A Case Report of Radiofrequency Ablation of Typical Atrial Flutter Combined with Atrial Tachycardia

A 63-year-old female patient with a history of pulmonary heart disease underwent radiofrequency ablation because ofa persistent atrial flutter. Endocardial mapping with the carto3 system confirmed atrial flutter counterclockwise reentryaround the tricuspid annulus. Routine ablation of the cavo-tricuspid isthmus line to bi-directional block was performed.However, tachycardia with the same cycle length was induced again. After remapping, the tachycardia was confirmedto be focal atrial tachycardia located in the crista terminalis. After ablation, the tachycardia was terminated and couldnot be induced again.

ST-Segment Depression in Leads I and aVL: Artifactual or Pathophysiological Findings?

The 12-lead electrocardiogram (ECG) is a routinely performed test but is susceptible to misinterpretation even byexperienced physicians. We report a case of a 72-year-old lady with no prior cardiac history presented to our hospitalwith atypical chest pain. Her initial electrocardiogram shows an initial ST depression followed by positive deflectionsleads I and aVL. Non-physiological ST segment and T-wave changes are also observed in the precordial leads V2 to V6. By contrast, these abnormalities are notably absent in lead II. A repeat of the ECG taken 30 minutes later reveals the resolution of most abnormalities seen in the initial ECG on a background of high-frequency noise in the limb leads. She was referred to the cardiology department for further management. An urgent echocardiogram revealed no regional wall motion abnormalities with preserved ejection fraction, and her coronary angiogram revealed no significant coronary stenosis. This case illustrates the importance of understanding different factors that can cause ST segment abnormalities, notably artifactual changes that can mimic ST segment myocardial infarction.

Better Than You Think—Appropriate Use of Implantable Cardioverter-Defibrillators at a Single Academic Center: A Retrospective Review

Background: Implantable cardioverter-defibrillators (ICDs) can be life-saving devices, although they are expensiveand may cause complications. In 2013, several professional societies published joint appropriate use criteria (AUC)assessing indications for ICD implantation. Data evaluating the clinical application of AUC are limited. Previous registry-based studies estimated that 22.5% of primary prevention ICD implantations were “non-evidence-based” implantations. On the basis of AUC, we aimed to determine the prevalence of “rarely appropriate” ICD implantation at our institution for comparison with previous estimates.Methods: We reviewed 286 patients who underwent ICD implantation between 2013 and 2016. Appropriateness of each ICD implantation was assessed by independent review and rated on the basis of AUC.Results: Of 286 ICD implantations, two independent reviewers found that 89.5% and 89.2%, respectively, were appropriate,5.6% and 7.3% may be appropriate, and 1.8% and 2.1% were rarely appropriate. No AUC indication was found for 3.5% and 3.4% of ICD implantations, respectively. Secondary prevention ICD implantations were more likely rarely appropriate (2.6% vs. 1.2% and 3.6% vs. 1.1%) or unrated (6.0% vs. 1.2% and 2.7% vs. 0.6%). The reviewers found 3.5% and 3.4% of ICD implantations, respectively, were non-evidence-based implantations. The difference in rates between reviewers was not statistically significant.Conclusion: Compared with prior reports, our prevalence of rarely appropriate ICD implantation was very low. Thehigh appropriate use rate could be explained by the fact that AUC are based on current clinical practice. The AUC couldbenefit from additional secondary prevention indications. Most importantly, clinical judgement and individualized care should determine which patients receive ICDs irrespective of guidelines or criteria.

Comparison of Diagnostic Effects of T2-Weighted Imaging, DWI, SWI, and DTI in Acute Cerebral Infarction

Objective: To achieve precision medicine, the use of imaging methods to help the clinical detection of cerebral infarctionis conducive to the clinical development of a treatment plan and increase of the cure rate and improvement of the prognosis of patients.Methods: In this work, T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), susceptibility-weighted imaging (SWI), and diffusion tensor imaging (DTI) examinations were performed on 34 patients with clinically diagnosed cerebral infarction to measure the difference in signal intensity between the lesion and its mirror area and make a comparative analysis by means of the Student-Newman-Keuls method.Results: The detection rate of T2WI was 79% (27/34), the detection rate of DWI was 97% (33/34), the detection rateof SWI was 88% (30/34), and the detection rate of DTI was 94% (32/34).Conclusion: The imaging performance was in the order DWI > DTI > SWI > T2WI for the diagnosis of cerebral infarction, and combined imaging is better than single imaging.

Using Three-Dimensional Lorenz Scatter Plots to Detect Patients with Atrioventricular Node Double Path Caused by Interpolated Ventricular Premature Systoles: A Case Study

A series of related electrophysiology phenomena can be caused by the occurrence of interpolated ventricular prematurecontraction. In our recent three-dimensional Lorenz R-R scatter plot research, we found that atrioventricular nodedouble path caused by interpolated ventricular premature contraction imprints a specific pattern on three-dimensionalLorenz plots generated from 24-hour Holter recordings. We found two independent subclusters separated from the interpolated premature beat precluster, the interpolated premature beat cluster, and the interpolated premature beat postcluster, respectively. Combined with use of the trajectory tracking function and the leap phenomenon, our results reveal the presence of the atrioventricular node double conduction path.

Junctional Pacemaker May Replace the Sinoatrial Node

Junctional rhythm is usually seen in the clinic with different causes. We report a case of bicuspid aortic valve accompaniedby sinoatrial node dysfunction. The junctional escape beat could accelerate with physiological needs and provided for the normal needs of daily life when dysfunction of the sinoatrial node occurred, which provides a new way for the treatment of sinoatrial node dysfunction. Our findings could be potentially significant for identifying causes and choosing appropriate treatment strategies by using ECG monitoring in the clinic in the future.

In-Hospital Cardiac Arrest after Emotional Stress in a Patient Hospitalized with Gastrointestinal Symptoms and Chronic Anxiety Disorder

Background: We report an acute emotional stress–induced in-hospital cardiac arrest in a patient admitted with gastrointestinal symptoms after experiencing chronic anxiety disorder.Case Presentation: The patient was admitted to the Second Xiangya Hospital, Central South University, withgastrointestinal symptoms and chronic anxiety disorder, and experienced cardiac arrest during hospitalization after acute emotional stress. Malignant ventricular tachycardia and cardiogenic shock were evidenced in this patient afterthe acute emotional stress. Severe and extensive coronary spasm was confirmed by emergency coronary angiography, and coronary spasm was relieved by intracoronary injection of nitroglycerin. The patient recovered from myocardial infarction with nonobstructive coronary arteries. However, the patient developed acute kidney dysfunction and severe pulmonary infection and eventually died of respiratory circulatory failure on the ninth day after the successful rescue.Conclusions: Acute emotional stress on top of chronic anxiety disorder in patients hospitalized for noncardiovascularreasons might lead to the development of life-threatening cardiovascular diseases, including coronary artery spasmand myocardial infarction with nonobstructive coronary arteries. Psychological management is of importance to improvethe outcome of these patients.

ECMO/CRRT Combined Support in the Treatment of Critically Ill SARS-CoV-2 Pneumonia Patients

Objective: To explore the experience with and complications of extracorporeal membrane oxygenation (ECMO)combined with continuous renal replacement therapy (CRRT) for treatment of critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia.Methods: The data on critically ill COVID-19 patients who received ECMO/CRRT at Tongji Hospital, which is affiliated with Huazhong University of Science and Technology, in February and March 2020 were collected and analyzed. All three patients were male, and the mean age was 50.6 years (range 44–58 years). The indications for ECMO in critically ill SARS-CoV-2 pneumonia patients at our center were severe acute respiratory distress syndrome with Pao2/Fio2 below 100 mmHg under an effective protective pulmonary ventilation strategy and inflammatory stormaccompanied by acute kidney injury. One patient, with severe heart failure, was selected for venoarterial ECMO, andthe other two patients were selected for venovenous ECMO.Results: In the three patients who received ECMO combined with bedside CRRT, the mean duration was 9.7 days (range 7–13 days). Four complications occurred during ECMO/CRRT, especially thrombocytopenia. Laboratory testing showed increased counts of leukocytes and lymphocytes and decreased levels of inflammatory factors. Lung CT was suggestive of significantly absorbed and reduced lesions and interstitial fibrosis.Conclusions: The survival rate of patients with cardiopulmonary failure treated with ECMO/CRRT in whom conventional treatment failed in this group was 100%, which indicates that combined treatment with ECMO and CRRT is an important treatment technique.

Main Renal Artery Plus Branch Ablation in the Treatment of Resistant Hypertension with Renal Denervation

Objective: To study the safety and efficacy of denervation of renal artery branches in the treatment of resistant hypertension.Methods: Sixty patients with resistant hypertension were enrolled. The patients were randomly assigned to the mainrenal artery plus branch ablation group or the main renal artery ablation group. The clinical data and operation-relatedparameters, including number of ablation points, temperature, and average energy, were recorded. Ambulatory bloodpressure were taken for all patients at the baseline and at 6 months after treatment. Office blood pressure was recordedbefore treatment and after treatment every 3 months for 2 years.Results: Sixty patients with resistant hypertension were enrolled in this study. There were 30 patients in each group.Angiography was performed after ablation. No renal artery complications, such as stenosis and dissection, occurredin the two groups. There was no significant difference in age, sex, BMI, comorbid disease, and medication betweenthe two groups (P > 0.05). The number of ablation points for the main renal artery plus branch ablation group wasgreater than that for the main renal artery ablation group. The office blood pressure and 24-hour blood pressure weresignificantly lower 6 months after treatment than before treatment in both groups (P < 0.05). Office blood pressure inthe main renal artery plus branch ablation group was lower than that in the main renal artery ablation group during the3–12-month follow-up period, with a statistical difference. However, as the follow-up time increased, the differencedisappeared.Conclusion: The results of this study show that main renal artery plus branch ablation is a safe interventional method,but there was no obvious advantage on long-term follow-up compared with only main renal artery ablation.