Freedom from ventricular tachycardia (VT) in patients with structural heart disease (SHD) is associated with improved survival. Management of patients with refractory VT despite multiple ablations and maximal medical therapy may involve neuro-axial modulation via cardiac sympathetic denervation (CSD).

Syncope is one of a number of conditions that result in transient loss of consciousness (TLOC). Syncope is distinguished from other causes of TLOC in that syncope results from transient global cerebral hypoperfusion. In the majority of cases, global cerebral hypoperfusion is the result of a fall in mean arterial pressure (MAP) to such a degree that cerebral blood flow autoregulatory mechanisms fail. A fall in MAP leading to syncope can result from a variety of mechanisms, which are often classified into four broad categories: (1) reflex syncope, (2) orthostatic hypotension, (3) arrhythmia, and (4) structural etiologies. Of these, reflex syncope syndromes are the most common regardless of the patient population being studied. Within a given category, more than one pathophysiologic mechanism may be involved. Initial evaluation is focused on identification of the cause of syncope. The cause of a given patient’s syncope can often be determined with a careful history and physical examination. On occasion, ancillary testing may be needed. Determining the cause of syncope is critical in order to determine an individual patient’s risk of recurrence and risk of morbidity and mortality. The cause of syncope must be established to allow for an effective treatment strategy.

INTRODUCTION:Epicardial exit sites of ventricular tachycardia (VT) are frequently encountered during VT ablation requiring an epicardial ablation approach for successful elimination of VT. We sought to assess the utility of repolarization markers in identifying individuals requiring an epicardial ablation approach in addition to an endocardial approach.METHODS:32 patients who underwent successful ablation for scar mediated VT were included in the study. Fourteen patients who required a combined endocardial and epicardial VT ablation were defined as epicardial VT group (Epi) whereas 18 patients who were successfully ablated from the endocardium alone constituted the endocardial VT group (Endo). Repolarization markers during sinus rhythm were compared between the two groups.RESULTS:A higher QTc max and QTc dispersion were seen in the Epi group compared to Endo group (479 ± 34 vs 449 ± 20, p = 0.008 and 63 ± 13 vs 38 ± 8, p = 0.001, respectively). Ts-p and Ts-p/Tp-e were higher in the Epi group (166 ± 23 vs 143 ± 23, p = 0.008 and 1.55 ± 0.26 vs 1.3 ± 0.21, p < 0.005). On multivariate regression, QTc dispersion was an independent predictor of the need for an epicardial approach to ablation. A QTc dispersion more than 51.5 msec identified individuals requiring a combined epicardial and endocardial approach to ablation with a sensitivity of 92.9% and a specificity of 100%.CONCLUSIONS:Patients requiring an epicardial ablation have a higher QTc dispersion. A value greater than 51.5 msec reliably differentiates between the two groups with high sensitivity and specificity.

Amyloid infiltration of the atrium is described in patients with valvular heart disease and is associated with an increased risk for atrial fibrillation(AF) while amyloid deposits in the ventricles is increasingly being diagnosed in patients with HFpEF. The role of amyloid deposits in patients with AF without valvular heart disease, which represents the most common form of AF globally, is undefined. In this study, we sought to assess the prevalence of sub-clinical isolated cardiac amyloidosis (ICA) at autopsy and the odds of AF in these patients. A total of 1083 patients were included in the study and 3.1% of patients were found to have asymptomatic ICA. Patients with ICA were older and had a higher odds of AF independent of age and CHA2DS2VASc score. Amongst patients with AF, those with ICA were more likely to have persistent forms of AF and had a lower sinus rhythm P-wave amplitude. Further studies are required to further define this entity, identify imaging modalities to aid in antemortem diagnosis of ICA and to establish the optimal management strategies in these patients.

ÖzAmaç: Kemik iliğinde bulunan kök hücreler, doku onarımını artırmak için miyokardiyal hasar sonrası dolaşıma salınmaktadır.Başta atriyal fibrilasyon olmak üzere; kardiyak aritmilerin radyofrekans ile ablasyonu sonrası dolaşımda bulunan kök hücrelerin inflamatuar aracılar vasıtasıyla salınımının tetiklendiği gösterilmiştir

Introduction: Many algorithms have been proposed for the differential diagnosis of supraventricular tachycardia (SVT). However, the effect of these algorithms on different sex and age groups has not been investigated. Our aim in this study is to observe the distribution of known electrocardiography (ECG) parameters in different age and sex groups. Patients and Methods: The ECG parameters (during tachycardia) of 114 patients diagnosed with atrioventricular nodal re-entrant tachycardia (AVNRT) or atrioventricular re-entrant tachycardia (AVRT) by electrophysiology or radiofrequency ablation were evaluated retrospectively. Results: For women, pseudo r'-waves in V1 and in aVR were significant in the AVNRT group (p< 0.05), whereas the QRS alternans was significant in the AVRT group (p< 0.05). In the AVNRT group, the ST depression in the right precordial leads was found to be significant in individuals aged < 60 years; the up-sloping ST depression was found to be a significant parameter for individuals aged > 60 years in the same group (p< 0.05). The mean ST depression amplitude was higher in the AVRT patients aged > 60 years than individuals aged < 60 years in the same group (p< 0.05). Conclusion: In this study, it was shown that known ECG parameters differ according to age and gender. It was also demonstrated that age and gender may be included in the SVT differential diagnosis and algorithms.

PURPOSE:Previous studies have demonstrated the relationship between hyperthyroidism and increased risk of cardiac arrhythmias. The most common causes of hyperthyroidism are Graves' disease (GD) and toxic nodular goiter (TNG). The aim of our study was to demonstrate if the underlying mechanism of hyperthyroidism, in other words autoimmunity, has an impact on the type of cardiac arrhythmias accompanying hyperthyroidism. METHOD:Twenty patients with TNG and 16 patients with GD who had overt hyperthyroidism were included in the study. Age, sex, thyroid hormone levels, thyroid autoantibody positivity, thyroid ultrasonography and scintigraphy results were recorded. 24-hour Holter ECG monitoring was performed in all patients. RESULTS:Mean age was significantly higher in the TNG group compared to the GD group (62.9±11.5 vs. 48.9±8.6 years, p=0.001). Free T3 was significantly higher (7.87±3.90 vs. 5.21±1.53 pg/mL, p=0.033) in the GD group while free T4 and TSH levels were similar between the two groups. In 24-hour Holter ECG recordings nonsustained ventricular tachycardia (VT) rates were significantly higher in the GD group than in TNG group [18.75% (n=3/16) vs. 0% (n=0/20), respectively, (p=0.043)]. Paroxysmal atrial fibrillation (AF) rates were significantly higher in the TNG group compared to GD group [(30% (n=6/20) vs. 0% (n=0/16), respectively, (p=0.016)]. CONCLUSION:Although free T3 levels were lower, paroxysmal AF rates were found significantly higher in the TNG group which may be associated with significantly higher age of this group. On the other hand, higher rate of nonsustained VT in the GD group may be related to either significantly higher free T3 levels or autoimmunity.

An 88-year-old woman was admitted to the emergency department after experiencing syncope while in a sitting position. Electrocardiogram showed advanced degree heart block. She has been on low-dose carbamazepine (200 mg/day) for the last year for trigeminal neuralgia (TN). After discontinuation of carbamazepine, the patient returned to normal sinus rhythm.

A single beat arising as extra systole within the His-Purkinje system or from ventricle or even atrium based on conduction timing can invoke delayed conduction or block within intra-Hisian or infra-Hisian sites. This may be either manifested in the form of premature atrial or ventricular complexes or concealed as with His extra systoles. It appears commonly there is disease within the His-Purkinje system.

With constantly evolving technology and an ever-increasing number of patients with pacemakers, clinicians will encounter various pacemaker malfunctions in their practice. While some of these issues can be solved even by using only the pacemaker׳s mode settings, others require re-intervention; neglecting a pacemaker׳s malfunction without full investigation threatens the patient׳s life. In this report, we describe a patient with a dual-chamber pacemaker with neglected or unresolved dyssynchronization that occurred 2 years after implantation.

Inappropriate sensing events revealing electrocautery-induced implantable cardioverter-defibrillator lead failureElectromagnetic interference (EMI) associated with current implantable cardioverter-defibrillator (ICD) generators and leads are less prone to long-term failure.Thus, it has been suggested that routine post-ICD replacement interrogation of the device may not be necessary.We present the case of a patient who underwent ICD replacement during which therapies were inadvertently not turned off, which lead to EMI and shock and subsequently lead failure.A 52-year-old-man who had ICD (BiotronikLumax340 VR-T, Berlin, Germany) implanted in 2008 presented with an ICD generator end-of-life and was scheduled for generator replacement.Before the procedure device interrogation showed a right ventricular (RV) pacing threshold of 0.6 V at 0.5 ms pulse width, R-wave sensing was 6.7 mV, RV lead pacing impedance was 715 Ω, and shock impedance was 46 Ω.The patient received a Medtronic D384DRG ICD, Minneapolis, USA.During the surgical closure of the device pocket, electrocautery was used for hemostasis, which resulted in EMI and inappropriate 35 J shock (Fig. 1).Postoperatively, inappropriate senses were monitored, which were concordant with lead failure (Fig. 2).The RV pacing threshold increased to 1.25 V at 0.5 ms, and the R-wave sensing decreased to 3.30 mV.Lead impedance measurements were RV pacing at 619 Ω, RV coil at 48 Ω, and SVC coil at 73 Ω.At the second week, a new pace sense lead was uneventfully implanted from the same site and over sense completely ended after the replacement of the lead.Despite the advances in ICD technology, electrocautery, especially when used close to the device, can still lead to lead failure, which might necessitate intervention.Thus, we still recommend routine postprocedural interrogation of the device.

Recent studies have reported that a novel cardiac biomarker, heart-type fatty acid-binding protein (h-FABP), significantly predicts mortality inpatients with pulmonary embolism (PE) at intermediate risk. The aim of this study was to evaluate the effect of thrombolytic therapy on prognosis of the intermediate risk acute PE patients with elevated levels of h-FABP. This is non-interventional, prospective, and single-center cohort study where 80 patients (mean age 62 ± 17 years, 32 men) with confirmed acute PE were included. Only patients with PE at intermediate risk (echocardiographic signs of right ventricular overload but without evidence for hypotension or shock) were included in the study. h-FABP and other biomarkers were measured upon admission to the emergency department. Thrombolytic (Thrl) therapy was administered at the physician’s discretion. Of the included 80 patients, 24 were h-FABP positive (30 %). 14 patients (58 %) with positive h-FABP had clinical deterioration during the hospital course and required inotropic support and 12 of these patients died. However, of 56 patients with negative test, only 7 patients worsened or needed inotropic support and five patients died during the hospital stay. Mortality of patients with PE at intermediate risk was 21 %. The 30-day mortality rate was significantly higher in h-FABP(+) patients compared to h-FABP(−) patients (9 vs. 50 %, p < 0.001). Multivariate analysis revealed h-FABP as the only 30 day mortality predictor (HR 7.81, CI 1.59–38.34, p = 0.01). However, thrl therapy did dot affect the survival of these high-risk patients. Despite, h-FABP was successful to predict 30-days mortality in patients with PE at intermediate risk; it is suggested to be failed in determining the patients who will benefit from thrl therapy.

A 34-year-old female patient was admitted with the complaints of inability to stand upright, palpitations, dizziness, and fatigue in the upright posture for the last one year. She was found to stand upright for less than one minute without symptoms. Tilt table testing showed that, compared to baseline her heart rate increased 55 beats/min in the fifth minute of the test with the symptoms of palpitations, fatigue and sweating without any significant change in her blood pressure. Postural orthostatic tachycardia syndrome was diagnosed, and pyridostigmine treatment was started. Four months after treatment her symptoms were relieved so that she was able to function as a nurse.

A 58 year-old-patient developed an episode of polymorphic atrial tachycardia which looked like "atrial torsades de pointes" after a 5J shock from implantable cardioverter defibrillator.

Organophosphate pesticides have emerged as a common cause of poisoning, particularly in developing countries. The most common electrocardiographic abnormalities observed in organophosphate poisoning are sinus tachycardia, QT interval prolongation, and, very rarely, ventricular arrhythmias. We report a case of organophosphate poisoning associated with atrial fibrillation, right bundle branch block, QT interval prolongation, and intermittent narrow QRS complexes that were most likely due to automaticity from the region of the left posterior fascicle.

There is conflicting evidence that operative technique affects the risk of atrial tachyarrhythmia after orthotopic heart transplantation (OHT). We sought to determine whether OHT by bicaval (BC) technique is associated with a lower risk of atrial tachyarrhythmia than biatrial (BA) technique. Consecutive patients who underwent OHT between 1997 and 2007 at the University of Minnesota were included in this retrospective cohort study with follow-up through December 31, 2011. We included 260 OHT recipients (BA, 155; BC, 105). Fifty-nine patients (22.7%) developed early atrial tachyarrhythmias. The multivariable odds ratio (95% confidence interval [CI]) of BC technique for early atrial tachyarrhythmias was 0.85 (0.46-1.57), P=0.59. After a median follow-up of 4.9 years, 40 (15.4%) patients developed late atrial tachyarrhythmias. The multivariable hazard ratio (HR) (95% CI) of BC technique for late atrial tachyarrhythmias was 0.99 (0.50-1.96), P=0.98. Graft rejection was found to be a multivariate predictor of late atrial tachyarrhythmias (HR, 2.89; 95% CI, 1.48-5.65; P=0.002). In contrast to prior reports, we did not find an association between operative technique and early or late atrial tachyarrhythmias after OHT. Graft rejection is a risk factor for late atrial tachyarrhythmias after OHT.