Successful Catheter Ablation for Multiple Atrial Arrhythmias in a Patient with Situs Inversus Totalis

A 70-year-old woman with situs inversus totalis underwent catheter ablation for atrial fibrillation and atrial flutter. Although her morphologic left atrium (LA) was enlarged, we performed cryoballoon ablation and liner radiofrequency ablation of the cava-tricuspid isthmus without mapping atrial arrhythmias. However, a different form of atrial tachycardia (AT) recurred. We performed catheter ablation a second time using a three-dimensional electroanatomic mapping system. AT was not terminated by the liner ablation at the roof of morphologic LA and mitral isthmus but sustained by changing the atrial activation sequence and cycle length. Multipolar mapping catheter revealed that fractionated low-amplitude potentials were densely located in a limited area of the anterior morphologic LA, and an activation map demonstrated the presence of small-circuit reentry with an extremely slow conduction at the anterior morphologic LA. A single energy application targeting the fragmented potentials successfully terminated the AT. We successfully treated multiple ATs with a complex anatomy using a three-dimensional electroanatomic mapping system.     

Rationale and design for a study using intravascular ultrasound to evaluate effects of rosuvastatin on coronary artery atheroma in Japanese subjects: COSMOS study (Coronary Atherosclerosis Study Measuring Effects of Rosuvastatin Using Intravascular Ultrasound in Japanese Subjects).

BACKGROUND: There have been few multicenter studies using intravascular ultrasound (IVUS) to assess the process of atherosclerosis in a Japanese population with hypercholesterolemia that is being treated with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors for control of low-density lipoprotein-cholesterol. METHODS AND RESULTS: An open-label multicenter study is planned to evaluate with IVUS whether treatment with rosuvastatin for 76 weeks results in regression of coronary artery atheroma volume in patients who have coronary heart disease (CHD) and hypercholesterolemia. Sample size is 200 subjects with CHD who are to undergo percutaneous coronary intervention. The planned duration is between October 2005 and October 2008. CONCLUSIONS: The COSMOS study will be the first multicenter cardiovascular study in a Japanese population and may provide new evidence on the effects of rosuvastatin on the progression of coronary atherosclerotic lesions.     

Decreased portal flow volume increases the area of necrosis caused by radio frequency ablation in pigs.

BACKGROUND/AIMS: Although radio frequency ablation (RFA) has been widely accepted as an effective treatment for hepatocellular carcinoma (HCC), severe complications are not uncommon. Major complications seem to occur as a result of over-ablation beyond the intended area. As most patients with HCC have underlying cirrhosis, we speculated that decreased portal flow might cause the necrosis associated with RFA. To confirm this hypothesis, we examined the area of necrosis resulting from RFA under varying conditions of portal flow in a porcine model. METHODS: RFA was performed using ultrasonographic guidance in anesthetized pigs. During the RFA procedure, portal flow was regulated by a balloon catheter, which was set in a portal trunk. The necrosis area was measured after sacrifice and was compared with the hyperechoic area that appeared during ablation. In another session, RFA was performed close to the hepatic vein and endothelial damage was examined. RESULTS: The necrosis area caused by RFA was significantly larger when the portal flow volume was decreased by 50% or more. The hyperechoic lesion was always larger than the area of pathological necrosis regardless of portal flow volume. Under conditions of decreased portal flow, the vessel endothelium near the ablated area was more readily damaged. CONCLUSION: Decreased portal flow volume resulted in enlargement of the area of necrosis caused by RFA. Our results indicate that over-ablation could easily occur in patients with advanced cirrhosis, and that this could lead to major complications. Ultrasonographic guidance may be helpful for avoiding over-ablation.     

Predictors for squamous re-epithelialization of Barrett's esophagus after endoscopic biopsy

BACKGROUND AND AIM: Acid suppressive therapy has been reported to regress Barrett's esophagus. However, it is still controversial as to whether all Barrett's esophagus patients respond to this therapy. The factors that might facilitate newly developed squamous re-epithelialization after biopsy excision of Barrett's mucosa were evaluated to identity individuals who may favorably respond to the regression therapy. METHODS: Two hundred and forty-seven biopsy sites from 185 patients with Barrett's esophagus were examined by endoscopy to investigate possible squamous re-epithelialization of Barrett's mucosa after endoscopic biopsy. Before endoscopic examination, all participants were requested to answer questionnaires concerning sociodemographic characteristics, lifestyle habits and drugs usage. The mucin phenotype, Cdx2 expression, cyclooxygenase-2 expression, cellular proliferation and apoptosis of Barrett's mucosa were immunohistochemically investigated in the biopsy samples taken from Barrett's esophagus. The influence of these factors on the newly developed squamous re-epithelialization of Barrett's mucosa after endoscopic biopsy excision was evaluated. RESULTS: By multivariate analysis, the independent factors that favored squamous re-epithelialization were the gastric mucin predominant phenotype of Barrett's mucosa and the absence of Cdx2 protein expression. In Barrett's mucosa with the gastric predominant mucin phenotype, proton pump inhibitor administration, the absence of reflux esophagitis and a low proliferating cell nuclear antigen index were found to be independent predictors for squamous re-epithelialization. CONCLUSIONS: The absence of the intestinal predominant mucin phenotype was a positive predictor for newly developed squamous re-epithelialization at the site of biopsy of Barrett's mucosa. Only Barrett's esophagus with the gastric predominant mucin phenotype may predict a favorable response to acid suppressive therapy.     

Characteristics and limitation of portable bedside swallowing test in elderly with dementia: comparison between the repetitive saliva swallowing test and the simple swallowing provocation test

Several bedside portable swallowing tests have been advocated for screening for dysphagia. However, the clinical usefulness and limitation of these tests have not been examined in elderly patients with dementia. We performed the repetitive saliva swallowing test (RSST) and the simple swallowing provocation test (SSPT) in 37 elderly inpatients (81.8 +/- 1.2 years old). Simultaneously, cognitive and verbal communication ability were assessed by the Hasegawa Dementia Scale revised version (HDSR) and the Mini-Communication Test (MCT). RSST was completed only in 22 patients (59%), whereas SSPT was successfully completed in all cases. Scores of HDSR and MCT were significantly lower in patients who were unable to cooperate with RSST compared to successful examinees (HDSR: 7 +/- 1 vs 15 +/- 3, p < 0.0; MCT: 47 +/- 8 vs 81 +/- 5, p < 0.01). Dysphagia was detected in 14 patients (64%) by RSST and 5 (14%) by SSPT. Patients with dysphagia showed significantly lower cognitive function (p < 0.05) and verbal communication ability (p < 0.05). In conclusion, RSST is more sensitive to detect dysphagia in elderly patients; however, compliance with RSST is strongly influenced by the patient's cognitive function and verbal communication ability. Comprehensive geriatric assessment will help to choose an alternative test for dysphagia such as SSPT which is more specific test for aspiration pneumonia.     

Oral health status of hospitalized amyotrophic lateral sclerosis patients: a single-centre observational study

Objective: To assess the intraoral conditions and oral function of patients with amyotrophic lateral sclerosis (ALS).

Material and methods: This single-centre, cross-sectional observational study included 50 ALS patients, who were treated with tracheostomy positive-pressure ventilation (TPPV) while hospitalized. The disease duration, TPPV duration, current number of teeth, number of occlusal units, number of decayed/missing/filled teeth, community periodontal index, bleeding on probing, dental calculus, maximum mouth opening, salivation rate, tongue anomalies (atrophy or hypertrophy) and tongue coating were determined for each patient. Differences in intraoral conditions according to disease duration or TPPV duration were statistically analysed.

Results: The maximum mouth opening was low in the included patients, with a mean distance of 13.7?±?7.4?mm. Furthermore, the maximum mouth opening showed a significant negative correlation with both disease duration and TPPV duration. No statistically significant differences were found between any other intraoral parameters and disease duration or TPPV duration.

Conclusions: Severe dental disease is uncommon among hospitalized ALS patients who receive oral care by nurses; however, mouth opening is very restricted in these patients. Early intervention for restricted mouth opening, directed by a dentist or dental hygienist, is essential in this population.     

Comparison of valsartan and amlodipine on ambulatory blood pressure variability in hypertensive patients

We tested the hypothesis that calcium channel blockers (CCBs: amlodipine group, n = 38)) are superior to angiotensin receptor blockers (ARBs: valsartan group, n = 38) against ambulatory blood pressure variability (BPV) in untreated Japanese hypertensive patients. Both drugs significantly reduced ambulatory systolic and diastolic BP values. With regard to BPV, standard deviation (SD) in SBP did not change with the administration of either drug, but the ARB significantly increased SD in awake DBP (12 ± 4–14 ± 4 mmHg). The ARB also significantly increased the coefficients of variation (CVs)in awake and 24-h SBP/DBP (all P < 0.05), but amlodipine did not change the CV. CCB significantly reduced the maximum values of awake SBP (193 ± 24–182 ± 27 mmHg, P = 0.02), sleep SBP (156 ± 18–139 ± 14 mmHg, P < 0 .001), and awake and sleep DBP (P < 0.01 in both cases), but the ARB did not change the maximum BP values. In conclusion, a once-daily morning dose of CCB amlodipine was more effective at controlling ambulatory BPV than ARB valsartan, especially in reducing maximum BP levels.