Notes

Assessment: Continuing development of SARS-CoV-2 immuno-enhanced COVID-19 vaccinations with nano-platform.
Effective biventricular pacing is important to improve survival in patients with heart failure. We report a case of a patient with heart failure, who underwent cardiac resynchronization therapy, who had loss of biventricular pacing when in low atrial rhythm. We discuss the probable mechanism for the same.Ventricular tachycardia arising from the papillary muscles and other endocavitary structures are preferably ablated under intracardiac echocardiographic (ICE) guidance whenever feasible. However, the availability, need of trained operators, and the expenses involved restrict the routine use of ICE in many cath labs. Point density exclusion (PDX) mapping is a simple technique that doesn't demand any additional expense or tool apart from the routine electroanatomical mapping and thus can be widely applied in mapping of arrhythmias arising from endocavitary structures. Immunology inhibitor The following report describes such a case and explains the method of performing PDX mapping.A 66-year-old lady presented with shortness of breath and a Wenckebach atrioventricular (AV) conduction pattern on the ECG. The electrophysiologic study showed split-His potentials and intra-Hisian Wenckebach. The case highlights the interesting finding of Wenckebach conduction in the His bundle.In a patient requiring pacing and defibrillation therapy, but without superior venous access, combined therapy with S-ICD and leadless pacemaker could be the best solution. An appropriate programming of both devices represents the technical challenge in order to avoid inappropriate shocks due to leadless pacing oversensing.1. We demonstrate a case diffuse tombstone-like QRS-ST segment elevations in the inferior and anterolateral leads -shark Fin sign. The transient diffuse tombstone-like ECG changes (Shark fin sign) seen in our patient were most consistent with multivessel coronary vasospasm likely secondary to hemopericardium.We report a case of percutaneous epicardial left atrial appendage exclusion in a patient with the atrial septal closure.Although a very VA interval ( less then 60 ms in proximal CS) is suggestive of simultaneous atrial capture, rarely it can have exception. A very short VA shall not be discarded without analysing the electro grams.Venous thrombosis or stenosis frequently occurs after implanting transvenous pacemaker leads, and it is usually asymptomatic. The reported incidence is 30%-64%. The mandatory treatments are balloon angioplasty, stenting, thrombolytic, mechanical thrombectomy, and venous grafting. We present a case with the special cooperation of an electrophysiologist and a coronary interventionist in Ha Noi Heart Hospital, Vietnam, to treat an implanted pacemaker patient with fracture ventricular lead and superior vena cava syndrome.Although the Needle's Eye Snare (Cook Medical) has been considered useful for lead extraction, serious complications can occur. We presented a case of atrial septal perforation associated with the Needle's Eye Snare. Our case highlights the importance of not persisting with the Needle's Eye Snare to prevent atrial damage.
Missense mutations in the hyperpolarization-activated cyclic nucleotide-modulated (HCN) channel 4 (HCN4) are one of the genetic causes of cardiac sinus bradycardia.

To investigate possible HCN4 channel mutation in a young patient with profound sinus bradycardia.

Direct sequencing of
and whole-exome sequencing were performed on DNA samples from the indexed patient (P), the patient's son (PS), and a family unrelated healthy long-distance running volunteer (V). Resting heart rate was 31bpm for P, 67bpm for PS, and 50bpm for V. Immunoblots, flow cytometry, and immunocytofluorescence confocal imaging were used to study cellular distribution of channel variants. Patch-clamp electrophysiology was used to investigate the properties of mutant HCN1 channels.

In P no missense mutations were found in the HCN4 gene; instead, we found two heterozygous variants in the HCN1 gene deletion of an N-terminal glycine triplet (
GGG
, "N-del") and a novel missense variant, P851A, in the C-terminal region. N-del variant was found before and shared by PS. These two variations were not found in V. Compared to wild type, N-del and P851A reduced cell surface expression and negatively shifted voltage-activation with slower activation kinetics.

Decreased channel activity HCN1 mutant channel makes it unable to contribute to early depolarization of sinus node action potential, thus likely a main cause of the profound sinus bradycardia in this patient.
Decreased channel activity HCN1 mutant channel makes it unable to contribute to early depolarization of sinus node action potential, thus likely a main cause of the profound sinus bradycardia in this patient.
Catheter ablation for atrial fibrillation is an effective treatment; however, periesophageal vagal nerve injury is not rare and sometimes results in acute gastroparesis (AGP) after atrial fibrillation ablation (AFA). We sought to investigate the incidence and risk factors of AGP via preprocedural computed tomography (CT) analysis.

We retrospectively reviewed 422 patients who underwent index AFA at our center. Using contrast-enhanced CT performed before ablation, the anatomical characteristics of the esophagus were compared between patients with and without post-ablation AGP. AGP was diagnosed by the presence of symptoms, fasting abdominal X-ray radiography as a screening test, and additional abdominal imaging.

Of the 422 patients (age, 67±11years; male, 68.5%; cryoballoon, 63.7%), AGP developed in 14 (3.3%) patients, and six of 14 patients were asymptomatic. AGP resolved in all patients within 4weeks without invasive treatment. In the AGP group, the esophagus was frequently located on the vertebra (middle-positioned esophagus) (AGP vs non-AGP, 42.9% vs 11.5%;
=.01), and additional posterior wall ablation was frequently performed (50.0% vs 14.5%;
=.02). In the multivariate analysis, middle-positioned esophagus (
=.02; odds ratio, 9.0; 95% confidence interval [CI], 1.5-53.3) and additional posterior wall ablation (
=.01; odds ratio, 7.6; 95% CI, 1.5-42.1) were independent predictors of AGP.

Anatomical evaluation of the esophagus using CT may be simple and useful for predicting AGP after AFA. High-risk patients who have middle-positioned esophagus or who underwent excessive posterior wall ablation should be followed up closely.
Anatomical evaluation of the esophagus using CT may be simple and useful for predicting AGP after AFA. High-risk patients who have middle-positioned esophagus or who underwent excessive posterior wall ablation should be followed up closely.
Left atrial volume index (LAVI) of >34mL/m
is the cutoff value for identifying an enlarged left atrium. The definition of left atrial (LA) reverse remodeling after atrial fibrillation (AF) ablation is undetermined. We hypothesized that patients with LA dilatation who achieve normal LA volume (LAVI<34mL/m
) after AF ablation have better long-term outcomes than those who do not. Furthermore, we investigated whether patients with a normal LA volume can also achieve normal LA function with AF ablation.

We enrolled 140 AF patients with baseline LAVI of ≥34mL/m
, without AF recurrence for 1year after the initial AF ablation. We acquired conventional and speckle-tracking echocardiographic parameters within 24hour and at 1year after the procedure. To define the normal range of LA function, age- and sex-matched controls without a history of AF were also enrolled.

After restoration of sinus rhythm, LA structural and functional parameters significantly improved, and 75 patients (54%) had normal LA volume. During a median follow-up of 44 (31-61) months, 32 patients (23%) experienced a late recurrence of AF (AF recurrence >1year). Patients who achieved normal LA volume after AF ablation had fewer late recurrences than those who did not (
<.01). However, LA abnormalities, especially LA dysfunction, persisted in AF patients even when the LA volume was normalized compared with controls.

Patients who achieved normal LA volume had better long-term outcomes of AF ablation than those who did not; however, LA abnormalities persisted even after successful ablation of AF.
Patients who achieved normal LA volume had better long-term outcomes of AF ablation than those who did not; however, LA abnormalities persisted even after successful ablation of AF.
Catheter ablation (CA) is the choice therapy of cavotricuspid isthmus (CTI) atrial flutter. The aim of this study was to describe our approach to improve the CTI ablation using a zero-fluoroscopy (ZF). The procedural difficulties could be related to anatomical characteristics of the CTI.

One hundred eighty-eight patients that performed CA of CTI were retrospectively and consecutively evaluated between 2017 and 2019. The studied population was divided into two groups. Eighty-eight patients who were undergone CA using ablation catheter without shaft visualization catheter (NSV) were Group 1. One hundred patients were undergone CA using ablation catheter with a shaft visualization (SV); they were Group 2. The catheter was looped at the Eustachian ridge after 200seconds of radiofrequencies (RF) without elimination of local electrogram.

A conduction line block of CTI was obtained in all patients of Group 2 using a ZF approach. In 16 patients of Group 1, the catheter inversion was obtained using fluoroscopy tted the catheter inversion safely in order to overcome some complex CTI anatomy and obtain bidirectional block. The SV reduced procedure time, RF applications and fluoroscopy exposition during CTI ablation.
Although less common, typical atrial flutter shares similar pathophysiological roots with atrial fibrillation. Following successful cavo-tricuspid isthmus ablation using radiofrequency, many patients, however, develop atrial fibrillation in the mid-to-long-term. This study sought to assess whether pulmonary vein isolation conducted at the same time as cavo-tricuspid isthmus ablation would significantly modify the atrial fibrillation burden upon follow-up in patients suffering from typical atrial flutter.

This was a multicenter randomized controlled study involving typical atrial flutter patients with history of non-predominant atrial fibrillation (1 atrial fibrillation episode only, in 67% of population) who were scheduled for cavo-tricuspid isthmus radiofrequency ablation. Patients were randomly assigned to either undergo cavo-tricuspid isthmus ablation alone or cavo-tricuspid isthmus plus pulmonary vein isolation (CTI+). Pulmonary vein isolation was performed using cryoballoon technology. An outpatient consultation with ECG and 1-week Holter monitoring was performed at 3, 6months, 1year, and 2years postprocedure. The primary endpoint was atrial fibrillation recurrences lasting more than 30s at 2years postablation.

Of the patients enrolled, 36 were included in each group. At 2-year follow-up, the atrial fibrillation recurrence rate was significantly higher in the CTI vs CTI+group (25/36, 69% vs. 12/36, 33% respectively;
<.001), with similar typical atrial flutter recurrence rates. There were no differences in undesirable events, except for transient phrenic nerve palsy reported from three CTI+patients (8.3%).

Pulmonary vein isolation using cryoballoon technology was proven to significantly reduce the atrial fibrillation incidence at 2years postcavo-tricuspid isthmus ablation.
Pulmonary vein isolation using cryoballoon technology was proven to significantly reduce the atrial fibrillation incidence at 2 years postcavo-tricuspid isthmus ablation.
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