Bidirectional transvenous/subcutaneous defibrillation of ventricular fibrillation in dogs: success rates, energy requirements, currents, voltages and impedance

Four hundred and thirteen defibrillations of alternating current-inducedventricular fibrillation were performed in 10 halothane-anaesthetizeddogs (body weight: 24.5–30.5 kg). Success rates, energydemands, currents, peak voltages and impedance were determined.A transvenous catheter electrode system (Medtronic 6880, rightventricular apex and superior vena cava, distance 100 or 150mm) and subcutaneous patch electrodes (Intec 67 L, 2nd/3rd and/or3rd/4th left intercostal space) were used for bidirectionaldefibrillation. Loading voltages ranged from 600 to 850 V. Withan electrode distance of 100 mm and a pulse duration of 2 msseparated by 1 ms, success rates were 100%, 40% and 0% for 850,650 and 600 V, respectively. With a 3-ms pulse duration, thecorresponding rates were 100%, 60% and 50%. With a 2-ms pulseduration, successful defibrillation was achieved with energieslower than 15 J in 27%, with energies between 15 and 20 J in77%, and 100% with energies higher than 20 J. Defibrillationcurrents were 4.4–9.3 A for pulse 1 (superior vena cava/ventricularapex) and 6.3–13.4 A for pulse 2 (patch/ventricular apex),respectively. Effective peak voltages ranged from 510 to 787V and from 514 to 777 V and averaged 89.6% of the loading voltages.Impedance values (peak voltage/current) were 75.5–117.7(pulse 1) and 51.7–94.9 Ohms (pulse 2). Fifty consecutivedefibrillations in one animal resulted in a decrease of impedance(114.6 to 84.9 Ohms, pulse 1; 75.4 to 53.0 Ohms, pulse 2). Defibrillationof ventricular fibrillation can be achieved with acceptablylow energies using a bidirectional transvenous/subcutaneoussystem, avoiding thoracotomy and general anaesthesia for implantationof the defibrillation system.     

Radiologic search for embolized leaflets of prosthetic heart valves: A report of two cases

In a radiologic search for embolized leaflets of Edwards-Duromedics bileaflet valves in 2 patients, the embolized fragments were localized in the iliac vessels using computed tomography. Sonography was successful in one case and standard X-ray films of the abdomen were negative in both cases.In vitro investigations with Björk-Shiley and Edwards-Duromedics leaflets suggested that standard X-ray films of the abdomen and pelvis should be considered as the first investigational technique. If negative, computed tomography of the lower abdomen should be done.     

Apoptosis of ileal Peyer's patch B cells is increased by glucocorticoids or anti-immunoglobulin antibodies

The ileal Peyer's patch (PP) in sheep plays a central role in the development and production of B cells. Associated with a tremendous amount of B cell proliferation in this site is the extensive diversification of the Ig repertoire by somatic hypermutation. Very few (<5%) of the B cells produced in the ileal PP differentiate and emigrate; instead, the vast majority of these cells soon die, and we have previously shown that death is associated with apoptosis. When placed in culture, ileal PP B cells die rapidly by apoptosis, such that after 24h, 60 ± 1 % of DNA is fragmented. Here, we show that the extent of this spontaneous B cell apoptosis in culture, as quantitated by DNA fragmentation, was significantly increased in a dose-dependent manner by the glucocorticoids hydrocortisone or dexamethasone. Furthermore, treatment of lambs with 2–2.5 mg/kg of dexamethasone resulted in a marked increase in the number of apoptotic cells in the ileal PP and an increase in ileal PP B cell DNA fragmentation to 20 ± 6%, compared with 2.4 ± 0.1 % in untreated lambs. Anti-immunoglobulin (Ig) antibodies also increased the extent of DNA fragmentation in cultured ileal PP B cells. After 24 or 48 h of culture with anti-Ig (PIg47A), DNA fragmentation was 74 ± 2 % and 75 ± 3 %, respectively. Ileal PP B cells are rescued from apoptosis by agents that activate protein kinase C and increase cytosolic Ca²⁺, and here we show that this treatment also results in apoptotic rescue in the presence of dexamethasone or anti-Ig. We speculate that the apoptosis of ileal PP B cells in situ may be modulated by glucocorticoids and by the cross-linking of surface Ig. Apoptosis, induced by a signal through surface Ig, may be an important mechanism in the deletion of self-reactive B cells during the expansion of the Ig repertoire in the ileal PP.     

Mechanical heart valve prostheses:: identification and evaluation (erratum)

Mechanical heart value prostheses have been in use since the 1950s. Many prostheses have been used for a while and then discontinued. Today, there are a large number and variety of prostheses in use and an even larger variety that are in place in patients. These may be explanted at any time for a number of reasons. It is essential for the practicing pathologist to be able to identify the prosthesis and be aware of some of its reported complications and modes of failure. This article, and a second one on bioprosthetic heart valves, is designed as a ready reference guide to heart valve prostheses, their important identifying features, their common complications, and modes of failure. It should help in the accurate identification of explanted prosthetic valves and more definitive reports. This accuracy of identification as well as tracking of abnormalities noted will, we hope, permit the identification of new failure modes and the recording of causes of failure of new (or even modified) prosthetic heart valves.     

Nitric oxide: a local signalling molecule controlling the activity of pre‐autonomic neurones in the paraventricular nucleus of the hypothalamus

Abstract Aim: The gas molecule nitric oxide (NO) has been shown to modulate autonomic function by acting both peripherally and centrally. Accumulating evidence indicates that the paraventricular nucleus (PVN) of the hypothalamus is an important locus mediating central NO actions on autonomic function, under both physiological and pathological conditions. However, the cellular targets and mechanisms mediating NO actions within the PVN are still poorly understood. Results: By combining in vitro patch‐clamp recordings with neuronal tract tracing techniques, we show that neuronal excitability of autonomic‐related neurones in the PVN is tonically inhibited by an endogenous NO input. Furthermore, immunohistochemical studies show that ～25% of autonomic‐related PVN neurones express neuronal nitric oxide synthase, suggesting that at least a proportion of them contribute to the cellular sources of NO within the PVN. Conclusion: In summary, this work suggests that NO modulation of the firing activity of autonomic‐related PVN neurones constitutes an efficient mechanism mediated central NO regulation of autonomic function.     

Correlation between ventricular flow field and valve closing sound of mechanical mitral prostheses

The Jyros (JR) valve and the newer On-X and MIRA valves, all installed antianatomically, were compared with the St. Jude Medical (SJM) valve in the mitral position to study the effects of valve design differences on the down-stream flow field and the associated valve closing sound. The dynamic particle image velocimetry method utilizing a high-speed video flow visualization technique was used to map the velocity field, and wavelet analysis of the sound was used to find the correlation between the ventricular flow field and the valve closing sound. Based on the experimental data, the following general conclusions can be made. In the velocity field directly below the mitral valve, where the distinct characteristic differences of the valve designs will be evident, twin symmetrical circulations were observed due to the divergent nature of the flow generated by the two inclined half-disks with the valve installed in the anti-anatomical orientation; the SJM, the On-X, and the MIRA valves generated a centrally downward circulation that opposed the valve leaflet closing movement, and resulted in relatively loud valve closing sounds.     

Time-resolved particle image velocimetry and laser doppler anemometry study of the turbulent flow field of bileaflet mechanical mitral prostheses

Dynamic particle image velocimetry (PIV) was applied to the study of the flow field associated with prosthetic heart valves. The results were compared with those of laser Doppler anemometry (LDA). Anatomically and antianatomically oriented Jyros (JR) and St. Jude Medical (SJM) valves were compared in the mitral position to study the effects of valve design on the downstream flow field. The experimental program used a dynamic PIV system utilizing high-speed, high-resolution video to map the true time-resolved velocity field inside the simulated ventricle. This system was complemented by a study using the more traditional LDA system for comparison. Based on the experimental data, the following general conclusions can be made. High-resolution dynamic PIV can capture true chronological changes in the velocity and turbulence fields. It also produces very detailed velocity and turbulence information comparable to the LDA results. In the vertical measuring plane that passes both the center of the aortic and mitral valves (A-A section), the two valves (the SJM and the JR) show distinct circulatory flow patterns when the valve is installed in the antianatomical orientation. Small differences in valve design can generate noticeable differences, particularly during the accelerating flow phase. The SJM valve maintains a relatively high velocity through the central orifice; the curved leaflets of the JR valve generate higher velocities with a divergent flow during the accelerating and peak flow phases. In the velocity field directly below the mitral valve and normal to the previous measuring plane (B-B section), where characteristic differences in valve design will be visible, symmetrical twin circulations were observed because of the divergent nature of the flow generated by the two inclined half-disks installed in the antianatomical orientation. The SJM valve, with a central downward flow near the valve, is contrasted with the JR valve, which has a peripheral downward circulation with higher, turbulent stresses.