Initial Experience with Fractionation Mapping in the Identification of Vagal Ganglionated Plexus During Cardioneuroablation

This is a series case report of five symptomatic patients presented with diagnosis of sinus bradycardia, first and second degrees atrioventricular (AV) blocks, that were referred to pacemaker implantation. During the screening, a functional cause for the bradycardia and AV blocks were documented by treadmill stress test, 24-hour Holter monitoring and atropine test. After the confirmation of the diagnosis, patients were submitted to cardioneuroablation on an anatomical basis supported by a tridimensional electroanatomical fractionation mapping software. The technique and the acute and short-term results of the cardioneuroablation are described.

Clinical Characteristics of Patients with Tetralogy of Fallot who Underwent an Invasive Procedure for Arrhythmias

Introduction: Tetralogy of Fallot (TOF) is a cyanotic congenital heart disease that has an incidence of sudden cardiac death of 0.2% per year, being arrhythmias the main cause of its occurrence. Objective: To compare characteristics of TOF patients referred for electrophysiological study (EPS) against those that were not (No-EPS). Method: Retrospective cohort with 215 patients (57.2% men; age = 29 ± 4) with corrected TOF (median of three years, ranging from 0.33 to 51) that underwent EPS between 2009-2020. The primary outcome was composed of death, implantable cardiac defibrillator (ICD) requirement and hospitalization. Results: Pre-syncope (EPS = 4.7%, No-EPS = 0%; p = 0.004), syncope (EPS = 7.1%, No-EPS = 1.7%; p = 0.056) and palpitations (EPS = 31%, No-EPS = 5.8%; p < 0.001) were symptoms that justified electrophysiological investigation. ICD was implanted in 24% of EPS and 0.6% of No-EPS (p=0.001). Twenty-six percent of the EPS group presented non-sustained ventricular tachycardia, while 0% in No-EPS (p = 0.012). The EPS group had more atrial fibrillation or atrial Flutter (35.7% vs. 6.9%; p < 0.001). The EPS patients had a wider QRS duration than the no-EPS group (171.12 ± 29.52 ms vs. 147 ± 29.77 ms; p < 0.001). Also, 26.2% of EPS performed ablation to correct macroreentrant atrial tachycardias. The incidence of primary outcome (death + ICD requirement + hospitalization) was higher in patients in the EPS group compared to the No-EPS group (p = 0.001). However, the total of seven deaths occurred during the clinical follow-up, but without differences between the groups (EPS = 4.7% vs. No-EPS = 2.8%; p = 0.480). Conclusion: EPS group had a profile of greater risk, more complex heart disease, and a greater occurrence of the primary outcome when compared to the No-EPS group.

Stiff Left Atrium Syndrome After Atrial Fibrillation Ablation – A Diagnosis Not To Forget

Atrial fibrillation is the most prevalent arrhythmia in clinical practice and has different strategies for its control. Of these strategies, the percutaneous ablation of the pulmonary veins stands out, with robust results in relation to drug treatment. It is an invasive procedure and, therefore, not free from complications, which must be properly diagnosed and treated. Among the possible complications, there is stiff atrium syndrome, characterized by reduced atrial compliance caused by post-ablation fibrosis, which, in turn, leads to atrial filling dysfunction and the consequent increase in atrial and venous capillary pulmonary pressures. The case report demonstrates this infrequent but important complication, which presents good results for clinical treatment, in addition to the contribution of cardiac magnetic resonance in its diagnosis and in the assessment of arrhythmia recurrence rates.

Orthodromic Atrioventricular Tachycardia in Wolff-Parkinson-White Syndrome with Two Accessory Pathways Participation during the Same AVT

Case report of a 49-year-old patient with Wolff-Parkinson-White syndrome, very symptomatic, with apparent parahisian pathway who, during an electrophysiological study, presented orthodromic atrioventricular tachycardia, featuring two accessory pathways, retrogradely, the parahisian pathway and a hidden left posterolateral pathway, during the same tachycardia, alternating the retrograde pathway of tachycardia without interruption.

Bidirectional Ventricular Tachycardia Due to Digitalis Intoxication

Bidirectional ventricular tachycardia (BDVT) is defined by beat-to-beat alternation of the QRS axis on the electrocardiogram. Its diagnosis is uncommon, and the most characteristic etiology is digitalis intoxication (DI). We report the case of a patient with heart failure of valve origin admitted for sepsis that progressed to BDVT and death, associated with DI.

Successful Left Atrial Appendage Closure with Watchman Device Implantation in Two Patients with Inferior Vena Cava Filters

Percutaneous procedures through femoral access in patients with inferior vena cava (IVC) filter may be at risk of complications. We evaluated the feasibility and safety of left atrial appendage closure (LAAC) through femoral access in patients previously implanted with IVC filter. We described the WatchmanTM device implantation in two patients with formal contraindication for oral anticoagulation. First patient had a GreenfieldTM filter and the second one an OpteaseTM filter, and in this patient an attempt to withdrawal the filter immediately before the LAAC procedure failed. A femoral approach was performed in both patients using a 14 Fr sheath. Before crossing IVC filters, venographies did not detect any thrombus. All steps of IVC filter crossing were performed under fluoroscopic guidance. No immediate or intrahospital complications related to the procedure occurred. Herein, we presented two cases of successful LAAC closure with Watchman device in patients with two different kinds of IVC filters.

Percutaneous Treatment to Inferior Vena Cava Perforation by Intracardiac Echocardiography Catheter after an Unsuccessful Conservative Approach

Catheter ablation is a well-established treatment for drug refractory arrhythmia, and intracardiac echocardiography is one of the tools used for this purpose. Despite a high volume of procedures performed worldwide, the incidence of vascular complications is still very low. We describe a case report of a percutaneous treatment to an inferior vena cava perforation by an intracardiac echocardiogram catheter after the failure of a conservative approach.

Cryoablation of a Mahaim Epicardial Accessory Pathway Inside Coronary Sinus Using an 8-mm Catheter

Cyoablation is a ablation technique underutilized except in parahissian pathways and atrial fibrillation ablation. Ablation inside venous coronary sinus remains a dreaded incursion, and cryoablation is rarely used. We present the case of a 43 YO female who had a recurrent wolff parkinson white syndrome due to an epicardial pathway inside the coronary sinus successfully treated with a large bore(8mm) cryocatheter. We also review literature and describe the advantages and similar reports of use of cryo in low flow recesses inside the heart.

Early Repolarization Pattern and Idiopatic Sustained Monomorphic Ventricular Tachycardia: an Infrequent Combination

Malignant early repolarization as cause of sudden death has taken on great importance in recent years. It has been described as an entity capable of producing ventricular arrhythmic events, causing from episodes of syncope to sudden cardiac death. Ventricular fibrillation is the typical arrhythmia in these patients, with no clear relationship to date with idiopathic monomorphic ventricular tachycardia. Electrocardiographic markers related to the development of arrhythmic events in early repolarization syndrome have been described. They seem not only related to the development of ventricular fibrillation, but also to sustained monomorphic ventricular tachycardia, as is the case described in the article.

Acquired Long QT Syndrome and Torsades de Pointes after Mitral Valve Replacement Surgery

Acquired long QT syndrome (aLQTS) can occur in up to one third of patients undergoing cardiac surgery and is often undisclosed. We present a case of a 55-year-old male patient admitted to our center for mitral valve replacement surgery, and, during the postoperative period, a long QT greater than 600 ms was confirmed and in the Holter monitoring Torsade de Pointes (TdP) was evidenced. The patient received appropriate medical treatment and was discharge in stable clinical conditions.