Furthermore permanent cardiac pacemaker implantation may
Furthermore, permanent cardiac pacemaker implantation may be required when severe bradyarrhythmia recurs for a long period. Sympathetic preganglionic neurons innervating the methylphenidate hcl may be damaged beyond recovery in such cases . Since placement of new leads immediately after infected lead removal has been identified as a risk factor for subsequent device infections , epicardial pacemaker implantation may be considered if the leads had been inserted to avoid fatality from refractory severe bradyarrhythmia due to cervical spinal cord injury.
Conflict of interest
Introduction Focal left atrial tachycardia (AT) is the most common late sequela of surgical valve replacements. Because sites of origin vary between patients, localizing the AT focus usually requires activation mapping during an ongoing episode of AT. Therefore, AT ablation can take longer than ablation of supraventricular tachycardias. AT originating from the mitral annulus (MA) is rare, and arrhythmia localization using three-dimensional electro-anatomic mapping facilitates its ablation . Safe transseptal puncture and access to the left atrium provide a gateway for emerging technologies and therapies, including left atrial (LA) ablation, LA appendage and ventricular assist devices, and percutaneous valve replacement and repairs. However, aortic root penetration is the most feared complication of transseptal puncture. Since the technique relies on fluoroscopic landmarks to identify anatomical boundaries, a comprehensive understanding of regional anatomy is critical to perform transseptal puncture safely and anticipate difficult situations where complications may arise. The presence of copathologies, including previous interventions on the atrial septum, dilated atria, kyphoscoliosis, dextrocardia, or prior heart surgery have varying degrees of anatomic atrial distortion resulting in fossa ovalis displacement  and representing a challenge to transseptal puncture due to movable traditional landmarks. Here, we present an inadvertent noncoronary cusp (NCC) puncture during radiofrequency catheter ablation of left AT originating from the MA in a patient with prior mitral valve replacement (MVR).
Case report A 57-year-old man with dilated cardiomyopathy and chronic heart failure, who had undergone MVR two years prior, was referred to our department for a second attempt at radiofrequency catheter ablation for refractory incessant atrial tachycardia (Fig. 1). Electrophysiological study (EPS) diagnosed left sided AT. Due to the prior MVR, we continued oral anticoagulation with a therapeutic INR during ablation for peri-interventional anticoagulation management. Because of a coronary sinus catheter placed from the left femoral vein via a 7 French sheath, we preferred the right femoral vein for the transseptal puncture using a Brockenbrough needle and an SL1 sheath. We administered heparin immediately after transseptal access has been safely achieved, avoiding transseptal puncture-related potential pericardial effusion. The contrast medium was injected through the transseptal needle to prevent an inadvertent puncture of adjacent tissues; however, the procedure was stopped prematurely because of inadvertent aortic root puncture resulting from unexpected aorta jumping (Video 1). Emergency surgical consultation recommended sheath removal to reduce the likelihood of tamponade. Because the patient was stable and without hemodynamic sequelae, Amplatzer occluder device use was preferred over open-heart surgery for percutaneous repair. However, after removing the dilatator from the aortic root, there was no regurgitation on the transesophageal echocardiogram (TEE) and aortic root angiogram (Video 2), and no oxygen step-up or pressure increase in the right atrium. Therefore, the patient was followed up conservatively in the catheterization laboratory with serial echocardiographic examinations that showed no evidence of aortic regurgitation or pericardial effusion (Video 3). The patient was followed up in the coronary care unit, where he remained stable without hemodynamic sequela for 2 days. Echocardiographic examinations remained normal. Two days later, the patient underwent EPS again. Transseptal puncture was performed successfully under TEE guidance confirming appropriate catheter positioning via a tent-shaped deformation of the interatrial septum. First, the right atrium was mapped, and the earliest activation was on the septal area. The activation time was at approximately zero when compared to the reference catheter in the coronary sinus ostium. The electro-anatomic fast activation mapping showed a focus on the posterior LA wall under the left inferior pulmonary vein ostium (Fig. 2), and the ablation terminated the incessant AT at this point. There was no retroperitoneal hematoma or peritoneal effusion immediately after the procedure or the following day, and the patient was discharged. Three months later, he was in sinus rhythm and off medication with no evidence of aorta–right atrial shunt.