Permanent direct his bundle pacing does not induce ventricular dyssynchrony unlike conventional right ventricular apical pacing. An intrapatient acute comparison study

BACKGROUND

Benefits of A-V synchrony during right ventricular apical pacing are neutralized by induction of ventricular dyssynchrony. Only a few data are reported about direct His bundle pacing influence on ventricular synchronism.

AIM

Was to assess the capability of direct His bundle pacing to prevent pacing-induced ventricular dyssynchrony comparing DDD- (or VVI- in case of Atrial Fibrillation) right ventricular apical pacing with DDD- (or VVI-) direct His bundle pacing in the same patients cohort.

METHODS

23 of 24 patients (mean age 75.1 +/- 6.4 years) with narrow QRS (HV < 65 ms) underwent permanent direct His bundle pacing for "brady-tachy syndrome" (11) or supra-Hisian II/III-degree AV Block (permanent atrial fibrillation 7, AV Node ablation 1). A 4.1 F screw-in lead was fixed in His position, guided by endocardial pacemapping and unipolar recordings. Additional permanent (13 patients) or temporary right ventricular apical pacing leads were also positioned. Inter- and left intra-ventricular dyssynchrony, mitral regurgitation and left systolic ventricular function Tei index were assessed during either direct His bundle pacing or right ventricular apical pacing.

RESULTS

Permanent direct His bundle pacing was obtained in 23 of 24 patients. Indexes of ventricular dyssynchrony were drastically reduced, mitral regurgitation decreased and left systolic ventricular function Tei index improved during direct His bundle pacing (or His bundle and septum pacing) in comparison to apical pacing (p < 0.05). No statistically significant differences were observed between direct His bundle pacing and combined His bundle and septum pacing.

CONCLUSION

Direct His bundle pacing (also fused with adjacent septum capture) prevents pacing-induced ventricular dyssynchrony.

[Reduction of radiological exposure time during radiofrequency catheter ablation procedures using a novel intracardiac localization system based on the Ohm's law]

BACKGROUND

Three-dimensional nonfluoroscopic system may be helpful to guide radiofrequency catheter ablation procedures and to reduce the radiological exposure. A new intracardiac navigation and multicatheter visualization system based on Ohm's law (LocaLisa, Medtronic, Minneapolis, MN, USA) has been recently introduced. The aim of our study was to assess the efficacy of the Loca-Lisa system in comparison to fluoroscopy-based approach in reducing the radiological exposure time required for radiofrequency catheter ablation procedures.

METHODS

One hundred and thirty-seven consecutive patients underwent LocaLisa-based radiofrequency catheter ablation procedures in our cardiac electrophysiology laboratory during 19 months of LocaLisa utilization (from October 2001 to April 2003): 46 atrial flutter, 44 atrioventricular node reentrant tachycardia, 16 atrioventricular reentry tachycardia due to atrioventricular accessory pathway, 14 atrial fibrillation, 11 ectopic atrial tachycardia, and 6 atrioventricular node modulation. We retrospectively compared the radiological exposure times of this group of patients to those of the last 137 patients undergone fluoroscopy-based radiofrequency catheter ablation procedures for curing the same index arrhythmia by the same procedural protocol.

RESULTS

The mean radiological exposure time was significantly shorter for the LocaLisa-based radiofrequency catheter ablation procedures (16 +/- 12 vs 34 +/- 17 min; reduction of 53%, p < 0.01) and it occurred for all the arrhythmia types. The reduction was of 64% (from 39 +/- 18 to 14 +/- 12 min, p < 0.01) for atrial flutter, 42% (from 24 +/- 10 to 14 +/- 11 min, p < 0.01) for atrioventricular nodal reentrant tachycardia, 30% (from 40 +/- 14 to 28 +/- 14 min, p = 0.02) for atrioventricular reentry tachycardia, 57% (from 49 +/- 12 to 21 +/- 13 min, p < 0.01) for atrial fibrillation (right atrial linear lesions), 50% (from 38 +/- 12 to 19 +/- 8 min, p < 0.01) for ectopic atrial tachycardia and 42% (from 12 +/- 11 to 7 +/- 5 min, p = NS) for atrioventricular node modulation. The reduction in the radiological exposure time progressively increased as our team got used with the nonfluoroscopic navigation system.

CONCLUSIONS

Overall and single arrhythmia-divided mean radiological exposure times can be significantly reduced by the LocaLisa system during radiofrequency catheter ablation procedures. The reduction of radiation increases progressively by becoming friendly to the system with a very short duration of learning curve phase.

Local electrogram assessment of unidirectional isthmus block is sufficient to predict the acute and long-term success of cavo-tricuspid isthmus ablation

BACKGROUND

This study investigated whether a minimal approach to typical atrial flutter ablation using an 8 mm tip catheter with a 150 W generator with only the documentation of clockwise block by means of local criteria predicts a good long-term outcome.

METHODS

Seventy patients underwent typical atrial flutter ablation. A multipolar catheter was inserted into the coronary sinus (CS) and an 8 mm tip ablation catheter was used to ablate and map the isthmus. The ablation line was performed in the posteroseptal region. The clockwise block was confirmed by recording a corridor of double potentials along the line and by counterclockwise activation of the portion of the isthmus just beyond the lesion line as demonstrated by measuring the conduction times during CS pacing.

RESULTS

In case of block, the mean distance between the two split atrial electrograms was 129 +/- 31 ms. Acute isthmus block was achieved in all 70 patients. The median of the radiofrequency pulses was 10 (range 1-36). No immediate or late complications were noted. The long-term follow-up (19.5 +/- 4 months) revealed recurrence of typical atrial flutter in 2 cases (2.8%).

CONCLUSIONS

Our results demonstrate that the acute success rate following typical atrial flutter isthmus ablation using an 8 mm tip catheter with a 150 W generator is high. No complications occurred. Moreover, the documentation of just the clockwise isthmus block using a minimal approach according to local electrogram criteria is a good predictor of the long-term success.

Postinfarctional remodeling: increased dye intensity in the myocardial risk area after angioplasty of infarct-related coronary artery is associated with reduction of ventricular volumes

OBJECTIVES

We sought to evaluate if angiographic dye videointensity of the risk area during percutaneous transluminal coronary angioplasty (PTCA) of the infarct-related artery (IRA) relates to remodeling.

BACKGROUND

Poor reflow after myocardial infarction (MI) predicts worse ventricular remodeling.

METHODS

Fifty-three patients with a first anterior MI and isolated disease of the left anterior descending (LAD), who underwent "primary" (n = 14), "rescue" (n = 7) or "late" (after 10 +/- 4 days, n = 32) PTCA, were retrospectively selected. In 10 patients prospectively collected, we assessed Doppler flow velocities and Doppler flow reserve (DFR), relating them to the videointensity technique. Coronary stenosis and TIMI flow were determined, and echocardiographic volumes (end-diastolic and end-systolic volume indexes) and regional asynergy were computed before hospital discharge (baseline) and at six months. Assuming higher peak videointensity reflects greater myocardial blood volume, a 1- to 5-point (poor-optimal) perfusion scale was devised.

RESULTS

The correlation of Doppler peak velocity and DFR with videointensity was significant (r = 0.58, p = 0.007 and r = 0.71, p < 0.001, respectively). Patients were subdivided into group A (increased videointensity post-PTCA > or = 1.5 points, n = 29) and group B (unchanged videointensity, n = 24). Analysis of variance showed a time-group interaction for end-diastolic volume index (-4.6 +/- 23% vs. +22 +/- 22%, p = 0.003) and end-systolic volume index (-3.05 +/- 11.1% vs. +4.1 +/- 12.5%, p = 0.027). There was no interaction for changes in LAD stenosis (p = 0.39) and TIMI flow after PTCA (p = 0.27), or regional asynergy at six months (p = 0.31).

CONCLUSIONS

Angiographic dye videointensity in the risk area correlates with Doppler peak velocity and DFR, and its increase after PTCA of IRA has a limiting effect on ventricular volumes, independent of coronary stenosis resolution, changes in Thrombolysis In Myocardial Infarction (TIMI) flow or extent of regional asynergy.

Comparison between low-dose dobutamine echocardiography and thallium-201 scintigraphy in the detection of myocardial viability in patients with recent myocardial infarction

AIM

To compare the predictive value of thallium-201 single photon emission computed tomography (SPECT) scintigraphy (Sci) and low-dose dobutamine echocardiography (Dob) in predicting late recovery of dysfunctioning myocardium in patients with recent, uncomplicated myocardial infarction (MI).

METHODS AND RESULTS

19 patients (18 male, aged 58+/-8 years) with recent MI and ejection fraction <50% (35.5+/-8.3%) underwent 5-15 microg/kg per min Dob, rest-redistribution Sci and coronary angiography, respectively, 14+/-6, 16+/-7 and 17+/-5 days after MI. On an eleven-segment ventricular model devised to compare Dob and Sci segment by segment, each dysfunctioning ventricular segment was considered viable if it showed recovery of mechanical function at the echocardiographic follow-up, performed 6.3+/-1.5 months after revascularization (five PTCA, five GABG) or medical therapy. Among the 104 dysfunctioning segments, of which 26 (25%) showed recovery at follow-up, Dob and Sci gave a concordant response in 50 (48%, k = 0.13), correctly predicting the recovery (or not) of function in 42. Forty-two of 54 discordant responses were due to segments judged viable only by Sci and which had no recovery at follow-up (of these 37 were akinetic or severely hypokinetic at baseline). At the segment-by-segment analysis, the sensitivity, specificity, and accuracy in predicting recovery of function at follow-up were, respectively, 69, 88 and 84% for Dob as against 88, 36 and 49% for Sci (P<0.001 for both specificity and accuracy, P=NS for sensitivity).

CONCLUSION

In patients with recent MI, the specificity of Dob in the detection of myocardium capable of late mechanical recovery is significantly higher with respect to Sci, whereas sensitivity is slightly, not significantly higher for the latter. It is conceivable that Sci detects viable myocardium even if it is transmurally limited to epicardial layers in segments with severely impaired mechanical function in which viability will not affect late recovery of function.

Stress protein-induced immunosuppression: inhibition of cellular immune effector functions following overexpression of haem oxygenase (HSP 32)

This is the first report on suppression of immune effector functions following upregulation of heat shock protein 32 (HSP 32), known as haem oxygenase (HO-1). Here we evaluated the effect of cobalt-protoporphyrin (CoPP)-induced HO-1 expression on cell-mediated immune responses. Administration of CoPP to CBA mice resulted in overexpression of HO-1 in the spleen, liver and kidneys. In vitro measurements of T cell-mediated and NK-cell-mediated cytotoxicity in spleens from CoPP-treated animals demonstrated a severe suppression of their effector functions while administration of Zn-PP or vitamin B12 had no effect. Furthermore, CoPP therapy decreased the lymphoproliferative alloresponse and differentiation of cytotoxic T cells. Inhibition of proliferation appeared to be due to cell growth arrest with an increased number of cells staying in G0/G1 phase. Despite the suppressed proliferative response, IL-2 production in the MLR was not inhibited. In contrast, CoPP decreased the production of IL-10, IFN-gamma and TNF-alpha. In vivo, CoPP prolonged the survival of heterotopic heart allografts in mice. The immunosuppressive effects following CoPP-mediated upregulation of HO-1 were similar to those observed after peptide-mediated upregulation of HO-1. The results indicate that overexpression of HO results in the inhibition of several immune effector functions and thus provides an explanation for stress-induced immunosuppression.

Characterization and biological significance of immunosuppressive peptide D2702.75-84(E --> V) binding protein. Isolation of heme oxygenase-1

This is the first report on peptidic inhibitors of heme oxygenase. Such peptides were originally developed from the immunomodulatory peptide 2702.75-84 which corresponds to amino acid residues 75 to 84 of the alpha1-helix of HLA-B2702 (2702.75-84) and has been shown to be immunosuppressive in vitro and in vivo. In vitro, 2702.75-84 inhibited cytotoxic T- and natural killer cell- mediated target cell lysis, and in vivo peptide therapy resulted in prolongation of heart and skin allograft survival in mice. The peptide was also shown to bind to heat shock protein 70. However, D-enantiomers of 2702.75-84 and derivatives thereof, while still being immunosuppressive, did not bind to heat shock protein 70. This study was designed to identify proteins binding to peptide D2702.75-84(E --> V) (rvnlrialry) consisting of D-amino acids. Compared with 2702.75-84 (RENLRIALRY), glutamic acid residue 76 (E) was replaced with valine (V). Affinity chromatography using immobilized D2702.75-84(E --> V) and mouse and human cell extracts, resulted in the isolation of heme oxygenase-1 (HO-1). Peptide D2702.75-84 inhibited HO activity in vitro in a dose dependent manner. Similar to what has been observed with other inhibitors of HO, administration of peptide into mice resulted in an up-regulation of HO-1 mRNA and protein, as well as enzyme activity in liver, spleen and kidney. Other peptides derived from 2702.75-84 with similar immunomodulatory activity displayed similar effects. In contrast, inactive derivatives of 2702.75-84 had no effect on HO activity. Therefore, the immunosuppressive effects of the described immunomodulatory peptides are similar to those of cobalt-protoporphyrin, a known up-regulator of HO-1. Our results suggest that HO-1 modulation may be a novel mechanism of immunomodulation.

Yohimbine elimination in normal volunteers is characterized by both one- and two-compartment behavior

We sought to determine the safety, pharmacodynamic response, and single- and multiple-dose pharmacokinetic profile of yohimbine hydrochloride. Thirty-two healthy volunteers received 6 days of yohimbine, 5.4 mg 3 times daily (t.i.d.), 10.8 mg t.i.d., 16.2 mg t.i.d., or 21.6 mg twice daily (b.i.d.), with determination of plasma catecholamine levels and mood/anxiety-inventory scores. The pharmacokinetic profile of yohimbine was determined after the first and last dose. Yohimbine exhibited one-compartment elimination in most subjects, with dose-dependent increases in maximal concentration (Cmax) and area under the curve (AUC) but no evidence of drug accumulation. At least two subjects in each cohort exhibited two-compartment elimination of yohimbine, with nonsignificant increases in day 7 AUC, Cmax, and terminal elimination half-life (t1/2beta). Plasma catecholamine levels increased significantly in relation to both average yohimbine AUC and Cmax, but there were no significant effects on heart rate, blood pressure, or anxiety/mood-inventory scores. The single- and multiple-dose pharmacokinetic profile of yohimbine exhibits a substantial degree of interpatient and intrapatient variability, possibly resulting from variability in first-pass and hepatic metabolism. There is a significant correlation between plasma norepinephrine levels and yohimbine AUC or Cmax. Further multiple-dose studies are warranted definitively to address the relation between yohimbine AUC or Cmax and pharmacologic effect.