Regional pericarditis following uncomplicated catheter ablation procedure: a case report

Background Acute post-ablation pericarditis is the most common complication of epicardial ablation of ventricular arrhythmias (VA), while regional pericarditis following an initially uneventful endocardial catheter ablation (CA) procedure is a rare and elusive diagnosis. Case summary We report a case of a 66-years old Russian female who developed chest pain accompanied by ECG changes—biphasic T waves in V1-V4 leads after an initially uncomplicated premature ventricular complex (PVC) CA procedure. After examination and investigations, including transthoracic echocardiography (TTE), cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CCT), she was diagnosed with regional pericarditis, which occurred even though the ablation was uneventful with the limited number of radiofrequency applications. Furthermore, the diagnosis was difficult due to normal body temperature and the absence of pericardial effusion and myocardial abnormalities on TTE, findings that are not characteristic of pericarditis. The patient's last office visit was in six months after the procedure. Neither patient had any complaints, nor there were any changes on ECG and TTE. Discussion Regional post-ablation pericarditis is a relatively rare type of postcardiac injury syndrome (PCIS). The varying severity of the PCIS clinical course makes the diagnosis of post-ablation pericarditis initially difficult, especially in patients undergoing an uneventful catheter ablation procedure. Non-invasive imaging modalities as cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CCT) should be considered initially in elusive cases of PCIS.

Abstract 17160: Cardiac Sarcoidosis Mimicking Arrhythmogenic Right Ventricular Cardiomyopathy Presenting With Syncope

A 35-year-old previous healthy man presented with palpitations and nearly syncope. Electrocardiography showed first degree atrioventricular block (PR interval 316 milliseconds) and premature ventricular complex (PVC) possibly originating from right ventricle (RV). The transthoracic echocardiography disclosed dilated RV with preserved right ventricular systolic function with a RV systolic pressure of 33mmHg, and thickened interventricular septum (12.7mm) with normal left ventricular size and function. At this point, the initial diagnosis was arrhythmogenic right ventricular cardiomyopathy (ARVC) with ventricular arrhythmias. The 24-hour Holter study showed 904 monomorphic PVCs and short-run ventricular tachycardia. The chest computed tomography demonstrated dilated RV with scalloping over free wall and multiple lung nodules mainly located in both upper lung fields (Figure A&B). Radiofrequency catheter ablation and implantation of implantable cardioverter defibrillator were suggested under the impression of ARVC. Therefore, he visited our hospital for second opinion. Since the diseased conduction system was unusual in patient with ARVC, CMR imaging was performed which revealed late gadolinium enhancement over both ventricles and basal interventricular septum (Figure C), raising the suspicion of cardiac sarcoidosis. Thereafter, the 18F-fluorodeoxyglucose (FDG)-Positron Emission Tomography study was arranged and showed FDG uptake over basal septum and lateral wall of LV, and multiple lung nodules (Figure D). Endomyocardial biopsy of RV showed myocardial fibrosis without a specific diagnosis. Thoracoscopic wedge resection of the lung nodule was performed, and pathology showed non-necrotizing granulomas distributed along with broncho-vascular bundles and subpleural area. No microorganism could be demonstrated. Sarcoidosis with cardiac and pulmonary involvement was impressed. Further steroid treatment will be initiated.

Incidental Detection of a Rare Coronary Anomaly During Catheter Ablation for Premature Ventricular Complexes: All in One Coronary Ostium

Single coronary artery is a rare congenital anomaly associated with sudden cardiac death even though most of the cases are asymptomatic. Cardiac computerized tomography angiography plays an essential role in establishing the diagnosis of single coronary artery and designating the arterial course. Being aware of coronary anomaly is crucial in some cases scheduled for catheter ablation of premature ventricular complex neighboring to coronary arteries to prevent radiofrequency ablation related vascular injury.

Premature ventricular complexes and development of heart failure in a community-based population

ObjectiveA higher premature ventricular complex (PVC) frequency is associated with incident congestive heart failure (CHF) and death. While certain PVC characteristics may contribute to that risk, the current literature stems from patients in medical settings and is therefore prone to referral bias. This study aims to identify PVC characteristics associated with incident CHF in a community-based setting.MethodsThe Cardiovascular Health Study is a cohort of community-dwelling individuals who underwent prospective evaluation and follow-up. We analysed 24-hour Holter data to assess PVC characteristics and used multivariable logistic and Cox proportional hazards models to identify predictors of a left ventricular ejection fraction (LVEF) decline and incident CHF, respectively.ResultsOf 871 analysed participants, 316 participants exhibited at least 10 PVCs during the 24-hour recording. For participants with PVCs, the average age was 72±5 years, 41% were women and 93% were white. Over a median follow-up of 11 years, 34% developed CHF. After adjusting for demographics, cardiovascular comorbidities, antiarrhythmic drug use and PVC frequency, a greater heterogeneity of the PVC coupling interval was associated with an increased risk of LVEF decline and incident CHF. Of note, neither PVC duration nor coupling interval duration exhibited a statistically significant relationship with either outcome.ConclusionsIn this first community-based study to identify Holter-based features of PVCs that are associated with LVEF reduction and incident CHF, the fact that coupling interval heterogeneity was an independent risk factor suggests that the mechanism of PVC generation may influence the risk of heart failure.

Persistent ventricular dysrhythmia follow in general anesthesia for tonsillectomy

Arrhythmia is one of the most common cardiovascular complications during anesthesia. Its occurrence has been reported in 70% of patients undergoing general anesthesia for various surgical procedures. Premature ventricular complex usually follows a benign course and shows a good response to medical therapy. In this study, a case was reported that did not respond to the usual treatment of ventricular tachycardia and frequent premature ventricular complex.

Characterization of the Electrophysiological Substrate in Patients with Barlow's Disease

BACKGROUND. Myxomatous mitral valve prolapse (MVP) and mitral-annular disjunction (Barlow disease) are at-risk for ventricular arrhythmias (VA). Fibrosis involving the papillary muscles and/or the infero-basal left ventricular (LV) wall was reported at autopsy in sudden cardiac death (SCD) patients with MVP. METHODS AND RESULTS: Twenty-three patients with VA were enrolled, including five with syncope and four with a history of SCD. Electrophysiological parameters were correlated with VA patterns, ECG inferior negative T wave (nTW), and late gadolinium enhancement (LGE) assessed by cardiac magnetic resonance. Premature ventricular complex (PVC) burden was 12061.9±12994.6 /24 hours with a papillary-muscle type (PM-PVC) in 18 patients (68%). Twelve-lead ECG showed nTW in 12 patients (43.5%). A large Uni<8.3mV area (62.4+/- 45.5 cm2) was detected in the basal infero-lateral LV region in 12 (73%) patients, and in the papillary muscles (2.2+/-2.9 cm2) in 5 (30%) of 15 patients undergoing EAM. A concomitant Bi<1.5 mV area (5.0±1.0 cm2) was identified in 2 patients. A history of SCD, and the presence of nTW, and LGE were associated with a greater Uni<8.3mV extension: (32.8+/-3.1 cm2 vs. 9.2+/-8.7 cm2), nTW (20.1+/-11.0vs.4.1+/-3.8cm2), and LGE (19.2 ± 11.7 cm2 vs. 1.0 ± 2.0 cm2, p=0.013), respectively. All patients with PM-PVC had a Uni<8.3mV area. CONCLUSIONS: Low unipolar low voltage areas can be identified with EAM in the basal infero-lateral LV region and in the papillary muscles as a potential electrophysiological substrate for VA and SCD in patients with MVP and Barlow disease phenotype

Characteristics and Outcomes of Ventricular Tachycardia and Premature Ventricular Contractions Ablation in Patients with Prior Mitral Valve Surgery

Background: Data regarding ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation following MVS is limited.) CA can be challenging given perivalvular substrate in the setting of mitral annuloplasty or prosthetic valves. Objective: To investigate the characteristics, safety, and outcomes of radiofrequency catheter ablation (CA) in patients with prior mitral valve surgery (MVS) and ventricular arrhythmias (VA). Methods: We identified consecutive patients with prior MVS who underwent CA for VT or PVC between January 2013- December 2018. We investigated the mechanism of arrhythmia, ablation approach, peri-operative complications, and outcomes. Results: In our cohort of 31 patients (77% men, mean age 62.3±10.8 years, left ventricular ejection fraction 39.2±13.9%) with prior MVS underwent CA (16 VT; 15 PVC). Access to the left ventricle was via transseptal approach in 17 patients, and a retrograde aortic approach was used in 13 patients. A combined transseptal and retrograde aortic approach was used in one patient, and a percutaneous epicardial approach was combined with trans-septal approach in 1patient. Heterogenous scar regions were present in 94% of VT patients and scar-related reentry was the dominant mechanism of VT. Clinical VA substrates involved the peri-mitral area in 6 patients with VT and 5 patients with PVC ablation. No procedure-related complications were reported. The overall recurrence-free rate at 1-year was 72.2%; 67% in the VT group and 78% in the PVC group. No arrhythmia-related death was documented on long-term follow-up. Conclusion: CA of VAs can be performed safely and effectively in patients with MVS