Assessing current technology takes time,1 and reviews may not reflect the current position. By the mid-1990s it was clear that pulmonary veins were the source of the triggering ectopics in most cases of paroxysmal atrial fibrillation. Various techniques for electrical isolation of the veins have been developed, with several types of radiofrequency ablation at the forefront. The evidence reviewed in this …

Background Implantable cardioverter-defibrillator (ICD) therapy can reduce sudden death due to ventricular arrhythmia (VT/VF) but is not without complication, particularly in young patients who live for many years with a device in situ. We aimed to determine the ICD complication rate in our inherited cardiac condition (ICC) population compared with international reports. Particular importance was given to inappropriate shock therapy due to lead failure as there are new ICD technologies available. Methods Patients with ICCs who had ICD implantation or box change between January 2006 and September 2009 were included. Data on clinical characteristics, complications and ICD therapies were obtained from pacing and hospital records. We compared our data with several ICD studies of patients with specific ICCs (Abstract 150 table 1). Results 101 patients (mean age 44.1±14.8 years; 59 male) were included (idiopathic VF 15%; DCM 17%; ARVC 22%; HCM 21%; long QT syndrome 17%; Brugada syndrome 6%; others 2%). During a mean follow-up of 74.0±53.2 months 2 patients died (1 inappropriate shocks; 1 stroke). Indications were secondary prevention in 71.3% of patients. ICD types were 56.4% single chamber; 39.6% dual chamber; 4.0% biventricular. Appropriate therapy successfully terminated VT/VF in 27 (26.7%) patients 34.7% of secondary and 6.9% of primary prevention patients received appropriate therapy. Inappropriate therapy occurred in 18 (17.8%) patients and lead failure (noise/wear/fracture) in 22 (20.8%) patients (Abstract 150 table 2). 12 out of 18 inappropriate shocks were due to lead failure, 5 sensing errors (1 T-wave oversensing; 4 AF), 1 generator fault. 10/22 leads that failed were Medtronic Sprint Fidelis and these were responsible for 8/12 patients receiving inappropriate shocks including one death due to lead fracture. Comparison with other studies indicates a high lead failure rate due to the long follow-up period, similar to the LQT Study which reports 25% lead failure over 87 months (Abstract 150 table 1). With lead failure excluded the complication rate is comparable to shorter follow-up studies. Inappropriate and appropriate therapy rates are similar among all studies. Conclusions There is a significant rate of ICD lead failure in patients with ICCs, which may be expected given the high frequency of Sprint Fidelis leads implanted during this period and the long follow-up. Our results compare favourably to other similar studies. The high rate of appropriate therapy highlights the clinical effectiveness of ICD intervention in secondary prevention. Lead complications may be lower with the use of new ICD technology in selected patients.

A 67-year-old man presented with palpitations. There was no significant past history, and the clinical examination was unremarkable. The electrocardiogram showed a regular, broad complex tachycardia at 220 beats/min with right bundle branch block morphology (Rs in lead V1), right inferior QRS axis, and precordial lead QRS concordance (Figure 1). P waves are possibly visible after the QRS complex, best seen in the inferior leads.

Up to 30% of men with clinically localized disease who receive radical prostatectomy develop a biochemical recurrence. Gene methylation in tumor tissue may distinguish men with aggressive cancer. This study evaluated methylation of GSTP1, RARβ2, CD44 and PTGS2 with biochemical recurrence among 60 patients who underwent radical prostatectomy using logistic regression and Kaplan Meier time to event analysis. Methylation of GSTP1 and RARβ2 was not associated with recurrence, however, CD44 and PTGS2 methylation were significant predictors. In multivariate models adjusting for Gleason grade, methylation profile of CD44 and PTGS2 combined was an independent predictor of biochemical recurrence (associated with 9-fold increased risk). In addition, Kaplan Meier analysis showed CD44 and PTGS2 methylation was associated with shorter time to recurrence. CD44 and PTGS2 methylation may predict biochemical recurrence in prostate cancer patients undergoing radical prostatectomy and if validated in larger studies, may identify patients with aggressive cancer.

We describe a successful transatrial repair in a patient with left ventricular pseudoaneurysm in the submitral position after a myocardial infarct.

Background: We studied the impact of recent advances in coronary prevention by assessing cardiovascular risk factors and their management in 98% of patients admitted to a coronary care unit with acute myocardial infarction (AMI) between January and December 1998 [177 patients, mean age 66±1 (S.E.M.) years, 114 males]. Methods and results: Sixty-two patients had a history of coronary heart disease (CHD). One in four of them was still smoking and 27% had a recorded history of hyperlipidaemia. Only 12 patients with known CHD (19%) were on lipid-lowering treatment. Total cholesterol was above 5 mmol/l in 98/168 (58%) of the patients and LDL-cholesterol was above 3 mmol/l in 91/148 (62%) of the patients. Twenty-eight patients (16%) died during the hospital stay (age 74±2 years). Of 149 patients discharged from hospital, 101 (68%) were treated with a statin, including 85% of the patients with a total fasting cholesterol on admission above 5 mmol/l and 91% with LDL-cholesterol on admission above 3 mmol/l. Sixty-three percent of the patients on a statin were on a dose below that shown in clinical trials to reduce cardiovascular events. Conclusions: Unrecognised and ineffectively treated cardiovascular risk factors were common among patients with documented CHD who were admitted with AMI. Our study provides important background for the implementation of guidelines for the prevention of CHD.

Objective-To report the initial and intermediate term results of stent implantation in children with coarctation of the aorta.Patients and design-17 patients with coarctation of the aorta underwent stent implantation (median age 11 years, range 0.4-15 years); six were treated for isolated coarctation, nine for recurrent coarctation (five after surgical repair and four after balloon dilatation), and two for complex long segment coarctation.Interventions-The procedure was guided by a second catheter placed transseptally in the left ventricle or the aorta proximal to the coarctation site, for angiographic and haemodynamic monitoring during the procedure.Twenty two stents were implanted in 17 patients.One of the patients with long segment coarctation received four stents and the other three.Palmaz 4014 stents were placed in 11 patients, Palmaz 308 in five, and Palmaz 154 in one.Results-Immediately after stent implantation the peak systolic gradient (mean (SD)) fell from 50.0 (24.5) to 2.1 (2.4) mm Hg (p < 0.05).The diameter of the stenotic lesion increased from 5.1 (1.5) mm to 13.9 (2.4) mm (p < 0.05).There were no deaths or procedure related complications.At a median follow up of 33 months, no cases of recoarctation were identified, either clinically (0/17; 0%, 95% confidence interval (CI) 0% to 19%) or angiographically (0/13; 0%, 95% CI 0% to 25%).Conclusions-Stent implantation for the treatment of coarctation of the aorta appears to have very low morbidity and mortality, and reasonable intermediate term results.Long term freedom from recoarctation using this method remains to be determined in comparison with simple balloon dilatation.

EDITOR—We support Causer and Connolly's editorial emphasising the value of implantable cardioverter-defibrillators in patients with life threatening ventricular arrhythmias.1 A recent audit conducted in our cardiac unit highlights two additional issues: psychosocial concerns of patients and cost implications. We reviewed clinical records and psychosocial structured questionnaires of the 42 patients receiving their first implantable cardioverter-defibrillator (through pectoral routes) between January 1995 and February 1998 (table). To our knowledge, this is the first reported series of such patients in the …

Implantation of internal cardioverter defibrillators (ICDs) for treatment of malignant ventricular arrhythmias is complicated by failure of therapy or inappropriate shocks. We studied 81 patients (age range 16-72 years; mean 48 +/- 13 years) who underwent ICD implantation for device therapy. The underlying aetiology was ischaemic heart disease (39%), cardiomyopathies (32%) and others (28%). Information regarding shocks was collected using Holter monitoring, telemetry or device memory (stored electrograms) and lastly by clinical follow-up. Fifty-eight patients completed 36 months of follow-up. Thirty-five patients experienced 337 spontaneous shocks, appropriate in 21, inappropriate in 12, and both in two patients. Of the 74 episodes of inappropriate discharges for rhythms other that ventricular tachycardia (VT) or ventricular fibrillation(VF), 55 percent were due to supraventricular arrhythmias (atrial flutter or fibrillation). Lead malfunction occurred in four and the device was replaced in two. Additional drugs controlled AF in one. There was no mortality in any of the 81 patients. The frequency of shocks was highest in the first six months after implantation and atrial fibrillation remains the main cause. In conclusion, inappropriate shocks are frequent in patients undergoing ICD implantation.

EDITOR,—We are concerned that Gregory Y H Lip and colleagues' article on cardioversion of atrial fibrillation omits important information about the technique of cardioversion.1 Direct current external cardioversion is the method most widely used to restore sinus rhythm in patients with atrial fibrillation. However, meticulous attention to detail is necessary if the technique is to have …

Implantable defibrillator systems have been used in over 20000 patients worldwide. Such systems use a variety of different electrodes and the identification of these and the recognition of associated problems with them presents a challenge to the radiologist. The appearance of currently available implantable defibrillation systems and the use of radiological examination in patient follow-up and system troubleshooting is discussed based on our experience with a large population of patients receiving these devices. Radiological examination is excellent for demonstrating displacement or distortion of defibrillation electrodes, but in our experience is ineffective for the identification of lead conductor fractures.

Clinical CardiologyVolume 17, Issue 5 p. 283-283 Book ReviewFree Access Electrocardiography: A physiologic approach, David M. Mirvis, Mosby–Yearbook Inc., St. Louis (1993) 532 pages, illustrated, $33.95 ISBN: 0–8016–7479–4 David E. Ward M.D., David E. Ward M.D. Regional Cardiothoracic Unit St. George's Hospital London, EnglandSearch for more papers by this author David E. Ward M.D., David E. Ward M.D. Regional Cardiothoracic Unit St. George's Hospital London, EnglandSearch for more papers by this author First published: May 1994 https://doi.org/10.1002/clc.4960170516AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume17, Issue5May 1994Pages 283-283 RelatedInformation

The diagnosis of subclinical myocardial disease in patients with ventricular tachycardias of right ventricular (RV) origin and no overt cardiac abnormalities is important, inasmuch as the presence of RV cardiomyopathy or arrhythmogenic dysplasia can be associated with a poor prognosis. To this end the relative value of symptoms, ECG features of ventricular tachycardia, signal-averaged ECGs, and RV echocardiograms as compared with endomyocardial biopsy findings was prospectively evaluated. Twenty-seven patients with chronic ventricular tachycardias with a left bundle branch block-like morphology, presumed to be of RV origin, were studied. Clinical examination findings, 12-lead ECGs in sinus rhythm, radiographs of the chest, coronary angiograms, and left ventricular cineangiograms were normal in all patients. RV biopsies were abnormal in 11 patients (41%) with findings suggestive of RV dysplasia or cardiomyopathy. A multivariate analysis showed a significant correlation between an abnormal biopsy and sustained ventricular tachycardia (p < 0.05), tachycardia with a superior frontal plane axis (p < 0.001), an abnormal signal-averaged ECG (p < 0.05), and an abnormal RV echocardiogram (p < 0.001). An abnormal RV echocardiogram was both a sensitive (73%) and a specific (94%) indicator of an abnormal RV biopsy. Sustained tachycardia although sensitive (90%) had a low specificity (56%). In comparison, a superior frontal plane axis of ventricular tachycardia and an abnormal signal-averaged ECG were indicative of high specificity and low sensitivity for abnormal myocardial histologic findings. We conclude that in a patient with RV tachycardia and no overt cardiac abnormalities, sustained tachycardia, a superior frontal plane axis of ventricular tachycardia, an abnormal signal-averaged ECG, and an abnormal RV echocardiogram suggest the presence of subclinical RV disease. An abnormal RV echocardiogram is both a specific and a sensitive indicator of myocardial abnormalities and precludes the need for endomyocardial biopsy.

Journal of Cardiovascular ElectrophysiologyVolume 4, Issue 1 p. 62-67 The Substrate for Atrioventricular “Nodal” Reentrant Tachycardia: Is There a “Third Pathway” DAVID E. WARD M.D., Corresponding Author DAVID E. WARD M.D. Cardiology Department, St George's Hospital, London, United KingdomDavid E. Ward, M.D., 69 Harley Street, London WIN IDE, United Kingdom. Fax: 44-81-767-9858.Search for more papers by this authorCLIFFORD J. GARRATT M.A., M.R.C.P., CLIFFORD J. GARRATT M.A., M.R.C.P. Cardiology Department, St George's Hospital, London, United KingdomSearch for more papers by this author DAVID E. WARD M.D., Corresponding Author DAVID E. WARD M.D. Cardiology Department, St George's Hospital, London, United KingdomDavid E. Ward, M.D., 69 Harley Street, London WIN IDE, United Kingdom. Fax: 44-81-767-9858.Search for more papers by this authorCLIFFORD J. GARRATT M.A., M.R.C.P., CLIFFORD J. GARRATT M.A., M.R.C.P. Cardiology Department, St George's Hospital, London, United KingdomSearch for more papers by this author First published: February 1993 https://doi.org/10.1111/j.1540-8167.1993.tb01213.xCitations: 8AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume4, Issue1February 1993Pages 62-67 RelatedInformation

OBJECTIVE:Patients with exercise induced ventricular tachycardia associated with a "clinically normal" heart may have an abnormality of the regional distribution of the cardiac sympathetic nerve supply. In this study the regional distribution of the myocardial nerve supply in patients with ventricular tachycardia (VT) and control subjects was examined by [123] meta-iodobenzylguanidine (MIBG) scanning.PATIENTS AND DESIGN:Eight patients with exercise induced VT and seven patients with VT unrelated to exercise with "clinically normal" hearts were studied and compared with a control group of six subjects with atrioventricular reentrant tachycardia not related to exercise and eight patients with angiographically normal left ventricular function and normal coronary anatomy who had thallium scans without evidence of ischaemia or fixed perfusion deficits.METHODS:Single photon emission computed tomography gamma scanning was performed in patients three hours after intravenous injection of MIBG. The left ventricular MIBG uptake data was processed into bull's-eye target plots. The inferior portion of the scan frequently showed artefact due to uptake of MIBG in the liver or spleen and was not used for statistical analysis. Asymmetry of uptake was defined as a ratio of uptake exceeding 1.25 in the upper quadrants (posterior (anterolateral free wall)/anterior (anteroseptal region)) of the MIBG scan.RESULTS:Patients with VT had a higher proportion of asymmetrical MIBG scans (47%) than subjects in the control groups (0%) and this was particularly obvious in the patients with exercise induced VT (62.5%). This suggests that patients with VT may have relative denervation in the septal portion of the left ventricle leading to an imbalance of the sympathetic supply to the myocardium and locally imbalanced sympathetic or parasympathetic interactions. Considerable evidence from animal experiments suggests that imbalance of the sympathetic supply to the myocardium is important in the genesis of ventricular arrhythmia.CONCLUSIONS:These results support the hypothesis that selective denervation of the human myocardium may be an important mechanism in the genesis of VT in "clinically normal" hearts.

OBJECTIVE:The aim was to assess the effects of therapeutic doses of intravenous adenosine on human atrial and ventricular repolarisation.METHODS:The effects of 6 mg and 12 mg bolus doses of adenosine on the atrial and ventricular monophasic action potentials were studied using the contact catheter technique in 19 patients undergoing routine diagnostic electrophysiology studies. The effect on atrial repolarisation was studied before and after beta blockade in a subgroup of patients.RESULTS:The duration of the monophasic action potential to 90% repolarisation (MAPD90) was measured in all cases. After 6 mg of adenosine the atrial MAPD90 shortened from 227(SD 29) ms to 188(25) ms (p < 0.005); after 12 mg it shortened from 221(31) ms to 168(32) ms (p < 0.001). The maximum shortening was unaltered by propranolol 0.15 mg.kg-1. The ventricular MAPD90 showed no significant change after 12 mg, at 240(32) ms v 234(33) ms.CONCLUSIONS:Therapeutic doses of adenosine shorten the atrial but not the ventricular monophasic action potential duration. The effect is dose dependent and not abolished by beta blockade.