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P6-110
S338 P6-110 CORONARY VENOUS ABLATION OF EPICARDIAL VENTRICULAR PREMATURE CONTRACTIONS WITH DISTINCTIVE QRS MORPHOLOGY Hitoshi Hachiya, MD, Kenzo Hirao, MD, Mihoko Kawabata, MD, PhD, Takeshi Sasaki, MD, Tetsuya Katsuno, MD, Toshiyuki Furukawa, MD, Hiroyuki Okada, MD, Tomoe Horikawa, MD and Mitsuaki Isobe, MD, PhD. Tokyo Medical and Dental University, Tokyo, Japan. The patient was a 50-year-old man with a history of palpitations caused by ventricular premature contractions (VPCs). The number of VPCs was 38464/ day. Twelve-lead ECG during VPCs showed rS in I and aVL, RS in V5 and V6, notched wide R wave in II, III, aVF, and wide R wave in V1-4. QRS duration was 192 ms, and peak deflection index (PDI), which was determined as the time from QRS onset to earliest peak deflection in any precordial lead divided by the total QRS duration, was 0.54. Pace mapping at an endocardial site close to the origin showed QRS duration of 170 ms to be shorter and PDI of 0.5 to be lower than those of the clinical VPCs. Electrophysiological Study and Ablation: Detailed endocardial activation mapping did not show an earlier ventricular site than that in the electrogram recorded from the coronary vein (CV). Coronary angiography showed a relatively large CV; therefore, we mapped in CV. The successful ablation site preceded QRS onset by 30 ms, and identical pace mapping was obtained at this site in CV. Radiofrequency energy (RF) was delivered using a 4-mm tip catheter to this site (max. temperature: 50°C, max. duration: 60 sec, max.
Heart Rhythm, Vol 3, No 5, May Supplement 2006 power: 25 Watts). No VPCs emerged after ablation, and repeat coronary angiography showed no coronary stenosis due to ablation. Conclusions: We experienced successful coronary venous ablation of epicardial VPCs having a distinctive QRS morphology. When VPCs with the distinctive QRS morphology are seen and detailed endocardial mapping has not shown an earlier ventricular site than that of CV electrogram, RF applications in CV should be considered. P6-111 INAPPROPRIATE PULMONARY VEIN ISOLATION: MISDIAGNOSIS SECONDARY TO COMPLEX AV CONDUCTION Robert M. Lobel, MD, Peter Spector, MD, James Calame, RN and Daniel Lustgarten, MD, PhD. University of Vermont College of Medicine, Burlington, VT. A 53 year old woman presented with intermittent palpitations. Echocardiogram and stress test were normal. An event monitor revealed a narrow complex, irregular rhythm with intermittent aberrantly conducted complexes, interpreted as atrial fibrillation (AF) (Figure 1). Figure 1. Event recorder The patient did not tolerate diltiazem or metoprolol and flecainide failed to suppress the rhythm. The patient was referred for AF ablation. Pulmonary vein isolation and right atrial isthmus ablation were performed without comprehensive EPS. Her symptoms recurred and another procedure was attempted. During the procedure the patient developed a tachycardia similar to that noted on the event recorder. Intracardiac electrograms revealed sinus rhythm with variable AV conduction and intermittent 2 for 1 ventricular response (Figure 2). Figure 2. (RA⫽Atrial Appendage, HB D⫽His catheter at Tricuspid annulus, CS⫽Coronary sinus, RV⫽Right Ventricle. Scale in ms) The tachycardia was eliminated with ablation of the slow AV nodal pathway. The patient has been symptom free for 6 months. Empiric ablation for “PAF” without careful analysis of the clinical arrhythmia may lead to inappropriate therapy.
P6-112 SEIZURE-SPECIFIC MYOPOTENTIALS DETECTED BY REVEAL DEVICES- DIAGNOSING MORE THAN CARDIAC ARRHYTHMIAS Reginald T. Ho, MD, Tammi Wicks, RN, BSN, Dale Wyeth, BA and Maromi Nei, MD. Thomas Jefferson University Hospital, Philadelphia, PA. Background: The implantable loop recorder (ILR) has become an important diagnostic tool for the evaluation of recurrent, unexplained episodes of loss of consciousness. It has identified serious arrhythmias in patients previously thought to have seizures. The converse might also be trueidentifying seizures in patients thought to have syncope. Case Report: We present 3 patients with refractory, video EEG-documented seizures who underwent ILR implantation as part of a study protocol evaluating rhythm abnormalities in such patients and whose device detected mul-
Heart Rhythm, Vol 3, No 5, May Supplement 2006 power: 25 Watts). No VPCs emerged after ablation, and repeat coronary angiography showed no coronary stenosis due to ablation. Conclusions: We experienced successful coronary venous ablation of epicardial VPCs having a distinctive QRS morphology. When VPCs with the distinctive QRS morphology are seen and detailed endocardial mapping has not shown an earlier ventricular site than that of CV electrogram, RF applications in CV should be considered. P6-111 INAPPROPRIATE PULMONARY VEIN ISOLATION: MISDIAGNOSIS SECONDARY TO COMPLEX AV CONDUCTION Robert M. Lobel, MD, Peter Spector, MD, James Calame, RN and Daniel Lustgarten, MD, PhD. University of Vermont College of Medicine, Burlington, VT. A 53 year old woman presented with intermittent palpitations. Echocardiogram and stress test were normal. An event monitor revealed a narrow complex, irregular rhythm with intermittent aberrantly conducted complexes, interpreted as atrial fibrillation (AF) (Figure 1). Figure 1. Event recorder The patient did not tolerate diltiazem or metoprolol and flecainide failed to suppress the rhythm. The patient was referred for AF ablation. Pulmonary vein isolation and right atrial isthmus ablation were performed without comprehensive EPS. Her symptoms recurred and another procedure was attempted. During the procedure the patient developed a tachycardia similar to that noted on the event recorder. Intracardiac electrograms revealed sinus rhythm with variable AV conduction and intermittent 2 for 1 ventricular response (Figure 2). Figure 2. (RA⫽Atrial Appendage, HB D⫽His catheter at Tricuspid annulus, CS⫽Coronary sinus, RV⫽Right Ventricle. Scale in ms) The tachycardia was eliminated with ablation of the slow AV nodal pathway. The patient has been symptom free for 6 months. Empiric ablation for “PAF” without careful analysis of the clinical arrhythmia may lead to inappropriate therapy.
P6-112 SEIZURE-SPECIFIC MYOPOTENTIALS DETECTED BY REVEAL DEVICES- DIAGNOSING MORE THAN CARDIAC ARRHYTHMIAS Reginald T. Ho, MD, Tammi Wicks, RN, BSN, Dale Wyeth, BA and Maromi Nei, MD. Thomas Jefferson University Hospital, Philadelphia, PA. Background: The implantable loop recorder (ILR) has become an important diagnostic tool for the evaluation of recurrent, unexplained episodes of loss of consciousness. It has identified serious arrhythmias in patients previously thought to have seizures. The converse might also be trueidentifying seizures in patients thought to have syncope. Case Report: We present 3 patients with refractory, video EEG-documented seizures who underwent ILR implantation as part of a study protocol evaluating rhythm abnormalities in such patients and whose device detected mul-