Intracardiac Locations Research Articles

« Myxoma Of The Left Atrium Responsible For Fatal Cerebrovascular Accident »

Left atrial myxoma is a rare tumor. The polymorphism of its clinical presentation is sometimes confusing for the clinician. Although its histologically benign nature is recognized by the majority of authors, its intracardiac location gives it a significant lethal evolutionary potential in the absence of surgical treatment. We report here the case of a 38-year-old patient who presented with a massive ischemic stroke.

BRUGADA-LIKE ECG PATTERN AND TUMORS INVOLVING RIGHT VENTRICULAR OUTFLOW TRACT - CASE SERIES AND LITERATURE REVIEW.

Mechanical heart compression, including that from mediastinal tumor, may cause Brugada-like ECG pattern. Such ECG pattern might also be observed in intracardiac tumor obstructing the right ventricular out"ow tract (RVOT). Eight cases with Brugada-like ECG and tumors involving RVOT have been described so far; 4 growing in the mediastinum (with one example of in"ammatory mass), 3 with intracardiac location, and 1 being an organized pericardial hematoma. The authors present other 3 cases of intracardiac metastatic tumors in RVOT and Brugada-like ECG pattern with coved ST-segment elevation in the right precordial leads. All patients had negative history of cardiovascular disease or familiar malignant arrhythmia occurrence. ECG were done routinely; none of the patients had chest pain or an increased level of cardiac troponins. In all patients, neoplastic disease was at advanced stage. A 76-year-old male, had a history of four neoplasms: bladder cancer was being treated with chemotherapy, while prostate, tongue, and lung cancers had been resected years ago and no signs of local relapse were found. A 78-year-old female, was diagnosed with colon cancer 1 month after an episode of venous thromboembolism. Six months after the resection of cancer, second focus of adenocarcinoma was found in the rectum. Third patient, a 65-year-old-male had undergone nephrectomy for renal cancer a year before cardiac metastasis diagnosis.

Safety and chronic lesion characterization of pulsed field ablation in a Porcine model.

BackgroundPulsed field ablation (PFA) has been identified as an alternative to thermal‐based ablation systems for treatment of atrial fibrillation patients. The objective of this Good Laboratory Practice (GLP) study was to characterize the chronic effects and safety of overlapping lesions created by a PFA system at intracardiac locations in a porcine model.MethodsA circular catheter with nine gold electrodes was used for overlapping low‐ or high‐dose PFA deliveries in the superior vena cava (SVC), right atrial appendage (RAA), and right superior pulmonary vein (RSPV) in six pigs. Electrical isolation was evaluated acutely and chronic lesions were assessed via necropsy and histopathology after 4‐week survival. Acute and chronic safety data were recorded peri‐ and post‐procedurally.ResultsNo animal experienced ventricular arrhythmia during PFA delivery, and there was no evidence of periprocedural PFA‐related adverse events. Lesions created in all anatomies resulted in electrical isolation postprocedure. Lesions were circumferential, contiguous, and transmural, with all converting into consistent lines of chronic replacement fibrosis, regardless of trabeculated or smooth endocardial surface structure. Ablations were non‐thermally generated with only minimal post‐delivery temperature rises recorded at the electrodes. There was no evidence of extracardiac damage, stenosis, aneurysms, endocardial disruption, or thrombus.ConclusionPFA deliveries to the SVC, RAA, and RSPV resulted in complete circumferential replacement fibrosis at 4‐week postablation with an excellent chronic myocardial and collateral tissue safety profile. This GLP study evaluated the safety and efficacy of a dosage range in preparation for a clinical trial and characterized the non‐thermal nature of PFA.

Pathologie des tumeurs primitives du cœur

Primary heart neoplasms are rare and poorly known by general pathologists. However, they are not exceptionally encountered in pathology laboratories having a recruitment of cardiac surgery specimens. About 80% of them are benign tumors and 20% are malignant tumors. Some tumors are specific to the heart or have characteristics when they grow in the heart, including myxoma and papillary fibroelastoma. The classification currently in use is the 4th edition of the WHO classification of heart tumors published in 2015, which takes into account the evolution of knowledge in the field of sarcomas, but which does not yet recognize cardiac intimal sarcoma. recently individualized in its intracardiac location.

S1707 Heart to Believe: Right Atrial Mass and New Onset Heart Failure Due to Metastatic Colon Adenocarcinoma

INTRODUCTION: A 58 year old male with history of early stage colon cancer diagnosed six years ago status post right hemi-colectomy without chemotherapy and apparently in remission presented with symptoms of heart failure and found to have a right atrial mass. CASE DESCRIPTION/METHODS: On admission, labs with mildly elevated liver enzymes. A transthoracic echo showed a pedunculated right atrial mass. Cardiac CT with contrast confirmed the presence of an 8 cm × 6 cm right atrial mass with extension into the hepatic vein and inferior vena cava. (Figure A, arrows). Biopsy of mass showed moderately differentiated colonic adenocarcinoma with cribriform glandular growth pattern (Figure B) staining positive for CDX1 and cytokeratin 20 (Figure C, D respectively), and negative for cytokeratin 7 (Figure E). Recent abdominal surveillance CT scans did not show any evidence of recurrent disease and tumor markers were normal. Subsequent colonoscopy showed a healthy appearing anastomosis without evidence primary colon tumor recurrence (Figure F). DISCUSSION: While colon cancer is the third most common cause of cancer in the United States, known metastasis to the cardia is extremely rare. To our knowledge there are only ten such cases, with all of them affecting the right atrium or ventricle.1–2 Given the clinically silent nature of metastatic cardiac malignancies, many are undiagnosed until autopsy, which estimates the presence of such metastasis ranging 2–7%.3 Spread is typically hematogenous given the intra-cardiac location of these tumors. Treatment is palliative FOLFOX based chemotherapy, although emergent surgical resection is considered in cases of hemodynamic compromise. Overall prognosis is poor with 5-year survival rates of 10-14%2.Although metastatic cardiac disease is rare, our case illustrates the need for an extensive diagnostic workup in any patient with a history of colorectal cancer presenting with new onset heart failure symptoms.Figure 1.: Figure A: Cardiac CT illustrating right atrial tumor (Arrows).Figure 2.: Figure B-E: Pathology images showing adenocarcinoma staining positive for CDX1/Cytokeratin 20 and negative for Cytokeratin 7.Figure 3.: Figure F: Colonoscopy with healthy appearing anastomosis.

Unusual variants of pre-excitation: From anatomy to ablation: Part III-Clinical presentation, electrophysiologic characteristics, when and how to ablate nodoventricular, nodofascicular, fasciculoventricular pathways, along with considerations of permanent junctional reciprocating tachycardia.

The recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, but frequently a difficult, challenge for the clinical cardiac arrhythmologist. In this third part of our series of reviews, we discuss the different steps required to come to the correct diagnosis and management decision in patients with nodofascicular, nodoventricular, and fasciculo-ventricular pathways. We also discuss the concealed accessory atrioventricular pathways with the properties of decremental retrograde conduction that are associated with the so-called permanent form of junctional reciprocating tachycardia. Careful analysis of the 12-lead electrocardiogram during sinus rhythm and tachycardias should always precede the investigation in the catheterization room. When using programmed electrical stimulation of the heart from different intracardiac locations, combined with activation mapping, it should be possible to localize both the proximal and distal ends of the accessory connections. This, in turn, should then permit the determination of their electrophysiologic properties, providing the answer to the question "are they incorporated in a tachycardia circuit?". It is this information that is essential for decision-making with regard to the need for catheter ablation, and if necessary, its appropriate site.

Part II-Clinical presentation, electrophysiologic characteristics, and when and how to ablate atriofascicular pathways and long and short decrementally conducting accessory pathways.

Recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, frequently difficult, challenge for the clinical cardiac arrhythmologist. In this second part of our series of reviews relative to this topic, we discuss the steps required to achieve the correct diagnosis and appropriate management in patients with the so-called "Mahaim" variants of pre-excitation. We indicate that, nowadays, it is recognized that these abnormal rhythms are manifest because of the presence of atriofascicular pathways. These anatomical substrates, however, need to be distinguished from the other long and short accessory pathways which produce decremental atrioventricular conduction. The atriofascicular pathways, along with the long decrementally conducting pathways, have their atrial components located within the vestibule of the tricuspid valve. The short decremental pathways, in contrast, can originate in the vestibules of either the mitral or tricuspid valves. As a starting point, careful analysis of the 12-lead electrocardiogram, taken during both sinus rhythm and tachycardias, should precede any investigation in the catheterization room. When assessing the patient in the electrophysiological laboratory, the use of programmed electrical stimulation from different intracardiac locations, combined with entrainment technique and activation mapping, should permit the establishment of the properties of the accessory pathways, and localization of its proximal and distal ends. This should provide the answer to the question "is the pathway incorporated into the circuit underlying the clinical tachycardia". That information is essential for decision-making with regard to need, and localization of the proper site, for catheter ablation.

Abstract 16812: Clinical Use of Rate Adaptive Pacing With a Leadless Pacemaker: Results From the Micra Transcatheter Pacing System Post-Approval Registry

Introduction: The Micra transcatheter pacemaker has similar functionality and features to existing transvenous VVIR systems despite its small size and intracardiac location. Rate adaptive pacing with Micra is achieved via a programmable 3-axis accelerometer that detects activity in the presence of cardiac motion and has demonstrated to be proportional to workload in the investigational trial. In this analysis, we report the clinical usage of rate adaptive pacing in the Micra Post-Approval Registry (PAR). Methods: The Micra PAR is a prospective, non-randomized, multi-center registry evaluating safety performance of Micra in real-world clinical practice following commercial release. All patients intended to be implanted with a Micra were eligible for enrollment. Micra PAR patients with device data available from an interrogation at least 30-days post-implant were included in this analysis. The clinical usage of VVIR vs. VVI pacing modes was summarized based upon last device interrogation. Results: Among the 713 patients included in this analysis from 117 centers, average age was 75.4 ± 14.4 years and 60.0% were male. Overall 45.3% had rate adaptive pacing enabled. Of 457 patients with a primary pacing indication of bradyarrhythmia with AF, 58.0% were programmed VVIR (figure). The pacing indication distribution for the VVIR patient group was: 82% bradycardia with AF, 4% sinus node dysfunction, 8% AV block, 4% syncope, and 1% other. Among patients with a primary indication of syncope or sinus node dysfunction, the majority were programmed VVI (83.9% and 79.1%, respectively). Of patients with <10% pacing, 2.5% were programmed VVIR vs. 97.5% VVI. Of those with >90% pacing, 88.8% were VVIR vs. 11.2% VVI. Conclusions: In real-world clinical practice, VVIR was programmed in <50% of Micra patients. Patient groups with the highest utilization of VVIR mode include those with >90% ventricular pacing and those with a primary pacing indication of bradyarrhythmia with AF.

First-in-Man Analysis of the Relationship Between Electrical Rotors From Noninvasive Panoramic Mapping and Atrial Fibrosis From Magnetic Resonance Imaging in Patients With Persistent Atrial Fibrillation.

Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging can be used to evaluate characteristics of atrial fibrosis. The novel noninvasive epicardial and endocardial electrophysiology system (NEEES) allows for the identification of sources with rotor activity. This study describes a new technique to examine the relationship between rotors and LGE signal intensity in patients with persistent atrial fibrillation (PERS) scheduled for ablation. Ten consecutive patients underwent pulmonary vein isolation for persistent atrial fibrillation. LGE CMR of both atria was performed, and NEEES-based analysis was conducted to identify rotors. For each mapping point, the intracardiac locations were transferred onto an individual CMR-derived 3-dimensional shell. This allowed the LGE signal intensity to be projected onto the anatomy from the NEEES analysis. NEEES analysis identified a total number of 410 electric rotors, 47.8% were located in the left atrium and 52.2% in the right atrium. Magnetic resonance imaging analysis was performed from 10 right atria and 10 left atria data sets, including 86 axial LGE CMR planes per atrium. The mean LGE burden for left atrium and right atrium was 23.9±1.6% and 15.9±1.8%, respectively. Statistical analysis demonstrated a lack of regional association between the extent of LGE signal intensity and the presence of rotors. This is the first study demonstrating that the presence of rotors based on NEEES analysis is not directly associated with the extent and anatomic location of LGE signal intensity from CMR. Further studies evaluating the relationship between rotors and fibrosis in patients with persistent atrial fibrillation are mandatory and may inform strategies to improve ablation outcome.

Lipoblastoma: an unusual tumour of the left ventricle

Lipoblastoma is a rare benign tumour of infancy originating from white foetal adipose tissue. Most commonly located in the extremities, intrathoracic and mediastinal involvement of this tumour is rare, and an intracardiac location is even rarer, with only one reported case. Herein, we present a 2-month old asymptomatic boy diagnosed with an echogenic mass in the left ventricular outflow tract. The patient underwent surgical excision and histopathological evaluation revealed a lipoblastoma.

0343: Obstructive cardiac tumor in Hodgkin’s lymphoma: course of cardiac involvement under emergency chemotherapy

Cardiac involvement in Hodgkin’s disease (HD) is one of the least investigated subjects in cardiac oncology. Emergency chemotherapy is a rare necessity in Hodgkin’s disease, but life-threatening cardiac involvement is possible, compromising hemodynamic stability. We report a case of Hodgkin’s lymphoma which presented with acute obstructive left heart failure. It is about a 37 years old patient treated in 2000 for HD, type3, stage IVB medullar by chemotherapy (4MOPP+ABVD) followed by radiotherapy, and judged in complete remission. Few months ago, the patient presents a cardiac relapse, echocardiography revealed an enormous left atrial mass inducing a subtotal mitral obstruction confirmed by the tomodensitomety. After a multidisciplinary concertation we used the CEOP protocol (cyclophosphamide 650 mg/m 2 , etoposid100 mg/m 2 , oncovin 1,4 mg/m 2 , prednisone, 40 mg/m 2 ) associated to the conventional heart failure treatement. Under chemotherapy the evolution was favourable with amelioration of symptoms strengthen by regression of cardiac mass gradually in the weekly echocardiography checking after 4 cures. HD is not a steroid-sensitive disease, no single drug is rapidly efficient, and no recommendation is available in the literature regarding urgent cytoreduction. Therefore, if a decision for emergency chemotherapy is made, an aggressive combination may be recommended. In addition, newer agents resulting in improved cancer therapy outcomes might alter the prevalence and location of metastatic deposits to include more unusual disease sites, including intracardiac locations. Lymphomatous involvement of the heart, previously a rarity, is now being reported with greater frequency. The increased incidence might be partly a result of increased clinical awareness, improved imaging techniques. Adaptative chemotherapy can successfully improve the long term outcome of these patients.

Comparison of preexisting and ablation-induced late gadolinium enhancement on left atrial magnetic resonance imaging.

Postablation atrial fibrillation recurrence is positively associated with the extent of preexisting left atrial (LA) late gadolinium enhancement (LGE) on magnetic resonance imaging (MRI), but negatively associated with the extent of postablation LGE regardless of proximity to the pulmonary vein antra. The characteristics of pre- vs postablation LA LGE may provide insight into this seeming paradox and inform future strategies for ablation. The purpose of this study was to define the characteristics of preexisting vs ablation-induced LA LGE. LGE-MRI was prospectively performed before and ≥3 months after initial ablation in 20 patients. The intracardiac locations of ablation points were coregistered with the corresponding sites on axial planes of postablation LGE-MRI. The image intensity ratio (IIR), defined as the LA myocardial MRI signal intensity divided by the mean LA blood pool intensity, and LA myocardial wall thickness were calculated on pre- and postablation images. Imaging data from 409 pairs of pre- and postablation axial LGE-MRI planes and 6961 pairs of pre- and postablation image sectors were analyzed. Ablation-induced LGE revealed a higher IIR, suggesting greater contrast uptake and denser fibrosis, than did preexisting LGE (1.25 ± 0.25 vs 1.14 ± 0.15; P < .001). In addition, ablation-induced LGE regions had thinner LA myocardium (2.10 ± 0.67 mm vs 2.37 ± 0.74 mm; P < .001). Regions with ablation-induced LGE exhibit increased contrast uptake, likely signifying higher scar density, and thinner myocardium as compared with regions with preexisting LGE. Future studies examining the association of postablation LGE intensity and nonuniformity with ablation success are warranted and may inform strategies to optimize ablation outcome.

Effects of sevoflurane anesthesia on righting reflex and hemolymph gas analysis variables for Chilean rose tarantulas (Grammostola rosea).

To determine the safety, efficacy, and effects on hemolymph gas analysis variables of sevoflurane anesthesia in Chilean rose tarantulas (Grammostola rosea). 12 subadult Chilean rose tarantulas of unknown sex. Spiders were anesthetized in a custom chamber with sevoflurane (5% in oxygen [1.0 L/min]), then allowed to recover in 100% oxygen. Righting reflex was evaluated every 3 minutes during anesthesia to determine time to anesthetic induction and recovery. Hemolymph samples were collected from an intracardiac location prior to and after induction of anesthesia and evaluated to determine various gas analysis variables. Mean ± SD induction and recovery times were 16 ± 5.91 minutes and 29 ± 21.34 minutes, respectively. Significant differences were detected for Po2, base excess, and glucose and ionized magnesium concentrations between hemolymph samples obtained before anesthesia and those obtained after induction of anesthesia. CONCLUSIONS AND CLINICAL RELEVANCE-Results of this study suggested that the use of sevoflurane as an anesthetic agent for Chilean rose tarantulas was safe and effective. Various hemolymph sample gas analysis values changed during anesthesia.

Intracardiac metastasis from germ cell testicular tumor

Intracardiac metastases of germ cell testicular tumors are not commonly seen in clinical practice. The clinical presentation of right-sided heart metastases ranges widely. Depending upon its size and intracardiac location, it could be highly symptomatic, leading to a congestive heart failure, pulmonary embolism, and death, or completely asymptomatic. Improved imaging techniques and treatment strategies demonstrate that right-sided heart metastasis should be considered a potentially dangerous but treatable disease. Presented is the case of a 24-year-old man with a testicular nonseminomatous germ cell tumor, which after metastasizing in the right atrium differentiated into a teratoma and resulted in an inflow obstruction of the right ventricle.

Basic Concepts in Metastatic Cardiac Disease.

The involvement of the heart in metastatic cancer is a rare clinical diagnosis, as it may be asymptomatic or symptoms, when present, may be attributed to other causes. Issues regarding incidence, intracardiac location, clinical presentation, diagnosis and treatment of metastatic cardiac tumors will be discussed here.

Fatal Disruption of a Left Atrial Myxoma Associated with Trauma

Cardiac myxomas are benign tumors composed of sparse stellate cells in an extensive mucoid stroma. The surface of these tumors is often friable and gelatinous. Their intracardiac location makes embolization a constant threat. We report a patient who had diffuse systemic embolization of a left atrial myxoma coincident with a low-velocity frontal motor vehicle crash.

Recurrence of a Familial Giant Multilocular Cardiac Myxoma in a Patient With Carney's Complex

A 20-year-old woman, whose father had a past medical history of Carney complex (cardiac myxoma and spotty pigmentation of the skin), was referred to our hospital with a necrotic fingertip. Vital signs and physical examination revealed no additional pathological findings. Blood count showed a slight anemia with a hemoglobin of 11.5 g/dL (reference range 12 to 18 g/dL), and the serum level of C-reactive protein was 57 mg/L (reference range 0 to 5 mg/L). 2D and 3D echocardiography revealed a giant left-ventricular tumor originating from the posterior papillary muscle and posterior wall, prolapsing into the left ventricular outflow tract during systole. A second tumor in the left atrium originating from the mitral valve with diastolic prolapse into the left ventricle could be diagnosed (Figure 1, see also Movies 1–3). The patient underwent immediate surgery. As a result of infiltrating tumor growth, a part of the papillary muscle and some chordae had to be resected. The mitral valve was reconstructed using artificial chordae and ring annuloplasty. Histological findings confirmed a diagnosis of cardiac myxoma (Figure 2). In a 1-year follow-up, the patient was free of symptoms, and echocardiography did not show any signs of …

Cystic tumour of the atrioventricular node: three cases of sudden death

Cystic tumour of the atrioventricular nodal region is a rare primary cardiac tumour that can cause sudden death. Antemortem diagnosis and successful excision of this type of tumour are extremely rare. Three cases of sudden death are reported: A 25- and 40-year-old with a history of heart block and a 60-year-old with no medical history. There have been more than 120 cases of sudden death attributed to primary cardiac tumours in the literature. Although over 100 of these lesions were histologically benign, their intracardiac locations precipitated conductive and haemodynamic abnormalities that resulted in sudden death. The most common intracardiac lesion causing sudden death, cystic tumour of the atrioventricular node, however, may not be discovered unless the atrioventricular node is microscopically examined.

Cardiac Involvement with Lymphoma: A Review of the Literature

Current literature suggests that the incidence of cardiac involvement by lymphoma as identified by autopsy varies widely, ranging from 8.7% to 20%. Historically, many cases might have been clinically undetected; however, improved imaging techniques increasingly identify cardiac involvement incidentally. In addition, newer agents resulting in improved cancer therapy outcomes might alter the prevalence and location of metastatic deposits to include more unusual disease sites, including intracardiac locations. We present 2 cases and a review of the literature.

A Percutaneous Catheter‐Based System for the Measurement of Potential Gradients Applicable to the Study of Transthoracic Defibrillation

The local electric (E) field or potential gradient produced by a shock reliably predicts VF termination. In this study we evaluated a multiple electrode, catheter-based device for closed-chest 3D measurements of E field from transthoracic defibrillation shocks. Catheters with multiple electrodes on the tip were placed in intracardiac locations in anesthetized swine. An empirically derived calibration matrix and custom microprocessor was used to transform simultaneously measured voltages into orthogonal E field vector components. E fields produced in six intracardiac locations by 30 and 300 J shocks were compared in eight animals. Correlations were determined for measured current and E field at various shock strengths at two different transthoracic impedances in five additional animals. VF was induced in 12 animals and E field measured during defibrillation attempts. The E field measurements resulting for 30 J transthoracic shocks were not significantly different among different intracardiac sites. At 300 J, however, significant differences were observed between sites with the greatest intensities recorded in the coronary sinus and right ventricle. Within animals, the variability of the measurement at each site was small, ranging from 2.8 +/- 1.6% to 5.7 +/- 4.5%. Significant correlations (P < 0.001) between measured E field and peak current were observed at native impedance (34 +/- 4 Omega, r = 0.81) and at adjusted impedance (76 +/- 4 Omega, r = 0.78) with transthoracic shocks of 200, 300, and 360 J. In VF studies, the probability of defibrillation was closely fit by a sigmoidal dose response curve in the coronary sinus E field with an approximate threshold of 4.7 V/cm with 50% defibrillation success at 9.3 V/cm. The measured intracardiac E field variability within animals and at a specific site was small, exhibiting a median value of 5.1%, contrasted to median variabilities across animals of 5-11% suggesting the capacity of this measurement system to provide subject specific information on the distribution of E fields. The measured E field magnitudes across animals in the coronary sinus were linearly correlated with applied shock current with a very strong linear relation to effective shock voltage observed in vitro in a saline tank. When evaluated as a predictor of shock success, the observed values were consistent with previously reported critical fields. This technique may be of value in evaluating waveforms for transthoracic defibrillation as well as electrode size, placement, and composition.