Irrigated Catheter Research Articles

Electrolyzed Saline Irrigation for Elimination of Bacterial Colonization in the Empyema Space.

Background: The empyema space is refractory to elimination of bacterial colonization. Electrolyzed saline (ES) was used as intra-pleural irrigation for rapid disinfection of the empyema space.Patients and Methods: Twenty consecutive patients with para-pneumonic empyema were reviewed in this study from 2007 to 2015. The empyema space was irrigated by miniaturized thoracoscopic surgery (mini VATS), and the efficacy and safety of the use of ES were evaluated.Results: Sixteen patients were male and four were female, with a mean age of 66.5 ± 9.5 y (27–90 y). Bacterial cultures of the purulent effusions from all 20 patients had positive results. Seventeen patients subsequently underwent continuous catheter irrigation and drainage. No patient had chest pain during ES irrigation. Fever duration after mini VATS was 2.8 ± 1.8 d (0–5 d). Catheter indwelling time was 10.3 ± 7.2 d (3–33 d). Inflammatory markers significantly improved (p < 0.05) within a week after mini VATS. Eighteen patients achieved pleural disinfection, and two patients had residual pathogens, one of whom later died of lung abscess. Space closure was successful in 14 patients. No patient underwent subsequent open drainage. Nineteen (95%) patients were discharged from the hospital. This treatment was successful in 18 (90%) patients, and one (5.6%) patient experienced recurrence.Conclusions: The ES irrigation facilitates the rapid disinfection and closure of the empyema space.

Preliminary experience with high-density electroanatomical mapping for ablation of atrial fibrillation – Comparison of mini-basket and novel open irrigated magnetic ablation catheter in consecutive patients

BackgroundRecently, a novel electroanatomic mapping system enabling rapid and automatic acquisition of high-resolution maps has been introduced. Previous reports focused on system use in combination with a mini-basket catheter. However, a novel system-specific, magnet-enabled ablation catheter eliminates the need for the mini-basket catheter and can potentially reduce procedure complexity and cost. Here we present our first experience from two consecutive case series using both procedural settings. MethodsIn 14 consecutive patients (67±9years, 5 male) with paroxysmal (n=10) or persistent AF (n=4) undergoing de-novo (n=8) or repeat (n=6) AF ablation, left atrial electroanatomical maps were acquired with a mini-basket and in 22 patients (64±9years, 17 male) with paroxysmal (n=4) or persistent AF (n=18) undergoing de-novo (n=12) or repeat (n=10) AF ablation with the new ablation catheter. ResultsBoth complete (7.9 [IQR 4.5–16.2] vs 18.8 [IQR 12.0–25.5] minutes, p=0.005) and partial maps (3.0 [IQR 2.0–4.6] vs 4.5 [IQR 2.0–6.0] minutes, p=0.014) acquired with mini-basket required significantly shorter mapping time and had higher point density: 8832±4809 vs 4460±3914 (p=0.014) and 2483±1774 vs 1111±1926 data points (p=0.002) in partial maps.However, procedural (201±52 vs 159±29min, p=0.004) and fluoroscopy time (33±11 vs 25±6min, p=0.005) was significantly higher in the mini-basket group. Procedural endpoints and complications rates were similar in both groups. ConclusionThe high-density mapping system can successfully be used with both mini-basket catheters and ablation catheters employed for electro-anatomic reconstruction of the left atrium. While mapping is faster and point density higher with the mini-basket, procedure and fluoroscopy times are longer. The clinical significance of those findings needs to be investigated in future and larger studies.

Efficacy of Long-Acting Octreotide on Reducing Mucus Production in Patients With Ileal Neobladder

PurposeTo evaluate the efficacy of long-acting-release octreotide (trade name Sandostatin) on decreasing mucus secretion, thus reducing catheter obstruction after radical cystectomy and orthotopic reconstruction. Patients and MethodsIn this double-blind, placebo-controlled study, we treated 73 cases of radical cystectomy between the years 2008 and 2014; 65 were deemed eligible for the study. Cases were randomly divided into 2 groups. Group A (n = 32) received 2 doses of 20 mg intramuscular long-acting-release octreotide 4 weeks before and on the day of surgery, while group B (n = 33) received placebo. Catheter irrigation was only performed when there was an obstruction due to a mucus plug. The need for catheter irrigation and the volume of mucus produced by the neobladder were evaluated and compared between the 2 groups. ResultsThe average number of neobladder irrigations required to treat mucus plugs was 2.3 ± 1.5 in group A and 9.5 ± 4.3 in group B (P < .001) before hospital discharge. This number changed to 2.5 ± 1.5 versus 11.4 ± 2.7 in groups A and B, respectively (P < .001), after discharge from the hospital. The 24-hour mucus production at the end of the first week was 5.4 ± 2.7 mL versus 21.5 ± 5.6 mL in groups A and B, respectively (P < .001). At the end of the third week, this amount changed to 5.5 ± 2.3 mL versus 21.8 ± 5.6 mL in groups A and B, respectively (P < .001). ConclusionTwo injections of long-acting-release octreotide can dramatically reduce mucus production and hence catheter obstruction due to mucus plugs after radical cystectomy and orthotopic reconstruction.

Retrospective Analysis of Ultrasound-Detected Bleeding Complications after Ultrasound-Guided Transcutaneous Kidney Biopsies

The aim of this retrospective single-center study was to examine ultrasound-detected complications after diagnostic parenchymal renal biopsies. After 471 ultrasound-guided kidney biopsies (225 native kidneys and 246 renal allografts), ultrasound revealed hematomas (21.9%), arterio-venous fistulas (8.9%), active bleeding (1.1%) and hematuria (0.4%). Only 0.8% of all patients required invasive intervention such as coiling (n = 3) and surgical procedures (n = 1). Three episodes of bleeding (0.6%) were solved with manual compression. One patient (0.2%) needed an irrigation catheter because of hematuria. Furthermore, six patients (1.3%) received blood transfusion. Ultrasound-guided biopsies are safe. With modern ultrasound machines using multi-frequency transducers with high resolution and harmonic imaging, even marginal bleeding after renal biopsy is detected.

Controlled Suction with Venous Catheter Irrigation in Neurosurgery: A Cost Effective Technique

Keeping the operating field clean and visible is an important technique in neurosurgery. Continuous irrigation-suction (IS) of the surgical field is currently often done using devices available that are expensive and demand technical proficiency. We report a simple method of continuous IS using a widely available central venous catheter and a controlled suction cannula. We used a controlled suction cannula attached to a central suction system. A single lumen central venous catheter is passed through the keyhole of a controlled suction cannula, which is connected to a continuous irrigation system. The operative field was clean throughout the procedure, obviating the need for an assisting surgeon to irrigate into the deep operating field and, hence, reducing the duration of surgery. The proposed IS system could be surgeon friendly, easily manageable, yet cost-effective and efficient.

Clinical outcome of 2nd generation cryoballoon pulmonary vein isolation in patients over 75 years of age

BackgroundPulmonary vein isolation is an established therapy for symptomatic atrial fibrillation. Despite the fact that incidence and prevalence of atrial fibrillation increases with age, patients over 75 years of age have been excluded in all major atrial fibrillation ablation trials. Pulmonary vein isolation with the cryoballoon has been shown to be equally effective compared to irrigated radiofrequency catheter ablation, but patients over 75 years have also been excluded. The 2nd generation cryoballoon has shown superior efficacy compared to the 1st generation cryoballoon. The aim of the study was to assess the efficacy of pulmonary vein isolation with the 2nd generation cryoballoon for symptomatic atrial fibrillation in elderly patients over 75 years. MethodsPatients over 75 years of age presenting with symptomatic paroxysmal or persistent atrial fibrillation refractory or intolerant to at least one class I or class III antiarrhythmic drug who underwent pulmonary vein isolation with the 2nd generation cryoballoon were included in this single-center observational study. ResultsA total of 40 patients with a mean age of 78.3±2.7 years with paroxysmal (n=31; 77.5%) or persistent (n=9; 22.5%) atrial fibrillation were identified. All patients had a successful pulmonary vein isolation procedure with 100% of veins isolated. After a 3-month blanking period during a mean follow-up of 15.1±8.2 months there were 9 (22.5%) arrhythmia recurrences, while 31 patients (77.5%) maintained stable sinus rhythm. Freedom from arrhythmia recurrence was 86.4% at 12 months and 80.2% at 24 months. ConclusionsPulmonary vein isolation with the 2nd generation cryoballoon appears to be an effective treatment for symptomatic atrial fibrillation also in patients over 75 years of age.

Development of a novel T-tube frontal sinus irrigation catheter.

The problem of postoperative management after frontal sinus surgery remains a challenge. The bilateral opening created in the Draf III procedure does not fit any currently available stent, and patients find rinsing the frontal sinus difficult, which thus decreases compliance. The objective of this study was to demonstrate the successful use of a novel frontal sinus catheter fashioned from a biliary T tube by addressing these issues in patients with complicated sinus disease. This was a review of 30 patients who underwent a Draf III procedure between January and October 2014, and who had a T-tube stent inserted at the end of the procedure. Patient charts were analyzed for complications such as bleeding, infection, and restenosis as well as indications of ease of rinsing ability after surgery. From the chart data, there was only one intraoperative bleed and only one postoperative bleed that required packing. Four patients had infections that required antibiotics after surgery. At the time of data collection, only one patient had signs of restenosis as judged by the operating surgeon. Patients reported an ease of rinsing ability with the T-tube stent. The novel biliary T-tube stent use presented in this article is a promising future direction for postoperative care after extended frontal sinus surgery.

Radiofrequency Ablation of Atrial Fibrillation: Nonrandomized Comparison of Circular versus Point-by-Point "Smart" Ablation for Achieving Circumferential Pulmonary Vein Isolation and Curing Arrhythmic Symptoms.

Pulmonary vein isolation (PVI) with radiofrequency (RF) ablation is now standard care for atrial fibrillation (AF). New improvements in PVI techniques include use of catheters that measure contact-force and circular ablation catheters. These techniques have not been compared. We compared the success rate of circumferential pulmonary vein isolation (CPVI) with: (1) "point by point" RF using an irrigated tip ablation catheter with "smart touch" contact-force; (2) irrigated nMARQ circular ablation catheter in 86 patients with AF. The endpoints of the study were acute and long-term success rate of CPVI. The 2 groups had similar characteristics: Smart Touch group with 50 patients, age 62 ± 8 years, 64% male; nMARQ group with 36 patients, 75% male, age 58.7 ± 10 years. The type of AF was similar in the 2 groups: paroxysmal and persistent in 68% and 32% in the Navistar group versus 64% and 36% in the nMARQ group. Follow-up periods were similar (18.4 months vs. 19 months, P = 0.59). All the pulmonary veins were successfully isolated in both groups. However, PVI could not be achieved with the nMARQ in 2.7% of the pulmonary veins ablated and was completed with a Smart Touch. The long-term success rate was comparable in the 2 groups. The nMARQ and Smart Touch catheters give similar results in PVI of both paroxysmal and persistent AF. The procedural time was shorter with the nMARQ in paroxysmal AF. Need for crossover from nMARQ to Smart Touch occurred in 2.7% of PVs ablated.

“Cardio‐Neuromodulation” With a Multielectrode Irrigated Catheter: A Potential New Approach for Patients With Cardio‐Inhibitory Syncope

Syncope is frequently neurally mediated and can seriously affect quality of life. Different ablation strategies have been successfully performed. These approaches have not gained wide acceptance and are quite extensive and complex, exposing patients to significant risks. This article reports the case of a 16-year-old girl who was severely affected by frequent and prolonged episodes of syncope and was treated by tailored ablation of the anterior right ganglionated plexus with a multielectrode irrigated catheter. She had fainted >30 times in the 5 years preceding treatment, experiencing approximately 10 severe episodes of syncope in the previous 12 months. After 3 minutes of ablation, the P-P interval was reduced by >400 milliseconds. Syncope disappeared and the patient has remained completely asymptomatic over a follow-up of 22 months. The "reset" basal P-P interval has remained unchanged (follow-up electrocardiogram at 16 months). At 6 months, there was no residual heart rate activity <50 bpm. On 24-hour rhythm registration, P-P intervals ≥1,000 milliseconds (corresponding to a heart rate of ≤60 bpm) were reduced by >16,000 beats. We believe that this case reportis original for several reasons: the unusual clinical presentation; the unique structure targeted; the very limited ablation, implying much lower risks for the patient; the anatomical approach; and the different endpoint. This new "cardio-neuromodulation" approach could be useful for the treatment of patients with neurally mediated syncope.

A Novel Endoscopic Catheter for "Laparoscopy-Like" Irrigation and Suction: Its Research and Development Process and Clinical Evaluation.

Inspired by natural orifice translumenal endoscopic surgery (NOTES), the authors launched a development of novel endoscopic irrigation and suction (I/S) catheter for "laparoscopy-like" I/S in flexible gastrointestinal (GI) endoscopy. The aims were to describe its basic research and development (R&D) process and to estimate its performance in both preclinical and clinical settings. In basic R&D phase, a layout of side hole at apex nozzle of endoscopic I/S (EIS) catheter were theoretically calculated and designed. Material of nozzle was selected based on the strength analysis. The performance of final prototype EIS catheter was then assessed preclinically in the porcine stomach, to compare with conventional endoscopic "tip irrigation" and "tip suction" as control. After regulatory clearance, safety and feasibility of I/S using EIS catheter were clinically assessed by endoscopists in small number of patients. Bench tests revealed 0.4 mm in diameter, 24 holes, and 6-8 holes per circumference as most suitable layout of side holes, and polyetheretherketone as an optimal nozzle material, respectively. Time to inject 500 mL saline with the EIS catheter was significantly shorter than tip irrigation (101 ± 3.1 seconds versus 154 ± 3.1 seconds; P < .05). The EIS suction was significantly weaker than conventional endoscopic tip suction, though it remained within the practical range. No mucosal injuries were noted in the EIS suction. In clinical assessments for human use, no adverse events were observed, and high degree of satisfaction for endoscopists was obtained. The newly developed EIS catheter is safely used with satisfactory performance in flexible GI endoscopy.

Clinical and biophysical evaluation of variable bipolar configurations during radiofrequency ablation for treatment of ventricular arrhythmias

Bipolar radiofrequency ablation (bRFA) has been used to create larger ablation lesions and to treat refractory arrhythmias. However, little is known about optimal bRFA settings. The purpose of this study was to evaluate various bRFA settings, including active and ground catheter tip orientation and use of variable active and ground catheters during bRFA. Two ablation catheters, 1 active and 1 ground, were oriented across from each other, with viable bovine myocardium in between. The catheter tips were placed in various combinations perpendicular or parallel to the myocardium. The active catheter was either a 3.5-mm externally irrigated or 8-mm tip, and the ground catheter was either a 4-mm, 3.5-mm irrigated, or 8-mm tip. Retrospective analysis was undertaken for all bRFA performed at University of Colorado. The largest and deepest lesions were produced using irrigated active and ground tips, oriented perpendicularly. In 14 cases (10 patients) of bRFA for ventricular tachycardia and premature ventricular complexes, acute success was achieved in 13 of 14 procedures. Long-term success was achieved in 7 of 10 patients, but 3 patients required multiple bRFA ablations. Active and ground catheter tip orientation and type are important determinants of lesion sizes during bRFA. The largest and deepest lesions, without a higher incidence of steam pops, were achieved using 2 irrigated catheters. As the largest published series to date, bRFA ablation can be performed safely and effectively in humans. Larger studies are necessary to better evaluate bRFA efficacy and safety.

16-31: Successful ablation of parahisian atrial tachycardia and pathway mediated tachycardia via non coronary cusp

Purpose: Atrial tachycardias (AT), antidromic reciprocating tachycardias and orthodromic reciprocating tachycardias (ORT) with parahisian origin are not uncommon. Catheter ablation at this area posed significant risk of heart block. Ablation at non- coronary cusp (NCC) was proposed to be safe and effective. We sought to investigate electrophysiological characteristics and catheter ablation in this area with various types of arrhythmia. Method: This study included 8 patients with focal AT, 4 patients with Wolff Parkinson White Syndrome (WPW) and 4 patients with concealed orthodromic reciprocating tachycardia (ORT). Activation mapping was performed during tachycardia in all cases. In WPW without tachycardia or retrograde atrial conduction, mapping ventricular insertion during maximal pre-excitation was done. Aortogram was done in all cases in order to confirm catheter position. Echocardiogram was done after procedure to look for new onset aortic regurgitation. Result: Four cases of AT (50%) and 4 cases of ORT (100%) were incessant during procedure. All cases of WPW had atrial fibrillation before index procedure. Parahisian origin were confirmed in all cases by pacing manoeuvre. In AT group, activation mapping demonstrated an earliest atrial activation preceded the atrial activation at the His Bundle by 18 ± 3 msec. All accessory pathway in WPW and ORT group were confirmed by parahisian pacing. Detailed mapping showed earliest atrial potential (ORT group) and ventricular potential (WPW group) during tachycardia was located superoposterior to His Bundle. During ablation in all cases, mapping was performed in aortic sinus and all cusps. Irrigation catheter was required to eliminate tachycardia in 8 cases. His potential were not found at the target ablation site. AT were terminated in all cases within 5 second and all accessory pathway was eliminated within 5 second. Neither junctional beats nor PR prolongation was found during ablation. No complication occurred. Post procedure echocardiography did not show new aortic regurgitation. All patients were arrhythmia free after 1 year follow up. Conclusion: In patient with AT, ORT or WPW near the His bundle, mapping in NCC is an viable option and catheter ablation is safe and effective.

PM190 Safety and Efficacy of Robotic Pulmonary Vein Isolation With a New Remote Catheter System

Pulmonary vein isolation (PVI) as a cornerstone for catheter ablation of atrial fibrillation (AF) remains a complex and time-consuming procedure.To assess feasibility, safety, and acute efficacy of a novel irrigated multielectrode ablation catheter guided by an electroanatomic mapping system for PVI in patients with paroxysmal AF.Twenty-five consecutive patients (60 ± 10 years) with paroxysmal AF underwent PVI by using a novel decapolar mapping and ablation catheter (nMARQ catheter, Biosense Webster Inc, Diamond Bar, CA). Ablation was guided by electroanatomic mapping allowing radiofrequency (RF) energy delivery in the antral region of pulmonary veins (PVs) from 10 irrigated electrodes simultaneously. The day after ablation, cardiac magnetic resonance imaging was performed routinely in order to assess for potential acute PV stenosis.Overall, 97 of 97 (100%) targeted PVs could be isolated with a mean of 27 ± 11 RF applications and a mean total burning time of 15 ± 6 minutes per patient. The total procedure time from femoral vein access to catheter withdrawal was 110 ± 31 minutes, including a mean total fluoroscopy time of 23 ± 9 minutes. On average, 6 ± 3 RF impulses with a maximum of 25 W were applied per vein. After a short learning curve, procedure, fluoroscopy, and total burning times decreased to 94 ± 16, 16 ± 3, and 9 ± 2 minutes, respectively (P < .05). Entrance and exit blocks could be verified by placing the ablation catheter into 90 of 97 (93%) PVs in 18 of 25 (72%) patients. No procedure-related complications were observed, especially no acute PV stenosis could be detected.The use of a novel irrigated multielectrode ablation system for PVI is feasible and safe, resulting in acute isolation of all targeted PVs with no complications and short procedure times. Sustainability of these initial results has to be confirmed in long-term efficacy and follow-up trials.

Use of the new contact force sensing ablation catheter dramatically reduces fluoroscopy time during atrial fibrillation ablation procedures

ObjectivesTo study the impact of contact force (CF) sensing on fluoroscopy, procedure, left atrial (LA) and ablation times and number of ablations during atrial fibrillation (AF) ablation. BackgroundCatheter ablation is an effective treatment for symptomatic AF. Recently a new ablation catheter providing real-time CF has been approved for use. MethodsA nested case-control study was performed comparing radiofrequency ablation of AF using the irrigated CF-sensing ThermoCool SmartTouch catheter versus open-irrigated ThermoCool SF catheter (Biosense Webster, Inc., Diamond Bar, California). Demographic and procedure data were obtained and student t-test was used to compare data between groups. ResultsThirty consecutive adult patients were included with 15 patients in each group. Mean fluoroscopy time was significantly lower in CF group (19.4 ± 8 vs 40.7 ± 8 min, p < 0.0001). LA time was significantly lower in CF group (151.7 ± 44 vs 185.7 ± 35 min, p = 0.01). There were no significant differences in procedure time between CF and SF groups (204 ± 37 vs 207 ± 36 min) and ablation time (121 ± 32 vs 122 ± 37 min). When patients who only underwent pulmonary vein isolation (PVI) were compared, fluoroscopy time was significantly lower in CF group (18 ± 9 vs 37.8 ± 5 min, p < 0.0001) as was LA time (141.4 ± 39 vs 171.8 ± 30 min, p = 0.04). Fluoroscopy time was also significantly lower in CF subgroup with additional ablation (20.9 ± 7 vs 44.9 ± 10 min, p < 0.001). ConclusionUse of CF-sensing catheter significantly reduced fluoroscopy and LA times during AF ablation with similar acute efficacy.

Electrical stimulation–based evaluation for functional modification of renal autonomic nerve activities induced by catheter ablation

Catheter ablation of the renal artery can be performed without apparent angiographic stenosis. This suggests that renal nerve function can be attenuated with minor structural damage to the renal artery. To clarify this hypothesis, we examined the relationship between electrical nerve stimulation (ENS)-induced blood pressure (BP) response and severity of histological injury of the renal artery using an acute canine model of renal artery ablation. An irrigation catheter was inserted into the renal arteries of 8 dogs, and radiofrequency current was delivered at 15, 20, or 25 W. ENS was applied to each artery before and after ablation. Before ablation, ENS increased the BP and heart rate from 145 ± 15/86 ± 13 to 189 ± 21/111 ± 19 mm Hg and from 116 ± 9 to 130 ± 6 beats/min, respectively. Heart rate variability indices and serum catecholamine levels were elevated concomitantly. After ablation, the ENS-induced increase in BP and heart rate were markedly attenuated after 15 W ablation and those were nearly completely inhibited after 20 or 25 W ablation. An increase in heart rate variability indices and serum catecholamine levels became insignificant regardless of the applied energy. Renal artery angiograms revealed stenotic lesions only after 25 W ablation procedures. Histological studies showed mild to moderate injury of the arterial wall and autonomic nerves caused by 20 and 25 W ablation procedures, whereas only minor changes caused by 15 W ablation. Functional renal autonomic nerve ablation is potentially performable with the guidance of ENS.

Image Integration to Guide Catheter Ablation in Scar‐Related Ventricular Tachycardia

Although multi-detector computed tomography (MDCT) and cardiac magnetic resonance (CMR) can assess the structural substrate of ventricular tachycardia (VT) in ischemic cardiomyopathy (ICM), non-ICM (NICM), and arrhythmogenic right ventricular cardiomyopathy (ARVC), the usefulness of systematic image integration during VT ablation remains undetermined. A total of 116 consecutive patients (67 ICM; 30 NICM; 19 ARVC) underwent VT ablation with image integration (MDCT 91%; CMR 30%; both 22%). Substrate was defined as wall thinning on MDCT and late gadolinium-enhancement on CMR in ICM/NICM, and as myocardial hypo-attenuation on MDCT in ARVC. This substrate was compared to mapping and ablation results with the endpoint of complete elimination of local abnormal ventricular activity (LAVA), and the impact of image integration on procedural management was analyzed. Imaging-derived substrate identified 89% of critical VT isthmuses and 85% of LAVA, and was more efficient in identifying LAVA in ICM and ARVC than in NICM (90% and 90% vs. 72%, P < 0.0001), and when defined from CMR than MDCT (ICM: 92% vs. 88%, P = 0.026, NICM: 88% vs. 72%, P < 0.001). Image integration motivated additional mapping and epicardial access in 57% and 33% of patients. Coronary and phrenic nerve integration modified epicardial ablation strategy in 43% of patients. The impact of image integration on procedural management was higher in ARVC/NICM than in ICM (P < 0.01), and higher in case of epicardial approach (P < 0.0001). Image integration is feasible in large series of patients, provides information on VT substrate, and impacts procedural management, particularly in ARVC/NICM, and in case of epicardial approach.

Regular pulse rate but irregular heart rate?

The 12-lead ECG shows a ventricular bigeminy with right bundle branch block, which is evidence of a left ventricular origin. The inferior axis and repetitive monomorphic occurrence points to an origin from the outflow tract. Thus, the diagnosis is repetitive left ventricular outflow tract premature beats. This extrasystole can be found in healthy individuals and does not increase the risk of sudden cardiac death. However, due to the short coupling interval of the extrasystole there is almost no diastolic filling before the extrasystolic beat, thus leading to a pulse deficit which is aggravated by the lack of a subsequent sinus beat (postextrasystolic pause). The subsequent sinus beat is augmented due to postextrasystolic potentiation and a prolonged diastole. During bigeminy there is a 2:1 pulse deficit leading to the reported slow but regular pulse rates of the patient. Outflow tract premature beats often show a fixed coupling interval due to triggered activity during phase III of the action potential (early afterdepolarisation) and thus sometimes responds to calcium channel inhibitors such as verapamil. Beta-blockers may be effective but sides effects such as arterial hypotension decrease compliance, especially in young adults. Accordingly, in this patient, ablation of the arrhythmia was scheduled. For electrophysiological mapping, a deflectable mapping and ablation catheter was introduced retrogradely into the left ventricle and mapping of the earliest ventricular activity was performed during spontaneous ventricular premature beats. In this case, earliest activity was recorded above the aortic valve inside the left coronary sinus cusp. Pacing from this site revealed a similar 12-lead ECG morphology as during spontaneous ventricular premature beats. Due to the proximity to the left main coronary artery, a left coronary angiography catheter was positioned into the left main coronary artery (Fig. 1 and 2) and simultaneous visualisation during ablation at this site was performed to identify impeding damage to the coronary vessel [1]. Ablation was performed using an irrigated catheter and the arrhythmia terminated after 10 seconds of radiofrequency ablation (Fig. 3). On the right side of the ECG you can see ST elevation which is documented near the coronary artery. After the ablation, this completely resolved. Since then, the patient has been free of symptoms and repetitive Holter ECGs did not show a recurrence of the arrhythmia. Fig. 1 Ablation catheter in the ascending aorta below the left main coronary artery as visualised by a diagnostic angiography catheter (JL-4). Additional electrode catheters are positioned in the high right atrium and right ventricle. Due to the anatomical ... Fig. 2 Under such ablations at critical points, imaging from different levels is important to safely prevent injury to the coronary arteries. (LAD left anterior descending) Fig. 3 12-lead ECG with termination of the premature beats (arrow) under radiofrequency ablation. On the right side of the ECG you can see ST elevation (*) which is documented near the coronary artery. After the ablation, these completely resolved

Regular pulse rate but irregular heart rate?

The 12-lead ECG shows a ventricular bigeminy with right bundle branch block, which is evidence of a left ventricular origin. The inferior axis and repetitive monomorphic occurrence points to an origin from the outflow tract. Thus, the diagnosis is repetitive left ventricular outflow tract premature beats. This extrasystole can be found in healthy individuals and does not increase the risk of sudden cardiac death. However, due to the short coupling interval of the extrasystole there is almost no diastolic filling before the extrasystolic beat, thus leading to a pulse deficit which is aggravated by the lack of a subsequent sinus beat (postextrasystolic pause). The subsequent sinus beat is augmented due to postextrasystolic potentiation and a prolonged diastole. During bigeminy there is a 2:1 pulse deficit leading to the reported slow but regular pulse rates of the patient. Outflow tract premature beats often show a fixed coupling interval due to triggered activity during phase III of the action potential (early afterdepolarisation) and thus sometimes responds to calcium channel inhibitors such as verapamil. Beta-blockers may be effective but sides effects such as arterial hypotension decrease compliance, especially in young adults. Accordingly, in this patient, ablation of the arrhythmia was scheduled. For electrophysiological mapping, a deflectable mapping and ablation catheter was introduced retrogradely into the left ventricle and mapping of the earliest ventricular activity was performed during spontaneous ventricular premature beats. In this case, earliest activity was recorded above the aortic valve inside the left coronary sinus cusp. Pacing from this site revealed a similar 12-lead ECG morphology as during spontaneous ventricular premature beats. Due to the proximity to the left main coronary artery, a left coronary angiography catheter was positioned into the left main coronary artery (Fig. 1 and 2) and simultaneous visualisation during ablation at this site was performed to identify impeding damage to the coronary vessel [1]. Ablation was performed using an irrigated catheter and the arrhythmia terminated after 10 seconds of radiofrequency ablation (Fig. 3). On the right side of the ECG you can see ST elevation which is documented near the coronary artery. After the ablation, this completely resolved. Since then, the patient has been free of symptoms and repetitive Holter ECGs did not show a recurrence of the arrhythmia. Fig. 1 Ablation catheter in the ascending aorta below the left main coronary artery as visualised by a diagnostic angiography catheter (JL-4). Additional electrode catheters are positioned in the high right atrium and right ventricle. Due to the anatomical ... Fig. 2 Under such ablations at critical points, imaging from different levels is important to safely prevent injury to the coronary arteries. (LAD left anterior descending) Fig. 3 12-lead ECG with termination of the premature beats (arrow) under radiofrequency ablation. On the right side of the ECG you can see ST elevation (*) which is documented near the coronary artery. After the ablation, these completely resolved

UTILIZATION OF AN ADVANCED ABLATION LESION ANNOTATION SYSTEM WITH FORCE SENSING CATHETERS DRAMATICALLY REDUCES ADENOSINE INDUCED PULMONARY VEIN RECONNECTION FOLLOWING RADIOFREQUENCY ABLATION FOR ATRIAL FIBRILLATION

The ability to achieve transmural, durable ablation lesions is a significant challenge of a pulmonary veins isolation (PVI) procedure resulting in their reconnection. We aim to assess the effect of utilization of a force-sense irrigated tip catheters in conjunction with a novel automated ablation

The Effectiveness of Single Shot Intravesical Chemotherapy with Mitomycin-C in Preventing Recurrence of Non-Muscle Invasive Bladder Cancer

OBJECTIVES:To determine the efficacy of single dose intravesical chemotherapy with Mitomycin-C following transurethral resection of non-muscle invasive bladder cancerMETHODS:It was a Descriptive case series study conducted in the admitted patients of bladder cancer in the institute of kidney disease, Peshawar within one year duration. Total of 128 patients were enrolled in the study. After TURBT patient were catheterized with 22 FR 3 ways foley’s catheter and urinary bladder irrigation was started with normal saline. Mitomycin 40 mg dissolved in 20 ml of normal saline was instilled once hematuria settles within 24 hours. All the patients were called back after 3 months for check cystoscopy and the findings were recorded so as to detect recurrence of bladder tumorRESULTS:In this study, 128 patients with transurethral resection of non-muscle invasive bladder cancer have been observed; male to female ratio was 5:1. The age ranges of patients were from 18 to 75 years. Average age was 51.13 years + 14.33SD. Recurrence was found in 20(15.62%) of cases while the remaining 108(84.38%) were free of recurrence.CONCLUSION:Our study confirmed the effectiveness of a single shot immediate Mitomycin-C instillation in patients with non-muscle-invasive bladder tumors.