Simultaneous Angiography Research Articles

Abstract 11601: Single-Volume Quantitative CT Myocardial Perfusion Measurement - Validation in a Swine Model

Introduction: Dynamic CT myocardial perfusion imaging enables accurate assessment of coronary artery disease (CAD). However, it is limited by the high radiation dose of serial acquisition of 10 or more volume scans per exam. Hypothesis: A single-volume quantitative CT myocardial perfusion technique can accurately measure perfusion in mL/min/g at a low radiation dose, as compared to microsphere perfusion measurement. Methods: The single-volume quantitative CT perfusion technique was validated in 6 swine (37 ± 8 kg). In each swine, several intermediate severity stenoses were induced in the left anterior descending (LAD) coronary artery using a balloon under intracoronary adenosine stress. Contrast-enhanced imaging was performed at 100 kVp and 200 mA with a 320-slice CT scanner, where 20 consecutive volume scans were acquired to capture the entire aortic enhancement curve. The image data were then used retrospectively to simulate prospective 2-mm-slice dynamic bolus tracking with aortic triggering at 150 HU followed by “acquisition” of a single volume scan at approximately the peak of the aortic enhancement: identical to a coronary CT angiogram. The dynamic bolus tracking, trigger, and single volume scan data were then used as analytical inputs into a novel first-pass analysis model to derive perfusion in mL/min/g. The accuracy versus microsphere perfusion was assessed via regression analysis. Results: Single-volume quantitative CT perfusion measurements (P CT ) were related to microsphere perfusion measurements (P MICRO ) by P CT = 1.00 P MICRO - 0.05 (Pearson’s r = 0.96; RMSE = 0.48 mL/min/g). The average CT dose index of the technique was only 5.4 mGy. Conclusions: The single-volume quantitative CT perfusion technique provides accurate, low-dose, myocardial perfusion measurement in mL/min/g using only bolus tracking images and a single volume scan. The technique can also provide simultaneous CT angiography when acquired at an appropriate radiation dose.

Abstract No. 512 Direct percutaneous treatment of peripheral vascular pathology

Abstract No. 512 Direct percutaneous treatment of peripheral vascular pathology

Results of treatment of patients with combined atherosclerotic lesions of the cerebral and coronary arteries who underwent carotid endarterectomy at different terms before aortic-coronary bypass surgery.

The quality of life of patients after surgical interventions in those of with combined atherosclerotic lesions of the cerebral and coronary arteries remains a topical issue of modern medicine. The purpose of the study: to analyze the results of treatment of patients with combined atherosclerotic lesions of the cerebral and coronary arteries in the temporal aspect, who underwent carotid endarterectomy as the first stage of treatment. The results of treatment of 112 patients were analyzed. All patients underwent simultaneous cerebral and coronary angiography. After the operation, if new neurological symptoms appeared or a cardiological pathology progressed, the angiographic study was performed again, and the results of this study were used to decide on further tactics. Treatment results were evaluated 30 days, 5 and 10 years after ACBS. With the revealed indications for ACBS, hemodynamically significant stenoses of the operated carotid artery were found in 10.7% of patients. Stenoses of other cerebral vessels that required surgical correction (opposite ICA, VA) in 7.1%. These patients had cerebral artery stenting before ACBS. In 9.8% of patients, indications were found for stenting of cerebral and coronary arteries, which were performed in one session. In 5.4%, only coronary artery stenting was performed. In the remaining 75 patients without indicated surgical correction of cerebral arteries ACBS was performed. So, in 3-5 years after CEE, ACBS was performed in 35 patients, later than in 5 years – in 40 patients. In the postoperative period, ACBS TIA was registered only in 4%, ischemic stroke – in 5.3%. The total lethality rate is 4%. The 10-year survival rate after myocardial revascularization was 46% [CI 95% 58%; 34%]. the most intensive decrease in survival function was registered during the first 5 years of follow-up (5-year survival rate 60% [71%; 48%]. Carotid endarterectomy is an effective method of treating atherosclerotic stenosis of the ICA and a method of preventing neurological complications in patients with combined atherosclerotic lesions of the cerebral and coronary arteries with the progression of cardiac pathology.

Single arm access venous sinus stenting (SAVeS) technique: Technical note.

Intracranial venous sinus stenting is gaining acceptance as an effective treatment for idiopathic intracranial hypertension (IIH). The typical approach is via femoral venous and arterial access for transvenous stenting with simultaneous angiography. These patients are at an above average risk for groin complications considering obesity is typically associated with IIH and the need for heparinization and dual antiplatelet therapy. Here, we describe cerebral venography, angiography, and venous sinus stenting via a single upper extremity. We utilize a transradial approach for angiography and a venous access via the brachial or basilic vein. Over a series of 28 consecutive procedures, we were able to successfully access the intracranial venous sinuses via the arm without access site complications. This method offers the advantages of immediate patient mobilization after the procedure and more easily monitored and compressible access sites for easier post-procedural care.

Accelerated high-resolution free-breathing 3D whole-heart T2-prepared black-blood and bright-blood cardiovascular magnetic resonance

BackgroundThe free-breathing 3D whole-heart T2-prepared Bright-blood and black-blOOd phase SensiTive inversion recovery (BOOST) cardiovascular magnetic resonance (CMR) sequence was recently proposed for simultaneous bright-blood coronary CMR angiography and black-blood late gadolinium enhancement (LGE) imaging. This sequence enables simultaneous visualization of cardiac anatomy, coronary arteries and fibrosis. However, high-resolution (< 1.4 × 1.4 × 1.4 mm3) fully-sampled BOOST requires long acquisition times of ~ 20 min.MethodsIn this work, we propose to extend a highly efficient respiratory-resolved motion-corrected reconstruction framework (XD-ORCCA) to T2-prepared BOOST to enable high-resolution 3D whole-heart coronary CMR angiography and black-blood LGE in a clinically feasible scan time. Twelve healthy subjects were imaged without contrast injection (pre-contrast BOOST) and 10 patients with suspected cardiovascular disease were imaged after contrast injection (post-contrast BOOST). A quantitative analysis software was used to compare accelerated pre-contrast BOOST against the fully-sampled counterpart (vessel sharpness and length of the left and right coronary arteries). Moreover, three cardiologists performed diagnostic image quality scoring for clinical 2D LGE and both bright- and black-blood 3D BOOST imaging using a 4-point scale (1–4, non-diagnostic–fully diagnostic). A two one-sided test of equivalence (TOST) was performed to compare the pre-contrast BOOST images. Nonparametric TOST was performed to compare post-contrast BOOST image quality scores.ResultsThe proposed method produces images from 3.8 × accelerated non-contrast-enhanced BOOST acquisitions with comparable vessel length and sharpness to those obtained from fully- sampled scans in healthy subjects. Moreover, in terms of visual grading, the 3D BOOST LGE datasets (median 4) and the clinical 2D counterpart (median 3.5) were found to be statistically equivalent (p < 0.05). In addition, bright-blood BOOST images allowed for visualization of the proximal and middle left anterior descending and right coronary sections with high diagnostic quality (mean score > 3.5).ConclusionsThe proposed framework provides high‐resolution 3D whole-heart BOOST images from a single free-breathing acquisition in ~ 7 min.

A two-year study of diffused retinal pigment epitheliopathy treated with half-dose photodynamic therapy guided by simultaneous angiography and optical coherence tomography

ObjectivesDiffused retinal pigment epitheliopathy (DRPE) is not necessarily the same as chronic central serous chorioretinopathy (CSC), but a severe subgroup under the umbrella of chronic CSC. This study was to evaluate the efficacy and safety of half-dose PDT treating DRPE.MethodsA retrospective case series design was used. Forty-eight consecutive patients (48 eyes) with DRPE treated with half-dose PDT underwent follow-up at baseline, 3 months, 6 months, 12 months and 24 months. Simultaneous FA, ICGA and OCT were used for the treatment and follow-up. The primary outcomes were the subretinal fluid and best-corrected visual acuity in optical coherence tomography.ResultsComplete fluid absorption was achieved in 95.8% of eyes at 3 months and 100.0% of eyes at 24 months. The baseline logarithm of the minimum angle of resolution (logMAR) BCVA, which was 0.51 ± 0.36, significantly improved to 0.43 ± 0.38 (p < 0.001) at 6 months. The boost continued to 0.29 ± 0.37 (p < 0.001) at 12 months and 0.19 ± 0.39 (p < 0.001) at 24 months. The integrities of the ellipsoid zone (EZ) and interdigitation zone (IZ) improved throughout. Regression analyses showed the BCVA in logMAR was inversely correlated with the EZ (p < 0.01) and IZ (p < 0.01). The recurrence rate was 6.3%. No severe complications were witnessed.ConclusionsIn 48 eyes with DRPE, simultaneous angiography and OCT facilitated a more comprehensive guidance for half-dose PDT treatment and follow-up. The BCVA improvement occurred at 6 months, which may be attributed to the restoration of the outer retinal structure.

Multislice spiral computed tomography of the heart in dilated cardiomyopathy: possibilities in the verification of myocarditis (in comparison with myocardial biopsy) and in the evaluation of prognosis

To investigate whether intravenous contrast-enhanced multislice spiral computed tomography (computed tomography) (MSCT) versus myocardial morphological examination can diagnose myocarditis and the non-inflammatory causes of dilated cardiomyopathy (DCM) and evaluate prognosis in patients with the latter. A study group consisted of 130 patients, including 95 men (46.8±11.9 years), with DCM (mean left ventricular (LV) end-diastolic dimension (EDD), 6.6±0.8 cm; mean LV ejection fraction (EF), 29.8±9.3%; NYHA functional class (FC) III (II; III)). All the patients underwent intravenous contrast-enhanced 320-slice CT of the heart; myocardial morphological examination was made in 48 patients (endomyocardial biopsy in 29 patients, intraoperative biopsy in 7, and autopsy in 9, and study of the explanted heart in 3). In addition, cardiotropic viral DNA in the blood and myocardium and the level of anticardiolipin antibodies were determined; echocardiography (in all the patients), scintigraphy (n = 45), magnetic resonance imaging (MRI) (n = 21), and coronary angiography (CG) (n = 46), and a genetic consultation were performed. A comparison group comprised 20 patients, including 14 men (69.3±9.2 years), with coronary atherosclerosis (40% or more stenoses) according to MSCT findings in the absence of criteria for DCM (mean LV EDD, 4.8±0.5 cm; mean LV EF, 59.4±4.6%). Morphological/comprehensive examination showed that myocarditis as a cause of DCM was diagnosed in 76 (65%) patients; its concurrence with genetic cardiomyopathies was in 17 more patients (17%). MSCT of the heart revealed lower accumulation areas in 2 (1.5%) patients (type 1 based on the proposed rating scale), delayed myocardial contrast agent accumulation (DMCAA) in 81 (62.3%): subendocardial accumulation (type 2) in 8, intramyocardial accumulation in 4 (type 3), subepicardial accumulation in 52 (type 4), and transmural accumulation in 15 (type 5); DMCAA was not noted in 49 patients. DMCAA was not found in the comparison group. As compared with biopsy, the sensitivity, specificity, predictive value of positive and negative results of the tests in detecting active myocarditis for all the types of DMCAA were 77.4, 47.1, 72.7, and 53.3%, respectively; those for types 3-5 of DMCAA were 77.4, 52.9, 75.0, and 56.3%; those in detecting all the morphological types of myocarditis were 68.3, 28.6, 84.8, and 13.3%, and those for types 3-5 were 65.9, 28.6, 84.4, and 12.5%, respectively. Comparison of the data of MSCT and those of comprehensive examination in all the patients with DCM, the diagnostic significance in detecting myocarditis for all the types of DMCAA was 70.6, 67.9, 88.9 and 38.8%, respectively; that for DMCAA types 3-5 was 60.8, 67.9, 87.3, and 32.3%. In the study group, MSCT also identified the non-compacted myocardium (n = 31 (23.8%)), coronary atherosclerosis (n = 31 (23%)), which is confirmed by CG findings in 15 patients. The patients with DMCAA significantly more frequently showed a relationship with previous infection, acute onset, significantly higher NYHA FCs, end-diastolic and end-systolic LV volumes, and insignificantly lower LV EF. During a mean follow-up periods of 12 (6; 37.25) months, the overall mortality rate was 17.7% (23 deaths); the death + transplantation index was 20% (n = 26). All the types of DMCAA were found to be significantly related to prognosis: in the DMCAA group, the mortality rate was 21.5% versus 7.8% in the non-DMCAA group (odds ratio 3.22; 95% confidence interval, 1.02 to 10.21; p < 0.05). MSCT with the assessment of delayed contrast enhancement (and simultaneous CT coronary angiography) can be used for the non-invasive diagnosis of myocarditis in patients with DCM, including that in the presence of contraindications to MRI. DMCAA correlates with the presence of myocarditis, its activity, the degree of functional disorders, and prognosis.

3D whole-heart phase sensitive inversion recovery CMR for simultaneous black-blood late gadolinium enhancement and bright-blood coronary CMR angiography

BackgroundPhase sensitive inversion recovery (PSIR) applied to late gadolinium enhancement (LGE) imaging is widely used in clinical practice. However, conventional 2D PSIR LGE sequences provide sub-optimal contrast between scar tissue and blood pool, rendering the detection of subendocardial infarcts and scar segmentation challenging. Furthermore, the acquisition of a low flip angle reference image doubles the acquisition time without providing any additional diagnostic information. The purpose of this study was to develop and test a novel 3D whole-heart PSIR-like framework, named BOOST, enabling simultaneous black-blood LGE assessment and bright-blood visualization of cardiac anatomy.MethodsThe proposed approach alternates the acquisition of a 3D volume preceded by a T2-prepared Inversion Recovery (T2Prep-IR) module (magnitude image) with the acquisition of a T2-prepared 3D volume (reference image). The two volumes (T2Prep-IR BOOST and bright-blood T2Prep BOOST) are combined in a PSIR-like reconstruction to obtain a complementary 3D black-blood volume for LGE assessment (PSIR BOOST). The black-blood PSIR BOOST and the bright-blood T2Prep BOOST datasets were compared to conventional clinical sequences for scar detection and coronary CMR angiography (CMRA) in 18 patients with a spectrum of cardiovascular disease (CVD).ResultsDatasets from 12 patients were quantitatively analysed. The black-blood PSIR BOOST dataset provided statistically improved contrast to noise ratio (CNR) between blood and scar when compared to a clinical 2D PSIR sequence (15.8 ± 3.3 and 4.1 ± 5.6, respectively). Overall agreement in LGE depiction was found between 3D black-blood PSIR BOOST and clinical 2D PSIR acquisitions, with 11/12 PSIR BOOST datasets considered diagnostic. The bright-blood T2Prep BOOST dataset provided high quality depiction of the proximal coronary segments, with improvement of visual score when compared to a clinical CMRA sequence. Acquisition time of BOOST (~10 min), providing information on both LGE uptake and heart anatomy, was comparable to that of a clinical single CMRA sequence.ConclusionsThe feasibility of BOOST for simultaneous black-blood LGE assessment and bright-blood coronary angiography was successfully tested in patients with cardiovascular disease. The framework enables free-breathing multi-contrast whole-heart acquisitions with 100% scan efficiency and predictable scan time. Complementary information on 3D LGE and heart anatomy are obtained reducing examination time.

Monocyte-endothelial cell interactions in the regulation of vascular sprouting and liver regeneration in mouse

Regeneration of the hepatic mass is crucial to liver repair. Proliferation of hepatic parenchyma is intimately dependent on angiogenesis and resident macrophage-derived cytokines. However the role of circulating monocyte interactions in vascular and hepatic regeneration is not well-defined. We investigated the role of these interactions in regeneration in the presence and absence of intact monocyte adhesion. Partial hepatectomy was performed in wild-type mice and those lacking the monocyte adhesion molecule CD11b. Vascular architecture, angiogenesis and macrophage location were analyzed in the whole livers using simultaneous angiography and macrophage staining with fluorescent multiphoton microscopy. Monocyte adhesion molecule expression and sprouting-related pathways were evaluated. Resident macrophages (Kupffer cells) did not migrate to interact with vessels whereas infiltrating monocytes were found adjacent to sprouting points. Infiltrated monocytes colocalized with Wnt5a, angiopoietin 1 and Notch-1 in contact points and commensurate with phosphorylation and disruption of VE-cadherin. Mice deficient in CD11b showed a severe reduction in angiogenesis, liver mass regeneration and survival following partial hepatectomy, and developed unstable and leaky vessels that eventually produced an aberrant hepatic vascular network and Kupffer cell distribution. Direct vascular interactions of infiltrating monocytes are required for an ordered vascular growth and liver regeneration. These outcomes provide insight into hepatic repair and new strategies for hepatic regeneration.

Morphologic features of focal choroidal excavation on spectral domain optical coherence tomography with simultaneous angiography.

To reveal clinically relevant morphologic findings in patients with focal choroidal excavation (FCE) using enhanced depth imaging optical coherence tomography. Thirty-one FCE lesions in 29 eyes of 26 patients (21 men, 23 eyes; 5 women, 6 eyes) were studies. In all 26 patients, color fundus photographs were obtained, and fluorescein angiography and indocyanine green angiography with simultaneous enhanced depth imaging optical coherence tomography were performed. Twenty-five eyes also underwent angiographic video recording. Focal choroidal excavation was detected in eyes with typical age-related macular degeneration, central serous chorioretinopathy, polypoidal choroidal vasculopathy, and idiopathic choroidal neovascularization, whereas in 8 eyes, FCE was considered to be idiopathic. Morphologically, FCE lesions were classified into 3 types: cone-shaped, bowl-shaped, and mixed. The cone-shaped type was detected in 17 lesions, bowl-shaped in 8, and mixed in 6, on optical coherence tomography findings. All bowl-shaped and mixed types had retinal pigment epithelial irregularities within the FCE lesion. The cone-shaped type was not observed in eyes with typical age-related macular degeneration. Morphologically, FCE lesions were classified into cone-shaped, bowl-shaped, and mixed types, based on optical coherence tomography findings. Focal choroidal excavation formation may be associated in part with chorioretinal diseases such as age-related macular degeneration and central serous chorioretinopathy, whereas some eyes are considered to have idiopathic FCE.

Native atretic coarctation of the aorta in a 37-year-old hypertensive woman, treated with a low-profile covered stent

We report on a 37-year-old woman with essential systemic hypertension. An MRI was performed because of weak femoral pulses, depicting a severe almost atretic coarctation of the aorta (Fig. 1). Angiography of the proximal distal thoracic aorta was simultaneously performed (Fig. 2a). The transverse arch was narrow (16 mm), as was the diameter of the terminal aortic arch distal to the left subclavian artery (10 mm). Distal of the coarctation the diameter of the descending aorta was 11 mm. A trajectory of 2 mm in length seemed atretic. The atretic segment could be crossed in an antegrade fashion with a straight 0,014 in. coronary wire and balloon pre-dilatation was performed with a 5 mm coronary balloon. Thereafter, a multi-purpose catheter could be advanced retrogradely across the coarctation segment. A 9 French Mullins sheath (Cook) was advanced to the transverse aortic arch. A 41 mm long Advanta V12 premounted covered stent (Atrium, Hudson, USA) on a 12 mm high pressure balloon was implanted. Consecutive angiography revealed complete expansion of the stent up to 12 mm without residual stenosis, and no aneurysm formation (Fig. 2b). Fig. 1 MRI imaging of the left ventricle (LV), ascending aorta (AAo). The left subclavian artery (LSA) is dilated and the descending aorta (DAo) is hypoplastic. The coarctation imposes as atresia. There are numerous collaterals. RV: right ventricle Fig. 2 a Simultaneous angiography of the proximal and distal descending aorta; anterior projection. Atretic coarctation (CoA). Some small collaterals can be seen right of the coarctation. Abbreviations: Cath: catheter, DAo: descending aorta, LSA: left subclavian ... In conclusion, treatment with placement of a low-profile covered stent, using a simultaneous radial and femoral approach and pre-dilatation, delivered an excellent result without complications and a short hospital stay. The patient’s blood pressure returned to normal and her antihypertensive medication could be stopped within 3 weeks after stent implantation. We emphasise that in so-called ‘unexplained’ systemic hypertension, especially in young adults, coarctation of the aorta has to be excluded [1, 2]. When coarctation is confirmed primary stenting is the first choice therapeutic option [3–5].

Simultaneous intracranial angiography and intraplaque hemorrhage imaging using SNAP

Background Intracranial atherosclerotic disease (IAD) accounts for 9-15% of all stroke incidents in the US [1], and the ratio is even higher in some racial groups [2]. Although angiography based imaging remains the prevalent diagnostic tool for IAD detection, it’s unable to detect high risk lesions via direct visualization of the vessel wall. Lesions with intraplaque hemorrhage (IPH) on the carotid arteries have been associated with significantly increased clinical symptoms and plaque progress. An imaging tool that can detect both the luminal stenosis and high risk vessel wall disease is of clinical importance for IAD patient management. In this study, the recently proposed SNAP [3] technique was particularly optimized to simultaneously detect luminal stenosis and IPH for IAD patients.

Pitfalls in colour photography of choroidal tumours

Colour imaging of fundus tumours has been transformed by the development of digital and confocal scanning laser photography. These advances provide numerous benefits, such as panoramic images, increased contrast, non-contact wide-angle imaging, non-mydriatic photography, and simultaneous angiography. False tumour colour representation can, however, cause serious diagnostic errors. Large choroidal tumours can be totally invisible on angiography. Pseudogrowth can occur because of artefacts caused by different methods of fundus illumination, movement of reference blood vessels, and flattening of Bruch's membrane and sclera when tumour regression occurs. Awareness of these pitfalls should prevent the clinician from misdiagnosing tumours and wrongfully concluding that a tumour has grown.

Teaching Neuro Images :Simultaneous angiography and ultrasonography in extracranial internal carotid artery dissection

A 26-year-old woman was admitted with amaurosis fugax in the left eye and transient aphasia. Diffusion-weighted MRI revealed a small infarction in the left insular cortex. Transoral carotid ultrasonography (TOCU)1 demonstrated left ICA dilatation with narrowing of the true lumen and intramural mass (figure 1A), which was consistent …

Simultaneous coronary angiography during titration of radiofrequency energy for ablation of left ventricular summit tachycardia in the ‘inaccessible area’

A 45-year-old patient with an implantable cardioverter defibrillator and a decreased left ventricular (LV) ejection fraction (40%) due to non-ischaemic cardiomyopathy was referred for ablation of recurrent LV outflow tract tachycardia. Endocardial and coronary venous mapping revealed earliest electrical activation within the distal great cardiac vein (GCV). Endocardial LV ablation was unsuccessful and …

Reply to Dainese

We thank Dr Dainese from Milan for his comments [1], although we are a little surprised by his first comment. As was already stated in our paper [2], our first implantation was done on 16 December 2008, our second implantation was done in January 2009 and Dainese [3] performed an implantation on 3 February 2009. Nevertheless, we would like to congratulate Dr Dainese and his colleagues and we acknowledge his contribution to this new field of valve treatment. In the interests of correctness of information, we would also like to draw attention to the first published report regarding TAVI in a degenerated homograft [4] written by Schmoeckel et al. and published in October 2009 in the same journal ( JTCVS) as the paper by Dr Dainese [3]. The colleagues from Munich performed the reported procedure in 2009, as was stated in their publication [4]. Therefore, according to both the contemporary literature and information from the valve manufacturing company, the first ‘TAVI in homograft’ procedure with a balloon expandable valve was done in December 2008 (in Berlin), the second in January 2009 in Berlin and then in Milan (February 2009) and Munich (in 2009). We completely agree with Dr Dainese that conventional reoperation in patients with homograft degeneration may be a challenging procedure, either because of the patients’ comorbidities or because of completely calcified homograft (so-called ‘porcelain aorta’). As pointed out by Dr Dainese, TAVI represents a valid alternative in these cases. We also agree with Dr Dainese about the modified implantation technique [5]. We have used a similar technique almost from the very beginning of the TAVI programme at our institution in April 2008 [6]. We additionally prefer to perform simultaneous angiography during slow and gradual valve deployment which enables perfect visualization of the aortic root and the coronary arteries and fine adjustment to the position of the new valve [6].

First implantation of the CE-marked transcatheter Sapien pulmonic valve in Europe

First implantation of the CE-marked transcatheter Sapien pulmonic valve in Europe

Abstract 5690: Idiopathic Catecholamine-sensitive Epicardial Ventricular Tachycardia At The Crux Of The Heart

Idiopathic ventricular tachycardia (VT) has been described from the epicardial surface of the left ventricle (LV), usually near the summit of the LV in the outflow tract. Ablation of these VTs may be possible by delivery of energy within the coronary venous system or directly on the epicardial surface. We describe a distinct syndrome of focal epicardial VT induced by catecholamine infusion that arises from the crux of the heart. Among 340 cases of idiopathic VT referred for catheter ablation, 4 patients were identified with a clinical syndrome of catecholamine sensitive VT that was mapped to the epicardial surface at the crux of the heart. There were 3 males and 1 female (age 31–79 yrs, mean 58). VT was sustained in all patients and associated with syncope or near syncope in 3 of 4 pts. The LVEF was &gt;0.55 in 3 pts and mildly depressed (0.45) in 1 pt. In all pts VT could be induced with programmed stimulation or burst pacing from the right ventricular apex but required the infusion of isoproterenol for induction in 3. The VT was very rapid with a mean cycle length of 264 msec. The surface ECG during VT demonstrated a left superior axis QRS morphology in all pts, with an abrupt precordial tansition from V1 to V2 in 3 pts and R waves across the precordium in one. The precordial maximal deflection index was &gt; 0.55 in all pts (mean 0.67). The site of earliest activation during intracardiac mapping occurred at the crux of the heart with activation in the middle cardiac vein or proximal coronary sinus recorded 20 –50 msec (mean −38 msec) prior to the onset of the surface QRS. Catheter ablation with irrigated RF was attempted within the middle cardiac vein or proximal coronary sinus in all pts and was successful in 1. In 2 of 3 remaining pts, percutaneous epicardial RF ablation was attempted and was successful. Simultaneous coronary angiography demonstrated the site of earliest activation within 5–10 mm of the proximal posterior descending coronary artery (PDA). There was no acute narrowing of the PDA in any pt following ablation. Idiopathic VT may arise from the epicardial surface at the crux of the heart in close proximity to the PDA. This syndrome can result in very rapid, catecholamine sensitive VT, and may require careful attention to the PDA during ablation.

Right Ventricular Outflow Tract Reconstruction With Contegra Bovine Valved Conduit

A 11-year-old boy affected by truncus arteriosus (type 1) underwent a late complete repair in another institution. The right ventricular outflow tract reconstruction was performed with an 18-mm Contegra conduit (Medtronic Inc, Minneapolis, Minn) despite its contraindication in cases of pulmonary hypertension. An additional apical muscular ventricular septal defect was closed with a percutaneous device. His postoperative course was uneventful. At 18 years of age, he was referred to our institution for right ventricular dilatation and conduit endocarditis. A group D streptococcus was isolated on blood culture. Echocardiography and cardiac catheterization showed right ventricular dilatation, isosystemic right ventricular pressure, and aneurysmal dilatation …

Reperfusion ventricular arrhythmia 'bursts' in TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction: a more precise definition of reperfusion arrhythmias

We sought to define reperfusion-induced ventricular arrhythmias (VAs) more precisely through simultaneous angiography, continuous ST-segment recovery, and beat-to-beat Holter analyses in subjects with anterior ST-elevation myocardial infarction (STEMI) undergoing primary angioplasty [percutaneous coronary intervention (PCI)]. All 157 subjects with final TIMI 3 flow had continuous 12-lead electrocardiography with simultaneous Holter recording initiated prior to PCI for continuous ST-segment recovery and quantitative VA analyses. Ventricular arrhythmia bursts were detected against subject-specific background VA rates using a statistical outlier method. For temporal correlations, timing and quality of reperfusion were defined as first angiographic TIMI 3 flow with >or=50% stable ST-segment recovery. Almost all subjects had VAs [156/157 (99%)], whereas VA bursts during or subsequent to reperfusion occurred in 97/157 (62%). The majority of VA bursts (72%) arose within 20 min of reperfusion (95% CI: 26.7, 72), with onset at a median of 4 min post-reperfusion (IQR: 0-43) Bursts comprised a median of 1290 ventricular premature complexes (VPCs) (IQR: 415-4632) and persisted for a median of 105 min (IQR: 35-250). Most background VAs occurred as single VPCs; bursts typically comprised runs of three or more VPCs. Subjects with bursts had higher absolute peak ST segments and more frequent worsening of ST elevation immediately after reperfusion. Ventricular arrhythmia bursts temporally associated with TIMI 3 flow restoration and stable ST-segment recovery (reperfusion VA bursts) can be precisely defined in subjects with anterior STEMI and may constitute a unique electric biosignal of myocellular response to reperfusion.