Identification of the dominant loop of a dual-loop macro-reentry left atrial flutter without prior intervention using high-density mapping technology:A case report

BACKGROUND Left atrial flutter without prior cardiac interventions is uncommon,especially dual-loop macro-reentry atrial flutter.The critical step to ablate dual-loop macroreentry atrial flutter is to identify the dominant loop and key isthmus.Although entrainment mapping could help identify the dominant loop and key isthmus,it may alter or terminate tachycardia.High-density mapping allows the generation of electroanatomic maps without altering or terminating tachycardia.CASE SUMMARY Here,we report a case of symptomatic left atrial flutter without prior intervention.In this case,high-density mapping revealed a dual-loop macro-reentry around the mitral annulus and central scar of the anterior wall.The propagation result showed that the dominant loop was around the mitral annulus,and the key isthmus was between the central scar and mitral annulus.The atrial flutter terminated successfully after ablation was performed.CONCLUSION In this case,we demonstrate that high-density mapping technology may help identify the dominant loop of dual-loop atrial flutter without entrainment,which makes ablation easier.

Giant androgen-producing adrenocortical carcinoma with atrial flutter: A case report and review of the literature

BACKGROUND Adrenocortical carcinoma(ACC),the second most aggressive malignant tumor,lacks epidemiological data worldwide;therefore,every new case can improve the understanding of the pathology and treatment of this malignancy.CASE SUMMARY We present the case of a 66-year-old Caucasian woman with a giant androgenproducing ACC(21 cm×17 cm×12 cm;2100 g),without metastases,which unusually presented with an acute onset of atrial flutter and congestive heart failure.The cardiac complications observed in our case support the hypothesis that androgen excess in women is a cardiovascular risk factor.Androgen excess in women can be a rare cause of reversible dilated cardiomyopathy,therefore a comprehensive approach to the patient is essential to improve the recognition of androgen-secreting ACC.The atrial flutter was remitted after initiation of drug treatment during admission.The severe heart failure was totally remitted at 6 mo after radical open surgery to remove the giant ACC.CONCLUSION Radical open surgery to remove a giant androgen-producing ACC was the firstline treatment to cure the excess of androgen,which determined the total remission of cardiac complications at 6 mo after surgery in the women of this case report.

A Case Report of Radiofrequency Ablation of Typical Atrial Flutter Combined with Atrial Tachycardia

A 63-year-old female patient with a history of pulmonary heart disease underwent radiofrequency ablation because of a persistent atrial fl utter.Endocardial mapping with the carto3 system confi rmed atrial fl utter counterclockwise reentry around the tricuspid annulus.Routine ablation of the cavo-tricuspid isthmus line to bi-directional block was performed.However,tachycardia with the same cycle length was induced again.After remapping,the tachycardia was confi rmed to be focal atrial tachycardia located in the crista terminalis.After ablation,the tachycardia was terminated and could not be induced again.

RATE-DEPENDENT SLOW CONDUCTION VELOCITY IN THE CAVO-TRICUSPID ISTHMUS AND SEPTUM IN PATIENTS WITH ATRIAL FLUTTER

Purpose. To evaluate and compare the effects of heart rate on conduction velocity in the cavotricus-pid isthmus (CTI) and septum in patients with and without typical atrial flutter (AF) using electro-anatomicmapping (EAM) of the right atrium (RA).Methods. Ten patients(age 53±10 yrs,7M/3F)with AF and 13 patients (age 51±11 yrs, 5M/8F) withatrio-ventricular nodal reentrant tachycardia (AVNRT) underwent conventional electrophysionogical study,electro-anatomic mapping and radiofrequency ablation. Using EAMs obtained during coronary sinus pacing at pac-ing cycle length (PCL) 600 ms, 400 ms, and 300 ms, we evaluated conduction velocities in the CTIand septum of RA in 10 patients with AF and compared EAMs to 13 patients with AVNRT to determinewhether the conduction slowing required to maintain AFL was related to changes in volume alone or al-tered RA electrophysiology.Results. Conduction velocities in CTI and septum were significantly slower at all PCL when AF wascompared to AVNRT(*P＜0.05). Additionally, in the AF group, septal conduction velocities were slowerat PCL 600 ms and 400 ms, but not at 300 ms compared to CTI (#P＜0.05). In AF, during PCL 300.conduction in CTI slowed significantly compared to PCL 600 and 400 ms such that there was no differ-ence between CTI and septum at PCL 300.Conclusionss. There is slower conduction in the septum compared to the CTI in all patients. However,in patients with AF, there is significant slowing of conduction in the CTI and septum as well as decremen-tal rate-dependent slowing of conduction in the CTI. These findings indicate that in addition to RA en-largement, changes in atrial electrophysiology distinguish AF patients from patients with AVNRT.

Radiofrequency catheter ablation in patients with symptomatic atrial flutter/tachycardia after orthotopic heart transplantation

Background Atrial tachycardia or flutter is common in patients after orthotopic heart transplantation. Radiofrequency catheter ablation to treat this arrhythmia has not been well defined in this setting. This study was conducted to assess the incidence of various symptomatic atrial arrhythmias and the efficacy and safety of radiofrequency catheter ablation in these patients. Methods Electrophysiological study and catheter ablation were performed in patients with symptomatic tachyarrhythmia. One Halo catheter with 20 poles was positioned around the tricuspid annulus of the donor right atrium, or positioned around the surgical anastomosis when it is necessary. Three quadripolar electrode catheters were inserted via the right or left femoral vein and positioned in the recipient atrium, the bundle of His position, the coronary sinus. Programmed atrial stimulation and burst pacing were performed to prove electrical conduction between the recipient and the donor atria and to induce atrial arrhythmias. Results Out of 55 consecutive heart transplantation patients, 6 males [（58±12） years] developed symptomatic tachycardias at a mean of （5±4） years after heart transplantation. Electrical propagation through the suture line between the recipient and the donor atrium was demonstrated during atrial flutter or during recipient atrium and donor atrium pacing in 2 patients. By mapping around the suture line, the earliest fragmented electrogram of donor atrium was assessed. This electrical connection was successfully ablated in the anterior lateral atrium in both patients. There was no electrical propagation through the suture line in the other 4 patients. Two had typical atrial flutter in the donor atrium which was successfully ablated by completing a linear ablation between the tricuspid annulus and the inferior vena cava. Two patients had atrial tachycardia which was ablated in the anterior septal and lateral donor atrium. There were no procedure-related complications. Patients were free of recurrent atrial tachyarrhythmias after a follow-up of （8± 7） months. Confusions Four electrophysiological mechanisms have been found to contribute to the occurrence of symptomatic supraventricular arrhythmias following heart transplantation. Radiofrequency catheter ablation in patients with atrial flutter/tachycardia is feasible and safe after heart transplantation.

Evaluation of transisthmus conduction interval in predicting bidirectional block after ablation of typical atrial flutter

Objective To determine whether the extent of prolongation of the transisthmus interval after ablation predicts complete bidirectional block.Methods Since 1996 to 2002, 30 consecutive patients underwent ablation procedures for isthmus-dependent atrial flutter. There were 23 males and 7 females [ mean age (47. 85 ±9. 35) years]. With the use of fluoroscopic view of anatomy, radiofrequency ablation was performed during coronary sinus pacing at a cycle length of 600 ms.Results Bidirectional block was achieved with ablation in 29 (97%) of 30 patients. The transisthmus intervals before ablation and after complete transisthmus block were (73.82±13. 01 ) ms and (140. 47±20. 48) ms, respectively, in the clockwise direction (P<0. 0001), and (77. 63±8. 36) ms and (138. 17 ±15. 55) ms, respectively, in the counterclockwise direction (P<0. 0001). A period of incomplete isthmus block was observed during 17 (58%) of the 29 ablation procedures. The clockwise transisthmus intervals during incomplete block [(107. 65 ±21. 33) ms] were (45.5 ± 8. 7)% longer than the baseline transisthmus intervals. An increase in the transisthmus interval by ≥50% in both directions after ablation predicted complete bidirectional block with 100.0% sensitivity and 83. 3% specificity. The positive and negative predictive values were 90. 6% and 100.0% , repectively. The diagnostic accuracy of a≥50% prolongation in the transisthmus interval was 83. 3%.Conclusion The analysis of transisthmus interval is a valuable method for determining complete bidirectional isthmus block.

Transesophageal cardioversion of atrial flutter and atrial fibrillation using an electric balloon electrode system

Objective To determine the feasibility and efficiency of terminating atrial flutter (AFL) and atrial fibrillation (AF) using synchronous low-energy shocks delivered through a novel transesophageal electric balloon electrode system.Methods By using a novel electric balloon electrode system, we attempted 91 transesophageal cardioversions in 52 patients, to treat 53 episodes of AFL and 38 episodes of AF.Results Of the 40 patients of AFL that failed to respond to drug therapy, 37 (92. 5%) were successfully countershocked to sinus rhythm by transesophageal cardioversion, with a mean energy of (22. 70 ?4. 50) J (20 - 30 J). Of the 19 patients in AF, transesophageal cardioversion was successful in 16 (84. 2%) cases, requiring a mean delivered energy of (17. 38±8. 58) J (3 -30 J). There were no complications such as heart block or ventricular fibrillation, and no evidence of esophageal injury.Conclusions Transesophageal cardioversion using an electric balloon electrode system is an effective and feasible method for the treatment of AFL and AF. It requires low energy and no anesthesia, leads to less trauma, and shows a high cardioversion success rate that may prove valuable in the management of tachyarrhythmias.

Repeated atrial arrhythmia induced by cochineal red poisoning:A case report

BACKGROUND Cochineal red is an organic compound widely used in food,cosmetics,pharmaceuticals,textiles,and other fields due to its excellent safety profile.Poisoning caused by eating foods containing cochineal red is rare,and repeated atrial arrhythmia due to cochineal red poisoning is even rarer.CASE SUMMARY An 88-year-old Asian female patient was admitted to hospital due to a disturbance of consciousness.Twelve hours prior to presentation,the patient consumed 12 eggs containing cochineal red over a period of 2 h.At presentation,the patient was in a coma and had a score of 6 on the Glasgow Coma Scale(E2+VT+M4).The patient’s skin and mucous membranes were pink.Electrocardiography(ECG)revealed rapid atrial fibrillation without any signs of ischemia.We prescribed cedilan and fluid replacement for arrhythmia correction.Shortly after admission,the atrial fibrillation corrected to a normal sinus rhythm.On the day 2 of admission,the patient had a sudden atrial flutter accompanied by hemodynamic instability and rapidly declining arterial oxygen saturation between 85%and 90%.The sinus rhythm returned to normal after two electrical cardioversions.Six days after admission,the skin color of the patient returned to normal,and the ECG results were normal.The patient was transferred out of the intensive care unit and eventually discharged after 12 d in hospital.At the 2-mo follow-up visit,the patient was in good health with no recurrence of arrhythmia.CONCLUSION Although cochineal red is a safe,natural food additive,excessive consumption or occupational exposure can induce cardiac arrhythmias.

普罗帕酮诱发Brugada样心电图改变一例

Brugada综合征主要在成年时期出现症状,且主要在休息或睡眠中发生猝死,儿童时期并不常见,尤其以心房扑动为首发表现的相关报道鲜见。本文报道一例以心房扑动为首发表现的13岁患儿,无基础心脏疾病,在接受普罗帕酮治疗的过程中诱发出Brugada样心电图改变,基因检测发现可疑变异基因SCN5A,变异位点为c.2834A>G(p.D945G)。希望通过本病例的诊断、治疗及相关文献回顾,提高临床医师对Brugada综合征的诱发因素以及其可合并多种心律失常的认识,加强在应用抗心律失常药物时的心电监测,并对此类高危人群进行指导和密切随访,从而避免不良事件的发生。

无水乙醇注射Marshall静脉消融二尖瓣峡部的效果观察

目的:评估无水乙醇注射Marshall静脉(vein of Marshall,VOM)在持续性心房扑动(简称房扑)、心房颤动(简称房颤)二尖瓣峡部线性消融中的有效性和安全性。方法:收集2019年9月—2020年5月上海市胸科医院采用射频消融+无水乙醇注射VOM治疗持续性房扑、房颤患者72例(VOM组)的临床资料,同时选择采用左房线性消融治疗持续性房扑、房颤患者72例作为对照(对照组)。入选患者均行二尖瓣峡部线性消融手术,术中验证二尖瓣峡部线阻断情况,术后随访房性心律失常和心包积液发生情况,均随访12个月以上。结果:VOM组术中验证二尖瓣峡部线阻断63例,其中需要联合心内和心外膜补点消融达到二尖瓣峡部线14例,未能阻断二尖瓣峡部线9例。对照组术中验证二尖瓣峡部线53例,未能阻断19例。随访12~20个月,VOM组房性心律失常复发20例,而对照组房性心律失常复发30例。结论:在持续性房扑、房颤消融治疗中,经VOM行无水乙醇注射能有效阻断二尖瓣峡部线性传导,有助于提高二尖瓣峡部线成功率,减少房颤消融术中二尖瓣峡部相关的房扑发生率,且不增加严重并发症的发生率。

复杂先心矫正术后合并起搏器植入患者房扑射频消融1例

心房扑动(atrial flutter,Af)是儿童时期较为少见的一类快速性心律失常,可为原发性,也可为继发性。其中继发性Af常见于先天性心脏病、心脏手术后、心肌病等。依据体表心电图的不同,房扑可分为典型Af和非典型Af^([1])。Af的治疗目前主要包括控制心室率、转复窦性心律以及抗凝治疗^([2])。射频消融治疗Af安全性和有效性高,因此逐渐成为根治Af的首选治疗方法^([3])。然而,心脏起搏器的植入无疑增加了射频消融术的难度。现就1例射频消融治疗复杂先心起搏器植入术后Af病例予以报道。

1例先天性心脏病术后房扑伴房颤合并前置胎盘出血及血小板减少先兆流产患者的药学监护

目的为先天性心脏病术后心房扑动伴心房颤动(以下简称“房扑伴房颤”)合并前置胎盘出血及血小板减少先兆流产患者的安全用药提供参考。方法临床药师参与1例先天性心脏病术后房扑伴房颤合并前置胎盘出血及血小板减少先兆流产患者的诊治过程,针对其使用依诺肝素钠后出现的血小板下降,建议停用依诺肝素钠,复查血常规后改为磺达肝癸钠;针对患者心率快、血压低,建议选择美托洛尔并根据心率调整剂量,同时将呋塞米改为氢氯噻嗪;针对医师拟于剖宫产术前停用美托洛尔,改为索他洛尔,建议继续使用美托洛尔;针对患者可能出现的药物相互作用,建议密切监测血钾等指标,并进行用药教育。结果医师采纳临床药师建议。患者出血得到控制,住院期间各项指标均维持稳定,孕周延长,并顺利行剖宫产术。结论临床药师通过参与先天性心脏病术后房扑伴房颤合并前置胎盘出血及血小板减少先兆流产患者的治疗过程,以药物不良反应、药物相互作用及患者用药教育为切入点,为患者制定个体化用药方案,确保了用药的安全性和有效性。

Coronary sinus reentrant tachycardia after atrial fibrillation ablation: From bad to worse

Herein we present a case of atrial tachycardia as a sequel of AF ablations. A 42-year-old man was admitted to our department because of a very symptomatic tachycardia. The patient, because of paroxysmal AF and typical atrial flutter, had been already submitted (three times) to ablation procedures in both left (pulmonary vein insulation) and right atria (cavo-tricuspidal isthmus). During the electrophysiological study, a huge and very fast atrial tachycardia was induced: 230 ms cycle length, 1/1 atrio-ventricular conduction with the ventricular rate of 260 bpm, complete left bundle branch block, and clinically recognized by the patient. Four minutes later, a 2/1 AV conduction without branch block permitted mapping and ablation. A high-density mapping around isthmus and coronary sinus (CS) was performed. The analysis of the chronological activation clearly showed a circuit propagation around the CS ostium with a very slow conduction in the anterior zone enlightened by the tight color progression, and counterclockwise activation of the right atrium lateral wall. In anterior zone of CS ostium diastolic fragmented electrograms were detected. After preventing his position localization, radiofrequency delivering (35 W) was effective to interrupt the arrhythmia in 3 seconds. Energy delivering was continued to anchor the lesion to the inferior vena cava. Confirmation of successful ablation was determined by unsuccessful attempts at reinduction of the arrhythmia, in basal state and during infusion of isoproterenol.

Novel therapies for treating atrial fibrillation

Atrial fibrillation is the most common cardiac arrhythmia and is a major risk factor for stroke, heart failure, and death. Current treatments focus on anti-coagulation as well as rate-control and rhythm-control strategies. Frequent INR checks associated with warfarin along with several adverse side effects of anti-arrhythmics have propelled investigations into novel treatments for atrial fibrillation. Research is focused not only on pioneering new pharmacological antico- agulation and anti-arrhythmic agents but also on improving surgical techniques in hopes of treating the arrhythmia. Here, we first briefly discuss the current treatment options, both pharmacological and non-pharmacological, for atrial fibrillation. We then present a focused review of recent animal and human investigations that examine the use of novel an-ticoagulation agents, mechanisms of new anti-arrhythmics, analyze potential triggers of atrial fibrillation, and highlight the role of genetics in atrial fibrillation.

Catheter Ablation of Mitral Isthmus Flutter Post Mitral Valve Repair and Surgical Maze: Case Report and Review of the Literature

Hereby we describe a case of LAF developed after a surgical Maze procedure that demonstrates the importance of a systematic approach to mapping and ablating atypical atrial flutter to prevent a recurrence of symptomatic arrhythmia. In patients with previous cardiac surgery procedures, and in particular after a surgical maze, there are many different potential LA reentry circuits that involve various pathways. Both activation mapping and entrainment mapping were performed in order to identify the critical isthmus of the circuit and to effectively terminate the arrhythmia.

RADIOFREQUENCY CATHETER ABLATION FOR TREATMENT OF ATRIAL ARRHYTHMIAS

In this paper,electrophysiologic study and RFCA were attempted in 3 patientswho had clinical episodes of atrial arrhythmias with multiple ECG recordings.Diagnoses were automatic atrial tachycardia in one,reentrant atrialtachycardia in one,and typical atrial flutter in one.Site for atrial flutterablation was based on anatomic barriers in the floor of the right atrinm.Forautomatic atrial tachycardia,the site of earliest activation before the pwave was sought and for reentrant atrial tachycardia,our goal was to identifya site of early activation in a zone of slow conduction.At target sites,20 to40w of radiofrequency energy were delivered during tachycardia.Procedureend point was inability to reinduce tachycardia by atrial pacing and infusionof isoproterenol,Acute success was achieved in all of three patients.Fortachycardia involves reentry(reentrant atrial tachycardia and atrial flutter),successful ablation required severing an isthmus of slow conduction.Foratrial flutter,this was between the tricuspid annulus and the coronary sinus osor between the inferior vena cava and the tricuspid annulus.Abla-tioo ofautomatic and reentrant atrial tachycardia and atrial flutter had a highsuccess rate and caused no complications.Repeat procedures may be requiredfor long-term success,especially in patient with atrial flutter.

Intraoperative sudden arrhythmias in cervical spine surgery adjacent to the stellate ganglion:A case report

BACKGROUND Atrial arrhythmias such as paroxysmal supraventricular tachycardia(PSVT)and atrial flutter(AF)are common in the perioperative setting.They commonly resolve spontaneously.However,occasionally,they may continually progress to fatal arrhythmias or cause complications.Therefore,prompt and appropriate management is important.CASE SUMMARY A 46-year-old female patient diagnosed with cervical C6-7 radiculopathy characterized by decreased sensation in the right third,fourth and fifth fingers underwent C6-7 anterior cervical disc fusion surgery.Electrocardiography showed PSVT and ventricular tachycardia during C6-7 disc retraction.However,the patient remained stable.Initial treatment with esmolol and lidocaine for ventricular tachycardia was ineffective.Carotid massage and Valsalva maneuver were attempted but PSVT did not resolve.The surgery was paused,and the patient’s fraction of inspired oxygen was set to 100%.Adenosine was administered for pharmacological management of PSVT.The arrhythmia temporarily resolved.However,it then transformed into AF.Diltiazem was administered,which briefly decreased blood pressure,which immediately recovered.Surgery resumed while the patient was in normal sinus rhythm.She was discharged safely on postoperative day 6 without complications or abnormalities.Currently,she is living a healthy life without arrhythmia recurrence.CONCLUSION Ganglia associated with cardiac arrhythmias in the surgical site should be identified during cervical spine surgery.

高龄急性心房扑动患者行开腹探查术的麻醉管理(附1例报告)

心房扑动是心房内折返回路引起的快速型心律失常,心室率甚至可超过150次/分,严重时会出现低血压、晕厥甚至休克。高龄患者发生急性心房扑动较为少见,可诱发心功能不全,甚至可导致死亡,麻醉管理困难且风险较大。本文报道1例80岁高龄急性心房扑动患者,行开腹探查术,并在术中成功电复律。患者术后心电监测显示窦性心律,转入ICU继续治疗13 d后,患者复查生化全项、血常规、血凝等指标未见明显异常,准予出院。

食管调搏终止心外科术后心房扑动的疗效及影响因素分析

目的 探讨经食管心房调搏(TEAP)终止心外科术后心房扑动的临床疗效及影响因素。方法 单中心心脏外科术后5 d内发生心房扑动的患者298例,按治疗方案不同分为胺碘酮治疗(对照)组150例和TEAP治疗(观察)组148例,分析2组心房内径和手术相关指标差异,以及有效率、不良反应、术后6个月的复发率等差异。Logistic回归分析影响TEAP终止房扑疗效的因素。结果 2组心房内径及手术相关指标差异均无统计学意义。与对照组比较,观察组治疗有效率增加(47.3%vs. 83.8%,P<0.05),2组不良反应、住院期间病死率、术后6个月的复发率差异无统计学意义。较大的左房前后径(OR=1.156,95%CI:1.066~1.255)、连续刺激终止方式(OR=6.019,95%CI:1.911~18.953)是TEAP治疗房扑失败的独立危险因素。结论 TEAP终止心脏外科术后心房扑动疗效可靠,刺激方式建议采用递增刺激。

术中峡部传导间期百分比对典型心房扑动导管消融终点判定的有效性评估

目的通过术中测量三尖瓣-下腔静脉峡部(CTI)依赖心房扑动(房扑)消融前后峡部传导间期百分比,探讨峡部传导间期百分比在CTI线性阻滞消融终点评估的临床价值。方法本研究入组2021年2月至2023年2月诊断CTI依赖房扑并行射频消融治疗患者共37例(首都医科大学附属北京安贞医院35例,河北省儿童医院2例),术中均诱发CTI依赖房扑,并采用解剖消融方法沿三尖瓣环至下腔静脉行线性消融,术后经右心房激动标测验证CTI呈线性阻滞。分别统计入组患者心动过速周长(TCL)、冠状窦起搏下消融前局部传导间期(P-ABL1)、冠状窦起搏下消融后局部传导间期(P-ABL2),计算局部传导期间百分比(P-ABL2/TCL)。评估P-A BL 2/T C L对诊断C T I双向传导阻滞的价值,并通过消融后激动顺序验证其有效性。结果所有入组患者均采用解剖方法行射频消融,并行激动标测验证CT I呈线性阻滞。术中诱发TCL为(310.00±46.32)ms。术前测定P-ABL1为(92.16±27.65)ms,术后测量P-ABL2为(173.65±16.35)m s,两组数据差异有统计学意义(P<0.001)。术后P-A B L 2/T C L为(0.81±0.12)。P-A B L 2/T C L越接近1,评估C T I双向传导阻滞的特异性及有效性越高。结论采用术前局部传导间期可预估CTI阻滞终点,并结合术后P-ABL2/TCL的方法可提高CTI阻滞线完整性,减少反复消融,提高手术成功率。