Risk of thromboembolism in chronic atrial flutter

Anticoagulant therapy is not conventionally used in the treatment of patients with atrial flutter. This recommendation has been based on sparse clinical experience, and recent preliminary reports suggest a significant risk of thromboembolism for these patients. A retrospective study was undertaken to assess the frequency of thromboembolic events as well as potential risk factors for these events in a cohort of patients with atrial flutter referred for radiofrequency ablation treatment. Eighty-six consecutive patients with a primary diagnosis of atrial flutter were evaluated. A history of embolic events was noted in 12 of 86 patients (14%) with atrial flutter, with an annual risk of approximately 3%. There were no differences in the prevalence of coronary artery disease, cardiomyopathy, valvular disease, or atrial fibrillation between the 2 groups of patients having an embolic event and those of patients without embolic events. Left ventricular function and left atrial size were also similar between the 2 groups. The only significant risk factor was hypertension (p < 0.05). However, in a regression model with other clinical variables (i.e., age, gender, left atrial size, presence or absence of any cardiac disease, length of time in flutter, left ventricular function, type of flutter, flutter cycle length, type of secondary arrhythmias) no significant predictors were found. Patients with transient ischemic attacks or pulmonary emboli were then excluded from the analysis in order to compare the thromboembolic risk in the present study to that reported in major atrial fibrillation trials. The overall risk becomes 7% (6 of 86), which over a mean follow-up period of 4.5 years yields an annual risk of approximately 1.6%. Although this risk is only 1/3 of that for patients with atrial fibrillation, this risk is higher than previously recognized for patients with chronic atrial flutter. Anticoagulant therapy should be seriously considered for these patients.

Slow AV nodal pathway ablation utilizing a unique temperature controlled radiofrequency energy system

Thirty-nine consecutive patients with symptomatic AV nodal reentrant tachycardia (AVNRT) underwent temperature guided slow AV nodal pathway ablation (group 1). Forty-three consecutive patients undergoing nontemperature guided slow AV nodal pathway ablation late in our experience compose the control population (group 2). Slow pathway ablation was achieved in all patients of both groups. The mean fluoroscopy and ablation times for group 1 were significantly shorter than for group 2 (26.1 +/- 14.9 vs 33.9 +/- 18.9 min, P < 0.05; 19.9 +/- 12.1 vs 30.9 +/- 23.3 min, P < or = 0.02). There were no episodes of coagulum formation in group 1, while there were 15 episodes (7.1% of energy applications) in group 2 (P = 0.0006) despite a significantly higher applied power in group 1 (53.4 +/- 25.1 vs 35.6 +/- 9.5W, P = 0.0001). Successful energy applications were associated with significantly higher temperatures than unsuccessful applications in group 1 (55.6 degrees +/- 5.8 degrees C vs. 52.9 degrees +/- 6.8 degrees C, P < or = 0.03). The minimum temperature required for successful ablation was 48 degrees C for two patients (5%) and was > or = 50 degrees C for the remainder of patients (37/39 [95%]). The catheter ablation system used in this study was safe, effective, and prevented coagulum formation while delivering relatively high power. In addition, shorter ablation times and radiation exposure were seen with this system. Although successful energy applications and the production of junctional rhythm were associated with higher achieved temperatures, temperature alone did not predict either endpoint. Future prospective, randomized trials are needed to confirm these findings and further evaluate the value of temperature monitoring.

Mechanism of initiation of atrial flutter in humans: site of unidirectional block and direction of rotation

OBJECTIVES

Using a standardized induction protocol, we investigated the mechanism of initiation of atrial flutter, before ablation, to determine the site of initiating unidirectional block and to test the hypothesis that the direction of rotation of atrial flutter depends on the pacing site from which it initiates.

BACKGROUND

The high recurrence rate of atrial flutter after presumed successful ablation may be due to difficulty in reinduction after termination. In addition, induction of clockwise flutter is currently of unknown clinical importance.

METHODS

Ten patients with documented typical flutter were studied before ablation. A standard protocol consisting of single and double extrastimuli followed by burst pacing was performed from four sites in the right atrium (high and low trabeculated and smooth right atrium) to assess efficacy at inducing atrial flutter. A 20-pole halo catheter placed around the tricuspid annulus and a decapole catheter placed in the coronary sinus were used for mapping during initiation to determine type of flutter induced and the site of unidirectional block during initiation.

RESULTS

Atrial flutter was induced in 52 (6.2%) of 838 attempted inductions. Of these, 33 were counterclockwise and 20 were clockwise. Of the 20 inductions resulting in clockwise flutter, 18 were from the trabeculated right atrium, whereas all the counterclockwise inductions were from the smooth right atrium. In all but the two inductions, the site of unidirectional block was identified between the os of the coronary sinus and the low lateral right atrium for both counterclockwise and clockwise flutter, in the same isthmus at which ablation is targeted.

CONCLUSIONS

Even in patients with clinical counterclockwise flutter, clockwise flutter is frequently induced before ablation and is dependent on the site of induction: Pacing from the smooth right atrium induces counterclockwise flutter, whereas pacing from the trabeculated right atrium induces clockwise flutter. The site of the unidirectional block during the initiation of either form of flutter is in the low right atrium isthmus.

Electrocardiographic and electrophysiologic characterization of atypical atrial flutter in man: use of activation and entrainment mapping and implications for catheter ablation

INTRODUCTION

Although the circuit in typical counterclockwise atrial flutter has been clearly delineated, the mechanisms of "atypical atrial flutters" have been less well characterized. The purpose of this study was to investigate the ECG and electrophysiologic (EP) characteristics of atypical atrial flutter.

METHODS AND RESULTS

Thirty-three patients with at least one form of atypical atrial flutter underwent EP evaluation with multipolar atrial activation and entrainment mapping. Nineteen patients with clockwise flutter had: (1) stereotypic ECG morphology; (2) same cycle length as counterclockwise flutter; (3) clockwise activation around the tricuspid annulus; (4) recording of discrete split potentials along the length of the crista terminalis, suggesting the presence of conduction block; (5) concealed entrainment from the low right atrial isthmus; (6) successful ablation in this isthmus. Twenty patients with atypical flutter not consistent with a clockwise mechanism ("true atypical flutter") showed: (1) heterogeneous ECG morphology; (2) cycle length shorter than that of clockwise flutter; (3) frequent transitions from and to atrial fibrillation; (4) could be entrained in only six patients and, when accomplished, demonstrated surface fusion when entraining from the low right atrial isthmus.

CONCLUSIONS

Atypical flutter falls into two broad categories. Clockwise flutter uses the same circuit with the same endocardial barriers as its counterclockwise counterpart and is best considered a form of typical flutter. True atypical flutter induced in the EP laboratory is a heterogeneous group of arrhythmias that are transitional to atrial fibrillation. Although it may superficially resemble clockwise or counterclockwise flutter based on the 12-lead ECG alone, the distinction can be readily made from a combined evaluation including activation and entrainment mapping.

Lipidic vector systems for gene transfer

Clinical application of gene therapy depends on the development of suitable gene transfer vehicles (vectors). Although generally not as efficient as viral vectors, nonviral systems such as lipidic vectors have the potential advantages of being less toxic, nonrestrictive in cargo DNA size, potentially targetable, and easy to produce in relatively large amounts. More important, lipidic vectors generally lack immunogenicity, allowing repeated in vivo transfection using the same vector. In this paper, we will attempt to summarize some of the recent advances in lipidic gene delivery vectors. Three types of lipidic gene transfer vectors are described: 1) DNA/cationic liposome complexes, 2) DNA encapsulated in neutral or anionic liposomes, and 3) liposome-entrapped, polycation-condensed DNA (LPDI and LPDII). We review the various factors affecting vector structure and gene delivery efficiency, and we discuss the possible mechanisms of gene transfer and their implications in vector design.

Biophysical characteristics of radiofrequency lesion formation in vivo: dynamics of catheter tip-tissue contact evaluated by intracardiac echocardiography

During clinical radiofrequency catheter ablation a wide range of delivered power may be necessary to achieve success despite an apparently stable catheter position on fluoroscopy. The purpose of this study was to use intracardiac echocardiography to characterize the relation between catheter tip-tissue contact and the efficiency of heating during applications of radiofrequency energy in vivo and to determine whether intracardiac echocardiography could be used prospectively to improve tissue contact. A closed-loop temperature feedback control system was used during radio-frequency applications at five anatomic regions in the right atrium of 15 anesthetized dogs to ensure achievement of a predetermined temperature (70 degrees C) at the catheter tip thermistor by automatic adjustment of delivered power (maximum 100 W). The efficiency-of-heating index was defined as the ratio of steady-state temperature (degrees Celsius) to power (watts). Two-dimensional intracardiac echocardiography was used to evaluate movement of the catheter tip relative to the endocardium. Perpendicular contact was scored as good, average, or poor and lateral catheter sliding as < 2, 2 to 5, or > 5 mm. Two groups of animals were included: group 1, in which tissue contact was guided by fluoroscopic and electrographic criteria for stability of contact, with intracardiac echocardiography used simply to observe the application; and group 2, in which tissue contact was guided by intracardiac echocardiography. Of 66 applications, 18 (27.3%) had poor perpendicular contact on echocardiography, and 12 (18.2%) demonstrated lateral sliding of > 5 mm even though they had been considered to have good tissue contact by fluoroscopic and electrographic criteria. Perpendicular catheter contact and anatomic location were shown to be independently related to the efficiency-of-heating index. Applications with good perpendicular contact had a significantly higher efficiency-of-heating index and a significantly greater lesion size than those with average or poor contact. The percentage of applications having good perpendicular tissue contact and the lesion size were significantly greater when tissue contact was guided by intracardiac echocardiography compared with fluoroscopic and electrographic guidance. This study demonstrates that variations in catheter tip-tissue contact account for differences in the efficiency of tissue heating, independently of the anatomic site of the application. Poor tissue contact was observed by intracardiac echocardiography and confirmed by indexes of tissue heating in approximately one third of radiofrequency applications despite a fluoroscopic appearance and electrographic morphologic appearance suggestive of good tissue contact. There was a significant correlation between echocardiographic evaluation of tissue contact, parameters of tissue heating (efficiency-of-heating index), and lesion size. In addition, intracardiac echocardiography could be used prospectively to improve the percentage of good contact applications and increase the lesion size.

Induction of cyclin D1 by simian virus 40 small tumor antigen

Cell-cycle progression is mediated by a co-ordinated interaction between cyclin-dependent kinases and their target proteins including the pRB and E2F/DP-1 complexes. Immunoneutralization and antisense experiments have established that the abundance of cyclin D1, a regulatory subunit of the cyclin-dependent kinases, may be rate-limiting for G1 phase progression of the cell cycle. Simian virus 40 (SV40) small tumor (t) antigen is capable of promoting G1 phase progression and augments substantially the efficiency of SV40 transformation through several distinct domains. In these studies, small t antigen stimulated cyclin D1 promoter activity 7-fold, primarily through an AP-1 binding site at -954 with additional contributions from a CRE site at -57. The cyclin D1 AP-1 and CRE sites were sufficient for activation by small t antigen when linked to an heterologous promoter. Point mutations of small t antigen between residues 97-103 that reduced PP2A binding were partially defective in the induction of the cyclin D1 promoter. These mutations also reduced activation of MEK1 and two distinct members of the mitogen-activated protein kinase family, the ERKs (extracellular signal regulated kinases) and the SAPKs (stress-activated protein kinases), in transfected cells. Dominant negative mutants of either MEK1, ERK or SEK1, reduced small t-dependent induction of the cyclin D1 promoter. SV40 small t induction of the cyclin D1 promoter involves both the ERK and SAPK pathways that together may contribute to the proliferative and transformation enhancing activity of small t antigen.

Long-term results of electrophysiologically guided sotalol therapy for life-threatening ventricular arrhythmias

The efficacy and safety of sotalol therapy for ventricular arrhythmias was evaluated in 133 patients with drug-refractory ventricular arrhythmias. All patients had baseline electrophysiologic studies before and after oral sotalol therapy. Sixty-six patients were discharged home, treated with sotalol (52 patients without inducible ventricular tachycardia or fibrillation and 14 patients with hemodynamically stable inducible ventricular tachycardia). The mean follow-up period was 41 +/- 27 months for the 14 patients with hemodynamically stable ventricular tachycardia. Sotalol was effective in 8 of these 14 patients. Recurrent nonlethal ventricular tachycardia occurred in 3 patients; 2 patients had sudden death; and 1 patient had adverse side effects. The 52 patients without inducible ventricular tachycardia were followed up for a mean period of 36 +/- 30 months. Thirty-five of 52 patients were successfully treated. Two patients had recurrent ventricular tachycardia; both of these episodes of ventricular tachycardia occurred within the first year. Four patients had sudden cardiac death; three of these deaths occurred within the first month, and the last episode of sudden death occurred after 8 years of sotalol therapy. The actuarial incidence of sotalol efficacy was 76% at 1 year, 72% at 2 years, 64% at 4 years, and 52% at 5 years. Approximately 46% of patients receiving long-term sotalol treatment reported side effects. Side effects severe enough to warrant withdrawal of sotalol occurred in 7 (11%) patients. The results of our study suggest that sotalol is effective for selected patients with drug refractory ventricular arrhythmias. Although the incidence of side effects are high, patients appear to tolerate long-term sotalol therapy well.

Effect of patient characteristics on the yield of prolonged baseline head-up tilt testing and the additional yield of drug provocation

OBJECTIVE

To define the value of tilt testing and hte additional yield of drug provocation over prolonged baseline tilt in different patient subgroups. (Many different protocols are in use for head-up tilt testing in heterogeneous groups of patients. Not all patients in reported series have recurrent syncope, and there is often a wide age range and a variable incidence of structural heart disease.)

DESIGN

In a prospective study, baseline 60 degrees head-up tilt testing was undertaken for 45 minutes, initially without drug provocation. Patients who remained symptom free were given intravenous isoprenaline (isoproterenol) and further tilting or edrophonium (10 mg bolus) during tilt, in an order determined randomly before the start of the test. If they were symptom free after the first drug, they were given the other drug. A positive test was recorded when syncope or pre-syncope occurred with a rapid fall (> 30%) in blood pressure. The impact on tilt result of the type of symptoms, presence of significant structural heart disease (SHD), presence of a non-cardiovascular cause of sudden diminished consciousness (SDC), and age was then assessed by subgroup analysis.

PATIENTS

145 patients (73 female, mean age 51 (25), range 8-94) with one or more episodes of pre-syncope or syncope.

RESULTS

39 patients (27%, 21 female, age 49 (25) years) had positive tests and 106 (73%, 52 female, age 52 (25) years) negative tests. 27 (69%) had a positive test during baseline tilt at 20.5 (10.8) minutes, five (13%) with isoprenaline infusion, and seven (18%) with edrophonium bolus. Patients with recurrent syncope rather than single syncopal episodes or single or recurrent pre-syncope were more likely to have a positive tilt test (41% v 17%, P < 0.005) and patients with SHD or SDC (69/14 patients) were much less likely than patients without (16% v 42%, P < 0.0001). The yield of positive tests was similar if patients were below (26%) or above (27%) the mean age (50 years). When multiple factors were combined, the yield ranged from 0% for 21 patients under 50 years with SHD or SDC and without recurrent syncope to 73% in 11 patients over 50 years with recurrent syncope and no SHD or SDC. The additional yield in subgroups over 45 minute baseline tilt (70 (11)%) of isoprenaline (13 (10)%) was similar to that of edrophonium (17 (8)%, P = NS), but six (50% of those who were drug positive) patients required a second drug to produce a positive result (two with isoprenaline second, four with edrophonium second).

CONCLUSIONS

Head-up tilt testing in a heterogeneous population has a low yield. Simple clinical characteristics define the type of patient who is likely to have a positive tilt test and the patient who is not and in whom other investigations should receive priority. The great majority of positive tests will occur during prolonged baseline testing if this is used. Isoprenaline and edrophonium produced similar additional yields of positive tests.

A potential role for cell cycle control proteins in regulation of the cyclic adenosine 5'-monophosphate-responsive glycoprotein hormone alpha subunit gene

The production of chorionic gonadotropin is coupled to the differentiation of the placenta. Expression of the alpha subunit of chorionic gonadotropin [glycoprotein hormone alpha (GPH-alpha)] is also known to be stimulated by treatment of placental cells with either cAMP or DNA synthesis inhibitors. Given these features, we used adenovirus E1A as a molecular probe to investigate a potential role for cell cycle regulatory proteins and kinases in the regulation of GPH-alpha expression. The E1A protein contains well-characterized domains that interact with a variety of cell cycle regulatory proteins. The E1A conserved regions 1 and 2 bind proteins that regulate cell cycle progression, including pRB, p107, and p130. The amino-terminal region of E1A binds several high molecular weight proteins and inhibits the transcriptional coactivator function of p300 and the homologous cAMP response element (CRE)-binding protein. We found that coexpression of E1A13S activated the GPH-alpha promoter, whereas E1A12S caused marked repression. Deletion mutants and point mutations revealed that repression by E1A12S required the CRE of the GPH-alpha promoter. Several distinct domains in E1A12S were necessary for maximal repression. A mutation of the E1A amino terminus (RG2), which inhibits binding of p300 and related high molecular weight proteins, reduced 12S repression by 40%. Mutation of the pocket protein-binding domains reduced repression by 20%, and mutations of both domains reduced repression by 80%. Overexpression of p300 or the pocket proteins (pRB, p130, and p107) induced GPH-alpha promoter activity 2-4-fold. Because the E1A amino terminus and pocket protein-binding domains together induce p34cdc2 kinase activity, the effect of p34cdc2 kinase expression on GPH-alpha activity was also assessed. Coexpression of p34cdc2 kinase or the activating p34cdc2 kinase mutant (T14AY15F) inhibited GPH-alpha promoter activity and acted through the CRE. We conclude that the GPH-alpha gene CRE is subject to regulation by cell cycle regulatory kinases and proteins.

Angiotensin II activation of cyclin D1-dependent kinase activity

Angiotensin II (AII) binds to specific G protein-coupled receptors and is mitogenic in adrenal, liver epithelial, and vascular smooth muscle cells. Since the cyclin D1 gene encodes the regulatory subunit of the cyclin D1-dependent kinase (CD1K) required for phosphorylation of the retinoblastoma protein (pRB), an essential and rate-limiting step in G1 phase progression of the cell cycle, we examined the effect of AII on cyclin D1 expression and CD1K activity in the human adrenal cell line H295R. AII (10(-6) M) stimulated G1 phase progression within 12 h, with a maximal effect after 72 h. This action was antedated by the induction of cyclin D1 mRNA (3-fold), cyclin D1 nuclear protein abundance (4-fold), and CD1K activity (4-fold). AII induced cyclin D1 promoter activity 4-fold, via the AT1 receptor through an enhancer sequence at -954 base pairs. c-Fos and c-Jun bound the cyclin D1 -954 enhancer sequence, and the abundance of c-Fos within this complex was increased by AII treatment. AII induced extracellular signal-regulated kinase (ERK) activity 7-fold, and dominant-negative mutants of either p21(ras) or ERK reduced AII-stimulated cyclin D1 promoter activity. These findings suggest that AII may stimulate mitogenesis by increasing CD1K activity through a p21(ras)/ERK/activator protein 1 pathway.

Stimulation of the P-450 side chain cleavage enzyme (CYP11A1) promoter through ras- and Ets-2-signaling pathways

Expression of the ovine P-450 side-chain cleavage enzyme gene (CYP11A1) is stimulated by epidermal growth factor (EGF) through a pathway that involves c-Jun in JEG-3 placental cells. Growth factor signaling involves ras-dependent and ras-independent signaling pathways, which in turn regulate gene transcription through related but distinct mitogen-activated protein kinase pathways (MAPKs) including the extracellular signal-regulated kinases (ERKs) and the stress-activated protein kinases (SAPKs). We investigated the intracellular signaling pathways governing EGF induction of the CYP11A1 promoter. EGF stimulation of the CYP11A1 promoter (4-fold) was reduced 60% by a dominant negative mutant of ras (N17), and 30-40% by antisense ras. EGF induced both ERK and SAPK activity in JEG-3 cells. EGF-induced CYP11A1 promoter activity was reduced 60% by the MEK1 inhibitor PD098059 and 50% by a dominant negative mutant of the ERK-specific regulator MEK1. In contrast, dominant negative mutants of the SAPK-specific activator, SEK1, induced a further increase in EGF-induced CYP11A1 promoter activity. Constitutively active mutants of ras (V12 or L61) increased CYP11A1 promoter activity 6- to 8-fold. Deletion of the EGF response element (EGF-RE) between -92 and -77 bp reduced ras induction by 60%; however, a residual 3-fold induction remained through the proximal -77 bp. Mutation of the EGF-RE AP-1-like sequence in the context of the native promoter reduced CYP11A1 promoter activation by ras 60%. The EGF-RE sequence was sufficient for 6-fold activation by ras in the context of an heterologous thymidine kinase promoter. Candidate transcription factor targets (c-Jun, c-Ets-2) for the ras-signaling cascade were examined for their effects on CYP11A1 promoter activity. Overexpression of c-Jun induced the CYP11A1 promoter through the EGF-RE; however, c-Ets-2 activation of the CYP11A1 promoter (12-fold) required the proximal ras-responsive promoter sequences that are distinct from the EGF/MEK/c-Jun-responsive element. Induction of the CYP11A1 promoter by EGF involves a ras/MEK1/AP-1-dependent pathway that is distinct from induction by ras/c-Ets-2.

Reduced cyclin D1 expression in the cerebella of nutritionally deprived rats correlates with developmental delay and decreased cellular DNA synthesis

Nutritional deprivation in the early postnatal period severely inhibits cerebellar growth and development, which is related in part to reduced levels of growth factors. Cyclin D1 encodes a growth factor-inducible regulatory subunit of a serine/thereonine kinase that is capable of phosphorylating the tumor suppressor pRB, thereby allowing normal progression through the G1 phase of the cell-cycle. Because the abundance of cyclin D1 is rate limiting in this progression, we examined the regulation of cyclin D1 expression in vivo, using a model of nutritional deprivation. Cyclin D1 expression in cerebella of fed control rats was detected in the external granular layer and was associated with cellular proliferation within this layer. Nutritional deprivation of rats reduced cerebellar weight, as well as the thickness of the molecular layer that largely consists of cells migrating from the external granular layer. Refeeding partially restored cerebellar weight, molecular layer thickness and increased external granular layer cyclin D1 immunostaining. Since nutritional deprivation is accompanied by lower levels of circulating insulin-like growth factor-I (IGF-I), we determined whether IGF-I directly stimulated the cyclin D1 promoter. The human cyclin D1 promoter linked to the luciferase reporter gene was stably integrated into PC12 cells. IGF-I stimulated cyclin D1 promoter activity 4- to 6-fold at 6 hours (h). These findings are consistent with the notion that nutritional deprivation may affect proliferative growth by altering expression of cyclin D1 in the germinal cell layer and that regulation of cyclin D1 expression by growth factors may contribute to normal neonatal cerebellar development. The reduction in cyclin D1 expression as cells differentiate in the cerebellum is consistent with a potential role for cyclin D1 in this process.

Personal defense sprays: effects and management of exposure

BACKGROUND

Most personal defense sprays contain o-chlorobenzylidene malononitrile (CS), w-chloroacetophenone (CN), oleoresin capsicum (OC), or a combination of these ingredients as the active agent. They are designed to incapacitate by causing acute ocular irritation, lacrimation, conjunctivitis, blepharospasm, and mild to moderate respiratory distress.

METHODS

To assess the ocular effects of sprays containing OC as the active agent. Snellen visual acuities and anterior segment appearances of 22 police officers were determined before and after spray exposure. To assess the effects of OC spray contamination on soft contact lenses, four brands of lenses were sprayed and cleaned twice with an alcohol-based cleaner. Gas chromatography was used to search for residual OC in the lenses.

RESULTS

All officers experienced intense blepharospasm, lacrimation, conjunctivitis, and incapacitation as the result of spray exposure. Acute effects lasted about 5 to 10 min, with relatively complete recovery occurring in about 30 to 60 min. All had significant conjunctivitis, and some had water-drop-shaped corneal defects that stained with fluorescein. These defects resolved within 24 hours without treatment. OC residue was found to be present in the soft lenses that had been sprayed and cleaned twice.

CONCLUSIONS

Optometrists can manage uncomplicated spray exposure patients by directing at-home irrigation with water, and following up with an in-office examination. Soft lenses contaminated by OC spray should be discarded.

Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical atrial flutter

BACKGROUND

The importance of anatomic barriers in the atrial flutter reentry circuit has been well demonstrated in canine models. It has been shown previously that the crista terminalis and its continuation as the eustachian ridge form a posterior barrier. In this study we tested the hypothesis that the tricuspid annulus forms the continuous anterior barrier to the flutter circuit.

METHODS AND RESULTS

Thirteen patients with typical atrial flutter were studied. A 20-pole halo catheter was situated around the tricuspid annulus. A mapping catheter was used for activation and entrainment mapping from seven sequential sites around the tricuspid annulus and from three additional sites including the tip of the right atrial appendage, at the fossa ovalis, and in the distal coronary sinus. Sites were considered to be within the circuit when the postpacing interval minus the flutter cycle length and the stimulus time minus the activation time were < or = 10 ms; sites were considered to be outside the circuit when these intervals were > 10 ms. All seven annular sites were within the circuit; activation occurred sequentially around the annulus and accounted for 100% of the flutter cycle length. The fossa ovalis, the distal coronary sinus, and the right atrial appendage were outside the circuit.

CONCLUSIONS

Closely spaced sites around the tricuspid annulus are activated sequentially, and are all within the flutter circuit according to entrainment criteria. This demonstrates that the tricuspid annulus constitutes a continuous anterior barrier constraining the reentrant wave front of human counterclockwise atrial flutter.

Measurement of endosome pH following folate receptor-mediated endocytosis

Free folic acid is believed to enter some cells by folate receptor-mediated endocytosis at membrane invaginations termed caveolae. Folate conjugated macromolecules also enter cells by folate receptor-mediated endocytosis, but their site of entry has never been conclusively identified. In this paper, we show that internalization of folate-macromolecule conjugates by receptor-bearing KB cells can be blocked by agents that specifically inhibit caveolae assembly or internalization such as nystatin and phorbol-12-myristate acetate (PMA). To characterize the intracellular conditions to which the macromolecule-folate conjugates are subsequently exposed, we have measured the pH of the major compartments of the folate endocytosis pathway. pH values of individual endosomal compartments in KB cells were determined by dual-excitation laser-scanning confocal microscopy, where the fluorescence ratio of folate-DM-NERF-dextran (pH-sensitive) and Texas Red-dextran (pH-insensitive) was used to calculate pH. These studies revealed that the pH of folate conjugate-containing endosomes commonly varies between 4.7 and 5.8, with the pH in some endosomes as low as 4.3. The most frequent pH value in these compartments was approximately 5.0.

Tumor-selective radiopharmaceutical targeting via receptor-mediated endocytosis of gallium-67-deferoxamine-folate

The receptor-mediated endocytosis uptake pathway for the vitamin folate was investigated as a target for tumor-selective radiopharmaceutical delivery. The molecular target for this delivery mechanism is a membrane-associated folate binding protein (FBP) that is overexpressed by a variety of malignant cell lines.

METHODS

The ability of a 67Ga-labeled deferoxamine-folate conjugate (67Ga-DF-folate) to target tumor cells in vivo was examined using an athymic mouse tumor model. Subcutaneous inoculation of approximately 4 X 10(6) folate-receptor-positive KB (human nasopharyngeal carcinoma) cells into athymic mice yielded approximately 0.20 g tumors in 15 days, at which time either 67Ga-DF-folate, 67Ga-deferoxamine (67Ga-DF) or 67Ga-citrate was administered by intravenous injection.

RESULTS

The 67Ga-DF-folate conjugate showed marked tumor-specific deposition in vivo, with 1.0 +/- 0.3% of the injected dose (%ID) in tumor at 4 hr postinjection (equating to 5.2 +/- 1.5 %ID/g tumor; n = 3 mice). Corresponding tumor-to-background ratios at 4 hr postinjection were: tumor/blood = 409 +/- 195; tumor/muscle = 124 +/- 47; tumor/liver = 11 +/- 3; and tumor/kidney = 2.6+/-0.9. Tumor uptake of 67Ga-DF-folate conjugate was effectively blocked by co-injection of 2.4+/-1.0 mg free folate. In control experiments, 67Ga-citrate exhibited tumor uptake of 2.2 +/- 0.4% of the injected dose (10.9 +/- 0.2 %ID/g tumor), but very poor target-to-background contrast (tumor/blood = 0.84 +/- 0.19; tumor/muscle = 5.4 +/- 0.7; tumor/liver = 2.3 +/- 0.2; and tumor/kidney = 2.4 +/- 0.3). Unconjugated 67Ga-deferoxamine showed no tumor affinity.

CONCLUSION

Receptor-mediated endocytosis of radiolabeled folate-conjugates may offer a suitable mechanism for selectively delivering radiopharmaceuticals to tumors for diagnostic imaging and/or radiation therapy.

Results of radiofrequency catheter ablation for atrial flutter

RF catheter ablation for symptomatic typical atrial flutter is associated with a high procedural success rate, but a second RF procedure may be required in up to one third of subjects, particularly those with right atrial enlargement. In those subjects with both established AF and flutter, RF ablation for atrial flutter may decrease the recurrence rate of AF. However, patients remain at risk for the development of newly documented AF, most likely secondary to the high incidence of underlying structural heart disease.

Importance of calcium for the vulnerability to ventricular fibrillation detected by premature ventricular stimulation: single pulse versus sequential pulse methods

Vulnerability to ventricular fibrillation (VF) is frequently evaluated by VF threshold, a variable which may not be free of confounding factors and which may not be sensitive to all factors contributing to vulnerability. Therefore, we tested whether VF threshold determination affects intracellular free Ca2+ ([Ca2+]i) and whether VF thresholds are sensitive to changes in [Ca2+]i. For this purpose, we analysed [Ca2+]i by surface fluorometry and indo-1 in intact perfused rat hearts undergoing VF threshold determination by a single pulse method and tested whether such thresholds are lowered by increased [Ca2+]i. Additionally, we sought to determine the importance of Ca2+ for the vulnerability to VF under nonischemic conditions. For this purpose, we measured VF thresholds by a new pulse number method which scanned the vulnerable period by an increasing number of sequential pulses at increasing prematurity but constant intensity. We found that VF threshold determination by a single pulse method led to a rise in systolic [Ca2+]i. However, this rise does not perturb VF threshold interpretation because such thresholds were insensitive to changes in [Ca2+]i. Nevertheless, [Ca2+]i is of importance for the vulnerability to VF under nonischemic conditions because the number of VF-free tolerated premature pulses was dependent on [Ca2+]i. This relationship may only be detectable if evaluated by sequential pulse methods. These findings suggest that the method of VF threshold determination may be crucial for the result of studies testing Ca2+ antagonists or situations of altered [Ca2+]i and could explain controversial results of VF threshold studies testing Ca2+ antagonists by varying methods.

Mechanism of action of the non-steroidal anti-inflammatory drug flufenamate on [Ca2+]i and Ca(2+)-activated currents in neurons

We have shown previously that the non-steroidal anti-inflammatory drug flufenamate (FFA) causes a maintained increase in [Ca2+]i and transient increases in a Ca(2+)-activated nonselective cation current (ICAN) and a Ca(2+)-activated slow, outward Cl- current (lo-slow) in molluscan neurons [Shaw T., Lee R.J., Partridge L.D. Action of diphenylamine carboxylate derivatives, a family of non-steroidal anti-inflammatory drugs, on [Ca2+]i and Ca(2+)-activated channels in neurons. Neurosci Lett 1995; 190:121-124]. Here we demonstrate that pretreatment of neurons with 10 microM thapsigargin eliminates the FFA-induced increase in [Ca2+]i and substantially reduces both ICAN and Io-slow supporting the hypothesis that the FFA-induced increase in [Ca2+]i results primarily from Ca2+ release from a thapsigargin-sensitive intracellular store. The [Ca2+]i response appears to be sustained, not by influx of extracellular Ca2+, but by inhibitory effects of FFA on Ca2+ removal from the cytosol. Inhibition of Ca2+ efflux may be an important component of the FFA-induced activation of both ICAN and Io-slow, as Ca2+ release by thapsigargin alone is not sufficient to activate either current. Our data also demonstrate that the effects of FFA on [Ca2+]i, ICAN and Io-slow are reversible and suggest that protein phosphorylation as well as an increase in [Ca2+]i are involved in the FFA-induced activation of Io-slow. Effects on neuronal Ca2+ handling as well as activation of ICAN or Io-slow may partially explain the analgesic effects of FFA.

Folate-targeted, anionic liposome-entrapped polylysine-condensed DNA for tumor cell-specific gene transfer

We have developed a lipidic gene transfer vector, LPDII, where DNA was first complexed to polylysine at a ratio of 1:0.75 (w/w) and then entrapped into folate-targeted pH-sensitive anionic liposomes composed of dioleoyl phosphatidylethanolamine (DOPE)/cholesteryl hemisuccinate/folate-polyethlene glycol-DOPE (6:4:0.01 mol/mol) via charge interaction. LPDII transfection of KB cells, a cell line overexpressing the tumor marker folate receptor, was affected by both the lipid to DNA ratio and the lipid composition. At low lipid to DNA ratios (e.g. 4 and 6), LPDII particles were positively charged; transfection and cellular uptake levels were independent of the folate receptor and did not require a pH-sensitive lipid composition. Meanwhile, transfection and uptake of negatively charged LPDII particles, i.e. those with high lipid to DNA ratios (e.g. 10 and 12), were folate receptor-dependent and required a pH-sensitive lipid composition. The transfection activity of LPDII was lost when the inverted cone-shaped DOPE was replaced by dioleoyl phosphatidylcholine. LPDII particles with lipid to DNA ratios of 4, 6, 10, and 12 were approximately 20-30 times more active than DNA.3-beta-[N-(N',N'-dimethylethane)carbamoyl]cholesterol cationic liposome complexes in KB cells and were much less cytotoxic. On the sucrose gradient, LPDII particles had a migration rate in between those of the free DNA and the DNA.polylysine complex. An electron micrograph of LPDII showed a structure of spherical particles with a positively stained core enclosed in a lipidic envelope with a mean diameter of 74 +/- 14 nm. This novel gene transfer vector may potentially be useful in gene therapy for tumor-specific delivery.

Phenylephrine-induced ventricular arrhythmias in dogs with inherited sudden death

INTRODUCTION

Dogs with an inherited predisposition to sudden death display ventricular arrhythmias having certain characteristics, such as pause dependence, that are suggestive of early afterdepolarization-induced triggered activity. We hypothesized that alpha-adrenergic stimulation may facilitate the development of these arrhythmias by inducing a reflex bradycardia and by exerting a direct myocardial effect.

METHODS AND RESULTS

Twenty affected dogs and 7 unaffected dogs were studied. The incidence and severity of ventricular arrhythmias were determined after administration of phenylephrine (0.01 mg/kg IV), with or without pretreatment with propranolol (0.1 to 0.3 mg/kg IV), atropine (0.04 mg/kg IV), or prazosin (0.5 mg/kg IV). Third-degree heart block was induced by AV nodal ablation in 4 affected dogs. Phenylephrine increased ventricular arrhythmias in affected dogs, with or without pretreatment with propranolol, but did not induce ventricular arrhythmias in unaffected dogs. In dogs with intact AV nodal conduction, atropine increased sinus rate, which suppressed baseline and phenylephrine-induced arrhythmias. In dogs with heart block, arrhythmias were increased during baseline and after phenylephrine, with or without pretreatment with atropine. Prazosin and overdrive ventricular pacing suppressed phenylephrine-induced arrhythmias.

CONCLUSION

Phenylephrine increases ventricular arrhythmias in dogs with inherited sudden death via both an induction of reflex bradycardia and a direct myocardial effect. Superimposition of heightened alpha-adrenergic and vagal tone may facilitate the development of sudden death in these animals.

Effect of Ca2+ influx on intracellular free Ca2+ responses in antigen-stimulated RBL-2H3 cells

We undertake a quantitative investigation of changes in intracellular free Ca2+ concentration ([Ca2+]i) in antigen-stimulated rat basophilic leukemia (RBL-2H3) cells, which include contributions of both Ca2+ store release and Ca2+ influx from the medium. Following Keizer and De Young (J. Keizer and G. De Young. Biophys. J. 61: 649-660, 1992), we develop a highly constrained mathematical model for [Ca2+]i oscillations in RBL-2H3 cells, which includes activation of the inositol trisphosphate receptor (IP3R) by inositol 1,4,5-trisphospate, indirect Ca2+ activation of the IP3R via Ca2+ -dependent activity of phospholipase C-gamma, slow inhibition of the IP3R by cytosolic Ca2+, refilling of Ca2+ stores by a Ca2+ -ATPase (SERCA)-type pump, and a simple representation of the dependence of plasma membrane (PM) fluxes on experimental conditions. Using this full (open cell) model, we simulate [Ca2+]i responses for protocols in which antigen concentration and external Ca2+ are manipulated and compare out calculations with experimental data. In protocol A, cells are stimulated in the presence of external Ca2+, in protocols B and C, cells are stimulated in the absence of external Ca2+, with external Ca2+ later reapplied in protocol C. We are able to reproduce quantitatively the important features of all three protocols, including the dose response of protocol B, the [Ca2+]i response to thapsigargin, and lag time results, and we provide qualitative explanations for the responses derived from our calculations. We also develop a simplified (closed cell) version of the model in which PM fluxes are neglected and total free Ca2+ concentration ([Ca2+]T) is a slowly varying parameter. This permits us to explain in a simple graphical fashion how PM fluxes may influence [Ca2+]i responses in RBH-2H3 cells through modulation of [Ca2+]T.

Quality of life and outcomes after radiofrequency His-bundle catheter ablation and permanent pacemaker implantation: impact of treatment in paroxysmal and established atrial fibrillation

One hundred seven patients underwent atrioventricular (AV)-junctional ablation and pacing for atrial fibrillation, and 90 were alive 2.3 +/- 1.2 years later. Quality of life index (1.9 +/- 1.2 to 3.6 +/- 1.1; 3.6 +/- 1.1; p<0.001) and ease of activities of daily living (2 +/- 0.4 to 2.4 +/- 0.3; p<0.001) were significantly improved. Doctor visits (10 +/- 13 to 5.06 +/-7; p<0.03), hospital admissions (2.8 +/- 6.8 vs 0.17 +/- 0.54; p<0.03, and antiarrhythmic drug trials (6.2 +/- 4 to 0.46 +/- 1.5; p<0.001) decreased significantly after treatment. Congestive heart failure episodes decreased from 18 before to 8 afterward. Twenty-eight of 36 patients with dual-chamber pacemakers remained in a dual-chamber mode at follow-up. Radiofrequency AV-junctional catheter ablation and pacing is a highly successful form of treatment for medically refractory atrial fibrillation.