Limits...
Wolff-Parkinson-White syndrome and rheumatic mitral stenosis: an uncommon coincidence that can cause severe hemodynamic disturbance.

Alper AT, Hasdemir H, Akyol A - Indian Pacing Electrophysiol J (2008)

Bottom Line: The combination of rheumatic mitral stenosis and Wolff-Parkinson-White syndrome is a rare situation.In this case, we are reporting an 72-year-old man presenting with multi-organ failure due to the this combination and successfully treated with radiofrequency ablation during preexcitated atrial fibrillation.

View Article: PubMed Central - PubMed

Affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery, Center, Cardiology Department Istanbul, Turkey. draalper@gmail.com

ABSTRACT
The combination of rheumatic mitral stenosis and Wolff-Parkinson-White syndrome is a rare situation. In this case, we are reporting an 72-year-old man presenting with multi-organ failure due to the this combination and successfully treated with radiofrequency ablation during preexcitated atrial fibrillation.

No MeSH data available.


Related in: MedlinePlus

a, b Ablation site (arrow) in the right and left anterior oblique views (RAO, LAO).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC2572024&req=5

Figure 2: a, b Ablation site (arrow) in the right and left anterior oblique views (RAO, LAO).

Mentions: A 72-year-old man presented to the emergency department with the complaint of palpitation, progressive dyspnea and mental status deterioration present for four days. Physical examination revealed a blood pressure of 70/40 mmHg and an irregular heart rate of 190-240 beats per minute. The 12 lead- electrocardiogram showed preexcited atrial fibrillation (Figure 1). Urgent cardioversion was required. So transesophageal echocardiography was performed to rule out the presence of left atrial thrombus. Echocardiography revealed a mitral valve area of 1.19 cm2 with a gradient of 20/10 mmHg, moderate tricuspid regurgitation and no left atrial thrombus. A biochemical profile obtained on admission revealed high levels of serum glutamic-oxaloacetic acid transferase (SGOT), serum glutamic pyruvic transaminase (SGPT), international normalized ratio (INR) and creatinine (CR) (SGOT 1800 IU/L, SGPT 3600 IU/L, INR 6.3 CR: 2.8 mg/dl) indicating hepatic and renal failure. Because of hemodynamic instability, immediate cardioversion was performed. But multiple attempts of electrical cardioversion using biphasic energy failed to restore normal sinus rhythm. Also it was not possible to control the ventricular rate medically. Because of hepatic failure, amiodarone couldn't be given to control the ventricular rate. After obtaining informed consent the patient was transferred to the electrophysiology laboratory. Because stable cannulation of coronary sinus was not possible due to anatomical reasons, two electrode catheters, one 6-French Josephson catheter, and one 7-French ablation catheter (Medtronic, Minneapolis, MN), were advanced through both femoral veins and placed at right ventricular apex, and tricuspid annulus positions. During AF, full preexcitation was present in 12-lead ECG. According to 12-lead ECG, accessory pathway was right paraseptal in location. But to exclude the possiblity of a left-sided paraseptal accessory pathway, coronary sinus was mapped by the ablation catheter. Mapping of coronary sinus revealed that earliest ventricular activation in coronary sinus was located in the ostium. Then, endocardial mapping of the tricuspid annulus during preexcited AF showed the area of earliest ventricular activation at the level of the right midseptal region (Figure 2: a, b). Current was delivered at this site using automatic temperature control with a maximum power setting of 30 watt and a target temperature of 50ºC. Because it was impossible to follow 1:1 AV conduction during ablation, we only observed bradycardia and regularity of the rhythm to follow AV conduction. Radiofrequency current was then applied abolishing the preexcitation in the first second of the application without bradycardia and regularity of AF (Figure 3). Then after 20 seconds, setting of the generator was changed to a maximum of 50 watt and a target temperature of 60ºC. Ablation was performed for total of 60 seconds. After ablation, AF was still present, but the rate was less than 100 bpm and QRS complexes were narrowed. No preexcitation was seen and there was no AV block. After ablation procedure, electrical cardioversion was reattempted and sinus rhythm was restored. But after 1 hour, atrial fibrillation resumed again. Because mitral stenosis was present and the recurrence risk of AF was high after even a successful cardioversion and rate control was perfect after ablation of accessory pathway, cardioversion was not considered. After ablation, rate control was obtained by AV nodal blocking agents easily. SGOT, SGPT, INR and CR levels reduced to normal range after sixth day of ablation.


Wolff-Parkinson-White syndrome and rheumatic mitral stenosis: an uncommon coincidence that can cause severe hemodynamic disturbance.

Alper AT, Hasdemir H, Akyol A - Indian Pacing Electrophysiol J (2008)

a, b Ablation site (arrow) in the right and left anterior oblique views (RAO, LAO).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2572024&req=5

Figure 2: a, b Ablation site (arrow) in the right and left anterior oblique views (RAO, LAO).
Mentions: A 72-year-old man presented to the emergency department with the complaint of palpitation, progressive dyspnea and mental status deterioration present for four days. Physical examination revealed a blood pressure of 70/40 mmHg and an irregular heart rate of 190-240 beats per minute. The 12 lead- electrocardiogram showed preexcited atrial fibrillation (Figure 1). Urgent cardioversion was required. So transesophageal echocardiography was performed to rule out the presence of left atrial thrombus. Echocardiography revealed a mitral valve area of 1.19 cm2 with a gradient of 20/10 mmHg, moderate tricuspid regurgitation and no left atrial thrombus. A biochemical profile obtained on admission revealed high levels of serum glutamic-oxaloacetic acid transferase (SGOT), serum glutamic pyruvic transaminase (SGPT), international normalized ratio (INR) and creatinine (CR) (SGOT 1800 IU/L, SGPT 3600 IU/L, INR 6.3 CR: 2.8 mg/dl) indicating hepatic and renal failure. Because of hemodynamic instability, immediate cardioversion was performed. But multiple attempts of electrical cardioversion using biphasic energy failed to restore normal sinus rhythm. Also it was not possible to control the ventricular rate medically. Because of hepatic failure, amiodarone couldn't be given to control the ventricular rate. After obtaining informed consent the patient was transferred to the electrophysiology laboratory. Because stable cannulation of coronary sinus was not possible due to anatomical reasons, two electrode catheters, one 6-French Josephson catheter, and one 7-French ablation catheter (Medtronic, Minneapolis, MN), were advanced through both femoral veins and placed at right ventricular apex, and tricuspid annulus positions. During AF, full preexcitation was present in 12-lead ECG. According to 12-lead ECG, accessory pathway was right paraseptal in location. But to exclude the possiblity of a left-sided paraseptal accessory pathway, coronary sinus was mapped by the ablation catheter. Mapping of coronary sinus revealed that earliest ventricular activation in coronary sinus was located in the ostium. Then, endocardial mapping of the tricuspid annulus during preexcited AF showed the area of earliest ventricular activation at the level of the right midseptal region (Figure 2: a, b). Current was delivered at this site using automatic temperature control with a maximum power setting of 30 watt and a target temperature of 50ºC. Because it was impossible to follow 1:1 AV conduction during ablation, we only observed bradycardia and regularity of the rhythm to follow AV conduction. Radiofrequency current was then applied abolishing the preexcitation in the first second of the application without bradycardia and regularity of AF (Figure 3). Then after 20 seconds, setting of the generator was changed to a maximum of 50 watt and a target temperature of 60ºC. Ablation was performed for total of 60 seconds. After ablation, AF was still present, but the rate was less than 100 bpm and QRS complexes were narrowed. No preexcitation was seen and there was no AV block. After ablation procedure, electrical cardioversion was reattempted and sinus rhythm was restored. But after 1 hour, atrial fibrillation resumed again. Because mitral stenosis was present and the recurrence risk of AF was high after even a successful cardioversion and rate control was perfect after ablation of accessory pathway, cardioversion was not considered. After ablation, rate control was obtained by AV nodal blocking agents easily. SGOT, SGPT, INR and CR levels reduced to normal range after sixth day of ablation.

Bottom Line: The combination of rheumatic mitral stenosis and Wolff-Parkinson-White syndrome is a rare situation.In this case, we are reporting an 72-year-old man presenting with multi-organ failure due to the this combination and successfully treated with radiofrequency ablation during preexcitated atrial fibrillation.

View Article: PubMed Central - PubMed

Affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery, Center, Cardiology Department Istanbul, Turkey. draalper@gmail.com

ABSTRACT
The combination of rheumatic mitral stenosis and Wolff-Parkinson-White syndrome is a rare situation. In this case, we are reporting an 72-year-old man presenting with multi-organ failure due to the this combination and successfully treated with radiofrequency ablation during preexcitated atrial fibrillation.

No MeSH data available.


Related in: MedlinePlus