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Transesophageal atrial pacing is feasible because of the proximity between the oesophagus and the posterior aspect of the atria1. Atrial pacing is possible through the oesophagus in almost all patients and can yield important information in many arrhythmias where single site atrial pacing is of value. It is a cheap procedure. There is no need for X Rays or cathlab. Technical considerations Transesophageal pacing and recording is done using specialized or non specialized catheters. There are two different lead types: 1) the pill electrode, connected to a flexible wire, that the patient swallows with water. This pill electrode necessitates patient collaboration. 2) a flexible catheter that can even be used in comatose or intubated patients. The pacing lead, in our cases a bipolar flexible catheter, is introduced into the oesophagus via the nares after local nose anesthesia with xylocaine spray. Sometimes throat anesthesia with the same spray is also performed. Xylocaine gel is used to lubricate the lead and the lead is introduced with guidewires in it in order to increase its stiffness. It is positioned into the oesophagus in order to record the posterior paraseptal atrial electrogram. There is a relationship between the site of maximal atrial amplitude and the lowest atrial pacing threshold. The optimal atrial pacing site is usually found around 40 cm from the nares. Bipolar or unipolar recordings can be made.

Introduction: A 13 old girl presented with recurrent wide QRS tachycardia since she was 4. Methods: An electrophysiologic study was performed. Results: The electrophysiologic study showed that QRS complexes identical to those of the tachycardia could be elicited with premature atrial extrastimuli but with a shorter atrioventricular (AV) delay when the QRS was wide compared with narrow QRS complexes. The tachycardia was ablated at 9 o'clock on the tricuspid annulus demonstrating the presence of an atriofascicular fiber. Conclusion: We believe that this atypical behavior can be explained by AV nodal like longitudinal dissociation of a slowly conducting accessory pathway. [ABSTRACT FROM AUTHOR]

Objective: Left atrial (LA) thrombus is routinely excluded by transoesophageal echocardiography (TOE) before cardioversion for non-valvular atrial fibrillation (AF). In the D-dimer blood concentrations to exclude LA thrombus in patients with AF study, two D-dimer cut-offs were compared to exclude LA thrombus prior to cardioversion. One was fixed to 500 ng/mL (DD500), based on clinical practice where such values are commonly accepted to exclude a thrombus. The other cut-off was adjusted to 10 times the patient's age (DDAge), based on the cut-off used to exclude pulmonary embolism.Methods: 142 consecutive patients with non-valvular AF aged 69.7±11.4 years (52% with paroxysmal AF) referred for precardioversion TOE to exclude LA thrombus were prospectively enrolled. D-dimers were measured at the time of TOE by an ELISA test.Results: LA thrombus was excluded with TOE in 129 (91%) and confirmed in 13 (9%) patients. D-dimers were significantly lower in patients without LA thrombus (729±611 vs 2376±1081 ng/L; p<0.05). DDAge indicated absence of LA thrombus with higher specificity than DD500 (66.4% vs 50.4%; p<0.05). Both cut-offs were able to identify all 13 patients with LA thrombus (false negative 0%). Patients with D-dimers Conclusions: This study demonstrates the efficacy of D-dimer cut-offs to exclude LA thrombus in patients with AF. Age adjustment greatly increases the proportion of patients in whom LA thrombus can be safely excluded and consequently avoid precardioversion TOE. [ABSTRACT FROM AUTHOR]

This report presents and discusses, on behalf of the Belgian College of Cardiology, the evolution of the peer review process in arrhythmology, focussing on pacemaker implantation. Data from the last 22 years are compared. The national annual increase in implants is around 1%, clinical patient characteristics remained stable over the years while dual chamber pacing was proportionally increasing. Analyses of the normalised sick sinus and complete atrioventricular block ratios revealed a quite homogenous practice between centres and patient district with the only exception of the two more crowded districts. Battery longevity and infection rate were also assessed. With an incidence of 1/1000 device-years follow-up, Belgium remains below accepted European levels. [ABSTRACT FROM AUTHOR]

Adenosine test, atrial fibrillation, concealed Delta wave, short PQ interval, Wolff-Parkinson-White syndrome Keywords: Adenosine test; atrial fibrillation; concealed Delta wave; short PQ interval; Wolff-Parkinson-White syndrome EN Adenosine test atrial fibrillation concealed Delta wave short PQ interval Wolff-Parkinson-White syndrome 756 757 2 12/26/22 20221001 NES 221001 Case report This 37 years old male with a previous history of left accessory pathway ablation presented with a poorly tolerated very fast irregular wide monomorphic tachycardia at 240 bpm (Figure 1(A)). In such cases of pre-excited atrial fibrillation, at least a small Delta wave can usually be seen on the sinus rhythm electrocardiogram. [Extracted from the article]

Aims: Non-invasive electrocardiogram (ECG) mapping allows the activation of the entire atrial epicardium to be recorded simultaneously, potentially identifying mechanisms critical for atrial fibrillation (AF) persistence. We sought to evaluate the utility of ECG mapping as a practical tool prior to ablation of persistent AF (PsAF) in centres with no practical experience of the system., Methods and Results: A total of 118 patients with continuous AF duration <1 year were prospectively studied at 8 European centres. Patients were on a median of 1 antiarrhythmic drug (AAD) that had failed to restore sinus rhythm. Electrocardiogram mapping (ECVUE™, CardioInsight, USA) was performed prior to ablation to map AF drivers (local re-entrant circuits or focal breakthroughs). Ablation targeted drivers depicted by the system, followed by pulmonary vein (PV) isolation, and finally left atrial linear ablation if AF persisted. The primary endpoint was AF termination. Totally, 4.9 ± 1.0 driver sites were mapped per patient with a cumulative mapping time of 16 ± 2 s. Of these, 53% of drivers were located in the left atrium, 27% in the right atrium, and 20% in the anterior interatrial groove. Driver-only ablation resulted in AF termination in 75 of the 118 patients (64%) with a mean radiofrequency (RF) duration of 46 ± 28 min. Acute termination rates were not significantly different amongst all 8 centres (P = 0.672). Ten additional patients terminated with PV isolation and lines resulting in a total AF termination rate of 72%. Total RF duration was 75 ± 27 min. At 1-year follow-up, 78% of the patients were off AADs and 77% of the patients were free from AF recurrence. Of the patients with no AF recurrence, 49% experienced at least one episode of atrial tachycardia (AT) which required either continued AAD therapy, cardioversion, or repeat ablation., Conclusion: Non-invasive mapping identifies biatrial drivers that are critical in PsAF. This is validated by successful AF termination in the majority of patients treated in centres with no experience of the system. Ablation targeting these drivers results in favourable AF-free survival at 1 year, albeit with a significant rate of AT recurrence requiring further management., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions please email: journals.permissions@oup.com.)

Aims: Recent developments of open irrigated catheters have sought to create uniform cooling of the entire ablating electrode. The aim of this randomized study was to assess whether the diffuse irrigation of the Coolflex(®) (CF) catheter results in improved short-term procedural benefits in patients undergoing ablation of right atrial typical flutter., Methods and Results: Sixty consecutive patients (age 62 ± 13) with typical atrial flutter were prospectively randomized to ablation of the cavotricuspid isthmus (CTI) using either a standard 3.5 mm tip ablation catheter with six distal irrigation channels (6C) (30 patients) or a 4 mm tip fully irrigated ablation catheter (CF) (30 patients). There were no significant differences seen between procedures performed with the diffusely irrigated CF catheter and the standard six-channel irrigated-tip catheter. This concerned the total procedural duration RF duration, fluoroscopic duration, the total amount of irrigation fluid, and the occurrence of steam pop., Conclusions: The use of a diffuse irrigation at the ablation catheter tip does neither facilitate lesion formation nor reduce the amount of irrigation during RF ablation for typical right atrial flutter using recommended flow and power settings., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)