Catheter Ablation of Focal Atrial Tachycardia from the Aortic Cusp: The Role of Electroanatomic Mapping and Intracardiac Echocardiography

Catheter ablation of periatrioventricular (peri‐AV) nodal atrial tachycardias (AT) from the noncoronary aortic cusp (NCC) can be challenging due to the close proximity of the AV node In such cases, intracardiac echocardiography (ICE) together with three‐dimensional mapping system can be helpful in guiding the ablation catheter and in assessing the anatomic relationship of the aorta to the surrounding structures. We report two patients with AT originating near the AV node who underwent successful catheter ablation from the NCC. ICE proved useful in positioning the ablation catheter within the aortic cusps. Electroanatomic mapping enabled tagging the earliest activation site and renavigation back. (PACE 2013; 36:e19–e22)     

Unusual ECG Pattern of Right Atrial Appendage Atrial Tachycardia in One Patient with Right Pneumonectomy

The right atrial appendage atrial tachycardia (RAA AT) has been previously reported as a rare site in focal AT. We report a patient with a history of a right pneumonectomy who underwent catheter ablation of the AT originating from the RAA. This RAA AT showed unusual P‐wave morphology compared with previous reports. We describe the RAA AT following right pneumonectomy using a NavX system (St. Jude Medical, St. Paul, MN, USA). (PACE 2010; e46–e48)     

Focal Ablation versus Single Vein Isolation for Atrial Tachycardia Originating from a Pulmonary Vein

Background: Rapid, disorganized firing from a pulmonary vein (PV) focus may initiate atrial fibrillation. The natural history of PV atrial tachycardia (AT), resulting in a slower, more organized form of firing, is less clear. Furthermore, the optimal therapeutic approach to a PV AT is poorly defined. Objective: This study assessed the characteristics and long‐term outcomes of focal ablation versus PV isolation for ATs arising from a single PV. Methods: We reviewed 886 consecutive patients who underwent an AT radiofrequency ablation at our institution from January 1997 through August 2008. Results: Twenty‐six patients had focal AT with a mean cycle length of 364 ± 90 ms that arose from within a single PV. Ten patients underwent focal ablation of their AT and 16 patients underwent PV isolation of the culprit vein. All procedures were acutely successful. The average follow‐up was 25 months (range 2–90 months). There were three recurrences of AT in patients who underwent a focal ablation. There were no recurrences in patients who underwent targeted PV isolation (P = 0.046). No patients developed atrial fibrillation or AT from another focus during the follow‐up period. Conclusion: PV AT can be successfully treated with single vein isolation or focal ablation with a low risk of recurrence or the development of atrial fibrillation. PV isolation may be the preferred approach when the AT focus arises from a site distal to the ostium where targeted ablation could result in phrenic nerve injury or occlusion of a pulmonary venous branch. (PACE 2010; 776–783)     

Clinical characteristics of focal atrial tachycardias arising from the atrial appendages during childhood

Background: Focal atrial tachycardias (ATs) arising from the atrial appendages (AAT) are uncommon in adults. On the other hand, we frequently encounter AATs during childhood. However, the topographic distribution and clinical characteristics of focal ATs during childhood have not yet been clearly revealed. The aim of this study was to investigate the clinical characteristics of AATs in childhood. Methods: The study population consisted of 16 consecutive pediatric patients with focal AT enrolled between March 1991 and June 2009. A retrospective analysis was performed. The patients with focal AT were divided into two groups: the AAT group and other AT (OAT) group, in which the foci arose from other atrial sites. Results: Fifty percent had AAT. The AAT patients consisted of more males (88% vs 25%; P < 0.05), were more often asymptomatic at the initial visit (75% vs 25%; P < 0.05), and more often presented with an incessant form of the AT (88% vs 25%; P < 0.05) than the OAT patients. Second‐degree atrioventricular block during slow ATs of <120 beats per minute were more often observed in the AAT patients (63% vs 13%; P < 0.05). The incidence of tachycardia‐mediated cardiomyopathy was 19% out of all our subjects and 38% of the AAT patients. Conclusions: The AATs are the major source of focal ATs in pediatric patients that are typically incessant. These characteristics probably explain why a much higher percentage of the patients are presented with TMC. (PACE 2011; 34:177–184)     

Prognostic significance of atrial arrhythmias in a primary prevention ICD population

Introduction : We investigated whether primary prevention implantable cardioverter defibrillator (ICD) patients with atrial arrhythmias are at higher risk for ICD shocks and mortality compared to patients without atrial arrhythmias in a subanalysis of the PREPARE study. Methods and Results : Details of the PREPARE study design and results have been previously reported. We now included 537 of the 700 patients enrolled in PREPARE. These patients had a dual or biventricular device and at least one device follow‐up after implantation. Continuously collected device diagnostics data were used to classify patients into two groups during follow‐up: with (n = 133) or without (n = 404) atrial tachycardia/atrial fibrillation (AT/AF). The primary outcomes were ICD shocks and mortality. Subjects were followed for a mean of 333 ± 73 (range 5–365) days. During a follow‐up of 1 year, ICD shocks occurred in 44 (8%) patients. Significantly, more patients with AT/AF received a shock (13.0% vs 6.9%, P = 0.03), with inappropriate shocks accounting for the majority of the difference (6.9% vs 2.6%, P = 0.02). There was no difference in prevalence of shocks between patients with and without a history of AF. Mortality was similar in patients with and without AT/AF, whether detected during the study or prior to the study. In addition, the 34 subjects with high average ventricular rate (≥110 beats per minute) during AT/AF had a higher risk of an inappropriate shock (21.0% vs 2.1%, P < 0.01). Conclusion : Primary prevention ICD patients with AT/AF are more likely to receive shocks, especially inappropriate shocks. Mortality was not higher in AT/AF patients. (PACE 2011; 34:1070–1079)     

Identification of anaerobic threshold by analysis of heart rate variability during discontinuous dynamic and resistance exercise protocols in healthy older men

The purposes of this study were to determine anaerobic threshold (AT) during discontinuous dynamic and resistive exercise protocols by analysing of heart rate variability (HRV) and blood lactate (BL) in healthy elderly subjects and compare the cardiovascular, metabolic and autonomic variables obtained from these two forms of exercise. Fourteen elderly (70 ± 4 years) apparently healthy males underwent the following tests: (i) incremental ramp test on cycle ergometer, (ii) one repetition maximum (1RM) leg press at 45°, (iii) a discontinuous exercise test on a cycle ergometer (DET‐C) protocol and (iv) a resistance exercise leg press (DET‐L) protocol. Heart rate, blood pressure and BL were obtained during each increment of exercise intensity. No significant differences (P>0·05) were found between methods of AT determination (BL and HRV) nor the relative intensity corresponding to AT (30% of maximum intensity) between the types of exercise (DET‐C and DET‐L). Furthermore, no significant differences (P>0·05) were found between the DET‐C and DET‐L in relation to HRV, however, the DET‐L provided higher values of systolic blood pressure and BL (P<0·05) from the intensity corresponding to AT. We conclude that HRV was effective in determination of AT, and the parasympathetic modulation responses obtained during dynamic and resistive exercise protocols were similar when compared at the same relative intensity. However, DET‐L resulted in higher values of blood pressure and BL at workloads beyond AT.     

Predicting acute acetaminophen hepatotoxicity with acetaminophen-aminotransferase multiplication product and the Psi parameter

Context. Prediction of potential hepatotoxicity is important for individualizing therapy with N-acetylcysteine (NAC) in patients with acute acetaminophen overdose. Acetaminophen-aminotransferase multiplication product (APAP × AT) and the Psi Parameter (Psi) have been reported to be the predictors of acetaminophen hepatotoxicity. Objective. To determine the validity of APAP × AT and Psi in predicting hepatotoxicity secondary to acute acetaminophen overdose. Materials and methods. We retrospectively reviewed acute acetaminophen overdose cases who were treated with NAC at Siriraj Hospital, Thailand during January 2004–June 2012. The patients’ ages were 12 years or more. Initial acetaminophen concentration (mg/L) and aminotransferase (IU/L) were multiplied to obtain APAP × AT. Psi were derived from initial acetaminophen concentrations (mg/L) and lag time (hours) to NAC therapy. The cut-off values for APAP × AT and Psi were 1500 mg?IU/L² and 5 mM?h, respectively. Hepatotoxicity (defined as aspartate or alanine aminotransferase (ALT) greater than 1000 IU/L) was the outcome of interest. Results. A total of 255 patients were included, 32 of whom developed hepatotoxicity. APAP × AT had sensitivity, specificity, and negative likelihood ratio of 90.6%, 62.8%, and 0.2, respectively. The sensitivity of Psi, specificity, and negative likelihood ratio were 96.9%, 91.5%, and 0.0, respectively. The areas under the curve of the receiver operating characteristic (ROC) curve for APAP × AT and Psi were 0.82 and 0.96, respectively, with a statistically significant difference between the two methods (p = 0.002). APAP × AT showed higher specificity (92.5%) in patients who presented 8–24 h after the overdose. Discussion and conclusion. Psi and APAP × AT are valid clinical tools in predicting hepatotoxicity secondary to acute acetaminophen overdose in adults. APAP × AT is useful in predicting a low likelihood of hepatotoxicity after standard NAC therapy among late-presenting patients.     

Factors that predict the post-discharge use of recommended assistive technology (AT)

Purpose.?This study investigated the ability of client-, assistive technology (AT)- and intervention-related factors to predict the post-discharge use of rails and bathing, toileting and dressing AT, which had been recommended by an occupational therapist during hospitalisation.

Method.?A prospective correlational study involving interviews conducted pre and post discharge for those clients who required rails and bathing, toileting and dressing AT was used. Additionally, a direct logistic regression analysis with backwards elimination was performed to identify predictor variables.

Results.?Variables found to predict AT use included participants' perceptions of the characteristics of the AT, the presence or absence of anxiety, and their ability to recall AT training. Additionally four other variables (intended post-discharge use of AT, negative perceptions about disability/illness, perceived benefit of the AT and having a choice during the AT selection process) were strongly related to AT use. Although these four variables were not included in the best final model they are nevertheless important and need to be considered when recommending AT.

Conclusions.?The findings suggest that occupational therapists need to ensure that AT is recommended using a client-centred approach, where clients' perceptions and opinions are considered along with their needs and goals. The Matching Person to Technology (MPT) Model is suggested as a useful framework to guide the process of recommending AT.     

Acceleration time in normal fetal umbilical artery at term and its relationship to the cord blood hematocrit

The purpose of this study was to test the hypothesis that the acceleration time (AT) of the fetal umbilical artery remains constant at term for normal pregnancies. In addition, we also examined whether the AT has any correlation with umbilical cord blood hematocrit (Hct). In total, 539 normal-term fetuses with menstrual ages (MA) ranging from 37 weeks to 42 weeks were enrolled in a cross-sectional design. The AT of the fetal umbilical artery was measured prior to delivery using a high-resolution, real-time Doppler scanner. All were delivered within 2 days of the ultrasound examination. At parturition, blood from the umbilical vein was collected and the red cell indices, including the Hct, were determined. The results indicated that the mean values of AT of the umbilical artery remained constant during normal-term pregnancies from 37 weeks to 42 weeks, menstrual age (mean: 0.104 sec, SE: 0.001 sec, n = 539). Although the AT was thought to be affected by the Hct, the AT had no correlation with umbilical venous Hct (n = 539, r = 0.002, p > 0.05). This constant value of the AT may be used as a reference for fetal physiology and perinatal medicine. © 1995 John Wiley & Sons, Inc.     

Assistive technology effects on the employment outcomes for people with cognitive disabilities: A systematic review

Purpose.?This systematic review examines the effects of assistive technology (AT) use on employment outcomes for people with cognitive disabilities (CD). AT is a necessary tool for gaining and maintaining skills for people with CD. Research suggests that AT can assist this population in performing tasks with greater ease and independence.

Method.?A literature search was conducted to examine the evidence supporting AT use in the workforce. Search criteria included: subjects with CD, use of an AT tool or device and participation in a vocational training program or active employment. The search results yielded nine articles focused on AT interventions used in vocational settings for people with CD.

Results.?AT interventions demonstrated positive outcomes on job performance. Positive outcomes were measured as a higher rate of accuracy and task completion, increased independence and generalization of skills. We found a trend in the literature over the past 25–30 years, moving from low- to high-tech visual and auditory cuing systems.

Conclusion.?Future research should focus on producing evidence to support the use of AT tools for this population, and provide guidelines for incorporating them in vocational training programs in schools and community settings.     

Accurate guidance of a catheter by ultrasound imaging and identification of a catheter tip by pulsed-wave Doppler

Background: With the advent of numerous minimally invasive medical procedures, accurate catheter guidance has become imperative. We introduce and test an approach for catheter guidance by ultrasound imaging and pulsed‐wave (PW) Doppler. Methods: A steerable catheter is fitted with a small piezoelectric crystal at its tip that actively transmits signals driven by a function generator. We call this an active‐tip (AT) catheter. In a water tank, we immersed a “target” crystal and a rectangular matrix of four “reference” crystals. Two‐dimensional (2D) ultrasound imaging was used for initial guidance and visualization of the catheter shaft, and then PW Doppler mode was used to identify the AT catheter tip and guide it to the simulated target that was also visible in the 2D ultrasound image. Ten guiding trials were performed from random initial positions of the AT catheter, each starting at approximately 8 cm from the target. Results: After the ten navigational trials, the average final distance of the catheter tip from the target was 2.4 ± 1.2 mm, and the range of distances from the trials was from a minimum of 1.0 mm to a maximum of 4.5 mm. Conclusions: Although early in the development process, these quantitative in vitro results show promise for catheter guidance with ultrasound imaging and tip identification by PW Doppler. (PACE 2012; 35:44–50)     

The impact of assistive technology services in post-secondary education for students with disabilities: Intervention outcomes,use-profiles,and user-experiences

The outcomes of assistive technology (AT) support services for post-secondary education students with disabilities are under-reported, and little is known about use-profiles and user experiences when AT interventions are applied to this rapidly growing population. We examined AT service outcomes related to performance and satisfaction of common academic tasks (using the Canadian Occupational Performance Measure [COPM]), as well as how students with disabilities use and experience AT and AT services (employing an AT-use survey). Three-hundred fifty-three students with disabilities completed the AT-use survey, with a subset of these (n = 216) also participating with pre-post AT intervention COPM assessment. COPM performance and satisfaction ratings significantly increased from pre- to post-AT intervention in all academic task categories (reading, writing, note-taking, test-taking, and studying; p < 0.001). The AT-use survey most notably revealed these students preferred face-to-face training, used their AT at least 3 days per week, used AT in a variety of environments, felt AT positively impacted their academic success, and believed they would continue using AT post-graduation. The study findings contribute to evidence-base for AT services with a hope we may improve AT services to best meet the changing needs of the growing number of college students with disabilities.     

Small‐molecule AT2 receptor agonists

The discovery of the first selective, small‐molecule ATR receptor (AT2R) agonist compound 21 (C21) ( 8 ) that is now extensively studied in a large variety of in vitro and in vivo models is described. The sulfonylcarbamate derivative 8 , encompassing a phenylthiofen scaffold is the drug‐like agonist with the highest affinity for the AT2R reported to date (K_i = 0.4 nM). Structure‐activity relationships (SAR), regarding different biaryl scaffolds and functional groups attached to these scaffolds and with a particular focus on the impact of various para substituents displacing the methylene imidazole group of 8 , are discussed. Furthermore, the consequences of migration of the methylene imidazole group and presumed structural requirements for ligands that are aimed as AT2R agonists (e.g. 8 ) or AT2R antagonists (e.g. 9 ), respectively, are briefly addressed. A summary of the pharmacological actions of C21 ( 8 ) is also presented.     

Initial results of linear duty-cycled radiofrequency for atypical flutter and atrial tachycardia

Background: Duty‐cycled radiofrequency (DCRF) is increasingly used for ablation of atrial fibrillation (AF). Many patients also have atrial flutter (AFL). Recently, a linear multielectrode has been shown to create linear block at the cavotricuspid isthmus and in the left atrium (LA). Objective: To map and ablate atypical AFL and atrial tachycardias (ATs) in the right and LA using a linear multielectrode with DCRF. Methods: The linear multielectrode delivers DCRF at 20–45 W maximum in 1:1 unipolar/bipolar temperature‐controlled mode. Target temperatures were manually titrated to 60 °C in the LA, if power >5W indicated adequate passive cooling. Results: A total of 76 AT/AFL were targeted in 57 patients. Acute success was reached in 14/15 (93%) right AT, in 17/22 (77%) left atrial roof AFL, in 5/6 (83%) septal AFL, in 9/9 (100%) other left atrial AT, but only in 8/23 (35%) AFL from the mitral isthmus (which rose to 13/23 [57%] with additional use of irrigated radiofrequency). Nevertheless, freedom of AF/AFL 10 ± 6 months after a single procedure was documented in 92% of right AT, 71% of roof AFL, 73% for mitral AFL, and 60% of septal or other LA AT/AFL. No char formation was noted. However, frequent induction of AF and one case of asystole occurred during delivery of DCRF in a pacemaker patient. Conclusion: The linear multielectrode allows mapping and ablation of atypical AFL/AT. Freedom of AF/AT was reached in 60%–92% depending on localization and number of arrhythmias. Technical modifications will improve safety and efficacy. (PACE 2011; 34:1128–1137)     

Effectiveness of adherence therapy in patients with early psychosis: A mirror image study

In patients with early psychosis, medication non‐adherence is associated with more frequent relapse. Observational studies have reported that up to 60% of patients fail to take medication as prescribed. This study aimed to establish the effectiveness of adherence therapy (AT) training for two multidisciplinary early intervention in psychosis (EIIP) teams in preventing relapse in their patients. This intervention involved six 1‐day team AT training sessions delivered monthly over a 6‐month period. Participants were patients with early psychosis who were on the caseload of the EIIP teams during the study period. A mirror‐image design was used, comparing clinician ratings of relapse in the year preceding training (year 0) and the subsequent year (year 1). Results showed that in year 0, the mean number of relapses was 0.96 (standard deviation (SD) = 1.10). During year 1, relapses reduced significantly (P < 0.01) to 0.34 (SD = 0.64). No unexpected effects of training were reported. A thematic analysis of staff views of training, and service users' views of their care received from EIIP teams, was also completed. Challenges in faithfully incorporating AT skills into practice were reported. In conclusion, AT training coincided with reductions in relapse rates in patients receiving services from an EIIP team, but no other changes in outcomes were detected.     

Providing assistive technology in Italy: the perceived delivery process quality as affecting abandonment

Purpose: The study brings together three aspects rarely observed at once in assistive technology (AT) surveys: (i) the assessment of user interaction/satisfaction with AT and service delivery, (ii) the motivational analysis of AT abandonment, and (iii) the management/design evaluation of AT delivery services. Methods: 15 health professionals and 4 AT experts were involved in modelling and assessing four AT Local Health Delivery Service (Centres) in Italy through a SWOT analysis and a Cognitive Walkthrough. In addition 558 users of the same Centres were interviewed in a telephone survey to rate their satisfaction and AT use. Results: The overall AT abandonment was equal to 19.09%. Different Centres' management strategies resulted in different percentages of AT disuse, with a range from 12.61% to 24.26%. A significant difference between the declared abandonment and the Centres' management strategies (p?=?0.012) was identified. A strong effect on abandonment was also found due to professionals' procedures (p?=?0.005) and follow-up systems (p?=?0.002). Conclusions: The user experience of an AT is affected not only by the quality of the interaction with the AT, but also by the perceived quality of the Centres in support and follow-up.

• Implications for Rehabilitation

• AT abandonment surveys provide useful information for modelling AT assessment and delivery process.

• SWOT and Cognitive Walkthrough analyses have shown suitable methods for exploring limits and advantages in AT service delivery systems.

• The study confirms the relevance of person centredness for a successful AT assessment and delivery process.

     

Circulating concentrations of hemostatic factors and two "steroid sensitive proteins" during oral hormone replacement therapy in women with coronary heart disease

Objective: To study a possible use of sex hormone-binding globulin (SHBG) and corticosteroid-binding globulin (CBG) as markers for changes in hemostatic factors during oral postmenopausal hormone replacement therapy (HRT). Methods: Twenty-eight postmenopausal women were treated with oral conjugated equine estrogens+oral medroxyprogesterone acetate (CEE+MPA, n=15) or with placebo (n=13). Serum SHBG, CBG, testosterone, cortisol and plasma coagulation factors, coagulation inhibitors and markers of coagulation activation were measured before and after 6 and 12 months of treatment. Results: Pretreatment plasminogen activator inhibitor 1 (PAI-1) levels correlated negatively to SHBG and antithrombin III (AT III) negatively to total and free cortisol. In the CEE+MPA group, CBG, SHBG and Factor VII increased, and PAI-1, AT III and free testosterone decreased during treatment. No significant changes were found in plasma von Willebrand factor antigen, thrombin-antithrombin complex, fibrin D-dimer and fibrinogen. A significant, negative correlation was found between changes in SHBG and PAI-1. No changes were found in the placebo group. Conclusion: The only correlation found between changes in "steroid sensitive" proteins and hemostatic factors was between increased SHBG and a possibly beneficial effect of estrogens, i.e. decreased PAI-1 values. SHBG or CBG could not be used as predictors of increased cardiovascular risk during postmenopausal oral HRT.