Invasive electrophysiological evaluation of patients with sleep apnoea-associated ventricular asystole—methods and preliminary results

SUMMARY  Twelve patients (aged 48 ± 12 y) with ventricular asystole of >3s due to complete atrioventricular (AV) block ( n = 8), sinoatrial (SA) block or sinus node arrest ( n = 3) or both ( n = 1) associated with obstructive sleep apnoea underwent invasive electrophysiological evaluation of sinus node function and AV conduction properties before and after administration of atropine (0.02 mg kg^-1). Ventricular asystole lasted for 5.9 ± 2.8 s (range 3.1–13 s). Sinus node function was assessed by measurement of sinus node recovery time, sinoatrial conduction time, and the response of sinus rate to atropine. Parameters of AV-conduction assessment included AH- and HV-intervals, AV- and VA-Wenckebach periods, and effective refractory period of the AV node before and after atropine. Sinus node function was normal in 11 of the 12 study patients and moderately abnormal in 1 patient. AV-nodal function was normal in 8 patients and moderately abnormal in 4 patients. A slightly prolonged HV-interval (59–63 ms) was present in 6 patients. Intra- or infra His block was not observed in any patient. In conclusion, normal or only moderately abnormal electrophysiological findings in patients with sleep apnoea-associated ventricular asystole suggest that a neurally mediated cardioinhibitory reflex may cause ventricular asystole in these patients. This sleep apnoea-triggered 'vasovagal' reflex may unmask pre-existing mild to moderate structural abnormalities of the AV conduction system.     

Neuropeptide Y: identification of the binding site

Based on the hypothetical 3D structure of neuropeptide Y (NPY), NPY 1-4-Aca-25-36, a 17 amino acid analogue, has been synthesized replacing the sequence NPY 5-24 by ε-aminocaproic acid (Aca). This low-molecular weight deletion analogue showed nearly comparable receptor affinity to NPY. In order to elucidate the structural requirements for receptor recognition each amino acid of 1-4-Aca-25-36 was exchanged by its D-enantiomer, glycine and L-alanine. In addition distinct amino acids were replaced by closely related residues. Multiple peptide synthesis was applied using Fmoc-strategy and BOP activation. Binding assay was performed on rabbit kidney membrane preparations. The results of structure affinity studies suggest that the C-terminal tetrapeptide NPY 33-36 is essential for receptor recognition.     

Magnetic Resonance Imaging and Signal-Averaged Electrocardiography in Patients with Repetitive Monomorphic Ventricular Tachycardia and Otherwise Normal Electrocardiogram

Early or localized forms of arrhythmogenic right ventricular dysplasia (ARVD) have been proposed as the arrhythmogenic substrate of repetitive monomorphic ventricular tachycardia (RMVT) originating in the right ventricular outflow tract in patients without any underlying cardiac abnormality on clinical examination and echocardiography. To further examine this hypothesis, magnetic resonance imaging (MRI) and signal-averaged electrocardiography (SAECG) were performed on 23 patients with RMVT and normal 12-lead standard ECG of conducted sinus beats. MRI was performed using ECG-gated turbo spin-echo images of the heart in order to detect signs of early or localized forms of ARVD, such as localized wall thickness reductions, signal intensity increase indicating adipose tissue infiltrates, and regional bulgings or aneurysms. MRI was normal in 22 (96%) of 23 study patients. In the remaining patient (4%), MRI demonstrated signal intensity increase in the intraventricular septum but not in the right ventricular outflow tract. Time-domain analysis of the SAECG was normal in 21 (91 %) of 23 patients and revealed ventricular late potentials in 2 study patients (9%). Frequency-domain analysis of the SAECG was normal in 22 (96%) of 23 patients and revealed ventricular late potentials in one study patient (4 %). We conclude that normal MRI findings of the heart and absence of ventricular late potentials in the SAECC in most patients with RMVT and otherwise normal ECG do not support the hypothesis that early or localized forms of ARVD create the arrhythmogenic substrate in the majority of these patients.     

Changes in serum lipoproteins in humans following the infusion of a fat emulsion containing medium- and long-chain triglycerides

Abstract. A fat emulsion containing equal parts of medium-chain triglycerides (MCT) and long-chain triglycerides (LCT) and emulsified with egg phospholipids (Lipofundin MCT 10%®) was compared with LCT emulsions (Intralipid 10%®, egg phospholipids; Lipofundin S 10%®, soya phospholipids) in six volunteers, using 4-h periods of infusion and doses of 0·15 g kg^-1 body h^-1. At the end of infusion very low density lipoprotein (VLDL) triglyceride concentrations were highest with Intralipid, marginally less with Lipofundin MCT and lowest with Lipofundin S. With Lipofundin MCT infusion the proportions of free mediumchain fatty acids in serum reached 30%. In VLDL the ratios triglycerides/apolipoprotein B and triglycerides/phospholipids rose most after Lipofundin MCT and least after Lipofundin S. With Lipofundin MCT and Intralipid, surface components in low density lipoproteins (LDL) are lessened in relation to the internal components; this does not occur with Lipofundin S. High density lipoprotein (HDL) subfractions are influenced in identical directions by all fat emulsions with exception of a single increase of phospholipids in (HDL₃) after Lipofundin MCT.     

The Six-Minute Walk—An Adequate Exercise Test for Pacemaker Patients?

LANGENFELD, H., ET AL.: The Six-Minute Walk—An Adequate Exercise Test for Pacemaker Patients? In many pacemaker patients bicycle and treadmill ergometry are not practicable. As an alternative, we performed a 6-minute walk on a 20-m corridor in 97 pacemaker patients, who were asked to walk as far as possible determining their speed by themselves. Results were compared with those of bicycle ergometry in 42 of these patients and with treadmill exercise of a group of 92 other pacemaker patients. In the 6-minute walk, performance and maximal heart rate were slightly lower (49 ± 18 W; 96 ± 23 beats/min) than in bicycle (57 ± 16 W; 110 ± 26 beats/min) and treadmill ergometry (50 ± 37 W; 102 ± 35 beats/min). A good correlation was found between walking and bicycling (r = 0.74) and in subgroups of patients with different pacemaker indications. All patients preferred the walk to bicycle ergometry considering it to be more related to daily physical activity. In conclusion, a 6-minute walk is a simple and physiological exercise test for nearly all pacemaker patients with good correlation to other types of exercise. It seems to be preferable to other tests because of its better acceptance and practicability.     

Value of Heart Rate Variability to Predict Ventricular Arrhythmias in Recipients of Prophylactic Defibrillators with Idiopathic Dilated Cardiomyopathy

GRIMM, W., et al. : Value of Heart Rate Variability to Predict Ventricular Arrhythmias in Recipients of Prophylactic Defibrillators with Idiopathic Dilated Cardiomyopathy. This study investigated the relation between heart rate variability (HRV) measured as standard deviation of normal to normal RR intervals (SDNN) on baseline 24-hour ambulatory electrocardiogram (ECG) and subsequent appropriate implantable cardioverter defibrillator (ICD) interventions in 70 patients with idiopathic dilated cardiomyopathy (IDC) in whom ICDs were implanted prophylactically in the presence of a low left ventricular ejection fraction (LVEF). During   43 ± 26   months of follow-up, 26 of 70 (37%) study patients with IDC received one or more appropriate ICD interventions for sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) documented by electrograms stored in the ICD. Mean SDNN at ICD implant was   94 ± 33 ms   . No difference was found between patients with   (90 ± 25 ms)   versus without   (96 ± 37 ms)   appropriate ICD interventions for VT or VF during follow-up. Multivariate Cox regression analysis of baseline clinical characteristics including age, gender, LVEF, NYHA functional class, nonsustained VT on Holter, history of syncope, left bundle branch block, baseline medication and HRV revealed LVEF as the only significant predictor of arrhythmia. These findings do not support the use of HRV measured as SDNN on 24-hour ambulatory ECG to select patients with IDC for prophylactic ICD therapy. (PACE 2003; 26[Pt. II]:411–415)     

Arrhythmia Risk Prediction in Idiopathic Dilated Cardiomyopathy Based on Heart Rate Variability and Baroreflex Sensitivity

This study examined the relation between heart rate variability (HRV) and baroreflex sensitivity (BRS) and subsequent major arrhythmic events (MAE), defined as sustained VT, VF or sudden death, in 263 patients with idiopathic dilated cardiomyopathy (IDC) in sinus rhythm. The predefined measure of HRV was the standard deviation of all normal-to-normal RR intervals (SDNN) on baseline 24-hour ambulatory ECG. BRS was determined by the phenylephrine method. Over 52 ± 21 months of follow-up, MAE occurred in 38 patients (14%). SDNN at baseline 24-hour ambulatory ECG (106 ± 46 vs 109 ± 45, ns) and BRS (7.9 ± 5.5 vs 7.7 ± 5.3 ms/mmHg, ns) were both similar in patients with versus without MAE during follow-up. In contrast, left ventricular ejection fraction was significantly lower in patients with versus without MAE (24%± 7% vs 31%± 10%, P < 0.019. Conclusions: Neither HRV nor BRS predicted MAE in patients with IDC.     

Follow-up of Gambian children recruited to a pilot safety and immunogenicity study of the malaria vaccine SPf66

A pilot safety and immunogenicity trial of the malaria vaccine SPf66 was undertaken in The Gambia in 1993. One hundred and fifty infants aged 6–11 months were immunized with either 0.5 mg or 1.0 mg of SPf66 produced either in Colombia or in the USA or with a control vaccine. Children who received SPf66 experienced more clinical attacks of malaria than did children in the control group during the first period of surveillance and the difference in incidence between children who had received high dose Colombian vaccine and the control children was statistically significant at the 5% level. During the 1995 malaria transmission season, 127 children from the original cohort of 150 were observed. During 18 weeks of intensive surveillance, the incidence of clinical malaria was again higher among children who had received SPf66 than among children who had received inactivated polio vaccine (6.23 vs 4.89 clinical attacks per 1000 days at risk), the effect being most marked among children who were in the high dose groups, but differences between groups were now no longer statistically significant .     

Autonomic indicators of information processing related to conditioning

The aim of the present study was to quantitatively investigate the role of information processing in conditioning using stimuli with varying amounts of information content. A letter reproduction task varying in complexity served as the unconditioned stimulus. In the first experiment, we tested the indicator function of electrodermal and car-diovascular variables. The amount of information processing resources required emerged most clearly in electrodermal reactions (EDRs), showing an increase with increasing stimulus information content. A second experiment was performed using the same design to confirm the role of processing resources allocation during conditioning by means of an independent indicator. A reaction time task was introduced as a measure of information processing resources utilized. The results paralled the dependence of EDRs on stimulus information content, as was found in the first experiment.