117 heart disease. The unusual radiographic picture appreciated preoperatively was not helped with echocardiography. Computed tomography scanning would have defined the tumour more accurately and has been shown to be superior to echocardiography in assessing pericardial tumours [4]. Magnetic resonance imaging may give even better visualization of cardiac masses [5]. Involvement of coronary arteries may render cardisc
lipomas
non-resectable
[l].
The
presence
of
a
giant lipoma in our patient was obviously causing some dcgrce of tamponade, as demonstrated by the improved cardiac output on opening the pericardium. Accurate diagnosis, using computed tomography and magnetic resonance imaging if available, would allow better planning and surgical management.
lnternutionul Journal of Cardiology, 37 (1992) 1 I7- 120 (!? 1992 Elsevier Science Publishers B.V. All rights reserved
CARD10
References
1 Hananouchi
GI, Goff WB. Cardiac lipoma: six-year followup with MRI characteristics, and a review of the literature. Magn Reson Imaging 1990$:825-X28.
2 Harjola
P-Tm, Ala-Kulju K, Ketonen P. Epicardial lipoma. Stand J Thor Cardiovasc Surg 3985;19:lXl-183. 3 Conces DJ, Vix VA. Tarter RD. Diagnosis of a myocardial lipoma by using CT. Am J Roentgen01 1989;153:725-726. 4 Dawson WB, Mayo JR. Miiller NL. Computed tomography of cardiac and pericardial tumours. Can Assoc Radio1 J 1990:41:270-275. 5 Moncada R, Baker M, Salinas M et al. Diagnostic role of computed tomography in pericardial heart disease: congenital defects, thickening, neoplasms. and effusions. Am Heart J 1982:103:263-2X2.
0167.5273/92/$05.00
15384
Radiofrequency ablation of incessant ventricular tachycardia to prevent multiple defibrillator shocks Luc Jordaens, Patrick Vertongen and Frank Provenier Department of Cardiology, Unicwsity Hospital Ghent, Ghent, Belgium (Received
17 May 1992; accepted
18 May 1992)
In a patient who received frequent shocks from an implantable defibrillator, a slow ventricular tachycardia originating in a large left ventricular aneurysm was ablated with radiofrequency current. Pacemapping perfectly matched the spontaneous, incessant arrhythmia. Local entrainment was present, along with a mid-diastolic potential of 65 pV. Application of 30 W terminated tachycardia within 12 s. He had no more recurrences during follow-up. Key words:
Ablation;
Implantable
cardioverter
defibrillator;
A 71-yr-old patient who had received an implantable cardiac defibrillator 13 months ago, was suddenly shocked several times by the device. Hitherto, he
Correspondence to: L. Jordaens, M.D., Dept. of Cardiology, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium. Tel. 32 91 403459. Fax 32 91 404966.
Radiofrequency
current;
Ventricular
tachycardia
had only experienced sporadic shocks from the Ventak 1600 unit (Cardiac Pacemakers Inc., St. Paul, USA). The implantable cardioverter defibrillator was implanted because of recurrent ventricular tachycardia with a rate of 200 beats/min and right bundle branch block pattern with left axis. This was due to chronic ischaemic heart disease with an inferior myocardial infarction. During the observation period immediately
118 implantation, he received appropriate shocks for recurrence of ventricular tachycardia. It was noted. however, that another, “slow”, tachycardia was not only induced once in the laboratory, but occurred also once spontaneously, without causing defibrillator discharge, because the cut-off rate of the device was programmed at 145/min. He was therefore discharged ‘on mexiletine treatment. During the first 13 months after discharge, he received 12 shocks. All episodes were terminated by the first 30 J shock. However, now he was admitted after receiving 9 shocks within 24 h. The “slow” tachycardia with right bundle branch block pattern, inferiorly directed axis, and a rate varying between 135 and 145, was recorded after admission, and was shocked immediately when the rate increased above the cut-off criterium. The implantable cardioverter defibrillator was programmed “off”, and a pacing wire was inserted to terminate recurrences. Lidocaine was given, and mexiletine increased in dosage. However, frequent recurrences were observed and overdrive resulted in acceleration on some occasions, so that the patient needed to be cardioverted externally. The tachycardia became incessant, and the condition of the patient deteriorated. Therefore, it was decided to perform an ablation of this particular tachycardia. after
Endocardial mapping was performed with a steerable 7 French quadripolar “Polaris” catheter (2.5 mm interelectrode distance), developed by Mansfield Inc., MA, USA. It had a 4 mm’ tip. In the lateral posterior region of the left ventricle, pacemapping matched the “slow” tachycardia, except that the pattern in leads V, and V, was not optimal. Local entrainment was demonstrated (Fig. 5). The local endocardial activation preceded the right ventricular apex electrogram by 270 ms. A sharp mid-diastolic potential with a 65 PV amplitude was present 45 ms before the Local ventricular electrogram. This potential was coupled to the subsequent complex. On this site, radiofrequency current with an energy of 25 W was delivered for 30 s with the HAT 200 (Osypka Medizintechnik, Germany). It terminated tachycardia after 18 s. After 89 s. tachycardia started again, and a 25 W current was again delivered at the same site. This time. tachycardia was interrupted after 18 s, but without intervening ventricular premature beat. Two backup applications were delivered. When tachycardia resumed, 35 W was delivered, but the impedance rose. Therefore, the catheter was removed, and cleaned. After replacement of the catheter. the mid-diastolic potential was much more distinct, and preceded the electrogram with the same distance. At this new position the pacemapping yielded
Fig. 1. Entrainment at the first ablation site. Pacing at 165/min (cycle length 364 ms) entrains the arrhythmia with a stimulus (s); QRS interval of 440 ms. After interruption of pacing, tachycardia resumes with a cycle length of 430 ms. At this site, pacemapping was not perfect: the pattern in leads V, and V, was not optimal. However, after application of energy, tachycardia was interrupted.
Fig. 2. Application of 30 W after replacement of the catheter. Tachycardia terminates within 12 s. Z = recording of impedance.
exactly the same electrocardiographic pattern as the spontaneous ventricular tachycardia. After application of 30 W, tachycardia terminated within 12 s (Fig. 2). A backup was given on the same site, and tachycardia remained absent for the next days. Creatinine kinase activity rose to 524 U/I, the MB fraction to 26 U/l. During programmed electrical stimulation on the 5th day, it was impossible to induce the same arrhythmia during a standard stimulation protocol. However, the tachycardia with left axis was twice induced. The implantable cardioverter defibrillator has a cut-off rate of 165 beats/min, and did not give shocks with a follow-up of 2 months. Discussion As treatment with implantable cardioverter defibrillators is extremely reliable with respect to survival, ablative therapy is nowadays not always the first therapeutic option for ventricular tachycardia. Furthermore, ablation of ventricular tachycardia sometimes has a low success rate, and is not always without risk, as hemodynamic problems and new arrhythmias may arise after such procedures [1,2]. On the other hand, ablation is a direct intervention on the arrhythmia substrate, and is therefore preferable to other strategies. In this case report two points are made. First, it is possible to ablate ventricular tachycardia originating in a large aneurysm with radiofrequency current, with a standard ablation catheter. Second, ablation is a treatment modality that can accompany treatment with an implantable cardioverter defibrillator.
The value and limitations of high-energy direct current shocks to ablate ventricular tachycardia are now well established. As the amount of myocardium destroyed by a high-energy shock, is about 65 mm’, it is clear that the success rate will be higher than that of a low-energy shock or application of radiofrequency current [3]. Such extensive destruction of tissue can be proarrhythmic as well. “Low’‘-energy shocks have been shown to be successful for specific indications (41. Howevei, when radiofrequency current is applied in the heart, lesions have to be given in a very precise position to be effective [5]. It is not entirely clear whether the described criteria for ablation with direct current shocks are sufficient to use with this less destructive energy [ 11. Local entrainment, mid-diastolic potentials, continuous electrical activity were all present in both sites that we selected to deliver energy. Tachycardia terminated at both sites during application. However, pacemapping was better on the second site, where entrainment was less impressive, and only this perfect pacemapping corresponded with the persistent success of the treatment. The implantable cardioverter defibrillator has a place in the treatment strategy of ventricular arrhythmias. It is not clear whether ablation of ventricular tachycardia can diminish the risk of subsequent sudden death, as has been shown for the implantable cardioverter defibrillator. Ablation will be useful to avoid frequent shocks in patients with incessant or frequently recurrent ventricular tachycardia, who have an implantable cardioverter-defibrillator.
I 20
References Fitzgerald DM, Friday KJ. Yeung Lai Wah JA, Jackman WM. Electrogram patterns predicting catheter ablation of ventricular tachycardia. 1988;77:806-814. Hauer RNW, Robles de Medina EO. Borst C. mic effects of ventricular electrical catheter dogs. J Am Coil Cardiol 1987;10:1350-1356. Bardy GH, ldeker RE, Kasell J, Worley SJ et
Internutional
Journal
((‘I 1992 Elsevier
CARD10
of CurdioloAy,
Science
Publishers
37 (1992)
Lazzara R, successful Circulation Proarrhythablation in al. Transve-
nous ablation of the atrioventricular conduction in dogs: electrophysiologic and histologic observations. Am J Cardial 1983;51:1775-1782. 4 Jordaens L, Roelandt R, Palmer A, Van Wassenhove E. Clement D. Ablation of ventricular tachycardia of right ventricular origin with low energy shocks. PACE 1989:12: 91 l-916. catheter ablation 5 Davis MJE. Murdock C. Radiofrequency of refractory ventricular tachycardia. PACE 1988;l I:7255 729..
120- 122
B.V. All rights reserved 0167-5273/92/$05.00
15385
Recurrent
acute myocardial infarction during sport Renzo Ciampricotti
Depurtment
of Curdiolob?:
(Received
and Rob Taverne
De Horse Hospitul,
1 June
1992: accepted
Terneuzcn,
Nether1und.s
1 June 1992)
A 4%yr-old well conditioned man developed acute myocardial infarction twice during sporting activities. After both events right coronary angiography showed a moderate proximal stenosis and, 5 months later, a subtotal obstruction at the site of prior slight lumen irregularity. This case suggests a causal relationship between sport and the occurrence of acute coronary events. Key words:
Myocardial
infarction
during sport
Introduction Numerous reports have focused on the occurrence of cardiac arrest and non-fatal acute coronary events rclatcd to sport [l-4]. Severe obstructive coronary artery disease is the predominant pathological finding in middle-aged victims of sport related sudden death [1,2]. However. non-evident or minor obstructive dis-
ease was shown in some survivors of exercise-related acute coronary syndromes [3]. The mechanism of these events still remains inconclusive. We report the case of a conditioned man who developed acute myocardial infarction twice during sport. The findings in this case can help us to understand the occurrence of acute coronary events related to vigorous exercise. Case Report
M.D., Dept. of Cardiology. De Honte Hospital. Wielingenlaan 2. 4535 PA Terneuzen, Netherlands. Tel. and Fax (0)1150-88485. Correspondence
to: R. Ciampricotti,
A 4%yr-old previously healthy man was admitted because of chest pain which started while playing vollcyball. Although he used to play more often during his youth he was now engaged in competitions for at least
lipomas
non-resectable
[l].
The
presence
of
a
giant lipoma in our patient was obviously causing some dcgrce of tamponade, as demonstrated by the improved cardiac output on opening the pericardium. Accurate diagnosis, using computed tomography and magnetic resonance imaging if available, would allow better planning and surgical management.
lnternutionul Journal of Cardiology, 37 (1992) 1 I7- 120 (!? 1992 Elsevier Science Publishers B.V. All rights reserved
CARD10
References
1 Hananouchi
GI, Goff WB. Cardiac lipoma: six-year followup with MRI characteristics, and a review of the literature. Magn Reson Imaging 1990$:825-X28.
2 Harjola
P-Tm, Ala-Kulju K, Ketonen P. Epicardial lipoma. Stand J Thor Cardiovasc Surg 3985;19:lXl-183. 3 Conces DJ, Vix VA. Tarter RD. Diagnosis of a myocardial lipoma by using CT. Am J Roentgen01 1989;153:725-726. 4 Dawson WB, Mayo JR. Miiller NL. Computed tomography of cardiac and pericardial tumours. Can Assoc Radio1 J 1990:41:270-275. 5 Moncada R, Baker M, Salinas M et al. Diagnostic role of computed tomography in pericardial heart disease: congenital defects, thickening, neoplasms. and effusions. Am Heart J 1982:103:263-2X2.
0167.5273/92/$05.00
15384
Radiofrequency ablation of incessant ventricular tachycardia to prevent multiple defibrillator shocks Luc Jordaens, Patrick Vertongen and Frank Provenier Department of Cardiology, Unicwsity Hospital Ghent, Ghent, Belgium (Received
17 May 1992; accepted
18 May 1992)
In a patient who received frequent shocks from an implantable defibrillator, a slow ventricular tachycardia originating in a large left ventricular aneurysm was ablated with radiofrequency current. Pacemapping perfectly matched the spontaneous, incessant arrhythmia. Local entrainment was present, along with a mid-diastolic potential of 65 pV. Application of 30 W terminated tachycardia within 12 s. He had no more recurrences during follow-up. Key words:
Ablation;
Implantable
cardioverter
defibrillator;
A 71-yr-old patient who had received an implantable cardiac defibrillator 13 months ago, was suddenly shocked several times by the device. Hitherto, he
Correspondence to: L. Jordaens, M.D., Dept. of Cardiology, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium. Tel. 32 91 403459. Fax 32 91 404966.
Radiofrequency
current;
Ventricular
tachycardia
had only experienced sporadic shocks from the Ventak 1600 unit (Cardiac Pacemakers Inc., St. Paul, USA). The implantable cardioverter defibrillator was implanted because of recurrent ventricular tachycardia with a rate of 200 beats/min and right bundle branch block pattern with left axis. This was due to chronic ischaemic heart disease with an inferior myocardial infarction. During the observation period immediately
118 implantation, he received appropriate shocks for recurrence of ventricular tachycardia. It was noted. however, that another, “slow”, tachycardia was not only induced once in the laboratory, but occurred also once spontaneously, without causing defibrillator discharge, because the cut-off rate of the device was programmed at 145/min. He was therefore discharged ‘on mexiletine treatment. During the first 13 months after discharge, he received 12 shocks. All episodes were terminated by the first 30 J shock. However, now he was admitted after receiving 9 shocks within 24 h. The “slow” tachycardia with right bundle branch block pattern, inferiorly directed axis, and a rate varying between 135 and 145, was recorded after admission, and was shocked immediately when the rate increased above the cut-off criterium. The implantable cardioverter defibrillator was programmed “off”, and a pacing wire was inserted to terminate recurrences. Lidocaine was given, and mexiletine increased in dosage. However, frequent recurrences were observed and overdrive resulted in acceleration on some occasions, so that the patient needed to be cardioverted externally. The tachycardia became incessant, and the condition of the patient deteriorated. Therefore, it was decided to perform an ablation of this particular tachycardia. after
Endocardial mapping was performed with a steerable 7 French quadripolar “Polaris” catheter (2.5 mm interelectrode distance), developed by Mansfield Inc., MA, USA. It had a 4 mm’ tip. In the lateral posterior region of the left ventricle, pacemapping matched the “slow” tachycardia, except that the pattern in leads V, and V, was not optimal. Local entrainment was demonstrated (Fig. 5). The local endocardial activation preceded the right ventricular apex electrogram by 270 ms. A sharp mid-diastolic potential with a 65 PV amplitude was present 45 ms before the Local ventricular electrogram. This potential was coupled to the subsequent complex. On this site, radiofrequency current with an energy of 25 W was delivered for 30 s with the HAT 200 (Osypka Medizintechnik, Germany). It terminated tachycardia after 18 s. After 89 s. tachycardia started again, and a 25 W current was again delivered at the same site. This time. tachycardia was interrupted after 18 s, but without intervening ventricular premature beat. Two backup applications were delivered. When tachycardia resumed, 35 W was delivered, but the impedance rose. Therefore, the catheter was removed, and cleaned. After replacement of the catheter. the mid-diastolic potential was much more distinct, and preceded the electrogram with the same distance. At this new position the pacemapping yielded
Fig. 1. Entrainment at the first ablation site. Pacing at 165/min (cycle length 364 ms) entrains the arrhythmia with a stimulus (s); QRS interval of 440 ms. After interruption of pacing, tachycardia resumes with a cycle length of 430 ms. At this site, pacemapping was not perfect: the pattern in leads V, and V, was not optimal. However, after application of energy, tachycardia was interrupted.
Fig. 2. Application of 30 W after replacement of the catheter. Tachycardia terminates within 12 s. Z = recording of impedance.
exactly the same electrocardiographic pattern as the spontaneous ventricular tachycardia. After application of 30 W, tachycardia terminated within 12 s (Fig. 2). A backup was given on the same site, and tachycardia remained absent for the next days. Creatinine kinase activity rose to 524 U/I, the MB fraction to 26 U/l. During programmed electrical stimulation on the 5th day, it was impossible to induce the same arrhythmia during a standard stimulation protocol. However, the tachycardia with left axis was twice induced. The implantable cardioverter defibrillator has a cut-off rate of 165 beats/min, and did not give shocks with a follow-up of 2 months. Discussion As treatment with implantable cardioverter defibrillators is extremely reliable with respect to survival, ablative therapy is nowadays not always the first therapeutic option for ventricular tachycardia. Furthermore, ablation of ventricular tachycardia sometimes has a low success rate, and is not always without risk, as hemodynamic problems and new arrhythmias may arise after such procedures [1,2]. On the other hand, ablation is a direct intervention on the arrhythmia substrate, and is therefore preferable to other strategies. In this case report two points are made. First, it is possible to ablate ventricular tachycardia originating in a large aneurysm with radiofrequency current, with a standard ablation catheter. Second, ablation is a treatment modality that can accompany treatment with an implantable cardioverter defibrillator.
The value and limitations of high-energy direct current shocks to ablate ventricular tachycardia are now well established. As the amount of myocardium destroyed by a high-energy shock, is about 65 mm’, it is clear that the success rate will be higher than that of a low-energy shock or application of radiofrequency current [3]. Such extensive destruction of tissue can be proarrhythmic as well. “Low’‘-energy shocks have been shown to be successful for specific indications (41. Howevei, when radiofrequency current is applied in the heart, lesions have to be given in a very precise position to be effective [5]. It is not entirely clear whether the described criteria for ablation with direct current shocks are sufficient to use with this less destructive energy [ 11. Local entrainment, mid-diastolic potentials, continuous electrical activity were all present in both sites that we selected to deliver energy. Tachycardia terminated at both sites during application. However, pacemapping was better on the second site, where entrainment was less impressive, and only this perfect pacemapping corresponded with the persistent success of the treatment. The implantable cardioverter defibrillator has a place in the treatment strategy of ventricular arrhythmias. It is not clear whether ablation of ventricular tachycardia can diminish the risk of subsequent sudden death, as has been shown for the implantable cardioverter defibrillator. Ablation will be useful to avoid frequent shocks in patients with incessant or frequently recurrent ventricular tachycardia, who have an implantable cardioverter-defibrillator.
I 20
References Fitzgerald DM, Friday KJ. Yeung Lai Wah JA, Jackman WM. Electrogram patterns predicting catheter ablation of ventricular tachycardia. 1988;77:806-814. Hauer RNW, Robles de Medina EO. Borst C. mic effects of ventricular electrical catheter dogs. J Am Coil Cardiol 1987;10:1350-1356. Bardy GH, ldeker RE, Kasell J, Worley SJ et
Internutional
Journal
((‘I 1992 Elsevier
CARD10
of CurdioloAy,
Science
Publishers
37 (1992)
Lazzara R, successful Circulation Proarrhythablation in al. Transve-
nous ablation of the atrioventricular conduction in dogs: electrophysiologic and histologic observations. Am J Cardial 1983;51:1775-1782. 4 Jordaens L, Roelandt R, Palmer A, Van Wassenhove E. Clement D. Ablation of ventricular tachycardia of right ventricular origin with low energy shocks. PACE 1989:12: 91 l-916. catheter ablation 5 Davis MJE. Murdock C. Radiofrequency of refractory ventricular tachycardia. PACE 1988;l I:7255 729..
120- 122
B.V. All rights reserved 0167-5273/92/$05.00
15385
Recurrent
acute myocardial infarction during sport Renzo Ciampricotti
Depurtment
of Curdiolob?:
(Received
and Rob Taverne
De Horse Hospitul,
1 June
1992: accepted
Terneuzcn,
Nether1und.s
1 June 1992)
A 4%yr-old well conditioned man developed acute myocardial infarction twice during sporting activities. After both events right coronary angiography showed a moderate proximal stenosis and, 5 months later, a subtotal obstruction at the site of prior slight lumen irregularity. This case suggests a causal relationship between sport and the occurrence of acute coronary events. Key words:
Myocardial
infarction
during sport
Introduction Numerous reports have focused on the occurrence of cardiac arrest and non-fatal acute coronary events rclatcd to sport [l-4]. Severe obstructive coronary artery disease is the predominant pathological finding in middle-aged victims of sport related sudden death [1,2]. However. non-evident or minor obstructive dis-
ease was shown in some survivors of exercise-related acute coronary syndromes [3]. The mechanism of these events still remains inconclusive. We report the case of a conditioned man who developed acute myocardial infarction twice during sport. The findings in this case can help us to understand the occurrence of acute coronary events related to vigorous exercise. Case Report
M.D., Dept. of Cardiology. De Honte Hospital. Wielingenlaan 2. 4535 PA Terneuzen, Netherlands. Tel. and Fax (0)1150-88485. Correspondence
to: R. Ciampricotti,
A 4%yr-old previously healthy man was admitted because of chest pain which started while playing vollcyball. Although he used to play more often during his youth he was now engaged in competitions for at least
