Faculty Bibliography

Introduction: Left ventricular diverticulum is a rare abnormality for which the etiology, management, and natural history are poorly understood. LV diverticuli are reported to be associated with ventricular tachycardia and sudden cardiac death, though the mechanisms of these ventricular arrhythmias have not been well characterized. Conversely, focal PVC triggers of idiopathic VF emanating from the distal Purkinje system have been well described. Here we report the first case of Purkinje fiber-mediated VF mapping to a LV diverticulum that was successfully treated with catheter ablation. Methods: N/A Results: An otherwise healthy 38 year old woman presented with sudden cardiac arrest. Electrocardiography demonstrated repeated episodes of polymorphic VT/VF. The initiating beats of VF were of a left-bundle branch pattern and were identical in ECG morphology to isolated PVCs that were observed in the aftermath of resuscitation. Cardiac MRI demonstrated a normal LVEF and, notably, a focal diverticulum at the inferoseptal wall. At electrophysiology study, a mapping/ablation catheter was positioned in the LV diverticulum via retrograde approach, where distinct purkinje potentials were noted to precede the onset of QRS complexes during sinus rhythm. Pace mapping from within the diverticulum demonstrated a 11/12 lead match for the index PVCs. Delivery of RF energy to this region terminated both the PVCs and future VF events. Conclusions: This is the first description of purkinje-fiber mediated VF mapping to a LV diverticulum and successfully treated with RF ablation. (Figure presented)

BACKGROUND: Atrial fibrillation catheter ablation is frequently guided by identification of fractionated electrograms, which are thought to be critical for maintenance of the arrhythmia. Objective automated means for identifying fractionation independent of physician interpretation have not been standardized or validated. OBJECTIVE: The purpose of this study was to standardize and validate an automated algorithm to rapidly identify fractionated electrograms for high-density atrial fibrillation fractionation mapping. METHODS: Left and right atrial fractionation maps were generated by EnSite NavX 6.0 software, using standardized ablation catheters in eight patients with atrial fibrillation. Two blinded electrophysiologists interpreted all electrograms as either fractionated or not fractionated. A stepwise approach was used to optimize automated settings to accurately identify fractionation. High-density fractionation maps were generated with a 20-pole mapping catheter in eight other patients. Two blinded electrophysiologists interpreted all electrograms as near field or far field. The algorithm was refined to optimize settings to exclude far-field signals and retain near-field signals. The sampling segment length was adjusted to optimize recording time to ensure reproducibility. RESULTS: Using 1,514 points, the automated software achieved sensitivity of 0.75 and specificity of 0.80 for identification of fractionated electrograms. Using 725 points collected via multipole catheters with optimal automated settings, 94% of near-field fractionated electrograms were accurately identified. A 6-second sampling length was needed for reproducible fractionation measurements. CONCLUSION: Standardized settings of EnSite NavX 6.0 software with 6-second data collection per point can rapidly and accurately generate high-density fractionation maps independent of physician electrogram interpretation. This may allow for an automated, standardized approach to atrial fibrillation fractionated ablation

A 21-year-old woman presented with a pacemaker-associated superior vena cava (SVC) syndrome refractory to medical therapy. In the past, treatment of this condition has involved surgical exploration which is invasive. With the evolution of percutaneous techniques, treatment has included venoplasty and stenting over the pacemaker lead. There is limited experience with a more advanced percutaneous technique in which the lead is extracted by an excimer laser sheath. The extraction is immediately followed by venoplasty and stenting at the site of stenosis with subsequent implantation of a new permanent pacemaker at the previously occluded access site. The patient underwent this procedure which proved to be safe, minimally invasive, and an efficient method of treating SVC syndrome secondary to a single chamber atrial pacemaker

OBJECTIVE: This article describes the development, administration, and reliability of the Cornell Services Index (CSI), a new instrument that measures health service use. The CSI was developed to create a standardized measure of the quantity and characteristics (for example, site and provider) of services used by adults. Descriptive data are provided to illustrate the application of the CSI in a community sample of adults who were newly admitted to outpatient mental health clinics. These data provide information about the pathways to care. METHODS: The interrater and test-retest reliability of the CSI were evaluated by using a sample of 40 adults who were seeking mental health treatment. Descriptive data on service use in a sample of 1,279 adults seeking care in outpatient mental health clinics was provided to demonstrate the application of the CSI. RESULTS: The CSI is a portable, easy to use, and brief assessment of service use. It has good interrater and test-retest reliability among adults without cognitive impairment. In the three months before seeking care, 31 percent of the adults interviewed had made a mental health visit, 36 percent had been hospitalized, and more than half (59 percent) had made a medical visit. Twenty-three percent of adults had sought care from a hospital's emergency department. CONCLUSIONS: The CSI is a reliable method to assess health service use for adults. The measure can extend assessment of use beyond the traditional mental health service use questions and provide a snapshot of service use patterns across types, providers, and sites of service among adults who seek mental health care

Biventricular pacing for the treatment of congestive heart failure has consistently demonstrated improvement in quality-of-life and reduction in heart failure symptoms. Though the over-the-wire systems will be helpful in overcoming many existing obstacles to optimal lead placement, anatomic variability will still limit overall success. Cardiac vein angioplasty may be required for deployment of leads into tortuous or obstructed cardiac veins. This case report describes the angioplasty of a focal cardiac vein stenosis allowing for successful implantation of a left ventricular pacing lead. The safety of this procedure is unknown, though the risks may be acceptable in certain patients