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A 57-year-old woman with frequent isolated and repetitive premature atrial contractions initiating paroxysmal atrial fibrillation, underwent electrophysiological study and catheter ablation. A real-time three-dimensional map of the left atrium was reconstructed using a nonfluoroscopic navigation system. By means of a deflectable decapolar catheter, the left superior pulmonary vein (PV) was identified as the arrhythmogenic vein, and PV potentials were found in the left inferior and right superior veins. Ablation was performed under electroanatomic guidance. After circumferential ablation outside the PV ostia, dissociation of PV potentials was obtained in the left superior vein, and PV potentials were eliminated in the other two veins. (PACE 2003; 26:1413–1416). [ABSTRACT FROM AUTHOR]

Presents a study which evaluated the feasibility and safety of the anatomic approach to isolate pulmonary veins, in a multicenter design. Methods; Results and discussion; Clinical implications.

Aims The purpose of this study was to investigate the relationship between the incidence of dual atrioventricular (AV) nodal pathways and age. Age-related changes in the AV node electrophysiological properties have rarely been investigated. AV nodal re-entrant tachycardia is more frequent in the young than in the elderly. Methods and Results From 1988 to 1998, premature atrial stimulation was performed in 1435 patients referred to our institution for transoesophageal electrophysiological study. 1276 patients (89%) with a diagnosis of ventricular pre-excitation, supraventricular arrhythmia or AV block were excluded. The study cohort consisted of the remaining 159 patients (11% of the whole group) referred for syncope (8·2% of the subgroup), suspected ventricular pre-excitation (10·7%), suspected sinus node dysfunction (52·8%) or undetermined palpitations (28·3%). The 159 study patients were divided into 3 groups according to age: group A (11–30 years, 50 patients), group B (30–60 years, 35 patients) and group C (>60 years, 74 patients). Conclusion The incidence of dual AV nodal pathways decreases with ageing, suggesting that the AV node undergoes age-related electrophysiological changes. This finding could explain the uncommon onset of AV nodal re-entrant tachycardia in the elderly. [ABSTRACT FROM PUBLISHER]

This case describes a young woman with a manifest left inferoparaseptal accessory pathway and previous history of surgical repair of a defect of the ventricular inlet septum in whom a transient complete A V block occurred during radiofrequency ablation performed from the coronary sinus. The presence of a preexisting surgery related A V block unmasked by anomalous pathway ablation is the more reliable explanation for this case. [ABSTRACT FROM AUTHOR]

Objectives: The aim of our study was to determine the incidence of asymptomatic recurrences of atrial fibrillation (AF) by daily transtelephonic (TT) electrocardiographic (ECG) monitoring, as compared with standard ECG and 24-h Holter recording, in patients who underwent radiofrequency catheter ablation (RCA) of AF. Background: The efficacy of RCA of AF is usually evaluated by means of patients’ symptoms. Methods: Seventy-two patients with paroxysmal (n = 37) or persistent (n = 35) drug-refractory AF underwent circumferential RCA of the pulmonary vein (PV) ostia. Left isthmus ablation was performed in 57 patients, and cavotricuspid isthmus ablation was done in 69 patients. Patients were scheduled to obtain an ECG and Holter recordings one and four months after ablation, as well as a daily TT ECG, from 30 to 120 days after ablation or in the event of symptoms. Results: A total of 5,585 TT ECGs were obtained (mean 77.5 per patient). In 20 patients (27.8%), AF recurrences were recorded during TT ECG, whereas ECG and Holter monitoring revealed AF recurrences in 10 patients (13.9%, p = 0.001). Ten patients had at least one asymptomatic AF recurrence, and eight were completely asymptomatic. The ECG recorded in the event of symptoms always showed AF. Conclusions: Transtelephonic ECG is better than standard ECG and 24-h Holter recordings in evaluating AF relapses after RCA, thus decreasing the short-term success of ablation from 86% to 72%. The absence of symptoms should not be interpreted as absence of AF, as 50% of patients were asymptomatic during at least one AF episode. [Copyright &y& Elsevier]

Objectives: We sought to evaluate the effects of mechanical thrombectomy on myocardial reperfusion during direct angioplasty for acute myocardial infarction (AMI).Background: Embolization of thrombus and plaque debris may occur during direct angioplasty for AMI. This may lead to distal vessel or side branch occlusion and to obstructions in the microvascular system, resulting in impaired myocardial reperfusion. Mechanical thrombectomy is used to reduce distal embolization.Methods: Ninety-two patients with AMI and angiographic evidence of intraluminal thrombus were randomized to either intracoronary thrombectomy followed by stenting or to a conventional strategy of stenting. Thrombectomy was performed using the X-Sizer catheter (EndiCOR Inc., San Clemente, California). Myocardial reperfusion was assessed by myocardial blush and ST resolution.Results: Postprocedure Thrombolysis in Myocardial Infarction-3 flow was not different between groups (93.5% vs. 95.7%, p = 0.39). Myocardial blush-3 was observed in 71.7% of patients undergoing thrombectomy and in 36.9% of patients undergoing conventional strategy (p = 0.006). ST-segment resolution >or=50% occurred more often in patients undergoing thrombectomy (82.6% vs. 52.2%, p = 0.001). By multivariate analysis, adjunctive thrombectomy was an independent predictor of blush-3 (odds ratio, 3.27; 95% confidence interval, 1.06 to 10.05; p = 0.039).Conclusions: Intracoronary thrombectomy as adjunct to stenting during direct angioplasty for AMI improves myocardial reperfusion as assessed by myocardial blush and ST resolution. [ABSTRACT FROM AUTHOR]

Background: Little information is available on the natural history of patients with AVNRT. The purpose of this study was to compare the outcome of patients with Atrioventricular node reentrant tachycardia (AVNRT) who underwent ablation with those on antiarrhythmic therapy and those not receiving drugs., Methods: 93 consecutive patients (mean age=33.5+/-18.1 years) with AVNRT referred to our institution from 1988 to 1993 were prospectively followed-up for a mean of 13.2+/-2.0 years (range=11.4-16.1 years)., Results: 18 patients underwent ablation (group 1), 24 received antiarrhythmic therapy (group 2), 38 received no drugs or remained on drug therapy for only few months (group 3), 3 died and 10 were lost to follow-up. The frequency of symptoms at the baseline was higher in group 1 than in groups 2 and 3 (7.8+/-3.7, 3.5+/-2.3, 2.3+/-1.9 episodes/month, respectively; p<0.02 in group 1 vs. group 3). At the end of the follow-up 18/18 (100%) of group 1, 14/23 (61%) of group 2 and 17/38 of group 3 (44.7%) reported being asymptomatic for the previous 3 years. Group 3 patients who became asymptomatic had a shorter duration of symptoms before enrolment (3.7+/-1.5 vs. 7.1+/-3.6 years, p<0.05) and a shorter mean length of the tachycardia episodes (3.8+/-2.4 vs. 42.6+/-17.8 min, p<0.02) than patients from the same group who remained symptomatic., Conclusions: The main result of this study is that during a long-term follow-up a considerable number of untreated patients with AVNRT become asymptomatic. This finding should be considered for choosing treatment modality and for calculating healthcare costs of ablation vs. medical therapy.

Background: Carotid artery stenting is emerging as an alternative to surgical endarterectomy for the treatment of extracranial carotid artery disease. However, few data are available on the long-term clinical efficacy of carotid artery stenting and on the incidence of restenosis., Methods: Stent implantation with the routine use of cerebral protection devices was attempted in a single center experience including 100 consecutive patients (104 lesions) with significant stenosis of the internal carotid artery (mean stenosis 82.8 +/- 9%). The mean age of the patients was 70.8 +/- 14 years, 27 lesions were symptomatic (26.0%) with a lesion related to a previous stroke or transient ischemic attack., Results: Procedural success was achieved in 103 lesions (99%) and the cerebral protection was successfully applied in 102 procedures (98%). The 30-day incidence of stroke and death was 4% (4 patients). Complications consisted of one major stroke (1%) with persistent ipsilateral amaurosis, two minor strokes (2%), and one (1%) fatal myocardial infarction occurring 4 days after the stent procedure. During follow-up (minimum 24 months; mean 31 +/- 6 months) no further neurological events occurred, 6 patients died of non-neurological causes (6%) and 2 (2%) presented with a non-fatal myocardial infarction. Echo color Doppler scan control (minimum 24 months) was carried out in all surviving patients showing a restenosis classified as moderate (50-69%) in 2 cases and as critical (> or = 70%) in another 2 cases (1.8%). Both critical restenotic lesions were successfully treated by repeating balloon angioplasty., Conclusions: The present study demonstrates that carotid artery stenting with routine cerebral protection can be performed with an acceptable procedural complication rate. At the 2-year follow-up carotid artery stenting appeared effective in stroke prevention and durable with a low incidence of restenosis.

Background: Percutaneous coronary interventions on saphenous vein grafts (SVG) and in patients with acute coronary syndromes (ACS) have been associated with the distal embolization of the thrombus and plaque and to the no-reflow phenomenon. We report on the safety and feasibility of a new distal emboli protection filter., Methods: Angioplasty using distal filter protection (Angioguard, Cordis, Warren, NJ, USA) was attempted in 38 patients (mean age 65 +/- 11 years, 79% males) affected by ACS. A percutaneous coronary intervention was performed in 27 native coronary arteries, in 10 SVG and in one arterial graft (mean diameter stenosis 88 +/- 9%). Patients with vessels presenting severe proximal tortuosity, more than mild calcification, a diameter < 3.0 mm and a lesion length > 15 mm were excluded., Results: It was possible to position the device in all patients (100%); in 7 patients (18%) the lesion could be crossed with the filter only after balloon predilation. Procedural success with final TIMI flow 3 was obtained in all patients and the mean residual diameter stenosis after stent implantation was 5 +/- 8%. Transient procedural complications without clinical sequelae included the no-reflow phenomenon (2 patients, 5%) and vessel perforation (1 patient, 2.5%). In no case was distal embolization observed. As regards the device-related complications, one occlusive dissection (2.5%) occurred and was successfully treated with stent implantation. In-hospital and 30-day major adverse cardiac events consisted of two non-Q wave myocardial infarctions (5%), both occurring during SVG interventions., Conclusions: The use of the Angioguard filter for preselected lesions in patients with ACS had a high technical success and carried a low rate of device-related complications. The clinical efficacy of the device needs further evaluation.

Background: The aim of this study was to identify the clinical and echocardiographic variables possibly correlated with the early relapses of atrial fibrillation (AF) after external electrical cardioversion (EC) in a large cohort of patients with persistent AF., Methods: Two hundred patients (117 males, 83 females, mean age 67.9 +/- 8.7 years) with successful EC of persistent AF (> 72 hours) were included in the present study. In order to identify the predictors of early relapses (within 7 days) of AF, 16 clinical and echocardiographic variables were compared at univariate analysis. The variables with a p value < 0.10 at univariate analysis were subsequently analyzed at multivariate analysis., Results: Seventy-five patients (37.5%) had relapses of AF within 7 days of EC. By univariate analysis only a younger age (65.9 +/- 8.9 vs 69.0 +/- 8.3 years, p = 0.01) was found to be significantly correlated with a higher incidence of early relapses of AF. At multivariate analysis no variable was found to be significantly correlated with early relapses of AF., Conclusions: In patients with persistent AF, recurrences of this arrhythmia within 7 days of EC occur frequently (37.5%). Multivariate analysis did not reveal any clinical or echocardiographic variable significantly correlated with the early recurrence of AF.

A 68-year-old male patient presented with massive hematemesis following the acute rupture of an aneurysm of the descending thoracic aorta into the esophagus. In view of the important cardiac and pulmonary comorbidities, surgical treatment was excluded and successful percutaneous implantation of an endovascular stent-graft in the descending aorta was performed. In selected patients endovascular treatment may constitute an alternative to the surgical repair of ruptured aortic aneurysms.