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Atrial fibrillation (AF) affects more than 6% of Americans older than 65. The American Heart Association states that about 2.5 million people in the U.S. have AF and that 300,000 new cases will be discovered each year. The origin of AF has been hotly debated, with some theories involving the tissue of pulmonary vein sleeves. More recently, the role of ganglia located around these veins and the ligament of Marshall (LOM) have been implicated as sites of origination.

Accessory pathways are formed embryologically during cardiogenesis and may be broad, slanted¹ and occasionally particularly challenging to ablate. Right- and left-sided pathways are derived differently, with right-sided pathways characteristically subendocardial as opposed to subepicardial.² Successful ablation of right-sided pathways is frequently limited by catheter stability, and ablation attempts are associated with a lower acute success and higher recurrence rate.^3,4 We report a challenging case of a right-sided accessory pathway with interesting surface ECG manifestations suggesting a long slanted pathway. Location and characteristics presented a challenge using standard ablation techniques, and required complex catheter manipulation and cooled tip energy applications to create an effective lesion formation necessary for pathway elimination.

Permanent pacemakers and implantable cardioverter-defibrillators (ICDs) are essential and well established treatments for heart rhythm disorders. Device malfunctions and component failures have been an issue since implantable devices came into medical use. In particular, the year 2005 has seen an unprecedented amount of attention paid to ICD and pacemaker and malfunction and recalls. However, the overall safety history of cardiac devices is excellent. In this article, we provide a brief overview of the year’s events, as well as describe how our lab has handled recall notification.

In the next installment of the “Troubleshooter’s Casebook” series, the author examines the clinical studies that have shaped electrophysiology over the years.

Have you ever watched a street clown spin five plates at once on skinny sticks? Or marveled at the juggler keeping three or four balls in the air while doing tricks? Think of these specialized artists the next time your Risk Manager walks by. Risk managers are the artists that are trained to balance many tasks at once while doing other “tricks.” Since managing risks is such a fast-paced, ever-changing challenge, administrators find it difficult to know exactly what it is that risk management is balancing, measuring, challenging, or promoting. Moreover, just when you think you've “got it,” the plan has changed a bit and there is a course correction underway. Clinical risk management is dynamic and will continue to change and evolve as the function moves from a traditional role of retroactive management to a strategic, enterprise-wide activity.