Resynchronization with left ventricle lead placement through the foramen ovale

Left ventricle (LV) lead placement in a coronary sinus branch for cardiac resynchronization therapy may fail because of anatomical variants, phrenic nerve stimulation, and/or lead instability. We report a case of successful resynchronization from a lead inserted from the left subclavian vein and positioned through a patent foramen ovale (PFO). In conclusion, endocardial LV lead insertion through a PFO enables effective resynchronization delivery without the risks associated with a thoracotomy or atrial transseptal puncture.

Reverse Remodeling with Resynchronization in an Asymptomatic Patient with Dilated Hypokinetic Cardiomyopathy

Cardiac resynchronization therapy (CRT) is a validated treatment for selected heart failure patients who remain highly symptomatic despite optimal drug treatment. Yet there is currently no indication for CRT in patients with few or no symptoms. We report a spectacular "reverse remodeling" effect after CRT in an asymptomatic patient with hypokinetic dilated myocardiopathy who needed pacing for atrio-ventricular conduction disorder. CRT was chosen to prevent deterioration of left ventricular function by conventional right apical pacing. Thus, CRT could be indicated in patients with hypokinetic dilated myocardiopathy before the appearance of symptoms.

Preclavicular Route Following Cephalic Venous Cutdown for Pacemaker or Defibrillator Lead Implantation

Following cephalic venous cutdown, an unexpected preclavicular course was used in two cases for a pacemaker and a defibrillator lead implantation. This very rare anomaly was documented by cephalic venogram but did not cause any significant intraoperative difficulty during single lead implantation.

Cardiac resynchronization therapy using a VDD lead

In heart failure patients with normal sinus node function, cardiac resynchronization therapy can be achieved with only two leads, one VDD type, and one left ventricular. This reduces the number of venous punctures, implanted leads, and possibly operation and fluoroscopic times and complication rates. We present two cases and discuss the advantages and limits of such a procedure.

Catheter ablation of accessory pathways: technique and results in 248 patients

Two hundred and forty-eight patients with refractory arrhythmias related to an accessory pathway underwent catheter ablation. Cathodal shocks (160 to 240 joules) were delivered through the distal electrode of a standard catheter (usually a quadripolar electrode catheter with 5-mm interelectrode distances). A paddle electrode positioned opposite to the catheter served as the anode. Ablation of 24 right anteroseptal, 16 right parietal, 86 posteroseptal, 120 left parietal and four Mahaim pathways was clinically successful in eliminating symptomatic tachycardia in 236 patients (greater than 96%) over a follow-up of 3 to 64 months. There was no procedure-related death but two patients developed a ventricular fibrillation at the fifth and seventh day, respectively. The latter led to a sudden death since this side effect occurred after discharge. There were no instances of systemic embolus but one pericardial effusion required subxiphoid needle drainage 6 weeks after the procedure. Other complications included: AV block in four patients with posteroseptal and in one with a right anterior septal pathway. In conclusion, a successful clinical outcome may be achieved in most patients. Catheter ablation is an important alternative to cardiac surgery and in our opinion represents first-line treatment when therapy is required.

Distinctive response of arrhythmogenic right ventricular disease to high dose isoproterenol

Arrhythmogenic right ventricular disease is a potential cause of ventricular arrhythmias. Diagnosis is important due to the risk of sudden death, particularly as first symptom. Diagnosis is based on the angiographic demonstration of abnormal right ventricular morphology and function, while the sensitivity of noninvasive tests is relatively low. Following a particular observation studied in 1984, we prospectively assessed the diagnostic value of high dose isoproterenol infusion in 44 patients with an angiographically determined arrhythmogenic right ventricle. A continuous infusion of isoproterenol (8-30 micrograms/min) was administered during a 3-minute period, regardless of the obtained heart rate. In a control group of 50 patients without structural heart disease, isoproterenol induced a monomorphic ventricular tachycardia salvo in only one patient (2%). In patients with an arrhythmogenic right ventricle, isoproterenol induced one or more ventricular tachycardia runs in 39/44 cases (88%): one triplet in three patients, several runs in 23 patients and a sustained ventricular tachycardia in 13 patients. Arrhythmia was polymorphous in 85% of cases, but left bundle branch block morphology was the predominant pattern. In conclusion, high dose isoproterenol is a highly sensitive test for the diagnosis of arrhythmogenic right ventricular disease.

Fulguration for AV nodal tachycardia: results in 42 patients with a mean follow-up of 23 months

This report describes a catheter ablation technique to treat atrioventricular nodal reentrant tachycardia while preserving anterograde conduction, and its application in 42 patients with drug-refractory repetitive episodes of tachycardia. One of these patients had common and reverse forms of tachycardia. Using atrial activation in the His-bundle lead as a reference, the optimal ablation site was selected by positioning an electrode catheter to obtain a synchronous or earlier atrial activation than the reference during tachycardia. At this site, His-bundle deflection was completely absent, or was present at a low amplitude (less than 0.1 mV). In the majority of patients, these criteria were found in the immediate vicinity of the site of proximal His-bundle recording (adjacent to the reference catheter). Shocks of 160 or 240 joules (J) were delivered at this site (mean +/- SD = 518 +/- 392 J/session) with a resulting preferential abolition of impairment of fast retrograde conduction. Anterograde conduction, though modified, was preserved in all patients, except for four (10%) patients who remained in complete heart block. Thirty patients (70%) remained free of arrhythmia without medication or pacemaker for a mean follow-up period of 23 +/- 13 (2-63) months. Six other patients (15%) were controlled with a previously ineffective medication.

[Malaria and retinal hemorrhages]

A 24-year-old woman presented with retinal hemorrhages, back from a travel in Cameroon. She took a chloroquine chemoprophylaxis. We diagnosed a malaria due to Plasmodium falciparum with anemia, splenomegaly and low parasitemia. A speedy clinical and ophthalmological recovery was obtained with mefloquine therapy. We discuss physiopathology of such uncommon retinal damage during malaria.