Is DDD Superior to VVI Pacing in Mixed Carotid Sinus Syndrome? An Acute and Medium-Term Study

The aim of this study was to evaluate fhe importance of atrial synchronism for pacing therapy of patients with mixed carotid sinus syndrome. In 23 patients (21 m, two f: mean age 69 ± 8 years) affected by symptomatic mixed carotid sinus syndrome we performed: (1) Research of ventriculo-atrial conduction, orthostatic hypotension and pacemaker effect; and [2] Carotid sinus massage in the standing position during VVI and DVI temporary pacing. Next, ail patients received a permanent DDD pacemaker and entered a 2 month two period single-blind, randomized, cross-over study on DVI/DDD versus VVI mode. During the DVI/DDD period, no syncope occurred in any patients, minor symptoms persisted in 11 (48%) of them; during VVI period syncopes recurred in three patients, symptoms requiring the withdrawal of VVI pacing and premature DVI/DDD reprogramming in eight patients, minor symptoms in 17 (74%). A comparison between 14 patients, who preferred DVI/DDD period (Group A), and the remaining nine patients who noted no preference between DVI/DDD and VVI period (Group B) was performed on the basis of the preimplant evaluation. Group A patients had a greater pacemaker effect (-34 ± 16 mmHg vs -16 ± 14 mmHg) and a higher prevalence of symptomatic pacemaker effect (50% vs 0%), of ventriculo-atrial conduction (78% vs 44%) and of orthostatic hypotension (50% vs 11%), while the entity of the systolic pressure fall caused by carotid sinus massage was similar in the two groups either during VVI mode (Group A-51 ± 16 mmHg vs Group B-56 ± 27 mmHg) or DVI mode (Group A-38 ± 17 mmHg vs Group 3–45 ± 17 mmHg). Thus, we conclude that vasodepressor reflex of carotid sinus syndrome is not prevented by DVI/DDD pacing even if the loss of atrial synchronism resulting from WI pacing, by adding an important pacemaker effect, causes a more severe hemodynamic consequence. DVI/DDD pacing is more effective than VVI in 61% of patients. When pacemaker effect, ventriculoatrial conduction and orthostatic hypotension are present, VVI failure is possible, therefore DVI/DDD stimulation is indicated; on the contrary the evaluation of the vasodepressor reflex during WJ or DVI temporary pacing is of little value in the choice of the mode of pacing.     

Orthodromic and Antidromic Pacemaker Circus Movement Tachycardia

Pacemaker circus movement tachycardia (PCMT) during DDD pacing is usually sustained by retrograde natural and antegrade electronic atrioventricular (AV) conduction. As PCMT is often initiated by a ventricular premature beat (VPB) one method of its prevention is the programming of an atrial stimulus synchronously following a ventricular extrasystole. A patient is described with preserved antegrade, but without retrograde, i.e., VA, conduction. The optional pacemaker mode of synchronous atrial stimulation following a VPB caused an unusual PCMT sustained by retrograde electronic and antegrade natural AV conduction. This PCMT is similar to a natural reentry tachycardia, the most common variety of which (based on retrograde conduction) is termed antidromic and that which we describe is orthodromic.     

Complete Atrioventricular Block As the First Manifestation of Noncompaction of the Ventricular Myocardium

Noncompaction of ventricular myocardium (NVM) is a rare cardiomyopathy, most probably caused by disturbances in embryonic morphogenesis of the myocytes, resulting in prominent trabeculations in the ventricular myocardium. Several diagnostic criteria have been proposed by echocardiography, and its association with other heart diseases is common. Its mortality is closely related to ventricular dysfunction, cardiac arrhythmias, and cardioembolic events. We report here a case of occurrence of atrioventricular block with syncope as the clinical manifestation of NVM. A brief review of the literature on morphological features, diagnosis, prognosis, and treatment will also be discussed.     

Useful Lessons from Body Surface Mapping

Useful Lessons from Body Surface Mapping. Body surface potential maps (BSMs) depict the time varying distribution of cardiac potentials on the entire surface of the torso. Hundreds of studies have shown that BSMs contain more diagnostic and prognostic information than can he elicited from the 12-lead ECG. Despite these advantages, body surface mapping has not become a routinely used clinical method. One reason is that visual examination and sophisticated analysis of BSMs do not permit inferring the sequence of excitation and repolarization in the heart with a sufficient degree of certainty and detail. These limitations can be partially overcome by implementing inverse procedures that reconstruct epicardial potentials, isochrones, and ECGs from body surface measurements. Furthermore, ongoing experimental work and simulation studies show that a great deal of information about intramural events can he elicited from measured or reconstructed epicardial potential distributions. Interpreting epicardial data in terms of deep activity requires extensive knowledge of the architecture of myocardial fibers, their anisotropic properties, and the role of rotational anisotropy in affecting propagation and the associated potential fields.     

Synthesis and conformational studies on peptides corresponding to a putative autophosphorylation site of abl TPK*

The transforming gene of Abelson murine leukaemia virus (v-abl) codes for a membrane-associated tyrosine-specific protein kinase (abl TPK). Analysis of the v-abl gene has shown that both the fibroblast-transforming and tyrosine-protein kinase activities reside within a minimal region encoding a protein of 43 kDa (p43^v-abl), which represents the most active, isolated form of this enzyme. Since the cellular substrates for p43 ^v-abl are yet to be identified, we synthesized by classical solution methods the octapeptide H-Gly-Asp-Thr-Tyr-Thr-Ala-His-Ala-OH, corresponding to the structural sequence of the main putative autophosphorylation site (Tyr 515) of the abl TPK, as well as some of its analogs modified in positions -2, -1, + 1 and + 3. The synthetic peptides were tested as substrates for the p43^v-abl. The kinetic data obtained indicate that the rates of their phosphorylation vary considerably depending on the sequence of the peptide, as expected. As a rule, no significant increment of the efficiency results from each substitution in the parent sequence. While the replacement of the two charged residues, namely Asp-2 and His-7, with neutral Ala is well tolerated, the substitution with amino acids bearing opposite charges is detrimental. The correlation between secondary structure of our synthetic octapeptides and their substrate recognition by p43^v-abl was studied using CD and fluorescence spectroscopy in 5 mM Tris, in 98% TFE/Tris and in 30 mM SDS solutions. The comparison of the spectroscopic data with the kinetic parameters does not confirm a close relationship between the conformational properties of these peptides and their enzymatic role.     

Structural studies of two antiaggregant RGDW peptides by lH and 13C NMR

The structural features of Arg-Gly-Asp-related sequences have been investigated by ¹H and ¹³C NMR. Two linear peptides which inhibit platelet aggregation with a high efficiency have been studied: D-Arg-Gly-Asp-Trp and L-Arg-Gly-Asp-Trp. Analysis of pH titration effects, amide proton exchange rates and inter-proton distances obtained from ROESY spectra suggest that these small fragments predominantly adopt a type II′β-turn structure in solution. Folding features of a non-active cyclic peptide based on the same sequence (cyclo-[Arg-Gly-Asp-Trp]₂) have also been investigated. The biological relevance of these structures is discussed.