Electrical isolation of the right ventricular outflow tract in idiopathic ventricular tachycardia: A case report

Background

Ventricular tachycardia (VT) originating in the right ventricular outflow tract (RVOT) is the most common form of idiopathic VT. Catheter ablation of RVOT-VT is associated with high success rates. However, non-inducibility of VT on electrophysiological (EP) study can severely impact ablation outcome. We describe a novel catheter ablation strategy which proved feasible and safe in a case of highly symptomatic, non-inducible RVOT-VT.

Case summary

A 51-year-old male with a history of non-sustained VT (NSVT) was referred to our hospital after two syncopal episodes resulting in collapse. Upon admission, a cluster of monomorphic NSVT (250-270 bpm) resulted in haemodynamic instability and required transfer to the intensive care unit. On 12-lead ECG, NSVT showed inferior axis and left bundle branch block, suggestive of RVOT-VT. Diagnostic work-up including echocardiography, coronary angiography and late-enhancement computed tomography (CT) revealed no evidence of structural heart disease. On two EP studies, non-inducibility of clinical VT despite repeated ventricular pacing and isoproterenol infusion rendered precise mapping of triggered activity unfeasible. Therefore, a bailout ablation strategy was developed by performing a circumferential electrical RVOT isolation using a 3.5 mm irrigated-tip ablation catheter under the guidance of high-density electroanatomic mapping (CARTO® 3) and CT reconstruction of cardiac anatomy. No procedural complications occurred and the patient remained arrhythmia-free during a 6-month follow-up period.

Discussion

Catheter ablation is a first-line therapy for symptomatic and therapy-refractory idiopathic RVOT-VT. Non-inducibility of RVOT-VT represents a relevant limitation for successful ablation which might be overcome by electrical RVOT isolation as a bailout ablation strategy.

Safety of high power and short duration ablation (70 watts over 5–7 seconds) in patients with persistent atrial fibrillation undergoing pulmonary vein isolation and additional substrate modification

Background

In paroxysmal atrial fibrillation (AF), pulmonary vein isolation using HPSD has shown a promising success rate compared to ablation using conventional power settings, as well as a significant reduction in procedural and ablation time. In persistent atrial fibrillation, left atrial substrate modification seems to be a promising additional ablation approach besides pulmonary vein isolation (PVI). However, results after additional substrate ablation are not consistently positive, which may be related to non-transmural lesions and tissue oedema. An extended time of the procedure may also influence safety. Recent publications showed that HPSD ablation provides more sufficient lesions due to acute cell necrosis instead of cell oedema.

Purpose

The aim of this study is to evaluate the safety of HPSD ablation in patients undergoing ablation of persistent atrial fibrillation with PVI and additional substrate modification.

Methods

We studied and compared n=300 patients from our register undergoing the first ablation of persistent atrial fibrillation with HPSD settings (n=150) between May 2018 and January 2019 and standard settings (n=150) between July 2017 and January 2018. Patients were followed up for three months to report procedure-related adverse events. In all patients, a modified stepwise approach using PVI followed by electrogram-guided substrate modification and linear-ablation, if necessary, was performed. A HPSD ablation was performed with 70 watts with a maximum duration of 5–7 seconds. Catheter irrigation was set to 20 ml/min using the Flexability™ ablation catheter and the Ampere™ generator. The patients were compared with a historical cohort that underwent PVI using a conventional power protocol with 30–40 watts over 20–40 seconds, using the same ablation catheter. A transthoracic echocardiogram was performed in all patients after the ablation-procedure and on the following day. Duplex sonography or clinical control were performed to assess groin complications.

Results

Baseline characteristics and procedural data are shown in table 1. No significant difference in the complication rates in both groups was observed by a significant procedure-time reduction in HPSD-Group (2:13h vs 2:31h p<0,001) and overall low risk of the procedure. No deaths, thromboembolic complications or atrioesophageal fistula were registered. Complication rates with statistical relevancy are shown in table 2.

Conclusion

Complex ablation using PVI and additional substrate modification in persistent atrial fibrillation using HPSD seems to be equally as safe regarding procedure-related outcomes as standard power settings ablation and can significantly reduce the time of the overall procedure.

Funding Acknowledgement

Type of funding sources: None.

Stages of Change for Osteoporosis Preventive Behaviors

Objective: This article presents a construct validation study for osteoporosis preventive behaviors based on a survey completed by 113 older adults. Methods: Participants were classified using stages of change for osteoporosis preventive behaviors according to an algorithm adapted from the Transtheoretical Model of health behavior change. Results: One-way analyses of variance and a hierarchical regression model indicate that stage of change location is significantly related to one’s level of knowledge about osteoporosis as well as age, gender, and educational attainment. These findings bring support to the validity of the instrument. Discussion: Findings from this study indicate that elders’ attitudes and knowledge about osteoporosis reflect public health messages heralding osteoporosis as the disease of the older White women. Significant health care expenditures in the nontargeted groups call for a revision in these messages. Further applications with more heterogeneous samples are necessary for thorough validation and reliability testing of the proposed instrument.

Meta-analysis of cognitive functioning in breast cancer survivors previously treated with standard-dose chemotherapy

PURPOSE

Evidence is mixed regarding long-term cognitive deficits in patients treated with chemotherapy. Previous meta-analyses have not focused specifically on the postchemotherapy period and have not incorporated several recent studies. The goal of the current study was to conduct a meta-analysis of cognitive functioning in breast cancer survivors who were treated with chemotherapy ≥ 6 months previously.

METHODS

A search of PubMed, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library yielded 2,751 abstracts, which were independently evaluated by pairs of raters. Meta-analysis was conducted on 17 studies of 807 patients previously treated with standard-dose chemotherapy for breast cancer. Neuropsychological tests were categorized according to eight cognitive domains: attention, executive functioning, information processing, motor speed, verbal ability, verbal memory, visual memory, and visuospatial ability.

RESULTS

Deficits in cognitive functioning were observed in patients treated with chemotherapy relative to controls or prechemotherapy baseline in the domains of verbal ability (g = -0.19; P < .01) and visuospatial ability (g = -0.27; P < .01). Patients treated with chemotherapy performed worse than noncancer controls in verbal ability and worse than patients treated without chemotherapy in visuospatial ability (both P < .01). Age, education, time since treatment, and endocrine therapy did not moderate observed cognitive deficits in verbal ability or visuospatial ability (all P ≥ .51).

CONCLUSION

Results indicate that, on average, observed cognitive deficits in patients with breast cancer previously treated with chemotherapy are small in magnitude and limited to the domains of verbal ability and visuospatial ability. This information can be used to inform interventions to educate patients with breast cancer regarding the long-term impact of chemotherapy on cognitive functioning.

Association of idiotype vaccine-induced T-cell response with improved survival and time-to-next treatment (TTNT) in untreated mantle cell lymphoma (MCL)

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Background: Murine models show Id-vaccines induce antitumor responses, possibly through Th1/Tc1 cytokines. We report an 11-year follow-up of Id-vaccine following DA-EPOCH-Rituximab in 26 untreated MCL patients. Methods: DA-EPOCH-R was administered q3 weeks × 6, followed 12 weeks later by 5 cycles of Id-vaccine. Id protein was made by hybridoma technology, conjugated to keyhole limpet hemocyanin (KLH) and administered with GM-CSF. Pre- and post-vaccine immune responses (IR) were tested in parallel: anti-Id and anti-KLH humoral responses (ELISA); anti-KLH cellular responses (intracellular cytokine assay); and anti-tumor cellular responses (cytokine induction, IFNγ ELISPOT). Results: Characteristics: median age 57 (r 22-73), blastoid variant 15%, and MIPI (low-65%; intermediate-16%; high-19%). With 122 mo median follow-up (r 111-132), the median PFS is 24 mo and OS is 104 mo. MIPI was associated with OS (p=0.0002); median OS: low (not reached), intermediate (84 mo) and high (44 mo). We found no association between OS and anti-KLH IR, anti-Id humoral response, IFNγ ELISPOT, or antitumor TNFα or IFNγ responses. Normalized antitumor T-cell GM-CSF response (median <4.3 vs. >4.3) was associated with OS of 79 mo vs. not reached, respectively (p=0.015 (unadj.) and p=0.045 (adj.)). MIPI (p=0.02) and GM-CSF (p=0.057) were independently associated with OS. TTNT (based on disease activity), correlated with antitumor GM-CSF response (p=0.018) but not MIPI and was independent of MIPI (GM-CSF; p=0.041). Correlation of pre-and post-treatment GM-CSF production suggested a priming effect. Tumor proliferation by GEP did not correlate with OS (n=14). Conclusions: Antitumor GM-CSF response was significantly associated with OS and TTNT, suggesting antitumor cellular immune response significantly delayed tumor growth. Antitumor GM-CSF response may serve as a surrogate biomarker for vaccine efficacy. Our results are consistent with recent data that T-cell GM-CSF production is required for breaking tolerance against self-antigens. Id vaccines may prolong survival of MCL following rituximab-based chemotherapy and should be further evaluated.

Vaccination with patient-specific tumor-derived antigen in first remission improves disease-free survival in follicular lymphoma

PURPOSE

Vaccination with hybridoma-derived autologous tumor immunoglobulin (Ig) idiotype (Id) conjugated to keyhole limpet hemocyanin (KLH) and administered with granulocyte-monocyte colony-stimulating factor (GM-CSF) induces follicular lymphoma (FL) -specific immune responses. To determine the clinical benefit of this vaccine, we conducted a double-blind multicenter controlled phase III trial.

PATIENTS AND METHODS

Treatment-naive patients with advanced stage FL achieving complete response (CR) or CR unconfirmed (CRu) after chemotherapy were randomly assigned two to one to receive either Id vaccine (Id-KLH + GM-CSF) or control (KLH + GM-CSF). Primary efficacy end points were disease-free survival (DFS) for all randomly assigned patients and DFS for randomly assigned patients receiving at least one dose of Id vaccine or control.

RESULTS

Of 234 patients enrolled, 177 (81%) achieved CR/CRu after chemotherapy and were randomly assigned. For 177 randomly assigned patients, including 60 patients not vaccinated because of relapse (n = 55) or other reasons (n = 5), median DFS between Id-vaccine and control arms was 23.0 versus 20.6 months, respectively (hazard ratio [HR], 0.81; 95% CI, 0.56 to 1.16; P = .256). For 117 patients who received Id vaccine (n = 76) or control (n = 41), median DFS after randomization was 44.2 months for Id-vaccine arm versus 30.6 months for control arm (HR, 0.62; 95% CI, 0.39 to 0.99; P = .047) at median follow-up of 56.6 months (range, 12.6 to 89.3 months). In an unplanned subgroup analysis, median DFS was significantly prolonged for patients receiving IgM-Id (52.9 v 28.7 months; P = .001) but not IgG-Id vaccine (35.1 v 32.4 months; P = .807) compared with isotype-matched control-treated patients.

CONCLUSION

Vaccination with patient-specific hybridoma-derived Id vaccine after chemotherapy-induced CR/CRu may prolong DFS in patients with FL. Vaccine isotype may affect clinical outcome and explain differing results between this and other controlled Id-vaccine trials.

Is the effect of reported physical activity on disability mediated by cognitive performance in white and african american older adults?

This study examined if reported physical activity has beneficial outcomes on disability through cognitive performance-mediated effects and if these mediation effects are comparable for White and African American elders. Longitudinal data from the Assets and Health Dynamics among the Oldest Old study (N = 4,472) are used to test mediation in multilevel models. During the 7-year follow-up, cognitive performance mediated the effects of reported physical activity on disability in the entire sample and in Whites but not in African Americans. Our results indicate that reported physical activity may delay the disability development through improvement in cognitive performance. Unmeasured education and comorbidity influences may have obscured the mediation effects in African Americans. Reported physical activity plays a key role in the independence of older adults and should be particularly promoted in African Americans and during the entire life course.