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The Left Atrial Roof - A Rare Cause of Incessant Focal Atrial Tachycardia
Abstracts
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Results: CT revealed that of leads placed in RVS position, 7 were on the anterior RV wall, 2 were at the anteroseptal junction, and 1 at the lower septum. The ECG demonstrated a QRS axis of −90◦ , absent R wave in V1 and a positive R wave in V6 in all cases. For the 8 RVA leads, 4 were anterior, 2 septal and 2 anteroseptal. The ECG axis varied between −90 and +110◦ , with an absent R wave in V1 in all cases but a positive R wave in V6 in 4. Conclusion: Although the surface ECG differentiates leads at either the apex or septum it does not provide consistent accuracy compared to CT imaging. http://dx.doi.org/10.1016/j.hlc.2016.06.368 368 Takotsubo Cardiomyopathy (TCM) Following Pacemaker Insertion in an Elderly Man H. Herbison ∗ , P. Venkataraman, V. Cheng, A. Koshy, R. Low Eastern Health, Box Hill, Australia Takotsubo cardiomyopathy (TCM) describes transient regional LV systolic dysfunction without obstructive coronary artery disease and can mimic acute coronary syndrome (ACS). It may result from a catecholaminergic surge secondary to a physical or emotional stressor. We describe an 86 year old man who presented with symptomatic complete heart block without ischaemic changes on a background of chronic kidney injury. He denied chest pain and serial HsTropT were 70. An isoprenaline infusion was continued until pacemaker insertion. He developed acute pulmonary oedema 8 hours post-procedure, increase in HsTropT to 600 and a transthoracic echocardiogram (TTE) showed apical ballooning and distal lateral wall hypokinesis (Figure 1). A stress thallium showed only a small area of reversible ischaemia in the distal anterior wall with no evidence of myocardial infarction (Figure 2). TCM was diagnosed on the clinical, TTE and stress thallium results. Repeat TTE 1 month later showed complete resolution of the apical akinesis and lateral wall hypokinesis. This is a rare case of a pacemaker implant causing TCM in a male patient with the prior use of isoprenaline a likely contributing factor. TCM should be a differential in patients who present with apparent ACS following pacemaker insertion.
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http://dx.doi.org/10.1016/j.hlc.2016.06.369 369 The Left Atrial Roof - A Rare Cause of Incessant Focal Atrial Tachycardia A. Lee 1,2,∗ , J. Betts 1 , R. Gluer 1,2 , H. Haqqani 1,2 1 The Prince Charles Hospital, Brisbane, Australia 2 The University of Queensland, Brisbane, Australia
Introduction: Incessant atrial tachycardia (AT) most commonly arise from the pulmonary veins or atrial appendages. We describe a case of incessant focal (AT) arising from the left atrial roof. Case Report: A 56 year old male presented with dypsnoea and dizziness over the prior week. Electrocardiograms (ECGs) revealed paroxysms of atrial tachycardia with a Pwave vector (positive in V1 and inferior leads, positive lead I) consistent with a right superior pulmonary vein (RSPV) origin. Electrolytes and thyroid function tests were normal. Transthoracic echocardiogram demonstrated no structural heart disease. The arrhythmia was not controlled despite sotalol therapy. The patient underwent an electrophysiology
Abstracts
study whilst in incessant AT. Activation mapping of the left atrium (LA) was performed with a circular mapping catheter via transeptal puncture after electrograms (EGMs) at the crista were shown to be late relative to the P-wave. EGMs from all four pulmonary veins and the left atrial appendage were either late or on-time to the P-wave. A fractionated EGM at a LA roof site was found to be 31 ms pre-P wave. Radiofrequency ablation (RFA) at this site resulted in immediate acceleration followed by termination of the AT. The AT remained non-inducible despite high dose isoprenaline and burst pacing.
Conclusion: The LA roof is a rare source of incessant focal AT. P-wave morphology is similar to that of the upper pulmonary veins. RFA can result in successful cure. http://dx.doi.org/10.1016/j.hlc.2016.06.370 370 The Pulmonary Venous Antrum in Patients with Persistent AF and Heart Failure Electrophysiologic and Electroanatomic Mapping S. Prabhu 1,2,3,∗ , A. McLellan 1,2,3 , A. Voskoboinik 1,2,3 , B. Pathik 2,3 , C. Nalliah 2,3 , S. Azzopardi 1 , G. Lee 2 , J. Mariani 1 , A. Taylor 1 , J. Kalman 2,3 , P. Kistler 2,3 1 Alfred
Health and Baker IDI Heart and Diabetes Institute, Melbourne, Australia 2 Royal Melbourne Hospital, Melbourne, Australia 3 University of Melbourne, Melbourne, Australia Introduction: AF is associated with increased recurrence following pharmacologic or catheter based intervention in the heart failure (HF) population. We performed detailed electrophysiologic and electroanatomic mapping of the pulmonary venous antrum in patients with and without LV dysfunction. Methods: Patients undergoing AF ablation with PeAF with LVEF<45% (HF group) were compared with LVEF>55% (Normal LV (NLV) group). In AF, PVCL was recorded via a multipolar lasso catheter in each PV and the left atrial appendage (LAA) for 100 consecutive cycles to determine average PV cycle length (PVCL) (PVaverage), fastest PVCL (PVfast), PVaverage/LAAaverage, PVfast/ LAA average. Following DCR, high density mapping of the PV antrum using a contact force catheter (points>10 g) was performed to determine voltage, scar, fractionation and conduction velocity (CV). Results (see table): Twenty-three patients (mean age 59±7yrs, AF duration 11.3±5.1months) were enrolled (HF=13, NLV=10; LVEF= 34±7% vs 59±2, p<:0.001).
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HF was associated with a significantly higher PVaverage/LAAaverage (1.06±0.05 vs 0.98±0.09, p=0.016) and PVfast/ LAAaverage (0.73±0.05 vs 0.55±0.12, p<0.0001). The PV antrum in HF was associated with greater fractionation (37% vs 20%, p=0.039); scar (<0.05 mV; HF 77% vs NLV 20% of patients, p=0.001) and reduction in unipolar and bipolar (HF 2.12±0.76 mV vs NLV 3.60±1.13 mV, p=0.027) voltage without difference in antral CV. Conclusion: HF was associated with significant differences in PVCL with lower antral tissue voltage, and an increase in fractionation and scar. This may in part explain an increased propensity to AF in HF and have implications for catheter ablation in this population. Baseline Characteristics
HF group (n=13)
NLV group (n=10)
P value
.............................................
34 ± 7% 59.2 ± 1.7% LVEF LA diameter (mm) 48 ± 4 47 ± 10 Electrophysiolological mapping (PV cycle length) PV average (4 vein 177 ± 26 165 ± 21 average – over 100 cycles) PV average (fastest 164 ± 24 154 ± 18 vein – over 100 cycles) (ms) PV fast (shortest CL 122 ± 18 93 ± 22 over 60s of any vein) (ms) LAA average (ms) 164 ± 21 170 ± 18 PV average (4 vein 1.06 ± 0.05 0.98 ± 0.09 average) / LAA average PV average (fastest 1.00 ± 0.07 0.91 ± 0.09 vein average) / LAA average PV fast / LAA average 0.73 ± 0.05 0.55 ± 0.17 PV fast / LAA average 80% 15% < 69% (% patients) Electroanatomical mapping (Pulmonary venous antral substrate) Bipolar voltage (mV) 1.34 ± 0.51 1.98 ± 0.83 Unipolar voltage (mV) 2.12 ± 0.76 3.06 ± 1.13 Complex electrograms 37.0 ± 19.2% 20.0 ± 17.3% (%) Low voltage (%) 25.7 ± 19.9% 13.2 ± 12.5% (<0.5 mV bipolar) Presence of any scar (% 54% 10% of patients)
http://dx.doi.org/10.1016/j.hlc.2016.06.371 371 The Short-Term Effect of Right Ventricular Mid-septal Pacing on Right Ventricular Function J. Ramchand ∗ , J. Chen, M. Yudi, L. Kearney, P. Calafiore, D. O’donnell, K. Lu, P. Srivastava, E. Jones Department of Cardiology, Austin Health, Melbourne, Australia
<0.001 0.73 0.26
0.25
0.003
0.56 0.016
0.021
<0.001 0.002
0.031 0.027 0.039 0.096 0.0019
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Results: CT revealed that of leads placed in RVS position, 7 were on the anterior RV wall, 2 were at the anteroseptal junction, and 1 at the lower septum. The ECG demonstrated a QRS axis of −90◦ , absent R wave in V1 and a positive R wave in V6 in all cases. For the 8 RVA leads, 4 were anterior, 2 septal and 2 anteroseptal. The ECG axis varied between −90 and +110◦ , with an absent R wave in V1 in all cases but a positive R wave in V6 in 4. Conclusion: Although the surface ECG differentiates leads at either the apex or septum it does not provide consistent accuracy compared to CT imaging. http://dx.doi.org/10.1016/j.hlc.2016.06.368 368 Takotsubo Cardiomyopathy (TCM) Following Pacemaker Insertion in an Elderly Man H. Herbison ∗ , P. Venkataraman, V. Cheng, A. Koshy, R. Low Eastern Health, Box Hill, Australia Takotsubo cardiomyopathy (TCM) describes transient regional LV systolic dysfunction without obstructive coronary artery disease and can mimic acute coronary syndrome (ACS). It may result from a catecholaminergic surge secondary to a physical or emotional stressor. We describe an 86 year old man who presented with symptomatic complete heart block without ischaemic changes on a background of chronic kidney injury. He denied chest pain and serial HsTropT were 70. An isoprenaline infusion was continued until pacemaker insertion. He developed acute pulmonary oedema 8 hours post-procedure, increase in HsTropT to 600 and a transthoracic echocardiogram (TTE) showed apical ballooning and distal lateral wall hypokinesis (Figure 1). A stress thallium showed only a small area of reversible ischaemia in the distal anterior wall with no evidence of myocardial infarction (Figure 2). TCM was diagnosed on the clinical, TTE and stress thallium results. Repeat TTE 1 month later showed complete resolution of the apical akinesis and lateral wall hypokinesis. This is a rare case of a pacemaker implant causing TCM in a male patient with the prior use of isoprenaline a likely contributing factor. TCM should be a differential in patients who present with apparent ACS following pacemaker insertion.
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
http://dx.doi.org/10.1016/j.hlc.2016.06.369 369 The Left Atrial Roof - A Rare Cause of Incessant Focal Atrial Tachycardia A. Lee 1,2,∗ , J. Betts 1 , R. Gluer 1,2 , H. Haqqani 1,2 1 The Prince Charles Hospital, Brisbane, Australia 2 The University of Queensland, Brisbane, Australia
Introduction: Incessant atrial tachycardia (AT) most commonly arise from the pulmonary veins or atrial appendages. We describe a case of incessant focal (AT) arising from the left atrial roof. Case Report: A 56 year old male presented with dypsnoea and dizziness over the prior week. Electrocardiograms (ECGs) revealed paroxysms of atrial tachycardia with a Pwave vector (positive in V1 and inferior leads, positive lead I) consistent with a right superior pulmonary vein (RSPV) origin. Electrolytes and thyroid function tests were normal. Transthoracic echocardiogram demonstrated no structural heart disease. The arrhythmia was not controlled despite sotalol therapy. The patient underwent an electrophysiology
Abstracts
study whilst in incessant AT. Activation mapping of the left atrium (LA) was performed with a circular mapping catheter via transeptal puncture after electrograms (EGMs) at the crista were shown to be late relative to the P-wave. EGMs from all four pulmonary veins and the left atrial appendage were either late or on-time to the P-wave. A fractionated EGM at a LA roof site was found to be 31 ms pre-P wave. Radiofrequency ablation (RFA) at this site resulted in immediate acceleration followed by termination of the AT. The AT remained non-inducible despite high dose isoprenaline and burst pacing.
Conclusion: The LA roof is a rare source of incessant focal AT. P-wave morphology is similar to that of the upper pulmonary veins. RFA can result in successful cure. http://dx.doi.org/10.1016/j.hlc.2016.06.370 370 The Pulmonary Venous Antrum in Patients with Persistent AF and Heart Failure Electrophysiologic and Electroanatomic Mapping S. Prabhu 1,2,3,∗ , A. McLellan 1,2,3 , A. Voskoboinik 1,2,3 , B. Pathik 2,3 , C. Nalliah 2,3 , S. Azzopardi 1 , G. Lee 2 , J. Mariani 1 , A. Taylor 1 , J. Kalman 2,3 , P. Kistler 2,3 1 Alfred
Health and Baker IDI Heart and Diabetes Institute, Melbourne, Australia 2 Royal Melbourne Hospital, Melbourne, Australia 3 University of Melbourne, Melbourne, Australia Introduction: AF is associated with increased recurrence following pharmacologic or catheter based intervention in the heart failure (HF) population. We performed detailed electrophysiologic and electroanatomic mapping of the pulmonary venous antrum in patients with and without LV dysfunction. Methods: Patients undergoing AF ablation with PeAF with LVEF<45% (HF group) were compared with LVEF>55% (Normal LV (NLV) group). In AF, PVCL was recorded via a multipolar lasso catheter in each PV and the left atrial appendage (LAA) for 100 consecutive cycles to determine average PV cycle length (PVCL) (PVaverage), fastest PVCL (PVfast), PVaverage/LAAaverage, PVfast/ LAA average. Following DCR, high density mapping of the PV antrum using a contact force catheter (points>10 g) was performed to determine voltage, scar, fractionation and conduction velocity (CV). Results (see table): Twenty-three patients (mean age 59±7yrs, AF duration 11.3±5.1months) were enrolled (HF=13, NLV=10; LVEF= 34±7% vs 59±2, p<:0.001).
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HF was associated with a significantly higher PVaverage/LAAaverage (1.06±0.05 vs 0.98±0.09, p=0.016) and PVfast/ LAAaverage (0.73±0.05 vs 0.55±0.12, p<0.0001). The PV antrum in HF was associated with greater fractionation (37% vs 20%, p=0.039); scar (<0.05 mV; HF 77% vs NLV 20% of patients, p=0.001) and reduction in unipolar and bipolar (HF 2.12±0.76 mV vs NLV 3.60±1.13 mV, p=0.027) voltage without difference in antral CV. Conclusion: HF was associated with significant differences in PVCL with lower antral tissue voltage, and an increase in fractionation and scar. This may in part explain an increased propensity to AF in HF and have implications for catheter ablation in this population. Baseline Characteristics
HF group (n=13)
NLV group (n=10)
P value
.............................................
34 ± 7% 59.2 ± 1.7% LVEF LA diameter (mm) 48 ± 4 47 ± 10 Electrophysiolological mapping (PV cycle length) PV average (4 vein 177 ± 26 165 ± 21 average – over 100 cycles) PV average (fastest 164 ± 24 154 ± 18 vein – over 100 cycles) (ms) PV fast (shortest CL 122 ± 18 93 ± 22 over 60s of any vein) (ms) LAA average (ms) 164 ± 21 170 ± 18 PV average (4 vein 1.06 ± 0.05 0.98 ± 0.09 average) / LAA average PV average (fastest 1.00 ± 0.07 0.91 ± 0.09 vein average) / LAA average PV fast / LAA average 0.73 ± 0.05 0.55 ± 0.17 PV fast / LAA average 80% 15% < 69% (% patients) Electroanatomical mapping (Pulmonary venous antral substrate) Bipolar voltage (mV) 1.34 ± 0.51 1.98 ± 0.83 Unipolar voltage (mV) 2.12 ± 0.76 3.06 ± 1.13 Complex electrograms 37.0 ± 19.2% 20.0 ± 17.3% (%) Low voltage (%) 25.7 ± 19.9% 13.2 ± 12.5% (<0.5 mV bipolar) Presence of any scar (% 54% 10% of patients)
http://dx.doi.org/10.1016/j.hlc.2016.06.371 371 The Short-Term Effect of Right Ventricular Mid-septal Pacing on Right Ventricular Function J. Ramchand ∗ , J. Chen, M. Yudi, L. Kearney, P. Calafiore, D. O’donnell, K. Lu, P. Srivastava, E. Jones Department of Cardiology, Austin Health, Melbourne, Australia
<0.001 0.73 0.26
0.25
0.003
0.56 0.016
0.021
<0.001 0.002
0.031 0.027 0.039 0.096 0.0019