This case represents a clear example of CRT induced proarrhythmia, which required inactivation of LV pacing for effective acute management. Such an intervention should be considered in CRT patients who exhibit a notable increase in drug refractory VT episodes.

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Right coronary artery (RCA) occlusion and acute myocardial infarction are rare during radiofrequency (RF) ablation of the cavotricuspid isthmus. Ventricular fibrillation (VF) or cardiac arrest in the periprocedural period may be the initial or only clinical manifestation. Septal or lateral RF delivery may increase the risk. We report 2 cases of RCA occlusion during ablation of typical atrial flutter (AFL). Angiographic and anatomical correlations are illustrated. One patient was ablated with a septal approach, the other with a lateral approach, and in each instance the RCA occluded near the ablative lesions. If septal or lateral ablation lines are contemplated during ablation of isthmus-dependent atrial flutter, fluoroscopic or electroanatomic confirmation of catheter position is pivotal. Smaller tipped catheters, energy titration (to minimally effective dose), saline irrigation, or cryoablation should also be considered to help avoid this serious complication.

Dofetilide is currently recommended as second-tier therapy to maintain sinus rhythm in patients with paroxysmal atrial fibrillation (PAF) and normal left ventricular function, yet limited data support this recommendation. We examined the safety and efficacy of dofetilide in this setting through a retrospective chart review. We evaluated patients who had symptomatic PAF, normal left ventricular function, and no significant valvular disease. The end points were complete suppression of symptomatic PAF and subjective symptomatic improvement with dofetilide treatment. Over a 3-year period, 34 patients who had failed previous antiarrhythmic therapy were included. Of these, 3 discontinued dofetilide treatment before discharge. Of the remaining 31 who continued treatment after discharge, it was eventually discontinued in 13. At 12 months, symptomatic improvement was observed in 18 of 31 patients, 6 of whom remained asymptomatic. Treatment with dofetilide in this study was successful in less than 1 in 5 patients. Despite careful precautions, serious proarrhythmias, the major limiting side effect of dofetilide, still occurred during long-term follow-up.