Although spontaneous tonsillar bleeding is a rare presentation, it is documented in the literature. Reported cases indicate an increased incidence in young patients, associated with a higher mortality rate. We propose a management plan for this potentially fatal condition.

Pacemakers can be directly involved in initiating or sustaining different forms of arrhythmia. These can cause symptoms such as dyspnea, palpitations, and decompensated heart failure. Early detection of these arrhythmias and optimal pacemaker programming is pivotal. The aim of this review article is to summarize the different types of pacemaker‐mediated arrhythmias, their predisposing factors, and mechanisms of prevention or termination.

Junctional Ectopic Tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. It is also called junctional tachycardia, focal junctional tachycardia, or junctional nonreentrant tachycardia. Heart rate in JET should be more than 95 th percentile of heart rate for age (typically more than 100 beats per minute in adults); otherwise, it is called accelerated junctional rhythm. 1-3 JET is more common in children and may be congenital or acquired in postoperative settings. JET is a rare arrhythmia in adults and the pathogenesis is not completely understood. Moreover, because its clinical and electrocardiographic presentation varies, the diagnosis is challenging, and it can be easily mistaken for more common arrhythmias like atrioventricular nodal reentrant tachycardia (AVNRT). 1,4-5 2 | CLINI C AL FE ATURE S This arrhythmia can be categorized as primary JET, without a clear predisposing factor, or secondary JET, which occurs in a clinical condition. Primary JET occurs as congenital form or as sporadic cases in children and adults. Congenital JET occurs within the first 6 months of age, usually presents at birth, and is associated with high morbidity and mortality. It is an arrhythmia with mean ventricular rates of 200 to 250 beats/min and is associated with a high incidence of ventricular systolic dysfunction and clinical heart failure. Prenatal cases may present with hydrops. 1 When it occurs after the age of 6 months, the clinical course is not malignant. Indeed, a similar clinical course to other supraventricular tachycardias has been reported in adults and the main symptom in these patients is palpitations with exacerbation during physical

Background By consensus statements, catheter ablation is a recommended treatment for patients with symptomatic drug-refractory paroxysmal atrial fibrillation (AF), as patients try to alleviate the burdensome AF symptoms that reduce the Quality of Life (QoL). Yet, first-line treatment of symptomatic patients via catheter ablation prior to initiation of antiarrhythmic drugs (AADs) is only a reasonable alternative (Class IIa). Clearly, more clinical data is necessary that compares catheter ablation to AAD therapy in treatment naïve patients. Purpose The Cryo-FIRST trial was designed to compare AAD treatment against pulmonary vein isolation (PVI) while using a cryoballoon catheter (Arctic Front Advance; Medtronic, Inc.). This current data analysis examines the QoL endpoints when comparing AADs to cryoballoon ablation in patients with symptomatic treatment naïve paroxysmal AF. Methods This randomized multicenter trial enrolled 220 patients from 18 sites in 9 countries (Europe, Australia, and Latin America) in a prospective open-blinded endpoint study design. Patients had not been administered a class I or III AAD for longer than 48 hours for inclusion into the study. Subjects were randomized (1:1) into a cohort that was administered AAD therapy or a cohort that received PVI via cryoablation. The prespecified QoL endpoint at 12 months was measured using the Atrial Fibrillation Effect on Quality of Life (AFEQT) scores, and QoL recordings were taken at baseline, 1, 3, 6, 9, and 12 months following the index treatment. Results Of the 218 patients randomized (age 52±13 years, 68% male) 86% completed the 12-month follow-up. Crossovers occurred in 9% of subjects (N=20), including: 1 subject in the cryoablation arm and 19 subjects in the AAD arm. At 12 months, 86.5% of the patients in the cryoablation arm and 70.4% of the patients in the AAD arm where without symptoms (EHRA score 1). The mean AFEQT summary score was more favorable in the catheter ablation group compared to the drug therapy group at 12 months (88.9 vs. 78.1 points, respectively). The adjusted difference was 9.9 points (95% CI: 5.5–14.2; P<0.0001). Conclusions Cryoballoon ablation resulted in a significant improvement in QoL at 12 months compared to AAD therapy in treatment naïve patients with first-line symptomatic paroxysmal AF. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Medtronic International Trading Sàrl

Here, we discuss the case of a man with a history of ischemic cardiomyopathy and cardiac resynchronization therapy defibrillator implantation, who presented to emergency department with decompensated heart failure due to the loss of resynchronization therapy. The reason for the malfunction was left ventricle upper rate interval lock-in due to inappropriate programming of the device.