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PP-287 ABLATION OF THE ATRIOVENTRICULAR NODE BY LEFT-SIDED APPROACH
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Poster Presentations / International Journal of Cardiology 163S1 (2013) S81–S211
hypertrophic cardiomyopathy (HCM), these are usually not outflow tract tachycardias. We present an IVT orginating from left aortic cusp in a patient with HCM. Case: A 39-year-old male patient with a diagnosis of hypertrophic cardiomyopathy presented with palpitation and dizziness. His history has been consistent with a diagnosis of HCM for five years. He had undergone electrophysiological study and had implanted ICD due to inducible VT one year ago. On physical examination, increased apical pulse was palpated and 1/6 pansystolic murmur was heard at mitral focus. ECG has showed unifocal VPC’s. VPCs were characterized by inferior axis and left bundle branch block pattern. Holter ECG demonstrated very frequent, unifocal VPCs including couplets and bigemines. Echocardiographic examination revealed asymmetric septal hypertrophy and diastolic interventricular septum thickness was measured as 20 millimeters. There was mild mitral valve regurgitation and mitral anterior movement. Left ventricular outflow tract gradient was 44 mmHg at rest and 66 mmHg with Valsalva maneuver. The patient was underwent to electrophysiology labarotory for VPC/VT ablation. ICD was interrogated and therapy zones were closed. VPCs were mapped. The earliest ventricular activity during VPC was detected in the left coronary cusp. Left coronary artery ostium was observed with coronary angiography. RF ablation (20 W; 60°C) was applied within the LCC. VPCs were disappeared immediately after RF. After RF ablation, the patient did not have any symptom and Holter ECG were normal 3 weeks later. Conclusion: IVTs can also be seen in patients with structural heart disease such as hypertrophic cardiomyopathy rarely. In these patients, RF ablation can be applied successfully.
Figure 1. (A) Before ablation ECG shows bigeminy ventricular premature beat orginating from right ventricular outflow tract. (B) After ablation ECG shows no VPC.
PP-286 THE HEART SYMBOL FORMED BY CATHETERS INSIDE THE HEART ¨ Uz, Z. Isılak, A. Tokatlı, F. Kılıcaslan, ¸ O. ¸ M. Yalcın. ¸ Department of Cardiology, GATA Haydarpasa Hospital, Istanbul, Turkey Introduction: In ancient times, it has been believed that the heart is the seat of the human soul. The heart symbol (♥) has been used as a symbol of romantic love for centuries. Although there is still controversy about what the symbol depicts, it is a worldwide symbol expressing love. Idiopathic ventricular tachycardia/premature beats (VPB) most oftenly originate from right ventricular outflow tract (RVOT). Radiofrequency catheter ablation is an effective treatment option for these patients. We present a patient who had RVOT VPB ablation. During the ablation procedure catheters inside the heart looked like the heart symbol. Case: A 30-year-old man was admitted to our hospital with palpitation. Physical examination was normal. ECG showed unifocal VPBs with inferior axis and left bundle branch block morphology. Transthoracic echocardiography findings were within normal limits and the EF was 68%. Exercise test was normal except for frequent VPBs. Routine biochemical tests and thyroid function tests were also normal. Despite beta-blocker and calcium channel blocker therapy, the patient’s symptoms did not improve. Holter ECG demonstrated very frequent, unifocal VPBs including couplets and bigeminy episodes. During electrophysiological study, a decapolar catheter was inserted into the coronary sinus (CS). It was advanced very deep in the CS until to the anterior cardiac vein. A quadripolar
catheter was inserted to His and then to right ventricle. Basal intracardiac measurements were within normal limits. Because we could not induce ventricular tachycardia, we decided to map and ablate VPBs. RVOT was mapped with an ablation catheter. The earliest ventricular activation was found in the septal RVOT region during VPBs. It was very difficult to advance the ablation catheter to septal region and several attempts were tried to reach to ablate VPBs successfully. At the site of successful ablation, we realized that fluoroscopy image of the catheters formed the heart symbol. Conclusion: RF ablation can be done safely and successfully in patients with RVOT VPBs. It is sometimes very challenging to reach appropriate ablation site. In our patient, it was interesting to see the heart symbol formed by catheters inside the heart.
Figure: Ventricular premature beat orginating from right ventricular outflow tract ablation and catheters showed heart symbol.
PP-287 ABLATION OF THE ATRIOVENTRICULAR NODE BY LEFT-SIDED APPROACH ¨ Uz, M. Yalcın. A. Tokatlı, F. Kılıcaslan, ¸ O. ¸ Department of Cardiology, GATA Haydarpasa Hospital, Istanbul, Turkey Introduction: Ablation of the atrioventricular (AV) node is reasonable for patients with atrial fibrillation (AF) who have rapid ventricular response despite optimal drug therapy. Catheter ablation of the AV node and permanent pacemaker implantation is an effective method for ventricular rate control in selected patients. Case: A-50-year old man was admitted to our hospital with palpitation, dizziness and dyspnea. His medical history was remarkable with coronary artery bypass greft surgery five years ago and VVI-R ICD implantation one year ago. During physical examination, inspiratory rales and S3 gallop were noted. His blood pressure was 90/50 mmHg and his pulse was 130/min. Several medications including, beta blockers, calcium channel blockers and digoxin were ineffective at rate control. ECG showed atrial fibrillation with a rapid ventricular rate of 130 beats per minute. Echocardiography revealed an ejection fraction of 30%, left ventricle (LV) dilatation, moderate mitral regurgitation and mild pulmonary hypertansion. He had inappropriate ICD shocks due to high ventricular rate during AF. During the last two months he had several hospital admission due to heart failure decompansation. Therefore, we decided to perform AV junction ablation and upgrade the VVI ICD to BiV ICD. The patient was taken to electrophysiology labaratory. Diagnostic catheter was advanced to the His bundle region. Ablation catheter was inserted to the AV node region. RF energy was applied with 30 W for 60 seconds. However, AV block could not be achieved despite several attempts. We decided to ablate AV junction from the LV. Ablation catheter was advanced to the LV by retrograde transaortic approach. The ablation catheter was positioned at septal region of the LV outflow tract where his bundle deflection was recorded. RF energy was applied to this region with 30 W for 60 seconds. During RF energy application permanent AV block was recorded. The patient was then transferred to coronary care unit
Poster Presentations / International Journal of Cardiology 163S1 (2013) S81–S211
where he had intravenous diuretic and levosimandan therapy. After he was stabilised clinically, we implanted a LV lead and upgraded ICD to BiV-ICD. Conclusion: AV junction ablation is usually performed from the right atrium. However, in some patients due to anatomical variations and morphological changes of the cardiac chambers, ablation of the AV node is not possible by right-sided approach. Ablation of the AV node from the LV outflow tract is feasible in these patients.
Figure: (A) AV block could not be achieved from right-sided approach. (B) Successful AV node ablation from left-sided approach.
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T-wave changes was 1 (50%) in normal preexcitation patients. These two groups, that are consistent with the results of earlier studies, wasn’t different (c2 = 2032, p = 0.57). Value that was considered as the degree of pre-excitation was related on AV node conduction. For this reason, the degree of pre-excitation seems like an individual value and does not seem to associated with the size of T wave change the after the ablation. Conclusion: In our study, size of T wave change (memory T) wasn’t related to the degree of pre-excitation. PP-289 SWALLOW INDUCED AV BLOCK AND SYNCOPE IN A PATIENT WITH ACHALASIA H.I˙ . Erdo˘gan, M. Karanfil, H. Gok. ¨ Department of Cardiology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey Achalasia is motor dysfunction of esophagus characterized by increased lower sphincter pressure and incomplete relaxation after swallow. Cardiovascular complications of achalasia are very rare. Swallow induced syncope occurs because of AV blocks and bradycardia associted with overstimulation of vagal stimuli. We discussed a patient with swallow induced syncope caused by atrioventricular (AV) block and bradycardia secondary to achalasia. The syncope disapperad after pneumatic dilatation therapy.
PP-288 DEGREE OF PRE-EXCITATION AND THE SIZE OF T WAVE CHANGE THE AFTER THE WPW (WOLFF–PARKINSON–WHITE) RF CATHETER ABLATION S. I˙ scen. ¸ Diyarbakır Military Hospital, Department of Cardiology, Turkey Introduction: Curative treatment of tachycardias due to accessory pathways, radiofrequency (RF) catheter ablation is safe and is known to reach 100% success rate. WPW (Wolff–Parkinson–White) after radiofrequency catheter ablation, ST and T changes that occur in the electrical repolarization disorders frequently encountered. Cardiac memory or surface ECG T-wave changes describe that T-wave can remember the chain of the previous miyocardial activation. Our work with the WPW (Wolff–Parkinson–White) was examined that relationship between T-wave changes after radiofrequency catheter ablation and the degree of pre-excitation. Method: In this study included 25 patients with WPW that between September 2011 and May 2012 was the successful radiofrequency catheter ablation. In 8 (32%) of the 25 patients was right posteroseptal (RPS), 3 (12%) patients was left posterolateral (LPL), 4 (16%) patients was left posteroseptal (LPS), 5 (20%) patients was left lateral (LL), and 5 (20%) patients was right Midseptal (RMS) localization. The working groups (5 groups, 25 patients) were identified due to accessory pathway. ECG recordings were obtained before and after 1 hour ablation. QRS width (referred to as the degree of preexistation) was calculated before ablation. More than 5 mm tapering and more than 3 mm flattening or negative on T wave was considered as the T wave changes (memory T) in ECG that was taken before and after 1 hour ablation. Results: Patients due to the width of the QRS (>100 ms, <100) were divided into two groups. Cross tables and chi-square test was used to show relationship between width of the QRS and number of T-wave changes. Number of T-wave changes patients were 18 (78.3%) in great preexcitation patients (>100 ms). Number of T-wave changes was 1 (50%) in normal preexcitation patients. There was no significant difference between the two groups (c2 = 2032, p = 0.57). Discussion: In our study, number of T-wave changes patients were 18 (78.3%) in great preexcitation patients (>100 ms). Number of
Figure 1. In the Thoracic Computed Tomography there was dilated esophagus. Figure 2. 24 hours of ambulatory ECG monitoring showing 2:1 and 3:1 AV blocks and pauses (longest one was 4.3 seconds).
A 47-year-old man had an eighteen-year history of dysphagia and odynophagia. The patient was diagnosed as achalasia and pneumotic dilatation was performed once and the patient is not taking medical treatment. The patient who had had three syncope attacks in the last month was investigated for syncope etiology in cardiology clinics. He was normotensive and had a normal cardiac examination. His resting electrocardiography (ECG) was normal. Transthoracic echocardiography was performed, there was not a significant wall motion disorder and valve dysfunction. In the Thoracic CT (computed tomography) there was dilated esophagus (Figure 1). 24 hours of ambulatory ECG monitoring was performed. At the time of breakfast and dinner it was seen that the patient was bradycardic; there was 2:1 and 3:1 AV blocks and pauses (longest one was 4.3 seconds) (Figure 2). At the same time with the pauses the patient was having dizziness. Pneumatic dilatation was performed again and nifedipine 60 mg/day and isosorbid dinitrate 40 mg/day as pharmacological treatment was given to the patient. The patient was complaining from mild dysphagia after the treatment but he did not have any syncope attacks again. 24 hours of ambulatory ECG monitoring was repeated. At the ECG holter there was bradycardia but no AV blocks were seen. PP-290 VENTRICULAR TACHYCARDIA SECONDARY TO INDAPAMIDE INDUCED HYPOKALEMIA H.I˙ . Erdo˘gan, M. Karanfil, H. Gok. ¨ Department of Cardiology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey Indapamide is a potent antihypertensive diuretic drug from sulphonamide group which can cause hypokalemia [1]. Even low dosages of indapamide can cause prolongation of qt, torsades de pointes, and ventricular tachycardia secondary to hypokalemia [2].
Poster Presentations / International Journal of Cardiology 163S1 (2013) S81–S211
hypertrophic cardiomyopathy (HCM), these are usually not outflow tract tachycardias. We present an IVT orginating from left aortic cusp in a patient with HCM. Case: A 39-year-old male patient with a diagnosis of hypertrophic cardiomyopathy presented with palpitation and dizziness. His history has been consistent with a diagnosis of HCM for five years. He had undergone electrophysiological study and had implanted ICD due to inducible VT one year ago. On physical examination, increased apical pulse was palpated and 1/6 pansystolic murmur was heard at mitral focus. ECG has showed unifocal VPC’s. VPCs were characterized by inferior axis and left bundle branch block pattern. Holter ECG demonstrated very frequent, unifocal VPCs including couplets and bigemines. Echocardiographic examination revealed asymmetric septal hypertrophy and diastolic interventricular septum thickness was measured as 20 millimeters. There was mild mitral valve regurgitation and mitral anterior movement. Left ventricular outflow tract gradient was 44 mmHg at rest and 66 mmHg with Valsalva maneuver. The patient was underwent to electrophysiology labarotory for VPC/VT ablation. ICD was interrogated and therapy zones were closed. VPCs were mapped. The earliest ventricular activity during VPC was detected in the left coronary cusp. Left coronary artery ostium was observed with coronary angiography. RF ablation (20 W; 60°C) was applied within the LCC. VPCs were disappeared immediately after RF. After RF ablation, the patient did not have any symptom and Holter ECG were normal 3 weeks later. Conclusion: IVTs can also be seen in patients with structural heart disease such as hypertrophic cardiomyopathy rarely. In these patients, RF ablation can be applied successfully.
Figure 1. (A) Before ablation ECG shows bigeminy ventricular premature beat orginating from right ventricular outflow tract. (B) After ablation ECG shows no VPC.
PP-286 THE HEART SYMBOL FORMED BY CATHETERS INSIDE THE HEART ¨ Uz, Z. Isılak, A. Tokatlı, F. Kılıcaslan, ¸ O. ¸ M. Yalcın. ¸ Department of Cardiology, GATA Haydarpasa Hospital, Istanbul, Turkey Introduction: In ancient times, it has been believed that the heart is the seat of the human soul. The heart symbol (♥) has been used as a symbol of romantic love for centuries. Although there is still controversy about what the symbol depicts, it is a worldwide symbol expressing love. Idiopathic ventricular tachycardia/premature beats (VPB) most oftenly originate from right ventricular outflow tract (RVOT). Radiofrequency catheter ablation is an effective treatment option for these patients. We present a patient who had RVOT VPB ablation. During the ablation procedure catheters inside the heart looked like the heart symbol. Case: A 30-year-old man was admitted to our hospital with palpitation. Physical examination was normal. ECG showed unifocal VPBs with inferior axis and left bundle branch block morphology. Transthoracic echocardiography findings were within normal limits and the EF was 68%. Exercise test was normal except for frequent VPBs. Routine biochemical tests and thyroid function tests were also normal. Despite beta-blocker and calcium channel blocker therapy, the patient’s symptoms did not improve. Holter ECG demonstrated very frequent, unifocal VPBs including couplets and bigeminy episodes. During electrophysiological study, a decapolar catheter was inserted into the coronary sinus (CS). It was advanced very deep in the CS until to the anterior cardiac vein. A quadripolar
catheter was inserted to His and then to right ventricle. Basal intracardiac measurements were within normal limits. Because we could not induce ventricular tachycardia, we decided to map and ablate VPBs. RVOT was mapped with an ablation catheter. The earliest ventricular activation was found in the septal RVOT region during VPBs. It was very difficult to advance the ablation catheter to septal region and several attempts were tried to reach to ablate VPBs successfully. At the site of successful ablation, we realized that fluoroscopy image of the catheters formed the heart symbol. Conclusion: RF ablation can be done safely and successfully in patients with RVOT VPBs. It is sometimes very challenging to reach appropriate ablation site. In our patient, it was interesting to see the heart symbol formed by catheters inside the heart.
Figure: Ventricular premature beat orginating from right ventricular outflow tract ablation and catheters showed heart symbol.
PP-287 ABLATION OF THE ATRIOVENTRICULAR NODE BY LEFT-SIDED APPROACH ¨ Uz, M. Yalcın. A. Tokatlı, F. Kılıcaslan, ¸ O. ¸ Department of Cardiology, GATA Haydarpasa Hospital, Istanbul, Turkey Introduction: Ablation of the atrioventricular (AV) node is reasonable for patients with atrial fibrillation (AF) who have rapid ventricular response despite optimal drug therapy. Catheter ablation of the AV node and permanent pacemaker implantation is an effective method for ventricular rate control in selected patients. Case: A-50-year old man was admitted to our hospital with palpitation, dizziness and dyspnea. His medical history was remarkable with coronary artery bypass greft surgery five years ago and VVI-R ICD implantation one year ago. During physical examination, inspiratory rales and S3 gallop were noted. His blood pressure was 90/50 mmHg and his pulse was 130/min. Several medications including, beta blockers, calcium channel blockers and digoxin were ineffective at rate control. ECG showed atrial fibrillation with a rapid ventricular rate of 130 beats per minute. Echocardiography revealed an ejection fraction of 30%, left ventricle (LV) dilatation, moderate mitral regurgitation and mild pulmonary hypertansion. He had inappropriate ICD shocks due to high ventricular rate during AF. During the last two months he had several hospital admission due to heart failure decompansation. Therefore, we decided to perform AV junction ablation and upgrade the VVI ICD to BiV ICD. The patient was taken to electrophysiology labaratory. Diagnostic catheter was advanced to the His bundle region. Ablation catheter was inserted to the AV node region. RF energy was applied with 30 W for 60 seconds. However, AV block could not be achieved despite several attempts. We decided to ablate AV junction from the LV. Ablation catheter was advanced to the LV by retrograde transaortic approach. The ablation catheter was positioned at septal region of the LV outflow tract where his bundle deflection was recorded. RF energy was applied to this region with 30 W for 60 seconds. During RF energy application permanent AV block was recorded. The patient was then transferred to coronary care unit
Poster Presentations / International Journal of Cardiology 163S1 (2013) S81–S211
where he had intravenous diuretic and levosimandan therapy. After he was stabilised clinically, we implanted a LV lead and upgraded ICD to BiV-ICD. Conclusion: AV junction ablation is usually performed from the right atrium. However, in some patients due to anatomical variations and morphological changes of the cardiac chambers, ablation of the AV node is not possible by right-sided approach. Ablation of the AV node from the LV outflow tract is feasible in these patients.
Figure: (A) AV block could not be achieved from right-sided approach. (B) Successful AV node ablation from left-sided approach.
S197
T-wave changes was 1 (50%) in normal preexcitation patients. These two groups, that are consistent with the results of earlier studies, wasn’t different (c2 = 2032, p = 0.57). Value that was considered as the degree of pre-excitation was related on AV node conduction. For this reason, the degree of pre-excitation seems like an individual value and does not seem to associated with the size of T wave change the after the ablation. Conclusion: In our study, size of T wave change (memory T) wasn’t related to the degree of pre-excitation. PP-289 SWALLOW INDUCED AV BLOCK AND SYNCOPE IN A PATIENT WITH ACHALASIA H.I˙ . Erdo˘gan, M. Karanfil, H. Gok. ¨ Department of Cardiology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey Achalasia is motor dysfunction of esophagus characterized by increased lower sphincter pressure and incomplete relaxation after swallow. Cardiovascular complications of achalasia are very rare. Swallow induced syncope occurs because of AV blocks and bradycardia associted with overstimulation of vagal stimuli. We discussed a patient with swallow induced syncope caused by atrioventricular (AV) block and bradycardia secondary to achalasia. The syncope disapperad after pneumatic dilatation therapy.
PP-288 DEGREE OF PRE-EXCITATION AND THE SIZE OF T WAVE CHANGE THE AFTER THE WPW (WOLFF–PARKINSON–WHITE) RF CATHETER ABLATION S. I˙ scen. ¸ Diyarbakır Military Hospital, Department of Cardiology, Turkey Introduction: Curative treatment of tachycardias due to accessory pathways, radiofrequency (RF) catheter ablation is safe and is known to reach 100% success rate. WPW (Wolff–Parkinson–White) after radiofrequency catheter ablation, ST and T changes that occur in the electrical repolarization disorders frequently encountered. Cardiac memory or surface ECG T-wave changes describe that T-wave can remember the chain of the previous miyocardial activation. Our work with the WPW (Wolff–Parkinson–White) was examined that relationship between T-wave changes after radiofrequency catheter ablation and the degree of pre-excitation. Method: In this study included 25 patients with WPW that between September 2011 and May 2012 was the successful radiofrequency catheter ablation. In 8 (32%) of the 25 patients was right posteroseptal (RPS), 3 (12%) patients was left posterolateral (LPL), 4 (16%) patients was left posteroseptal (LPS), 5 (20%) patients was left lateral (LL), and 5 (20%) patients was right Midseptal (RMS) localization. The working groups (5 groups, 25 patients) were identified due to accessory pathway. ECG recordings were obtained before and after 1 hour ablation. QRS width (referred to as the degree of preexistation) was calculated before ablation. More than 5 mm tapering and more than 3 mm flattening or negative on T wave was considered as the T wave changes (memory T) in ECG that was taken before and after 1 hour ablation. Results: Patients due to the width of the QRS (>100 ms, <100) were divided into two groups. Cross tables and chi-square test was used to show relationship between width of the QRS and number of T-wave changes. Number of T-wave changes patients were 18 (78.3%) in great preexcitation patients (>100 ms). Number of T-wave changes was 1 (50%) in normal preexcitation patients. There was no significant difference between the two groups (c2 = 2032, p = 0.57). Discussion: In our study, number of T-wave changes patients were 18 (78.3%) in great preexcitation patients (>100 ms). Number of
Figure 1. In the Thoracic Computed Tomography there was dilated esophagus. Figure 2. 24 hours of ambulatory ECG monitoring showing 2:1 and 3:1 AV blocks and pauses (longest one was 4.3 seconds).
A 47-year-old man had an eighteen-year history of dysphagia and odynophagia. The patient was diagnosed as achalasia and pneumotic dilatation was performed once and the patient is not taking medical treatment. The patient who had had three syncope attacks in the last month was investigated for syncope etiology in cardiology clinics. He was normotensive and had a normal cardiac examination. His resting electrocardiography (ECG) was normal. Transthoracic echocardiography was performed, there was not a significant wall motion disorder and valve dysfunction. In the Thoracic CT (computed tomography) there was dilated esophagus (Figure 1). 24 hours of ambulatory ECG monitoring was performed. At the time of breakfast and dinner it was seen that the patient was bradycardic; there was 2:1 and 3:1 AV blocks and pauses (longest one was 4.3 seconds) (Figure 2). At the same time with the pauses the patient was having dizziness. Pneumatic dilatation was performed again and nifedipine 60 mg/day and isosorbid dinitrate 40 mg/day as pharmacological treatment was given to the patient. The patient was complaining from mild dysphagia after the treatment but he did not have any syncope attacks again. 24 hours of ambulatory ECG monitoring was repeated. At the ECG holter there was bradycardia but no AV blocks were seen. PP-290 VENTRICULAR TACHYCARDIA SECONDARY TO INDAPAMIDE INDUCED HYPOKALEMIA H.I˙ . Erdo˘gan, M. Karanfil, H. Gok. ¨ Department of Cardiology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey Indapamide is a potent antihypertensive diuretic drug from sulphonamide group which can cause hypokalemia [1]. Even low dosages of indapamide can cause prolongation of qt, torsades de pointes, and ventricular tachycardia secondary to hypokalemia [2].