A Foreign Material Image In The Coronary Sinus During Coronary Sinus Angiography

Mustafa Yildiz, Gokhan Kahveci, Yunus Emiroglu, Okan Erdogan

A 63-year-old man with history of bedside temporary pacemaker lead insertion a year ago was hospitalized for cardiac resynchronization and defibrillator device implantation. After insertion of the right ventricular shocking lead we tried to engage the ostium of the coronary sinus (CS) and injected some dye to delineate its anatomy. Unfortunately, the proximal portion of the main CS was occluded. In addition, 2 fixed and rounded neighboring foreign materials were incidentally detected within its opacified portion (Fig. 1A, arrow indicates foreign material). A subsequent multislice computed tomography (Fig. 1B, Fig. 1C * indicates foreign material) confirmed CS occlusion and foreign metallic materials (Hounsfield unit: 2686) resembling metallic electrodes most probably originating from the previous inserted temporary pacemaker lead. We suggested that the forceful blunt insertion of the firm lead tip dissected the CS wall and cretaed a subintimal pouche. Further blood accumulation and formation of intense coagulum externally compressed the wall and occluded the lumen of the CS. When the temporary pacing lead that was partly encapsulated and fixed by the fibrocoagulative tissue was forcefully pulled out, the metallic electrodes overlying the lead tip might have been teared off and retained within the CS. This interesting and rare case highlights an unusual cause of CS occlusion and unexpected complication of temporary pacemaker lead insertion. One must be sure that no fragments have been retained or embolized when removing the pacing leads from the body.

Symptoms In Atrial Fibrillation: A Contemporary Review And Future Directions

Steven T. Heidt, Anna Kratz, Kayvan Najarian, Afton L. Hassett, Hakan Oral, Richard Gonzalez, Brahmajee K. Nallamothu, Daniel Clauw, Hamid Ghanbari

Atrial fibrillation (AF) is the most prevalent arrhythmia leading to hospital admissions in the United States. The majority of patients with AF report symptoms associated with this condition that can lead to a decrease in health related quality of life (HRQOL) and functional status. Therefore, along with reducing the risk of stroke and mortality, improvements in such symptoms are important therapeutic goals in the management of patients with AF.  Our current understanding of how AF and symptoms are linked is hampered by the dominant assessment paradigm, where symptoms thought to be associated with AF are measured at a single point in time (frequently at a clinic visit). Unfortunately, this “static” snapshot does not capture the variability of symptoms and heart rhythm within a person over time and does not shed light on how symptoms are related to heart rhythm. This focused review summarizes current methods for assessing symptoms including generic and AF-specific HRQOL and functional status tools.  It also describes gaps in the current assessment paradigm and where future research using mobile applications and digital technology might be able to assist with patient care.

Symptom/Rhythm Correlation With Patient Owned Device: Insights Into Practice And Challenges

Mohammed Shurrab, Anatoly Langer, Eugene Crystal, David Newman

Capturing symptom/rhythm correlation is crucial in patients who have rhythm-related symptoms. Evolving technology has led from 24 hour and 14 day Holter monitors to now external loop recorders to capture symptom/rhythm correlation. In patients with very infrequent and short-lived symptoms, the only recourse is an implantable recording device. Recently, patient activated recording devices have become available. These have the potential to significantly increase the duration for monitoring symptom/rhythm correlations. We report cases of using such devices to demonstrate some of the uses and challenges of this new ECG recording technology.

Arguments to Apply Epinephrine for Pocket Hematoma Reduction. The MAITRE Study

Nikolay Ilov, Anatoly Nechepurenko, Albert Abdulkadyrov, Damir Paskeev, Elena Damrina, Elena Kulikova, Marina Terent’eva, Dinara Stompel, Dmitry Tarasov
Pocket hematoma (PH) is a common complication of implantations of cardiac electrophysiological devices with occurring at a particularly high rate in patients on oral anticoagulation or antiplatelet treatment. Different pharmacological agents with hemostatic effect are used to avoid PH. We supposed that the vasoconstrictor effects of epinephrine may reduce bleeding extent and be effective in prevention of PH. Maitre is the first clinical trial conducted with an aim to show the safety and efficacy of epinephrine in PH prophylaxis. We randomized 133 patients to receive either epinephrine or saline solution, which were added to a local anesthetic administered during pacemaker implantation. In cases of diffuse bleeding a method of pocket drainage was effectively used. Results showed that risk of PH was significantly higher in the group receiving epinephrine. We conclude that a local epinephrine effect may lead to a false impression of adequate hemostasis and force a surgeon to refuse from drainage insertion.

Interactive In-Vitro Training In Physics Of Radiofrequency Ablation For Physicians And Medical Engineering Students

Haber T, Kleister G, Selman B, Härtig J, Melichercik J, Ismer B

Radiofrequency (RF) ablation requires a complex set of devices as well as profound electrophysiological experience and substantial knowledge of physical science basics. To establish RF ablation in-vitro teaching-system, six workstations were equipped with computer-controlled RF ablation generators. Universal connection boxes allow ablation-essays with catheters of different make and model. Special wetlabs were developed combining a basin containing isotonic saline solution with a thermostat and a pump to simulate blood flow. This hands-on teaching system can be used to demonstrate differences in lesion-forming dependent on tip-electrodes, sensor technology and ablation techniques, influence of blood flow and electrode-angle to the myocardium. It was also utilized to reproduce industrial in-vitro tests.

Influence Of Novel Electrocardiographic Features Of Provocable Brugada ECG In Arrhythmogenic Cardiomyopathy And Its Exclusion By Lead AVR

Stefan Peters

In 19 patients (14 females, mean age 49.1 ± 11.3 years) with typical arrhythmogenic cardiomyopathy and provocable type I Brugada ECG pattern by ajmaline administration were analysed by novel electrocardiographic features as having “true” or “false” Brugada syndrome. Three patients turned out as having false Brugada syndrome, the diagnosis is pure arrhythmogenic cardiomyopathy.
In 16 patients, however, true Brugada syndrome could be provoked. In these patients the diagnosis was arrhythmogenic cardiomyopathy associated by provocable Brugada syndrome.

Clinical Use And Limitations Of Non-Invasive Electrophysiological Tests In Patients With Atrial Fibrillation

Valentina D.A, Corino, Luca T, Mainardi, Frida Sandberg, Leif Sörnmo, Pyotr G. Platonov

Atrial fibrillation (AF) is a complex arrhythmia, that has been studied non-invasively assessing atrial refractory period, atrioventricular node (AV) node refractory period, and ventricular response. The AV node plays a fundamental role as it filters many of the numerous irregular atrial impulses bombarding the node. Despite its importance, the electrophysiological (EP) characteristics of the AV node are not routinely evaluated since conventional EP techniques for assessment of refractory period or conduction velocity of the AV node are not applicable in AF. Since rate-control drugs control ventricular response through their effect on the AV node, noninvasive assessment of AV node electrophysiology may be useful. The RR series, though being highly irregular, contains information that can be used for risk stratification and prediction of outcome. In particular, RR irregularity measures during AF have been shown to be related to clinical outcome. This paper reviews the attempts done to noninvasively characterize the AV node and the ventricular response, highlighting clinical applications and limitations of the noninvasive techniques.