Radiofrequency Catheter Ablation of Posteroseptal Accessory Pathways–Results of a Step-by-Step Ablation Approach

Introduction: Transcatheter radiofrequency ablation of posteroseptal accessory pathways (AP) is challenging. A number of different interventional approaches have been suggested by different groups. The selection of the initial approach is crucial in order to reduce radiation exposure and the number of unsuccessful lesions applied. We present our ablation technique as guided by a simplified electrocardiographic analysis of the delta wave polarity and the electrophysiologic mapping results. Methods and Results: Out of 35 manifest APs encountered in the right (n=17) or the left posteroseptum (n=18) in 35 patients, 34 were successfully ablated. Despite their left sided location, 7 of the 18 left sided APs were ablated after switching from an initial arterial to a venous approach looking for an appropriate target site in the right posteroseptal space or within the coronary sinus network. The other 11 left sided APs were ablated in the mitral ring, on 2 occasions, on their atrial aspect through a retrograde transmitral approach. On the contrary, 16 of the 17 right sided APs were successfully ablated exclusively through a venous approach. Fourteen of these were ablated in the right posteroseptum, in 2 cases, only after reaching their ventricular aspect. Two right sided APs were interrupted in the coronary sinus os and the middle cardiac vein respectively. Conclusion: It appears that even though the electrocardiographic and electrophysiologic location of the AP in the posteroseptal space helps select the appropriate initial approach, it does not always guarantee a successful ablation procedure in the expected site of the corresponding atrioventricular ring. Not uncommonly, it will be necessary to look after intermediate target sites within the coronary sinus to improve the overall ablation success rate.     

The Use of Esophageal Radiography in the Location of Atrial-Septal Puncture： Clinical Analysis of 486 Cases

Objectives To determine the safety and value of esophageal radiography as a means of locating transseptal puncture. Methods 486 patients who underwent transseptal puncture were randomized into two groups. An esophagus radiographic method of locating tansseptal puncture site was applied in the study group （n = 243 ） and modified-Ross locating method was used in the control group （n = 243 ）. After successful location, transseptal puncture was made. We observed the success rate and incidence complications in the 2 groups. Results Left atrium impression in the study group was clearly seen. Nonetheless in 120 cases of control group, the left atria silhouette was not clearly visualised. The success rate of locating transseptal puncture site in the study group and control group were 100% and 50. 6% respectively （ P 〈 0. 001 ）. The success rate of transseptal puncture in the study group and control group was 99. 6% and 45.7% respectively （ P 〈 0. 001 ）. There were no complications associated with puncture in the study group and pericardial tamponade occurred in 1 control patient. Conclusions The esophagus radiographic method of locating transseptal puncture site is accurate, safe and simple to perform. Transseptal puncture has a high success rate with few complications.     

Glucagon for the Relief of Esophageal Food Impaction Does It Really Work?

We sought to evaluate our experience with glucagon used in the emergency department setting to relieve esophageal food impaction (EFI). We reviewed the records of patients with food impaction who received glucagon between January 1998 and May 2003 and recorded patient demographics, medical history, symptoms following glucagon administration, and endoscopic findings. There were 92 episodes of food impaction in 85 patients. Thirty-three percent of the episodes resulted in resolution of symptoms following a dose of glucagon. Sixty-seven percent had symptoms of food impaction after glucagon and underwent upper endoscopy in the emergency room. Only previous solid food dysphagia was positively associated with response to glucagon. Patients who received glucagon plus a benzodiazepine were more likely to have resolution of the EFI. In our experience, glucagon appears to relieve food impaction in one third of patients treated. This result is comparable to previously published data examining glucagon and placebo. The lack of advantage over placebo questions the practice of glucagon administration for EFI.     

Etiology of Esophageal Atresia and Tracheoesophageal Fistula: “Mind the Gap”

Esophageal atresia and tracheoesophageal fistula (EA/TEF) are major congenital malformations affecting 1:3500 live births. Current research efforts are focused on understanding the etiology of these defects. We describe well-known animal models, human syndromes, and associations involving EA/TEF, indicating its etiologically heterogeneous nature. Recent advances in genotyping technology and in knowledge of human genetic variation will improve clinical counseling on etiologic factors. This review provides a clinical summary of environmental and genetic factors involved in EA/TEF.     

A Beginning or the End? A Meta-analysis to Assess the Diagnostic Accuracy of Transient Elastography for the Prediction of Esophageal Varices

Background/Aims:To assess the accuracy of transient elastography (TE) in the prediction of esophageal varices (EV).Result:Twenty studies (2530 patients) were identified for inclusion. The pooled sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.84 (95% confidence interval [CI], 0.79–0.87), 0.68 (95% CI, 0.61–0.73), 2.58 (95% CI, 2.15–3.10), 0.24 (95% CI, 0.19–0.32), and 10.60 (95%CI, 7.20–15.62), respectively. The summary area under receiver operating characteristics (AUROC) curves was 0.82 (95% CI, 0.79–0.86). Especially, for hepatitis C patients, the diagnostic performance of TE for detecting the presence of EV was similar to all other patients with a sensitivity of 0.83 and a specificity of 0.63, but without heterogeneity (I² = 0.00). For the prediction of large esophageal varices in patients with viral liver cirrhosis, the pooled sensitivity and specificity of TE were 0.82 (95% CI 0.74–0.89) and 0.77 (95% CI 0.65-0.85), respectively, without significant heterogeneity (I² = 0.00).Conclusion:Transient elastography has good sensitivity and moderate specificity. TE can be used as an effective noninvasive screening tool for the prediction of esophageal varices, especially in hepatitis C patients, and for the prediction of large esophageal varices in patients with viral liver cirrhosis.Key Words: Esophageal varices, liver stiffness, meta-analysis, transient elastographyCirrhosis is a chronic liver disease that can be caused by almost all progressive liver injuries, such as viral, autoimmune, hereditary, metabolic, and toxin-mediated liver diseases. Esophageal varices (EV) is a frequent complication of cirrhosis. Although the survival rate of cirrhotic patients with bleeding EV has improved because of the progress in variceal hemorrhage management, the inhospital mortality rate still remains at 14.5%.[1] Adequate detection of EV in all patients with liver cirrhosis is required in order to improve the mortality.Esophagogastroduodenoscopy (EGD) is the gold standard for the diagnosis of varices. Screening with EGD to identify EV in all cirrhotic patients at baseline as well as periodic intervals is recommended by current guidelines.[2] However, the high cost and invasive procedures undercut its acceptance and applicability in patients. Several noninvasive methods, such as capsule endoscopy, computed tomography scan, and Fibrotest, are also frequently used to avoid the unpleasant experience with EGD for many patients. However, these methods are expensive and/or do not have a high sensitivity or specificity in detecting EV.[3,4,5] Thus there is a need to develop and validate noninvasive methods that can accurately diagnose EV.Transient elastography (TE) is a noninvasive method measuring liver stiffness (LS). Several studies have been conducted in the past few years to evaluate the accuracy of TE (Fibroscan^®) for the prediction of EV in cirrhosis. However, the accuracy of TE evaluated by different studies was not consistent, especially in identifying cirrhotic patients with EV from different etiologies.[6,7,8] To confirm the foregoing findings, we performed a meta-analysis based on the Grading, Assessment, Development, and Evaluation (GRADE) framework[9] to assess the predictive accuracy of TE, as compared with EGD (the gold standard), for the prediction of EV in cirrhotic patients.     

Low Grade Esophageal Eosinophilia in Adults: An Unrecognized Part of the Spectrum of Eosinophilic Esophagitis?

Background  

Eosinophilic esophagitis (EoE) is defined by a minimum of 15 eosinophils (eos) per high-powered field (HPF) on esophageal biopsy, along with esophageal symptoms and the exclusion of gastroesophageal reflux (GERD). The clinical significance of fewer eosinophils is unknown.     

Esophageal tuberculosis: is it so rare? Report of 12 cases and review of the literature

OBJECTIVE: Mycobacterial involvement of the esophagus is rare in both immunocompetent and immunocompromised hosts with advanced pulmonary tuberculosis, even in countries with high prevalence rates like India. Most of the reported cases of esophageal tuberculosis (ET) are secondary to tuberculosis elsewhere in the body, most commonly pulmonary tuberculosis. Very few cases of isolated or primary ET have been reported, and most of them have been from developing countries. The upsurge in reported cases of tuberculosis linked to the AIDS epidemic has increased the incidence of this infection in developed countries also. Our aim is to study tuberculosis as an etiological factor in the causation of dysphagia, the role of cytology and histopathology in establishing its diagnosis, and the outcome of antitubercular treatment in these patients. METHODS: A hospital-based, retrospective study was performed. We reviewed records of all of the patients who underwent upper GI endoscopic examination for complaints of persistent dysphagia (>6 wk) in a tertiary care hospital in India between 1995 and 1999. Patients with abnormal endoscopic findings were subjected to endoscopic fine needle aspiration/brush cytology and biopsies. Those with pathological findings suggestive of tuberculosis were treated with antitubercular therapy. RESULTS: Tubercular involvement of the esophagus, confirmed by pathological examination, was found in 12 patients. They constituted 0.5% of all patients with persistent dysphagia, and 1.3% of all patients having abnormal esophagoscopic findings. Cytological examination provided a very useful diagnostic parameter in detection of these cases. Patients diagnosed as having ET responded well to antitubercular therapy. CONCLUSIONS: Tuberculosis as a causative factor for dysphagia should be considered in developing countries with high incidences of tuberculosis and in immunocompromised hosts. Detection of these cases by careful examination of cytological smears and biopsies and treatment with standard antitubercular therapy appear effective.     

Ventricular Fibrillation: Ablation of a Trigger?

We report the case of a patient with recurrent ventricular fibrillation (VF) and no evidence of structural heart disease. VF was consistently initiated by a relatively early-coupled premature ventricular contraction with identical morphology on each occasion. Treatment with antiarrhythmic agents failed to suppress the arrhythmia. Electrophysiologic testing showed high-frequency potential at the earliest activation site, and radiofrequency ablation resulted in abolition of the ventricular ectopy with no further VF recurrence. Suppression of VF arising from focal triggers in patients with frequent ventricular ectopy and normal heart can be achieved with catheter ablation, but further studies are needed to evaluate the prevalence of such a mechanism.     

Radiofrequency Ablation for Dysplasia in Barrett’s Esophagus Restores β-Catenin Activation Within Esophageal Progenitor Cells

Background and Aims  

Endoscopic therapies for Barrett’s esophagus (BE) associated dysplasia, particularly radiofrequency ablation (RFA), are popular alternatives to surgery. The effect of such therapies on dysplastic stem/progenitor cells (SPC) is unknown. Recent studies suggest that AKT phosphorylation of β-Catenin occurs in SPCs and may be a marker of activated SPCs. We evaluate the effect of RFA in restoring AKT-mediated β-Catenin signaling in regenerative epithelium.     

Rapid progression of hepatocellular carcinoma after Radiofrequency Ablation

AIM:To report the results of radiofrequency ablation (RFA)of hepatocellular carcinoma (HCC) in cirrhotic patients andto describe the treatment related complications (mainly therapid intrahepatic neoplastic progression).METHODS:Eighty-seven consecutive cirrhotic patients with104 HCC (mean diameter 3.9 cm,1.3 SD) were submittedto RFA between January 1998 and June 2003.In all casesRFA was performed with percutaneous approach underultrasound guidance using expandable electrode needles.Treatment efficacy (necrosis and recurrence) was estimatedwith dual phase computed tomography (CT) and alpha-fetoprotein (AFP)level.RESULTS:Complete necrosis rate after single or multipletreatment was 100%,87.7% and 57.1% in HCC smallerthan 3 cm,between 3 and 5 cm and larger than 5 cmrespectively (P=0.02).Seventeen lesions of 88(19.3%)developed local recurrence after complete necrosis during amean follow up of 19.2 mo.There were no treatment-relateddeaths in 130 procedures and major complications occurredin 8 patients (6.1%).In 4 patients,although complete localnecrosis was achieved,we observed rapid intrahepaticneoplastic progression after treatment.Risk factors for rapidneoplastic progression were high preoperative AFP valuesand location of the tumor near segmental portal branches.CONCLUSION:RFA is an effective treatment for hepatocellularcarcinoma smaller than 5 cm with complete necrosis in morethan 80% of lesions.Patients with elevated AFP levels andtumors located near the main portal branch are at risk forrapid neoplastic progression after RFA.Further studies arenecessary to evaluate the incidence and pathogenesis ofthis underestimated complication.