Specific Electrocardiographic Features of Manifest Coronary Vein Posteroseptal Accessory Pathways

Coronary Vein Accessory Pathways. Introduction: Some posteroseptal accessory pathways (APs) can be successfully ablated by radiofrequency current only from inside the coronary sinus (CS) or its branches, because of an absolute or relatively epicardial location. The aim of this study was to identify ECG features of manifest posteroseptal APs requiring ablation in the CS or the middle cardiac veins (MCVs). Methods and Results: One hundred seventeen consecutive patients with manifest posteroseptal APs successfully ablated: (1) ≥ 1 cm deep inside the MCV (group MCV: n = 13); (2) inside the CS, including the area adjacent to the MCV ostium (group CS: n = 10); (3) at the right (group R: n = 60); or (4) the left posteroseptal endocardial region (group L: n = 34) were included. We reviewed delta wave polarity (initial 40 msec) and QRS morphology during sinus rhythm and atrial pacing as well as electrogram characteristics in these patients. The local target site electrogram in groups MCV and CS was characterized by a longer atrial to ventricular electrogram interval, suggesting a longer course of the pathway and more frequent recording of a presumptive AP potential compared to the group ablated at the right or left endocardium. The most sensitive ECG feature for group CS or group MCV was a negative delta wave in lead II in sinus rhythm (87%), but specificity (79%) and positive predictive value (50%) were relatively low. A steep positive delta wave in aVR during maximal preexcitation possessed the highest specificity and positive predictive value (98% and 88%, sensitivity 61%) which increased to 99% and 91%, respectively, when combined with a deep S wave in V₆ (R wave ≤ S wave). Conclusion: These data suggest that posteroseptal APs ablated inside the coronary venous system have highly specific features, including the combination of a steep positive delta wave in lead aVR and a deep S wave in lead V₆ (R wave ≤ S wave) during maximal preexcitation. The highest sensitivity is provided by a negative delta wave in lead II. These findings may be helpful for anticipating and planning an epicardial ablation strategy.     

Trisomy 3 in marginal zone B-cell lymphoma: a study based on cytogenetic analysis and fluorescence in situ hybridization

Trisomy 3 represents the most frequent and consistent chromosomal abnormality characterizing the recently defined entity marginal zone B-cell lymphoma (MZBCL). By cytogenetic analysis and/or fluorescence in situ hybridization (FISH) on interphase nuclei we found an increased copy number of chromosome 3 in 22/36 (61%) successfully analysed cases, including 8/12 cases with extranodal MZBCL, 8/13 cases with nodal MZBCL, and 6/11 patients with splenic MZBCL. Sensitivity of interphase cytogenetics was somewhat higher than that of conventional cytogenetic investigation. Structural chromosomal changes involving at least one chromosome 3 were seen in 11/20 cases with an increased copy number of chromosome 3: +del(3)(p13) was demonstrated in three cases, and was the sole chromosomal abnormality in one of them; +i(3)(q10) was seen in two other patients; and rearrangements involving various breakpoints on the long arm of chromosome 3 were found in the remaining cases. FISH on metaphase spreads confirmed these structural abnormalities and additionally showed two unexpected translocations involving chromosome 3. We conclude that: (1) trisomy 3 occurs in a high proportion of extranodal, nodal and splenic MZBCL; (2) FISH on interphase nuclei is an additional and sensitive tool in detecting an increased copy number of chromosome 3 in MZBCL; (3) additional structural abnormalities involving the long arm of chromosome 3 are frequent but non-recurrent and are perhaps secondary changes; and (4) abnormalities such as +del(3)(p13) and +i(3)(q10) suggest that genes located on the long arm of chromosome 3 are of particular importance in the pathogenesis of MZBCL.     

Optimal Stimulation of the Left Ventricle

Optimal Stimulation of the Left Ventricle. Cardiac resynchronization therapy has been proposed to alleviate heart failure symptoms refractory to classic drug treatment. Potential benefits hinge on a number of key components, including judicious selection of patients likely to respond to the therapy and appropriate placement of the leads, particularly the lead responsible for left ventricular pacing. Evidence of ventricular asynchrony is an individual prerequisite for consideration of cardiac resynchronization therapy. Ventricular asynchrony can be diagnosed by recording a QRS duration > 150 msec or during echocardiography, with the goal of investigating the mechanical aspect of asynchrony. The optimal left ventricular pacing site can be defined by the latest segmental contraction, which is mainly the mid‐lateral wall. The first‐choice technique to initiate left ventricular pacing consists of a transvenous approach via the coronary sinus tributaries. In practice, the final left ventricular pacing location also depends on highly variant coronary sinus anatomy, acceptable electrical parameters, and lead stability. Procedure‐related complications, which consist mainly of coronary sinus perforation and phrenic nerve stimulation, remain low (<1%) and should decrease further with the use of new features specific to the procedure.     

Transseptal Implantation of a Left Ventricular Pacing Lead for an Ectopic Location of the Coronary Sinus Ostium in the Left Atrium

Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation of a cardiac resynchronization therapy device. We report the case of an ectopic drainage of the CS in the left atrium. A left ventricular lead was implanted by the transseptal route. (PACE 2013; 36:e51–e52)     

An audit of the complications of paediatric tonsillectomy,adenoidectomy and adenotonsillectomy

Tonsillectomy, adenoidectomy and adenotonsillectomy are among the commonest surgical procedures undertaken in children. The notes of 413 consecutive children having tonsillectomy, adenoidectomy or adenotonsillectomy were analysed retrospectively to determine complication rates. Of the total number of children, 5.6% had at least one complication, the most common of which was haemorrhage occurring as a first complication in 3.9% (16 children). Three children with bleeding required active treatment (0.7%), one requiring transfusion and two requiring a return to theatre, all within 3 1/2 hours of operation. The incidence of reactionary bleeding was not associated with the grade or seniority of the surgeon. Six children (1.5%) developed a fever post-operatively, of which one required antibiotic treatment. On the basis of these results it is feasible for such procedures to be carried out on a day-care basis.     

Salt-dependent conformational diversity of alternating poly (Glu-Leu)

Alternating poly(Glu-Leu) was synthesized by the condensation of the corresponding dipeptide p-nitrophenyl ester at high concentration. It exhibits a random coil structure in pure water at neutral pH. Addition of monovalent cations, such as NH⁺₄ to a final 0.1 M solution, induces a transition to a water soluble β-structure. The salt effect is quite selective since no transition was observed with Li⁺, Na⁺ or Cs⁺ ions. Addition of 0.5 equiv. of calcium, cobalt or manganese chlorides per glutamyl residue induces similar coil to β-sheet transitions. No polymer precipitation was observed at these very low salt concentrations. Addition of 0.5 equiv. of Cu²⁺ or 0.15 equiv. of Fe³⁺ induces a coil to α-helix transition. Molecular modeling has been used to understand tentatively the main factors controlling the different conformations observed with the various metal ions. © Munksgaard 1997.