Authors:Z. Ruzsa, K. HÜttl, K. Tóth and B. Merkely
Rotational atherectomy (RA) in peripheral circulation is an advanced revascularization procedure, often used in cases where traditional percutaneous transluminal angioplasty (PTA) is inadequate and bypass grafting is either unavailable or undesired. We report on a case, where RA was successfully performed after failed traditional PTA. The case highlights the importance of RA in peripheral cases where severe calcification occurs and the lesion is not suitable for PTA (cannot be passed with balloon or is undilatable).
Authors:Valentina Kutyifa, B. Merkely, V. K. Nagy, A. Apor, E. Zima and L. Gellér
Real-time three-dimensional transesophageal echocardiography (RT 3D TEE) is a novel method providing high spatial and temporal resolution imaging of the heart. During pulmonary vein isolation procedures visualization of the atria, interatrial septum and the ablation catheter is of high importance to increase safety. RT 3D TEE might be a useful tool to guide left atrial ablations.
A 53-year-old man was referred to our hospital to undergo pulmonary vein isolation procedure for the treatment of symptomatic drug-refractory paroxysmal atrial fibrillation. The transseptal puncture was performed under RT 3D TEE-guidance with direct visualization of the interatrial septum and fossa ovalis. RT 3D TEE provided a three-dimensional view of the puncture with “tenting”-sign and the transseptal needle-fossa ovalis angle enhancing the manipulation of the ablation catheter within the left atrium. The ablation catheter was visualized and tracked during the procedure. No adverse events occurred during the procedure.
Our case report demonstrates the feasibility of RT 3D TEE-guided atrial fibrillation ablation procedures. Safety profile might be improved by the real-time direct view of fossa ovalis. Decrease in fluoroscopy time can be achieved by visualizing the ablation catheter during the procedure.
Authors:I. F. Édes, Z. Ruzsa, T. Szűk, Gy. Szabó and B. Merkely
Rotational atherectomy (RA) is an advanced coronary debulking technique, often used in cases, where traditional percutaneous coronary intervention (PCI) methods (e.g. balloon predilatation, use of cutting balloons, direct stenting etc.) are inadequate. We report a case of a male patient, who previously underwent PCI of the right coronary artery (RCA) and was free of chest pain for several weeks, but his clinical symptoms have developed again. Angiography showed a “de novo”, highly calcified left anterior descending (LAD) lesion that, after high-pressure balloon inflation, failed to dilate, thus the intervention was suspended. RA was scheduled for the patient within one month. As a complication of the previous LAD dilatation attempt, a chronic dissection of the target lesion occurred. Problems arose during the direct wiring attempt of the main vessel and the true lumen was only found via plaque modification, after accessing a small septal branch. Accessing the true lumen was only possible by using a conventional cross-wire. This was exchanged to a RA wire, with the help of an over-the-wire (OTW) balloon catheter. RA and debulking of the target lesion was performed. An everolimus-eluting stent (BioMatrix, Biosensors Europe, Morges, Switzerland) was implanted, with excellent results. The patient is free of clinical symptoms since the intervention, which took place 14 months ago.
Authors:G. Széplaki, T. Tahin, SZ. Szilágyi, I. Osztheimer, T. Bettenbuch, M. Srej, B. Merkely and L. Gellér
Pace-mapping is an important tool during the ablation of premature ventricular complexes (PVCs) or ventricular tachycardia. The automated pace mapping system software (PaSo module, CARTO XP v9, Biosense/Webster) allows direct comparisons between paced ECGs and the acquired PVC ECG during ablation in a reasonable time. We report our experience with the automated pace mapping system during the ablation of PVCs in the left ventricular outflow tract (LVOT). A 67-year-old male patient was referred to our Department because of recurrent resting atypical chest pain. A 12 lead ECG showed frequent PVCs with LVOT morphology and a 24-hour Holter ECG revealed, that 31% of the total beats were monomorphic PVCs. We decided to perform a radiofrequency catheter ablation. After recording an electroanatomic and an activation map during PVCs, pace-mapping was performed with the PaSo module of the CARTO system. The best percent match area (89.0%) was found in the LVOT, where we performed multiple ablations and PVCs disappeared. According to our initial experience, automated pace-mapping systems might be useful during ablation of PVCs or ventricular tachycardias. Appropriate use of the software allows more objective and faster comparisons compared with conventional manual techniques.
Authors:István Hartyánszky, A. Tóth, G. Veres, B. Berta, E. Zima, Z. Szabolcs, G. Y. Acsády, B. Merkely and F. Horkay
Background: Although circular ventricle resection techniques are the gold standard of left ventricle restoration, these techniques can lead to suboptimal results. Postoperative systolic resection line can be inadequate, as it must be planned on a heart stopped in diastole. The impaired geometry and contractility may lead to increased short- and long-term mortality. Moreover, postoperative low cardiac output due to insufficient left ventricular volume results in a potentially unstable condition, and cannot be corrected. Our aim was to find a preoperative method to minimize risk and maximize outcome with left ventricle restoration. Methods: We have created a novel method combining surgery with modern imaging techniques to construct a preoperative 3D systolic heart model. The model was utilized to determine resection could be intraoperatively used to create the new left ventricle. Results: The computer assisted ventricle engineering technique is described step by step through a successful aneurysmectomy of a 61-year-old female patient with a complicated giant left ventricle aneurysm. Conclusions: Using this model we are able to find the optimal resection line providing excellent postoperative result, thus minimizing the risk of low cardiac output syndrome. This is the first report of our new combined approach to left ventricle restoration.
Authors:N Szegedi, E Zima, M Clemens, A Szekely, RG Kiss, G Szeplaki, L Geller, B Merkely, Z Csanadi and G Duray
Catheter ablation is a proven therapy of focal atrial tachycardia. However limited information is available about the additional value of electroanatomical over conventional mapping methods for this specific arrhythmia.
Consecutive catheter ablation procedures of FAT were analyzed in two cardiology centres. Only conventional mapping was used in 30 of the 60 procedures whereas additionally CARTO mapping was performed in another 30 procedures. Acute, six-month success rate, and procedural data were analyzed.
Localization of ectopic foci is congruent with previously published data. There was no statistically significant difference between procedure time and fluoroscopy time using additionally CARTO mapping, compared to conventional mapping only. Acute success rate was higher in procedures guided by CARTO mapping than in procedures based on conventional mapping (27/30 vs. 18/30, p = 0.0081). During the 6-month follow-up period there was a better outcome (p = 0.045) in case of CARTO guided procedures (success: 11 cases, partial success: 12 cases, failure: 4 cases) compared to conventional mapping (success: 4 cases, partial success: 18 cases, failure: 7 cases).
Catheter ablation of focal atrial tachycardias using the CARTO electroanatomical mapping system seems to provide higher acute and 6-month success rate compared to ablation using conventional mapping methods only.
Authors:Zsolt Szelid, G. Kerecsen, P. Maurovich-Horvat, Á. Lux, E. Marosi, A. Kovács, R. G. Kiss, I. Préda and B. Merkely
Diagnostic accuracy of 64-slice CT angiography in the evaluation of in-stent restenosis is improved compared to previous CT methods. The image quality and exact diagnostic performance is, however, limited by several method, stent and patient-related factors. In this retrospective multicenter study the first results with dual source 64-slice scanner are presented in a Hungarian post PCI patient population (n=99). Radiation dose was 11.3±5.2 mSv (average±STD) using a helical scan. In 5.6% of all (n=142) examined stents clinicians were not able to give a final diagnosis using CT scan. This limitation showed correlation with the stent diameter. Nondiagnostic stents were smaller compared to the diagnostic stents (diameter 2.4±0.2 mm versus 3.2±0.5 mm, average±STD, respectively, P<0.01). Despite its high negative predictive value in the detection of restenosis, positive predictive value of CTA is lower, than that of invasive angiography. CT was not powerful enough in our study to distinguish vessel occlusion from severe restenosis. Heart rate was decreased by administration of intravenous metoprolol and in 75.8% of the patients scan was performed at a heart rate over 70 beats/minute, which did not have a significant influence on the diagnostic value.
Authors:E. Kovács, D. Pilecky, Z. Szakál-Tóth, A. Fekete-Győr, V.A. Gyarmathy, L. Gellér, B. Hauser, J. Gál, B. Merkely and E. Zima
We investigated the effect of age on post-cardiac arrest treatment outcomes in an elderly population, based on a local database and a systemic review of the literature.
Data were collected retrospectively from medical charts and reports. Sixty-one comatose patients, cooled to 32–34 °C for 24 h, were categorized into three groups: younger group (≤65 years), older group (66–75 years), and very old group (>75 years). Circumstances of cardiopulmonary resuscitation (CPR), patients' characteristics, post-resuscitation treatment, hemodynamic monitoring, neurologic outcome and survival were compared across age groups. Kruskal-Wallis test, Chi-square test and binary logistic regression (BLR) were applied. In addition, a literature search of PubMed/Medline database was performed to provide a background.
Age was significantly associated with having a cardiac arrest on a monitor and a history of hypertension. No association was found between age and survival or neurologic outcome. Age did not affect hemodynamic parameter changes during target temperature management (TTM), except mean arterial pressure (MAP). Need of catecholamine administration was the highest among very old patients. During the literature review, seven papers were identified. Most studies had a retrospective design and investigated interventions and outcome, but lacked unified age categorization. All studies reported worse survival in the elderly, although old survivors showed a favorable neurologic outcome in most of the cases.
There is no evidence to support the limitation of post-cardiac arrest therapy in the aging population. Furthermore, additional prospective studies are needed to investigate the characteristics and outcome of post-cardiac arrest therapy in this patient group.