Pulmonary Vein Isolation With or Without Left Atrial Appendage Ligation in Atrial Fibrillation: The aMAZE Randomized Clinical Trial

Importance

Left atrial appendage elimination may improve catheter ablation outcomes for atrial fibrillation.

Objective

To assess the safety and effectiveness of percutaneous left atrial appendage ligation adjunctive to catheter pulmonary vein isolation for nonparoxysmal atrial fibrillation.

Design, Setting, and Participants

This multicenter, prospective, open-label, randomized clinical trial evaluated the safety and effectiveness of percutaneous left atrial appendage ligation adjunctive to planned pulmonary vein isolation for nonparoxysmal atrial fibrillation present for less than 3 years. Eligible patients were randomized in a 2:1 ratio to undergo left atrial appendage ligation and pulmonary vein isolation or pulmonary vein isolation alone. Use of a 2:1 randomization ratio was intended to provide more device experience and safety data. Patients were enrolled from October 2015 to December 2019 at 53 US sites, with the final follow-up visit on April 21, 2021.

Interventions

Left atrial appendage ligation plus pulmonary vein isolation compared with pulmonary vein isolation alone.

Main Outcomes and Measures

A bayesian adaptive analysis was used for primary end points. Primary effectiveness was freedom from documented atrial arrythmias of greater than 30 seconds duration 12 months after undergoing pulmonary vein isolation. Rhythm was assessed by Holter monitoring at 6 and 12 months after pulmonary vein isolation, symptomatic event monitoring, or any electrocardiographic tracing obtained through 12 months after pulmonary vein isolation. Primary safety was a composite of predefined serious adverse events compared with a prespecified 10% performance goal 30 days after the procedure. Left atrial appendage closure was evaluated through 12 months after pulmonary vein isolation.

Results

Overall, 404 patients were randomized to undergo left atrial appendage ligation plus pulmonary vein isolation and 206 were randomized to undergo pulmonary vein isolation alone. Primary effectiveness was 64.3% with left atrial appendage ligation and pulmonary vein isolation and 59.9% with pulmonary vein isolation only (difference, 4.3% [bayesian 95% credible interval, -4.2% to 13.2%]; posterior superiority probability, 0.835), which did not meet the statistical criterion to establish superiority (0.977). Primary safety was met, with a 30-day serious adverse event rate of 3.4% (bayesian 95% credible interval, 2.0% to 5.0%; posterior probability, 1.0) which was less than the prespecified threshold of 10%. At 12 months after pulmonary vein isolation, complete left atrial appendage closure (0 mm residual communication) was observed in 84% of patients and less than or equal to 5 mm residual communication was observed in 99% of patients.

Conclusions and Relevance

Percutaneous left atrial appendage ligation adjunctive to pulmonary vein isolation did not meet prespecified efficacy criteria for freedom from atrial arrhythmias at 12 months compared with pulmonary vein isolation alone for patients with nonparoxysmal atrial fibrillation, but met prespecified safety criteria and demonstrated high rates of closure at 12 months.

Trial Registration

ClinicalTrials.gov Identifier: NCT02513797.

Incidence, Risk Score Performance, and In-Hospital Outcomes of Postoperative Atrial Fibrillation After Cardiac Surgery

BACKGROUND

Postoperative atrial fibrillation (POAF) frequently complicates cardiac surgery. Predicting POAF can guide interventions to prevent its onset. This study assessed the incidence, risk factors, and related adverse outcomes of POAF after cardiac surgery.

METHODS

A cohort of 1,606 patients undergoing cardiac surgery at a tertiary referral center was analyzed. Postoperative AF was defined based on the Society of Thoracic Surgeons' criteria: AF/atrial flutter after operating room exit that either lasted longer than 1 hour or required medical or procedural intervention. Risk factors for POAF were evaluated, and the performance of established risk scores (POAF, HATCH, COM-AF, CHA2DS2-VASc, and Society of Thoracic Surgeons risk scores) in predicting POAF was assessed using discrimination (area under the receiver operator characteristics curve) analysis. The association of POAF with secondary outcomes, including length of hospital stay, ventilator time, and discharge to rehabilitation facilities, was evaluated using adjusted linear and logistic regression models.

RESULTS

The incidence of POAF was 32.2% (n = 517). Patients who developed POAF were older, had traditional cardiovascular risk factors and higher Society of Thoracic Surgeons risk scores, and often underwent valve surgery. The POAF risk score demonstrated the highest area under the receiver operator characteristics curve (0.65), but risk scores generally underperformed. Postoperative AF was associated with extended hospital stays, longer ventilator use, and higher likelihood of discharge to rehabilitation facilities (odds ratio, 2.30; 95% CI, 1.73-3.08).

CONCLUSION

This study observed a high incidence of POAF following cardiac surgery and its association with increased morbidity and resource utilization. Accurate POAF prediction remains elusive, emphasizing the need for better risk-prediction methods and tailored interventions to diminish the effect of POAF on patient outcomes.

Risk Stratification in Patients Who Underwent Percutaneous Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) is effective in preventing thromboembolism. Risk stratification tools could help identify patients at risk for early mortality after LAAO. In this study, we validated and recalibrated a clinical risk score (CRS) to predict risk of all-cause mortality after LAAO. This study used data from patients who underwent LAAO in a single-center, tertiary hospital. A previously developed CRS using 5 variables (age, body mass index [BMI], diabetes, heart failure, and estimated glomerular filtration rate) was applied to each patient to assess risk of all-cause mortality at 1 and 2 years. The CRS was recalibrated to the present study cohort and compared with established atrial fibrillation-specific (CHA2DS2-VASc and HAS-BLED) and generalized (Walter index) risk scores. Cox proportional hazard models were used to assess the risk of mortality and discrimination was assessed by Harrel C-index. Among 223 patients, the 1- and 2-year mortality rates were 6.7% and 11.2%, respectively. With the original CRS, only low BMI (<23 kg/m2) was a significant predictor of all-cause mortality (hazard ratio [HR] [95% CI] 2.76 [1.03 to 7.35]; p = 0.04). With recalibration, BMI <29 kg/m2 and estimated glomerular filtration rate <60 ml/min/1.73 m2 were significantly associated with an increased risk of death (HR [95% CI] 3.24 [1.29 to 8.13] and 2.48 [1.07 to 5.74], respectively), with a trend toward significance noted for history of heart failure (HR [95% CI] 2.13 [0.97 to 4.67], p = 0.06). Recalibration improved the discriminative ability of the CRS from 0.65 to 0.70 and significantly outperformed established risk scores (CHA2DS2-VASc = 0.58, HAS-BLED = 0.55, Walter index = 0.62). In this single-center, observational study, the recalibrated CRS accurately risk stratified patients who underwent LAAO and significantly outperformed established atrial fibrillation-specific and generalized risk scores. In conclusion, clinical risk scores should be considered as an adjunct to standard of care when evaluating a patient's candidacy for LAAO.

Detection of atrial fibrillation in real world setting in patients with cryptogenic stroke and an implantable loop recorder

INTRODUCTION

Implantable loop recorders (ILR) are used to screen for atrial fibrillation (AF) in patients with cryptogenic stroke (CS). However, there is limited real-world data regarding the long-term rate of AF detection using ILR and management consequences in patients with CS. The objective is to assess the rate of AF detection in patients with CS in a real-world study over 36 months of follow-up and its consequences on stroke prevention.

METHODS

This retrospective study included patients with an ILR placed for CS at Baylor College of Medicine and Baylor St. Luke's Medical Center between January 2014 and July 2021. The primary outcome was AF detection in patients with ILR. The secondary outcome was the rate of subsequent strokes after ILR placement in patients with or without diagnosed AF. The AF detection rate in our cohort was compared to the rate in CRYSTAL-AF Trial at 36-month follow-up. The impact of AF detection on clinical management was examined.

RESULTS

We identified 225 patients. 51.1% were women and 38.2% African American. Among 85 patients with ILR labeled AF, 43 patients had true AF, and 42 had incorrectly labeled AF (48.3% false positive). The estimated AF detection rate at 36 months follow-up was 28.6% (95% CI, 26.6%-30.6%). 58.1% of patients with AF were initiated on oral anticoagulation, 80.0% of whom were started on a direct oral anticoagulant. 13.8% of patients had recurrent strokes after ILR implantation; 4 of whom were diagnosed with AF.

CONCLUSION

Compared to CRYSTAL-AF, the AF detection rate in our cohort is similar, but this cohort includes a higher proportion of female and African American patients. Most patients with recurrent strokes after ILR implant did not have AF during 36 months of monitoring.

The transgenerational consequences of maternal parasitism for aphid life history and suitability for subsequent parasitism

Aphids parasitized in later instars can give birth to several nymphs before their reproduction is curtailed by the developing parasitoid. We examined the life histories of Aphis fabae Scopoli born to mothers parasitized by Lysiphlebus fabarum Marshall, and their suitability as subsequent hosts, to test the 'fecundity compensation' hypothesis. Maternal parasitism negatively impacted life history parameters, resulting in reduced estimates of population increase (rm, R0, and λ), and increased generation time (GT) and doubling time (DT). These impacts were greater when the larva developing in the mother turned out to be female rather than male, and greater still when mothers were superparasitized. Maternal parasitism produced aphids with shorter hind tibia (HTL), at birth and at maturity, but their developmental time was unaffected. Although female L. fabarum readily accepted such aphids for oviposition, rates of mummification and wasp emergence were lower, and more so when the maternal parasitoid was female. The resulting parasitoids took longer to develop than progeny from control wasps, had shorter HTLs, lower egg loads, smaller eggs, and produced fewer mummies with lower rates of adult emergence, all differences that were more pronounced when the maternal parasitoid was female. The progeny of these wasps exhibited similar impairments to these biological parameters as their parents, demonstrating that the negative impacts of development in maternally parasitized hosts extended for at least two generations. Thus, our results do not support fecundity compensation, but suggest that any benefits of post-parasitism reproduction will be offset by reduced fitness in both aphid progeny and the parasitoids that develop in them.

Confirming pericardial access by using impedance measurements from a micropuncture needle

BACKGROUND

Pericardial access is complicated by two difficulties: confirming when the needle tip is in the pericardial space, and avoiding complications during access, such as inadvertently puncturing other organs. Conventional imaging tools are inadequate for addressing these difficulties, as they lack soft-tissue markers that could be used as guidance during access. A system that can both confirm access and avoid inadvertent organ injury is needed.

METHODS

A 21G micropuncture needle was modified to include two small electrodes at the needle tip. With continuous bioimpedance monitoring from the electrodes, the needle was used to access the pericardium in porcine models (n  =  4). The needle was also visualized in vivo by using an electroanatomical map (n  =  2). Bioimpedance data from different tissues were analyzed retrospectively.

RESULTS

Bioimpedance data collected from the subcutaneous space (992.8 ± 13.1 Ω), anterior mediastinum (972.2 ± 14.2 Ω), pericardial space (323.2 ± 17.1 Ω), mid-myocardium (349.7 ± 87.6 Ω), right ventricular cavity (235.0 ± 9.7 Ω), lung (1142.0 ± 172.0 Ω), liver (575.0 ± 52.6 Ω), and blood (177.5 ± 1.9 Ω) differed significantly by tissue type (P < .01). Phase data in the frequency domain correlated well with the needle being in the pericardial space. A simple threshold analysis effectively separated lung (threshold  =  1120.0 Ω) and blood (threshold  =  305.9 Ω) tissues from the other tissue types.

CONCLUSIONS

Continuous bioimpedance monitoring from a modified micropuncture needle during pericardial access can be used to clearly differentiate tissues. Combined with traditional imaging modalities, this system allows for confirming access to the pericardial space while avoiding inadvertent puncture of other organs, creating a safer and more efficient needle-access procedure.

Slow-pathway visualization by using voltage-time relationship: A novel technique for identification and fluoroless ablation of atrioventricular nodal reentrant tachycardia

BACKGROUND

Atrioventricular nodal reentrant tachycardia (AVNRT) is treatable by catheter ablation. Advances in mapping-system technology permit fluoroless workflow during ablations. As national practice trends toward fluoroless approaches, easily obtained, reproducible methods of slow-pathway identification, and ablation become increasingly important. We present a novel method of slow-pathway identification and initial ablation results from this method.

METHODS AND RESULTS

We examined AVNRT ablations performed at our institution over a 12-month period. In these cases, the site of the slow pathway was predicted by latest activation in the inferior triangle of Koch during sinus rhythm. Ablation was performed in this region. Proximity of the predicted site to the successful ablation location, complication rates, and patient outcomes were recorded. Junctional rhythm was seen in 40/41 ablations (98%) at the predicted site (mean, 1.3 lesions and median, 1 lesion per case). One lesion was defined as 5 mm of ablation. The initial ablation was successful in 39/41 cases (95%); in two cases, greater or equal to 2 echo beats were detected after the initial ablation, necessitating further lesion expansion. In 8/41 cases (20%), greater than one lesion was placed during initial ablation before attempted reinduction. Complications included one transient heart block and one transient PR prolongation. During follow-up (median, day 51), one patient had lower-extremity deep-vein thrombosis and pulmonary embolus, and one had a lower-extremity superficial venous thrombosis. There was one tachycardia recurrence, which prompted a redo ablation.

CONCLUSIONS

Mapping-system detection of late-activation, low-amplitude voltage during sinus rhythm provides an objective, and fluoroless means of identifying the slow pathway in typical AVNRT.

Thromboembolism in Atrial Fibrillation: Role of the Left Atrial Appendage

Atrial fibrillation (AF) is the most common arrhythmia. Patients with AF have a higher risk for thromboembolism than individuals without AF. The left atrial appendage (LAA) is the main source of thromboembolism because of its anatomic, mechanical, and electrophysiologic properties, and accounts for more than 90% of thrombus formation in patients with AF. Advancement in imaging expands knowledge about anatomic and physiologic characteristics of LAA. The risk of thromboembolism events in patients with AF depends on clinical comorbidities and structural and physiologic parameters of atria, especially LAA. This article discusses AF-related thromboembolic events and the role of the LAA.

P1008Increased incidence of supraventricular tachycardia during high influenza activity

Background/Introduction

Influenza remains a major risk to human health, estimated to result in 290,000 to 650,000 annual deaths worldwide. The association of influenza with coronary events is well established but influenza's impact on cardiac arrhythmias has received less attention.

Purpose

We investigated the effect of influenza on triggering supraventricular tachycardia (SVT).

Methods

This retrospective observational study included de-identified data from patients who had a Zio patch continuous cardiac monitoring from October 2012 to September 2017. The “influenza activity” was defined as the percentage of positive respiratory specimens that tested for influenza virus during each influenza season per reports from the Centers for Disease Control and Prevention. We included all SVT events from the weeks with the highest and lowest influenza activity up to two consecutive weeks after them. A paired t-test was used to compare the incidence of SVT episodes in weeks with the highest and lowest influenza activity.

Results

We reviewed records of 825869 patients (mean age, 61.06±15.31 years; 48.75% male); of these patients, 49984 had Zio patch during highest and lowest influenza activity time frame. The overall average episodes of SVT per person was 25% higher in the highest influenzas activity period comparing to the lowest activity (59.05 vs 47.26) and the higher incidence of SVT episodes in the highest influenza activity was significant (P value <0.01). A similar significant trend was observed during each individual influenza season.

Figure 1. average number of SVT episodes

Conclusion

High seasonal influenza activity is associated with increased odds of supraventricular tachycardia. Prospective studies are needed to determine the clinical implications of this finding.

Epicardial Left Atrial Appendage Exclusion Reduces Blood Pressure in Patients With Atrial Fibrillation and Hypertension

BACKGROUND

Percutaneous left atrial appendage exclusion (LAAE) has evolved as an alternative strategy for stroke prevention in atrial fibrillation (AF). Recent observational data have suggested that epicardial LAAE can have substantial impact on arrhythmia burden and hemodynamic profile.

OBJECTIVES

The authors aimed to study the impact of epicardial versus endocardial LAAE on systemic blood pressure in hypertensive AF patients.

METHODS

This was a prospective, nonrandomized study comparing 247 patients who underwent epicardial LAAE with 124 patients with endocardial exclusion. Clinical outcomes were measured at 3 months and 1 year. Primary outcome was improvement in systolic blood pressure (SBP) between both groups compared with baseline. Secondary outcome included changes in diastolic pressures (DBP), serum electrolytes, and creatinine.

RESULTS

There was no significant difference in baseline SBP between epicardial and endocardial groups. SBP was significantly lower in the epicardial group both at 3 months (122 ± 11.8 mm Hg vs. 129.7 ± 8.2 mm Hg; p < 0.001) and 1 year (123 ± 11.6 mm Hg vs. 132.2 ± 8.8 mm Hg; p < 0.001) compared with the endocardial group. An adjusted multivariate linear mixed effects model demonstrated that epicardial LAAE significantly decreased SBP by 7.4 mm Hg at 3 months and by 8.9 mm Hg at 1 year (p < 0.0001). There was a trend toward lower DBP with epicardial LAAE at 3 months by 1.3 mm Hg (p = 0.2) and at 1 year by 1.8 mm Hg (p = 0.09). There was no significant difference in serum electrolytes and creatinine between both groups.

CONCLUSIONS

In hypertensive AF patients, epicardial LAAE significantly decreases SBP both at 3 and 12 months compared with endocardial exclusion.

Functional Response of Hyperaspis polita (Coleoptera, Coccinellidae) to the Recently Invaded Mealybug Phenacoccus solenopsis (Hemiptera, Pseudococcidae)

Hyperaspis polita Weise is the major predator of Phenacoccus solenopsis Tinsley in southwestern Iran. The functional response of fourth instar larva, adult female and male of the ladybird, H. polita, preying upon different stages of the mealybug P. solenopsis was evaluated. All stages of H. polita exhibited type II functional responses against all stages of P. solenopsis with an exception that the functional response of the adult female stage of H. polita to first instar P. solenopsis nymphs was type III. Changing prey and predator stages did not result in significant differences in attack rates. Handling times, however, differed for different prey and predator stages. This parameter was the shortest for any stage of predator fed on first instar P. solenopsis nymphs and was estimated to be 0.1100, 0.1868, and 0.2939 h for fourth instar larval stage, adult females and males, respectively. Also, the handling time was the shortest for the fourth instar larval stage followed by adult females and males to different prey stages. Maximum predation rate (T/T_h) decreased as P. solenopsis developed from one life stage to another, the lowest estimated value being obtained by feeding on adult female mealybug and the fourth instar larval stage was the most predatory. According to these results, the feeding potential of H. polita is noticeable with the fourth larval instar stage being considered the most efficient predatory stage for use in biological control programs. Further field-based studies are needed, however, before a comprehensive estimation of the biocontrol abilities of H. polita toward P. solenopsis can be made.

Complex Left Atrial Appendage Morphology Is an Independent Risk Factor for Cryptogenic Ischemic Stroke

Importance: Ischemic strokes pose a significant health burden. However, the etiology of between 20 and 40% of these events remains unknown. Left atrial appendage morphology may influence the occurrence of thromboembolic events. Design: A retrospective cross-sectional study was conducted to investigate the role of LAA morphology in patients with atrial fibrillation (AF) and cardioembolic-associated stroke and patients with cryptogenic stroke without atrial fibrillation. LAA morphology is classified into two groups: (1) simple (chicken-wing) vs. (2) complex (non-chicken wing) based on transesophageal echocardiography (TEE) findings. In addition to the LAA morphology, left atrial parameters, including orifice diameter, depth, emptying velocity, and filling velocity, were collected for both groups. Mathematical, computational models were constructed to investigate flow velocities in chicken-wing and non-chicken wing morphological patterns to assess LAA function further. Findings: TEE values for volume, size, emptying, and filling velocities were similar between simple and complex LAA morphology groups. Patients with cryptogenic stroke without coexisting AF were noted to have significantly higher rates of complex LAA morphology. Chicken-wing LAA morphology was associated with four-fold higher flow rate (kg/s) in computational simulations. Conclusions: Complex LAA morphology may be an independent contributing factor for cryptogenic strokes. Further studies are warranted to investigate the mechanism involved in LAA morphology and thromboembolic events.

Cornicle secretions by Aphis fabae (Hemiptera: Aphididae) result in age-dependent costs and improved host suitability for Lysiphlebus fabarum (Marshall) (Hymenoptera: Braconidae)

We examined the life history consequences of cornicle secretion by Aphis fabae Scopoli in second and fourth instars, and its effects on host suitability for its parasitoid, Lysiphlebus fabarum (Marshall). Cornicle secretion did not affect aphid fecundity, but secretion in the second instar enhanced life table parameters, whereas secretion in the fourth instar affected them negatively, suggesting a higher cost of secretion in later instars. Secretion in either instar improved host suitability for L. fabarum. Although control and treated aphids were parasitized at similar rates, and with similar success, wasps developed faster and emerged as larger adults in aphids that had secreted, regardless of instar. Transgenerational effects were also evident. Progeny emergence was higher when parental wasps developed in fourth instars than in seconds, whether aphids secreted or not, and progeny were larger when parental hosts secreted in the second instar, but not in the fourth. Secreting fourth instars were preferred to controls by L. fabarum females in choice tests, but not secreting second instars, and fourth-instar secretion improved wasp emergence. When control aphids were attacked, second instars were more likely to secrete than fourth instars, whereas the latter were more likely to kick the parasitoid. Cornicle secretion reduced the probability of subsequent secretion events and the frequency of other aphid defensive behaviors, indicating energetic tradeoffs among defensive tactics. Overall, our results revealed that cornicle secretion by immature A. fabae exacts both physiological and behavioral costs and results in improved host suitability for its parasitoid.

Near-field impedance accurately distinguishes among pericardial, intracavitary, and anterior mediastinal position

INTRODUCTION

Epicardial catheter ablation is increasingly used to treat arrhythmias with an epicardial component. Nevertheless, percutaneous epicardial access remains associated with a significant risk of major complications. Developing a technology capable of confirming proper placement within the pericardial space could decrease complication rates. The purpose of this study was to examine differences in bioimpedance among the pericardial space, anterior mediastinum, and right ventricle.

METHODS

An ovine model (n = 3) was used in this proof-of-concept study. A decapolar catheter was used to collect bipolar impedance readings; data were collected between each of five electrode pairs of varying distances. Data were collected from three test regions: the pericardial space, anterior mediastinum, and right ventricle. A control region in the inferior vena cava was used to normalize the data from the test regions. Analysis of variance was used to test for differences among regions.

RESULTS

A total of 10 impedance values were collected in each animal between each of the five electrode pairs in the three test regions (n = 340) and the control region (n = 145). The average normalized impedance values were significantly different among the pericardial space (1.760 ± 0.370), anterior mediastinum (3.209 ± 0.227), and right ventricle (1.024 ± 0.207; P < 0.0001). In post hoc testing, the differences between each pair of regions were significant, as well (P < 0.001 for all).

CONCLUSION

Impedance values are significantly different among these three anatomical compartments. Therefore, impedance can be potentially used as a means to guide percutaneous epicardial access.

Anesthetic Management of Patients Undergoing Percutaneous Endocardial and Epicardial Left Atrial Appendage Occlusion

Atrial fibrillation is the most common cardiac arrhythmia in adults affecting almost 6 million adults in the United States. The 2 most common comorbidities associated with atrial fibrillation are heart failure and thromboembolic events. Heart failure symptoms may be treated with rate control, antiarrhythmic medications or by catheter ablation. Unfortunately, despite optimal medical management, thromboembolic events still occur. Recently, there has been a great deal of interest and innovation in finding an alternative to chronic anticoagulation. Several percutaneous left atrial appendage occlusion devices have been developed over recent years, some of which have proven to be noninferior to anticoagulation in preventing strokes in atrial fibrillation patients. The 2 most widely used left atrial appendage occlusion devices are the WATCHMAN (Atritech Inc, Plymouth, MN, USA) and the LARIAT (SentreHEART, Palo Alto, CA, USA) devices. After a detailed description of the procedures, the anesthetic considerations of each procedure and management of specific adverse events are discussed within this review.

Gamma irradiation on canola seeds affects herbivore-plant and host-parasitoid interactions

As an agricultural modernization, gamma irradiation is an important method for enhancing crop yield and quality. Nevertheless, its use can alter other plant traits such as nutrition and resistance to different biotic/abiotic stresses that consequently affect plant-insect interactions. A tritrophic system was utilized based on two canola mutant lines produced through gamma irradiation (RGS 8-1 and Talaye 8-3). Plutella xylostella (L.), as a worldwide pest of Brassicaceae and Cotesia vestalis (Holiday) as a key biocontrol agent of P. xylostella were examined for the potential indirect effects of canola seed irradiation on the experimental insects' performance when acting on the respective mutant lines. This study showed that physical mutation did not affect plant nitrogen and herbivore-damaged total phenolics; however, phenolic compounds showed greater concentration in damaged leaves than undamaged leaves of both mutant and control plants. The relative growth rate and pupal weight of P. xylostella reared on RGS 8-1 were significantly higher than those reared on the control RGS. There was no significant difference by performance parameters of the parasitoid, C. vestalis, including total pre-oviposition period, adult longevity, adult fresh body weight of males and females, pupal weight, forewing area, and total longevity of both sexes on tested canola cultivars in comparison with their mutant lines. Life table parameters of C. vestalis on mutant lines of both cultivars, RGS and Talaye, were not significantly different from their control treatments. Comprehensive studies should be conducted to find out the mechanisms under which gamma rays affect plant-insect interactions.

Accuracy of Voltage Signal Measurement During Radiofrequency Delivery Through the SMARTTOUCH Catheter

INTRODUCTION

Current methods for measuring voltage during radiofrequency (RF) ablation (RFA) necessitate turning off the ablation catheter. If voltage could be accurately read without signal attenuation during RFA, turning off the catheter would be unnecessary, allowing continuous ablation. We evaluated the accuracy of the Thermocool SMARTTOUCH catheter for measuring voltage while RF traverses the catheter.

METHODS AND RESULTS

We studied 26 patients undergoing RFA for arrhythmias. A 7.5F SMARTTOUCH catheter was used for sensing voltage and performing RFA. Data were collected from the Carto-3 3-dimensional mapping system. Voltages were measured during ablation (RF-ON) and immediately before or after ablation (RF-OFF). In evaluating the accuracy of RF-ON measurements, we utilized the RF-OFF measure as the gold standard. We measured 465 voltage signals. The median values were 0.2900 and 0.3100 for RF-ON and RF-OFF, respectively. Wilcoxon signed rank testing showed no significant difference in these values (P = 0.608). The intraclass correlation coefficient (ICC) was 0.96, indicating that voltage measurements were similarly accurate during RF-OFF versus RF-ON. Five patients had baseline atrial fibrillation (AF), for whom 82 ablation points were measured; 383 additional ablation points were measured for the remaining patients. The voltages measured during RF-ON versus RF-OFF were similar in the presence of AF (P = 0.800) versus non-AF rhythm (P = 0.456) (ICC, 0.96 for both).

CONCLUSION

Voltage signal measurement was similarly accurate during RF-ON versus RF-OFF independent of baseline rhythm. Physicians should consider not turning off the SMARTTOUCH ablation catheter when measuring voltage during RFA.

Impact of Periprocedural Colchicine on Postprocedural Management in Patients Undergoing a Left Atrial Appendage Ligation Using LARIAT

INTRODUCTION

Left atrial appendage (LAA) can be effectively and safely excluded using a novel percutaneous LARIAT ligation system. However, due to pericardial catheter manipulation and LAA ligation and subsequent necrosis, postprocedural course is complicated by pericarditis. We intended to evaluate the preprocedural use of colchicine on the incidence of postprocedural pericardial complications.

METHODS AND RESULTS

In this multicenter observational study, we included all consecutive patients who underwent LARIAT procedure at the participating centers. Many patients received periprocedural colchicine at the discretion of the physician. We compared the postprocedural outcomes of patients who received prophylactic periprocedural colchicine (colchicine group) with those who did not receive colchicine (standard group). A total of 344 consecutive patients, 243 in the "colchicine group" and 101 in the "standard group," were included. The mean age, median CHADS2VASc score, and HASBLED scores were 70 ± 11 years, 3 ± 1.7, and 3 ± 1.1, respectively. There were no significant differences in major baseline characteristics between the two groups. Severe pericarditis was significantly lower in the "colchicine group" compared to the "standard group" (10 [4%] vs. 16 [16%] P<0.0001). The colchicine group, compared to the standard group, had lesser pericardial drain output (186 ± 84 mL vs. 351 ± 83, P<0.001), shorter pericardial drain duration (16 ± 4 vs. 23 ± 19 hours, P<0.04), and similar incidence of delayed pericardial effusion (4 [1.6%] to 3 [3%], P = 0.42) when compared to the standard group.

CONCLUSION

Use of colchicine periprocedurally was associated with significant reduction in postprocedural pericarditis and associated complications.

A Review Of Clinical Trials On LARIAT Device

The risk of embolic stroke is 5 times higher among patients with atrial fibrillation (AF) compared with those without AF. More than 90% of thrombi form in the left atrial appendage (LAA) in AF. The purpose of this review is to determine the efficacy and safety of the left atrial appendage (LAA) closure via a percutaneous LAA ligation approach, thus preventing a stroke among patients with AF and contraindication to oral anticoagulant therapy.

A Review of the LARIAT Suture Delivery Device for Left Atrial Appendage Closure

The prevalence of atrial fibrillation (AF) is 1-2 % in the general population, and the risk of embolic stroke in AF patients is 4-5 times higher than that in the general population. AF-related strokes are often severe, and the rate of permanent disability is much higher among individuals who have AF-related strokes than in those who have strokes unrelated to AF. In patients with AF, more than 90 % of thrombi originate from the left atrial appendage (LAA). The purpose of this paper is to review the efficacy and safety of performing the LAA closure with the LARIAT Suture Delivery Device to prevent AF-related stroke in patients with contraindications to oral anticoagulant therapy.

Initial experience with a novel percutaneous left atrial appendage exclusion device in patients with atrial fibrillation, increased stroke risk, and contraindications to anticoagulation

Atrial fibrillation (AF) increases by fivefold a patient's risk for thromboembolic stroke. The main source of emboli in AF is the left atrial appendage (LAA). Therefore, LAA closure could reduce the risk for thromboembolic events in AF. The investigators report the first United States experience with a novel percutaneous LAA closure device, the Lariat snare device, and its outcomes in 21 patients with AF, CHADS2 scores ≥2, and contraindications to anticoagulation. The LAA was closed with a snare containing suture from within the pericardial space. The intraoperative success of the procedure was confirmed by left atrial angiography and transesophageal echocardiographic color Doppler flow. The effectiveness of the procedure was evaluated by follow-up transesophageal echocardiography. The incidence of periprocedural and short-term complications was assessed by reviewing medical records. Twenty patients (100%) had successful LAA exclusion that was preserved at 96 ± 77 days. No patient had a stroke during an average of 352 ± 143 days of follow-up. One patient had right ventricular perforation and tamponade that required surgical exploration and repair. Two patients required prolonged hospitalization: 1 because of pericardial effusion that required repeat pericardiocentesis and 1 because of noncardiac co-morbidities. Three patients developed pericarditis <1 month after the procedure, of whom 1 had associated pericardial effusion that required drainage. In conclusion, percutaneous LAA exclusion can be achieved successfully and with an acceptable incidence of periprocedural and short-term complications. Further studies are needed to determine whether LAA exclusion lowers the long-term risk for thromboembolic events in patients with AF and contraindications to anticoagulation.

Transseptal biopsy of a left atrial mass with 3-dimensional transesophageal echocardiographic guidance

A 31-year-old man presented with a large cardiac mass that originated from the basal posterior left atrial wall and occupied most of the dilated atrium. Minimally invasive studies yielded inconclusive results, but the patient was considered at high risk for an open cardiac biopsy due to the size of the mass. To establish a tissue diagnosis for definitive treatment, we performed a transseptal cardiac biopsy guided by 3-dimensional transesophageal echocardiography. We thereby determined that the mass was a primary left atrial sarcoma. To the best of our knowledge, this is the first report concerning the use of 3-dimensional transesophageal echocardiography for biopsy of a left atrial mass.