Which patient should be referred to an electrophysiologist: supraventricular tachycardia

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Left Atrial Intramural Hematoma Post-Ablation of Supraventricular Tachycardia: A Rare Complication Treated Successfully

We report successful management of left atrial hematoma after ablation of supraventricular tachycardia. A 43-year-old female patient experienced chest pain immediately after radiofrequency ablation of a symptomatic left posterolateral accessory pathway. Transthoracic echocardiography demonstrated a large mass occupying the left atrium. Computed tomography and transesophageal echocardiography results were consistent with posterolateral intramural hematoma. She became hemodynamically unstable, requiring emergent surgery. The mass resolved completely by 6 weeks. (Level of Difficulty: Beginner.)

Atrial and ventricular tachyarrhythmias in military personnel

Although rare, sudden cardiac death does occur in British military personnel. In the majority of cases, the cause is considered to be a malignant ventricular tachyarrhythmia, which can be precipitated by a number of underlying pathologies. Conversely, a tachyarrhythmia may have a more benign and treatable cause, yet the initial clinical symptoms may be similar, making differentiation difficult. This is an overview of the mechanisms underlying the initiation and propagation of arrhythmias and the various pathological conditions that predispose to arrhythmia genesis, classified according to which parts of the heart are involved: atrial tachyarrhythmias, atrial and ventricular, as well as those affecting the ventricles alone. It encompasses atrial tachycardia, atrial flutter, supraventricular tachycardias and ventricular tachycardias, including the more commonly encountered inherited primary electrical diseases, also known as the channelopathies. The clinical features, investigation and management strategies are outlined. The occupational impact-in serving military personnel and potential recruits-is described, with explanations relating to the different conditions and their specific implication on continued military service.

Single-beat noninvasive imaging of cardiac electrophysiology of ventricular pre-excitation

OBJECTIVES

The aim of this study was to determine whether noninvasive imaging of cardiac electrophysiology (NICE) is feasible in patients with Wolff-Parkinson-White (WPW) syndrome in the clinical setting of a catheter laboratory and to test the accuracy of the noninvasively obtained ventricular activation sequences as compared with that of standard invasive electroanatomic mapping.

BACKGROUND

NICE of ventricular activation could serve as a useful tool in the treatment of cardiac arrhythmias and might help improve our understanding of arrhythmia mechanisms.

METHODS

NICE works by fusing the data from high-resolution electrocardiographic mapping and a model of the patient's cardiac anatomy obtained by magnetic resonance imaging. The ventricular activation sequence was computed with a bidomain theory-based heart model to solve this inverse problem. Noninvasive imaging of cardiac electrophysiology was performed in 7 patients with WPW syndrome undergoing catheter ablation of the accessory pathway. The position error of NICE was defined as the distance between the site of earliest activation computed by NICE and the successful ablation site identified by electroanatomic mapping (CARTO; Biosense Webster, Diamond Bar, California) for normal atrioventricular (AV) conduction as well as for adenosine-induced AV block.

RESULTS

The error introduced by geometric coupling of the CARTO data and the NICE model was 5 +/- 3 mm (model discretization 10 mm). All ventricular accessory pathway insertion sites were identified with an accuracy of 18.7 +/- 5.8 mm (baseline) and 18.7 +/- 6.4 mm (adenosine).

CONCLUSIONS

The individual cardiac anatomy model obtained for each patient enables accurate noninvasive electrocardiographic imaging of ventricular pre-excitation in patients with WPW syndrome. Noninvasive imaging of cardiac electrophysiology might be used as a complementary noninvasive approach to localize the origin and help identify and understand the underlying mechanisms of cardiac arrhythmias.