Correlation of spontaneous and induced premature atrial complexes initiating atrial fibrillation in humans: electrophysiologic parameters for guiding therapy

INTRODUCTION

The low frequency of spontaneous premature atrial contractions (PACs) may be an impediment to mapping and ablation of atrial fibrillation (AF). It has been shown that PACs following external or internal cardioversion of AF can initiate AF. If this method could reproducibly induce PACs from the same location as spontaneous PACs, it would be clinically significant. High-resolution noncontact mapping can map a single beat, should help identify the sites of spontaneously occurring PACs and PACs induced following cardioversion of spontaneous or induced AF, and could help correlate the trigger sites for AF induction.

METHODS AND RESULTS

Twelve patients (8 men and 4 women; mean age 49+/-10 years) with spontaneous PACs were included in the study. In all patients, AF was induced and subsequently cardioverted to assess and map isolated PACs or PACs that induced AF. Using the EnSite 3000 noncontact mapping system, mapping was performed of spontaneously occurring isolated PACs and PACs that induced AF and PACs (both with and without AF) that occurred on at least two different occasions following cardioversion. The locations of the spontaneous and the induced PACs were similar; 97% of induced PACs came from the same locations as those of spontaneous PACs (P = 0.5). Radiofrequency lesions guided by this mapping technique were delivered at 14 pulmonary vein sites. Following a single ablation attempt during a mean follow-up of 19+/-4 weeks, 42% of the patients were in sinus rhythm and drug-free, whereas an additional 24% of patients could be maintained in sinus rhythm on drugs that had failed before.

CONCLUSION

There is a high degree of correlation between spontaneous and induced PACs as the trigger sites for AF initiation. Cardioversion of spontaneous or induced AF could be used as an electrophysiologic parameter for guiding therapy.

Helicobacter pylori arginase inhibits nitric oxide production by eukaryotic cells: a strategy for bacterial survival

The antimicrobial effect of nitric oxide (NO) is an essential part of innate immunity. The vigorous host response to the human gastric pathogen Helicobacter pylori fails to eradicate the organism, despite up-regulation of inducible NO synthase (iNOS) in the gastric mucosa. Here we report that wild-type strains of H. pylori inhibit NO production by activated macrophages at physiologic concentrations of l-arginine, the common substrate for iNOS and arginase. Inactivation of the gene rocF, encoding constitutively expressed arginase in H. pylori, restored high-output NO production by macrophages. By using HPLC analysis, we show that l-arginine is effectively consumed in the culture medium by wild-type but not arginase-deficient H. pylori. The substantially higher levels of NO generated by macrophages cocultured with rocF-deficient H. pylori resulted in efficient killing of the bacteria, whereas wild-type H. pylori exhibited no loss of survival under these conditions. Killing of the arginase-deficient H. pylori was NO-dependent, because peritoneal macrophages from iNOS(-/-) mice failed to affect the survival of the rocF mutant. Thus, bacterial arginase allows H. pylori to evade the immune response by down-regulating eukaryotic NO production.

Salimuzzaman Siddiqui, M.B.E.: 19 October 1897 - 14 April 1994

Salimuzzaman Siddiqui must be one of the few scientific personalities of the twentieth century to lay genuine claim to being a true Renaissance man. His early university education was in philosophy, a subject for which he retained a lifelong passion. He wrote poetry and admired the work of great Urdu and Persian poets of the past. He remained enchanted by oriental and European classical music right up to the closing years of his long life. He was a significant practitioner of modern painting and could have made a name as an artist. Above all, he was a natural product chemist of the highest quality with the genius of isolating from the plants of the Indian subcontinent pharmacologically active compounds whose structures, when determined by others, were found to contain novel architectural features. Siddiqui was a gifted experimentalist, an immensely cultured and charismatic man.

Infantile nephrotic syndrome and congenital glaucoma

A case of infantile nephrotic syndrome (NS) with advanced membranoproliferative glomerulonephritis (MPGN), type I, and bilateral congenital glaucoma, is presented. The patient also had persistent thrombocytopenia and subclinical hypothyroidism. The parents were second-degree cousins and the affected infant had a sibling who was born with congenital glaucoma. His mother had an aunt and uncle on the maternal side who were born with congenital glaucoma. In addition, there was a history of infantile death in five family members of unknown causes (pedigree). To the best of our knowledge, the association of congenital glaucoma and infantile NS due to MPGN has not been reported previously.

Electroanatomically guided catheter ablation of ventricular tachycardias causing multiple defibrillator shocks

With conventional techniques, RF catheter ablation is difficult in patients with unstable VT or with multiple VTs. The feasibility of RF catheter ablation guided by three-dimensional electroanatomic mapping technique in patients whose implanted ICD continued to deliver multiple shocks due to VT despite use of antiarrhythmic medications was assessed in 19 patients (15 men, 4 women; mean age [+/- SD] 70+/-7 years). All had a prior history of MI and subsequently had received an ICD due to VT. During the 12-week preablation period, these patients received 31+/-15 shocks (range 4-62 shocks) due to refractory monomorphic VTs. An electroanatomic mapping technique using the CARTO system was performed to delineate scar tissue. RF catheter ablation was then performed at appropriate sites identified by pace mapping and by substrate mapping. Seventeen patients were on amiodarone at the time of ablation. Twenty-seven VTs were documented clinically, and 45 were induced during electrophysiological evaluation. Of the 45 tachycardias induced, 38 VTs were targeted for ablation. Catheter ablation was performed during sinus rhythm in 31 episodes and during VT in 7 episodes. During a mean follow-up of 26+/-8 weeks (range 18-48 weeks), 13 (66%) patients had no recurrence of VT (P < 0.0001) and antiarrhythmic drugs were discontinued or the number of medications reduced in 17 patients (P < 0.0001). Electroanatomic mapping is helpful in identifying sites for catheter ablation in highly symptomatic patients with refractory VT associated with myocardial scarring.

Noncontact mapping for radiofrequency ablation of complex cardiac arrhythmias

Radiofrequency (RF) catheter ablation is the current treatment of choice for several cardiac arrhythmias. The conventional approach utilizing intracardiac electrograms during sinus rhythm and during tachycardia has inherent limitations, including limited two-dimensional fluoroscopic imaging and limited ability to evaluate several potential sites for ablation then go precisely to the most suitable site. Recently, a noncontact mapping system has been developed that can be used to perform single beat high resolution mapping of cardiac arrhythmias. In this report, we describe the advantage of utilizing the system in facilitating a successful outcome in 5 patients with different complex arrhythmias.

Expression of Set-alpha during morphogenesis of mouse lower first molar

The detailed in situ expression pattern of the Set-alpha gene has been studied. Previously we showed that Set-alpha is a differentially expressed gene in the embryonic mouse mandible at day 10.5 (E10.5) gestational age. Cells expressing Set-alpha were widely distributed in both the epithelial and underlying ectomesenchymal cells at E10.5. At E12, they were slightly aggregated in an area where tooth germ of the lower first molar is estimated to be formed. At E13.5, Set-alpha was strongly expressed in the tooth germ. At the cap stage, Set-alpha was expressed in the enamel organ and dental papilla. At the bell stage, Set-alpha was distinctly expressed in the inner enamel epithelial and dental papilla cells facing the inner enamel epithelial layer, which were intended to differentiate into ameloblasts and odontoblasts, respectively. Interestingly, Set-alpha was also expressed in several embryonic craniofacial tissues derived from the ectoderm. This study is the first report that Set-alpha is distinctly expressed in the developing tooth germ, and suggests that Set-alpha plays an important role in both the initiation and the growth of the tooth germ, as well as in the differentiation of ameloblasts and odontoblasts.

Usefulness of midodrine in patients with severely symptomatic neurocardiogenic syncope: a randomized control study

INTRODUCTION

The efficacy of midodrine for the management of patients with neurocardiogenic syncope was assessed prospectively in a randomized control study.

METHODS AND RESULTS

Patients who had at least monthly occurrences of syncope and a positive tilt-table test were included in the study. A total of 61 patients were randomly allocated to treatment either with midodrine or with fluid, salt tablets, and counseling. Midodrine was given at a starting dose of 5 mg three times a day and increased up to a dose of 15 mg three times a day when required. Midodrine was given during the daytime every 6 hours. Thirty-one patients were assigned to treatment with midodrine; the other 30 patients were advised to increase their fluid intake and were instructed to recognize their prodromes and abort the progression to syncope. Patients were followed-up for at least 6 months. A quality-of-life questionnaire was administered at the time of randomization and 6 months after. At the 6-month follow-up, 25 (81%) of 31 midodrine-treated patients and 4 (13%) of the 30 fluid-therapy patients had remained asymptomatic (P < 0.001). One patient had to discontinue taking midodrine due to severe side effects and another six patients experienced minor side effects that did not require drug discontinuation.

CONCLUSION

Midodrine appeared to provide a significant benefit in patients with neurocardiogenic syncope. To prevent recurrence of symptoms, dose adjustments were required in about one third of patients.

DOT for patients with limited access to health care facilities in a hill district of eastern Nepal

SETTING

The hill district in Nepal, where access to health care facilities is difficult.

OBJECTIVE

To compare results before and after a decentralised directly observed treatment (DOT) intervention.

DESIGN

Prospective study of patients registered in Dhankuta district, Nepal, 1996-1999. Patients received their intensive phase treatment under health worker supervision via one of three DOT options: 1) ambulatory from the peripheral government health facilities; 2) ambulatory from an international non-governmental organisation (INGO) TB clinic in district centre; or 3) resident in INGO TB hostel in district centre. Historical data from 1995-1996, with unsupervised short-course chemotherapy, were used for comparison.

RESULTS

Of 307 new cases, respectively 126 (41%), 86 (28%) and 95 (31%) took their intensive phase treatment via options 1, 2 and 3. Smear conversion (at 2 months) and cure rates in new smear-positive pulmonary tuberculosis cases were respectively 81.6% (vs. 58.8% historical, P = 0.001) and 84.9% (vs. 76.7% historical, P = 0.03). Overall costs to the INGO provider fell by 7%, mainly as a result of staffing reductions in the INGO services made possible by rationalisation with government services during the intervention.

CONCLUSION

By offering varied DOT delivery routes, including an in-patient option, satisfactory results are possible with DOT even in areas where access to health care facilities is difficult. Provision of in-patient care via an INGO TB hostel allowed a significant proportion of new cases (31%) to receive their intensive phase treatment who otherwise may have had difficulty accessing treatment, due either to the distance to the nearest health facility or to disease severity. Substitution of government hospital beds or local hotel beds for the INGO hostel beds may allow the model to be reproduced elsewhere in similar geographical conditions in Nepal, but further studies should be performed in a non-INGO supported district beforehand.

Database Conference January 27-30, 2000, Washington D.C.--Do existing databases answer clinical questions about geriatric cardiovascular disease and stroke?

EXECUTIVE SUMMARY: Most randomized, controlled trials evaluating the effectiveness of pharmaceutical, surgical, and device interventions for the prevention and treatment of cardiovascular disease have excluded patients over 75 years of age. Consequently, the use of these therapies in the older population is based on extrapolation of safety and effectiveness data obtained from younger patients. However, there are many registries and observational databases that contain large amounts of data on patients 75 years of age and older, as well as on younger patients. Although conclusions from such data are limited, it is possible to define the characteristics of patients who did well and those who did poorly. The goal of this conference was to convene the principal investigators of these databases, and others in the field of geriatric cardiology, to address questions relating to the safety and effectiveness of treatment interventions for several cardiovascular conditions in the elderly. Seven committees discussed the following topics: (I) Risk Factor Modification in the Elderly; (II) Chronic Heart Failure; (III) Chronic Coronary Artery Disease: Role of Revascularization; (IV) Acute Myocardial Infarction; (V) Valve Surgery in the Elderly; (VI) Electrophysiology, Pacemaker, and Automatic Internal Cardioverter Defibrillators Databases; (VII) Carotid Endarterectomy in the Elderly. The chairs of these committees were asked to invite principal investigators of key databases in each of these areas to discuss and prepare a written statement concerning the available safety and efficacy data regarding interventions for these conditions and to identify and prioritize areas for future study. The ultimate goal is to stimulate further collaborative outcomes research in the elderly so as to place the treatment of cardiovascular disease on a more scientific basis.

Ventricular fibrillation sensing and detection by implantable defibrillators: is one better than the others? A prospective, comparative study

INTRODUCTION

We prospectively compared the performance of the sensing and detection systems of three leading defibrillator manufacturers: Medtronic, Guidant, and Ventritex.

METHODS AND RESULTS

Ventricular fibrillation signal was digitally recorded during defibrillator implantation and subsequently played back sequentially to a Medtronic Micro Jewel II 7223Cx, a Guidant MINI II 1762, and a Ventritex Cadet V-115C. The devices were programmed for single-zone detection, at nominal settings. Rate cutoff was set at 320 msec (185/min for the MINI). We analyzed 253 episodes from 47 patients. Median undersensing was 0%, 2.1%, and 5.3% for the Jewel, MINI, and Cadet, respectively (P < 0.001 for each paired comparison). Detection time was 4.1 +/- 1.6 seconds, 3.4 +/- 1.6 seconds, and 4.3 +/- 2.2 seconds for the Jewel, MINI, and Cadet, respectively (P < 0.001 between MINI-Jewel and MINI-Cadet; P < 0.01 between Jewel-Cadet). Delayed detection (detection time longer than the mean of all observations + 2 SD) occurred in 3 (1.2%), 7 (2.8%), and 18 (7.1%) episodes for the Jewel, MINI, and Cadet, respectively. Performance for all devices was worse when the short-separation integrated bipolar lead was used and when the episode followed a failed high-energy shock.

CONCLUSION

Statistically significant differences were seen in sensing and detection performance among the devices and device/lead combinations during ventricular fibrillation. These differences are related to specific features of the respective devices and should be taken into account during clinical practice, as well as in future device development.