategy in patients with paroxysmal atrial fibrillation, with a recent clinical trial reporting greater than a 70% 12 month success rate with the use of contact force sensing technology [2]. Those with persistent and long-standing persistent atrial fibrillation or moderatesevere structural heart disease continue to experience suboptimal results and often require multiple ablations [1]. Many operators believe that in these patients additional ablation beyond PVI is needed. Additional ablation approaches have included such strategies as linear ablation, ablation of complex fractionated electrograms (CFAE), focal impulse or rotor modulation (FIRM), among others. However, recent results of the multi-center STAR-AF 2 trial have shown that linear ablation and ablation of CFAE have not been superior to that of PVI alone in persistent AF [3]. As such, the ideal ablation strategy in these patients uncertain. Furthermore, there appears to be a subset of patients with paroxysmal AF that have poor long term outcomes from PVI alone, as well as a subset of patients with persistent AF patients that have excellent outcomes from PVI alone [4]. Given these data, we believe that classifying AF as either paroxysmal or persistent is inadequate to guide ablation strategy.