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Thomas F. Lüscher
Bernard J. Gersh
Schematic of the anatomo-functional arrhythmic mechanism and common ablation strategies in paroxysmal and long-standing/ persistent AF. (A) Active triggers arising from the atrial myocardium within the PVs and other thoracic veins (CS, vein/ligament of Marshall, and the SVC) are shown in green. Autonomic ganglia and nerves are shown in yellow. Abrupt changes of fibre orientation along the PV antrum and posterior LA wall favouring anatomic re-entry or high frequency rotors are also shown. (B) The two most common approaches for paroxysmal AF: segmental PV isolation for electric disconnection of triggers within the veins; and circumferential ostial PV isolation (one-by-one linear ablation of the PVs). (C) Simultaneous isolation of the ipsilateral PVs, encircling the antrum and additional linear lesions between the superior and inferior PVs. (D) Combinations of more than two techniques are usually necessary for a successful outcome in long-standing or persistent AF. These approaches include (i) PV isolation; (ii) isolation of the thoracic veins and non-PV triggers; (iii) additional linear lesions such as the ‘mitral isthmus’ line connecting the mitral valve and the lesion encircling the LIPV, a ‘roof’ line connecting the lesions encircling the left and right PVs, a ‘right atrial isthmus’ line, and an ‘anterior’ line connecting the roof line to the mitral annulus anteriorly; (iv) ablation of complex fractionated activity; and (v) ablation of autonomic plexuses.
CS, coronary sinus; LAA, left atrial appendage; LIPV, left inferior PV; LSPV, left superior PV; RIPV, right inferior PV; RSPV, right superior PV; SVC, superior vena cava.
Tilt testing and neurally mediated syncope: too many protocols for one condition or specific protocols for different situations?
Eur. Heart J. (2009), 30 (18), 2174-2176; 10.1093/eurheartj/ehp290 - Click here to view the abstract
This figure shows very schematically the different possible afferent pathways of neurally mediated syncope and how tilt testing and the different drugs can act on these different triggers. Tilt testing and nitroglycerin provoke central hypovolaemia by increasing venous pooling; isoproterenol, increases the adrenergic nerve tone, as happens in those cases triggered by fear or pain; clomipramine enhances central serotonergic activity as probably happens in some syncopal centrally induced syncopal episodes.
Psychosis, depression, and high risk for sudden cardiac death: time for co-operation between psychiatrists and cardiologists
Eur. Heart J. (2011) 33 (6), 687; 10.1093/eurheartj/ehr405 - Click here to view the abstract
The triangle of sudden death in psychiatric patients.
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