Ventricular Tachycardia/Ventricular Fibrillation Ablation in the Setting of Ischemic Heart Disease

Recurrent ventricular tachycardia (VT) in the setting of coronary artery disease is frequently a life-threatening electrophysiologic emergency. Even in patients with an implantable defibrillator, recurrent VT is frequently accompanied by repeated and disabling shock therapy. Catheter ablative therapy offers the ability to provide immediate control of recurrent VT. Long-term elimination of VT should be anticipated in most patients. This article reviews the strategies, tools, techniques, and expected outcome for catheter ablation of stable and unstable ventricular arrhythmias in the setting ischemic heart disease.     

Just How Stable Are Escape Rhythms after Atrioventricular Junction Ablation?

Background: Atrioventricular (AV) node ablation with implantation of a permanent pacemaker is an established mode of therapy in the treatment of atrial fibrillation. However, concern exists regarding subsequent dependency on an entirely paced rhythm and the possible sequela of unheralded pacemaker failure. Data regarding escape rhythm lability, an important feature of pacemaker dependency, are limited. Aims and Methods: The purpose of this study was twofold: (1) to determine the characteristics of escape rhythms at predefined serial time intervals following AV node ablation and pacemaker implantation, and (2) to identify risk factors predictive of unstable escape rhythms. Patients undergoing AV node ablation and pacemaker implantation were assessed for the presence or absence of an escape rhythm during pacemaker interrogation at five predetermined serial time points. Baseline demographics and comorbid conditions were evaluated as potential predictors of those with labile escape rhythms. Results : Seventy‐nine percent of the 96 patients studied had an underlying escape rhythm (≥30 beats per minute) immediately postablation. Although the percentage of patients with an escape rhythm increased at each follow‐up interval, the number of patients who consistently demonstrated an escape rhythm declined with each follow‐up, with 28% of patients lacking an escape rhythm at some time point, i.e., labile escape rhythm. There were no significant predictors of a labile escape rhythm. Conclusion: Among patients who have undergone AV node ablation and pacemaker implantation, 72% have a stable escape rhythm over time, but others are at risk for pacemaker dependency, as predicted by an underlying absent or labile escape rhythm. (PACE 2010; 939–944)     

Successful resuscitation of bupivacaine‐induced cardiotoxicity in a neonate

We report a case of bupivacaine‐induced cardiotoxicity in a neonate following caudal epidural block under general anesthesia for urologic surgery. Prompt recognition of the complication allowed early intervention with both standard resuscitative measures and administration of 20% Intralipid^®, resulting in a good outcome.     

Apolipoprotein E genotype and cerebral palsy

Aim Apolipoprotein E (APOE, protein; [ApoE, gene]) is a lipid transport protein abundantly present in brain cells. We investigated whether the APOE genotype is associated with cerebral palsy (CP) and whether patients with CP with comorbid conditions and more severe neurological deficits are likely to have a particular genotype. Method In a cross‐sectional study, 243 individuals with spastic CP (135 males, 108 females; mean age at data collection 11 year ([SD 6y 7mo], 34% with hemiplegia, 37% with diplegia, 29% with triplegia/tetraplegia; 44% with mild motor involvement), 31% with moderate motor involvement, 25% with severe motor involvement, were compared with healthy individuals matched by age, race, and sex to analyse the association between APOE genotype and the incidence of CP. Associations between the APOE genotype and the incidence of comorbidities and neurological deficits were studied in the group with CP. Results The APOE ε2ε3 genotype was significantly more prevalent in the group with CP (11%) than the comparison group (5%) (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.01–7.66). The presence of the ε2 allele raised the probability of having CP (OR 3.2; 95% CI 1.27–8.27). The presence of ApoE ε4 was not significantly different among groups. No relation was found between APOE genotype and severity of neurological deficit or distribution of motor involvement. Four patients with CP presented the ε4ε4 genotype, and all exhibited epilepsy and microcephaly. Eleven of 12 individuals with CP and macrocephaly carried the ε3ε3 genotype. Interpretation A higher prevalence of the APOE ε2 genotype was found among those with CP. The association of microcephaly and epilepsy with the ε4ε4 genotype and the association of macrocephaly with ε3 demand further investigation.     

Anxiety and depression in children and adolescents with spinal cord injuries

Aim  To determine the levels of anxiety and depression in young people with spinal cord injuries (SCI) and their associated factors and outcomes.
Method  Children and adolescents aged 7 to 17 years at interview who had sustained SCI at least 1 year before the study were assessed using the Children's Depression Inventory, the Revised Children's Manifest Anxiety Scale, the Pediatric Quality of Life Inventory, the Children's Assessment of Participation and Enjoyment, and a demographic questionnaire designed for the study.
Results  The 118 participants (61 males, 57 females) had a mean age of 12 years 4 months, SD 3y 1mo, range 7-17y. Mean age at injury was 5 years 11 months, SD 4y 11m, range 0-16y; 89 participants (75%) had paraplegia and 29 (25%) had tetraplegia. Fifty-seven (52%) had complete injuries and 52 (48%) had incomplete injuries according to the American Spinal Injury Association impairment scale. Thirteen participants (13%) reported significant symptoms of anxiety, and seven (6%) reported significant levels of depression, which were comparable to the normative population. Age, race, and sex were not associated with anxiety or depression, but participants with shorter duration of injury were more likely to be anxious, and those with less functional independence were more likely to be depressed. Only one dimension of participation was associated with anxiety and depression, but all aspects of quality of life were decreased among those with anxiety or depression.
Interpretation  The levels of anxiety and depression in young people with SCI are comparable to the normative range. When anxiety and depression occur they are associated with reduced levels of quality of life.     

AMERICAN CUTANEOUS LEISHMANIASIS: INTERMEDIATE FORM

A man of Portuguese nationality presented with increased volume of the forehead and multiple pustules, which subsequently ulcerated. The pustules appeared progressively on the rest of the face and in the right scapular region during a period of 2 years.
Physical examination revealed multiple rounded ulcers of different sizes with erythematous and infiltrated borders covered by serosanguineous scabs on the face and right scapular region (Figs. 1 and 2).
The otorhinolaryngologic examination showed an infiltrate of granulomatous aspect in the anterior third of the septum. Posterior rhinoscopy was normal.
When the patient was first seen, complete hematology and hepatic and renal tests were normal. Additional tests included: HIV, nonreactive; venereal disease reference laboratory test, nonreactive; chest x-ray, normal; Montenegro skin test, 14 mm; purified protein derivative, 0 mm.
The skin biopsy revealed a granulomatous infiltrate with a dense infiltrate composed principally of plasmocytes, with few lymphocytes (Fig. 3).
A skin smear stained with Giemsa and culture of biopsy material in blood agar were positive for the presence of Leishmania. Antibodies against Leishmania measured in an ELISA test were strongly positive, titer 1:6400. Typing of the isolate using absorbed polyclonal antisera revealed Leishmania braziiiensis .
During hospitalization, the patient received systemic immunotherapy with a combined vaccine containing heat-killed Leishmania mexicana promastigotes and bcg ,^1,2 as well as chemotherapy with meglumine antimoniate in a dose of 50 mg/kg/day IM, two cycles of 20 days with an in-terval of 7 days of rest.
The patient presented clinical healing of his lesions without relapse during a 2 year follow up after completion of therapy.