Decremental intravenous pulse propagation during extrastimulus pacing: relevance for catheter ablation of focal atrial fibrillation.

We report a case study demonstrating delayed circumferential intrapulmonary-venous conduction characteristics during coronary sinus extrastimulus pacing. This phenomenon allowed the unmasking and discrimination of a localized left atrial to PV breakthrough from secondarily activated PV muscle in a common left-sided PV ostium. Thus, this pacing manoeuvre may serve to guide RF delivery in the treatment of focal AF.     

Amiodarone-associated "torsade de pointes". Relevance of concomitant cardiovascular medication in a patient with atrial fibrillation and structural heart disease

A 69 year old female with history of coronary heart disease, myocardial infarction and paroxysmal atrial fibrillation suffered from occipital apoplexy. Under treatment with amiodarone 600 mg daily and concomitant medication with beta-acetyldigoxine (0.1 mg daily) and bisoprolole (1.25 mg daily), significant QT-prolongation (max. 700 ms; QTc: 614 ms) could be documented. Out of normofrequent sinus rhythm but as well out of bradycardia, the patient developed repetitive short-lasting "torsade de pointes" tachycardias (320 bpm) which terminated spontaneously. Serum electrolytes, plasma levels of digoxine (1.76 ng/ml) and amiodarone (1.9 mcg/ml) were within therapeutic range. This case report is the first to describe induction of amiodarone-associated "torsade de pointes" tachycardia during concomitant beta-blocker and digitalis medication in a patient with atrial fibrillation and structural heart disease. This points towards an elevated risk for proarrhythmia under this triple therapy.     

Erstdiagnose einer Fallot-Tetralogie bei einem 74-j?hrigen Mann Kasuistik über einen komplexen Fall einer Fallot-Tetralogie bei einem 74-j?hrigen Erwachsenen, der ohne chirurgische oder medizinische Behandlung überlebte

Die Fallotsche Tetralogie gilt im späteren Kindes- und Erwachsenalter als häufigster zyanotischer Herzfehler und tritt bei ca. 0,25 Neugeborenen unter tausend Geburten auf. Wegen der niedrigen Überlebenschance der Patienten ohne frühe chirurgische Korrektur konnten die Spätfolgen dieses Krankheitsbildes nur in wenigen Fällen untersucht werden. Wir berichten über ein komplexes Beispiel einer Fallot-Tetralogie bei einem Erwachsenen, der ohne chirurgische oder medizinische Behandlung überlebte. Seit Kindheit war ein Ventrikelseptumdefekt bekannt. Die Diagnose der Fallotschen Tetralogie wurde im Alter von 74 Jahren gestellt, als der Patient zur invasiven Diagnostik und ICD-Implantation wegen einer dokumentierten ventrikulären Tachykardie mit nachfolgender Synkope in unsere Einrichtung aufgenommen wurde.     

Vorhofflimmern: Stimulation und Schrittmachertherapie

Pacing therapy is well established in all cases of symptomatic bradyarrhythmic atrial fibrillation. In paroxysmal or persistent atrial fibrillation, the implanted dual chamber pacemaker device should incorporate an automatic mode switching algorithm. Mode switch in case of atrial fibrillation detection avoids pacemaker mediated rapid ventricular pacing during an atrial tachyarrhythmia and allows to perform dual chamber pacing during phases of sinus rhythm which is the preferable mode due to improved hemodynamics, rate adaptation, lower progress in atrial fibrillation burden and a lower rate of thromboembolic events as compared to ventricular pacing. PERSPECTIVE: The possibility to prevent from atrial fibrillation recurrencies by pacing is currently under investigation. Various methodological approaches, for example multisite or alternate single site pacing, preventive pacing algorithms or hybrid- and even triple-therapy concepts are used for that purpose. Due to the theoretical point of view, that all these pacing interventions may reduce atrial fibrillation but also have the potential to act in a proarrhythmic manner, the data from adequately designed trials is of major importance: Septal pacing and preventive pacing algorithms seem to have a beneficial effect in a limited number of so far available studies. CONCLUSION: In clinical practice, preventive pacing and/or placement of the atrial lead in a septal position should therefore be available in those patients with a conventional pacing indication in addition to symptomatic recurrent atrial fibrillation. Preventive pacing is so far with a significant and not-predictable amount of non-responders no "early" stage of therapy in patients with recurrent symptomatic atrial fibrillation and no additional conventional pacing indication.     

Azurophil granules are heterogeneous with respect to mobilization induced by different concentrations of fMLP

Azurophil granules of neutrophils beyond their already known heterogeneity of beta-glucuronidase and myeloperoxidase enzyme contents are heterogeneous with respect to a spontaneous or low concentration (2.3 or 23 nM) of formyl-Met-Leu-Phe-induced mobilization. This suggests that the heterogeneity of azurophil granules is manifested in their functions too.     

Pro-arrhythmic effects of amiodarone and concomitant rate-control medication.

AIMS: Amiodarone is one of the most efficient and safe antiarrhythmic drugs in the treatment of atrial fibrillation (AF). Although pro-arrhythmic effects of amiodarone therapy are rare, the aim of the present study was to identify clinical constellations which may lead to amiodarone-associated pro-arrhythmia. METHODS AND RESULTS: Sixty-three consecutive patients (pts) (49 males; 64+/-10.3 years; 35 with coronary heart disease, 17 with lone AF) were retrospectively included in this study. All received an oral (92.1%) or i.v. (7.9%) loading dose of amiodarone for the treatment of AF. Cardiac diseases, concomitant medical treatment, and incidence of pro-arrhythmic effects were analysed. Three pts (4.8% of the total population) developed a clinical relevant, polymorphic ventricular tachyarrhythmia, 3-48 h after initiation of amiodarone loading. Coronary heart disease was present in all of these pts, and in two of them left ventricular ejection fraction was severely reduced. The mean QTc in these pts was only slightly prolonged; mean heart rate was significantly decreased compared with the total study population (61.0+/-7.5 vs. 74.5+/-24.1 bpm; P < or = 0.05). In all pts with pro-arrhythmia, amiodarone (two pts i.v., one patient oral) was initiated during concomitant beta-blocker/digitalis therapy. Twenty-five per cent of the patients receiving this 'triple' therapy developed ventricular arrhythmia. CONCLUSION: The present study implies that initiation of amiodarone therapy in pts with structural heart disease and AF that are concomitantly treated with beta-blockers and digitalis may have an increased risk of amiodarone-associated pro-arrhythmia.     

The potential impact of the tension of the pelvic muscles on set-up errors in radiotherapy for pelvic malignancies

The purpose of the study reported here was to evaluate the potential impact of the tension of pelvic muscles on set-up errors. Twenty-nine consecutive patients with rectal cancer were included. The treatment simulation of the lateral beam in prone position was performed twice-with relaxed and next with maximally tense pelvic muscles. During the second simulation, the couch was moved so as to align the centre of the beam with the actual position of the skin mark tattooed during the first simulation. The bony landmarks on both images of corresponding lateral fields were matched. The beam's centre displacement and the rotation were measured using the beam image taken in relaxed position as a reference. The absolute values were used in calculation of the mean. For the anterior-posterior direction, the mean value of displacements was 15.3 mm, standard deviation (SD) 6.9 mm and the maximal value 37 mm. For the cranial-caudal direction, the mean value was 4.4 mm, SD 4 mm and the maximal value 17 mm. The mean rotation of the pelvis was 5.3 degrees, SD 2.4 degrees and maximal rotation 11 degrees. The majority of displacements were in the posterior (86%) and caudal (55%) directions. The majority of rotations were clockwise (76%). It was shown that pelvic muscle tension was the reason for anal verge displacements and mispositionings of the shielding block. This results in set-up inaccuracy, especially in the anterior-posterior direction, shielding block mispositioning and anal verge displacement.