Recurrent Palpitations Research Articles

Recurrent atrial flutter after radiofrequency ablation for atrial fibrillation in a patient with hypertrophic obstructive cardiomyopathy undergoing repetitive transcoronary ablation of septal hypertrophy

IntroductionWe described the clinical characteristics of a patient with hypertrophic obstructive cardiomyopathy (HOCM) who had undergone transcoronary ablation of septal hypertrophy (TASH) twice and developed atrial flutter after radiofrequency ablation for atrial fibrillation (AF) due to pulmonary vein reconnection. This case of HOCM is unique because of its complex complications and multiple complex atrial arrhythmias. The treatment of HOCM was successful and the postoperative follow-up results was good.Methods and resultsA 71-year-oldfemale, developed exertional dyspnea with palpitations 12 years ago, with a valid diagnosis of HOCM according to the echocardiography which showed an absolute increase in the interventricular septum thickness (22.8 mm). She underwent two rounds of TASH and only the second round was successful. During a visit due to recurrent palpitations, the patient was diagnosed with AF based on electrocardiographic examination. Circumferential pulmonary vein isolation (CPVI) was performed to treat AF. However, the recurrence of atrial flutter was detected on her electrocardiograms (ECGs) three years after the operation. Since the patient had an interstitial lung injury, there were relative contraindications for antiarrhythmic drugs. Due to restrictive use of antiarrhythmic drugs and continuous palpitation, the patient agreed to receive a second radiofrequency ablation. Left-sided macroreentrant circuits were identified via high-density mapping and successful ablation was performed at the isthmus.ConclusionsPerforming catheter ablation and TASH respectively in patients with HOCM associated with AF would be tricky. But taking such a comprehensive and respective clinical treatment would be beneficial to patients in the long term.

ECG Changes in a Patient With Recurrent Palpitations

ECG Changes in a Patient With Recurrent Palpitations

Sinus venosus atrial septal defect device closure

ABSTRACT With technical advancements, transcatheter closure of sinus venosus atrial septal defect (SVASD) proves safe and effective, even in developing countries. A 38-year-old male with recurrent palpitations underwent transesophageal echocardiography and cardiac computerized tomography, confirming a 14 mm SVASD with left-to-right shunt. Under GA and mechanical ventilation, we deployed a 19–25 mm ZYPHER-covered peripheral stent using 22 mm × 60 mm Z-Med II Balloon guidance. An angiogram confirmed adequate defect coverage. Postprocedure, occasional ventricular premature contractions and intermittent atrioventricular block were noted on 72-h Holter. Follow-up showed symptom resolution, with transthoracic echocardiography confirming stent placement and no residual shunt, endorsing device closure as a viable alternative to surgery.

Nonagenarians in Hyperpolypharmacy: relationship between the level of drug interactions and sociodemographic, clinical, and functional characteristics

Aim: This research aimed to study the association of drug interactions and sociodemographic, clinical, and functional characteristics in nonagenarians in hyperpolypharmacy. Methods: This was a secondary analysis of an evaluation performed by the Multiprofessional Care for the Oldest-old Project in 2016, with participants identified in hyperpolypharmacy. Results: Results revealed that 69% of 29 participants had at least one major drug interaction, 41% had 10 or more moderate interactions, and 59% had minor interactions. The study revealed significant relationships for major drug interactions with the characteristics of recurrent urinary tract infections, anxiety, and palpitations. The study found near significance for white colour, not good general health and appetite, depression, and impaired cognition. For moderate drug interaction, findings showed a relationship near significance for females, perception of not good general health and appetite, hypertension, diabetes, urinary infection, depression scale change, agitation, pain, fatigue, and a fear of falling. For minor drug interactions, the study revealed significant findings for an association with depression, and apathy or sleepiness. There were findings near significance for an association with white colour, diabetes, agitation, pain, fatigue, and cough. Conclusion: Drug interactions are highly prevalent among nonagenarians in hyperpolypharmacy, with clinical and quality of life impact. Thus, they must be constantly evaluated for the presence of drug interactions at all levels of care, whether in primary care or in specialized care. A study with larger sample size and longitudinal contour is proposed to prove the importance of our observations.

Abstract 18669: Pheochromocytoma Crisis Precipitated by Carvedilol

Description of case: Pheochromocytomas are rare, catecholamine-secreting tumors of the adrenal gland. Definitive treatment is surgical, but requires pre-operative optimization with alpha, followed by beta blockade (BB). Initial treatment with BB can precipitate pheochromocytoma crisis, characterized by hemodynamic instability and end-organ dysfunction. This case describes pheochromocytoma crisis in a young, healthy female after switching from metoprolol to carvedilol. A 27-year-old woman is evaluated by an outpatient cardiologist for recurrent palpitations, “hot flashes” and headaches. Mobile telemetry monitor reveals episodes of “SVT” for which she is started on metoprolol succinate. Given her symptoms, testing for plasma free metanephrines is ordered and is markedly abnormal. Subsequently the patient is switched from metoprolol to carvedilol. Within a few hours of taking carvedilol the patient reports sudden onset dyspnea, nausea, vomiting and chest pain. On arrival, vital signs are remarkable for a resting pulse of 130 and blood pressure of 130/97. EKG shows sinus tachycardia. Labs reveal a high-sensitivity troponin of 1,816 ng/L and a 2-hour troponin of 4,560. CT shows a 5.8 cm left adrenal mass. An echocardiogram reveals a reduced LVEF of 45-50% and is suggestive of reverse takotsubo cardiomyopathy. Her carvedilol is discontinued, she is started on prazosin and her symptoms resolve within 24 hours. She later resumes metoprolol and proceeds with surgical excision. Discussion: This case reports a pheochromocytoma crisis likely precipitated by carvedilol and complicated by reverse-takotsubo cardiomyopathy. Interestingly, the patient tolerated metoprolol despite being in the same class. This switch was made knowing she tolerated BB and with the idea that she would benefit from additional alpha-blockade. Carvedilol is a racemic mixture, with S-carvedilol binding beta-1 and -2 receptors while R-carvedilol binds strictly alpha-1. There is evidence that patients catabolize the enantiomers differentially, resulting in higher concentrations of one enantiomer in an unpredictable manner. It is therefore preferred to avoid all BB before sustained alpha blockade while treating pheochromocytoma despite the patient’s previous tolerance.

PO-04-077 EPICARDIAL ABLATION OF A PREVIOUSLY FAILED RIGHT LATERAL ACCESSORY PATHWAY

Catheter ablation is a potentially curative treatment for accessory pathways. However, ablation of right lateral accessory pathways is challenging and has a lower procedural success rate and high recurrence rate due to catheter instability and difficulty in catheter manipulation, inadequate tissue contact and structural heart disease like Ebstein's anomaly. We describe a challenging case of WPW syndrome with right lateral accessory pathway, where the pathway was located epicardially. N/A N/A A 23-year-old female with history of recurrent palpitations was evaluated and diagnosed as a case of WPW syndrome with right free wall pathway with structurally normal heart and normal biventricular function and failed ablation twice in 2018 and 2020. In view of recurrent symptoms, patient was started on anti-arrhythmic therapy. As the patient was refractory to flecainide, sotalol and amiodarone , she was referred to our center for a repeat ablation. Baseline ECG showed manifest pre-excitation. A standard electrophysiology study was performed under general anaesthesia with sequential endocardial and epicardial mapping approach. Retrograde ERP (effective refractory period) of the pathway was 240 ms whereas antegrade ERP was 340 ms (on amiodarone and general anaesthesia). Orthodromic atrio-ventricular reciprocating tachycardia was easily induced by programmed stimulation with a tachycardia cycle length of 470 ms with earliest atrial electrogram noted in the lateral right atrium. However, despite extensive mapping of the tricuspid annulus, ablation at the earliest endocardial site failed to terminate the tachycardia. Hence, epicardial access was obtained using Sosa’s tenchique and mapping along the tricuspid annulus was performed. At lateral tricuspid annulus epicardially, fused atrial and ventricular signals were obtained with local ventricular signal preceding the surface delta wave by 35 ms. Right coronary angiography revealed safe distance between the right coronary artery and the site of ablation. Epicardial ablation at this site led to loss of accessory pathway conduction within 5 seconds. Post ablation, no tachycardia was inducible despite aggressive pacing protocols and bidirectional AV block was demonstrated using intravenous adenosine. At 1-year follow-up, patient is asymptomatic with no evidence of accessory pathway conduction. Epicardial mapping and ablation should be considered in previously failed cases of endocardial ablation of right lateral accessory pathways.

Short RP tachycardia with Concentric atrial activation: What is the mechanism?

A 50-year old man with a structurally normal heart presented with recurrent palpitations for six months. This was in spite of a recent radiofrequency ablation at another center for a presumed diagnosis of atrio-ventricular nodal reentrant tachycardia (AVNRT). Interestingly, his first radiofrequency ablation for a tachyarrhythmia was over a decade ago, but records were unavailable. The 12 lead Electrocardiogram (ECG) revealed a short RP tachycardia at rate of 170 bpm. There was no preexcitation during sinus rhythm. Baseline intervals were normal during the ensuing electrophysiology study (EPS). The catheter positions with the annotations His (His bundle), CS (coronary sinus; proximal bipole 9-10 at CS ostium and distal bipole 1-2) and RV (right ventricle apex) are self-explanatory. A regular narrow complex tachycardia with rate related right bundle branch block (CL 280-340 ms, shortest VA 90 ms, and AH 165 ms) was reproducibly induced with a single atrial extra stimulus test (AEST) (Figure 1a). The response to maneuvers performed during tachycardia are denoted: i.e. right ventricular overdrive pacing (VOP) (Figure 1b), His refractory ventricular extra stimulus (HRVES) from the RV (Figure 1c), as well the left ventricular (LV) apex via the radiofrequency ablation catheter (RF 1-2, Figure 1d). What can be deciphered as the mechanism of this tachycardia? This article is protected by copyright. All rights reserved.

Wolff-Parkinson-White Syndrome in a Male Adult with Recurrent Palpitation: A Case Report

Wolff-Parkinson-White Syndrome in a Male Adult with Recurrent Palpitation: A Case Report

Reentrant atrial tachycardia in a patient with arrhythmogenic right ventricular cardiomyopathy

A 59-year-old man with a diagnosis of definite ARVC without overt left ventricular involvement presented with recurrent palpitations. The surface 12-lead electrocardiogram raised the suspicion of atrial tachycardia.

Arrhythmia-Induced Cardiomyopathy. A Palestinian Experience

A 20 year-old male was admitted with a history of recurrent palpitations from 5 years. Baseline ECG revealed premature ventricular contractions (PVCs) with delta waves. Stress ECG showed short non-sustained Ventricular tachycardia (VT). Echocardiography showed moderate dilation of the left ventricle with mild reduced systolic function and Ejection fraction was estimated to be 42%. Right ventricle was mildly dilated and hypokinetic. Both atria were mildly dilated. The patient referred to CVC for EP study with possible ablation. The ablation of the focus led to complete suppression of the ectopy. Post-procedure ECG and echocardiography showed normalized rhythm and systolic function.

Abstract 15038: Collateral Flow From the Right Coronary Artery Alone is Not Sufficient for Adult Alcapa: Clinical Case Report

Introduction: Myocardial ischemia in adult ALCAPA (Anomalous left coronary artery from the pulmonary artery) may lead to sudden death as the first clinical presentation. Cardiac blood supply from the right coronary artery alone is not sufficient for an adult ALCAPA. The aim of the present study was to describe a clinical case of severe myocardial ischemia in an adult female with ALCAPA supplied by the right coronary artery alone. Patient and Clinical data: 45-year-old female patient admitted to our hospital due to recurrent palpitation with tachypnoea after physical exertion for 2 years. Resting ECG on admission with ST-T changes and frequent premature ventricular contractions (PVC) indicated significant myocardial ischemia. Transthoracic echocardiography (TTE) showed dilated left ventricle (LVDd 64mm) with regional systolic dysfunction anterolateral and posterolateral with EF of 44% and dilated right coronary artery. An ALCAPA was observed with dilated caliber of 9 mm at ostium (Panel A) which was confirmed by computed tomographic angiography of the coronary artery and coronary angiography. Well-developed collateral vessels between peripheral right posterior descending (RPD) and distal left anterior descending (LAD) were demonstrated (Panel F). No collateral vessel was found between bronchial artery and ALCAPA. The bronchial arteries were visualized in normal size. The left coronary ostium was not found in the aortic root at aortography. The patient underwent anatomical reconstruction of left main coronary artery by using autologous pulmonary flap and recovered well postoperatively. Results: Postoperative ECG showed that the preoperative ST-T changes and PVC disappeared completely. Cardiac magnetic resonance imaging and TTE one month and 6 months postoperatively demonstrated continuously improved LV systolic function and myocardial perfusion posterolaterally and anterolaterally. Conclusion: Collateral flow from the right coronary artery alone is not sufficient for adult ALCAPA and completely surgical correction is necessary.

An Ayurvedic Management of Paroxysmal Supraventricular Tachycardia

Background: Paroxysmal Supraventricular Tachycardia is a type of Supraventricular tachycardia (SVT) and is defined as intermittent SVT and typically presents with a ventricular rhythm of 160 bpm. The patient morbidity with paroxysmal supraventricular tachycardia (PSVT) is directly proportional to the frequency of episodes, and it can be life-threatening in patients with atrial fibrillation and ventricular pre-excitation. Its management depends and varies according to severity of the symptoms which includes long-term treatment to surgical procedure like catheter ablation. Case Report: A 26-year Female patient, who was a known case PSVT, approached with complaints of recurrent palpitations, chest discomfort with breathing difficulty, palpitation, lightheadedness and exercise intolerance. Conclusion: the patient was diagnosed as vataja hridaroga and treated with ayurvedic medicine for the duration of 3-4 months. With the help of ayurvedic medicines, patient is free from symptoms and chronic drug therapy.

Left atrial non-Hodgkin’s lymphoma: A case report

Primary cardiac lymphoma is an extremely rare cardiac tumor. Herein, we report a 67-year-old male patient who sought medical attention for recurrent heart palpitations and left atrial mass on echocardiography. The left atrial space-occupying lesion was surgically removed. The final pathological diagnosis was cardiac non-Hodgkin’s lymphoma, and the patient’s heart palpitations and discomfort significantly improved after surgery.

Change in atrial activation pattern during ventricular pacing: What is the mechanism?

A 46-year-old lady presented to out-patient department with recurrent episodic palpitations having preexcitation on ECG. She was advised electrophysiology study (EPS) and radiofrequency ablation (RFA) This article is protected by copyright. All rights reserved.

An Unusual Case of Dense Mitral Annular Calcification in a Young with Plethora of Mitral Annular Premature Ventricular Complexes

We report a rare case of dense mitral annular calcification in a 26-year-old male presenting with recurrent palpitation for the last year with a plethora of mitral annular premature ventricular complexes (PVCs). PVCs had right bundle branch block morphology, were notched in inferior leads with negative QRS complexes in aVL suggestive of likely origin from the lateral mitral annulus. Patients with PVCs from mitral annulus are usually advised to undergo cardiac magnetic resonance imaging to localize the site of subtle mitral annular calcification and plan subsequent delivery of radiofrequency lesions at the same site during radiofrequency ablation. Dense calcification of the lateral mitral annulus is extremely rare to encounter in such a young age of below 30 years without the presence of any predisposing risk factors for calcification. Our case is the first illustration of dense mitral annular calcification secondary to the plethora of mitral annular PVCs in a symptomatic young person below the age of 30 years. PVCs-induced excessive local excursion with wear and tear phenomenon and secondary dystrophic calcification may be the plausible explanation behind this interesting presentation.

Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway and Atrial Flutter: A Case Report

A 57-year-old man presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had higher refractory period than atrioventricular node.

An Unusual Association of lEft-Sided Inferior Vena Cava with Slow-Fast Atrioventricular Reentrant Tachycardia

We report an extremely rare association of left-sided inferior vena cava (IVC) in a 38-year-old female presenting with recurrent palpitation for the past 2 years with typical slow-fast atrioventricular reentrant tachycardia (AVNRT). We delineated the course of the left-sided IVC with pigtail injection and catheter course to the right atrium and successfully modified the slow pathway with conventional catheters with difficulty in ablation catheter maneuvering and his catheter stability was an issue. Our case is the first description of an unusual association of isolated left-sided IVC in a patient with typical AVNRT.

Patent ductus arteriosus in a Nigerian adult: A case report and overview of treatment modalities

A 22-year-old university student presented to our hospital with a 7-year history of recurrent palpitation and easy fatigability, with occasional dry cough and no history of fever or weight loss. Examination revealed the presence of machinery murmur, and echocardiography revealed isolated patent ductus arteriosus (PDA). She had left thoracotomy and double ligation of the uncalcified PDA. Chest drain was inserted and she did well postoperatively, and she was discharged home on the 5th postoperative day. Postoperative echocardiography revealed no residual PDA.

Role of speckle tracking in precise localization of accessory pathway in Wolff-Parkinson-White syndrome

Background: The non-Doppler echocardiographic technique known as two-dimensional speckle tracking echocardiography (2D-STE) has been demonstrated to help assess dyssynchrony and allow quantification of cardiac deformity and timing in 2D greyscale images. This study evaluated the 2D speckle tracking role in the accessory pathway (AP) localization compared to the electrophysiology study (EPS) as the gold standard technique. Methods: This study was performed on patients with evident Wolff-Parkinson-White (WPW) syndrome who were recommended to undergo EPS and ablation. Patients were recruited based on results from the resting ECG, clinical history of recurrent palpitations, or an ECG with confirmed bouts of atrioventricular reentrant tachycardia (AVRT). The patients were evaluated using electrocardiography, conventional 2D echocardiography, and 2D-STE and were assessed for the possibility of ablation. Results: Thirteen patients were included (seven males and six females) with a mean age of 29.23 ± 9.3 years. All patients had a negative family history of WPW syndrome. ECG revealed that AP localization was posteroseptal in 4 patients (30.8%), anteroseptal in 3 (23.1%), right lateral in 2 (15.4%), left lateral in 1 (7.7%), anterolateral in 1 (7.7%), right posterior in 1 (7.7%), and left posterior in 1 (7.7%).

C9. An Extremely Rare Dual Congenital Disorder of The Heart: Aberrant Tendinous Chords with Tethering of The Tricuspid Leaflet Associated with Wolff-Parkinson-White Syndrome

Abstract Background Aberrant tendinous chords with tethering of the tricuspid leaflets is a rare congenital etiology of tricuspid regurgitation (TR), defined as abnormal insertion of tendinous cords at the clear zone of the tricuspid leaflet and connect to the endocardium instead of the papillary muscles. Wolff-Parkinson-White (WPW) syndrome defined as a congenital condition involving additional conductive cardiac tissue between the atria and the ventricles that provides a pathway for a reentrant tachycardia circuit. Ebstein's anomaly (EA) is the most commonly occurring congenital abnormality that caused TR associated with the WPW. Until now, there is no case report of aberrant tendinous chords with tethering of the tricuspid leaflets that associated with WPW. Case Illustration A 26-year-old female with history of recurrent palpitation she was given was referred to our hospital. Resting ECG revealed sinus rhythm with delta wave suggesting diagnostic of WPW. On physical examination we found loud systolic murmur on left lower sternal border. Echocardiography examination revealed dilated right atrial and right ventricle, severe tricuspid regurgitation with restricted septal TV caused by aberrant tendinous chords. No apical displacement of tricuspid leaflet >8 mm/m2 excluding the diagnosis of EA. Discussion Both WPW and aberrant tendinous chords with tethering of the tricuspid leaflet are rare congenital disorder of the heart. EA is most common congenital TR associated with WPW, there are rarely reported other congenital TR associated with WPW. This case illustrates extremely rare case where we found both WPW and Aberrant Tendinous Chords.