Gender differences in patients with structural heart disease undergoing VT ablation

INTRODUCTION

This study sought to examine gender differences in patients with structural heart disease (SHD) referred for ablation of ventricular tachycardia (VT).

BACKGROUND

Female patients are often underrepresented in large studies. Significant differences in the clinical presentation, treatment, and prognosis of female patients have been described in previous studies.

METHODS AND RESULTS

We investigated 88 female patients with SHD undergoing VT ablation (mean age 59 years, 56% nonischemic cardiomyopathy, mean left ventricular ejection fraction 35%, 82% in electrical storm). A case-control study with 88 male patients was performed and the results regarding clinical and procedural characteristics, acute and long-term results of the two groups were compared. The female patients had more arrhythmogenic substrate, as they more commonly presented with electrical storm (p = .016) and had a higher number of inducible VT morphologies during the procedure (p = .018). Moreover, the female patients were less likely to have an optimized heart failure medical treatment at baseline (p = .030) and required more time from the first manifestation of the VT to ablation referral (p = .034). Although fewer epicardial ablations were performed in female patients (p = .019), the two groups showed similar results regarding VT noninducibility as ablation endpoint (p = .844), major procedure-related complications (p = .719) and freedom from VT during follow-up (p = .268). Moreover, the overall mortality in the two groups was similar (p = .176). Advanced NYHA class was associated with worse transplant and assist-device-free survival in the female group.

CONCLUSION

Female patients presenting for VT ablation had more arrhythmogenic substrate and were less likely to have an optimized heart failure medical treatment. Nevertheless, the procedural acute and long-term outcomes between the two genders were similar.

Role of assist device implantation and heart transplantation in the long-term outcome of patients with structural heart disease after catheter ablation of ventricular tachycardia

Introduction

Ablation of ventricular tachycardias (VTs) in patients with structural heart disease (SHD) has been associated with advanced heart failure and poor survival.

Methods and results

This matched case-control study sought to assess the difference in survival after left ventricular assist device (LVAD) implantation and/or heart transplantation (HTX) in SHD patients undergoing VT ablation. From the initial cohort of 309 SHD patients undergoing VT ablation (187 ischemic cardiomyopathy, mean age 64 ± 12 years, ejection fraction of 34 ± 13%), 15 patients received an LVAD and nine patients HTX after VT ablation during a follow-up period of 44 ± 33 months.

Long-term survival after LVAD did not differ from the matched control group (p = 0.761), although the cause of lethal events was different. All post-HTX patients survived during follow-up.

Conclusion

In this matched case-control study on patients with SHD undergoing VT ablation, patients that received LVAD implantation had similar survival compared to the control group after 4‑year follow-up, while the patients with HTX had a significantly better outcome.

Observations during the COVID-19 pandemic in chronic heart failure patients with complex devices in a tertiary care cardiac centre using the HeartLogic software

Funding Acknowledgements

Type of funding sources: None.

Introduction

Decompensation of heart failure leading (HF) to hospitalisation is the single most important drain on healthcare resources when managing patients with left ventricular systolic dysfunction. Cardiac resynchronisation therapy with/without defibrillators (CRT-P/D) decreases hospitalisation due to HF and improves survival while implantable cardiac defibrillators (ICD"s) have a favourable effect on the former. Proprietary software algorithms embedded in these complex devices give an early warning to clinicians when decompensation of HF is imminent allowing preventative action to be undertaken.

HeartLogic (HL) is one such new algorithm in Boston Scientific CRT-D/ICD devices using multiple sensors to track 5 physiological parameters, combining them into one composite Index, with an Alert being triggered if the Index is >16. The COVID-19 pandemic, due to multiple reasons, resulted in a significant decrease in availability of routine HF services in the United Kingdom, especially during the initial lockdown period from 23rd March to 1st July 2020.

Aim

To assess the impact of the COVID-19 pandemic, using HL, in patients with HF and complex devices. 

Materials and Methods

Retrospective analysis of patients in a tertiary care cardiac centre in whom the HL software had been activated in March/April 2019 (n = 49) and comparison of those with (Group A n = 21) and without (Group B n = 28) an Alert (HLA) during the COVID-19 pandemic. 

Results (Table): Whole cohort n = 49. Age:  72 ± 12 years, Median: 75, Range: 36-95. 36/49 (73.5%) males. Type of device implanted: Resonate X4 CRT-D: 28/49 (57.1%); Momentum CRT-D: 8/49 (16.3%); Resonate ICD: 13/49 (26.5%). Ischaemic aetiology of HF: 35/49 (71.4%), Total duration of HL monitoring: 632 ± 7 days (median: 632; range: 626-672).  There was no difference in the age, gender, and type of device implanted between Group A and Group B. Over nearly ∼1 year of monitoring in each of the groups, Group A had more unstable HF with 10/21 (47.6%) having their first HLA during the pandemic. Multiple HLA"s, longer period in HLA and those with ischaemic aetiology of HF were higher in Group A. 17/40 (42.5%) HLA"s in Group A were within the first lockdown period (March - July). 24/28 (85.7%) patients in Group B had no HLA"s either before or during the pandemic. There was no difference in the HLA score between Groups A and B.

Conclusion

In this limited group of patients with a medium term follow-up, using the HeartLogic software, patients with ischaemic aetiology of HF and those with more HLA"s prior to the pandemic did worse than those who no HLA"s. First HLA"s, multiple alerts and longer duration of alerts in this group of patients suggests a lack of access to adequate HF services during the pandemic. It has implications with regard to how HF services are configured in future whenever resources are constrained.

Chemical ordering as a precursor to formation of orderedδ-UZr2phase: a theoretical and experimental study

A combination of special quasi-random structure (SQS) analysis, density functional theory (DFT) based simulations and experimental techniques are employed in determining the transformation pathway for the disorderedγ-(U, Zr) phase (bcc structure) to transform into the chemically orderedδ-UZr₂phase (C32, AlB₂type structure). A novel Monte-Carlo based strategy is developed to generate SQS structures to study theβ→ωdisplacive phase transformation in A_1-xB_xbinary random alloy. Structures generated with this strategy and using DFT calculations, it is determined that (222)_bccplane collapse mechanism is energetically unfavorable in chemically disordered environment at UZr₂composition. A mechanically and dynamically stable 24 atom SQS structure is derived which serves as a structural model of chemically orderedδ-UZr₂structure. Finally, a thermodynamic basis for the mechanism of theγtoδtransformation has been established which ensures chemical ordering is a precursor to the subsequent displacive transformation to form chemically orderedδ-UZr₂structure.

Association of low-voltage areas with the regional wall deformation and the left atrial shape in patients with atrial fibrillation: A proof of concept study

Background

Left atrium (LA) remodeling is associated with atrial fibrillation (AF) and reduced success after AF ablation, but its relation with low-voltage areas (LVA) is not known. This study aimed to evaluate the relation between regional LA changes and LVAs in AF patients.

Methods

Pre-interventional CT data of patients (n = 24) with LA-LVA (<0.5 mV) in voltage mapping after AF ablation were analyzed (Surgery Explorer, QuantMD LLC). To quantify asymmetry (ASI = LA-A/LAV) a cutting plane parallel to the rear wall and along the pulmonary veins divided the LA-volume (LAV) into anterior (LA-A) and posterior parts. To quantify sphericity (LAS = 1-R/S), a patient-specific best-fit LA sphere was created. The average radius (R) and the mean deviation (S) from this sphere were calculated. The average local deviation (D) was measured for the roof, posterior, septum, inferior septum, inferior-posterior and lateral walls.

Results

The roof, posterior and septal regions had negative local deviations. There was a correlation between roof and septum (r = 0.42, p = 0.04), lateral and inferior-posterior (r = 0.48, p = 0.02) as well as posterior and inferior-septal deviations (r = −0.41, p = 0.046). ASI correlated with septum deformation (r = −0.43, p = 0.04). LAS correlated with dilatation (LAV, r = 0.49, p = 0.02), roof (r = 0.52, p = 0.009) and posterior deformation (r = −0.56, p = 0.005). Extended LVA correlated with local deformation of all LA walls, except the roof and the septum. LVA association with LAV, ASI and LAS did not reach statistical significance.

Conclusion

Extended LVA correlates with local wall deformations better than other remodeling surrogates. Therefore, their calculation could help predict LVA presence and deserve further evaluation in clinical studies.

Plasma Levels and Gene Expression of RANK in Non-Alcoholic Fatty Liver Disease

BACKGROUND

The pathobiology of initiation and progression of nonalcoholic fatty liver disease (NAFLD) has not been completely elucidated. It seems that the RANK/RANKL/OPG cytokine system play an etiologic role in pathogenesis of this disease. This study aimed to investigate the plasma content and gene expression of RANK in NAFLD patients as compared to healthy individuals.

METHODS

This case-control work was performed on 63 patients with NAFLD and 25 healthy subjects. The plasma levels of RANK and biochemical parameters were measured using ELISA and colorimetric methods, respectively. Also, RANK mRNA content was evaluated by quantitative RT-PCR in peripheral blood mononuclear cells.

RESULTS

RANK plasma contents were shown to be lower in NAFLD patients than in control subjects (1.02 ± 0.75 and 1.41 ± 1 ng/mL, respectively (p = 0.008)). The differences in gene expression of RANK between NAFLD patients and controls were significant (p = 0.001). In the NAFLD patients, RANK was inversely correlated with HDL. Logistic regression showed the association of RANK plasma content with the risk of NAFLD. Moreover, ROC curve analysis showed that RANK has a great ability to differentiate between NAFLD patients and controls.

CONCLUSIONS

This study for the first time showed lower plasma and mRNA levels of RANK in NAFLD patients compared to control individuals. These results recommend a possible association between RANK and pathobiology of NAFLD.

VT ablation in geriatric patients with structural heart disease: Should there still be an age limit?

INTRODUCTION

This study sought to examine the feasibility and outcome of ablation of ventricular tachycardias (VTs) in a contemporary cohort of geriatric patients with structural heart disease (SHD).

BACKGROUND

Geriatric patients are often underrepresented in large studies. As frailty is becoming an increasing problem, we need to examine the best course of action for this population.

METHODS AND RESULTS

We investigated 68 SHD-patients ≥ 75 years old undergoing VT-ablation (men 88%, ischemic cardiomyopathy 77%, electrical storm 72%, mean left ventricular ejection fraction 31%) and divided the cohort into two groups: 75-79 years old (n = 51) and ≥80 years old (n = 17). The two groups showed similar results regarding noninducibility as ablation endpoint (p = .693), major procedure-related complications (p = .488), and VT-recurrence (p = .882) during the 39-month follow-up. At the end of the follow-up, 10 patients in the octogenarian group (59%) versus 16 patients of the other group (31%) died.

CONCLUSION

Geriatric patients with SHD including octogenarians showed similar results regarding procedural endpoints, freedom of VT, and major procedure-associated complications after VT-ablation. When ablation is indicated, age alone should not be an inhibiting factor to treat these patients.

Validation of the VT-LVAD score for prediction of late VAs in LVAD recipients

OBJECTIVES

This study sought to validate the performance of the VT-LVAD risk model in predicting late ventricular arrhythmias (VAs) in patients after left ventricular assist device (LVAD) implantation.

BACKGROUND

The need for implantable cardioverter-defibrillator (ICD)-implantation in LVAD recipients is not well studied. A better selection of the patients with high risk for late VAs could lead to a more targeted ICD-implantation or replacement.

METHODS

The study evaluated the performance of the VT-LVAD prognostic score (VAs prior LVAD, no ACE-inhibitor in medication, heart failure duration > 12 months, early VAs post-LVAD implantation, atrial fibrillation prior LVAD, idiopathic dilated cardiomyopathy) for the endpoint of the occurrence of late VAs in 357 LVAD patients in Heart Centre of Leipzig.

RESULTS

From the initial 460 patients, 357 (age: 58 ± 10 years; left ventricular ejection fraction: 20 ± 6%; HeartWare: 50%; HeartMate III: 42%) were assigned to four risk groups according to their VT-LVAD score varying from low risk to very high risk. After 25 months, late VAs occurred in 130 patients. The VT-LVAD score was an independent predictor of late VAs (multivariate analysis; p = < .001; goodness-of-tip p = .347; odds ratio: 4.8). While there was no statistically significant difference between the low- and intermediate-risk group, risk stratification for patients with high risk and very high risk performed more accurately (pairwise comparison p = .005 and p < .001, respectively).

CONCLUSIONS

The VT-LVAD score predicted accurately the occurrence of late VAs in high-risk LVAD recipients in a large external cohort of LVAD recipients supporting its utility for more targeted ICD implantations.

Predictors of rhythm outcomes after cardiac resynchronization therapy in atrial fibrillation patients: When should we use an atrial lead?

BACKGROUND

Cardiac resynchronization therapy (CRT) is widely used in atrial fibrillation (AF) patients and could impact rhythm stability.

HYPOTHESIS

We aimed to identify predictors of sinus rhythm (SR) stability or AF progression in a real-word cohort of CRT-AF patients.

METHODS

From 330 consecutive implantable cardioverter-defibrillator implantations due to ischemic or dilated cardiomyopathy, 65 (20%) patients with AF history (paroxysmal, n = 32) underwent a CRT implantation with an atrial electrode and were regularly followed every 4-6 months. Rhythm restoration was attempted for most AF patients based on symptoms, biventricular pacing (BP), and lack of thrombi.

RESULTS

After 33 months, 18 (28%) patients progressed to permanent mode switch (MS≥99%) and 20 (31%) patients had stable SR (MS < 1%). Logistic regression showed that history of persistent AF (OR: 8.01, 95%CI: 2.0-31.7, p = .003) is associated with higher risk of permanent MS. In persistent AF patients, a bigger left atrium (OR: 1.2 per mm, 95%CI: 1.03-1.4, p = .025) and older age (OR: 1.15 per life-year, 95%CI: 1.01-1.3, p = .032) were predictors of future permanent MS. Paroxysmal AF at implantation (OR: 5.96, 95%CI: 1.6-21.9, p = .007) and increased BP (OR: 1.4 per 1%, 95%CI: 1.05-1.89, p = .02) were associated with stable SR. In persistent AF patients, stable SR correlated with higher BP (98 ± 2 vs. 92 ± 8%, p < .001).

CONCLUSION

In patients with AF undergoing CRT implantation, persistent AF, LA dilatation and advanced age relate to future permanent MS (AF), whereas high BP promotes SR stability. These findings could facilitate the management of CRT-AF patients and guide therapy in order to maximize its effect on rhythm.

Very late arrhythmia recurrences in patients with sinus rhythm within the first year after catheter ablation: The Leipzig Heart Center AF Ablation Registry

AIMS 

Arrhythmia recurrences after catheter ablation of atrial fibrillation (AF) still remain an important management issue. Recently, the APPLE score had been introduced to predict rhythm outcomes within 12 months after catheter ablation, while the simple MB-LATER score was developed for the prediction of very late recurrence of AF (VLRAF) occurring after 12 months. The aim of this study was to compare APPLE and MB-LATER scores in predicting VLRAF.

METHODS AND RESULTS 

The study population included arrhythmia-free patients within first 12 months after first radiofrequency catheter ablation from The Heart Center Leipzig AF Ablation Registry. The APPLE [one point for Age >65 years, Persistent AF, imPaired eGFR <60 mL/min/1.73 m2, Left atrial (LA) diameter ≥43 mm, EF <50%] and MB-LATER scores [one point for Male gender, Bundle branch block or QRS >120 ms, LA diameter ≥47 mm, AF Type (persistent AF), Early Recurrence <3 months] were calculated before and 3 months after ablation, respectively. We followed 482 patients {age 61 [interquartile range (IQR) 54-68] years, 66% males, 32% persistent AF} for median 40 (IQR 35-50) months. There were 184 patients (38.3%) with arrhythmia recurrences within 13-60 months after ablation. On multivariate analysis, APPLE [odds ratio (OR) 1.517, 95% confidence interval (CI) 1.244-1.850, P < 0.001] and MB-LATER (OR 1.437, 95% CI 1.211-1.705, P < 0.001) scores and diabetes mellitus (OR 2.214, 95% CI 1.353-3.625, P = 0.002) were significantly associated with arrhythmia recurrences. Receiver operating characteristic curve analyses demonstrated moderate prediction for both scores [area under the curve (AUC) 0.607, P < 0.001 for APPLE score, AUC 0.604, P < 0.001 for MB-LATER].

CONCLUSION 

Prediction of VLRAF is similar for both APPLE and MB-LATER scores. A better score remains still a clinical unmet need.

Left atrial activation and asymmetric anatomical remodeling in patients with atrial fibrillation: The relation between anatomy and function

BACKGROUND

Identifying patients with advanced left atrial (LA) remodeling before catheter ablation (CA) of atrial fibrillation (AF) is crucial.

HYPOTHESIS

This study aimed to identify echocardiographic parameters associated with changes in anatomy and conduction properties of the left atrium (LA).

METHODS

We examined 75 AF patients prior to CA and measured the intervals from the P-wave-onset to four mitral annulus sites by pulsed-wave tissue Doppler imaging (PW-TDI). Patients were grouped to an upward U-pattern (delayed anterior activation) and a downward D-pattern (earliest LA activation anterior). CT-data were used to measure the LA volume (LAV). LAV was divided into anterior- (LA-A) and posterior-parts by a plane, parallel to the posterior wall and between the veins and the appendage, to calculate the asymmetry index (ASI = LA-A/LAV).

RESULTS

Patients with U-pattern (n = 66) had a higher ASI (65 ± 6 vs. 61 ± 3%, p = .014), older age (61 ± 11 vs. 51 ± 11 years, p = .03) and more diastolic dysfunction (71 vs. 22%, p = .008) Multivariate regression showed that age (OR 1.1 per year, CI 1.007-1.199) and diastolic dysfunction (OR 6.36, CI 1.132-35.7, p = .036) were independent predictors of the U-pattern. Diastolic dysfunction (B 4.49, CI 1.61-7.37, p = .003) was the only independent predictor of ASI in linear regression analysis.

CONCLUSION

AF patients with a U-pattern have an increased LA asymmetry. Diastolic dysfunction is a common cause of this LA activation and remodeling. Therefore, detection of a U-pattern signifies patients with advanced AF and may facilitate selection for an appropriate ablation strategy.

Circulating mRNA and plasma levels of osteoprotegerin and receptor activator of NF-κB ligand in nonalcoholic fatty liver disease

Pathogenesis of the beginning and progression of nonalcoholic fatty liver disease (NAFLD) has not been clarified exactly. The osteoprotegerin (OPG)/receptor activator of NF-κB ligand (RANKL) axis seems to play an imperative function in the onset and progression of this disease. The goal of the present study was to investigate the peripheral blood mononuclear cell (PBMC) expression and plasma levels of RANKL and OPG cytokines in NAFLD patients and compare them with healthy group. Plasma levels of OPG and RANKL were determined with ELISA kits in 57 men with NAFLD and 25 healthy men as controls. Biochemical and anthropometric parameters tests were also evaluated in the study groups. RANKL and OPG mRNA contents were evaluated by quantitative RT-PCR. OPG contents were markedly decreased in NAFLD patients as compared with healthy patients [1.43 (1.05-5.45)] versus [2.94 (1.76-4.73)] ng/mL; P = 0.007). The levels of RANKL were significantly reduced in NAFLD patients [74.00 (56.26-203.52) ng/mL] than in healthy patients [119.37 (83.71-150.13) ng/mL]; (P = 0.03). Also, OPG and RANKL gene expression were significantly decreased in NAFLD patients in comparison with the control group (P < 0.05). Moreover, receiver operating characteristic curve indicated that OPG may have a good capability to discriminate between NAFLD patients and normal individuals. A positive correlation was observed between OPG and RANKL in plasma sample (r = 0.495) (P = 0.000). Decreased plasma levels and gene expression of RANKL and OPG cytokines in NAFLD patients indicate that there is a relationship between these cytokines and the pathology of NAFLD disease. Confirmation of this association as well as the mechanism and role of these cytokines in NAFLD require further studies.

Feasibility and Reliability of SmartWatch to Obtain 3-Lead Electrocardiogram Recordings

Some of the recently released smartwatch products feature a single-lead electrocardiogram (ECG) recording capability. The reliability of obtaining 3-lead ECG with smartwatches is yet to be confirmed in a large study. This study aimed to assess the feasibility and reliability of smartwatch to obtain 3-lead ECG recordings, the classical Einthoven ECG leads I-III compared to standard ECG. To record lead I, the watch was worn on the left wrist and the right index finger was placed on the digital crown for 30 s. For lead II, the watch was placed on the lower abdomen and the right index finger was placed on the digital crown for 30 s. For lead III, the same process was repeated with the left index finger. Spearman correlation and Bland-Altman tests were used for data analysis. A total of 300 smartwatch ECG tracings were successfully obtained. ECG waves' characteristics of all three leads obtained from the smartwatch had a similar duration, amplitude, and polarity compared to standard ECG. The results of this study suggested that the examined smartwatch (Apple Watch Series 4) could obtain 3-lead ECG tracings, including Einthoven leads I, II, and III by placing the smartwatch on the described positions.

Complex cases of acquired pulmonary vein stenosis after radiofrequency ablation: is surgical repair an option?

Aims

Results of catheter based interventional treatment for pulmonary vein stenosis (PVS) following radiofrequency ablation (RFA) for atrial fibrillation remain suboptimal. Surgical repair may represent an alternative therapy, though long-term results have not been thoroughly investigated.

Methods and results

We retrospectively assessed all patients in our centre undergoing surgical repair for radiofrequency-induced PVS. Data regarding surgical technique, clinical outcome, and rate of pulmonary vein (PV) restenosis were collected and analysed. Between 2004 and 2016, the rate for PVS resulting from RFA for atrial fibrillation in our institution was 0.79% (76/9633). During this period, five male patients with multiple PVS (3 ± 1) underwent surgical repair of a total of 13 symptomatic PVS. Surgery was performed in a standard setting under cardiopulmonary bypass. Stenotic veins were incised longitudinally followed by a patch augmentation plasty using either bovine pericard (n = 7) or polytetrafluoroethylene (PTFE) patches (n = 5). Localization of incision was on the anterior side of the PV only (n = 8) or on both the anterior and posterior sides (n = 4). In one PVS lesion, mechanical dilatation was sufficient. Long-term follow-up after 60 ± 69 months revealed an average restenosis rate of 38%. Restenosis was defined as narrowing >70%. All patients reported clinical improvement of symptoms at follow-up.

Conclusion

Even in the era of wide circumferential lesions, PVS still occurs. While surgical PV patch plasty represents a valuable treatment option, restenosis remains an issue during follow-up. Nevertheless, surgical repair achieves highly acceptable long-term results for RFA-acquired PVS. Hence, it should be routinely discussed as a therapeutic option in cases with multiple PVS.

Predictors of long-term mortality after catheter ablation of ventricular tachycardia in a contemporary cohort of patients with structural heart disease

Aims

Ablation of ventricular tachycardias (VTs) in patients with structural heart disease has been established in the past decades as an effective and safe treatment. However, the prognosis and long-term outcome remains poor.

Methods and results

We investigated 309 patients with ischaemic cardiomyopathy (ICM) and non-ischaemic cardiomyopathy (NICM) (186 ICM, 123 NICM; 271 males; mean age 64.1 ± 12 years; ejection fraction 34 ± 13%) after ≥1 VT ablations over a mean follow-up period of 34 ± 28 months. Electrical storm was the indication for 224 patients (73%), whereas 86 patients (28%) underwent epicardial as well as endocardial ablation. During follow-up, 132 patients (43%) experienced VT recurrence and 97 (31%) died. Ischaemic cardiomyopathy and NICM patients showed comparable results, regarding procedural endpoints, complications, VT recurrence and survival. The Cox-regression analysis for all-cause mortality revealed that the presence of higher left ventricular end-diastolic volume (LVEDV; P &lt; 0.001), male gender (P = 0.018), atrial fibrillation (AF; P &lt; 0.001), chronic obstructive pulmonary disease (COPD; P = 0.001), antiarrhythmic drugs during the follow-up (P &lt; 0.001), polymorphic VTs (P = 0.028), and periprocedural complications (P = 0.001) were independent predictors of mortality.

Conclusion

Ischaemic cardiomyopathy and NICM patients undergoing VT ablation had comparable results regarding procedural endpoints, complications, VT recurrence and 3-year mortality. Higher LVEDV, male gender, COPD, AF, polymorphic VTs, use of antiarrhythmics, and periprocedural complications are strong and independent predictors for increased mortality. The PAINESD score accurately predicted the long-term outcome in our cohort.

Oesophageal Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation (OPERA): results from a prospective randomized trial

Aims

The aim of the study was to determine the incidence of oesophageal lesions after radiofrequency ablation (RFA) of atrial fibrillation (AF) with or without the use of oesophageal temperature probes.

Methods and results

Two hundred patients were prospectively randomized into two groups: the OPERA+ group underwent RFA using oesophageal probes (SensiTherm™); the OPERA− group received RFA using fixed energy levels of 25 W at the posterior wall without an oesophageal probe. All patients underwent post-interventional endoscopy and Holter-electrocardiogram after 6 months. (Clinical.Trials.gov: NCT03246594). One hundred patients were randomized in OPERA+ and 100 patients in OPERA−. The drop-out rate was 10%. In total, 18/180 (10%) patients developed endoscopically diagnosed oesophageal lesions (EDEL). There was no difference between the groups with 10/90 (11%) EDEL in OPERA+ vs. 8/90 (9%) in OPERA− (P = 0.62). Despite the higher power delivered at the posterior wall in OPERA+ [28 ± 4 vs. 25 ± 2 W (P = 0.001)], the average EDEL size was equal [5.7 ± 2.6 vs. 4.5 ± 1.7 mm (P = 0.38)]. The peak temperature did not correlate with EDEL size. During follow-up, no patient died. Only one patient in OPERA− required a specific therapy for treatment of the lesion. Cumulative AF recurrence after 6 (3–13) months was 28/87 (32%) vs. 34/88 (39%), P = 0.541.

Conclusion

This first randomized study demonstrates that intraoesophageal temperature monitoring using the SensiTherm™ probe does not affect the probability of developing EDEL. The peak temperature measured by the thermoprobe seems not to correlate with the incidence of EDEL. Empiric energy reduction at the posterior wall did not affect the efficacy of the procedure.

Direct hybridization gap from intersite and onsite electronic interactions in CeAg2Ge2

Electronic and crystal structure studies are presented to describe the role of intersite and onsite interactions for antiferromagnetic ordering in CeAg2Ge2. The crystal structure showed a prominent magnetovolume effect with anomalous negative thermal expansion at low temperature as a consequence of itinerant electron magnetism. The direct hybridization gap with a V-shaped band observed in the angle resolved photoemission data at room temperature, indicates that spin polarized quasiparticle states exist in the gapped region. Valence band broadening and enhanced localization effects at low temperature indicate strong hybridization of the valence orbitals of Ce atoms with the near neighbor Ge atoms. We find that the intersite interaction between the Ce atoms at high temperature stabilizes the onsite interaction at low temperature that leads to the spin density wave type antiferromagnetism in CeAg2Ge2.

Clinical utility of cardiovascular magnetic resonance imaging in patients with implantable cardioverter defibrillators presenting with electrical instability or worsening heart failure symptoms

BACKGROUND

Data on the usefulness of cardiovascular magnetic resonance (CMR) imaging for clinical decision making in patients with an implanted cardioverter defibrillator (ICD) are scarce. The present study determined the impact of CMR imaging on diagnostic stratification and treatment decisions in ICD patients presenting with electrical instability or progressive heart failure symptoms.

METHODS

212 consecutive ICD patients underwent 1.5 T CMR combining diagnostic imaging modules tailored to the individual clinical indication (ventricular function assessment, myocardial tissue characterization, adenosine stress-perfusion, 3D-contrast-enhanced angiography); four CMR examinations (4/212, 2%) were excluded due to non-diagnostic CMR image quality. The resultant change in diagnosis or clinical management was determined in the overall population and compared between ICD patients for primary (115/208, 55%) or secondary prevention (93/208, 45%). Referral indication consisted of documented ventricular tachycardia, inadequate device therapy or progressive heart failure symptoms.

RESULTS

Overall, CMR imaging data changed diagnosis in 40% (83/208) with a significant difference between primary versus secondary prevention ICD patients (37/115, 32% versus 46/93, 49%, respectively; p = 0.01). The information gain from CMR led to an overall change in treatment in 21% (43/208) with a similar distribution in primary versus secondary prevention ICD patients (25/115,22% versus 18/93,19%, p = 0.67). The effect on treatment change was highest in patients initially scheduled for ventricular tachycardia ablation procedure (18/141, 13%) with revision of the treatment plan to medical therapy or coronary revascularization.

CONCLUSIONS

CMR imaging in ICD patients presenting with electrical instability or worsening heart failure symptoms provided diagnostic or management-changing information in a considerable proportion (40% and 21%, respectively).

Circulating Levels of Pro-inflammatory Cytokines in Patients with Nonalcoholic Fatty Liver Disease and Non-Alcoholic Steatohepatitis

BACKGROUND

Pro-inflammatory cytokines are associated with systemic inflammatory responses.

OBJECTIVE

To investigate the levels of pro-inflammatory cytokines (IL-1β, IL-6, and TNF-α) in patients with non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH) compared to healthy individuals.

METHODS

This case-control study was conducted on 30 patients with NAFL, 30 patients with NASH, and 30 healthy volunteers. The plasma level of IL-1β, IL-6, and TNF-α were determined by ELISA, and biochemical parameters were measured using colorimetric methods.

RESULTS

IL-1β and IL-6 levels were significantly higher in patients with NASH compared with NAFL and control group. However, TNF-α levels had no significant variations in NAFL and NASH patients compared to the control group (p=0.903 and p=0.960, respectively).

CONCLUSION

Results showed that the levels of ALT activity and pro-inflammatory cytokines were higher in patients with NASH compared to control and NAFL subjects; Therefore, steatosis and inflammation develop as a result of excessive pro-inflammatory factors in NASH.

Structural, thermodynamic, electronic and elastic properties of Th1-xUxO2 and Th1-xPuxO2 mixed oxides

The structural, thermodynamic, electronic, and elastic properties of Th1-xUxO2 and Th1-xPuxO2 mixed oxides (MOX) have been calculated with Hubbard corrected density functional theory (DFT+U) to account for the strong 5f electron correlations. The ideal solid solution is approximated by special quasi-random structures and the U-ramping method is used to account for the presence of metastable states in the self-consistent field solution of the DFT+U approach. The mixing enthalpy (ΔHmix) is positive throughout the composition range of the Th1-xUxO2 MOX, consistent with a simple miscibility gap (at low temperature) phase diagram. The behavior of the Th1-xPuxO2 MOX is more complex, where ΔHmix is positive in the ThO2-rich region and negative in the PuO2-rich region. Electronic structure analysis shows that substitution of Th by U/Pu in ThO2 leads to a reduction of the average Th-O bond lengths, causing distortion in the crystal structure. The distortion in the crystal structure results in an increase in the conduction bandwidth and a reduction of the band-gap in the MOX. Good agreement of our DFT+U calculated elastic properties of ThO2, UO2 and PuO2 compounds with experiments leads to convincing prediction of these properties for Th1-xUxO2 and Th1-xPuxO2 MOX.

Dynamic changes in the signal-averaged electrocardiogram are associated with the long-term outcomes after ablation of ischemic ventricular tachycardia

PURPOSE

Signal-averaged ECG (SAECG) can detect inhomogeneous myocardial conduction in patients presenting with ventricular tachycardia (VT) after myocardial infarction. Radiofrequency ablation (RFCA) aims at elimination of the endocardial late potentials and non-inducibility of VT. Previously, we demonstrated that abnormal SAECG at baseline can return to normal after a successful VT ablation. The present research investigates the post-ablation changes in SAECG after RFCA of VT and their relation to the procedural long-term outcomes.

METHODS

Thirty-three patients (31 male; age 68 ± 9 years; EF 36 ± 12%) with ischemic VT were prospectively enrolled to receive RFCA. One VT (range 1-7) per patient was ablated using substrate-guided RFCA and complete success was achieved in 28 (85%) cases. SAECG was performed before (t1), immediately after (t2), and at least 6 months (t3) after the RFCA.

RESULTS

After RFCA, the amount of patients showing abnormal SAECG decreased from 82% initially (t1) to 57.6% post-interventionally (t2); P = 0.008; and remained unchanged thereafter in 57% (t3). Patients who experienced VT recurrence (VT+) during the follow-up period had broader averaged QRS (t2): (VT+) 150 ± 26 vs. (VT-) 129 ± 21 ms; P = 0.015, as well as longer LAS40 (t2): (VT+) 60 ± 26 vs. (VT-) 43 ± 18 ms; P = 0.03. Abnormal SAECG (t2) was a strong predictor for VT recurrence: HR 5.4; 95% CI 1.5-21. SAECG detected more late potentials in patients with inferior than in those with anterior scars: 95% vs. 58%; P = 0.016.

CONCLUSIONS

RFCA of VT in the left ventricle can improve an abnormal SAECG in some patients after myocardial infarction. Normal SAECG after RFCA of VT is associated with a lower risk for VT recurrence and death.

Materiality of Edible Film Packaging in Muscle Foods: A Worthwhile Conception

Muscle foods are extremely extensive food products that are relished throughout the world. They are known for their exclusive nutritional content and bio-availability however, at the same time, they also provide apposite media for the growth of pathogenic and spoilage microorganisms. Packaging seems to be a substantial approach to overcome this problem, but most of the packaging involves the usage of non-biodegradable and non-renewable material like plastic, nylon, polyester, etc. The alarming situation caused by synthetic material has been realized worldwide and several scientists, agencies, and the food industry are working globally to explore materials that are derived from the natural source. Biodegradable films are an excellent alternative to conventional plastics. These biodegradable films and coatings are derived from various biological sources and are receiving considerable importance in recent years. Different meat and meat product needs specific packaging condition and these active, composite bio-based films are having a wide potential in the meat sector. This review gathers the research and findings over the period of time-related to biodegradable edible film applied to muscle foods.