Deglutition induced atrial tachycardia and atrial fibrillation

Deglutition induced supraventricular tachycardia is an uncommon condition postulated to be a vagally mediated phenomenon due to mechanical stimulation. Patients usually present with mild symptoms or may have severe debilitating symptoms. Treatment with Class I agents, beta blockers, calcium channel blockers, amiodarone and radiofrquency catheter ablation has shown to be successful in the majority of reported cases. We report the case of a 46-year-old healthy woman presenting with palpitations on swallowing that was documented to be transient atrial tachycardia with aberrant ventricular conduction as well as transient atrial fibrillation. She was successfully treated with propafenone with no induction of swallowing-induced tachycardia after treatment. This is also the first case to show swallowing-induced atrial tachycardia and atrial fibrillation in the same patient.     

Catheter ablation in a patient with a congenital giant right atrial diverticulum presented as Wolff-Parkinson-White syndrome

A young woman symptomatic for tachycardia showed right ventricular preexcitation on the surface ECG with a pattern during induced atrial fibrillation suggestive of multiple APs. Noninvasive imaging techniques performed prior to catheter ablation demonstrated the presence of a giant right atrial diverticulum confirmed by hemodynamic procedure. This structure functioned as an enormous accessory AP. We performed catheter ablation of this pathway using a special 4-mm multipolar catheter inside the diverticulum. This is the first case of such as anomaly being successfully treated with catheter ablation.     

Quality of life and occurrence of atrial fibrillation in long-term follow-up of common type atrial flutter ablation:

Objectives The ablation of common type atrial flutter is mainly performed by two approved techniques, whose efficacy and outcome in terms of quality of life have not been evaluated so far in a long-term follow-up study over years. A high proportion of patients suffer from coexistent atrial fibrillation, which may worsen the ablation result. The question arises whether one technique is more effective than the other when immediate ablation results, the occurrence of atrial fibrillation and the quality of life are compared. Considering these facts, it is reasonable to think about new ablation strategies for common type atrial flutter in the era of new concepts in catheter ablation of atrial fibrillation. Methods In a retrospective study we evaluated a detailed questionnaire in 132 patients who underwent ablation of common type between 1999 and 2004. Radiofrequency ablation was performed irrespective of coexistent atrial fibrillation either with an irrigated tip or the 8 mm tip electrode. Acute and long-term ablation outcome, and the associated quality of life, pre-, under- and post-ablation was compared in the two different ablation groups. Recurrent tachycardia were re-evaluated by 12 lead ECG analysis and assessed for both ablation groups. Results 88 (67%) of the 132 patients contacted answered the questionnaire polling the perceived benefits of the procedure. Of the other 44 patients (33%); 4 (3%) had died, 7 (5.3%) had moved, 33 patients (25%) could not be included due to missing or incoherent answers. Independent of the ablation technique there was a high acute and long-term ablation success rate at about 95%. After a mean of 3 years of follow-up this benefit persists in spite of a high proportion of recurrent tachycardia, mainly atrial fibrillation (55/88 patients, 59.1%). Despite the occurrence of secondary tachycardia, there was a high significant long-term symptomatic benefit in the state of healthy and daily practice work, evaluated with a p-value of < 0.0005. The frequency of episodes and the symptom "tachycardia" were significantly reduced after effective ablation of common type atrial flutter, p-values of 0.003 and 0.002, respectively. Therefore the need for hospitalization was significant reduced (p = 0.001). Comparison of both approaches revealed that there was no significant difference related to the incidence and occurrence of atrial fibrillation. Conclusions The two mainly accepted and applied techniques for the ablation of common type atrial flutter show an excellent outcome under the aspect of ablation efficacy and quality of life in longterm follow-up. Three years after the ablation procedure the majority of patients consider the intervention beneficial. Despite the relatively high appearance of atrial fibrillation in the long-term follow-up this effect is still traceable.     

Influence of reciprocating tachycardia on the development of atrial fibrillation in patients with preexcitation syndrome

BACKGROUND: We sought to evaluate the influence of atrio-ventricular reentrant tachycardia (AVRT) on atrial pressures during tachycardia and the presence of atrial fibrillation (AF) in patients with preexcitation syndrome. METHODS: The study population consisted of 88 patients (37 females, mean age 37.3 years) with left-sided accessory pathway and AVRT induced during electrophysiologic study. The AF-inducible group consisted of 32 patients with sustained episodes of AF provoked during electrophysiologic study, whereas the noninducible group comprised 56 patients without AF. RESULTS: We found significantly higher values of maximal and mean left (LAP) and right (RAP) atrial pressures in the AF group compared with noninducible group: LAP max 32.0 versus 20.8, LAP mean 21.6 versus 13.2, RAP max 15.2 versus 11.5, RAP mean 8.2 versus 6.2 respectively (P < 0.001). When analyzing the effect of AVRT on atrial pressures, we found a significant (P < 0.001) negative correlation between anterograde conduction times during tachycardia and LAP max and LAP mean in the whole population, but a significant positive correlation between retrograde conduction time and left atrial pressures. Similar effects of AVRT on the right atrial pressures were found. CONCLUSIONS: Atrial pressures during AVRT, which depend on the electrophysiological features of tachycardia, play an important role in the genesis of atrial fibrillation in patients with preexcitation syndrome.     

风湿性心脏病慢性房颤心房扩大与心房电生理的相关性研究

目的:探讨风湿性心脏病慢性房颤左房内径大小对心房电生理特性的影响。方法:选择风湿性心脏病慢性房颤患者16例,术前采用超声心动图测量左心房内径,采用心外膜标测技术测量心房有效不应期(AERP)和波长指数(WLI),并与左房内径行相关性分析。结果:慢性房颤患者左房内径和右房压力明显高于窦性心律患者(P<0.05),左房内径与AERP和WLI呈负相关(r=-0.882和-0.745)。结论:风心病慢性房颤左心房扩张影响心房的电生理特性,提示左心房的扩张引起心房结构重构,并影响心房的电生理重构而导致房颤的发生和维持。     

Cardiac surgery for arrhythmias

Cardiac arrhythmia surgery was initiated in 1968 with the first successful division of an accessory AV connection for the Wolff-Parkinson-White Syndrome. Subsequent surgical procedures included the left atrial isolation procedure and the right atrial isolation procedure for automatic atrial tachycardias, discrete cryosurgery of the AV node for AV nodal reentry tachycardia, the atrial transection procedure, corridor procedure and Maze procedure for atrial fibrillation, the right ventricular disconnection procedure for arrhythmogenic right ventricular tachycardia, the encircling endocardial ventriculotomy, subendocardial resection procedure, endocardial cryoablation, the Jatene procedure, and the Dor procedure for ischemic ventricular tachycardia. Because of monumental strides in the treatment of most refractory arrhythmias by endocardial catheter techniques during the past decade, the only remaining viable surgical procedures for cardiac arrhythmias are the Maze procedure for atrial fibrillation and the Dor procedure for ischemic ventricular tachycardia. Nevertheless, the 25-30 years of intense activity in the field of cardiac arrhythmia surgery provided the essential foundation for the development of these catheter techniques and represent one of the most exciting and productive eras in the history of medicine. In one short professional career, we have witnessed the birth of arrhythmia surgery, its adolescence as an "esoteric" specialty, its prime as an enlightening yet exhausting period, and finally its waning years as a source of knowledge and wisdom on which better methods of treatment have been founded. One could hardly ask for a more rewarding experience.     

Right Atrial Separation Procedure for Eliminating Chronic Atrial Fibrillation Associated with Atrial Septal Defect

Chronic atrial fibrillation (AF) had been documented in a patient with atrial septal defect for 7 years. A right atrial separation procedure was performed for ablation of chronic AF, concomitant with repair of the atrial septal defect, and followed by atrial electrophysiological mapping. A horizontal transectional incision extending to the borders of the atrial septum and the tricuspid annulus was made. Cryolesions of the atrial isthmus between the margin of the upper incision and the tricuspid valve annulus were created at -60†C for 2 minutes at a time. After the operation, the patient had restored normal sinus rhythm during a subsequent follow-up period of 48 months.     

经食管超声心动图对心房颤动患者右心耳自发显影回声和血栓发生的研究

目的探讨经食管超声心动图(TEE)观察慢性心房颤动(房颤)时右心房、右心耳自发显影(SEC)和血栓发生情况。方法选取26例房颤患者和13例窦性心律患者，常规经胸超声心动图资料留取后，采用TEE充分清楚显示左、右心耳图像并采集血流流速曲线和其他相应指标。结果26例房颤患者左心耳内均可测及SEC，共测及血栓形成者10例；房颤患者右心耳内有SEC者共17例，共测及右心耳血栓形成者1例。结论房颤时右心耳内可有血栓发生，TEE检查在房颤抗凝治疗中和复律前后具有重要意义。     

Persistent tachycardia originating from the superior vena cava as a driver for atrial fibrillation

We describe a patient with drug-resistant paroxysmal atrial fibrillation who underwent radiofrequency catheter ablation of tachycardia originating from the superior vena cava (SVC). A continuous and rapid tachycardia conducted to the atrium with evidence of exit block and drove atrial fibrillation (AF) and atrial tachycardia. Neither AF nor atrial tachycardia could be induced after SVC isolation, and nor were they observed during follow-up. We conclude that continuous and rapid tachycardia originating from the SVC can act as a driver as well as an initiator of AF.     

经食管超声心动图对心房颤动时右心耳血流动力学的研究

目的　应用经食管超声心动图(TEE)技术观察慢性心房颤动(房颤)时右心耳结构、功能和血流流速曲线的改变。方法　选取 26例房颤患者和 13例窦性心律患者,采用TEE充分清楚显示右心耳图像并采集血流流速曲线和其他相应指标。结果　与对照组相比,房颤组右心房射血分数 (RAEF)和右心耳射血分数(RAAEF)均显著降低(P<0. 05~0. 01);房颤时右心耳血流流速曲线峰值排空、充盈流速和流速积分均显著下降(P<0. 05~0. 01)。右心耳峰值排空、充盈流速与右室射血分数 (RVEF)、RAAEF、RAEF、右心房最大面积(Smax RA)等指标具有显著的相关性。结论　TEE可以安全、准确地评价右心耳血流动力学情况;房颤时右心耳血流流速曲线是反映右心房、右心耳功能的良好指标。     

P wave separation after atrial compartment operation for atrial fibrillation

Surgically induced abnormalities in atrial conduction could result in unusual P wave changes. A 31-year-old woman underwent concomitant mitral valve surgery and atrial compartment operation for mitral stenosis and atrial fibrillation (AF). After operation, the AF was successfully converted to sinus rhythm, whereas an unusual electrocardiogram (ECG) with a discrete negative deflection before the T wave in V1 was noted. Electrophysiological study showed a marked conduction delay from the high right atrium (HRA) to the right atrial appendage (RAA) compartment, which resulted in a separation of P waves. The P wave preceding the QRS complex represented the activation of sinus node and the left atrial compartments, and the P at the vicinity of T wave represented the activation of RAA compartment. The conduction from HRA to RAA was worsened on HRA pacing at a faster rate, and improved after isoproterenol infusion. This report demonstrated that conduction across a surgically created isthmus in the atrium could be severely impaired and result in unusual P wave separation.     

Enhancement of myocardial vulnerability by atrial fibrillation

Certain groups are known to have an increased risk for sudden cardiac death. Epidemiologic studies have suggested that patients with atrial fibrillation may be at higher risk. The authors hypothesize that atrial fibrillation may increase myocardial vulnerability. To test this hypothesis, 37 dogs were studied using programmed electrical stimulation techniques to determine myocardial vulnerability as assessed by the ability to provoke ventricular tachycardia. Prior to atrial fibrillation, programmed electrical stimulation did not induce ventricular tachycardia. Aconitine was then topically applied to the right atrial appendage with care taken not to make contact with the ventricle. Application of aconitine caused atrial fibrillation with an increase in ventricular rate, but did not affect arterial blood pressure. Ventricular tachycardia was induced by programmed electrical stimulation studies in 25 of 26 dogs in atrial fibrillation. The enhanced vulnerability was noted following atrial fibrillation, not after aconitine application to the great veins, which did not cause atrial fibrillation. To further exclude the possibility that aconitine application may cause changes in ventricular threshold, atrial fibrillation was induced by pacing techniques in five dogs. Prior to atrial fibrillation induction, programmed electrical stimulation did not induce ventricular tachycardia. Following atrial fibrillation, ventricular tachycardia could be repeatedly induced. Mean heart rate following atrial fibrillation increased, while pacing animals at this increment in rate did not change the noninducibility of dogs in sinus rhythm. Six patients with a history of atrial fibrillation and ventricular tachycardia were studied to determine if AF lowered myocardial threshold to VT induction. Ventricular tachycardia could only be induced by PES techniques in four of five patients when the patients' rhythm was AF (P < 0.05). This study suggests that atrial fibrillation lowers myocardial threshold for ventricular tachycardia induction and thus enhances myocardial vulnerability. The association of AF with a higher incidence of sudden death may be due to an enhanced electrical instability.     

Cardiac leiomyosarcoma of the right atrium in a teenager: unusual manifestation with a lifetime history of atrial ectopic tachycardia

A 16-year-old girl presented with atrial fibrillation. Transesophageal echocardiography revealed a right atrial leiomyosarcoma. Her past medical history was remarkable for incessant atrial ectopic tachycardia (AET) beginning in early infancy and continuing throughout childhood and adolescence that was refractive to medical and nonpharmacological treatment. After combined surgical and medical therapy, normal sinus rhythm was restored and the patient is currently in complete remission with no recurrent symptoms or atrial arrhythmias at 31 months after surgery and 23 months after the discontinuation of chemotherapy. Atrial tachycardia may be the first, and for prolonged periods, the only manifestation of a cardiac tumor and should prompt thorough investigation of its underlying morphological substrate.     

Coexistence of sinus bradycardia and junctional tachycardia in a patient with fibrotic atrial cardiomyopathy

A 65‐year‐old woman was referred for catheter ablation in the treatment of persistent tachycardia after surgery for atrial fibrillation and mitral regurgitation. Bipolar voltage mapping of both atria revealed that severe and extensive atrial fibrosis isolated the sinoatrial node from the atrioventricular junction and led to the coexistence of sinus bradycardia and persistent junctional tachycardia.     

The effect of the atrial pacing site on the total atrial activation time

The effect of dual site pacing for prevention of atrial fibrillation may be due to synchronization of right and left atrial activation. Little is known, however, about the effect of pacing from single right atrial sites on differences in interatrial conduction. Twenty-eight patients without structural heart disease were studied following radiofrequency catheter ablation of supraventricular arrhythmias. Pacing was performed using standard multipolar catheters from the presumed insertion site of Bachmann's bundle, the coronary sinus ostium, the high lateral right atrium, and the right atrial appendage (n = 8 patients). Bipolar recording was performed from the distal coronary sinus, the high and low lateral right atrium, and the posterolateral left atrium (n = 13 patients). The longest conduction time from each pacing to each recording site was considered the total atrial activation time for the respective pacing site. During high right atrial pacing, the total atrial activation time was determined by the conduction to the distal coronary sinus (118 +/- 18 ms), during coronary sinus ostium pacing by the conduction to the high right atrium (94 +/- 18 ms), and during Bachmann's bundle pacing by the conduction to the distal coronary sinus (74 +/- 18 ms). The total atrial activation time was significantly shorter during pacing from Bachmann's bundle, as compared to pacing from other right atrial sites. Thus, in normal atria, pacing from the insertion of Bachmann's bundle causes a shorter total atrial activation time and less interatrial conduction delay, as compared to pacing from other right atrial sites. These findings may have implications for alternative pacing sites for prevention of atrial fibrillation.     

A technique of lead insertion for low atrial septal pacing

BACKGROUND: Pacing in the low right atrial septum (LAS) appears superior to right atrial appendage or free wall stimulation for the prevention of paroxysmal atrial fibrillation. However, insertion of active fixation lead in the low right atrial septal position is difficult and time consuming, inhibiting application of this pacing method in daily practice. METHODS: The technique of handling and positioning of a new "over the wire" lead system is presented with emphasis on electrocardiographic P wave pattern and fluoroscopic landmarks. RESULTS: The initial results demonstrate an acute implantation and short-term success of LAS pacing of >90% in the first 100 patients without major complications. Pacing thresholds at 3 and 6 months were fully comparable with that of the conventional atrial pacing, whereas impedance and atrial sensing signals were significantly higher at 3 and 6 months follow-up. CONCLUSION: These favorable initial results justify recommanding chronic LAS pacing with the active fixation atrial lead and providinge guidelines and fluoroscopic landmarks for the implantation. Insertion of the atrial active fixation lead positioned with the Locatortrade mark tool strongly supports the implantation procedure.     

Clinical experience with electroanatomic mapping of ectopic atrial tachycardia

The aim of this study was to evaluate the clinical use of a new three-dimensional mapping system as a guide for catheter ablation of ectopic atrial tachycardia. A series of 42 consecutive patients with drug refractory ectopic atrial tachycardia was studied in a prospective observational trial with the electroanatomic mapping system CARTO. The arrhythmogenic focus was found in the right atrium in 30 patients and in the left atrium in 12 patients. The construction of a complete electroanatomic map of the right or left atrium was possible in 37 of 42 consecutive patients with ectopic atrial tachycardia. Mean activation time of the right atrium, including the proximal coronary sinus, was 94 +/- 25 ms for right atrial tachycardias; left atrial activation time during left atrial tachycardias was 86 +/- 17 ms. Average mapping time was 30 minutes for right atrial tachycardias and 22 minutes for left atrial tachycardias, allowing the collection of 86 +/- 50 and 65 +/- 28 catheter positions, respectively. The size of the area of earliest atrial activation calculated from the electroanatomic map amounted to 0.6 +/- 0.4 cm2 in right atrial tachycardias and 1.0 +/- 0.9 cm2 in left atrial tachycardias. In the right atrium the most common locations of the 33 arrhythmogenic foci in 30 patients were the high or mid-lateral right atrium (n = 10) and the inferoparaseptal region near the coronary sinus ostium (n = 7). Ectopic left atrial foci were most commonly located in an inferior position near the mitral annulus (n = 5) and in proximity to the ostium of the pulmonary veins (n = 4). Biatrial electroanatomic mapping allowed visualization of earliest right atrial activation during left atrial tachycardia at the high interatrial septum or near the coronary sinus ostium. Catheter ablation was successful in 85% of right atrial tachycardias and 82% of left atrial tachycardias. In patients with ectopic atrial tachycardia electroanatomic mapping is a safe and feasible technique that allows three-dimensional visualization of the automatic focus in a precise anatomic reconstruction of the atria. This novel mapping technology facilitates catheter ablation of complex ectopic atrial tachycardia.     

Identical QRS Complexes during Atrial Fibrillation with Aberrant Conduction and Ventricular Tachycardia. The Value of a His Bundle Recording

In a patient with chronic congestive heart failure, right bundle branch block-shaped QRS complexes occurred in salvos during atrial fibrillation. The site of origin of these complexes could not be determined from the 12-lead ECG alone. Recording of a His bundle electrogram showed that both intraventricular aberrant conduction and ventricular tachycardia were responsible for salvos having the same QRS complexes in the 12-lead ECG.     

Angiotensin-converting enzyme inhibitor suppresses the incidence of prolonged and fractionated right atrial electrograms

INTRODUCTION: Although prolonged and fractionated right atrial electrograms have been reported as predictors of the development of chronic atrial fibrillation in patients with paroxysmal atrial fibrillation (PAF), the effects of angiotensin-converting enzyme inhibitor (ACEI) on these electrophysiologic abnormalities remain unknown. The purpose of this study was to evaluate whether ACEI influences these electrophysiologic abnormalities of atrial muscle in patients with PAF. METHODS: While taking oral ACEI for hypertension, 12 patients (ACEI group) with PAF underwent electrophysiologic study (EPS). Catheter mapping of 12 right atrial sites and right atrial extrastimulation were performed during sinus rhythm. Twenty-four age-matched patients with PAF but not taking oral ACEI were included as a control group. RESULTS: The longest duration of the right atrial electrogram was significantly shorter and the maximum number of fragmented deflections per patient was significantly lower in the ACEI group than in the control group (79 +/- 15 ms vs 100 +/- 15 ms, P < 0.005; 5.5 +/- 1.9 vs 7.9 +/- 2.4, P < 0.001, respectively). The number of abnormal atrial electrograms per patient was significantly lower in the ACEI group than in the control group (0.5 +/- 1.4 vs 2.1 +/- 1.8, P < 0.05). The percentage of patients with at least one abnormal atrial electrogram was significantly lower in the ACEI group than in the control group (16.7% vs 79.2%, P < 0.0005). CONCLUSIONS: ACEI use is associated with a decrease in the incidence of prolonged and fractionated right atrial electrograms in patients with PAF. In addition, we suggest that ACEI may help prevent PAF from becoming chronic.     

孤立性房颤与心脏结构功能相关性研究

目的:探讨孤立性房颤(LAF)患者心脏结构功能的特点。方法:依据ACC/AHA/ESC 2006房颤指南孤立性房颤诊断标准(LAF标准)分为LAF组(LAF组)49例,对照组(Normal组)49例均为同期健康体检者。观察超声心动图检测的各腔室容积、收缩功能和左室质量。结果:LAF组左室质量、左室质量指数、左房容积、右房容积明显大于对照组(P<0.05)。在房颤组中可看到左房容积与左室质量指数存在正相关(r=0.335,P<0.05)。结论:即使无器质性心脏病,孤立性房颤患者的双房、左室质量也已增大;心房容积、左室质量有可能成为孤立性房颤新的预测因子。