Summary:The incidence of cardiac complications from atrial transseptal catheterization has never been quantified in patients with normal-sized atria. Series defining the complication rate are derived from diseased hearts with structural changes that may alter the complication rate of the procedure. The generation of a standardized incidence of perforation in a population of structurally normal atria ha3 important implications. A total of 46 atrial Vansseptal catheterizations guided by transesophageal echocardiography (TEE) for radiofrequency ablation of left-sided accessory pathways was performed in 42 patients during a 3-year period (199c-1993). Clinical and echocardiographic data were analyzed, with special attention given to TEE reports pre-and post-transseptal catheterization. Only one coniplication occurred in the 46 procedures (2.2%): a perforation of the left atrium that led to pericardial effusion and cardiac tamponade. In a small series of patients with normalsized atria, we have demonstrated that TEE-guided transseptal catheterization is a procedure with a low complication rate.

These data indicate that the atrial insertion site of the AP can be successfully ablated in the majority of patients with left free-wall APs by using either a transseptal or transaortic approach. Furthermore, both techniques are associated with minimal morbidity and no mortality.

Vero M3 cells, a line derived from the kidney of an African Green Monkey, display certain alterations in their protein synthetic apparatus as a function of time during a growth cycle. (Growth cycle here refers to exponential growth of unsynchronized cells in culture and their subsequent passage into the stationary phase.) The capacity of cytoplasmic extracts of these cells to promote endogeneous mRNA-mediated polypeptide synthesis or poly U-mediated polyphenylalanine synthesis declines from the second day after the initiation of the growth cycle. The ribosome sedimentation profile indicates that after the second day of growth a decrease also occurs in the total amount of ribosomes per cell, and that a shift occurs from predominantly polyribosome structures to predominantly subunits and monoribosomes structures. The activity of the translation factor, elongation factor 1, also progressively decreases after the second day of growth. Furthermore, when crude factor preparations from cells in the second day of growth (Exponential phase) and from cells in the fifth day of growth (Stationary phase) are compared for leucyl-tRNA synthetase and prolyl-tRNA synthetase activities, it is found that the extracts from fifth-day cells have significantly less activity. The activity of another enzyme, acid phosphatase, remains relatively unaffected as a function of time during the cell growth cycle. When HeLa S3 plating cells are grown under the same conditions, they do not display the same responses.

Atrial transseptal catheterization is usually performed with fluoroscopic guidance of the needle. We report our experience with both fluoroscopic and transesophageal guidance in patients who would otherwise have been at risk by using only fluoroscopy. A total of eleven procedures were performed during a 4 year period. The relative contraindications (some patients had several contraindications) included prior valve replacement (5 patients), prior myocardial revascularization (4 patients), severe dilatation of the left atrium (4 patients), severe dilatation of the ascending aorta (4 patients), and kyphoscoliosis (3 patients). All eleven patients had the transesophageal guided transseptal catheterization performed without complications and without significantly prolonging the procedure. The results of this preliminary, small, and retrospective study suggest that transesophageal echocardiography may enhance the safety of transseptal catheterization in high risk patients. Further prospective studies are needed.

This study reports our initial experience in performing radiofrequency ablations (RFA) of Wolff-Parkinson-White accessory pathways in the lateral wall of the left ventricle with monitoring and guidance provided by transesophageal echocardiography (TEE). Fifty R F A procedures were performed in 48 patients. TEE was used to detect underlying heart disease (in nine patients), monitor coronary sinus catheterization (in 15 patients), guide atrial transseptal catheterization (in 29 procedures), help position the RFA catheter's tip, and evaluate for possible complications in all patients. The study suggests that TEE may help to guide electrophysiologists during their initial experience with RFA procedures.

The literature suggests that during transesophageal echocardiography (TEE), a short-axis view can be obtained in the gastric position using a single-plane probe. Recently, we have found that a long-axis apical display of the heart can be achieved by placing the tip of the probe in the fundus of the stomach. In a 3-month period, we attempted to obtain this view in 54 consecutive patients. Twelve of the patients had TEE done under general anesthesia, while the other 42 patients had the procedure performed under sedation with midazolam at hospital bedside or as an outpatient. The long-axis transgastric view was obtained in 51 of the 54 patients (94%). The image quality was graded subjectively as good in 39 (72%) and fair in the other 12 patients (22%). This view helped to establish the diagnosis in eight patients (15%) and to increase the level of confidence about the accuracy of the diagnosis in 23 (43%) other patients. Four patients' findings are described. We conclude that the new long-axis transgastric view is easy to obtain, does not add much time to the usual TEE study, does not add to the low complication rate of TEE, and may help to interrogate the distal structures of the heart.

Historically, health insurance carriers (HIC) have reimbursed physicians on a fee-for-service basis for echocardiographic studies. With the emergence of managed care, the HIC now may have the option of paying on a capitation basis. To determine whether the method of reimbursement had any bearing on the types of patients referred for echocardiographic services, we conducted a two-phase (retrospective) study. In Phase One, we assessed two groups of ambulatory patients with regard to patient characteristics, medical reason for referral, and echocardiographic results. Group A (4,066 patients) had insurance plans that stipulated reimbursement for echocardiographic services as part of capitation for cardiology services. Group B (3,061 patients) had plans that reimbursed for echocardiographic services on a fee-for-service basis. In Phase Two, we assessed a total of 5,947 patients (3,833 from Group A and 2,114 from Group B) over a period of 40 months to determine the frequency of referral for a second echocardiogram within 2 years of a normal one and the repeat normalcy rate. The results showed that the capitation reimbursement group included younger, predominantly female patients who were referred more often for a more benign reason and who more frequently were diagnosed echocardiographically with less severe disease, higher rates of normalcy, and repeat normalcy. These findings suggest that in our geographic area the capitation method of reimbursement permitted more liberal utilization of echocardiographic services. In this era of cost awareness, the study suggests the need for better screening of patients referred for echocardiographic services.