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Ventricular tachycardia (VT) ablation of mid- or epicardial substrate is difficult and requires a creative approach in patients with a history of coronary bypass that precludes percutaneous epicardial catheter manipulation. The coronary venous system (CVS) provides limited access to the epicardial surface of the heart. The objective of this study is to assess the feasibility, safety, and efficacy of epicardial mapping and ablation of VT substrates from the CVS in patients with history of coronary bypass.Patients undergoing VT ablation at our institution were retrospectively reviewed. Those who had basal to mid ventricular substrate based on computed tomography imaging and history of coronary bypass were included. Endocardial and CVS mapping and ablation was performed in standard fashion using 3D electroanatomic mapping. The primary endpoint was defined as VT circuit elimination, termination, non-inducibility, or perturbation of the circuit.Of 192 consecutive VT ablations from 2017 to 2020, 35 (18%) had a history of coronary bypass and basal to the mid-ventricular substrate by imaging. There were no significant characteristic differences between the endocardial only (n = 19) vs endocardial + CVS (n = 16) groups. In 14 (88%) of patients undergoing CVS mapping, the VT circuit was identified to be within access from the epicardial surface. Ablation was attempted in 8 (57%) of these patients, and the primary endpoint was reached in 88% of those undergoing CVS ablation. There were no complications related to CVS ablation.Mapping and ablation of mid- or epicardial VT circuits from the CVS branches are feasible and safe and may be helpful in the treatment of VT in patients who are otherwise not candidates for percutaneous epicardial ablation.

INTRODUCTION Cor triatriatum sinister (CTS) is a rare congenital heart defect characterized by fibromuscular septation of the left atrium associated with atrial fibrillation (AF). The incidence of hemodynamically insignificant CTS in the AF ablation population and effect on ablation success are not known. Furthermore, little is known about the potential effect of CTS on arrhythmogenic substrate. OBJECTIVE We define the incidence of hemodynamically insignificant CTS in patients undergoing AF ablation with RF and cryoballoon ablation, the technical challenges created by the left atrial partitioning, and the potentially arrhythmogenic effects of the membrane. We also review the literature of CA in patients with CTS. METHODS First-time AF ablation cases at our institution over a 10-year period were screened to identify patients with CTS. Retrospective review was performed to obtain clinical characteristics and ablation data. RESULTS Of the 3953 consecutive patients undergoing initial AF ablation during the study period, four patients (0.10%) had CTS. Ablation was successful acutely in all patients. One patient had recurrent AF and required repeat ablation for a single procedure success rate of 75% and multi-procedure success rate of 100%. The CTS membrane was associated with low voltage zones in the two patients in whom it was measured and with substrate for macro-reentrant atrial tachycardia in one of these patients. CONCLUSION The incidence of hemodynamically insignificant CTS in patients undergoing CA for AF is very low, but does not serve as a significant barrier to successful ablation as long as directed access to the superoposterior chamber is obtained.

Transradial cardiac catheterization is equally effective but has fewer vascular complications than transfemoral catheterization. There is a paucity of data on biradial approach for alcohol septal ablation (ASA). This study seeks to study the differences in procedural outcomes between the transradial vs traditional transfemoral approach in ASA.A total of 274 consecutive patients who underwent ASA were retrospectively assigned to the study subgroups (137 transradial, 137 femoral). Procedural success, reduction in left ventricular outflow tract gradient (LVOTG), contrast volume, fluoroscopy time, and complications were compared between the 2 groups.There were no differences in reduction of resting LVOTG (91% vs 92%; P=.50), provoked LVOTG (80% vs 82%; P=.47) post procedure between transradial vs transfemoral subgroups. Iodinated contrast volume was significantly lower in the transradial group (98 mL vs 111 mL; P=.04), whereas fluoroscopy time was higher in the transradial group (17.42 minutes vs 13.00 minutes; Plt;.001). The incidence of complications was lower in the transradial group (0.13 vs 0.23; P=.04).ASA via transradial approach is equally effective and associated with significantly less contrast use and fewer complications as compared with the traditional transfemoral approach.

The ICD is an important part of the treatment and prevention of sudden cardiac death in many high-risk populations. Traditional transvenous ICDs (TV-ICDs) are associated with certain short- and long- term risks. The subcutaneous ICD (S-ICD) was developed in order to avoid these risks and complications. However, this system is associated with its own set of limitations and complications. First, patient selection is important, as S-ICDs do not provide pacing therapy currently. Second, pre-procedural screening is important to minimise T wave and myopotential oversensing. Finally, until recently, the S-ICD was primarily used in younger patients with fewer co-morbidities and less structural heart disease, limiting the general applicability of the device. S-ICDs achieve excellent rates of arrhythmia conversion and have demonstrated noninferiority to TV-ICDs in terms of complication rates in real-world studies. The objective of this review is to discuss the latest literature, including the UNTOUCHED and PRAETORIAN trials, and to address the risk of inappropriate shocks.

Alcohol septal ablation (ASA) is an accepted treatment for medically refractory hypertrophic obstructive cardiomyopathy (HOCM). The procedural and medium-term outcomes have been reassuring. The iatrogenic targeted septal infarction has raised theoretical concerns about risk of arrhythmia and long-term survival. In this study, we describe the long-term survival in a large cohort of patients from a single referral center and the iterative improvement in procedural technique since its inception.This cohort includes 580 consecutive patients who underwent 664 ASA procedures between the years 1999 and 2015. Procedural details and outcomes are described. Long-term survival is compared with expected survival of demographically similar controls.Fifty-four percent were women and 85% were Caucasian. At the time of ablation, mean age was 57 ± 15 years, septal thickness was 2.1 ± 0.5 cm, and left ventricular outflow tract (LVOT) gradient was 72 ± 40 mm Hg at rest and 102 ± 58 mm Hg with Valsalva provocation. Mean follow-up was 8.0 ± 4.3 years. LVOT gradient reduction50% was achieved in 94% of patients with reduction in New York Heart Association functional class scores and increase in exercise treadmill duration. Procedural mortality was 0.9%. Over the 16-year period, survival estimates at 1, 5, 10, and 15 years were 98%, 92%, 84%, and 81%, respectively, which are comparable to demographically similar controls. The standardized mortality ratio was 0.84 (95% confidence interval, 0.66-1.06); P=.09.ASA appears to be a safe and effective treatment for symptomatic HOCM refractory to medical therapy with long-term survival comparable to a demographically similar United States population.

Intra-aortic balloon pump (IABP) has been used more recently as a bridge to cardiac transplantation in hospitalized patients. Femoral IABP limits mobility and rehabilitation; thus, transaxillary approach has been described. However, a transaxillary IABP may migrate, causing significant vascular injury, potential death, or disqualification from transplantation. We describe a case of a 67-year-old male with transaxillary IABP inserted to allow for pre-transplant physical rehabilitation. Due to the unfolded nature of his aorta, the IABP coiled onto itself and migrated several times. We employed a novel technique to mitigate IABP migration using a long 25-cm introducer sheath.

Alcohol septal ablation (ASA) is a septal reduction therapy modality for patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM). ASA is a targeted infarction of the basal anteroseptum achieved by selective injection of ethanol into septal arteries. The characteristics of

Coronary artery no-reflow phenomenon is an incidental outcome of percutaneous coronary intervention in patients presenting with acute myocardial infarction. Despite advances in pharmacologic and non-pharmacologic therapies, coronary no-reflow phenomenon occurs more commonly than desired. It often results in poor clinical outcomes and remains as a relevant consideration in the cardiac catheterization laboratory. In this systematic review, we have sought to discuss the topic in detail, and to relay the most recent discoveries and data on management of this condition. We discuss several pharmacologic and non-pharmacologic treatments used in the prevention and management of coronary no-reflow and microvascular obstruction. Covered topics include the understanding of pharmacologic mechanisms of current and future agents, and recent discoveries that may result in the development of future treatment options. We conclude that the pathophysiology of coronary no-reflow phenomenon and microvascular obstruction still remains incompletely understood, although several plausible theories have led to the current standard of care for its management. We also conclude that coronary no-reflow phenomenon and microvascular obstruction must be recognized as a multifactorial condition that has certain predispositions and characteristics, therefore its prevention and treatment must begin pre-procedurally and be multi-faceted including certain medications and operator techniques in the cardiac catheterization laboratory.

Isolated left ventricular noncompaction (ILVNC) is a cardiomyopathy that was first described in 1926 as a “spongy myocardium.” The disorder results from intrauterine arrest of compaction of the loose interwoven meshwork of the fetal myocardial primordium and subsequent persistence of deep trabecular recesses in the myocardial wall. The classical clinical presentation is a triad of heart failure, arrhythmias, and embolic events from mural thrombi. ILVNC has been associated with several autosomal dominant, X-linked, and mitochondrial genetic mutations that are also shared among other cardiomyopathies. Over the past decade, ILVNC has been subject to intensive research, as it increases the risk for sudden cardiac death. This review focuses on the current understanding of ILVNC in adult populations and attempts to provide organized insight into the disease process, screening, diagnosis, management, role of device therapy, and prognosis.

Hypertrophic obstructive cardiomyopathy (HOCM) treated with alcohol septal ablation (ASA) often results in right bundle branch block (RBBB). The effect of RBBB-induced dyssynchrony on cardiac function has not been well described. We sought to determine the effect of ASA-induced RBBB on RV function

Left ventricular end diastolic pressure (LVEDP) is a representation of left ventricular performance. An increased LVEDP correlates to an increased left ventricular workload, which can be seen in pathologic conditions such as an obstructed left ventricular outflow tract (LVOT) in hypertrophic

Alcohol septal ablation (ASA) produces a targeted infarction of the septum, thereby relieving the outflow obstruction in hypertrophic obstructive cardiomyopathy (HOCM). There are several changes in the left ventricle with the relief of outflow obstruction. We sought to determine the medium-term

Aims Treatment of ischaemic mitral regurgitation (IMR) remains controversial. While IMR is associated with worse outcomes, randomized controlled trials (RCTs) and observational studies provided conflicting evidence regarding the benefit of mitral valve replacement (MVR) or repair (MVr) in addition to coronary artery bypass grafting (CABG). We conducted a meta-analysis incorporating data from published RCTs and observational studies comparing CABG vs. CABG + MVR/MVr. Methods and results We searched PubMed, MEDLINE, Embase, Ovid, and Cochrane for RCTs and observational studies comparing CABG (Group 1) vs. CABG + MVR/MVr (Group 2). Outcome was 30-day and 1-year mortality after surgical intervention. Mantel–Haenszel odds ratio (OR) was calculated using random-effects meta-analysis for the outcome. Heterogeneity was assessed by I 2 statistics. Four RCTs and 11 observational studies met the inclusion criteria (5781 patients, 507 in RCTs, 5274 in observational studies). Group 1 vs. 2 weighted mean left ventricular ejection fraction in RCTs and combined RCTs/observational studies was 41.5 ± 12.3 vs. 40.3 ± 10.4% ( P -value = 0.24) and 45.5 ± 7.2 vs. 38 ± 10% ( P -value < 0.001), respectively. In RCTs, there was no difference in 30-day [OR: 0.95, 95% confidence interval (95% CI): 0.30–3.08, P = 0.94] or 1-year (OR: 0.90, 95% CI: 0.43–1.87, P = 0.78) mortality, respectively. For combined RCTs/observational studies, there was no difference in mortality at 30 days (OR: 0.67, 95% CI: 0.43–1.04, P = 0.08) or at 1 year (OR: 0.90, 95% CI: 0.7–1.15, P = 0.39). Conclusion In a meta-analysis of RCTs and observational studies of IMR patients, the addition of MVR/MVr to CABG did not improve survival.

CASE PRESENTATION A65-year-old otherwise healthy man presented to the emergency department with complaints of headache, aphasia, confusion and partial vision loss. He had presented to his primary care physician with a nodule on the left parieto-occipital region of his head, 4 months prior. The lesion had been excised in the emergency department. However, the sample had not been sent for pathologic analysis as it was believed to be a lipoma. In the emergency department, physical examination revealed a large soft-tissue mass as depicted in Figure A. Magnetic resonance imaging (T2weighted image) of the head revealed a large tumor with erosion into the cranium accompanied by mass effect (Figure B). He was admitted to our solid tumor service where biopsy revealed proliferation of plasma cells with CD-138 immunostaining and kappa antibody immunoreactivity. The diagnosis of plasmacytoma was made, and the patient received 5 fractions of 2,000 cGy radiation therapy. He furthermore received chemotherapy with lenalidomide and dexamethasone. Response to therapy was successfully achieved, and the patient was referred to surgery for cranioplasty. Extramedullary plasmacytoma is a rare tumor that usually arises from the head and neck, and is predominantly seen in men with a median age of 55 years. The 10-year overall survival rate is 70%.

The content and quality of medical information available on video sharing websites such as YouTube is not known. We analyzed the source and quality of medical information about Ebola hemorrhagic fever (EHF) disseminated on YouTube and the video characteristics that influence viewer behavior. An inquiry for the search term ‘Ebola’ was made on YouTube. The first 100 results were arranged in decreasing order of “relevance” using the default YouTube algorithm. Videos 1–50 and 51–100 were allocated to a high relevance (HR), and a low relevance (LR) video group, respectively. Multivariable logistic regression models were used to assess the predictors of a video being included in the HR vs. LR groups. Fourteen videos were excluded because they were parodies, songs or stand-up comedies (n = 11), not in English (n = 2) or a remaining part of a previous video (n = 1). Two scales, the video information and quality and index and the medical information and content index (MICI) assessed the overall quality, and the medical content of the videos, respectively. There were no videos from hospitals or academic medical centers. Videos in the HR group had a higher median number of views (186,705 vs. 43,796, p

Observational data indicate that increased myeloperoxidase (MPO) levels may be associated with increased risk of development of acute coronary syndrome (ACS) in patients with stable coronary artery disease (CAD). We performed a meta-analysis of observational studies to study the relationship between