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

In vivo role of heme oxygenase in ischemic coronary vasodilation

The heart constitutively expresses heme oxygenase (HO)-2, which catabolizes heme-containing proteins to produce biliverdin and carbon monoxide (CO). The heart also contains many possible substrates for HO-2 such as heme groups of myoglobin and cytochrome P-450s, which potentially could be metabolized into CO. As a result of observations that CO activates guanylyl cyclase and induces vascular relaxation and that HO appears to confer protection from ischemic injury, we hypothesized that the HO-CO pathway is involved in ischemic vasodilation in the coronary microcirculation. Responses of epicardial coronary arterioles to ischemia (perfusion pressure approximately 40 mmHg; flow velocity decreased by approximately 50%; dL/dt reduced by approximately 60%) were measured using stroboscopic fluorescence microangiography in 34 open-chest anesthetized dogs. Ischemia caused vasodilation of coronary arterioles by 36 +/- 6%. Administration of N(G)-monomethyl-L-arginine (L-NMMA, 3 micromol.kg(-1).min(-1) intracoronary), indomethacin (10 mg/kg iv), and K(+) (60 mM, epicardial suffusion) to prevent the actions of nitric oxide, prostaglandins, and hyperpolarizing factors, respectively, partially inhibited dilation during ischemia (36 +/- 6 vs. 15 +/- 4%; P < 0.05). The residual vasodilation during ischemia after antagonist administration was inhibited by tin mesoporphyrin IX (SnMP, 10 mg/kg iv), which is an inhibitor of HO (15 +/- 4 vs. 7 +/- 2%; P < 0.05 vs. before SnMP). The guanylyl cyclase inhibitor 1H-[1,2,4]oxadiazole[4,3-a]quinoxalin-1-one (10(-5) M, epicardial suffusion) also inhibited vasodilation during ischemia in the presence of L-NMMA with indomethacin and KCl. Moreover, administration of heme-L-arginate, which is a substrate for HO, produced dilation after ischemia but not after control conditions. We conclude that during myocardial ischemia, HO-2 activation can produce cGMP-mediated vasodilation presumably via the production of CO. This vasodilatory pathway appears to play a backup role and is activated only when other mechanisms of vasodilation during ischemia are exhausted.

Entrainment Mapping of Dual-Loop Macroreentry in Common Atrial Flutter:. New Insights into the Atrial Flutter Circuit

INTRODUCTION

The aim of this study was to determine using entrainment mapping whether the reentrant circuit of common type atrial flutter (AFL) is single loop or dual loop.

METHODS AND RESULTS

In 12 consecutive patients with counterclockwise (CCW) AFL, entrainment mapping was performed with evaluation of atrial electrograms from the tricuspid annulus (TA) and the posterior right atrial (RA) area. We hypothesized that a dual-loop reentry could be surmised from "paradoxical delayed capture" of the proximal part of the circuit having a longer interval from the stimulus to the captured beat compared with the distal part of the circuit. In 6 of 12 patients with CCW AFL, during entrainment from the septal side of the posterior blocking line, the interval from the stimulus to the last captured beat was longer at the RA free wall than at the isthmus position. In these six patients with paradoxical delayed capture, flutter cycle length (FCL) was 227 +/- 12 ms and postpacing interval minus FCL was significantly shorter at the posterior blocking line than at the RA free wall (20 +/- 11 ms vs 48 +/- 33 ms, P < 0.05). In two of these patients, early breakthrough occurred at the lateral TA. A posterior block line was confirmed in all six patients in the sinus venosa area by intracardiac echocardiography.

CONCLUSION

Half of the patients with common type AFL had a dual-loop macroreentrant circuit consisting of an anterior loop (circuit around the TA) and a posterior loop (circuit around the inferior vena cava and the posterior blocking line).

Nitric oxide inhibits matrix metalloproteinase-2 expression via the induction of activating transcription factor 3 in endothelial cells

Nitric oxide (NO) has been shown to inhibit migration of cells in which various matrix metalloproteinases (MMPs) are involved. The underlying molecular mechanisms of this inhibition remain elusive. Endothelial cells (ECs) constitutively produce MMP-2. The effect of NO on MMP-2 expression was examined. A dose-dependent inhibition of MMP-2 mRNA level was demonstrated in ECs treated with NO. ECs infected with adenovirus carrying endothelial NO synthase (Ade-NOS) reduced MMP-2 expression. The inhibitory effect of NO on MMP-2 expression was a transcriptional event because NO reduced MMP-2 promoter activity. NO treatment of ECs consequently suppressed MMP-2 secretion revealed by zymographic assay. Functional analysis of MMP-2 promoter (1716 base pairs) indicated that the p53-binding site (-1659 to -1629) was crucial for MMP-2 promoter activity. Activating transcription factor 3 (ATF3) has been reported to act as a transcriptional repressor for p53. ECs treated with NO induced ATF3 expression. Consistently, Ade-NOS-infected ECs showed an increase of ATF3 level. Moreover, ECs either over-expressed ATF3 or, when treated with an ATF3 activator (MG-132; carbobenzoxy-l-leucyl-l-leucyl-l-leucinal), resulted in a repression of MMP-2 promoter activity. Because of MMP-2 suppression by NO, ECs treated with NO inhibited endothelial migration, a phenomenon similar to that of ECs treated with MMP-2 antibody or MG-132. These results indicate that NO-attenuating endothelial migration is mediated at least in part by its reduction of MMP-2 expression via the up-regulation of ATF3. This study provides a molecular basis that supports the notion that NO acts as a negative regulator in endothelial migration.

High-Resolution Mapping Around the Crista Terminalis During Typical Atrial Flutter:. New Insights into Mechanisms

INTRODUCTION

The aim of this study was to delineate activation patterns around the crista terminalis (CT) using high-resolution noncontact mapping.

METHODS AND RESULTS

Twenty-six patients with typical atrial flutter (20 counterclockwise and 6 clockwise) were enrolled in the study. A noncontact mapping system was used to map atrial flutter. There were three activation patterns around the line(s) of block. Type I (n = 6) showed activation around a single complete line of block located in the CT. Type II (n = 17) showed activation around a single incomplete line of block with a conduction gap in the CT. Type III (n = 3) showed activation around double lines of block, one located in the CT and the other located in the sinus venosa region. Simultaneous activation around the tricuspid annulus and through the CT gap could result in double loop reentry (n = 12). After successful ablation of the cavotricuspid isthmus (CTI) in 24 patients, upper loop reentry was still induced in 12 patients with double loop reentry. Subsequent ablation of the CT gap was performed successfully in these 12 patients, and no arrhythmia was inducible thereafter. During the follow-up period of 8.4 +/- 4.1 months, there was no recurrence of atrial flutter in any patient.

CONCLUSION

During typical atrial flutter, the CT might be an incomplete barrier. Simultaneous conduction through the CTI and CT gap could result in double loop reentry. Radiofrequency ablation of the CTI and CT gap was effective in eliminating this arrhythmia.

Pseudomonas aeruginosa-Induced Neutrophilic Lung Inflammation Is Attenuated by Adenovirus-Mediated Transfer of the Heme Oxygenase 1 cDNA in Mice

Heme oxygenase (HO) is well known as the rate-limiting enzyme in the oxidative degradation of heme to biliverdin, carbon monoxide (CO), and iron. Based on recent evidence that overexpression of HO-1 confers protection against various types of cell and tissue injury by regulating apoptotic cell death or cytokine expression profiles, the present study was performed to examine whether the transfer of exogenous HO-1 cDNA in the lung would provide therapeutic effect in a murine model of lung inflammation induced by Pseudomonas aeruginosa. HO-1 overexpression clearly attenuated neutrophil influx and decreased numbers of apoptotic bronchial epithelial cells. Interestingly, the overexpression of Bcl-2, a known antiapoptotic factor, was observed and thought to be the mechanism that inhibits bronchial epithelial cellular apoptosis. It is thus suggested that HO-1 overexpression is useful for treating P. aeruginosa-associated lung inflammation by attenuating neutrophil influx and apoptotic cell death.

Clinical study of the efficacy of a cooled-tip catheter ablation system for common atrial flutter

BACKGROUND

Radiofrequency catheter ablation (RF-CA) of common atrial flutter (AFL) requires the creation of a transmural incision to create a bidirectional conduction block in the cavotricuspid isthmus (ITH).

METHODS AND RESULTS

RF-CA of the ITH using a cooled-tip system was carried out in 40 patients. In the 'conventional' mode (CONV) of the system, RF energy was applied for 2 min with the temperature set at 60 degrees C and power of up to 50 W, and in the failed cases the 'cooled-tip' mode (COOL) was utilized at 45 degrees C with up to 30 W (with a 15 ml/min saline flow rate). Of the 40 patients, 29 crossed over from the CONV to the COOL after a failed ablation of the AFL. As a result, in all 40 patients a complete linear incision could be created with either the COOL or the CONV, resulting in the successful abolition of the AFL. Complete bi-directional block was successfully created in all patients. No significant side effects occurred.

CONCLUSIONS

The COOL was found to be more effective and just as safe as the CONV for AFL ablation, thus facilitating the rapid and complete elimination of the AFL.

Delineation of Intra-Atrial Reentrant Tachycardia Circuits After Mustard Operation for Transposition of the Great Arteries Using Biatrial Electroanatomic Mapping and Entrainment Mapping

INTRODUCTION

Intra-atrial reentrant tachycardia (IART) circuits after Mustard operation remain incompletely understood due to the complex atrial anatomy after extensive surgical procedures. The aim of this study was to delineate IART circuits and their relations to the individual anatomic boundaries in Mustard patients.

METHODS AND RESULTS

Twelve patients (10 men and 2 women; age 29 +/- 4.6 years) with atrial tachyarrhythmias after Mustard operation were included in this study. During 14 IARTs and 2 focal atrial tachycardias, electroanatomic mapping and entrainment mapping were performed in both the systemic venous atrium and the pulmonary venous atrium. The latter was accessed via a retrograde transaortic approach. Thirteen IARTs used a single-loop reentrant circuit, and 1 IART used a dual-loop reentrant circuit. Ten (77%) of 13 single-loop reentrant circuits used the tricuspid annulus (TA) as their central barrier. The remaining 3 IARTs rotated around the inferior vena cava (IVC) (n = 2) or ostium of the right upper pulmonary vein (n = 1). In 6 (60%) of the 10 peritricuspid IARTs, both pulmonary venous atrium and systemic venous atrium components of the mid-portion of the TA-IVC isthmus were demonstrated to be part of the reentry. Overall, 12 (86%) of 14 IARTs in 10 patients were successfully ablated by bridging two barriers that constrained the reentrant circuit. Eight (80%) of 10 peritricuspid circuits were abolished by linear ablation connecting the TA to the IVC (n = 4), incisional scar (n = 2), patch (n = 1), and atriotomy (n = 1).

CONCLUSIONS

In Mustard patients, the TA serves as the most frequent central barrier of IART. Biatrial electroanatomic mapping combined with entrainment mapping facilitates delineation of IART circuits in relation to their anatomic barriers and enables the design of individual ablation strategies to achieve high success.

Atrial noninvasive activation mapping of paced rhythm data

INTRODUCTION

Atrial arrhythmias have emerged as a topic of great interest for clinical electrophysiologists. Noninvasive imaging of electrical function in humans may be useful for computer-aided diagnosis and treatment of cardiac arrhythmias, which can be accomplished by the fusion of data from ECG mapping and magnetic resonance imaging (MRI).

METHODS AND RESULTS

In this study, a bidomain-theory-based surface heart model activation time (AT) imaging approach was applied to paced rhythm data from four patients. Pacing sites were the right superior pulmonary vein, left inferior pulmonary vein, left superior pulmonary vein, coronary sinus, posterior wall of right atrium, and high right atrium. For coronary sinus pacing, the AT pattern of the right atrium was compared with a CARTO map. The root mean square error between CARTO geometry (85 nodal points) and the surface model of the right atrium was 8.6 mm. The correlation coefficient of the noninvasively obtained AT map of the right atrium and the CARTO map was 0.76. All pulmonary vein pacing sites were identified. The reconstructed pacing site of right posterior atrial pacing correlates with the invasively determined pacing catheter position with a localization distance of 4 mm.

CONCLUSION

The individual anatomic model of the atria of each patient enables accurate noninvasive AT imaging within the atria, resulting in a localization error for the pacing sites within 10 mm. Our findings may have implications for imaging of atrial activity in patients with focal arrhythmias or focal triggers.

Time course for resolution of left atrial appendage stunning after catheter ablation of chronic atrial flutter

OBJECTIVES

This study assessed the time course of resolution of left atrial appendage (LAA) stunning after catheter ablation of chronic atrial flutter (AFL).

BACKGROUND

Although the presence of LAA stunning after ablation of chronic AFL calls for anticoagulation in the post-cardioversion period, limited information has been obtained, particularly regarding its duration.

METHODS

Sixteen patients who underwent ablation of chronic, pure AFL were studied, only five of whom had structural heart disease and one of whom had a reduced left ventricular ejection fraction. The LAA emptying velocities (LAAEV) and left atrial spontaneous echo contrast (SEC) were assessed using transesophageal echocardiography before, within 24 h after, one week after, and two weeks after ablation.

RESULTS

Within 24 h after ablation, the LAAEV decreased from 39 +/- 10 cm/s during AFL to 21 +/- 10 cm/s during sinus rhythm (p < 0.01), with eight patients (50%) having documented SEC. After one week, the LAAEV increased (39 +/- 17 cm/s, p < 0.01 vs. within 24 h) and SEC resolved in five of eight patients. After two weeks, the increase in LAAEV persisted (54 +/- 14 cm/s, p < 0.01 vs. 1 week) and SEC was no longer present in any of the patients. The numbers of patients with LAAEV >30 cm/s and absence of SEC were three within 24 h, 11 at one week, and 16 at two weeks after ablation.

CONCLUSIONS

Patients with chronic, pure AFL and preserved left ventricular function who will undergo catheter ablation may not require anticoagulation therapy for more than two weeks after the procedure because of the presence of forceful mechanical LAA contractions and the absence of SEC.

Phased-array intracardiac echocardiography for defining cavotricuspid isthmus anatomy during radiofrequency ablation of typical atrial flutter

INTRODUCTION

Cavotricuspid isthmus (CTI) topography includes ridges, pouches, recesses, and trabeculations. These features may limit the success of radiofrequency ablation (RFA) of typical atrial flutter (AFL). The aim of this study was to assess the utility of phased-array intracardiac echocardiography (ICE) for imaging the CTI and monitoring RFA of AFL.

METHODS AND RESULTS

Fifteen patients (mean age 64 +/- 9 years) underwent ICE assessment (imaging frequency 7.5-10 MHz) before and after RFA of AFL. The ICE catheter was positioned at the inferior vena cava-right atrial junction and the following parameters were measured: (1) CTI length from the tricuspid valve to the eustachian ridge; (2) extent of CTI pouching; and (3) thickness pre/post RFA of the anterior, mid, and posterior CTI. CTI length was 35 +/- 6 mm at end-ventricular systole but shorter (30 +/- 6 mm) and more pouched at end-ventricular diastole (P = 0.02). A pouch or recess was seen in 11 of 15 patients (mean depth 6 +/- 2 mm). The septal CTI was more pouched than the lateral CTI, but the latter had more prominent trabeculations. Trabeculations were seen in 10 of 15 patients, and at these locations the CTI was 4.6 +/- 1 mm thick. Anterior, mid, and posterior CTI thickness pre-RFA was 4.1 +/- 0.8, 3.3 +/- 0.5, and 2.7 +/- 0.9 mm, respectively (P < 0.001 by analysis of variance). ICE guided RFA away from unfavorable CTI features (recesses/thick trabeculations). RFA applications created discrete CTI lesions that coalesced, forming diffuse CTI swelling. Post-RFA thickness was as follows: anterior 4.8 +/- 0.8 mm (P = NS vs pre); mid 3.8 +/- 0.8 mm (P = 0.05 vs pre); and posterior 3.8 +/- 0.8 mm (P = 0.02 vs pre).

CONCLUSION

Phased-array ICE permits novel real-time CTI imaging with excellent endocardial resolution and may facilitate RFA of AFL.

Ibutilide in rapid conversion of atrial flutter in octogenarians

INTRODUCTION

Atrial flutter is a common sustained atrial tachyarrhythmia for which frequency increases with age. Ibutilide is a novel class III antiarrhythmic agent used for the rapid cardioversion of atrial fibrillation or atrial flutter.

AIM

The aim of our study was to assess the use of ibutilide in a selected population of very elderly patients (octogenarians) with recent-onset atrial flutter.

METHOD

Twenty-nine consecutive elderly patients (11 male, 18 female; mean age 83 +/- 3 years; interquartile range of 10) with recent-onset atrial flutter were included in the study; none of them had signs or symptoms of severe heart failure, angina or impaired renal or hepatic function. All patients underwent a 10-minute intravenous infusion of ibutilide (0.87 mg in 10 ml).

RESULTS

The rate of successful arrhythmia termination was 75.9% within a mean time of 31 +/- 20 minutes. No clinical variables were shown to be associated with successful cardioversion, although there was a tendency towards higher efficacy in patients with a shorter duration of arrhythmia. Two female patients (6.9%) developed torsade de pointes, requiring direct current cardioversion under general anaesthesia. Episodes of nonsustained ventricular tachycardia occurred in two other patients.

CONCLUSION

Ibutilide appears to be an effective and well tolerated drug for rapid conversion of recent-onset atrial flutter in octogenarian patients, and may represent a valid approach in the acute management of atrial flutter in this particular set of patients.

Heme oxygenase-1 and the ischemia-reperfusion injury in the rat heart

Carbon monoxide (CO) is a signaling gas produced intracellularly by heme oxygenase (HO) enzymes using heme as a substrate. During heme breakdown, HO-1 and HO-2 release CO, biliverdin, and Fe(2+). In this study, we investigated the effects of manipulation of the HO-1 system in an in vivo model of focal ischemia-reperfusion (FIR) in the rat heart. Male Wistar albino rats, under general anesthesia and artificial ventilation, underwent thoracotomy, the pericardium was opened, and a silk suture was placed around the left descending coronary artery; ischemia was induced by tightening the suture and was monitored for 30 min. Subsequently, the ligature was released to allow reperfusion lasting for 60 min. The first group of rats was sham operated and injected intraperitoneally (i.p.) with saline. The second group underwent FIR. The third group was treated ip 18 hr before FIR with hemin (4 mg/kg). The fourth group was pretreated ip 24 hr before FIR and 6 hr before hemin with zinc protoporphyrin IX (ZnPP-IX, 50 microg/kg). Specimens of the left ventricle were taken for determination of HO expression and activity, infarct size, malonyldialdehyde (MDA) production, and tissue calcium content. FIR led to a significant increase in the generation of MDA and notably raised tissue calcium levels. Induction of HO-1 by hemin significantly decreased infarct size, incidence of reperfusion arrhythmias, MDA generation, and calcium overload induced by FIR. These effects were prevented by the HO-1 inhibitor ZnPP-IX. The present experiments show that the concerted actions of CO, iron, and biliverdin/bilirubin modulate the FIR-induced myocardial injury.

Conduction velocity around the tricuspid valve annulus during type 1 atrial flutter: defining the location of areas of slow conduction by three-dimensional electroanatomical mapping

BACKGROUND

Conduction velocity (CV) around the tricuspid valve annulus (TVA) during type 1 atrial flutter (AFL) has been shown to be slowest in the tricuspid valve-inferior vena cava (TV-IVC) isthmus, compared to the septal or free wall segments of the TVA. However, fiber orientation in the triangle-of-Koch suggests that the inferior septum and medial TV-IVC isthmus should be the most slowly conducting segments around the TVA.

METHODS

To test this hypothesis we evaluated CV around the TVA during type 1 atrial flutter in 11 patients, using an electro-anatomical mapping system (Carto). CV was first calculated in 4 segments around the TVA including the TV-IVC isthmus, lateral free wall, superior free wall and septum, and then calculated in 8 segments around the TVA including medial (MI) and lateral isthmus (LI), inferior (IL) and superior lateral (SL) free wall, lateral (LS) and medial superior (MS) free wall, and superior (SS) and inferior septum (IS). Statistical comparison of CV from these multiple segments was made by one-way analysis of variance.

RESULTS

Measured in 4 segments around the TVA, mean CV (m/sec) in the TV-IVC isthmus (0.81 +/- 0.23) and the septum (0.93 +/- 0.18) was significantly slower than CV in the lateral free wall (1.16 +/- 0.23) and superior free wall (1.10 +/- 0.20), and CV in the TV-IVC isthmus was significantly slower than in the septum (p < 0.05). However, when analyzed in 8 segments, mean CV in the MI (0.56 +/- 0.16) and IS (0.59 +/- 0.24) was significantly (p < 0.05) slower than in all other segments including the LI (1.06 +/- 0.46), IL (1.17 +/- 0.40), SL (1.15 +/- 0.40), LS (1.04 +/- 0.25), MS (1.15 +/- 0.28), and SS (1.26 +/- 0.36) segments.

CONCLUSIONS

Consistent with previous reports, CV around the TVA during type 1 AFL was slowest in the TV-IVC isthmus, compared to the septum, superior and lateral free wall regions. However, when the TVA was further subdivided into 8 segments, CV in the MI and IS segments was significantly slower than in all other segments around the TVA. These observations more precisely define the regions of slow conduction in human type 1 AFL, and are consistent with the known anisotropy and slow conduction in the Triangle of Koch.

Large tip electrodes for successful elimination of atrial flutter resistant to conventional catheter ablation

The most widely accepted criterion for successful radiofrequency catheter (RFC) ablation of typical atrial flutter is the development of bi-directional isthmus block. In a subset of patients, conventional RFC ablation fails to achieve this endpoint because deeper and wider lesions are required. We investigated the efficacy of a long 8-mm tip catheter in these cases. One hundred and seventy-four consecutive patients (137 male; 61 +/- 9 years) with recurrent typical atrial flutter underwent conventional RFC ablation first with a standard 4 mm tip catheter. In resistant cases (n = 52), ablation was continued using a large tip 8-mm catheter when the 4-mm tip catheter failed. Resistant atrial flutter was identified when 21 RFC pulses failed to reach the selected endpoint of bi-directional isthmus block or in cases of transient bi- directional block (at least 3 episodes). In 122 of the 174 patients (70%) conventional atrial flutter ablation was successfully performed with 13 +/- 5 RFC applications. In the remaining 52 subjects (30%), the ablation procedure was completed using the large tip electrode catheter. In 30 of these 52 patients (58%), the catheter was changed because of persistent intra-atrial conduction after 21 RFC pulses and in 22 (42%) because of intermittent conduction block after 11 +/- 5 applications. Using the large tip electrode catheter, the selected endpoint was achieved in all patients of both groups with 3 +/- 2 RFC pulses (power output of 50-60 W, pulse duration of 60 sec). No post-procedure complications were observed. After 15 +/- 5 months of follow-up, 16 patients (9%) had recurrence of atrial flutter. Five of the patients had been in the resistant group. In patients with atrial flutter resistant to conventional ablation therapy, the long tip (8-mm) catheter appears to be a safe and effective alternative to use of the conventional 4-mm tip catheter.

Use of different catheter ablation technologies for treatment of typical atrial flutter: acute results and long-term follow-up

OBJECTIVES

We report the acute success and long-term follow-up in consecutive patients undergoing catheter ablation of typical right atrial flutter (AFL) using different ablation technologies.

METHODS

One hundred and two patients presenting for treatment of AFL to our laboratory were included in the study. Based on availability and physician preference, ablation was performed with either a cooled-tip catheter (39 patients, group I), an 8- or 10-mm tip catheter connected to a high-power radiofrequency (RF) generator (25 patients, group II), or a 4- or 5-mm tip catheter (38 patients, group III). Acute ablation success was achieved in all group II and group III patients. Among the 38 patients undergoing ablation with the conventional catheter tip (group I), crossover to an 8-mm tip or a cooled tip ablation catheter was required in 11 patients (29%). The mean fluoroscopy time was significantly higher in group I (54.3 +/- 26.4 minutes) when compared to group II (39.6 +/- 19.6 minutes; P < 0.05) and group III (40 +/- 16 minutes; P = 0.0.5). After a mean follow up of 20 +/- 5 months no patient in group II experienced recurrence of AFL, whereas 18.4% (7 of 38 patients; P < 0.05) in group I and 10% (4 of 39 patients; P < 0.05) in group III had recurrence of AFL. Ablation technologies designed to obtain larger size lesions appeared to be more effective in achieving acute ablation success of AFL and in limiting the long-term recurrence rate of this arrhythmia.

Optimizing the detection of bidirectional block across the flutter isthmus for patients with typical isthmus-dependent atrial flutter

The purpose of this study was to show that multipolar electrographic recordings along the subeustachian isthmus (SI) can better differentiate slow conduction from complete isthmus block after atrial flutter ablation, leading to a lower incidence of recurrent atrial flutter (Afl). Despite the presence of various techniques to identify bidirectional conduction block (BDB) after isthmus ablation for typical Afl, several studies, including a report from a national registry, suggest that radiofrequency ablation is still associated with a 15% recurrence rate. Thus, techniques that can distinguish slow conduction from complete isthmus block have the potential for reducing long-term recurrences. We evaluated patients who underwent radiofrequency ablation for typical isthmus-dependent Afl. Patients were separated into 2 groups. Group A underwent assessment of BDB with conventional methods. In group B, BDB was assessed by placing a multipolar catheter along the floor of the SI, pacing adjacent to the line of radiofrequency application, and assessing electrographic activation on either side. One hundred thirty-one cases of Afl ablation were analyzed (86 in group A, 45 in group B). Over a mean follow-up period of 17 months, recurrence rates of Afl were 16.5% in group A and 4.3% in group B (p = 0.043). Thus, assessment of BDB by placement of a multipolar catheter across the SI after ablation of typical Afl is associated with a significant reduction in long-term recurrence of Afl.

"Double" potentials define linear lesion conduction block using a novel mapping/linear lesion ablation catheter

INTRODUCTION

A novel mapping/ablation catheter using a coaxially ablation electrode (E) that is moveable between distal and proximal ring electrodes along its shaft was used to create a linear lesion over the cavotricuspid isthmus (CTI) and bidirectional block in 32 patients (21 men; age 38-79 years) undergoing ablation for counterclockwise atrial flutter.

METHODS AND RESULTS

Two bipolar electrograms (E1 and E2) were recorded: between E and the distal ring electrode and between E and the proximal ring electrode. Interpole distance varied for both as the E traversed the slide shaft. Given the catheter's concept, these bipoles are orientated exactly along the line of lesion creation. Prior to ablation, unitary bipolar electrograms were recorded along the catheter slide shaft position. As the CTI lesion was created (E moved along the catheter slide shaft in 2-mm steps with radiofrequency energy delivered to achieve 65 degrees C for 60 sec at each), double potentials (DP) were observed. Interpotential distance became maximal with completion of the linear lesion and bidirectional block. DPs were noted in all these procedures. With pacing from the low septal right atrium at bidirectional block creation, interpotential timing was 140.9 +/- 15 msec and from the low right atrial free wall was 145.13 +/- 18 msec. In sinus rhythm, DP interpotential timing was less (35.13 +/- 9 msec) as activation fronts arrived from both septal and anterior atrial aspects.

CONCLUSION

Bipolar recordings from the coaxially moveable electrode catheter provide unique electrogram data. DPs recorded during and after linear lesion creation can define conduction block across that lesion without the need for additional mapping catheters or complex mapping technology.

Identification of Functional Block Line in Atrial Flutter Using Three-Dimensional Intracardiac Echocardiography

The crista terminalis (CT) is reportedly a critical barrier for maintaining typical atrial flutter (AFL), but recent observations have suggested the presence of posteromedial functional block, as well as crista conduction. Therefore, this study was designed to identify the correlation between the posterior boundary of AFL and anatomical architecture in the human right atrium (RA) using 3-dimensional (D) intracardiac echocardiography (ICE). In 11 patients with AFL (typical 9, reverse typical 2), mapping with a 10-pole (n=5) or 32-pole (n=6) catheter was performed during AFL. ICE was used to determine the catheter's position relative to the intra-atrial structures. In all patients, double potentials were recorded at the posteromedial RA and the catheter positions were recognized as posterior to the CT by 3-D ICE. Double potentials were not recorded on the CT, and the activation sequence revealed a craniocaudal direction in the 9 patients with typical AFL and caudocranial direction in the 2 patients with reverse typical AFL. These findings demonstrate that the posterior boundary of the AFL circuit is in the sinus venosa region posterior to the CT, which may provide an important insight into the mechanism of maintaining AFL.

Adenovirus-mediated transfer and overexpression of heme oxygenase 1 cDNA in lung prevents bleomycin-induced pulmonary fibrosis via a Fas-Fas ligand-independent pathway

Heme oxygenase 1 (HO-1) is an inducible enzyme that catalyzes heme to generate bilirubin, ferritin, and carbon monoxide. Because enhanced expression of HO-1 confers protection against many types of cell and tissue damage by modulating apoptotic cell death or cytokine expression profiles, we hypothesized that adenovirus-mediated transfer of HO-1 cDNA and subsequent overexpression of the protein in lung would provide therapeutic benefit in a murine model of bleomycin-induced pulmonary fibrosis. In C57BL/6 mice, HO-1 overexpression clearly suppressed the development of fibrotic changes and was associated with enhanced interferon gamma production in lung and reduced numbers of respiratory epithelial cells with damaged DNA. However, HO-1 overexpression did not prevent pulmonary fibrosis induced by agonistic anti-Fas antibody inhalation in C57BL/6 or ICR mice, a strain known to develop pulmonary fibrosis via the Fas-Fas ligand (FasL) pathway. Consistent with the concept that HO-1 overexpression prevents fibrosis via a pathway independent of Fas-FasL interaction, Ad.HO-1 administration prevented bleomycin-induced pulmonary fibrosis in gld/gld mice, which express nonfunctional FasL. These observations suggest that using HO-1 overexpression strategies to treat idiopathic pulmonary fibrosis, or fibrotic disorders of other target organs, by attenuating apoptotic cell death likely would be effective in clinical situations.

Noninvasive myocardial activation time imaging: a novel inverse algorithm applied to clinical ECG mapping data

Linear approaches like the minimum-norm least-square algorithm show insufficient performance when it comes to estimating the activation time map on the surface of the heart from electrocardiographic (ECG) mapping data. Additional regularization has to be considered leading to a nonlinear problem formulation. The Gauss-Newton approach is one of the standard mathematical tools capable of solving this kind of problem. To our experience, this algorithm has specific drawbacks which are caused by the applied regularization procedure. In particular, under clinical conditions the amount of regularization cannot be determined clearly. For this reason, we have developed an iterative algorithm solving this nonlinear problem by a sequence of regularized linear problems. At each step of iteration, an individual L-curve is computed. Subsequent iteration steps are performed with the individual optimal regularization parameter. This novel approach is compared with the standard Gauss-Newton approach. Both methods are applied to simulated ECG mapping data as well as to single beat sinus rhythm data from two patients recorded in the catheter laboratory. The proposed approach shows excellent numerical and computational performance, even under clinical conditions at which the Gauss-Newton approach begins to break down.

Variable electrocardiographic characteristics of isthmus-dependent atrial flutter

OBJECTIVES

The purpose of this study was to characterize variations in flutter-wave (F-wave) morphology among patients with clockwise isthmus-dependent (CWID) and counterclockwise isthmus-dependent (CCWID) right atrial flutter (AFL) and to attempt to correlate F-wave morphology with echocardiographic data and clinical patient characteristics.

BACKGROUND

Variations in F-wave morphology on surface electrocardiogram (ECG) during CCWID and CWID flutter have been reported but never systematically characterized.

METHODS

Over a four-year period, 139 patients with AFL on ECG underwent electrophysiologic study and echocardiography at our institution. Electrocardiographic data, intracardiac recordings, echocardiographic data, and patient characteristics were reviewed retrospectively.

RESULTS

Of 156 AFLs evaluated, 130 were CCWID, 26 were CWID. Three types of CCWID flutter were observed: type 1 had purely negative F-waves inferiorly, types 2 and 3 had F-waves inferiorly with small (type 2) or broad (type 3) positive terminal deflections; CCWID flutter types 2 and 3 were associated with higher incidence of left atrial (LA) enlargement, heart disease, and atrial fibrillation (Afib) than type 1. Two types of CWID flutter were observed: type 1 had notched positive F-waves with a distinct isoelectric segment inferiorly. Type 2 had broader F-waves inferiorly with positive and negative components and a short isoelectric segment.

CONCLUSIONS

Variable ECG patterns for CCWID and CWID AFL exist. A positive component of the F-wave in the inferior leads during CCWID flutter is associated with an increased likelihood of heart disease, Afib, and LA enlargement.

Noncontact three-dimensional mapping and ablation of upper loop re-entry originating in the right atrium

OBJECTIVES

This study was aimed at delineating the reentrant circuit of right atrial (RA) upper loop re-entry using noncontact three-dimensional mapping.

BACKGROUND

Various forms of atypical atrial flutter including lower loop re-entry and left atrial flutter have been demonstrated. However, little is known about upper loop re-entry in the RA.

METHODS

The study population consisted of eight patients (65 +/- 12 years, seven men) with atypical atrial flutter. Right atrial activation during atrial flutter was visualized using a noncontact mapping system (EnSite-3000 with Clarity Software, St. Paul, Minnesota) for a three-dimensional reconstruction of the endocardial depolarization. The narrowest part of the re-entrant circuit was targeted using radiofrequency catheter ablation.

RESULTS

Noncontact mapping showed macro-re-entry confined to the RA free wall with RA activation time accounting for 100% of the cycle length (214 +/- 21 ms) in all eight patients. Two patients had counterclockwise activation, and six patients had clockwise activation around the central obstacle, which was composed of the crista terminalis, the area of functional block, and superior vena cava. The lower turn-around points were located at the conduction gap in the crista terminalis. Radiofrequency linear ablation of the conduction gap in the crista terminalis was performed and eliminated atrial flutter in six patients without recurrence during a follow-up of 3.2 +/- 1.1 months.

CONCLUSIONS

Atypical atrial flutter could arise from upper loop re-entry in the RA with conduction through the gap in the crista terminalis. Radiofrequency linear ablation of the conduction gap was effective in eliminating this atrial arrhythmia.

Pharmacological preconditioning with resveratrol: an insight with iNOS knockout mice

Resveratrol, a natural antioxidant and polyphenol found in grapes and wine, has been found to pharmacologically precondition the heart through the upregulation of nitric oxide (NO). To gain further insight of the role of NO in resveratrol preconditioning, mouse hearts devoid of any copies of inhibitory NO synthase (iNOS) (iNOS knockout) and corresponding wild-type hearts were perfused with 10 microM resveratrol for 15 min followed by 25 min of ischemia and 2 h of reperfusion. Control experiments were performed with wild-type and iNOS knockout hearts that were not treated with resveratrol. Resveratrol-treated wild-type mouse hearts displayed significant improvement in postischemic ventricular functional recovery compared with those of nontreated hearts. Both resveratrol-treated and nontreated iNOS knockout mouse hearts resulted in relatively poor recovery in ventricular function compared with wild-type resveratrol-treated hearts. Myocardial infarct size was lower in the resveratrol-treated wild-type mouse hearts compared with other group of hearts. In concert, a number of apoptotic cardiomyocytes was lower in the wild-type mouse hearts treated with resveratrol. Cardioprotective effects of resveratrol was abolished when the wild-type mouse hearts were simultaneously perfused with aminoguanidine, an iNOS inhibitor. Resveratrol induced the expression of iNOS in the wild-type mouse hearts, but not in the iNOS knockout hearts, after only 30 min of reperfusion. Expression of iNOS remained high even after 2 h of reperfusion. Resveratrol-treated wild-type mouse hearts were subjected to a lower amount of oxidative stress as evidenced by reduced amount of malonaldehyde content in these hearts compared with iNOS knockout and untreated hearts. The results of this study demonstrated that resveratrol was unable to precondition iNOS knockout mouse hearts, whereas it could successfully precondition the wild-type mouse hearts, indicating an essential role of iNOS in resveratrol preconditioning of the heart.

Intracardiac phased-array imaging: methods and initial clinical experience with high resolution, under blood visualization: initial experience with intracardiac phased-array ultrasound

OBJECTIVES

This study was designed to test the feasibility of high-resolution phased-array intracardiac imaging.

BACKGROUND

Intracardiac echocardiographic imaging of the heart during interventional electrophysiologic (EP) procedures has been limited by inadequate ultrasound penetration and absence of Doppler hemodynamic and flow information produced by rotating mechanical ultrasound elements.

METHODS

A 10F (3.2 mm) phased-array, variable 5.5 to 10 MHz frequency imaging catheter with a four-way deflectable tip was applied in 24 patients undergoing EP studies. Sixteen prespecified cardiac targets were imaged from a right heart venue.

RESULTS

Fifteen patients had no underlying organic heart disease; nine had ischemic, cardiomyopathic, valvular or congenital heart disorders. Longitudinal and short-axis imaging readily disclosed each cardiac valve, support structures and chamber, as well as the pericardium, right and left atrial appendages, the junction of the right atrium and superior vena cava, crista terminalis, tricuspid valve isthmus, coronary sinus orifice, membranous fossa ovalis and pulmonary veins. The average target depth was 8.8+/-1.5 cm (range 0.5 to 15 cm), with adequate penetration at a 7.5 MHz imaging frequency. Color flow and Doppler utilities clearly characterized transaortic and pulmonic valve and pulmonary vein blood flow, including during low output states.

CONCLUSIONS

These first human studies with this technology demonstrate the methods, feasibility and utility of intracardiac phased-array vector and Doppler imaging for long-axis, apex-to-base global cardiac imaging. High resolution of endocardial structures and catheters suggests additional utility for visualizing interventional procedures from the right heart.

[Ablation of the cavotricuspid isthmus. Randomized prospective study of radiofrequency ablation with irrigated catheters versus standard catheters]

INTRODUCTION AND OBJECTIVES

An important limitation of the ablation with standard catheter is the volume and limited depth of the lesions created. The irrigated catheters, due to a larger and deeper lesion could be useful in patients with typical atrial flutter. The aim of this study was to prospectively compare the ablation procedure with an irrigated-tip catheter versus the standard catheter in this group of patients.

METHODS

A total of 37 consecutive patients referred to ablation of the cavotricuspid isthmus for typical atrial flutter were randomized either to be performed by an standard catheter (20 patients with mean age of 62 18 years, 18 males) or an irrigated-tip catheter (17 patients with mean age 71 4 years, 13 males).

RESULTS

With standard catheters, complete ablation of the cavotricuspid isthmus was achieved in 18 patients (90%). With a mean of 19 15 applications. With the irrigated-tip catheters the complete ablation of the isthmus was achieved with a mean of 8 7 applications (p < 0.001). Both mean duration of the procedure (164 56 versus 70 35 minutes) and fluoroscopic time (40 16 versus 16 8 minutes) was significantly less with irrigated catheters (p < 0.001). There were no significant clinical complications during the procedure nor later on. No patient presented ischemic symptoms nor alterations on the ST segment.

CONCLUSIONS

The employment of irrigated-tip catheters achieved a high success rate with safety shortening the procedure time and radiation exposure.

Role of heme oxygenase-1 in hypoxia-reoxygenation: requirement of substrate heme to promote cardioprotection

Heme oxygenase-1 (HO-1) catalyzes the enzymatic degradation of heme to carbon monoxide, bilirubin, and iron. All three products possess biological functions; bilirubin, in particular, is a potent free radical scavenger of which its antioxidant property is enhanced at low oxygen tension. Here, we investigated the effect of severe hypoxia and reoxygenation on HO-1 expression in cardiomyocytes and determined whether HO-1 and its product, bilirubin, have a protective role against reoxygenation damage. Hypoxia caused a time-dependent increase in both HO-1 expression and heme oxygenase activity, which gradually declined during reoxygenation. Reoxygenation of hypoxic cardiomyocytes produced marked injury; however, incubation with hemin or bilirubin during hypoxia considerably reduced the damage at reoxygenation. The protective effect of hemin is attributable to increased availability of substrate for heme oxygenase activity, because hypoxic cardiomyocytes generated very little bilirubin when incubated with medium alone but produced substantial bile pigment in the presence of hemin. Interestingly, incubation with hemin also maintained high heme oxygenase activity levels during the reoxygenation period. Reactive oxygen species generation was enhanced after hypoxia, and hemin and bilirubin were capable once again to attenuate this effect. These results indicate that the HO-1-bilirubin pathway can effectively defend hypoxic cardiomyocytes against reoxygenation injury and highlight the issue of heme availability in the cytoprotective action afforded by HO-1.

Postoperative arrhythmias and conduction disorders

Cardiac arrhythmias are common in the perioperative period. Most arrhythmias are clinically benign. Occasionally, cardiac arrhythmias and conduction disturbances can pose a major additional risk to the patient in the perioperative and postoperative periods. The current availability of a wide array of techniques for controlling serious arrhythmias--pharmacologic, electrical, and interventional--enable the physician to manage most arrhythmias and conduction disturbances successfully. The added risks posed by arrhythmias and conduction disturbances in the perioperative period now can be minimized.

Characterization of the anatomy and conduction velocities of the human right atrial flutter circuit determined by noncontact mapping

OBJECTIVES

This study was done to characterize human right atrial (RA) flutter (AFL) using noncontact mapping.

BACKGROUND

Atrial flutter has been mapped using sequential techniques, but complex anatomy makes simultaneous global RA mapping difficult.

METHODS

Noncontact mapping was used to map the RA of 13 patients with AFL (5 with previous attempts), 11 with counterclockwise and 2 with clockwise AFL. "Reconstructed" electrograms were validated against contact electrograms using cross-correlation. The Cartesian coordinates of points on a virtual endocardium were used to calculate the length and thus the conduction velocity (CV) of the AFL wave front within the tricuspid annulus-inferior vena cave isthmus (IS) and either side of the crista terminalis (CT).

RESULTS

When clearly seen, the AFL wave front split (n = 3) or turned in the region of the coronary sinus os (n = 6). Activation progressed toward the tricuspid annulus (TA) from the surrounding RA in 10 patients, suggesting that the leading edge of the reentry wave front is not always at the TA. The IS length and CV was 47.73 +/- 24.40 mm (mean +/- SD) and 0.74 +/- 0.36 m/s. The CV was similar for the smooth and trabeculated RA (1.16 +/- 0.48 m/s and 1.22 +/- 0.65 m/s, respectively [p = 0.67]) and faster than the IS (p = 0.03 and p = 0.05 for smooth and trabeculated, respectively).

CONCLUSIONS

Noncontact mapping of AFL has been validated and has demonstrated that IS CV is significantly slower than either side of the CT.

Intra-atrial reentry tachycardia in pediatric patients

Intra-atrial reentry tachycardia (IART), also known as atrial flutter, is a major problem in pediatric cardiology and adult congenital cardiology. Patients have significant morbidity and even mortality associated with this arrhythmia. The use of antiarrhythmic medications has been disappointing in this population. Ablation techniques are being developed which offer some advantages over the use of medication. These techniques include: sophisticated mapping using entrainment, electro-anatomic and non-contact methods for assessment of the anatomy and the reentrant circuit; radiofrequency ablation methods which allow for the creation of linear and transmural lesions; and new methods for assessment of the effects of ablation which focus on the documentation of the creation of a new line of block. These new techniques provide hope for more effective ablation procedures and the possibility of definitive cure of atrial flutter in many patients in this population.

L-arginine polymer mediated inhibition of graft coronary artery disease after cardiac transplantation

BACKGROUND

Nitric oxide (NO) limits the development of graft coronary artery disease (GCAD) in transplanted hearts. We hypothesized that l-arginine polymers administered to cardiac allografts ex vivo would translocate across vascular cellular membranes, up-regulate inducible nitric oxide synthase (iNOS) production of NO, and inhibit the development of GCAD.

METHODS

Three groups of PVG rat donor hearts were incubated with either 0.8 ml phosphate-buffered saline, (PBS, n=12) or 50 microM L-arginine polymer solutions of length five (R5, n=12) or nine (R9, n=12) prior to heterotopic transplantation into ACI recipients. Graft vessels were scored at POD 60 and 90 for percentage luminal narrowing (%LN), intima to media ratio (I/M), and percentage affected vessels (%AV). Translocation efficiency was determined by treatment with biotinylated polymers. NO production of treated aortic segments was determined in vitro by Griess reaction.

RESULTS

Translocation efficiencies were 89+/-19% (R9), 7+/-10% (R5), and 0+/-0% PBS (ANOVA, P<0.001) which corresponded to NO production in treated aortic segments of 0.175+/-0.17 (R9), 0.120+/-0.006 (R5), and 0.135+/-0.035 microM/mg (PBS), (ANOVA, P=0.002). GCAD scores at POD 60 were: %LN: 3.2+/-3.8% (R9), 12.6+/-6.7% (R5), 11.3+/-4.2% (PBS) (ANOVA, P=0.025); I/M: 0.03+/-0.04 (R9), 0.13+/-0.07 (R5), 0.12+/-0.05 (PBS) (ANOVA, P=0.037); %AV: 7+/-7% (R9), 19+/-7%(R5), 22+/-9%(PBS) (ANOVA, P=0.021). Reduction of GCAD parameters was maintained at POD 90.

CONCLUSION

R9 efficiently translocated across cytoplasmic membranes, enhanced vascular NO production, and decreased neointimal hyperplasia. This ex vivo treatment may have a therapeutic role in preventing GCAD.

Complications associated with radiofrequency catheter ablation of cardiac arrhythmias

Catheter ablation using radiofrequency energy has evolved as a safe and effective means for the treatment of various supraventricular and ventricular arrhythmias. Despite the overall efficacy of radiofrequency catheter ablation, cardiovascular complications can occur in a small number of patients. The purpose of this article is to review the current understanding of the risks and complications that can occur during catheter ablation procedures.

The N + 1 difference: a new measure for entrainment mapping

OBJECTIVES

The purpose of this study was to develop and test a new entrainment mapping measurement, the N + 1 difference.

BACKGROUND

Entrainment mapping is useful for identifying re-entry circuit sites but is often limited by difficulty in assessing: 1) changes in QRS complexes or P-waves that indicate fusion, and 2) the postpacing interval (PPI) recorded directly from the stimulation site.

METHODS

In computer simulations of re-entry circuits, the interval from a stimulus that reset tachycardia to a timing reference during the second beat after the stimulus was compared with the timing of local activation at the site during tachycardia to define an interval designated the N + 1 difference. The N + 1 difference was compared with the PPI-tachycardia cycle length (TCL) difference in simulations and at 65 sites in 10 consecutive patients with ventricular tachycardia (VT) after myocardial infarction and at 45 sites in 10 consecutive patients with atrial flutter.

RESULTS

In simulations, the N + 1 difference was equal to the PPI-TCL difference. During mapping of VT and atrial flutter, the N + 1 difference correlated well with the PPI-TCL difference (r > or = 0.91, p < 0.0001), identifying re-entry circuit sites with sensitivity of > or = 86% and specificity of > or = 90%. Accuracy was similar using either the surface electrocardiogram or an intracardiac electrogram (Eg) as the timing reference.

CONCLUSIONS

The N + 1 difference allows entrainment mapping to be used to identify re-entry circuit sites when it is difficult to evaluate Egs at the mapping site or fusion in the surface electrocardiogram.

Catheter ablation for cardiac arrhythmias

The safety and efficacy of catheter ablation for treatment of most types of cardiac arrhythmias are well established. These arrhythmias and arrhythmia substrates include AVNRT, accessory pathways, focal atrial tachycardia, atrial flutter, idiopathic ventricular tachycardia, and bundle-branch re-entry. Catheter ablation is considered as an alternative to pharmacologic therapy in the treatment of these cardiac arrhythmias.

Different patterns of atrial activation in idiopathic atrial fibrillation: simultaneous multisite atrial mapping in patients with paroxysmal and chronic atrial fibrillation

OBJECTIVES

We aimed to evaluate: 1) the behavior of electrical activity simultaneously in different atrial regions during atrial fibrillation (AF); 2) the difference of atrial activation between paroxysmal and chronic AF; 3) the atrial refractoriness dispersion; and 4) the correlation between the effective refractory periods (ERPs) and the FF intervals.

BACKGROUND

Little data exist on the electrophysiologic characteristics of the different atrial regions in patients with AF. A more detailed knowledge of the electrical activity during AF may provide further insights to improve treatment of AF.

METHODS

Right and left atria were extensively mapped in 30 patients with idiopathic AF (18 paroxysmal and 12 chronic). In different atrial locations, we analyzed 1) the FF interval duration; and 2) the grade of organization and, in case of organized electrical activity, the direction of atrial activation. Furthermore, in patients with paroxysmal AF, we determined the atrial ERP, evaluated the ERP dispersion and assessed the presence of a correlation between the ERPs and the FF intervals.

RESULTS

In patients with chronic AF, we observed a shortening of the FF intervals and a greater prevalence of disorganized activity in all the atrial sites examined. In patients with paroxysmal AF, a significant dispersion of refractoriness was observed. The right lateral wall showed longer FF intervals and more organized atrial activity and, unexpectedly, the shortest mean ERPs. In contrast, the septal area showed shorter FF intervals, greater disorganization and the longest mean ERPs.

CONCLUSIONS

Electrical activity during AF showed a significant spatial inhomogeneity, which was more evident in patients with paroxysmal AF. The mean FF intervals did not correlate with the mean ERPs.

Electrical conduits within the inferior atrial region exhibit preferential roles in interatrial activation

Differences between conduction properties of interatrial conduits and their roles in initiation and maintenance of supraventricular arrhythmias remain unclear. Our objective was to determine details of interatrial activation in inferior atrial region and to correlate intra-atrial and interatrial activation patterns with the site of origin of atrial ectopic activation. In 9 dogs, basket-catheters carrying 64 electrodes were deployed into both the right atrium (RA) and left atrium (LA). A 10-electrode catheter was inserted into the coronary sinus (CS). Activation patterns of the RA, LA, and CS were compared during pacing in the CS, in RA inferoparaseptum posterior to Eustachian ridge-tendon of Todaro (TT), and in inferior RA near the CS ostium (anterior to TT). We found that pacing in proximal and middle CS resulted in a RA breakthrough invariably at the CS ostium, consistent with conduction through a CS-RA connection. Meanwhile, LA breakthrough emerged in inferoposterior region (inferior to mitral annulus), suggesting conduction through a CS-LA connection. While pacing in distal CS, LA breakthrough shifted to middle posterolateral wall. Whereas, the RA was activated by the LA directly through the septum. During pacing in RA inferoparaseptum posterior to TT, the LA was activated directly through the septum at 22 +/- 4 ms. Whereas, during pacing anterior to TT, the LA was activated through both the CS and the septum while earliest activation was delayed by 38 +/- 5 ms. In conclusion, both the interatrial septum and CS musculature form electrical conduits in inferior atrial region in canine. Differences in activation properties between the conduits in inferior interatrial region result in selective interatrial activation patterns during ectopic activation.

Diagnosis and ablation of atrial flutter using a high resolution, noncontact mapping system

The ablation of atrial flutter can sometimes be time consuming and unsuccessful using conventional catheter techniques especially in patients with recurrences after previous ablation procedures. Simultaneous high resolution mapping from multiple sites may overcome some of the limitations. Therefore, a new high resolution noncontact mapping system was used for diagnosis and ablation of atrial flutter in 15 patients. The mapping system consists of a catheter-mounted multielectrode array, an amplifier, and a computer workstation. Far-field potentials recorded by the multielectrode catheter are amplified, digitized, and sampled at 1.2 kHz, and digitally filtered to construct high resolution activation maps during tachycardia. Ablation catheters can be steered to target sites without fluoroscopy. In 12 of the 15 patients the analysis of the activation sequence during tachycardia showed a counter-clockwise, and in 1 of 15 patients a clockwise, rotating wavefront using the isthmus as part of the reentrant circuit. In two patients no tachycardia could be induced. In 3 of the 15 patients with previous conventional ablation procedures the gap in the line of block in the isthmus region was identified and marked on the animation model. The isthmus in the right atrium was ablated and isthmus block verified by the mapping system in all patients. No complications were observed. No recurrences of atrial flutter occurred during follow-up of 4 +/- 1.7 months. The total procedure and fluoroscopy time was 171 +/- 50.0 minutes and 24 +/- 12.7 minutes, respectively. In conclusion, the use of the new high resolution noncontact mapping system in patients with right atrial flutter is safe and highly effective. In patients with previously failed conventional ablation procedures the use of a noncontact mapping system may facilitate the identification of the gap in the line of block in the isthmus region and reablation of atrial flutter.

Regulation of endothelial heme oxygenase activity during hypoxia is dependent on chelatable iron

The regulation of heme oxygenase (HO) activity and its dependence on iron was studied in bovine aortic endothelial cells (BAEC) subjected to hypoxia-reoxygenation (H/R). HO activity was induced by hypoxia (10 h) and continued to increase during the reoxygenation phase. HO-1 protein levels were strongly induced by hypoxia from undetectable levels and remained elevated at least 8 h postreoxygenation. Addition of the Fe(3+) chelator desferrioxamine mesylate (DFO) or the Fe(2+) chelator o-phenanthroline during hypoxia alone or during the entire H/R period inhibited the induction of HO activity and HO-1 protein levels. However, DFO had no effect and o-phenanthroline had a partial inhibitory effect on HO activity and protein levels when added only during reoxygenation. Loading of BAEC with Fe(3+) enhanced the activation of the HO-1 gene by H/R, whereas loading with L-aminolevulinic acid, which stimulates heme synthesis, had little effect. These results suggest that chelatable iron participates in regulating HO expression during hypoxia.

A peculiar form of focal atrial tachycardia mimicking atypical atrial flutter

A 55-year-old man was referred because of congestive heart failure and atrial flutter. A 12-lead electrocardiogram (ECG) showed positive P waves in leads II, III, and aVF with a continuously undulating pattern that lacked an isoelectric baseline. Tachycardia was diagnosed as atypical atrial flutter based on classical criteria. An electrophysiological study and catheter ablation using an electroanatomical system revealed the mechanism of the tachycardia to be focal atrial tachycardia originating from the left atrial roof. This case indicates that focal atrial tachycardia may present as atypical atrial flutter on the surface ECG.

Location of acutely successful radiofrequency catheter ablation of intraatrial reentrant tachycardia in patients with congenital heart disease

Intraatrial reentrant tachycardia (IART) is common after surgery for congenital heart disease (CHD). Radiofrequency (RF) catheter ablation of IART targets anatomic areas critical to the maintenance of the arrhythmia circuit, areas that have not been well defined in this patient population. The purpose of this study was to determine the anatomic areas critical to IART circuits, defined by activation mapping and confirmed by an acutely successful RF ablation at the site. A total of 110 RF ablation procedures in 88 patients (median age 23.4 years, range 0.1 to 62.7) with CHD were reviewed. Patients were grouped according to surgical intervention: Mustard/Senning (n = 15), other biventricular repaired CHD (n = 24), Fontan (n = 43), and palliated CHD (n = 6). In first-time ablation procedures, > or = 1 IART circuits were acutely terminated in 80% of Mustard/Senning, 71% of repaired CHD, and 72% of Fontan (p = NS). The palliated CHD group underwent 1 of 6 successful procedures (17%), and this patient was excluded. The locations of acutely successful RF applications in Mustard/Senning patients (n = 14 sites) were at the tricuspid valve isthmus (57%) and at the lateral right atrial wall (43%). In patients with repaired CHD (n = 18 sites), successful RF sites were at the isthmus (67%) and the lateral (22%) and anterior (11%) right atria. In the Fontan group (n = 40 sites), successful RF sites included the lateral right atrial wall (53%), the anterior right atrium (25%), the isthmus area (15%), and the atrial septum (7%). Location of success was statistically different for the Fontan group (p = .002). In conclusion, the tricuspid valve isthmus is a critical area for ablation of IART during the Mustard/ Senning procedure and in patients with repaired CHD. IART circuits in Fontan patients are anatomically distinct, with the lateral right atrial wall being the more common area for successful RF applications. This information may guide RF and/or surgical ablation procedures in patients with CHD and IART.

Management of postoperative arrhythmias

Arrhythmias occur commonly in patients after cardiac surgery. Atrial fibrillation is the most common arrhythmia in the postoperative period; it accounts for significant morbidity to the patient and prolonged hospital stays, and it contributes significantly to the cost of hospitalization. It occurs more commonly in elderly men and in patients undergoing valvular procedures. Beta blockers are effective agents that keep patients from developing postoperative atrial fibrillation and help maintain ventricular rate control. Prophylaxis with antiarrhythmic agents such as amiodarone and sotalol and recently with atrial pacing have shown promise in recent randomized trials. Patients with atrial fibrillation that persists for longer than 48 hours appear to be at a greater risk for cerebroembolic events and should receive anticoagulation unless a contraindication exists. Although frequent premature ventricular contractions and nonsustained ventricular tachycardia (NSVT) occur frequently in patients after cardiac surgery, sustained ventricular tachycardia and ventricular fibrillation are rare and are associated with a poor prognosis. Polymorphic ventricular tachycardia may occur in the setting of myocardial ischemia, metabolic disturbances, and drug toxicities (including antiarrhythmic agents used to treat atrial fibrillation). Poor left ventricular function is a potent risk factor for sudden death in patients with NSVT. Patients with persistent NSVT and ischemic cardiomyopathy with left ventricular ejection fractions of less than 40% should undergo electrophysiologic testing. Conduction abnormalities that may be encountered in patients after cardiac surgery are rarely life threatening. Patients who have undergone valve replacement or repair are at higher risk of developing significant bradyarrhythmias that may require temporary pacing.

Differences in organization between acute and chronic atrial fibrillation in dogs

OBJECTIVES

The purpose of this study was to determine differences in acute and chronic atrial fibrillation (AF) "organization" in canine models.

BACKGROUND

Electrophysiologic changes occur during atrial remodeling, but little is known about how remodeling affects AF organization. We hypothesized that atrial remodeling induced by long-term rapid atrial rates heterogeneously decreases AF organization.

METHODS

In seven dogs, acute AF was induced by atrial burst pacing, and in eight dogs chronic AF was created by six weeks of continuous rapid atrial pacing. Atrial fibrillation was epicardially mapped from the right atria (RA) and left atria (LA). Atrial cycle length (CL), spatial organization and activation maps were compared. Spatial organization was quantified by an objective signal processing measure between multiple electrograms. RESULTS In acute AF, mean CL was slightly shorter in the LA (124 +/- 16 ms) than it was in the RA (131 +/- 14 ms) (p < 0.0001). In chronic AF, LA CL (96 +/- 14 ms) averaged 24 ms shorter than RA CL (121 +/- 18 ms) (p < 0.0001). Right atria and LA in acute AF had similar levels of organization. In chronic AF, the LA became approximately 25% more disorganized (p < 0.0001) while the RA did not change. In acute AF, a single broad wave front originating from the posterior and medial atrium dominated LA activation. In chronic AF, LA activation was more complex, sustaining multiple reentrant wavelets in the free wall and lateral appendage.

CONCLUSIONS

Acute and chronic AF exhibit heterogeneous differences in CL, organization and activation patterns. The LA in chronic AF is faster and more disorganized than it is in acute AF. Differences in the models may be due to heterogeneous electrophysiologic remodeling and anatomic constraints. The design of future AF therapies may benefit by addressing the patient specific degree of atrial remodeling.

Basket catheter-guided three-dimensional activation patterns construction and ablation of common type atrial flutter

Construction of three-dimensional activation maps and evaluation of ablation-created bidirectional block in the tricuspid valve-inferior vena caval (TV-IVC) isthmus in patients with atrial flutter (AF) are difficult with conventional mapping technique. In 36 patients with type I AF (25 men, 11 women; mean age 62 +/- 10.5 years) a multielectrode basket catheter (BC) was deployed in the right atrium (RA). Out of 64 BC electrodes, 56 bipolar electrograms were derived. Three-dimensional activation patterns were constructed with a software program. Stable electrograms of satisfactory quality were obtained in 49 +/- 2 electrode pairs. Capture was possible in 36 +/- 3 of bipoles. In counterclockwise AF (CCW-AF) and clockwise AF (CW-AF) episodes, cycle lengths and TV-IVC isthmus conduction times were 248 +/- 26 ms and 251 +/- 23 ms, (P = 0.74) and 105 +/- 28 ms and 106 +/- 33 ms (P = 0.92), respectively. Conduction velocity in the TV-IVC isthmus was lower than in the anterior or septal limbs of the circuit, in counterclockwise or clockwise episodes. Double potentials were recorded in 94% of patients. Three-dimensional activation patterns were delineated and displayed as isochronal maps. The reentry circuit involved the TV-IVC isthmus, septal, and anterior walls and a part of the RA roof anterior to superior vena cava. Postablation isthmus conduction was evaluated through the sequence criteria, local electrogram-based criteria, and the analysis of three-dimensional activation patterns of the paced rhythms. The complete isthmus block was associated with a significant increase of the low anterior low septal conduction interval (152 +/- 29 vs 104 +/- 32 ms, P = 0.001) and the low septal-low anterior conduction interval (150 +/- 31 vs 107 +/- 33 ms, P = 0.001). Radiofrequency ablation was successful in 32 (90%) of 36 patients. In conclusion, the current mapping system enables construction of three-dimensional activation patterns and facilitates evaluation of the postablation TV-IVC isthmus block in patients with AF.

Heme oxygenase-1 is upregulated in the rat heart in response to chronic administration of angiotensin II

Heme oxygenase (HO) is a heme-catabolizing enzyme that converts heme into biliverdin, iron, and carbon monoxide. HO-1, an inducible form of HO, is thought to act as an endogenous antioxidant defense mechanism. To determine whether chronic administration of angiotensin II affects HO-1 expression in the heart, expression and localization of HO-1 were investigated in the heart of rats receiving angiotensin II infusion (0.7 mg. kg(-1). day(-1)) via osmotic minipump for up to 7 days. Angiotensin II induced formation of granulation tissue, characterized by myofibroblast proliferation, fibrous deposition, and inflammatory cell migration. Angiotensin II also upregulated cardiac HO-1 expression. Immunohistochemistry revealed that HO-1 was intensively expressed in the granulation tissue. The selective AT(1)-receptor antagonist, losartan, completely, but hydralazine only partially, suppressed angiotensin II-induced granulation tissue formation and HO-1 upregulation. Chronic norepinephrine infusion (2.8 mg. kg(-1). day(-1)) did not induce granulation tissue formation or HO-1 upregulation. Our data suggest that angiotensin II upregulates cardiac HO-1 expression in the newly formed inflammatory lesion, which may represent an adaptive response to angiotensin II-induced cardiac damage.

Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter

BACKGROUND

Despite the high success rate of radiofrequency (RF) ablation, pharmacologic therapy is still considered the standard initial therapeutic approach for atrial flutter.

OBJECTIVE

We prospectively compared the outcome at follow-up of patients with atrial flutter randomly assigned to drug therapy or RF ablation.

METHODS

Patients with at least two episodes of symptomatic atrial flutter in the last four months were randomized to regimens of either antiarrhythmic drug therapy or first-line RF ablation. After institution of therapy, end points included recurrence of atrial flutter, rehospitalization and quality of life.

RESULTS

A total of 61 patients entered the study, 30 of whom were randomized to drug therapy and 31 to RF ablation. After a mean follow-up of 21 +/- 11 months, 11 of 30 (36%) patients receiving drugs were in sinus rhythm, versus 25 of 31 (80%) patients who underwent RF ablation (p < 0.01). Of the patients receiving drugs, 63% required one or more rehospitalizations, whereas post-RF ablation, only 22% of patients were rehospitalized (p < 0.01). Following RF ablation, 29% of patients developed atrial fibrillation which was seen in 53% of patients receiving medications (p < 0.05). Sense of well being (pre-RF 2.0 +/- 0.3 vs. post-RF 3.8 +/- 0.5, p < 0.01) and function in daily life (pre-RF 2.3 +/- 0.4 vs. post-RF 3.6 +/- 0.6, p < 0.01) improved after ablation, but did not change significantly in patients treated with drugs.

CONCLUSION

In a selected group of patients with atrial flutter, RF ablation could be considered a first-line therapy due to the better success rate and impact on quality of life, the lower occurrence of atrial fibrillation and the lower need for rehospitalization at follow-up.

Body surface mapping of counterclockwise and clockwise typical atrial flutter: a comparative analysis with endocardial activation sequence mapping

OBJECTIVES

This study was directed at developing spatial 62-lead electrocardiogram (ECG) criteria for classification of counterclockwise (CCW) and clockwise (CW) typical atrial flutter (Fl) in patients with and without structural heart disease.

BACKGROUND

Electrocardiographic classification of CCW and CW typical atrial Fl is frequently hampered by inaccurate and inconclusive scalar waveform analysis of the 12-lead ECG.

METHODS

Electrocardiogram signals from 62 torso sites and multisite endocardial recordings were obtained during CCW typical atrial Fl (12 patients), CW typical Fl (3 patients), both forms of typical Fl (4 patients) and CCW typical and atypical atrial Fl (1 patient). All the Fl wave episodes were divided into two or three successive time periods showing stable potential distributions from which integral maps were computed.

RESULTS

The initial, intermediate and terminal CCW Fl wave map patterns coincided with: 1) caudocranial activation of the right atrial septum and proximal-to-distal coronary sinus activation, 2) craniocaudal activation of the right atrial free wall, and 3) activation of the lateral part of the subeustachian isthmus, respectively. The initial, intermediate and terminal CW Fl wave map patterns corresponded with : 1) craniocaudal right atrial septal activation, 2) activation of the subeustachian isthmus and proximal-to-distal coronary sinus activation, and 3) caudocranial right atrial free wall activation, respectively. A reference set of typical CCW and CW mean integral maps of the three successive Fl wave periods was computed after establishing a high degree of quantitative interpatient integral map pattern correspondence irrespective of the presence or absence of organic heart disease.

CONCLUSIONS

The 62-lead ECG of CCW and CW typical atrial Fl in man is characterized by a stereotypical spatial voltage distribution that can be directly related to the underlying activation sequence and is highly specific to the direction of Fl wave rotation. The mean CCW and CW Fl wave integral maps present a unique reference set for improved clinical detection and classification of typical atrial Fl.