From 2005, Vol. 5, No. 2: At MUSC Children s Hospital in Charleston, South Carolina, patients with complex congenital heart disease often have complex and difficult-to-manage arrhythmias. Perhaps the most difficult case they have managed was that of a four-month-old 4.7 kg baby boy with partially repaired congenital heart disease and multiple types of VT. After having arrhythmia surgery on the RV outflow tract and being the smallest child in the world at the time to have an ICD implanted, he continued to have incessantly recurrent LV fascicular VT, requiring 70 shocks and over 400 ATPs over a two-week period. They finally took him to the lab in the middle of the night and successfully ablated his VT using a retrograde aortic approach to the LV. Although they had to leave him with complete AV block, he never had VT again, and his ICD was replaced with a standard dual-chamber pacemaker. They have also done an emergency case in a 12-year-old boy with tachycardia-induced myopathy who was on ECMO during the cath. They successfully ablated an ectopic right atrial focus, leading to eventual complete recovery. From 2005, Vol. 5, No. 1: At Central Baptist Hospital in Lexington, Kentucky, they ablated five different atrial arrhythmias in a patient with an orthotopic-transplanted heart. They also had a recent pulmonary vein isolation ablation case with possible congenital absence of the left inferior pulmonary vein. Another recent interesting case involved the successful use of the Navistar irrigated tip ablation catheter for a difficult case of inappropriate sinus tachycardia. They also have a case series of 11 symptomatic VT ablated from the left main coronary cusp. From 2004, Vol. 4, No. 12: At United s John Nasseff Heart Hospital in St. Paul, Minnesota, they have had cases of orthodromic tachycardia with intermittent LBBB, Mahaim fiber ablation, and attempted CS cannulation of LV lead placement in a patient with a left-sided SVC. Overall, they write, there are too many bizarre lead extractions to discuss! From 2004, Vol. 4, No. 11: At Lancaster General Hospital in Lancaster, Pennsylvania, they note a couple of cases that were pretty interesting. During one of their atrial fibrillation ablations, it was mentioned that a patient undergoing an AF ablation somewhere else actually had his esophagus ablated during the procedure. This had one of their electrophysiologists thinking what he could do to prevent an esophageal ablation. They ended up inserting a Biosense Navistar down the esophagus and actually created a map. This ended up showing them their proximity to the esophagus during ablation. Another case was a BiV. Their target coronary was blocked, and the vessel prior to the blockage had poor pacing thresholds. Ultimately, a stent was placed to open up the vessel. Upon advancing the lead, they still were unable to pass beyond the stent. Interestingly enough, when they placed the lead at the stent, they found pacing was conducting through the stent to the area where they would have liked the lead placed. Thresholds were great. The other bizarre case was a BiV with a totally occluded subclavian vein. They accessed the left subclavian with a 7 French (Fr) peel-away sheath, and followed that with the Frontrunner device. After trying a few Frontrunners, they proceeded to the groin to obtain retrograde access. Once again they used the Frontrunner, going retrograde, and advanced into the left subclavian vein. They followed by advancing a Glidewire ® in retrograde fashion to the subclavian vein. Next they took a snare, advanced it through the 7 Fr sheath, and snared the Glidewire. They pulled the Glidewire out of the sheath. They were then able to advance a balloon over the wire and perform venoplasty. Ultimately, CS access was achieved, and the CS lead placed within minutes. From 2004, Vol. 4, No. 7: At Lenox Hill Hospital in New York, they recently performed an ablation on a young gentlemen with WPW syndrome. His ECG revealed a left lateral accessory pathway (AP). During the diagnostic EP study he had antidromic AVRT down the left lateral AP and up a different septal AP, as well as orthodromic AVRT utilizing both the septal AP and another left posterior AP. They successfully ablated the left lateral and left posterior accessory pathways. He still had orthodromic AVRT utilizing the septal AP (only on Isuprel). Given the proximity of the septal accessory pathway to his AV node, they opted to treat him medically and bring him back at a later date for recurrent/breakthrough supraventricular tachycardia. From 2004, Vol. 4, No. 6: At Porter Adventist Hospital in Littleton, Colorado, they recently had an interesting ablation case of a patient with upper loop atrial tachycardia. They also did a VT ablation in a patient with an ICD post generator replacement. The patient had never received therapies prior, and then developed frequent sustained monomorphic VT that was responsive to VT ablation. From 2004, Vol. 4, No. 4: At Medical City Heart in Dallas, Texas, once they implemented the three-dimensional mapping system, they noted that they started to see a lot of interesting cases. From 2004, Vol. 4, No. 3: At Tufts-New England Medical Center and Cardiac Arrhythmia Center in Boston, Massachusetts, complex right- and left-sided atrial arrhythmias were very interesting to map using their CARTO system. They write that biventricular coronary sinus lead placement can also become challenging. From 2004, Vol. 4, No. 2: At St. Luke s-Roosevelt Hospital Center in New York, they have had a large number of difficult referrals sent to their physician staff, who has seen a number of challenging cases. They have had several dextrocardias that required either ablation or device implantation. They write that atrial fibrillation and pulmonary vein ablations are almost always interesting, although they are more difficult procedures. Some of these cases have been plagued by atrial fibrillation for so long that their doctors had given up hope of restoring sinus rhythm. Then they ablated their atrial fibrillation focus, normal sinus rhythm was restored, and the patients have done dramatically well. From 2003, Vol. 3, No. 9: At Emory Crawford Long Hospital in Atlanta, Georgia, they never cease to be amazed at the variety and complexity of cases they see. Recently, they evaluated a young male referred after aborted sudden cardiac death. They ended up diagnosing myotonic muscular dystrophy and treating the patient with a defibrillator. From 2003, Vol. 3, No. 8: At St. John Hospital and Medical Center in Detroit, Michigan, they have had many interesting cases. They think it is due largely to their fairly high volume of patients and a myriad of procedures performed in their laboratory. From 2003, Vol. 3, No. 7: At the UCLA Cardiac Arrhythmia Center in Los Angeles, they write that there are too many cases to list here! However, some include transseptal puncture of the septum via the left subclavian for LV endocardial lead implant for a patient in cardiogenic shock, and complex congenital cases such as Fontan s and VT ablations also come to mind. From 2003, Vol. 3, No. 5: At the University of Iowa Hospitals in Iowa City, Iowa, they write that as they remain a tertiary referral center for the state, they get to see some of the most complex cases. Many of the issues, however, involved more than just the arrhythmia problems. From 2003, Vol. 3, No. 4: At the University of California - San Diego in California, they note that by their nature as a tertiary referral center, they have numerous rare and challenging cases that continue to make their job interesting. From 2003, Vol. 3, No. 3: At the University of Rochester Medical Center at Strong Memorial Hospital in New York, they had a patient with two sinus and AV nodes in for radiofrequency ablation (RFA). They managed to do a successful ablation. While doing a BiV/pacer, they discovered their patient had a persistent left SVC; this system was successfully implanted. Another case involved a patient in for AVNRT and they found he had a bystander Maheim bypass tract. A patient complaining of syncope episodes was referred for a tilt table test, and stated that only certain conditions brought on the symptoms. Their dedicated staff would go to any lengths to set about replicating these conditions as closely as possible. While the test was in progress with the patient hooked up to various monitors and equipment, strapped to the table and tilted at 60 degrees, the primary nurse, the attending physician and patient were observed by another staff member to all be sipping ice-cold Coca Colas! Contrary to the patient s claim, this did not induce syncope in any of them. From 2003, Vol. 3, No. 2: At Advocate Illinois Masonic Medical Center in Chicago, Illinois, since they serve as a referral center for many hospitals throughout Illinois, they very often have cases that are interesting from an arrhythmic standpoint. Since they reside in a major metropolitan area, the bizarre and unusual cases are too numerous to mention. They tell us that their holiday parties are often filled with anecdotal reminiscing about the odd requests they have received and their physicians humorous responses to them. They did have one very interesting young patient who had not one but three concealed accessory pathways. Every time they ablated one, they would uncover another. Later, after patiently ablating all three, they discharged him right into the hands of law enforcement officers who were waiting to arrest him. He is now serving his sentence in the state penitentiary in beautiful sinus rhythm. From 2003, Vol. 3, No. 1: At the Carle Heart Center in Urbana, Illinois, patients present with multiple arrhythmias, interesting body piercings and tattoos. Using RA mapping for atrial fibrillation, interesting cases with radiofrequency triggers and atypical flutters have been uncovered. The most troublesome are the infected devices referred in for lead extraction, sometimes in septic shock. From 2002, Vol. 2, No. 6: At Mercy General Hospital in Sacramento, California, a young man with intractable sustained ventricular tachycardia (of many years), who had unsuccessful ablations in the past at another medical facility and also failed pharmaceutical therapy, was recently referred for services. During a short procedure, the ventricular tachycardia source was identified and successfully ablated. The patient was discharged with normal sinus rhythm.