Antiarrhythmic drugs management in patients with atrial fibrillation: the new guidelines

Antiarrhythmic drug therapy will continue to play an important role in the treatment of atrial fibrillation (AF). Pharmacological therapy is focused on AF symptom relief and on prevention of tachycardiomyopathy. The choice between the various anti-arrhythmic drugs available, either for rate or rhythm control, mainly depends on the underlying cardiac disease, type of AF and possible side-effects. New anti-arrhythmic drugs in the guidelines vernakalant and dronedarone are promising, but further research is required to explore their role in treatment of patients with AF. In this review, we will discuss the role of antiarrhythmic drugs in management of patients with AF according to the new AF guidelines of the European Society of Cardiology.

Paradoxical effects of interatrial conduction delay in a hypertrophic cardiomyopathy patient in the long-term: time is a great healer

We present a unique case where early proarrhythmic and late antiarrhythmic characteristics of interatrial conduction delay were observed during the long-term progression of HCM. Occurrence of AT constantly increased as the interatrial conduction delay became more prominent, while the P-wave width in sinus rhythm and the AT cycle length both showed an instantaneous increase in parallel. As the interatrial delay reached a critical point, the right and left atrial P-wave became virtually separated, as demonstrated by the findings of ECGs and echocardiography. This phenomenon resulted in the complete cessation of tachycardias.

Migraine accompagnée after transseptal puncture

Migraine has never been reported as a complication of transseptal puncture for ablation of atrial fibrillation. We studied its incidence before and after such procedures after observing some striking new migraine in several patients. A total of 8% of procedures for pulmonary vein isolation with a 15 Fr sheath used for transseptal puncture were associated with new headache with ocular symptoms or migraine within three months. Exacerbation of pre-existing migraine was reported in another 7% of procedures. More complaints were seen in redo procedures. The questionnaires were performed at three months after the intervention and there was no more evidence of persisting flow over the atrial septum at that time, when most complaints had already disappeared. This has important implications for follow-up after ablation for atrial fibrillation. (Neth Heart J 2010;18:374-5.).

An in vivo comparison of radiofrequency cardiac lesions formed by standard and magnetically steered 4 mm tip catheters

Background. In vivo comparison of cardiac radiofrequency ablation lesions between standard and magnetically steered 4 mm tip catheters has never been reported.Methods. High and low right atrium (RA) free wall, isthmus, right ventricle (RV) free wall and outflow tract lesions were studied macroscopically and microscopically five days after lesion formation in seven pigs. Shape, size, thrombus formation, and ablation parameters were compared. The effect of minimal, medium and high wall contact was assessed by a contact measurement utility for magnetic catheters.Results. All 14 RA free wall lesions were transmural with a similar epicardial and endocardial surface area. In the RV, the epicardial area usually appeared to be smaller than the endocardial area with standard catheters. Isthmus lesions were difficult to assess transmurality. There was no difference in endocardial area: standard 39 mm(2) (range 16 to 82 mm(2)) vs. magnetic 36 mm(2) (range 23 to 111 mm(2)). If the catheter tip was perpendicular to the tissue, magnetic lesions were more often round or oval, while standard lesions were more often elongated (p<0.05). When the catheter tip was parallel to tissue, lesions always tended to be elongated. Microscopic characteristics were similar. The contact utility was not useful. Average impedance (p<0.0001) and energy delivered (p<0.05) were less with magnetic catheters.Conclusion. Lesions from magnetically steered catheters are transmural of similar size, but with less variability than standard catheter lesions when the tip is perpendicular to the tissue. Magnetic lesions are associated with lower impedance and energy delivery. This suggests a more stable tip-to-tissue contact. (Neth Heart J 2010;18:66-71.).

Recurrence of cardiac arrest after 14 years without ICD interventions: a VF cluster immediately after delivery

One day after childbirth, a 29-year-old woman had several episodes of polymorphic ventricular tachycardia and ventricular fibrillation. She was rescued by an internal cardioverter defibrillator (ICD) which she had received 14 years ago, after out-of-hospital cardiac arrest, without recurrences until now. The electrocardiogram showed a normal QT interval, and ventricular premature beats, which seemed to arise from the same site. This case report illustrates that, even after years with freedom of ICD therapy, depleted devices still have to be replaced. (Neth Heart J 2008;16:242-5.).