Global right atrial mapping delineates double posterior lines of block in patients with typical atrial flutter: a study using a three dimensional noncontact mapping system

Double Posterior Lines of Block in Typical Atrial Flutter. INTRODUCTION: The crista terminalis (CT) has been shown to be a barrier to transverse conduction during typical atrial flutter (AFL). However, some studies have demonstrated the presence of functional block in the sinus venosa region but not at the CT. The aim of this study was to define these regions of block in the right atrium using a three-dimensional noncontact mapping system. METHODS AND RESULTS: In 39 AFL patients (33 men and six women, mean age 56 +/- 13 years), a noncontact multielectrode array was used to reconstruct electrograms in the right atrium. Isochronal and isopotential propagation mapping was performed during AFL and during pacing from the coronary sinus ostium and the low lateral wall (cycle length from 600 to 240 msec) in sinus rhythm after creation of isthmus block. A single line of block along the CT area was found in 18 patients (46%). Two lines of block were found in 21 patients (54%), with the first line located along the CT area. The second was located in the sinus venosa region in 20 patients (51%) and in the lateral wall in 1 patient (3%). In all patients, the block in the lower part of the CT was observed during AFL (60%) and during pacing at all cycle lengths (48%-62%). The length and proportion of block were inversely proportional to pacing cycle length. CONCLUSION: Double lines of block were frequently observed in patients with AFL, and both lines may form the posterior boundaries of the AFL circuit. Block was fixed in the lower part of the CT and was functional in the upper part of the CT.     

V-A block during atrioventricular nodal reentrant tachycardia: reentry confined to the AV node

Retrograde block during atrioventricular (AV) nodal reentrant tachycardia is considered a rare phenomenon that can potentially occur in the AV node or in the atrium. A patient with slow-fast AV nodal reentrant tachycardia and transient VA block localized in the AV node is presented. Pharmacological and stimulation maneuvers identified the site of block in the AV node and not in the atrium. Thus, AV nodal reentry can be confined to the AV node.     

Effects of lactoferrin on rat dermal interstitial fluid pressure (Pif) and in vitro endothelial barrier function.

We recently demonstrated that intravenous (i.v.) injection of the iron-binding protein lactoferrin (Lf) followed by antilactoferrin (aLf) antibodies or iron-saturated Lf alone increased albumin extravasation in vivo in several tissues including skin. Increased driving pressure for blood-tissue exchange or direct effects of Lf on the endothelial barrier are possible mechanisms. We therefore, firstly, measured interstitial fluid pressure (Pif) in dermis of rats given 1 mg Lf i.v. followed 30 min later by aLf or saline and circulatory arrest 1 or 5 min thereafter and compared with controls. Secondly, transmonolayer passage of Evans blue labelled albumin (EB-albumin) was evaluated in porcine pulmonary artery endothelial cells exposed to iron-free or iron-saturated Lf (both 100 microg mL-1) in the absence and presence of 0.5 mM hydrogen peroxide. Pif increased significantly at 11-30 min following Lf to +2.1 +/- 0.3 and +1.7 +/- 0.2 mmHg at 11-20 and 21-30 min, respectively, compared with +0.1 +/- 0.2 mmHg before Lf (P < 0.05, n=25). Endothelial transmonolayer passage of EB-albumin during 3 h was not affected by iron-free or iron-saturated Lf neither in the absence nor presence of hydrogen peroxide that increased passage 3.5 times compared with controls. In conclusion, Lf-induced increase in albumin extravasation in rat skin is not explained by changes in Pif (because Lf raised Pif significantly) or direct effects of Lf on the endothelial barrier.     

Effects of lactoferrin on rat dermal interstitial fluid pressure (Pif) and in vitro endothelial barrier function

We recently demonstrated that intravenous (i.v.) injection of the iron‐binding protein lactoferrin (Lf) followed by antilactoferrin (aLf) antibodies or iron‐saturated Lf alone increased albumin extravasation in vivo in several tissues including skin. Increased driving pressure for blood‐tissue exchange or direct effects of Lf on the endothelial barrier are possible mechanisms. We therefore, firstly, measured interstitial fluid pressure (P_if) in dermis of rats given 1 mg Lf i.v. followed 30 min later by aLf or saline and circulatory arrest 1 or 5 min thereafter and compared with controls. Secondly, transmonolayer passage of Evans blue labelled albumin (EB‐albumin) was evaluated in porcine pulmonary artery endothelial cells exposed to iron‐free or iron‐saturated Lf (both 100 μg mL^–1) in the absence and presence of 0.5 mM hydrogen peroxide. P_if increased significantly at 11–30 min following Lf to +2.1 ± 0.3 and +1.7 ± 0.2 mmHg at 11–20 and 21–30 min, respectively, compared with +0.1 ± 0.2 mmHg before Lf (P < 0.05, n=25). Endothelial transmonolayer passage of EB‐albumin during 3 h was not affected by iron‐free or iron‐saturated Lf neither in the absence nor presence of hydrogen peroxide that increased passage 3.5 times compared with controls. In conclusion, Lf‐induced increase in albumin extravasation in rat skin is not explained by changes in P_if (because Lf raised P_if significantly) or direct effects of Lf on the endothelial barrier.     

Rate-dependent block in the sinus venosa of the swine heart during transverse right atrial activation: correlation between electrophysiologic and anatomic findings

Rate-dependent block in the sinus venosa. INTRODUCTION: Whether the crista terminalis or the sinus venosa result in rate-dependent block during transverse activation of the right atrial activation remains unknown. In the present study, right atrial activation at different cycle lengths was studied in the swine heart using high-resolution noncontact mapping (Endocardial Solutions). The location of the block was tagged and correlated with postmortem anatomical findings. METHODS AND RESULTS: Eight pigs were studied using noncontact mapping to obtain right atrial geometry and detailed sequence of activation using noncontact endocardial mapping. During sinus rhythm, activation proceeded uninterrupted craniocaudally along the sinus venosa and crista terminalis with similar conduction velocities (1.08+/-0.17 and 1.17+/-0.14 m/sec, respectively). Proximal coronary sinus stimulation was used to create transverse activation of the posterior right atrial wall. A rate-dependent decrease in conduction velocity occurred in the sinus venosa region (0.93+/-0.21, 0.82+/-0.14, and 0.52+/-0.09 m/sec at 500, 400, and 300 ms, respectively; P<0.05). The line of block verified by isopotential mapping and double potentials was obtained at cycle lengths of 240+/-30 ms. This line of the block was tagged with radiofrequency current lesions. Postmortem, all lesions were located in the sinus venosa region, 9.8+/-4.1 mm from the posteromedial edge of the crista terminalis. This region showed abrupt changes in muscle fiber thickness and orientation as well as in collagen content. CONCLUSIONS: The sinus venosa and not the crista terminalis results in a rate-dependent line of block during transverse right atrial activation. The morphologic characteristics of the sinus venosa appear to facilitate block in this region.     

Lactoferrin and anti-lactoferrin antibodies: effects of ironloading of lactoferrin on albumin extravasation in different tissues in rats

Lactoferrin is a cationic iron-binding protein, which is released from activated neutrophils in concert with reactive oxygen species. In vitro, lactoferrin has both anti- and proinflammatory effects; many of them dependent on iron-binding. In vivo, only iron-free lactoferrin reduced inflammatory hyperpermeability in the lung. We therefore examined whether 1 mg iron-free (Apo-Lf) or iron-saturated lactoferrin (Holo-Lf) alone or followed by anti-lactoferrin antibodies (aLf) affected permeability evaluated by extravasation of radiolabelled bovine serum albumin (CBSA) in different tissues of anaesthetized rats. Fifteen minutes after i.v. injection of Lf, aLf or saline was given and circulatory arrest was induced 20 min thereafter. Measurements were performed in control, after Apo-Lf, Holo-Lf, Apo-Lf + aLf, Holo-Lf + aLf and aLf alone (n=6-8 in each group). No intergroup differences were found for plasma volume and haematocrit at the start and end of the 37 min extravasation period or for total tissue water in any of the six different tissues studied, excluding larger transcapillary fluid shifts. However, increases in CBSA were seen without differences in tissue intravascular volume. Iron-free lactoferrin and aLf alone did not change CBSA significantly. Iron-saturated lactoferrin significantly increased CBSA in skin (neck), trachea and left ventricle of the heart to 249 +/- 9, 284 +/- 16 and 160 +/- 7% of control, respectively. When followed by aLf, both Apo- and Holo-Lf increased CBSA significantly in four and five of the tissues studied, respectively. However, no significant effect was seen for Holo-Lf + aLf compared with Holo-Lf alone. In conclusion, iron-saturated, but not iron-free lactoferrin increased CBSA, whereas antilactoferrin increased CBSA compared with lactoferrin alone only when following iron-free lactoferrin.     

iCPR: a new application of high-quality cardiopulmonary resuscitation training

Objectives

The present study evaluates a new CPR feedback application for the iPhone (iCPR) designed to improve chest compression performance tested in a cardiac arrest simulation to evaluate performance and acceptance by healthcare professionals and lay people.

Methods

We built an application specifically dedicated to self-directed CPR training through a tutorial that includes a simple feedback module to guide training in order to improve the quality of chest compressions. We tested it in a sample of 50 users to evaluate the effect of iCPR on performance and it is acceptance. The participants were randomly assigned to one of the study groups and were asked to perform a trial of 2 min of chest compressions (CC), to answer a predefined set of questions and then to perform two more minutes of CC. The first group performing the sequence of CC with iCPR - questions - CC without feedback, and the second the sequence CC without feedback - questions CC with iCPR.

Results

The mean compression rate was 101 ± 2.8 min⁻¹ when CC were performed with iCPR and 107.8 ± 20.5 min⁻¹ when performed without iCPR (p < 0.01). Overall, the participants considered iCPR useful to maintain CC at the desired rate of 100 compressions per minute.

Conclusions

The iCPR feedback tool was able to significantly improve the performance of chest compressions in terms of the compression rate in a simulated cardiac arrest scenario. The participants also believed that iCPR helped them to achieve the correct chest compression rate and most users found this device easy to use.     

Acute resumption of conduction in the cavotricuspid isthmus after catheter ablation in patients with common atrial flutter. Real-time evaluation and long-term follow-up.

AIMS: Cavotricuspid isthmus conduction (CIC) is closely associated with the maintenance and recurrence of common atrial flutter (AFL). This study systematically sought to assess the prevalence and characteristics of acute CIC recovery during AFL ablation and to define its predictors and its relationship with the results of long-term follow-up. METHODS AND RESULTS: A total of 124 consecutive patients (105 men, 19 women, mean age 58 +/- 11 years) who underwent successful AFL ablation were included. The procedure endpoint was defined as complete bi-directional CIC block. During an observation period of 30 min, the incidence of CIC restoration was 34.% in patients and 39.8% in applications. It increased with increasing block time and decreased over time during the observation period. Block time in successful burns followed by persistent block was shorter than in those followed by CIC resumption (12 +/- 6 vs 33 +/- 12 s, P<0.0001). A negative correlation between block time and resumption time was found (r = - 0.57, P<0.001). Patients with permanent pacemakers had a higher incidence of acute CIC resumption than those without pacemakers (5/7 vs 29/117, P = 0.007). The AFL recurrence rate was 4.8% during a mean follow-up period of 21 +/- 8 months. Our results suggest that acute CIC resumption may be a potential risk for clinical AFL recurrence during long-term follow-up. CONCLUSIONS: Acute CIC resumption in common AFL ablation varies in terms of incidence and time course. Block time has a predictive value for acute CIC recovery. Observation time can be shortened if block time is short. With longer block time, it is essential to observe for a longer period in order to minimize CIC resumption.