Left superior vena cava isolation in patients undergoing pulmonary vein antrum isolation: impact on atrial fibrillation recurrence.

BACKGROUND: A persistent left superior vena cava (SVC) can be an arrhythmogenic source in patients with atrial fibrillation (AF) through connections from the coronary sinus (CS) and the left atrium (LA). The left SVC can be electrically isolated. However, little clinical data about the impact of left SVC disconnection on AF outcome are available. We report on six patients with left SVC and recurrent AF. OBJECTIVES: The purpose of this study was to assess the impact of left SVC isolation on AF recurrence. METHODS: Six patients (4 men and 2 women; age 50 +/- 6.4 years) with symptomatic drug-refractory AF and persistent left SVC presented to our laboratory for treatment. Four of the patients had left SVC isolation only because there was no conduction recovery in the pulmonary veins (PVs) after several previous procedures. RESULTS: Conduction between the left SVC and the CS and LA was documented, as was spontaneous ectopies in three patients that degenerated into AF in one patient. Isolation of the left SVC was successful in all patients. Isolation was relatively easy to perform (10.25 +/- 1.6 minutes), with no complications. After follow-up of 13 +/- 7.4 months, all patients were in sinus rhythm and free from AF without antiarrhythmic drugs. CONCLUSION: This study stresses the importance of looking for unusual sources of AF in patients presenting for repeat procedures or in those in whom the PVs have been ruled out as a source triggering AF. We present clinical evidence that in patients with AF and left SVC, isolation of the PVs only may not be sufficient to suppress AF. Thus, diagnosis and isolation of the left SVC appears critical to preventing AF recurrence in patients with AF when ablation is considered.     

Safety and efficacy of radiofrequency energy catheter ablation of atrial fibrillation in patients with pacemakers and implantable cardiac defibrillators

BACKGROUND: Catheter ablation has significantly transformed the clinical management of atrial fibrillation (AF). The safety and efficacy of this procedure are not well understood in patients with pacemakers and defibrillators. OBJECTIVES: The purpose of this study was to study the impact of radiofrequency catheter ablation of AF in patients with pacemakers and implantable cardiac defibrillators. METHODS: We studied 86 patients with pacemakers and defibrillators (group I) and a similar number of age- and gender-matched controls (group II) who underwent AF ablation between 1999 and 2004. Clinical and procedural variables were compared between the two groups. In group I, various generator and lead parameters were compared before and after the procedure. Resurgence of clinical AF after 2 months was considered recurrence. RESULTS: Both groups were similar with regard to age, gender, body mass index, and type of AF. Group I had a higher incidence of diabetes (17% vs 6%, P = .03), coronary artery disease (25% vs 13%, P = .05), less prolonged AF (31 +/- 21 vs 45 +/- 30 months, P <.001), lower left ventricular ejection fraction (49 +/- 13% vs 52 +/- 9%, P = .03), and left ventricular end-diastolic dimensions (4.97 +/- 0.81 vs 4.72 +/- 0.67, P = .03). No changes in the sensing and pacing thresholds, impedance of atrial and ventricular leads, or defibrillator coil impedance after AF ablation were observed in group I. Atrial lead dislodgment was seen in two patients. Transient abnormal but "expected" pulse generator behavior was seen in 25% of patients without permanent malfunction. Stroke (1% vs 1%, P = 1.000), pulmonary vein stenosis (2% vs 1%, P = .77), and AF recurrence rates at 12 months were similar between groups I and II, respectively (19% vs 21%, P = .73). CONCLUSION: AF ablation is safe and efficacious in patients with pacemakers and defibrillators.     

Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients

OBJECTIVES: In patients with atrial flutter (AFL) and postoperative right atrial incisional scars, we sought to assess if the use of additional ablative lesions that targeted all potential re-entrant circuits, regardless of the presenting type of flutter, would prevent long-term recurrence. BACKGROUND: Patients with AFL and incisional scars have a complex atrial substrate that may promote multiple mechanisms of intra-atrial re-entry. METHODS: Twenty-nine patients with single right atrial incisional scars undergoing ablation for scar-dependent (n = 15) and cavotricuspid isthmus (CTI)-dependent (n = 14) flutter were studied. RESULTS: In the scar-dependent group, 9 of 15 (60%) patients had inducible or spontaneous CTI-dependent flutter immediately after ablation. In the group with CTI flutter, 7 of 14 (50%) patients had scar-related flutter immediately after ablation. If a second type of flutter was found during the initial ablation, a second ablation was performed either along the isthmus (scar-dependent group) or from the scar to another anatomic boundary (isthmus-dependent group). Patients were followed for 24 +/- 5 months and 18 +/- 6 months in the scar- and CTI-dependent groups, respectively. In the scar-dependent group, five of six (83%) who underwent only a single flutter line had recurrence at 3 +/- 1 months. In the isthmus-dependent group, three of seven (42%) patients who had only one flutter line performed had recurrence at 5 +/- 3 months. There was no flutter recurrence in patients who initially received two different flutter lines or in patients who subsequently underwent a second flutter line at follow-up. CONCLUSIONS: In patients with postoperative right atrial incisional scar and flutter, multiple ablation lines that target both scar-related and classic isthmuses appear necessary to prevent long-term recurrence.     

Biochemical effects,hypolipidemic and anti-inflammatory activities of Artemisia vulgaris extract in hypercholesterolemic rats

The purpose of the present study was to investigate hypolipidemic and anti-inflammatory effects of Artemisia vulgaris extract in hypercholesterolemic rats. Hypercholesterolemia was induced by feeding of rats with high fat diet containing 3% cholesterol in olein oil, for 8 weeks. Feeding of rats with high fat diet for 8 weeks, leading to a significant increase in serum triglycerides, total cholesterol, low density lipoprotein cholesterol, malondialdehyde and nitric oxide, tumor necrosis factor-α levels and a significant decrease in serum high density lipoprotein cholesterol level, liver hydroxymethylglutaryl-CoA reductase activity and paraoxonase-1 activities as compared to the normal control group. Treatment of high fat diet rats with Artemisia vulgaris extract for 4 weeks at a dose of 100 mg/kg per day, resulted in normalized serum lipid profile, a significant increase in paraoxonase-1 activity and decrease in serum malondialdehyde, nitric oxide and tumor necrosis factor-α level as compared to high fat diet-treated animals. Also the extract caused a significant decrease in hydroxymethylglutaryl-CoA reductase activity as compared with both high fat diet-treated animals and control ones. In conclusion, Artemisia vulgaris extract has hypolipidemic, anti-inflammatory, antioxidant properties; it may serve as a source for the prevention of atherosclerosis and cardiovascular diseases.     

Anesthesia and the developing brain: a way forward for clinical research

It is now well established that many general anesthetics have a variety of effects on the developing brain in animal models. In contrast, human cohort studies show mixed evidence for any association between neurobehavioural outcome and anesthesia exposure in early childhood. In spite of large volumes of research, it remains very unclear if the animal studies have any clinical relevance; or indeed how, or if, clinical practice needs to be altered. Answering these questions is of great importance given the huge numbers of young children exposed to general anesthetics. A recent meeting in Genoa brought together researchers and clinicians to map a path forward for future clinical studies. This paper describes these discussions and conclusions. It was agreed that there is a need for large, detailed, prospective, observational studies, and for carefully designed trials. It may be impossible to design or conduct a single study to completely exclude the possibility that anesthetics can, under certain circumstances, produce long‐term neurobehavioural changes in humans; however , observational studies will improve our understanding of which children are at greatest risk, and may also suggest potential underlying etiologies, and clinical trials will provide the strongest evidence to test the effectiveness of different strategies or anesthetic regimens with respect to better neurobehavioral outcome.     

Traumatic female urethral avulsion

Traumatic female urethral avulsion in the absence of a pelvic fracture is an exceedingly rare entity, with no consensus on its management. Here, we present a 35-year-old pregnant woman with severe anterior vaginal wall laceration and complete urethral avulsion secondary to straddle injury. Management consisted of primary urethral and vaginal repair.Complete circumferential rupture of the female urethra is extremely rare, and represents a challenging management situation.1 As the entire posterior length of the urethra is closely adherent to the anterior wall of the vagina; it is subsequently prone to simultaneous injury. Most reported cases were associated with pelvic bone fractures, but there is no current consensus on management.2 The diagnosis should be considered in cases of deep vaginal lacerations, with an inability to void with unsuccessful catheterization.3 Our objective in presenting this particular case is to highlight that early recognition and strict adherence to the principles of reconstructive surgery are necessary to maximize the results and prevent subsequent risks of morbidity.     

Inflammatory bowel disease in rats： Bacterial and chemical interaction

AIM：To develop a novel model of colitis in rats, using a combination of iodoacetamide and enteropathogenic E. coli（EPEC）, and to elucidate the pathophysiologic processes implicated in the development of ulcerative colitis （UC）.
METHODS： Hale Sprague-Dawley rats （/7 = 158） were inoculated intrarectally on a weekly basis with 4 different combinations： （a） 1% methylcellulose （HC）, （b） 100 μL of 6% iodoacetamide （IA） in 1% HC, （c） 200 p.L containing 4×10^8 colony factor units （CFU） of EPEC, and （d） combined treatment of （IA） followed by bacteria （13） after 2 d. Thirty days post treatment, each of the four groups was divided into two subgroups; the inoculation was stopped for one subgroup and the other subgroup continued with biweekly inoculation until the end of the experiment. Colitis was evaluated by the clinical course of the disease, the macroscopic and microscopic alterations, activity of myeloperoxidase （HPO）, and by TNF-α gene expression. RESULTS： Findings indicative of UC were seen in the combined treatment （IA ＋ B） as well as the IA continued treatment groups： the animals showed slow rate of increase in body weight, diarrhea, bloody stools, high colonic ulcer score, as well as histological alterations characteristic of UC, with an extensive inflammatory reaction. During the course of the experiment, the MPO activity was consistently elevated and the TNF-α gene expression was upregulated compared to the control animals.
CONCLUSION： The experimental ulcerative colitis model used in the present study resembles, to a great extent, the human disease. It is reproducible with characteristics indicative of chronicity.     

The Association of Diurnal Blood Glucose Variability With Subclinical Cardiac Disease in Patients With Type 2 Diabetes Mellitus

BackgroundThe relationship between glycemic control and the risk of cardiac disease in patients with Type 2 Diabetes Mellitus (T2DM) is controversial. 1,5-Anhydroglucitol (1,5-AG) is a biomarker of Glucose Variability (GV) and has been associated with clinical cardiovascular disease. However, its association with Subclinical Cardiac Disease (SCD) is unknown.Aim of the workStudy the association between GV and SCD.Subjects and methodsA cross-sectional study was conducted on 46 asymptomatic patients with T2DM as T2DM individuals group. Another 46 non-diabetic age and sex matched subjects were included as the healthy group. 1,5-AG was measured for all subjects. M-mode echocardiography in parasternal long axis view was used to measure Left Ventricular (LV) end diastolic dimension, LV end systolic dimension, ejection fraction, interventricular septum, LV posterior wall thickness, LV fractional shortening, left atrial dimension and aortic root dimension. Global Longitudinal Strain (GLS) was assessed by speckled tracking echocardiography.ResultsThere were no significant differences between both groups as regarding age, sex, BMI, AST, ALT, and serum creatinine. 1,5-AG was lower in T2DM individuals group. As regarding the echo parameters no significant difference found between both groups regarding left ventricular, left atrial and aortic root dimensions. T2DM individuals group showed a statistically significant higher mitral valve area, apical 2 chambers, apical 4 chambers, apical longitudinal axis and GLS. No correlation found between HbA1c and any echo parameters while 1,5-AG showed a significantly negative correlation with apical 2 chambers, apical 4 chambers, apical longitudinal axis and GLS. ROC curve analysis detected 1,5-AG less than 7.51 ng/ml as the best cut off value with sensitivity of 85.7%, specificity 75% to diagnose patients with T2DM and SCD.Conclusion1,5-AG might be used as an additional surrogate marker to identify patients with T2DM and SCD.