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  • br Material and methods br Results br Discussion br Conclusi

    2019-05-10


    Material and methods
    Results
    Discussion
    Conclusions
    Conflict of interest
    Introduction Scoliosis forms a complex curve in all three planes, not only in the coronal plane, leading to deformities caused by the self-rotating movement of the spine [1]. Spinal anomalies may impair cardiorespiratory function.
    Case report A 62-year-old man visited our emergency department complaining of palpitations. His Cobb angle was over 50°, indicating severe scoliosis [Fig. 1(A)]. He was diagnosed with paroxysmal AF, and the heart rhythm was restored to normal by defibrillation. We planned to perform catheter ablation on an outpatient basis. We performed the Brockenbrough method safely under CT guidance, but an ordinary radiofrequency (RF) needle (Japan Lifeline Co.) was unsuitable for the patient. Normally, the Brockenbrough needle is positioned posterior to the septum at approximately 5 o’clock, but CT had shown that the patient’s heart was rotated clockwise from the usual position. The needle was curved and positioned at 4 o’clock in this case [Fig. 1(B)]. After transseptal puncture, we obtained an X-ray image of the left atrium (LA) following injection of a radiopaque dye. CT performed prior to the procedure was integrated into the 3-dimensional (3D) reconstruction electromechanical map of the patient’s atrium (EnSite® NavX®, St. Jude Medical Inc. St. Paul, Minnesota, USA). The 3D map also showed abnormal position and clockwise rotation of the heart: both the LA and RA were rotated clockwise. The anatomical relationship between the Anisomycin and pulmonary vein is shown in Fig. 1(C). The right pulmonary vein was difficult to isolate because there was insufficient space for manipulating the ablation catheter near the right pulmonary vein [Fig. 2(A)]. The ablation catheter was positioned slightly differently in the RA isthmus [Fig. 2(B)]; however, we successfully performed extensive encircling pulmonary vein isolation and ablation of the RA isthmus without any complications, using enhanced CT and 3D mapping [Fig. 2(C) and (D)].
    Discussion This is the first case report to describe AF ablation in a patient with scoliosis. AF ablation with scoliosis required extra precautions with respect to the anatomical position, based on data obtained by CT. The superimposition of pre-acquired CT/magnetic resonance imaging (MRI) images onto the electroanatomic 3D reconstruction is associated with an improved clinical outcome in AF ablation procedures [2]. 3D-CT fusion images provide an excellent overview of the morphology of the LA and pulmonary vein, thereby enhancing the safety of the AF ablation procedures [3]. There are many instances of angiectopia other than those associated with scoliosis. For example, anomalies and variations of inferior vena cava anatomy without abnormal cardiac comorbidity occur in approximately 0.3% of the population, depending on the specific abnormality [4]; however, these anatomical variations are often clinically silent and incidentally discovered. Venous CT images, particularly in cases that are anatomically different, ensure appropriate localization of the vein and heart. Prior CT is very effective to avoid discovering unexpected anatomical differences during ablation. Therefore, not only 3D CT reconstruction of the LA and pulmonary vein, but also venous CT images, is important in AF ablation with complex heart and vein morphology.
    Conflict of interest
    Introduction A sigmoid-shaped interventricular septum (SIS) is generally considered a normal part of the aging process and is of little clinical significance. However, certain patients with SIS may experience clinical symptoms such as dyspnea upon effort and Anisomycin syncope. In patients with hypertrophic obstructive cardiomyopathy (HOCM), narrowing of the left ventricular outflow tract (LVOT) generates a left ventricular (LV) pressure gradient, resulting in reduced cardiac output and subsequent syncope. In these patients, the vasovagal reflex, i.e., the Bezold–Jarisch reflex [1], could play an important role in the occurrence of syncope. By contrast, the mechanisms of syncope in patients with SIS without left ventricular hypertrophy (LVH) [2–4] have yet to be fully elucidated. Here, we report two patients with SIS who presented with recurrent syncope. We were successful in clarifying the mechanisms of syncope and effects of beta-blockers in these cases.