Surgical Catheter Ablation of Ventricular Tachycardia Using Left Thoracotomy in a Patient with Hindered Access to the Left Ventricle

We report the case of a patient presenting with incessant monomorphic ventricular tachycardia resistant to antiarrhythmic drugs, and in whom usual percutaneous vascular or pericardial access to the left ventricle was hindered by mechanical aortic and mitral prosthetic valves. Because an epicardial location was suspected by electrocardiogram features and because access to the target area through the coronary sinus was not possible, we decided to perform a surgically based radiofrequency (RF) ablation. Catheter mapping of the epicardial surface through surgical left lateral thoracotomy in the operating room confirmed the epicardial location of the arrhythmogenic substrate and allowed successful RF ablation of the clinically incessant tachycardia. Combined surgical and electrophysiological approach should therefore be performed when RF ablation is needed in case of unadvisable, difficult, or failed nonsurgical percutaneous access.     

Prevalence of activated protein C resistance and analysis of clinical profile in thromboembolic patients. A Belgian prospective study

Objectives. To assess the prevalence of activated protein C resistance (APC-R) among healthy subjects and thromboembolic patients and to determine the clinical characteristics associated with APC-R.
Design. A prospective study.
Setting. One academic medical centre.
Subjects. 91 health controls and 126 thromboembolic patients.
Measurements. Patients and control were genotyped for the factor V Leiden (VaQ506) mutation. The anticoagulant response of the patient's plasma to activated protein C was also determined.
Results. The frequency of APC-R was 3.3% among healthy control subjects and 22% among thrombotic patients of whom 18% were heterozygous and 4% were homozygous. The mean age at the first thrombotic event and the severity of thrombotic disease including the proportion of proximal deep vein thrombosis and the frequency of lung embolism were identical among APC-R positive and negative patients. A family history of thromboembolic disease was elicited more frequently in APC-R positive than in APC-R negative patients (57% vs. 22%, P <0.001). The recurrence rate was higher for APCR-R positive patients (57% vs. 34%, P <0.05). The percentage of cases with a factor predisposing to thrombosis was very similar in APC-R positive (57%) and negative (68%) patients.
Conclusions. A familial history of thromboembolic disease and recurrences are significantly more frequent among APC-R positive than APC-R negative patients.     

Sotalol: From "Just Another Beta Blocker" to "The Prototype of Class III Antidysrhythmic Compound"

Sotalol is a beta-blocking drug devoid of membrane stabilizing properties, as well as intrinsic sympathomimetic actions, or cardioselectivity. In addition, sotalol prolongs atrial and ventricular repolarization (Class III antiarrhythmic activity). It appears to have less myocardial depressant effect than other beta-blocking agents. Given orally, bioavailability of the drug reaches 100%. Sotalol's plasma half-life is 15 hours (range 7–18) and is dependent only on renal function. In clinical practice, it has been found effective in the suppression of nearly all supraventricular and ventricular dysrrhythmias except those related to prolonged ventricular repolarization. Most common adverse effects are dyspnea, bradycardia, and fatigue, which results in drug termination in 16% of the cases. Torsades de pointes usually associated with bradycardia and drug induced QTc prolongation has been reported in 1.9%–3.5% of the patients receiving sotalol. This complication may be reduced by limiting the dose (< 640 mg/day) especially in patients with impaired renal function. In addition hypokalemia must be avoided. To sum up, the combination of Class II and Class III effects may carry additional benefits. However, further studies are required to test such hypotheses.     

BINDING OF TUBOCURARINE, FAZADINIUM, PANCURONIUM AND ORG NC 45 TO SERUM PROTEINS IN NORMAL MAN AND IN PATIENTS WITH CIRRHOSIS

The protein binding of four non-depolarizing neuromuscular blockingdrugs-tubocuranne, fazadinium, pancuronium and Org NC45-wasmeasured, in serum from normal patients and from patients withcirrhosis of the liver, by an ultracentrifugation method. Thefraction bound to serum protein in normal panents was 56% fortubocuranne, 51percnt; for fazadinium, 29% for pancuronium and30percnt; for Org NC 45 In patients with cirrhosis, the proteinbinding of the four drugs was similar to that obtained in thenormal patients.     

VJ REARRANGEMENTS OF THE TCRγ LOCUS IN PERIPHERAL T-CELL LYMPHOMAS: ANALYSIS BY POLYMERASE CHAIN REACTION AND DENATURING GRADIENT GEL ELECTROPHORESIS

Using Southern blotting for the diagnosis of clonality in peripheral T-cell lymphomas (PTCLs), analysis of the T-cell receptor (TCR) γ gene rearrangement was shown to be more informative than that of the TCR β gene rearrangement. In order to amplify every VJγ rearrangement, a polymerase chain reaction (PCR) procedure using newly designed GC-clamp primers has been developed. All primers can be mixed in a single multiplex PCR. PCR products are analysed by denaturing gradient gel electrophoresis (DGGE), providing tumour-specific imprints inasmuch as the procedure characterizes N sequence polymorphism at the VJ junctions. In a series of 30 PTCL cases, the PCR procedure demonstrated 27 cases to be clonally rearranged and failed in three cases. PCR was more accurate than Southern blotting, showing 47 rearranged γ alleles, four of which were undetectable on the Southern blot. When lymphomas were studied at different sites and at relapse, the DGGE pattern remained unchanged. In PTCL, the proposed PCR is helpful for the diagnosis and staging of the disease and should improve the follow-up monitoring. The undetectability of clonal rearrangements in a few cases is discussed in the light of concepts of lymphomagenesis and T-cell differentiation.     

“Cardio‐Neuromodulation” With a Multielectrode Irrigated Catheter: A Potential New Approach for Patients With Cardio‐Inhibitory Syncope

Syncope is frequently neurally mediated and can seriously affect quality of life. Different ablation strategies have been successfully performed. These approaches have not gained wide acceptance and are quite extensive and complex, exposing patients to significant risks. This article reports the case of a 16‐year‐old girl who was severely affected by frequent and prolonged episodes of syncope and was treated by tailored ablation of the anterior right ganglionated plexus with a multielectrode irrigated catheter. She had fainted >30 times in the 5 years preceding treatment, experiencing approximately 10 severe episodes of syncope in the previous 12 months. After 3 minutes of ablation, the P‐P interval was reduced by >400 milliseconds. Syncope disappeared and the patient has remained completely asymptomatic over a follow‐up of 22 months. The “reset” basal P‐P interval has remained unchanged (follow‐up electrocardiogram at 16 months). At 6 months, there was no residual heart rate activity <50 bpm. On 24‐hour rhythm registration, P‐P intervals ≥1,000 milliseconds (corresponding to a heart rate of ≤60 bpm) were reduced by >16,000 beats. We believe that this case report is original for several reasons: the unusual clinical presentation; the unique structure targeted; the very limited ablation, implying much lower risks for the patient; the anatomical approach; and the different endpoint. This new “cardio‐neuromodulation” approach could be useful for the treatment of patients with neurally mediated syncope.     

Recording of Peak Endocardial Acceleration in the Atrium

Background: The important role played by peak endocardial acceleration (PEA or sonR) in hemodynamic monitoring of cardiac resynchronization therapy (CRT) was recently highlighted in several studies with the sensor embedded in a right ventricular (RV) lead tip. This study examined the short- and long-term reliability of a right atrial (RA) sonR sensor.
Methods: RA and RV sonR signals were measured from RA and RV leads respectively, at implant and up to 12 months of follow-up, in 19 recipients of either single chamber pacemakers or CRT systems. At 1 month of follow up, RA sonR signals and heart rate were simultaneously recorded during exercise.
Results: A reliable RA sonR signal amplitude was measured at implant, proportional to the RV amplitude. We observed in both the right atrium and right ventricle (1) a similar signal noise ratio at implant, (2) a similar evolution of the sonR signal amplitude up to 12 months of follow-up, and (3) a high correlation between heart rate and RA sonR signal amplitude during exercise.
Conclusions: The RA sonR signal was reliable and proportional to the RV signal on the short and long term, and reflected changes in activity. These observations suggest that the sonR sensor could be placed in the atrium for the hemodynamic monitoring of CRT system recipients.