Successful catheter ablation by radiofrequency energy of posteroseptal accessory pathway in a patient with drug refractory Wolff--Parkinson--White syndrome

A 45-year-old patient with the Wolff-Parkinson-White syndromesuffering from recurrent intractable reciprocating atrioventriculartachycardia (RAVT) is reported. He used amiodarone, sotalol,quinidine, propafenone and flecainide unsuccessfully. An electrophysiological study (EPS) performed with four catheterslocalized the site of the anomalous pathway in the ostium ofthe coronary sinus. In this region we could also record a Kentpotential. In the ostium of the coronary sinus, radiofrequencv energy wasrepeatedly applied until the conduction over the accessory pathwaywas abolished both in the anterograde and the retrograde direction.The Kent deflection detectable before ablation, could not bedetected after it. During follow-up (1 month) the patient remainedasymptomatic and the control EPS showed no evidence of pre-excitation,either anterogradely or retrogradely.     

Long-term follow-up of patients with unexplained syncope and negative electrophysiologic study

Fifty-eight patients (29 M, 29 F, mean age 60.8 ± 16years) with unexplained syncope at the end of a complete clinicaland electrophysiological evaluation, were followed for a meanperiod of 36.6 ± 20.5 months (median: 30.5 months). Structural heart disease was present in 32 patients (55.2%).The standard ECG was normal in 24 (41.4%) and showed sinus bradycardia(>40m^-1) and/or first degree AV block and/or intraventricularconduction disturbances in 29 patients (50%). During follow-up, recurrences of syncope were observed in 11of 43 untreated patients (25.6%), three of seven electricallytreated patients (42.9%) and two of eight pharmacologicallytreated patients (25%). The cause of these recurrences was cardiacin one (1.7%), non-cardiac in 10 (17.2%) and remained undeterminedin five (8.6%). Sudden death occurred in only one patient (1.7%),who was receiving chronic amiodarone therapy. These results indicate that (1) syncopal recurrences may occurin an appreciable percentage of patients with unexplained syncopeand a negative electrophysiologic study during a relativelylong-term follow-up, (2) syncopal recurrences, when they occur,are generally due to a non-cardiac cause, (3) sudden death isan occasional and rare event in this patient population and(4) empirical prophylactic treatment with apermanent pacemakeror antiarrhythmic drugs does not usually prevent complicationsduring the follow-up.     

ALBRIGHT'S HEREDITARY OSTEODYSTROPHY

Abstract. Boscherini, B., Coen, G., Bianchini, G., Gallucci, G., Ballanti, P., Pasquino, A. M., Piccolo, F., Manca Bitti, M. L. and Spadoni, G. L. (First Paediatric Clinic and Second Medical Clinic, University of Rome, Italy). Albright's hereditary osteodystrophy. Acta Paediatr Scand, 69:305, 1980. The authors observed different clinical forms of Albright's hereditary osteodystrophy in 4 members of a family (two sisters, their mother and the maternal grandfather). The sisters were affected by pseudohypoparathyroidism type I, the older manifested the hypocalcemic variety, the younger the normocalcemic variety; the mother and the grandfather presented only with short stature and subcutaneous calcifications. The variety of clinical and biochemical alterations observed in these 3 generations supports evidence that Albright's hereditary osteodystrophy has a broad spectrum and that distinctions between the various forms of pseudohypoparathyroidism should not be rigidly considered.     

Hypoepiluminescence Microscopy of Pigmented Skin Lesions: New Approach to Improve Recognition of Dermoscopic Structures

BACKGROUND: Hypoepiluminescence microscopy (HELM) is a new dermoscopic approach for analysis of pigmented skin lesions (PSLs) after surgical excision. OBJECTIVES: The objective was to verify whether this method could provide additional morphologic information for diagnostic or didactic purposes compared to conventional epiluminescence microscopy (ELM). PATIENTS AND METHODS: Thirty-one PSLs from 30 patients were consecutively evaluated by ELM and, after excision, by HELM. For HELM examination, the lesion was positioned on a glass slide and illuminated from above with a halogen lamp and from underneath with an LED source. All lesions were subsequently examined histopathologically. RESULTS: In 11 of 31 (35.5%) lesions, a typical pigment network, as assessed by ELM, appeared bidimensional with HELM. In 9 lesions (9/31; 29%) ELM showed a gray-blue area, while HELM allowed us to distinguish 5 lesions (5/9, 55.5%) with gray area predominant showing a lichenoid lymphocytic infiltration and few melanophages from the other 4 lesions (4/9, 44,5%) with heavy dermal accumulation of pigmented melanocytes or melanophages where a blue area was clearly visible at HELM. In 9 other cases (29%), ELM analysis revealed a central homogeneous dark brown/black pigmentation that in 7 cases was seen under HELM examination to consist of globules. CONCLUSIONS: HELM is particularly useful in evaluating heavily PSLs or structures located in the reticular dermis.     

Oxaliplatin‐induced interstitial lung disease

Oxaliplatin‐induced lung disease is an increasingly recognised phenomenon. We describe here three cases of presumed oxaliplatin‐induced interstitial lung disease. With increasing use of oxaliplatin for colorectal cancer, awareness of this complication and the need for early diagnosis and treatment of respiratory symptoms can lead to early cessation of chemotherapy, rapid exclusion of alternative diagnoses and initiation of treatment with corticosteroids.     

Causes of Death in Patients with Unipolar Single Chamber Ventricular Pacing: Prevalence and Circumstances in Dependence on Arrhythmias Leading to Pacemaker Implantation

Cardiac pacing improves the prognosis of patients with severe impulse formation and conduction disturbance, though sudden death can occur frequently in paced patients. In the present study, we analyzed the causes and the circumstances of 378 deaths in 2,243 paced patients followed over a 5-year period. Sudden cardiac death occurred in 71 of these 378 patients (18.7%), 56 patients died of stroke (15%), heart failure was the cause of death in 91 subjects (24%). We analyzed the causes of death in two groups with respect to the arrhythmia that had led to pacemaker implantation. The prevalence of cardiac sudden death was higher in patients with AV block than in patients with sick sinus syndrome, while stroke was more frequent in patients with sick sinus syndrome, particularly those with both fast and slow components. Atrial fibrillation is common in patients with sick sinus syndrome and is an important well-known risk factor for stroke. Death from heart failure was frequently reported in our population, but in our study group only a few patients had heart failure at the moment of pacemaker implantation. We conclude that sudden death is a common event in paced patients and the disturbance that led the patient to pacemaker implantation was also a factor in the cause of death.     

Successful catheter ablation by radiofrequency energy of posteroseptal accessory pathway in a patient with drug refractory Wolff--Parkinson--White syndrome

A 45-year-old patient with the Wolff-Parkinson-White syndromesuffering from recurrent intractable reciprocating atrioventriculartachycardia (RAVT) is reported. He used amiodarone, sotalol,quinidine, propafenone and flecainide unsuccessfully. An electrophysiological study (EPS) performed with four catheterslocalized the site of the anomalous pathway in the ostium ofthe coronary sinus. In this region we could also record a Kentpotential. In the ostium of the coronary sinus, radiofrequencv energy wasrepeatedly applied until the conduction over the accessory pathwaywas abolished both in the anterograde and the retrograde direction.The Kent deflection detectable before ablation, could not bedetected after it. During follow-up (1 month) the patient remainedasymptomatic and the control EPS showed no evidence of pre-excitation,either anterogradely or retrogradely.     

Value of Serial Electropharmacological Testing in Managing Patients Resuscitated from Cardiac Arrest

Electrophysiologic studies were performed in 11 patients (9 men, 2 women; mean age: 59.9 yrs) who had survived an episode of cardiac arrest due to ventricular tachycardia (VT) or ventricular fibrillation. The purpose of the studies was to evaluate the usefulness of serial acute drug testing in selecting an effective chronic antiarrhythmic regimen. Ten of the patients were suffering from chronic ischemic heart disease with one or more previous myocardial infarctions while one had no evidence of structural heart disease. A ventricular aneurysm was present in four of them. During control electrophysiologic study, a sustained VT was induced by ventricular stimulation (single and double extrastimuli at various paced ventricular cycle lengths plus bursts of rapid ventricular pacing) in nine of the ten patients (90%) who were studied while not receiving antiarrhythmic drugs; a non-sustained VT was induced in one of them (10%). In three patients (30%) VT could be initiated only by right ventricular stimulation at a side different from the apex (outflow tract). No arrhythmia was observed in the only patient who was studied while taking amiodarone orally (400 mg/day for more than three months). During serial acute drug testing a totally effective drug regimen (successful in preventing the induction of any ventricular arrhythmia) was found in seven of the ten patients (70%) who underwent this procedure and a partially effective drug regimen (a sustained VT was no longer inducible; it was easier to interrupt and it was considerably slower) was found in two patients (20%). None of the nine patients who received chronic antiarrhythmic therapy based on the results of serial acute drug testing died suddenly during a mean follow-up of 14 months (range: 3-28) and only one had a recurrence of cardiac arrest. The latter, however, was taking antiarrhythmic drugs at a dosage less than that proved to be effective during electropharmacological testing. The only patient who refused serial acute drug testing and received an empiric antiarrhythmic therapy died suddenly at the 21st month of follow-up. These results indicate that serial electropharmacological testing is useful in selecting an effective long-term drug regimen in survivors of cardiac arrest.