Clinical Experience with a Single Catheter for Mapping and Ablation of Pulmonary Vein Ostium

Introduction: The aim of this single center study is to evaluate the safety and the efficacy of performing pulmonary vein isolation (PVI) using a single high-density mesh ablator (HDMA) catheter.
Methods: A total of 17 consecutive patients with paroxysmal (10 patients) or persistent atrial fibrillation (7 patients) and no heart disease were enrolled. A single transseptal puncture was performed and the HDMA was placed at each PV ostium identified with anatomic and electrophysiological mapping. Pulsed radiofrequency (RF) energy was delivered at the targeted temperature of 58°C with maximum power of 80 watts. No other ablation system was utilized. The primary objective of the study was acute isolation of the targeted PV, and the secondary objective was clinical efficacy and safety of PVI with HDMA for atrial fibrillation (AF) prevention. Patients were followed at intervals of 1, 3, 6, and 12 months.
Results: PVI was attempted with HDMA in 67/67 PVs. [Correction made after online publication October 27, 2008: PVs changed from 6/67 to 67/67] Acute success rate were: 100% (16/16) for left superior PV, 100% (16/16) for left inferior PV, 100% (17/17) for right superior PV, 100% (1/1) for left common trunk and 47% (8/17) for right inferior PV. Total procedure time was 200 ± 36 minutes (range 130–240 minutes) and total fluoroscopy time was 42 ± 18 minutes (range 23–75 minutes). During a mean follow-up of 11 ± 4 months, 64% of patients remained in sinus rhythm (8/10 paroxysmal AF and 3/7 for persistent AF). No complications occurred either acutely or at follow-up.
Conclusions: PV isolation with HDMA is feasible and safe. The midterm efficacy in maintaining sinus rhythm is higher in paroxysmal than in persistent patients.     

Inspiratory stridor in a 12-month-old girl

Congenital tracheal stenosis is a rare disorder, characterized by the presence of focal or diffuse complete tracheal cartilage rings, resulting in a fixed tracheal narrowing. The entity may be seen in isolation or in conjunction with other malformations that include an anomalous right upper lobe bronchus. We here report the case of a 12-month-old girl who had severe bi-segmental congenital tracheal stenosis with the interposition of a tracheal bronchus between the two stenotic segments.     

Angiographic Correlates of Different Mechanical Effects During the Dipyridamole Echocardiography Test Shortly After Acute Myocardial Infarction

The aim of this study was to analyze the different mechanical patterns during the dipyridamole echocardiography test (DET) performed in 167 patients 8–10 days after a first myocardial infarction. The results were correlated with coronary angiography. In a first series of 98 patients retrospectively analyzed (group I), four different types of dipyridamole-induced wall-motion abnormalities were observed: (1) worsening of wall motion in the same region showing asynergy at rest (type I); (2) new wall-motion abnormality in a territory adjacent to the resting asynergies and fed by the same vessel (type II); (3) new wall-motion abnormality in a territory adjacent to the resting asynergies, but supplied by a vessel different from the infarct related artery (type III); and (4) new wall-motion abnormality not directly adjacent to the infarct zone (type IV). Type IV asynergies were found in one of 44 patients with single vessel disease and in 14 of 54 patients with multivessel disease (sensitivity 70.4%, specificity 92.3%). Type III asynergies developed in two patients with single vessel disease and in 24 of those with multivessel disease. The frequency and distribution of the four asynergy types were subsequently analyzed in a second prospective series of 69 patients (group II). Type III and IV asynergies were found almost exclusively in patients with multivessel disease (17/34 patients with multivessel disease and 2/35 with single vessel disease) (sensitivity 50%, specificity 94.3%). Combining type III and IV asynergies, an overall sensitivity of 62% and a specificity of 94% for predicting multivessel disease were obtained. The ability of DET to predict specific vessel obstruction was also investigated. A positive correlation was found only for the laterobasal segment (specificity 82% in predicting critical stenosis of the left circumflex artery [LCX]), and for the apical and distal septal segments (specificity 95% and 93% for lesions of the left anterior descending artery [LAD], respectively). A substantial overlap was noted when an attempt was made to distinguish LCX from right coronary artery (RCA) lesions. Nevertheless, new simultaneous wall-motion abnormalities of the posterobasal septal and laterobasal segments were observed in all but one patient with combined lesions of LCX and RCA (specificity 99%). In conclusion, the mechanical patterns of dipyridamole-induced new wall-motion abnormalities correlate with coronary angiography: new remote asynergies are highly specific in predicting multivessel disease, but are not frequent. New asynergies adjacent to the infarct zone can also predict multivessel disease, provided they are located in a different vascular region. The ability of DET to predict specific vessel obstructions was excellent for LAD lesions, but it was less helpful in differentiating LCX from RCA lesions. Nevertheless, new simultaneous wall-motion abnormalities of the posterobasal septal and laterobasal wall predict critical lesions of the LCX and RCA.     

Serum Apolipoproteins,Lipoproteins and Fatty Acids in Relation to Ischaemic Heart Disease in Northern and Southern European Males

ABSTRACT Serum apolipoprotein and lipoprotein concentrations, fatty acid spectra of various lipids, dietary habits and common risk factors for ischaemic heart disease were studied in 73 and 77 randomly selected, 50-year-old healthy men in Naples and Stockholm, respectively. Mean serum cholesterol concentration was higher in Stockholm than in Naples men (6.23 vs. 5.47 mmol/l, p < 0.001) as were low (LDL) (4.08 vs. 3.57 mmol/l, p < 0.001) and high (HDL) (1.40 vs. 1.25 mmol/l, p < 0.001) density lipoprotein fractions. Mean serum triglyceride concentrations did not differ. Mean apolipoprotein B and C-I concentrations were higher in Stockholm men (1116 vs. 1020 mg/l, p < 0.05 and 96 vs. 79 mg/l, p < 0.01, respectively). Stockholm men derived significantly more of their calories from fat (38 vs. 28%, p < 0.001) and the dietary fat had significantly lower polyunsaturated-to-saturated fatty acid ratio (P/S-ratio 0.29 vs. 0.51, p < 0.001), and less from carbohydrate (44 vs. 49%, p < 0.001) than Naples men, respectively. Mean caloric intake and mean weight/height index did not differ. Stockholm men had higher blood pressures, but there were more smokers among Naples men. The higher fat intake in Stockholm men may offer an explanation of the differences seen in lipoprotein and apoprotein concentrations and compositions but other factors, such as genetic influences cannot be excluded. A greater cholesterol flux through the plasma compartment in Stockholm men may be one important factor contributing to the higher incidence of ischaemic heart disease in this population.     

"Peak Summation" Left Ventricular Filling Pattern in Patients with Chronic Heart Failure

In patients with chronic heart failure (CHF) and a “peak summation” left ventricular pattern, no hemodynamic and prognostic information can be drawn from Doppler examination of mitral flow. In 263 consecutive patients with CHF who were undergoing simultaneous right heart catheterization and echo-Doppler examination, we prospectively determined (1) the frequency of the peak summation left ventricular filling pattern and (2) the incremental information contributed by pulmonary venous flow velocity patterns in providing noninvasive hemodynamic profile estimation. Isovolumic relaxation time of mitral flow, peak systolic (X), diastolic forward (Y), reverse (Z) flow velocity, and systolic fraction (X/X + Y) of pulmonary venous flow were measured. Forty-six of 263 (17%) patients had a peak summation left ventricular filling pattern. This subgroup showed more clinical deterioration (New York Heart Association functional class III-IV, 57% vs 49%; P < 0.01) and left atrial dysfunction (left atrial ejection fraction, 31% vs 39%; P < 0.001). However, 40% of these patients had a pulmonary wedge pressure of> 18 mmHg and a cardiac index of < 2.2 L/min/m². The systolic fraction of peak velocities of pulmonary venous flow showed a good correlation with pulmonary wedge pressure (r = -0.70, P < 0.05). The correlation was stronger in patients without mitral regurgitation (r = -0.81, P < 0.05). A systolic fraction of < 40% was accurate (sensitivity, 100%; specificity, 95%) in identifying patients with a pulmonary wedge pressure of < 18 mmHg. In patients without mitral regurgitation, this variable was also correlated with cardiac index (r = -0.65, P < 0.05) and predicted a cardiac index of < 2.2 L/min/m² (sensitivity, 91% specificity, 71%). In conclusion, a peak summation left ventricular filling pattern is common in patients with CHF. Pulmonary venous flow provides useful information about the hemodynamic profile of these patients.