Repeat Left Atrial Catheter Ablation

Background—

Studies have reported an inverse relationship between late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) signal intensity and left atrial (LA) endocardial voltage after LA ablation. However, there is controversy regarding the reproducibility of atrial LGE CMR and its ability to identify gaps in ablation lesions. Using systematic and objective techniques, this study examines the correlation between atrial CMR and endocardial voltage.

Methods and Results—

Twenty patients who had previous ablation for atrial fibrillation and represented with paroxysmal atrial fibrillation or atrial tachycardia underwent preablation LGE CMR. During the ablation procedure, high-density point-by-point Carto voltage maps were acquired. Three-dimensional CMR reconstructions were registered with the Carto anatomies to allow comparison of voltage and LGE signal intensity. Signal intensities around the left and right pulmonary vein antra and along the LA roof and mitral lines on the CMR-segmented LA shells were extracted to examine differences between electrically isolated and reconnected lesions. There were a total of 6767 data points across the 20 patients. Only 119 (1.8%) of the points were ≤0.05 mV. There was only a weak inverse correlation between either unipolar ( r =−0.18) or bipolar ( r =−0.17) voltage and LGE CMR signal intensities with low voltage occurring across a large range of signal intensities. Signal intensities were not statistically different for electrically isolated and reconnected lesions.

Conclusions—

This study demonstrates that there is only a weak point-by-point relationship between LGE CMR and endocardial voltage in patients undergoing repeat LA ablation. Using an objective method of assessing gaps in ablation lesions, LGE CMR is unable to reliably predict sites of electrical conduction.

Pathophysiology and Management of Arrhythmias Associated with Atrial Septal Defect and Patent Foramen Ovale

Atrial septal defects (ASDs) are among the most common of congenital heart defects and are frequently associated with atrial arrhythmias. Atrial and ventricular geometrical remodelling secondary to the intracardiac shunt promotes evolution of the electrical substrate, predisposing the patient to atrial fibrillation and other arrhythmias. Closure of an ASD reduces the immediate and long-term prevalence of atrial arrhythmias, but the evidence suggests that patients remain at an increased long-term risk in comparison with the normal population. The closure technique itself and its timing impacts future arrhythmia risk profile while subsequent transseptal access following surgical or device closure is complicated. Newer techniques combined with increased experience will help to alleviate some of the difficulties associated with optimal management of arrhythmias in these patients.

Cardiac magnetic resonance and electroanatomical mapping of acute and chronic atrial ablation injury: a histological validation study

AIMS

To provide a comprehensive histopathological validation of cardiac magnetic resonance (CMR) and endocardial voltage mapping of acute and chronic atrial ablation injury.

METHODS AND RESULTS

16 pigs underwent pre-ablation T2-weighted (T2W) and late gadolinium enhancement (LGE) CMR and high-density voltage mapping of the right atrium (RA) and both were repeated after intercaval linear radiofrequency ablation. Eight pigs were sacrificed following the procedure for pathological examination. A further eight pigs were recovered for 8 weeks, before chronic CMR, repeat RA voltage mapping and pathological examination. Signal intensity (SI) thresholds from 0 to 15 SD above a reference SI were used to segment the RA in CMR images and segmentations compared with real lesion volumes. The SI thresholds that best approximated histological volumes were 2.3 SD for LGE post-ablation, 14.5 SD for T2W post-ablation and 3.3 SD for LGE chronically. T2-weighted chronically always underestimated lesion volume. Acute histology showed transmural injury with coagulative necrosis. Chronic histology showed transmural fibrous scar. The mean voltage at the centre of the ablation line was 3.3 mV pre-ablation, 0.6 mV immediately post-ablation, and 0.3 mV chronically.

CONCLUSION

This study presents the first histopathological validation of CMR and endocardial voltage mapping to define acute and chronic atrial ablation injury, including SI thresholds that best match histological lesion volumes. An understanding of these thresholds may allow a more informed assessment of the underlying atrial substrate immediately after ablation and before repeat catheter ablation for atrial arrhythmias.

Tachyarrhythmias and catheter ablation in adult congenital heart disease

Advances in surgical technique have had an immense impact on longevity and quality of life in patients with congenital heart disease. However, an inevitable consequence of these surgical successes is the creation of a unique patient population whose anatomy, surgical history and haemodynamics result in the development of a challenging and complex arrhythmia substrate. Furthermore, this patient group remains susceptible to the arrhythmias seen in the general adult population. It is through a thorough appreciation of the cardiac structural defect, the surgical corrective approach, and haemodynamic impact that the most effective arrhythmia care can be delivered. Catheter ablation techniques offer a highly effective management option but require a meticulous attention to the real-time integration of anatomical and electrophysiological information to identify and eliminate the culprit arrhythmia substrate. This review describes the current approach to the interventional management of patients with tachyarrhythmias in the context of congenital heart disease.

Surface flattening of the human left atrium and proof-of-concept clinical applications

Surface flattening in medical imaging has seen widespread use in neurology and more recently in cardiology to describe the left ventricle using the bull's-eye plot. The method is particularly useful to standardize the display of functional information derived from medical imaging and catheter-based measurements. We hypothesized that a similar approach could be possible for the more complex shape of the left atrium (LA) and that the surface flattening could be useful for the management of patients with atrial fibrillation (AF). We implemented an existing surface mesh parameterization approach to flatten and unfold 3D LA models. Mapping errors going from 2D to 3D and the inverse were investigated both qualitatively and quantitatively using synthetic data of regular shapes and computer tomography scans of an anthropomorphic phantom. Testing of the approach was carried out using data from 14 patients undergoing ablation treatment for AF. 3D LA meshes were obtained from magnetic resonance imaging and electroanatomical mapping systems. These were unfolded using the developed approach and used to demonstrate proof-of-concept applications, such as the display of scar information, electrical information and catheter position. The work carried out shows that the unfolding of complex cardiac structures, such as the LA, is feasible and has several potential clinical uses for the management of patients with AF.

Quantitative Assessment of the Effects of Therapeutic Hypothermia on Early Repolarization in Idiopathic Ventricular Fibrillation Survivors

Background—

The early repolarization (ER) pattern on ECG is associated with an increased risk of idiopathic ventricular fibrillation (ID-VF). Hypothermia is known to result in similar electrocardiographic changes. In this retrospective cohort study, we examine the impact of therapeutic hypothermia on ER in survivors of cardiac arrest attributed to ID-VF and draw comparisons with a control group who experienced coronary artery disease–related VF (CAD-VF).

Methods and Results—

All patients who had cardiac arrest and were treated with therapeutic hypothermia over a 7-year period were considered for inclusion in the study. Forty-three patients were identified with ID-VF or CAD-VF arrest. ECGs were obtained during cooling and again after rewarming. ECGs were digitized and assessed for the presence of ER by 2 independent observers. Cooling significantly increased the prevalence (74% during cooling versus 51% at baseline temperature; P =0.044) and mean amplitude (0.78±0.10 mV during cooling versus 0.56±0.09 mV at baseline temperature; P =0.038) of ER in the overall cohort. During cooling, ER was more common among survivors of ID-VF than of CAD-VF (100% versus 67%; P =0.043). ER magnitude was significantly greater among ID-VF survivors than CAD-VF survivors both during cooling (1.16±0.18 versus 0.70±0.11 mV; P =0.044) and at baseline temperature (1.02±0.21 versus 0.42±0.09 mV; P =0.005).

Conclusions—

Hypothermia increases both the prevalence and magnitude of ER in cardiac arrest survivors. Despite the association of ER with ID-VF, therapeutic hypothermia only increases ER amplitude in CAD-VF survivors.

Abstract T P111: The Use of Smartphone Applications to Provide Information to Patients and Their Carers

Introduction: Patients and their carers find it difficult to access information following a stroke or transient ischaemic attack (TIA). To improve the provision of this information, the Royal College of Physicians' National Clinical Guideline for Stroke (4th edition, 2012) was accompanied by a booklet designed for patients and their carers. Dissemination of the information was enhanced with the development of smartphone applications that are freely available on both iOS and Android devices. Here we present a report into the use of these applications.

Methods: The applications were designed to reflect the content of the booklet with the information primarily accessed via a scrollable index, with separate sections to provide information on support services available in the UK. Data on usage were anonymously collected during the first eight months following global release. The hypothesis that users would preferentially access information on particular topics was tested.

Results: The smartphone applications were downloaded a total of 2,046 times (1,503 iOS and 543 Android), of which 61.3% was by individuals in the UK. Topics covering rehabilitation were most commonly accessed, accounting for 33.2% of all application usage. Within this category, ‘Care after a stroke or TIA (principles)’ represented 14.5% of use and ‘Sex after stroke’ represented 13.1%. The next most commonly accessed category was ‘Specialist early care’ with 25.0% of total application usage, of which the topic ‘Brain scan’ accounted for 24.5%. Overall, the most commonly accessed index item was titled ‘Stroke, what is it?’, and this represented 8.27% of total application usage. Within the category of support services, 45.6% of usage was directed towards accessing information on ‘Local health services and stroke clubs’.

Conclusions: Smartphone applications are useful adjuncts for the dissemination of information to patients and their carers following a stroke or TIA. Users exhibit a preference for information on rehabilitation and specialist early care. Future publications should target these topics for more in-depth discussion.

Classification of the reduced vertical component of the ground reaction force in late stance in cerebral palsy gait

Children with cerebral palsy (CP) often experience significant problems supporting their bodyweight (BW) and decelerating the downward velocity of the centre of mass (CoM) in late stance. This is seen as a decreased second peak of vertical ground reaction force (GRF) nominated FZ(2). This study categorises gait data by the degree of reduced FZ(2). Kinetic data were analysed from a CP database. Data from 129 patients, able to walk barefoot unaided, were investigated. Of these, 84 had kinetic data, 59 diplegics (both legs) and 15 hemiplegics (affected leg only), thus providing data from 133 legs. A reduced FZ(2) was observed in 116 legs (87%). Of the 133 legs, 44% failed to generate FZ(2)>BW. By including the Type 2 data this figure rises to, a staggering 66% who are having difficulty supporting BW at this stage of the stance phase. Only 12% of the legs showed a normal pattern (FZ(2) approximately equal to FZ(1)). In conclusion, the majority of CP children referred to the gait laboratory exhibited some degree of reduced FZ(2) and can be categorised as having a 'Ben Lomonding' gait pattern. 'Ben Lomonding,' is the term used to describe this phenomenon of reduced FZ(2), as the shape of the GRF graph resembles the shape of the Scottish mountain, Ben Lomond, which has two peaks, the second peak being much smaller than the first. Crucially, clinicians should be aware that nearly half of the CP children in this study were in difficulty supporting their BW in late stance and must use compensatory mechanisms to prevent collapse of the affected limb.

Leaf closure in the venus flytrap: an Acid growth response

The rapid closure of leaves in the Venus flytrap (Dionaea muscipula) involves irreversible cell enlargement, which can be initiated by acidifying the cell walls to pH 4.50 and below. Leaves infiltrated with neutral buffers that keep the pH above 4.50 to 4.75 will not close in response to stimulation of their trigger hairs even though the action potentials that ordinarily cause closure are produced. During the 1 to 3 seconds required for closure about 29 percent of the cellular adenosine triphosphate is lost. It is likely that this adenosine triphosphate is used in very rapid transport of hydrogen ions from the motor cells and that the movement is due to a mechanism of "acid growth."

Ecological specialization and population size in a biodiversity hotspot: how rare species avoid extinction

Species with narrow environmental niches typically have small geographic ranges. Small range size is, in turn, often associated with low local abundance. Together, these factors should mean that ecological specialists have very small total populations, putting them at high risk of extinction. But some specialized and geographically restricted species are ancient, and some ecological communities have high proportions of rare and specialized endemics. We studied niche characteristics and patterns of distribution and abundance of terrestrial vertebrates in the rainforests of the Australian Wet Tropics (AWT) to identify mechanisms by which rare species might resist extinction. We show that species with narrow environmental niches and small geographic ranges tend to have high and uniform local abundances. The compensation of geographic rarity by local abundance is exact, such that total population size in the rainforest vertebrates of the AWT is independent of environmental specialization. This effect would tend to help equalize extinction risk for specialists and generalists. Phylogenetic analysis suggests that environmental specialists have been gradually accumulating in this fauna, indicating that small range size/environmental specialization can be a successful trait as long as it is compensated for by demographic commonness. These results provide an explanation of how range-restricted specialists can persist for long periods, so that they now form a major component of high-diversity assemblages such as the AWT.

Functional MRI of working memory in paediatric head injury

A case study examining the recovery of a 9 year old boy who sustained a severe head injury is reported. The subject sustained damage to the left parietal-occipital and right frontal-parietal regions. Structural and functional imaging and cognitive data were collected at the time of injury and 1 year post-injury. Cognitive assessment revealed improvement over time. Functional imaging at the time of injury revealed minimal activation in the right posterior temporal region. Imaging 1 year post-injury revealed increased activation in the right pre-frontal cortex, bilateral pre-motor cortex and bilateral posterior parietal cortex. This activation pattern is consistent with the performance of unaffected individuals on working memory tasks. These findings differ from those in the adult literature and suggest an alternative pattern of recovery of function in children.

Identification and dynamics of a cryptic suture zone in tropical rainforest

Suture zones, shared regions of secondary contact between long-isolated lineages, are natural laboratories for studying divergence and speciation. For tropical rainforest, the existence of suture zones and their significance for speciation has been controversial. Using comparative phylogeographic evidence, we locate a morphologically cryptic suture zone in the Australian Wet Tropics rainforest. Fourteen out of 18 contacts involve morphologically cryptic phylogeographic lineages, with mtDNA sequence divergences ranging from 2 to 15 per cent. Contact zones are significantly clustered in a suture zone located between two major Quaternary refugia. Within this area, there is a trend for secondary contacts to occur in regions with low environmental suitability relative to both adjacent refugia and, by inference, the parental lineages. The extent and form of reproductive isolation among interacting lineages varies across species, ranging from random admixture to speciation, in one case via reinforcement. Comparative phylogeographic studies, combined with environmental analysis at a fine-scale and across varying climates, can generate new insights into suture zone formation and to diversification processes in species-rich tropical rainforests. As arenas for evolutionary experimentation, suture zones merit special attention for conservation.

Effects of drag factor on physiological aspects of rowing

This study examined the effects of two resistances, or "drag factors" on selected physiological variables during incremental progressive rowing tests (seven 3-min stages) on a Concept2 ergometer. Subjects were seven male and seven female university club rowers. Their mean age, body mass and height were 19.6 +/- 1.5 years, 72.7 +/- 8.0 kg, and 172.2 +/- 7.5 cm, respectively. Progressive tests were conducted using drag factors 100 (D100) and 150 (D150) before the spring racing season. Values were determined for the following physiological variables: ventilation (V.E), oxygen uptake (V.O2), heart rate (HR), blood lactate concentration (BLC), respiratory exchange ratio (R) and rowing economy (W/V.O2). Comparisons across all six submaximal stages showed no significant difference between D(100) and D(150) for any of the variables measured (p > .05). Maximal V.E(max) was significantly greater at D100 than D150 (p < .02). Maximal V.O(2), HR, BLC, R, stroke rate (SR) and W/V.O2 were greater at D100 than at D150, though not significantly so. The mean D100-D150 differences in V.E and SR for each stage were significantly correlated (r = 0.76, p < .01), suggesting drag factor may affect V.E via SR.

ARE PIKAS EXPOSED TO AND AFFECTED BY SELENIUM DEFICIENCY?

Regional extirpations of pikas (Ochatona princeps) within the last few decades have been attributed to global warming. Other recent global alterations such as increased nitrogen (N) deposition and associated selenium (Se) deficiency may further stress pika populations. In 2003 and 2004, we live-trapped pikas from three populations in Wyoming and measured Se values in their hair. We also sampled hair and liver from museum specimens collected throughout the Northern Rocky Mountains in 1987 and 1988. Our results suggest that liver and hair values were related, and that pika hair reflected the Se concentrations of the geologic parent materials. We determined that animals residing in several remote areas in the Rocky Mountain region could be Se deficient and that increase in N deposition correlated with an increase rather than a decrease in Se values in pika hair. In addition, we found no relation between Se contents in hair and body condition index, suggesting that low Se levels may not have negative effects on individual pikas. Whether Se levels influence reproductive success of pikas is unknown and should be the focus of future studies.

Parafibromin is a nuclear protein with a functional monopartite nuclear localization signal

Parafibromin is a nuclear protein with a tumour suppressor role in the development of non-hereditary and hereditary parathyroid carcinomas, and the hyperparathyroidism-jaw tumour (HPT-JT) syndrome, which is associated with renal and uterine tumours. Nuclear localization signal(s), (NLS(s)), of the 61 kDa parafibromin remain to be defined. Utilization of computer-prediction programmes, identified five NLSs (three bipartite (BP) and two monopartite (MP)). To investigate their functionality, wild-type (WT) and mutant parafibromin constructs tagged with enhanced green fluorescent protein or cMyc were transiently expressed in COS-7 cells, or human embryonic kidney 293 (HEK293) cells, and their subcellular locations determined by confocal fluorescence microscopy. Western blot analyses of nuclear and cytoplasmic fractions from the transfected cells were also performed. WT parafibromin localized to the nucleus and deletions or mutations of the three predicted BP and one of the predicted MP NLSs did not affect this localization. In contrast, deletions or mutations of a MP NLS, at residues 136-139, resulted in loss of nuclear localization. Furthermore, the critical basic residues, KKXR, of this MP NLS were found to be evolutionarily conserved, and over 60% of all parafibromin mutations lead to a loss of this NLS. Thus, an important functional domain of parafibromin, consisting of an evolutionarily conserved MP NLS, has been identified.

SLPI and elafin: one glove, many fingers

Elafin and SLPI (secretory leucocyte protease inhibitor) have multiple important roles both in normal homoeostasis and at sites of inflammation. These include antiprotease and antimicrobial activity as well as modulation of the response to LPS (lipopolysaccharide) stimulation. Elafin and SLPI are members of larger families of proteins secreted predominantly at mucosal sites, and have been shown to be modulated in multiple pathological conditions. We believe that elafin and SLPI are important molecules in the controlled functioning of the innate immune system, and may have further importance in the integration of this system with the adaptive immune response. Recent interest has focused on the influence of inflamed tissues on the recruitment and phenotypic modulation of cells of the adaptive immune system and, indeed, the local production of elafin and SLPI indicate that they are ideally placed in this regard. Functionally related proteins, such as the defensins and cathelicidins, have been shown to have direct effects upon dendritic cells with potential alteration of their phenotype towards type I or II immune responses. This review addresses the multiple functions of elafin and SLPI in the inflammatory response and discusses further their roles in the development of the adaptive immune response.

The antimicrobial/elastase inhibitor elafin regulates lung dendritic cells and adaptive immunity

Infections with bacteria and viruses such as adenovirus are a feature of chronic lung diseases such as chronic obstructive pulmonary diseases (COPD), and may be instrumental in the generation of disease exacerbations. We have previously shown in acute models that elafin (a lung natural chemotactic molecule for macrophages and neutrophils, with potent antimicrobial and neutrophil elastase inhibitor activity) is upregulated in infection and modulates innate immunity. Here we present data using two independent systems of elafin overexpression in vivo (recombinant adenovirus [Ad-elafin] and an elafin transgenic mouse line) to examine the function of elafin in adaptive immunity. We show that elafin increases the number (immunofluorescence) and activation status (flow cytometric measurement) of CD11c+/MHCII+ lung dendritic cells in vivo. Analysis of cytokines produced by spleen and lung cells, and of antibodies measured in serum and bronchoalveolar lavage fluid, shows that the immunity induced is biased toward a type 1 response (production of IL-12, IFN-gamma, and IgG2a). Furthermore, elafin overexpression protected mice against further challenge with Ad-LacZ, as assessed by antibody levels and neutralization titer, as well as LacZ expression in lung tissue. Thus, the pleiotropic molecule elafin has significant potential in modulating antigen-presenting cell numbers and activity, and could be beneficial in mucosal protective strategies.