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A 35-year-old man was referred for ablation of ventricular tachycardia with two different morphologies triggering each other. After elimination of the first arrhythmia in the right ventricular outflow tract, ablation of the second morphology was performed 8 mm below the left main stem after contrast injection into the left coronary cusp through the irrigated-tip ablation catheter. (PACE 2012;35:e356–e357)

As more and more patients receive complex implantable cardioverter-defibrillators (ICDs), profound knowledge about the incidence of inappropriate device therapy, the reasons it happens, and the possibilities for prevention is crucial. In this article, the most important prevention algorithms incorporated in current ICD models and their advantages and handicaps are discussed in detail, which should help to guide the device selection for a particular patient. Also, emphasis is put on adjunctive drug therapy and interventional treatment strategies, which are crucial in managing patients with inappropriate ICD shocks.

A case of a professional ice-hockey with a blunt chest trauma is presented. A year after the first cardiac evaluation, he experienced sustained ventricular tachycardia after another slight chest trauma. An implantable cardioverter-defibrillator was implanted. The pathophysiological background of tachycardias after a blunt chest trauma and its management are discussed.

Bei dem 18jahrigen Mann wurde anlasslich einer Varikozelen-Operation eine Pulsunregelmassigkeit festgestellt und eine kardiale Abklarung empfohlen. Der Patient war vollkommen asymptomatisch und als Mitglied einer Junioren-Nationalmannschaft in einer korperlich ubermassig fordernden Sportart voll leistungsfahig. Ergometrie und Echokardiographie waren entsprechend bland. Das Ruhe-EKG zeigte ebenfalls keine Auffalligkeiten. Es wurde dennoch ein 24-StundenEKG veranlasst. Die Abbildungen 1 und 2 zeigen Ausschnitte aus dieser Untersuchung.

Background: Good catheter-tissue contact force (CF) is critical for transmural and durable lesion formation during radiofrequency (RF) ablation, but difficult to assess in clinical practice. CF-sensing catheters have been developed recently. Tissue heating during RF-application results in an impedance decrease at the catheter tip. Methods: We correlated initial impedance decreases with the achieved CF during RF applications in atrial fibrillation ablations with a CF-sensing RF-catheter with stable catheter position and CF during the first 20 seconds. We analyzed 642 RF-applications in 12 patients undergoing ablation with the Tacticath catheter (Endosense) and 562 RF-applications in 21 patients undergoing ablation with the SmartTouch catheter (Biosense-Webster). Results: When RF-applications were analyzed according to an achieved average CF of 20g, starting impedance levels were 152Ω, 150Ω and 155Ω with the Tacticath catheter (p=0.12), and 124Ω, 126Ω and 131Ω with the SmartTouch catheter (p=0.001). The initial impedance decreases were significantly larger when greater CF was achieved. The corresponding median values were 3Ω (IQR -3-7), 7Ω (4-11) and 11Ω (7-16) at 10 seconds, and 4Ω (-4-10), 8Ω (4-12) and 13Ω (7-18) at 20 seconds with the Tacticath (p

Good catheter-tissue contact force (CF) is critical for transmural and durable lesion formation during radiofrequency (RF) ablation but is difficult to assess in clinical practice. Tissue heating during RF application results in an impedance decrease at the catheter tip.The purpose of this study was to correlate achieved CF and initial impedance decreases during atrial fibrillation (AF) ablation.We correlated achieved CF and initial impedance decreases in patients undergoing ablation for AF with two novel open-irrigated CF-sensing RF catheters (Biosense Webster SmartTouch, n = 647 RF applications; and Endosense TactiCath, n = 637 RF applications). We then compared those impedance decreases to 691 RF applications with a standard open-irrigated RF catheter (Biosense Webster ThermoCool).When RF applications with the CF-sensing catheters were analyzed according to an achieved average CF5 g, 5-10 g, 10-20 g, and20 g, the initial impedance decreases during ablation were larger with greater CF. Corresponding median values at 20 seconds were 5 Ω (interquartile range [IQR] 2-7), 8 Ω (4-11), 10 Ω (7-16), and 14 Ω (10-19) with the SmartTouch and n/a, 4 Ω (0-10), 8 Ω (5-12), and 13 Ω (8-18) with the TactiCath (P.001 between categories for both catheters). When RF applications with the SmartTouch (CF-sensing catheter, median achieved CF 12 g) and ThermoCool (standard catheter) were compared, the initial impedance decrease was significantly greater in the CF-sensing group with median decreases of 10 Ω (6-14 Ω) vs 5 Ω (2-10 Ω) at 20 seconds (P.001 between catheters).The initial impedance decrease during RF applications in AF ablations is larger when greater catheter contact is achieved. Monitoring of the initial impedance decrease is a widely available indicator of catheter contact and may help to improve formation of durable ablation lesions.

We congratulate Linde et al. ([1][1]) on the meticulously carried out REVERSE (REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction) trial that addressed the question of the clinical benefit of cardiac resynchronization therapy (CRT) in patients with New York Heart

www.thelancet.com Vol 367 March 25, 2006 1007 The notion that there is a heart inside the heart is a conviction that poets have shared for centuries. When Hamlet shouted, “in my heart’s core, ay, in my heart of heart”, Shakespeare coined a phrase still in use. Goethe’s Gretchen and von Hofmannsthal’s Ariadne also felt sudden sorrow in their “heart’s hearts”, and with his story on little Sophie, similar emotions arose in the Romantic German poet Novalis. Thus, it may be of interest to the medical community that the heart’s heart has finally been discovered (figure). However, something about this discovery remains elusive, and sceptics may find it more poetic than scientific. Medically, it is simply a superposition of the left anterior artery and the diagonal branch mimicking a heart-like structure. This explanation may imply, of course, that the search of philosophers and physicians for that heartfelt point within our heart connecting us to love and sudden sorrow has not yet ended. Exploring the heart of the human heart

A 75-year-old man had several syncopes with severe skull contusions (figure 1). These events were not preceded by vegetative symptoms such as nausea, dizziness, or palpitations. Holter-EKG was normal and an EEG was performed for suspected epilepsy, during which complete atrioventricular block …

Percutaneous transtracheal ventilation with intermittent jets of oxygen under high pressure has been used for approximately five years. This paper briefly reviews published reports on the use of this technique for resuscitation and during anaesthesia. Complications occurring in the reports reviewed are tabulated. The complications occurring in a series of 80 patients (52 elective prior to anaesthesia and 28 for acute respiratory distress) at the Pittsburgh Eye and Ear Hospital are documented. This includes three detailed case reports. No deaths and few serious complications have so far been reported, particularly with the elective use of transtracheal ventilation. This technique has established itself as an important adjunct in life support. When used in properly selected cases, its continued use appears justified.