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  • CA-074 Several cases of injury to the circumflex artery owin

    2019-04-18

    Several cases of injury to the circumflex artery owing to ablation of the lateral mitral isthmus and inside the CS have been reported. The circumflex artery and the CS share a close relationship. Takahashi et al. reported the first case of acute circumflex artery occlusion during CS ablation, which was performed to achieve mitral isthmus block [14]. Hasdemir et al. found that the circumflex artery was <2mm from the CS catheter at the lateral and anterolateral mitral annulus in 24% of patients [15]. Wittkampf et al. postulated that the risk of damaging the circumflex artery increased along with more distal ablation because the relationship between the circumflex artery and the CS might be even closer at a more distal, “anterior” position, while myocardial thickness increases at a more posteromedial mitral isthmus position [11]. Other potential barriers to successful mitral isthmus ablation are lack of stability of the ablation catheter and poor tissue contact. Matsuo et al. demonstrated that the use of Steerable sheaths significantly improved the efficacy of ablation at the mitral isthmus by improving navigation and stability [16]. Recent studies have suggested that mitral isthmus ablation may be proarrhythmic if bidirectional block across the line is not achieved or in the case of conduction recovery [7,17]. Tzeis et al. reported on the safety and feasibility of an alternative line: the modified anterior line, extending from the anterior/anterolateral mitral annulus to the orifice of the left superior PV, just medial to the LAA [18]. However, with this technique, a high incidence of inadvertent isolation of the left atrial appendage (LAA) and delayed activation of the LAA were potential drawbacks. The line from the right inferior CA-074 to the mitral annulus can be substituted with the lateral mitral isthmus line for ablation. However, it was found to have a less favorable anatomy, i.e., a longer isthmus and greater percentage of ridges [13]. All our patients had re-isolation of any recovered PV prior to mapping and ablation of their PMF. We believe that re-isolating the veins is a cornerstone of successful, long-term treatment of atrial flutters. This idea was confirmed by the PROPOSE study, in which targeting the possible triggers of atrial flutter appeared to result in higher freedom from arrhythmia than did targeting the flutter only [19].
    Study limitations
    Conclusion
    Conflict of interest
    Introduction Pulmonary vein isolation (PVI) has become an important option for treating patients with atrial fibrillation (AF) [1]. However, a few reports have described esophageal injury after PVI, including the development of lethal atrioesophageal fistulae. In addition, periesophageal nerve (PEN) injury after PVI may rarely cause pyloric spasms and gastric hypomotility [2]. These disorders lead to abdominal distension and discomfort. No quantitative or objective methods have been published for diagnosing PEN injury after PVI. The 13C-acetate breath test has been used to diagnose delayed gastric emptying induced by gastric hypomotility and/or pyloric spasms. This method is a noninvasive alternative to scintigraphy. The objectives of this study were to clarify the impact of PVI on gastric motility, the prevalence of gastric hypomotility after PVI, and the relationship between de novo esophageal injury and gastric hypomotility following PVI. The 13C-acetate breath test and esophagogastroduodenoscopy (EGD) were performed before and after the procedure to achieve these objectives.
    Material and methods
    Results
    Discussion
    Conclusions
    Conflict of interest
    Introduction Cardiac resynchronization therapy (CRT) is an important treatment for drug-refractory heart failure and left ventricular (LV) dyssynchrony. Pacing leads have often been placed at the coronary vein and right ventricle to reduce LV dyssynchrony and to improve hemodynamics in patients with heart failure. In some patients, clinicians encounter difficulties when placing leads; in approximately one-quarter of patients, there is an insufficient response to biventricular (BiV) pacing, primarily because of difficulty in accurately placing the LV lead due to patients’ anatomical features, pacing thresholds, twitching, or pacing lead anchoring [1]. Some researchers have described other pacing sites that yield better hemodynamics and less dyssynchrony than BiV pacing. For example, Derval et al. attempted lateral LV wall pacing in patients with left bundle branch block pattern who were referred for CRT device implantation [2]. Van Gelder et al. reported that transseptal lead placement was useful in cases where there was difficulty in placing a coronary sinus (CS) lead [3]. Yoshida et al. reported that triventricular pacing, which uses two right ventricular leads and one LV lead, results in greater improvement in hemodynamics in patients with severe heart failure, when compared with Bi-V pacing [4], Sashida et al. reported improved LV function with His bundle pacing (HBP) in a patient with dilated cardiomyopathy due to atrial fibrillation without intraventricular conduction delay [5], However, whether these or other pacing sites are superior to conventional BiV pacing remains unclear. Some recent studies reported that BiV pacing with LV endocardial stimulation sites yield better hemodynamics and LV synchrony, compared with conventional BiV pacing. These procedures would have the benefit of lead placement in an extended area, regardless of coronary vein location, with better threshold and avoidance of twitching.