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Pre-excited, fast conducting atrial fibrillation (AF) is a serious life-threatening arrhythmia that requires urgent pharmacological or electrical cardioversion. When anti-arrhythmic medications fail to restore sinus rhythm, biphasic, direct current (DC) cardioversion is required. Appropriate synchronization of the DC shock with the QRS is crucial, however not easily achieved. Since the QRS-T complexes in pre-excited AF are severely distorted, the diagnosis of inaccurate synchronization may be overlooked. Here, we report a unique case where during electrical cardioversion of pre-excited AF with inappropriate synchronization on the T wave inadvertently resulted in ventricular fibrillation (VF), and review the literature.

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BACKGROUND: Patients with ischemic cardiomyopathy (ICM) are at an increased risk for sudden death. Although earlier trials used programmed electrical stimulation (PES) for risk stratification, more recent data demonstrate the benefit of implantable cardiac defibrillators (ICDs) in selected patients with reduced left ventricular ejection fraction (LVEF) without performing PES. However, little is known about the outcome of non-inducible patients. The purpose of this study was to evaluate the efficacy of PES for mortality risk stratification in patients with ICM. METHODS: All consecutive patients who met the inclusion criteria (history of coronary artery disease, LVEF≤35%, and absence of documented spontaneous sustained ventricular tachycardia or aborted sudden cardiac death) were included in the study. The stimulation protocol involved up to three extrastimuli from two different sites in the right ventricle, with 180 ms as the shortest coupling interval. The primary endpoint was overall survival. RESULTS: A total of 198 patients were included in the study; of these, 60 exhibited negative (-)PES, and 138 had positive (+)PES and also underwent ICD implantation. The mean follow-up duration was 4.5 years. There was no difference in age or LVEF between the patient groups. We found a trend towards an increased 5-year survival rate in the (+)PES group in whom ICD implantation had been performed (p=0.058). Survival was significantly better in patients under 68 year olds in the (+)PES group in whom ICD implantation was performed (hazard ratio=0.3, p=0.01). The survival rate of patients ≥68 years old was similar in both groups (p=0.95). CONCLUSIONS: Non-inducibility during PES does not predict the prognosis of patients with ischemic cardiomyopathy.

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BACKGROUND: Randomized clinical trials have shown conflicting data on the benefit of implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with more advanced heart failure (HF) symptoms. Using the Israeli ICD Registry data, we sought to examine the effect of HF functional class on the outcome of patients who receive device therapy in a real-world setting. METHODS: The association between HF functional class (categorized as baseline New York Heart Association [NYHA] functional class I and II in [61%] vs class III and IV in [39%]) and clinical outcomes was assessed among 913 patients who received an ICD (n = 514) or a cardiac resynchronization therapy with a defibrillator (CRT-D; n = 399) device and were prospectively followed in the Israeli ICD Registry between July 2011 and June 2013. RESULTS: The risk associated with advanced HF functional class was significantly different in ICD and CRT-D recipients. In the former group, patients with NYHA classes III and IV experienced >3-fold increased risk of HF or death (hazard ratio [HR] = 3.28; P < 0.001), whereas among CRT-D recipients the risk was similar between patients with NYHA III/IV and those with less advanced HF symptoms (HR = 0.97 [95% confidence interval (CI) 0.54-1.78]; P = 0.42; P value for NYHA functional class by device type interaction = 0.002). The risk for ventricular arrhythmia (VA) was significantly lower among patients with more advanced NYHA functional class, regardless of device type (overall HR = 0.52; 95% CI 0.33-0.91; P = 0.04). CONCLUSION: Our findings suggest that patients with less advanced HF symptoms experience a greater risk for VA and the development of HF is attenuated in CRT-D recipients with more advanced NYHA functional class.

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A case of peri-procedural perforation of right atrium following the implantation of atrial screw-in lead in a 74-year-old man is reported. The perforation caused acute pericardial tamponade and worsening of the patient's clinical and haemodynamic conditions. Urgent surgical intervention with lead extraction was performed.

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Organophosphate poisoning may precipitate complex ventricular arrhythmias, a frequently overlooked and potentially lethal aspect of this condition. Acute effects consist of electrocardiographic ST-T segment changes and AV conduction disturbances of varying degrees, while long-lasting cardiac changes include QT prolongation, polymorphic tachycardia ("Torsades de Pointes"), and sudden cardiac death. Cardiac monitoring of organophosphate intoxicated patients for relatively long periods after the poisoning and early aggressive treatment of arrhythmias may be the clue to better survival. We present here a review of the literature with a focus on late cardiac arrhythmias (mainly "Torsades de pointes"), possible mechanisms, and treatment modalities, with special emphasis on postpoisoning monitoring for development of arrhythmias.

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Right-sided prepectoral implantation of an ICD is performed in unusual circumstances only, like in patients with abnormal venous drainage and preexisting left-sided devices. This case report describes a 42-year-old man who had undergone previous right pneumonectomy and who required ICD implantation for symptomatic inducible nonsuppressable hemodynamically unstable ventricular tachycardia. To avoid the small but real possibility of inadvertent iatrogenic left-sided pneumothorax in a patient with previous right pneumonectomy, a dual chamber ICD with an active can was implanted in the right prepectoral position.

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