Cryoballoon Pulmonary Vein Isolation Guided by Transesophageal Echocardiography: Novel Aspects on an Emerging Ablation Technique

Background: Pulmonary vein (PV) isolation using a balloon-mounted cryoablation system is a new technology for the percutaneous treatment of atrial fibrillation (AF). Transesophageal echocardiography (TEE) allows real-time visualization of cryoballoon positioning and successful vein occlusion via color Doppler. We hypothesized that PV mechanical occlusion monitored with TEE could predict effective electrical isolation.
Methods: We studied 124 PVs in 30 patients. Under continuous TEE assessment, a cryoballoon was placed in the antrum of each PV aiming for complete PV occlusion as documented by color Doppler. At the end of the procedure, PV electrical isolation was evaluated using a circumferential mapping catheter.
Results: Of the 124 PVs studied, 123 (99.2%) could be visualized by TEE: the antrum was completely visualized in 80 of them (64.5%), partially in 36 (29.0%), and only disappearance of proximal flow could be observed in the remaining 7 PVs (5.7%). Vein occlusion could be achieved in 111 of the 123 (90.2%) visualized PVs. Postinterventional mapping demonstrated electrical isolation in 109 of 111 occluded PVs (positive predictive value 98.2%) and only in 1 of 12 nonoccluded PVs (negative predictive value 91.7%, P < 0.001). After a mean follow-up of 7.4 ± 3.7 months, 73.3% of patients remained in sinus rhythm without antiarrhythmic drugs.
Conclusion: Color Doppler documented PV occlusion during cryoballoon ablation can predict effective electrical isolation.     

Hereditary deficiency of phosphoglycerate kinase: a new variant in erythrocytes and leucocytes, not associated with haemolytic anaemia

An X-chromosome linked phosphoglycerate kinase deficiency in erythrocytes and leucocytes was discovered in a large German kindred. Seven males of two generations were found to have only 21% of the normal enzyme activity in their erythrocytes, and twelve females of three generations showed various degrees of this defect. The differences in the expression of the deficiency in heterozygote females are explained by the Lyon hypothesis. The deficiency is caused by a variant enzyme, named phosphoglycerate kinase München. Although it differs from the normal enzyme electrophoretically, the two enzymes resemble one another closely in many respects. They have essentially the same Km for the substrates of the backward reaction, identical pH optima and similar rates of thermal inactivation. In contrast to the nine previously described phosphoglycerate kinase deficiencies, all of which are associated with haemolytic anaemia, the carriers of phosphoglycerate kinase München show no overt clinical symptoms. The erythrocyte concentrations of adenine nucleotides and 2,3-diphosphoglycerate are normal.     

Inhibition of human fat cell adenylate cyclase mediated via alpha-adrenoceptors

Human adipose tissue contains alpha- as well as beta-adrenoceptor sites mediating antagonistic catecholamine effects on lipolysis. To characterize the mechanisms of catecholamine action in biochemical terms we have studied the effects of the almost pure beta-adrenoceptor agonist isoproterenol and of the mixed adrenergic agonist adrenaline on human fat cell adenylate cyclase in the presence of alpha- and beta-adrenoceptor blocking drugs. In contrast to the almost pure beta-adrenergic agent isoproterenol, the mixed agonist adrenaline, besides its stimulatory action, also had inhibitory effects which became apparent upon complete beta-adrenoceptor blockade using 0.05 mmol/l propranolol. Under these conditions adrenaline caused a dose-dependent inhibition of basal and parathyroid hormone-activated enzymic activity with a maximum of 30-50%, which was dependent on GTP and could be reversed by simultaneous alpha-adrenergic blockade using 5 mumol/l dihydroergotamine or 10 mumol/l phentolamine. These results support the concept of antogonistic alpha- and beta-adrenoceptor sites coexisting as regulatory subunits of the human fat cell adenylate cyclase.     

Radiofrequency Catheter Ablation of Frequent Monomorphic Ventricular Ectopic Activity

INTRODUCTION: Frequent ventricular ectopic beats can result in severe symptoms and may even be incapacitating in some patients. Although radiofrequency catheter ablation is an effective and safe therapy for drug refractory idiopathic ventricular tachycardia, it has not been widely used in ventricular ectopy. The purpose of this study was: (1) to assess the potential role of catheter ablation in eliminating monomorphic ventricular ectopy in symptomatic patients regarding feasibility and safety and (2) to determine the usefulness of various mapping strategies. METHODS AND RESULTS: Forty-one patients with symptomatic ventricular ectopic activity (right ventricular origin in 23 patients, left ventricular origin in 18 patients) were enrolled. The mean frequency of ventricular ectopic beats was 1512+/-583/hour documented by Holter ECG monitoring. These patients had previously been unable to tolerate or had been unsuccessfully treated with a mean of 3+/-1 antiarrhythmic agents. The site of origin was mapped using earliest endocardial activation times, unipolar electrograms and pace mapping. Radiofrequency ablation was successful in 34 (83 %) of 41 patients. Multivariate logistic regression analysis revealed pace mapping as the only independent predictor for a successful ablation site (P < 0.01). After a follow-up of 3 months, the overall success rate was 71%. The mean frequency of ventricular ectopic beats after successful ablation was 12+/-10 ventricular premature beat/hour. CONCLUSION: Radiofrequency catheter ablation is an effective and safe treatment for frequent symptomatic drug refractory monomorphic ventricular ectopic activity. Pace mapping predicts best successful ablation of ventricular ectopic beats.     

Reproducibility of irritant patch test reactions to sodium lauryl sulfate in a double-blind placebo-controlled randomized study using clinical scoring

Reading of doubtful patch test reactions can be improved by comparing them to dened negative, allergic and irritant controls. For the latter, an irritant patch test is needed that gives sufficiently reproducible results. In our double-blind, placebo-controlled, randomized study, we have analysed the synchronous reproducibility of patch tests with 0%, 0.0625%, 0.125%, 0.25%, 0.5% and 1.0% sodium lauryl sulfate (SLS). Tests and readings were done according to ESCD guidelines. 139 patients (75 women, 64 men) 18 to 77 years old were tested. The % of positive patients as well as the % of reproducible positive reactions increased with rising concentrations of SLS to a maximum of approximately 90% and 85%, respectively, with 1 % SLS. Time courses of reactions were also related to the concentration of SLS: with 1 % SLS, plateau-type time courses were most common (65%), followed by decrescendo- (23%) and crescendo-type reactions (12%). With 1% SLS, very similar mild to moderate reactions were obtained on days 2 and 3. The reaction threshold and reproducibility of tests were not related to age and sex of patients or to their own assessment of skin irritability. We conclude that 1% SLS is appropriate for an irritant patch test that gives sufficiently reproducible results.     

Unexpected Complete AV Block Following Transcatheter Ablation of a Left Posteroseptal Accessory Pathway

Radiofrequency catheter ablation is the procedure of choice for the nonpharmacological treatment of AV connections that are responsible for debilitating tachycardia. This article describes a patient with a manifest left posteroseptal accessory pathway and recurrent syncopes in whom a transient complete AV block occurred after transcatheter radiofrequency ablation of the left posteroseptal pathway. Three electrical abnormalities were present in this patient: AV infra-Hisian block, a left posteroseptal accessory pathway, and an AV nodal reentry tachycardia. This case report reminds you that one should be prepared for all fall backs during catheter ablation.     

Spatial Differences of the Duration of Ventricular Late Fields in the Signal-Averaged Magnetocardiogram in Patients with Ventricular Late Potentials

Magnetocardiography (MCG) allows one to noninvasively localize cardiac electrical activity in three dimensions. It was the purpose of this study to obtain information about the spatial variations of signal-averoged ventricular Jate magnetic fields recorded by a biomagnetic multichannel system. Biomagnetic signals of 170–600 heart cycles obtained hy the 37-channel system KRENIKON^R (Siemens Medical Engineering Group) were simultaneously averaged in all channels. The absolute values of the filtered signals (digital, bidirectional, four-pole butterworth, bandpass filter [3-dB range, 40–250 Hz]) were calculated in each channel. The noise level was determined within the TP segment. The onset of the terminal low amplitude signals (TLAS) was defined when the signals became lower than 1/23 of R_maxof the QRS complex for the channel with the largest filtered QRS complex after filtering. The TLAS ended when the signal was lower than twice the standard deviation (2 sigma) above the mean noise level. Ventricular late fields were defined as present when the TLAS had a duration of more than 39 msec. In this study, five patients with ventricular late potentials (four with sustained ventricular tachycardia) and three healthy individuals were examined. Ventricular late fields were detected in the patient group in 2–15 MCG channels with a mean length of 49.6 msec (43–60 msec). The spatial distribution of the ventricular late fields was consistently found to exhibit maximum duration in a certain area. In the normal subjects no ventricular late fields were detected. Thus, MCG is able to detect ventricular late fields and their spatial variations. In addition to the information obtained hy signal averaging from the surface ECG, averaging of biomagnetic signals with a multichannel device can reveal spatial inhomogeneity of delayed myocardial excitation.