- Email: [email protected]
Catheter Ablation of Focal Atrial Tachycardia From the Non-Coronary Aortic Sinus
Letters to the Editor
Figure 2. After aspiration of the thrombus, the transverse slice (to the left), performed in the same point as in the previous study, shows a reduction in the load of plaque with an increase in luminal area. Likewise, in the longitudinal slice we can see a reduction in the green-coloured area.
By analysing the volumetric figures for the segment and the images of the longitudinal slice, as well as the transversal slice at the most obstructed point of the lumen using conventional IVUS and VH-IVUS, we conclude that the thrombotic material extracted from the patient’s DA was for the most part coded wrong by the ultrasound and coloured green, as if it were fibrous tissue. However, it is possible to deduce the approximate volume of the extracted thrombus by subtracting both total volumes, which gives us 4.7 µL. As a result, we find that VH-IVUS is a useful tool for studying the composition of coronary plaque,3 but it should be perfected technically for use in further studies that may help us to predict the plaque’s instability, vulnerability,4 and complications. José D. Cascón-Pérez, Luciano Consuegra, and Francisco Picó-Aracil
Unidad de Hemodinámica, Hospital Universitario Santa María del Rosell, Cartagena, Murcia, Spain
REFERENCES
1. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons from sudden coronary death. A comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol. 2000;20:1262-75. 2. Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF, et al. Accuracy of in vivo coronary plaque morphology assessment. A validation study of in vivo virtual histology compared with in vitro histopathology. J Am Coll Cardiol. 2006;47:2405-12. 3. Surmely JF, Nasu K, Fujita H, Terashima M, Matsubara T. Coronary plaque composition of culprit/target lesions according
706 Rev Esp Cardiol. 2009;62(6):704-12
to the clinical presentation: a virtual histology intravascular ultrasound analysis. Eur Heart J. 2006;27:2939-44. 4. Kari I. Saunamaki. Virtual histology and the hunt for the vulnerable plaque. Eur Heart J. 2006;27:2914-29.
Catheter Ablation of Focal Atrial Tachycardia From the Non-Coronary Aortic Sinus To the Editor: We present the case of a 78-year-old woman with a history of allergy to acetylsalicylic acid, type-2 diabetes mellitus, and dyslipidaemia. In January 2008, she experienced dyspnoea and palpitations with no chest pain; she was seen to have incessant atrial tachycardia (AT) and severe left ventricular dysfunction (LVEF, 25%), which was presumed to be secondary. An electrophysiological study was carried out in February 2008 in which an AT with 2 different P-wave morphologies and a cycle length of 460 ms (Figure 1) was induced in a spontaneous, repeatable way using steady atrial stimulation. An activation map was made of the left atrium using the CARTO® navigation system and a 4 mm Navistar® F-Type catheter, which showed a focal
Letters to the Editor
Figure 1. Left: record of the atrial tachycardia in a 12-lead ECG, where we can see the P-wave morphology. The first and third arrows show a different morphology from that shown by the central arrow, with no change in the length of the tachycardia cycle (490 ms). Right: intracavity record of electrograms at the level of the coronary sinus, the bundle of His and the distal ablation catheter (Abl d). Observe how the local activation registered in the ablation catheter, located in the non-coronary aortic sinus, occurs before the one registered in the bundle of His; this finding is characteristic of this type of tachycardia.
AT with an earlier response in the anteroseptal region. Several applications were made in the zone with the earliest response compared with the surface ECG (0 ms), but they were not effective. A left atrial activation map was made via the transseptal approach; earliest endocardial activation corresponded to the interatrial septum area, with later electrograms than in the right atrium. By the retrograde aortic approach, we registered atrial activation electrograms from the non-coronary sinus of Valsalva, which registered early activation of – 12 ms. We performed an aortography to verify the catheter’s position in the non-coronary sinus of Valsalva and a single radiofrequency application (90 s; 20-30 W/55º) which was effective and ended the tachycardia when the application began, without it being induced again. In a revision in June 2008, the LVEF was 65% and the 24 h Holter monitor did not register tachyarrhythmia; the patient noted a subjective improvement. AT originate principally in certain anatomic regions of the atria,1,2 and ablation procedures have a high rate of success and minimal risks.1,3 However, ablation of ATs located in the anteroseptal region of the atrium has a higher risk level due to their proximity to the conduction system. The interatrial septum anatomy is complex, which makes it difficult to identify the origin of the tachycardia. In a normal heart, the aortic root is located close to the atrial epicardium, between the mitral valves and the tricuspid (Figure 2). The non-coronary sinus of Valsalva makes up the upper edge of the interatrial septum and is bound to the central fibrous body where the bundle of His penetrates. Few studies, containing low patient numbers, describe AT located in the non-coronary sinus of Valsalva. The condition
NCS
LA
RA CS
Figure 2. In the upper part of the image, activation map of the 2 atria and the non-coronary sinus during tachycardia, taken with the CARTO® navigation system in a left anterior oblique projection. The earliest zones (in red) correspond with the parts of the left and right atria proximal to the septum and the non-coronary aortic sinus. In the lower part of the image, the schema shows the anatomical relationship of both atria with the aortic root. CS indicates coronary sinus; LA, left atrium; NCS, non-coronary sinus; RA, right atrium.
makes up about 4% of focal ATs at specialised centres. Clinically, its behaviour is no different from that of other supraventricular tachycardias, and in the electrocardiograph, the P-wave morphology, which shares common characteristics with focal tachycardias originating in the para-Hisian area and the interatrial septum, seems to vary from study to study, which reflects the high level of anatomical and conduction heterogeneity in that zone. As in our case, the presence of different P-wave morphologies Rev Esp Cardiol. 2009;62(6):704-12 707
Letters to the Editor
in the surface ECG without major changes to the tachycardia cycle length has been described, which indicates different preferential conduction channels for the transmission of impulses from the ectopic focus (Figure 2).4 The activation map during tachycardia reflects an early atrial electrogram in the non-coronary sinus of Valsalva, which precedes the activation of the right atrium in the bundle of His. The earliest activation in the right atrium is several milliseconds earlier than the earliest activity in the left atrium, due to the fact that the non-coronary sinus of Valsalva is closer to the bundle of His than to the left atrial anteroseptal region. As a result, before performing ablation from the aortic root, it is necessary to demonstrate that the local activation in the non-coronary sinus of Valsalva precedes that registered in the Hisian region3,4 (Figure 1). This case makes it clear that for some ATs that appear to originate in the para-Hisian zone and which would be impossible to ablate from the atrial endocardium, mapping the non-coronary sinus of Valsalva and applying radiofrequency to it can effectively eliminate the tachycardia. Ignacio Gil-Ortega, Arcadio García-Alberola, Juan Martínez-Sánchez, and Mariano Valdés-Chávarri
Unidad de Arritmias, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
REFERENCES
1. Ouyang F, Ma J, Ho SY, Bänsch D, Schmidt B, Ernst S, et al. Focal atrial tachycardia originating from the non-coronary aortic sinus: electrophysiological characteristics and catheter ablation. J Am Coll Cardiol. 2006;48:122-31. 2. Raatikainen MJ, Huikuri HV. Successful catheter ablation of focal atrial tachycardia from the non-coronary aortic cusp. Europace. 2007;9:216-9. 3. Das S, Neuzil P, Albert CM, d’Avila A, Mansour M, Mela T, et al. Catheter ablation of peri-AV nodal atrial tachycardia from the noncoronary cusp of the aortic valve. J Cardiovasc Electrophysiol. 2008;19:231-7. 4. Yamada T, Huizar JF, McElderry HT, Kay GN. Atrial tachycardia originating from the noncoronary aortic cusp and musculature connection with the atria: relevance for catheter ablation. Heart Rhythm. 2006;3:1494-6.
Early Complete Regression of Multiple Cardiac Tumors Suggestive of Cardiac Rhabdomyomas To the Editor: Primary cardiac tumours are infrequently seen in paediatrics, with an established prevalence between 0.0017% and 0.28% in post-mortem studies. During 708 Rev Esp Cardiol. 2009;62(6):704-12
the development of the foetus, a prevalence of 0.14%1 has been described. Rhabdomyoma is the most frequent cardiac tumour in infants and children, comprising more than 60% of all cases.2 It generally presents as small multiple tumours that are usually located in the ventricular myocardium, although cases affecting the atrium have also been described. It is intimately associated with tuberous sclerosis, with percentages that vary between 60% and 80% according to published studies.3,4 In a parallel way, presence of cardiac rhabdomyomas has been described in between 43% and 72% of all patients with a confirmed diagnosis of tuberous sclerosis. Physical examination of the patient can reveal a heart murmur, a reduction in peripheral pulse or cyanosis. The appearance of cardiac arrhythmias is not infrequent, and has been described with a higher incidence of Wolf-Parkinson-White syndrome. In more than half of the cases, it spontaneously remits after weaning.5 We present the case of a patient with an echocardiographic diagnosis of suspected multiple rhabdomyomas with spontaneous, complete early remission. A 1-day-old newborn was referred to a paediatric cardiology consultation due to a heart murmur. Gestational development had been uneventful. The patient was asymptomatic from a cardiovascular point of view. Cardiac auscultation detected a systolic heart murmur in the LSE retaining a second tone. The rest of the physical examination was not significant. ECG was in sinus rhythm with no significant findings. The echocardiography revealed multiple cardiac tumours located in the apex of the right ventricle, the interventricular septum and the left ventricular outflow tract (Figure 1A) where the largest tumour (9×8 mm, Figure 1B) was located, producing a slight obstruction (maximum estimated systolic pressure gradient at 23 mm Hg). The systolic function of the left ventricle was conserved. The diagnosis of suspected multiple cardiac rhabdomyomas was given, and a conservative course of action with clinical follow-up was determined for the patient. Tuberous sclerosis screening was completed and the criteria for its diagnosis were met. Six weeks later, the echocardiographic study was repeated, and it showed the disappearance of all of the cardiac tumours described above (Figure 2A), including the largest one, which had been located in the left ventricular outflow tract (Figure 2B). The patient remained asymptomatic. Miguel A. Ramírez-Marrero,a Victorio Cuenca-Peiró,b Juan I. Zabala-Argüelles,b and Lourdes Conejo-Muñozb
Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain Sección de Cardiología Pediátrica, Hospital Regional Carlos Haya, Málaga, Spain
a
b
Figure 2. After aspiration of the thrombus, the transverse slice (to the left), performed in the same point as in the previous study, shows a reduction in the load of plaque with an increase in luminal area. Likewise, in the longitudinal slice we can see a reduction in the green-coloured area.
By analysing the volumetric figures for the segment and the images of the longitudinal slice, as well as the transversal slice at the most obstructed point of the lumen using conventional IVUS and VH-IVUS, we conclude that the thrombotic material extracted from the patient’s DA was for the most part coded wrong by the ultrasound and coloured green, as if it were fibrous tissue. However, it is possible to deduce the approximate volume of the extracted thrombus by subtracting both total volumes, which gives us 4.7 µL. As a result, we find that VH-IVUS is a useful tool for studying the composition of coronary plaque,3 but it should be perfected technically for use in further studies that may help us to predict the plaque’s instability, vulnerability,4 and complications. José D. Cascón-Pérez, Luciano Consuegra, and Francisco Picó-Aracil
Unidad de Hemodinámica, Hospital Universitario Santa María del Rosell, Cartagena, Murcia, Spain
REFERENCES
1. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons from sudden coronary death. A comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol. 2000;20:1262-75. 2. Nasu K, Tsuchikane E, Katoh O, Vince DG, Virmani R, Surmely JF, et al. Accuracy of in vivo coronary plaque morphology assessment. A validation study of in vivo virtual histology compared with in vitro histopathology. J Am Coll Cardiol. 2006;47:2405-12. 3. Surmely JF, Nasu K, Fujita H, Terashima M, Matsubara T. Coronary plaque composition of culprit/target lesions according
706 Rev Esp Cardiol. 2009;62(6):704-12
to the clinical presentation: a virtual histology intravascular ultrasound analysis. Eur Heart J. 2006;27:2939-44. 4. Kari I. Saunamaki. Virtual histology and the hunt for the vulnerable plaque. Eur Heart J. 2006;27:2914-29.
Catheter Ablation of Focal Atrial Tachycardia From the Non-Coronary Aortic Sinus To the Editor: We present the case of a 78-year-old woman with a history of allergy to acetylsalicylic acid, type-2 diabetes mellitus, and dyslipidaemia. In January 2008, she experienced dyspnoea and palpitations with no chest pain; she was seen to have incessant atrial tachycardia (AT) and severe left ventricular dysfunction (LVEF, 25%), which was presumed to be secondary. An electrophysiological study was carried out in February 2008 in which an AT with 2 different P-wave morphologies and a cycle length of 460 ms (Figure 1) was induced in a spontaneous, repeatable way using steady atrial stimulation. An activation map was made of the left atrium using the CARTO® navigation system and a 4 mm Navistar® F-Type catheter, which showed a focal
Letters to the Editor
Figure 1. Left: record of the atrial tachycardia in a 12-lead ECG, where we can see the P-wave morphology. The first and third arrows show a different morphology from that shown by the central arrow, with no change in the length of the tachycardia cycle (490 ms). Right: intracavity record of electrograms at the level of the coronary sinus, the bundle of His and the distal ablation catheter (Abl d). Observe how the local activation registered in the ablation catheter, located in the non-coronary aortic sinus, occurs before the one registered in the bundle of His; this finding is characteristic of this type of tachycardia.
AT with an earlier response in the anteroseptal region. Several applications were made in the zone with the earliest response compared with the surface ECG (0 ms), but they were not effective. A left atrial activation map was made via the transseptal approach; earliest endocardial activation corresponded to the interatrial septum area, with later electrograms than in the right atrium. By the retrograde aortic approach, we registered atrial activation electrograms from the non-coronary sinus of Valsalva, which registered early activation of – 12 ms. We performed an aortography to verify the catheter’s position in the non-coronary sinus of Valsalva and a single radiofrequency application (90 s; 20-30 W/55º) which was effective and ended the tachycardia when the application began, without it being induced again. In a revision in June 2008, the LVEF was 65% and the 24 h Holter monitor did not register tachyarrhythmia; the patient noted a subjective improvement. AT originate principally in certain anatomic regions of the atria,1,2 and ablation procedures have a high rate of success and minimal risks.1,3 However, ablation of ATs located in the anteroseptal region of the atrium has a higher risk level due to their proximity to the conduction system. The interatrial septum anatomy is complex, which makes it difficult to identify the origin of the tachycardia. In a normal heart, the aortic root is located close to the atrial epicardium, between the mitral valves and the tricuspid (Figure 2). The non-coronary sinus of Valsalva makes up the upper edge of the interatrial septum and is bound to the central fibrous body where the bundle of His penetrates. Few studies, containing low patient numbers, describe AT located in the non-coronary sinus of Valsalva. The condition
NCS
LA
RA CS
Figure 2. In the upper part of the image, activation map of the 2 atria and the non-coronary sinus during tachycardia, taken with the CARTO® navigation system in a left anterior oblique projection. The earliest zones (in red) correspond with the parts of the left and right atria proximal to the septum and the non-coronary aortic sinus. In the lower part of the image, the schema shows the anatomical relationship of both atria with the aortic root. CS indicates coronary sinus; LA, left atrium; NCS, non-coronary sinus; RA, right atrium.
makes up about 4% of focal ATs at specialised centres. Clinically, its behaviour is no different from that of other supraventricular tachycardias, and in the electrocardiograph, the P-wave morphology, which shares common characteristics with focal tachycardias originating in the para-Hisian area and the interatrial septum, seems to vary from study to study, which reflects the high level of anatomical and conduction heterogeneity in that zone. As in our case, the presence of different P-wave morphologies Rev Esp Cardiol. 2009;62(6):704-12 707
Letters to the Editor
in the surface ECG without major changes to the tachycardia cycle length has been described, which indicates different preferential conduction channels for the transmission of impulses from the ectopic focus (Figure 2).4 The activation map during tachycardia reflects an early atrial electrogram in the non-coronary sinus of Valsalva, which precedes the activation of the right atrium in the bundle of His. The earliest activation in the right atrium is several milliseconds earlier than the earliest activity in the left atrium, due to the fact that the non-coronary sinus of Valsalva is closer to the bundle of His than to the left atrial anteroseptal region. As a result, before performing ablation from the aortic root, it is necessary to demonstrate that the local activation in the non-coronary sinus of Valsalva precedes that registered in the Hisian region3,4 (Figure 1). This case makes it clear that for some ATs that appear to originate in the para-Hisian zone and which would be impossible to ablate from the atrial endocardium, mapping the non-coronary sinus of Valsalva and applying radiofrequency to it can effectively eliminate the tachycardia. Ignacio Gil-Ortega, Arcadio García-Alberola, Juan Martínez-Sánchez, and Mariano Valdés-Chávarri
Unidad de Arritmias, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
REFERENCES
1. Ouyang F, Ma J, Ho SY, Bänsch D, Schmidt B, Ernst S, et al. Focal atrial tachycardia originating from the non-coronary aortic sinus: electrophysiological characteristics and catheter ablation. J Am Coll Cardiol. 2006;48:122-31. 2. Raatikainen MJ, Huikuri HV. Successful catheter ablation of focal atrial tachycardia from the non-coronary aortic cusp. Europace. 2007;9:216-9. 3. Das S, Neuzil P, Albert CM, d’Avila A, Mansour M, Mela T, et al. Catheter ablation of peri-AV nodal atrial tachycardia from the noncoronary cusp of the aortic valve. J Cardiovasc Electrophysiol. 2008;19:231-7. 4. Yamada T, Huizar JF, McElderry HT, Kay GN. Atrial tachycardia originating from the noncoronary aortic cusp and musculature connection with the atria: relevance for catheter ablation. Heart Rhythm. 2006;3:1494-6.
Early Complete Regression of Multiple Cardiac Tumors Suggestive of Cardiac Rhabdomyomas To the Editor: Primary cardiac tumours are infrequently seen in paediatrics, with an established prevalence between 0.0017% and 0.28% in post-mortem studies. During 708 Rev Esp Cardiol. 2009;62(6):704-12
the development of the foetus, a prevalence of 0.14%1 has been described. Rhabdomyoma is the most frequent cardiac tumour in infants and children, comprising more than 60% of all cases.2 It generally presents as small multiple tumours that are usually located in the ventricular myocardium, although cases affecting the atrium have also been described. It is intimately associated with tuberous sclerosis, with percentages that vary between 60% and 80% according to published studies.3,4 In a parallel way, presence of cardiac rhabdomyomas has been described in between 43% and 72% of all patients with a confirmed diagnosis of tuberous sclerosis. Physical examination of the patient can reveal a heart murmur, a reduction in peripheral pulse or cyanosis. The appearance of cardiac arrhythmias is not infrequent, and has been described with a higher incidence of Wolf-Parkinson-White syndrome. In more than half of the cases, it spontaneously remits after weaning.5 We present the case of a patient with an echocardiographic diagnosis of suspected multiple rhabdomyomas with spontaneous, complete early remission. A 1-day-old newborn was referred to a paediatric cardiology consultation due to a heart murmur. Gestational development had been uneventful. The patient was asymptomatic from a cardiovascular point of view. Cardiac auscultation detected a systolic heart murmur in the LSE retaining a second tone. The rest of the physical examination was not significant. ECG was in sinus rhythm with no significant findings. The echocardiography revealed multiple cardiac tumours located in the apex of the right ventricle, the interventricular septum and the left ventricular outflow tract (Figure 1A) where the largest tumour (9×8 mm, Figure 1B) was located, producing a slight obstruction (maximum estimated systolic pressure gradient at 23 mm Hg). The systolic function of the left ventricle was conserved. The diagnosis of suspected multiple cardiac rhabdomyomas was given, and a conservative course of action with clinical follow-up was determined for the patient. Tuberous sclerosis screening was completed and the criteria for its diagnosis were met. Six weeks later, the echocardiographic study was repeated, and it showed the disappearance of all of the cardiac tumours described above (Figure 2A), including the largest one, which had been located in the left ventricular outflow tract (Figure 2B). The patient remained asymptomatic. Miguel A. Ramírez-Marrero,a Victorio Cuenca-Peiró,b Juan I. Zabala-Argüelles,b and Lourdes Conejo-Muñozb
Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain Sección de Cardiología Pediátrica, Hospital Regional Carlos Haya, Málaga, Spain
a
b