Long‐Term Survival of Routine Implantable Cardioverter/Defibrillator Recipients Appears to be Significantly Impaired with Concomitant Diuretics and Improved with Aldosterone Antagonists

Evidence‐based treatment for heart failure (HF) comprises beta‐blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists (ARA). Diuretics (DR) are prescribed in acute and chronic HF, but their impact on survival and ventricular tachyarrhythmias (VT/VF) is unclear. The present observational study aims to examine the influence of DR and ARA on survival and appropriate cardioverter/defibrillator (ICD) treatment episodes in routine ICD patients. In 352 consecutive ICD patients (291 men, 60 ± 12 years, LVEF 34 ± 15%, follow‐up 37 ± 19 months) overall survival and the time to a first appropriate VT/VF episode were assessed. Electrograms were validated. Potassium and creatinine serum levels and the medical treatment regimen for heart failure were documented at baseline. Multivariate Cox regression analyses revealed significantly worse survival for patients with DR compared to those without DR (OR 0.24, CI 0.08–0.76, P= 0.016), whereas the group with ARA had better survival compared to patients without (OR 2.05, CI 1.02–4.10, P= 0.04). Patient groups did not differ regarding survival without incident VT/VF (DR+ vs. DR– OR 1.10, CI 0.67–1.83, P= 0.70; OR 0.66, CI 0.40–1.09, P= 0.10). Long‐term survival appears to be compromised in ICD patients receiving concomitant DR, but is favorably influenced by ARA, although VT/VF incidence does not differ. Randomized analyses are warranted to assess long‐term prognostic effects of DR in HF.     

Cerebral activation using a MR-compatible piezoelectric actuator with adjustable vibration frequencies and in vivo wave propagation control

Functional magnetic resonance imaging (fMRI) studies are increasingly used in patients with brain tumors near the sensory motor cortex for planning of therapy. Passive stimuli can be helpful for reproducible results. The purpose of our study was to investigate frequency and amplitude dependencies of cerebral activation patterns using a vibratory stimulus that involves sensory and motor function and allows exact adjustment of vibratory frequencies and direct control of penetration depth into the tissue. Fifteen volunteers were studied with fMRI during vibratory stimulation of the right biceps muscle utilizing a block design (frequencies: 150 and 300 Hz, amplitudes: 400, 600, and 800 microm). In addition, visualization of the wave propagation into the biceps tissue itself was performed with a modified phase contrast sequence. A specially developed MR-compatible mechanical oscillator was used to apply the vibrotactile sensations. fMRI revealed activation of the left primary somatosensory cortex during application of both vibratory frequencies. Additionally, activity of the primary and supplementary motor cortex was revealed using 150-Hz stimuli, while only minimal at 300 Hz. The activity strength correlated with increasing stimulus amplitudes and the visualized penetration depth. Activation of motor areas was more pronounced at the beginning of the rest period. In conclusion, sensory motor areas can be activated using a piezoelectric actuator, with less pronounced motor area activation at higher frequencies. Our setup allowed local control of stimulus penetration through the tissue correlated to central activation, providing objective stimulus control. The pronounced activation of the motor cortex during the rest condition may reflect the subjective feeling of arm movement after the end of the stimulus.     

Efficacy and safety of everolimus in elderly patients with metastatic renal cell carcinoma: an exploratory analysis of the outcomes of elderly patients in the RECORD-1 Trial

Background

Elderly patients with metastatic renal cell carcinoma (mRCC) may require special treatment considerations, particularly when comorbidities are present. An understanding of the efficacy and safety of targeted agents in elderly patients with mRCC is essential to provide individualized therapy.

Objective

To evaluate the efficacy and safety of everolimus in elderly patients (those ≥65 and ≥70 yr of age) enrolled in RECORD-1.

Design, setting, and participants

The multicenter randomized RECORD-1 phase 3 trial (Clinicaltrials.gov identifier, NCT00410124; http://www.clinicaltrials.gov) enrolled patients with mRCC who progressed during or within 6 mo of stopping sunitinib and/or sorafenib treatment (n = 416).

Intervention

Everolimus 10 mg once daily (n = 277) or placebo (n = 139) plus best supportive care. Treatment was continued until disease progression or unacceptable toxicity.

Measurements

Median progression-free survival (PFS), median overall survival (OS), and time to deterioration in Karnofsky performance status (TTD-KPS) were assessed using the Kaplan-Meier method; the log-rank test was used to compare treatment arms. Other outcomes evaluated included reduction in tumor burden, overall response rate (ORR), and safety.

Results and limitations

In RECORD-1, 36.8% of patients were ≥65 yr and 17.5% were ≥70 yr of age. PFS, OS, TTD-KPS, reduction in tumor burden, and ORR were similar in the elderly and the overall RECORD-1 population. Everolimus was generally well tolerated in elderly patients, and most adverse events were grade 1 or 2 in severity. The toxicity profile of everolimus was generally similar in older patients and the overall population; however, peripheral edema, cough, rash, and diarrhea were reported more frequently in the elderly regardless of treatment. The retrospective nature of the analyses was the major limitation.

Conclusions

Everolimus is effective and tolerable in elderly patients with mRCC. When selecting targeted therapies in these patients, the specific toxicity profile of each agent and any patient comorbidities should be considered.     

Role of diabetes in heart rhythm disorders

The incidence of diabetes mellitus(DM) is increasing rapidly. DM is the leading cause of cardiovascular diseases, which can lead to varied cardiovascular complications by aggravated atherosclerosis in large arteries and coronary atherosclerosis, thereby grows the risk for macro and microangiopathy such as myocardial infarction, stroke, limb loss and retinopathy. Moreover diabetes is one of the strongest and independent risk factor for cardiovascular morbidity and mortality, which associated frequently rhythm disorders such as atrial fibrillation(AF) and ventricular arrhythmias(VA). The present article provides a concise overview of the association between DM and rhythm disorders such as AF and VA with underlying pathophysiological mechanisms.     

Magnetic Navigation and Catheter Ablation of Right Atrial Ectopic Tachycardia in the Presence of a Hemi-Azygos Continuation: A Magnetic Navigation Case Using 3D Electroanatomical Mapping

Introduction: We report on a 63-year-old female patient in whom an electrophysiologic study discovered a hemi-azygos continuation. Using the magnetic navigation system, remote-controlled ablation was performed in conjunction with the 3D electroanatomical mapping system.
Methods and Results: Failing the attempt to advance a diagnostic catheter from the femoral vein, a diagnostic catheter was advanced via the left subclavian vein into the coronary sinus. The soft magnetic catheter was positioned in the right atrium via the hemi-azygos vein, and 3D mapping demonstrated an ectopic atrial tachycardia. Successful ablation was performed entirely remote controlled. Fluoroscopy time was only 7.1 minutes, of which 45 seconds were required during remote navigation.
Conclusion: Remote-controlled catheter ablation using magnetic navigation in conjunction with the electroanatomical mapping system proved to be a valuable tool to perform successful ablation in the presence of a hemi-azygos continuation.     

Right ventricular rapid pacing in catheter ablation of atrial fibrillation: a novel application for cryoballoon pulmonary vein isolation

Background  Cryoballoon ablation (Arctic Front, Cryocath™) represents a novel technology for pulmonary vein isolation (PVI). The initial phase of a freeze is crucial for cryolesion formation which is determined by local temperature depending on blood flow. We investigated the impact of right ventricular rapid pacing (RVRP) on temperature kinetics in patients (pts) with paroxysmal atrial fibrillation (PAF). Methods and results  Right ventricular rapid pacing was performed from the RV apex. Absolute minimal temperature (MT, °C), temperature slopes [time (s) to 80% MT; dT/dt), area under the curve (AUC) and arterial blood pressure (ABP, mmHg) were compared (group I: with RVRP vs. group II: without RVRP). RVRP (mean duration 55 ± 7 s) was performed in 11 consecutive PAF pts (41 PVs, age 58 ± 9 years, LA size 44 ± 6 mm, normal ejection fraction). Only freezes with identical balloon positions were analyzed (11/41 PVs). RVRP (cycle length 333 ± 3 ms) induced a significant drop in ABP (group I: 45 ± 3 mmHg vs. group II: 100 ± 18 mmHg, p < 0.001). MT was not different between group I and group II (−45.0 ± 4.4 vs. −44.3 ± 3.4°C, p = 0.46), whereas slope (38.0 ± 4.6 s vs. 51.6 ± 14.4 s, p = 0.0034) and AUC (1090 ± 4.6 vs. 1181 ± 111.2, p = 0.02) was significantly changed. In one pt, a ventricular tachycardia was induced. PVI was achieved in 41/41 PVs. Conclusion  Right ventricular rapid pacing significantly accelerates cryoballoon cooling during the initial phase of a freeze possibly suggesting improved cryolesions. K. H. Kuck is a current member of the European Cryocath advisory board. K. R. J. Chun received travel grants from Cryocath.     

Influence of geometric and hemodynamic parameters on aneurysm visualization during three-dimensional rotational angiography: an in vitro study

BACKGROUND AND PURPOSE: Aneurysm depiction with three-dimensional (3D) rotational angiography is influenced by investigator-defined parameters such as image acquisition and contrast agent injection and by the hemodynamic pattern in the parent artery and aneurysm. To assess the impact of the geometric configuration of parent artery and aneurysm on the 3D visualization of saccular aneurysms, we studied silicone aneurysm models under pulsatile-flow conditions. METHODS: Rotational angiography was performed in three bifurcation and three lateral aneurysm models with ostia of different widths. Three acquisition modalities (5, 8, and 14 seconds in duration, acquisition rate of 10 frames per second) and two techniques for the injection of contrast material (continuous flow and injection with an initial bolus) were applied. 3D reconstructions were obtained with a volume-rendering technique. RESULTS: Bifurcation aneurysms were visualized with high accuracy. Filling deficits distant to the inflow zone could be compensated for with the bolus-injection technique, and complete depiction of aneurysm shape was achieved in the 8-second rotation with 20 mL of contrast agent. In lateral aneurysms, the accuracy of 3D reconstructions depended on the width of the ostium. Although rotational studies in wide-necked lateral aneurysms yielded adequate reconstructions, 3D visualization of small-necked aneurysms was incomplete with the preferential depiction of the distal shell, which represents the inflow zone into the aneurysmal lumen. CONCLUSION: Contrast agent injection with the initial-bolus technique improved the depiction of aneurysms, compared with the continuous-flow method. Reconstructions of rotational studies of narrow-necked lateral aneurysms yielded incomplete visualization of the aneurysm.