Safety and immunogenicity of a trivalent virus-like particle vaccine against western, eastern, and Venezuelan equine encephalitis viruses: a phase 1, open-label, dose-escalation, randomised clinical trial

BACKGROUND

Western (WEEV), eastern (EEEV), and Venezuelan (VEEV) equine encephalitis viruses are mosquito-borne pathogens classified as potential biological warfare agents for which there are currently no approved human vaccines or therapies. We aimed to evaluate the safety, tolerability, and immunogenicity of an investigational trivalent virus-like particle (VLP) vaccine, western, eastern, and Venezuelan equine encephalitis (WEVEE) VLP, composed of WEEV, EEEV, and VEEV VLPs.

METHODS

The WEVEE VLP vaccine was evaluated in a phase 1, randomised, open-label, dose-escalation trial at the Hope Clinic of the Emory Vaccine Center at Emory University, Atlanta, GA, USA. Eligible participants were healthy adults aged 18-50 years with no previous vaccination history with an investigational alphavirus vaccine. Participants were assigned to a dose group of 6 μg, 30 μg, or 60 μg vaccine product and were randomly assigned (1:1) to receive the WEVEE VLP vaccine with or without aluminium hydroxide suspension (alum) adjuvant by intramuscular injection at study day 0 and at week 8. The primary outcomes were the safety and tolerability of the vaccine (assessed in all participants who received at least one administration of study product) and the secondary outcome was immune response measured as neutralising titres by plaque reduction neutralisation test (PRNT) 4 weeks after the second vaccination. This trial is registered at ClinicalTrials.gov, NCT03879603.

FINDINGS

Between April 2, 2019, and June 13, 2019, 30 trial participants were enrolled (mean age 32 years, range 21-48; 16 [53%] female participants and 14 [47%] male participants). Six groups of five participants each received 6 μg, 30 μg, or 60 μg vaccine doses with or without adjuvant, and all 30 participants completed study follow-up. Vaccinations were safe and well tolerated. The most frequently reported symptoms were mild injection-site pain and tenderness (22 [73%] of 30) and malaise (15 [50%] of 30). Dose-dependent differences in the frequency of pain and tenderness were found between the 6 μg, 30 μg, and 60 μg groups (p=0·0217). No significant differences were observed between dosing groups for any other reactogenicity symptom. Two adverse events (mild elevated blood pressure and moderate asymptomatic neutropenia) were assessed as possibly related to the study product in one trial participant (60 μg dose with alum); both resolved without clinical sequelae. 4 weeks after second vaccine administration, neutralising antibodies were induced in all study groups with the highest response seen against all three vaccine antigens in the 30 μg plus alum group (PRNT₈₀ geometric mean titre for EEEV 60·8, 95% CI 29·9-124·0; for VEEV 111·5, 49·8-249·8; and for WEEV 187·9, 90·0-392·2). Finally, 4 weeks after second vaccine administration, for all doses, the majority of trial participants developed an immune response to all three vaccine components (24 [83%] of 29 for EEEV; 26 [90%] of 29 for VEEV; 27 [93%] of 29 for WEEV; and 22 [76%] of 29 for EEEV, VEEV, and WEEV combined).

INTERPRETATION

The favourable safety profile and neutralising antibody responses, along with pressing public health need, support further evaluation of the WEVEE VLP vaccine in advanced-phase clinical trials.

FUNDING

The Vaccine Research Center of the National Institute of Allergy and Infectious Diseases, National Institutes of Health funded the clinical trial. The US Department of Defense contributed funding for manufacturing of the study product.

Safety and immunogenicity of an HIV-1 prefusion-stabilized envelope trimer (Trimer 4571) vaccine in healthy adults: A first-in-human open-label, randomized, dose-escalation, phase 1 clinical trial

BACKGROUND

Advances in therapeutic drugs have increased life-expectancies for HIV-infected individuals, but the need for an effective vaccine remains. We assessed safety and immunogenicity of HIV-1 vaccine, Trimer 4571 (BG505 DS-SOSIP.664) adjuvanted with aluminum hydroxide (alum), in HIV-negative adults.

METHODS

We conducted a phase I, randomized, open-label, dose-escalation trial at the National Institutes of Health Clinical Center in Bethesda, MD, USA. Eligible participants were HIV-negative, healthy adults between 18-50 years. Participants were randomized 1:1 to receive Trimer 4571 adjuvanted with 500 mcg alum by either the subcutaneous (SC) or intramuscular (IM) route at weeks 0, 8, and 20 in escalating doses of 100 mcg or 500 mcg. The primary objectives were to evaluate the safety and tolerability of Trimer 4571 with a secondary objective of evaluating vaccine-induced antibody responses. The primary and safety endpoints were evaluated in all participants who received at least one dose of Trimer 4571. Trial results were summarized using descriptive statistics. This trial is registered at ClinicalTrials.gov, NCT03783130.

FINDINGS

Between March 7 and September 11, 2019, 16 HIV-negative participants were enrolled, including six (38%) males and ten (62%) females. All participants received three doses of Trimer 4571. Solicited reactogenicity was mild to moderate in severity, with one isolated instance of severe injection site redness (6%) following a third 500 mcg SC administration. The most commonly reported solicited symptoms included mild injection site tenderness in 14 (88%) and mild myalgia in six (38%) participants. The most frequent unsolicited adverse event attributed to vaccination was mild injection site pruritus in six (38%) participants. Vaccine-induced seropositivity occurred in seven (44%) participants and resolved in all but one (6%). No serious adverse events occurred. Trimer 4571-specific binding antibodies were detected in all groups two weeks after regimen completion, primarily focused on the glycan-free trimer base. Neutralizing antibody activity was limited to the 500 mcg dose groups.

INTERPRETATION

Trimer 4571 was safe, well tolerated, and immunogenic in this first-in-human trial. While this phase 1 trial is limited in size, our results inform and support further evaluation of prefusion-stabilized HIV-1 envelope trimers as a component of vaccine design strategies to generate broadly neutralizing antibodies against HIV-1.

FUNDING

Intramural Research Program of the Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health.

Safety and immunogenicity of a ferritin nanoparticle H2 influenza vaccine in healthy adults: a phase 1 trial

Currently, licensed seasonal influenza vaccines display variable vaccine effectiveness, and there remains a need for novel vaccine platforms capable of inducing broader responses against viral protein domains conserved among influenza subtypes. We conducted a first-in-human, randomized, open-label, phase 1 clinical trial ( NCT03186781 ) to evaluate a novel ferritin (H2HA-Ferritin) nanoparticle influenza vaccine platform. The H2 subtype has not circulated in humans since 1968. Adults born after 1968 have been exposed to only the H1 subtype of group 1 influenza viruses, which shares a conserved stem with H2. Including both H2-naive and H2-exposed adults in the trial allowed us to evaluate memory responses against the conserved stem domain in the presence or absence of pre-existing responses against the immunodominant HA head domain. Fifty healthy participants 18-70 years of age received H2HA-Ferritin intramuscularly as a single 20-μg dose (n = 5) or a 60-μg dose either twice in a homologous (n = 25) prime-boost regimen or once in a heterologous (n = 20) prime-boost regimen after a matched H2 DNA vaccine prime. The primary objective of this trial was to evaluate the safety and tolerability of H2HA-Ferritin either alone or in prime-boost regimens. The secondary objective was to evaluate antibody responses after vaccination. Both vaccines were safe and well tolerated, with the most common solicited symptom being mild headache after both H2HA-Ferritin (n = 15, 22%) and H2 DNA (n = 5, 25%). Exploratory analyses identified neutralizing antibody responses elicited by the H2HA-Ferritin vaccine in both H2-naive and H2-exposed populations. Furthermore, broadly neutralizing antibody responses against group 1 influenza viruses, including both seasonal H1 and avian H5 subtypes, were induced in the H2-naive population through targeting the HA stem. This ferritin nanoparticle vaccine technology represents a novel, safe and immunogenic platform with potential application for pandemic preparedness and universal influenza vaccine development.

Triggering of RNA interference with RNA-RNA, RNA-DNA, and DNA-RNA nanoparticles

Control over cellular delivery of different functionalities and their synchronized activation is a challenging task. We report several RNA and RNA/DNA-based nanoparticles designed to conditionally activate the RNA interference in various human cells. These nanoparticles allow precise control over their formulation, stability in blood serum, and activation of multiple functionalities. Importantly, interferon and pro-inflammatory cytokine activation assays indicate the significantly lower responses for DNA nanoparticles compared to the RNA counterparts, suggesting greater potential of these molecules for therapeutic use.

Co-transcriptional production of RNA-DNA hybrids for simultaneous release of multiple split functionalities

Control over the simultaneous delivery of different functionalities and their synchronized intracellular activation can greatly benefit the fields of RNA and DNA biomedical nanotechnologies and allow for the production of nanoparticles and various switching devices with controllable functions. We present a system of multiple split functionalities embedded in the cognate pairs of RNA-DNA hybrids which are programmed to recognize each other, re-associate and form a DNA duplex while also releasing the split RNA fragments which upon association regain their original functions. Simultaneous activation of three different functionalities (RNAi, Förster resonance energy transfer and RNA aptamer) confirmed by multiple in vitro and cell culture experiments prove the concept. To automate the design process, a novel computational tool that differentiates between the thermodynamic stabilities of RNA-RNA, RNA-DNA and DNA-DNA duplexes was developed. Moreover, here we demonstrate that besides being easily produced by annealing synthetic RNAs and DNAs, the individual hybrids carrying longer RNAs can be produced by RNA polymerase II-dependent transcription of single-stranded DNA templates.

Analyzing caspase-1 activation during Legionella pneumophila infection in macrophages

Caspase-1 is a critical factor in the innate immune response to Legionella pneumophila. The development of methods for analyzing caspase-1 activation pathways and downstream caspase-1-associated activities has helped in understanding the regulation of this protease and the signaling components involved. Here we outline methods for directly detecting active caspase-1, measuring caspase-1 activities and analyzing components involved in the regulation of caspase-1 during L. pneumophila infection in macrophages.

Regulating caspase-1 during infection: roles of NLRs, AIM2, and ASC

Pathogens are detected by a variety of innate immune sensors in host cells leading to rapid induction of cell autonomous responses. Proinflammatory cytokine secretion and a specialized form of inflammatory cell death called pyroptosis are induced during infection through activation of caspase-1. Pathogen-induced caspase-1 activation is regulated in large part by a vast array of cystosolic sensor proteins, including NLRs and AIM2, and an adaptor protein called ASC. Together, these proteins cooperate in forming caspase-1 activation platforms and, more importantly, direct caspase-1 toward cytokine secretion or cell death.

Rapid pathogen-induced apoptosis: a mechanism used by dendritic cells to limit intracellular replication of Legionella pneumophila

Dendritic cells (DCs) are specialized phagocytes that internalize exogenous antigens and microbes at peripheral sites, and then migrate to lymphatic organs to display foreign peptides to naïve T cells. There are several examples where DCs have been shown to be more efficient at restricting the intracellular replication of pathogens compared to macrophages, a property that could prevent DCs from enhancing pathogen dissemination. To understand DC responses to pathogens, we investigated the mechanisms by which mouse DCs are able to restrict replication of the intracellular pathogen Legionella pneumophila. We show that both DCs and macrophages have the ability to interfere with L. pneumophila replication through a cell death pathway mediated by caspase-1 and Naip5. L. pneumophila that avoided Naip5-dependent responses, however, showed robust replication in macrophages but remained unable to replicate in DCs. Apoptotic cell death mediated by caspase-3 was found to occur much earlier in DCs following infection by L. pneumophila compared to macrophages infected similarly. Eliminating the pro-apoptotic proteins Bax and Bak or overproducing the anti-apoptotic protein Bcl-2 were both found to restore L. pneumophila replication in DCs. Thus, DCs have a microbial response pathway that rapidly activates apoptosis to limit pathogen replication.

The immune system is designed to identify microbes that enter the body and elicit responses that prevent the replication and dissemination of these organisms. Dendritic cells play an important role in regulating host immunity to pathogens. Their phagocytic capacity enables DCs to internalize and destroy most microbes, and the ability of DCs to migrate to specialized lymphoid organs is important for inducing antigen-specific immunity. Here, we analyzed interactions between DCs and Legionella pneumophila, a bacterial pathogen that can subvert phagocytic host cell functions to create a vacuole that permits intracellular replication. We found that L. pneumophila infection rapidly induced DCs to commit cell death through apoptosis. Rapid apoptosis was not observed after infection of macrophages, which are the phagocytic cells that support L. pneumophila replication in the lungs of infected animals. Using cells derived from knockout mice, we found that DCs deficient in the proteins Bax and Bak, which are essential for induction of the apoptosis pathway, were unable to restrict the intracellular replication of L. pneumophila. Likewise, overproduction of Bcl-2, which is a negative regulator of apoptosis, resulted in DCs that were permissive for L. pneumophila replication. These data indicate DCs have the ability to rapidly undergo apoptosis when infected with a microbe capable of replicating intracellularly, and this response effectively prevents pathogen replication. We hypothesize that this response may be designed to interfere with the migration of infected DCs through the lymphatic system, which would prevent DCs from serving as a “Trojan Horse” that transports pathogenic microbes from peripheral sites to central organs.

Tyr235 of human cytosolic phosphoenolpyruvate carboxykinase influences catalysis through an anion-quadrupole interaction with phosphoenolpyruvate carboxylate

Tyr235 of GTP-dependent phosphoenolpyruvate (PEP) carboxykinase is a fully invariant residue. The aromatic ring of this residue establishes an energetically favorable weak anion-quadrupole interaction with PEP carboxylate. The role of Tyr235 in catalysis was investigated via kinetic analysis of site-directed mutagenesis-derived variants. The Y235F change lowered the apparent K(m) for PEP by about six-fold, raised the apparent K(m) for Mn(2+) by about 70-fold, and decreased oxaloacetate (OAA)-forming activity by about 10-fold. These effects were due to an enhanced anion-quadrupole interaction between the aromatic side chain at position 235, which now lacked a hydroxyl group, and PEP carboxylate, which probably increased the distance between PEP and Mn(2+) and consequently affected the phosphoryl transfer step and overall catalysis. For the Y235A and Y235S changes, an elimination of the favorable edge-on interaction increased the apparent K(m) for PEP by four- and six-fold, respectively, and the apparent K(m) for Mn(2+) by eight- and six-fold, respectively. The pyruvate kinase-like activity, representing the PEP dephosphorylation step of the OAA-forming reaction, was affected by the substitutions in a similar way to the complete reaction. These observations indicate that the aromatic ring of Tyr235 helps to position PEP in the active site and the hydroxyl group allows an optimal PEP-Mn(2+) distance for efficient phosphoryl transfer and overall catalysis. The Y235A and Y235S changes drastically reduced the PEP-forming and OAA decarboxylase activities, probably due to the elimination of the stabilizing interaction between Tyr235 and the respective products, PEP and pyruvate.

Characterization of an NADH oxidase of the flavin-dependent disulfide reductase family from Methanocaldococcus jannaschii

Methanocaldococcus jannaschii, a deeply rooted hyperthermophilic anaerobic methanarchaeon from a deep-sea hydrothermal vent, carries an NADH oxidase (Nox) homologue (MJ0649). According to the characteristics described here, MJ0649 represents an unusual member within group 3 of the flavin-dependent disulfide reductase (FDR) family. This FDR group comprises Nox, NADH peroxidases (Npx) and coenzyme A disulfide reductases (CoADRs); each carries a Cys residue that forms Cys-sulfenic acid during catalysis. A sequence analysis identified MJ0649 as a CoADR homologue. However, recombinant MJ0649 (rMJNox), expressed in Escherichia coli and purified to homogeneity an 86 kDa homodimer with 0.27 mol FAD (mol subunit)−1, showed Nox but not CoADR activity. Incubation with FAD increased FAD content to 1 mol (mol subunit)−1 and improved NADH oxidase activity 3.4-fold. The FAD-incubated enzyme was characterized further. The optimum pH and temperature were ≥10 and ≥95 °C, respectively. At pH 7 and 83 °C, apparent K m values for NADH and O2 were 3 μM and 1.9 mM, respectively, and the specific activity at 1.4 mM O2 was 60 μmol min−1 mg−1; 62 % of NADH-derived reducing equivalents were recovered as H2O2 and the rest probably generated H2O. rMjNox had poor NADPH oxidase, NADH peroxidase and superoxide formation activities. It reduced ferricyanide, plumbagin and 5,5′-dithiobis(2-nitrobenzoic acid), but not disulfide coenzyme A and disulfide coenzyme M. Due to a high K m, O2 is not a physiologically relevant substrate for MJ0649; its true substrate remains unknown.

Type IV secretion-dependent activation of host MAP kinases induces an increased proinflammatory cytokine response to Legionella pneumophila

The immune system must discriminate between pathogenic and nonpathogenic microbes in order to initiate an appropriate response. Toll-like receptors (TLRs) detect microbial components common to both pathogenic and nonpathogenic bacteria, whereas Nod-like receptors (NLRs) sense microbial components introduced into the host cytosol by the specialized secretion systems or pore-forming toxins of bacterial pathogens. The host signaling pathways that respond to bacterial secretion systems remain poorly understood. Infection with the pathogen Legionella pneumophila, which utilizes a type IV secretion system (T4SS), induced an increased proinflammatory cytokine response compared to avirulent bacteria in which the T4SS was inactivated. This enhanced response involved NF-κB activation by TLR signaling as well as Nod1 and Nod2 detection of type IV secretion. Furthermore, a TLR- and RIP2-independent pathway leading to p38 and SAPK/JNK MAPK activation was found to play an equally important role in the host response to virulent L. pneumophila. Activation of this MAPK pathway was T4SS-dependent and coordinated with TLR signaling to mount a robust proinflammatory cytokine response to virulent L. pneumophila. These findings define a previously uncharacterized host response to bacterial type IV secretion that activates MAPK signaling and demonstrate that coincident detection of multiple bacterial components enables immune discrimination between virulent and avirulent bacteria.

The host immune system senses bacterial infection by recognizing conserved bacterial components. The host can differentiate between virulent and avirulent bacteria by detecting the activity of bacterial secretion systems that inject effector proteins into cells. How the host responds to such bacterial secretion systems is not fully understood. Using the bacterial pathogen Legionella pneumophila and isogenic mutants that differ in defined virulence properties, a robust immune response to L. pneumophila and its type IV secretion system was identified. Using macrophages lacking various aspects of the innate immune system, it was found that this host response is comprised of signaling by extracellular and intracellular immune receptors, as well as host signaling triggered by the type IV secretion system. Through genomic and biochemical analyses of L. pneumophila–infected macrophages, type IV secretion was found to activate additional host signaling pathways distinct from known immune pathways. Our data indicate that coincident detection of multiple bacterial components is required for a robust immune response to bacterial infection and highlights a key host pathway triggered by bacterial type IV secretion that contributes to this immune response.

Kinetic characterization of recombinant human cytosolic phosphoenolpyruvate carboxykinase with and without a His10-tag

We report the first kinetic characterization of human liver cytosolic GTP-dependent phosphoenolpyruvate carboxykinase (GTP-PEPCK), which plays a major role in the development of type 2 diabetes in human. In this work two recombinant forms of the enzyme were studied. One form had a His10-tag and the other was His-tag-free, and with one exception, both exhibited similar kinetic properties. When Mn2+ was used as the sole divalent cation, the His10-tagged enzyme, but not the His-tag-free enzyme, was increasingly inhibited at Mn2+ concentrations greater than 0.7 mM. This inhibition did not pose any problem in kinetic analysis, for within the relevant Mn2+ concentration range the His-tagged human PEPCK behaved almost identically to the tag-free enzyme. This property will bring simplicity and speed to purifying and studying multiple structural variants of this important enzyme. Apparent Km values of tag-free enzyme for phosphoenolpyruvate, GDP and bicarbonate were 450, 79 and 20,600 microM, respectively, while those for oxaloacetate and GTP were 4 and 23 microM, respectively, emphasizing the enzyme's gluconeogenic character. Bicarbonate (>100 mM) inhibited OAA-forming activity, which was a new observation with a GTP-PEPCK. The apparent Km for Mn2+ in the PEP-forming direction was 30-fold lower than that for the OAA-forming direction. Mn2+ and bicarbonate or CO2 might regulate the enzyme in vivo.

Roles of Asp75, Asp78, and Glu83 of GTP-dependent Phosphoenolpyruvate Carboxykinase from Mycobacterium smegmatis

The roles of Asp(75), Asp(78), and Glu(83) of the (75)DPSDVARVE(83) element of Mycobacterium smegmatis GTP-dependent phosphoenolpyruvate (PEP) carboxykinase (GTP-PEPCK) were investigated. Asp(78) and Glu(83) are fully conserved in GTP-PEP-CKs. The human PEPCK crystal structure suggests that Asp(78) influences Tyr(220); Tyr(220) helps to position bound PEP, and Glu(83) interacts with Arg(81). Experimental data on other PEPCKs indicate that Arg(81) binds PEP, and the phosphate of PEP interacts with Mn(2+) of metal site 1 for catalysis. We found that D78A and E83A replacements severely reduced activity. E83A substitution raised the apparent K(m) value for Mn(2+) 170-fold. In contrast, Asp(75) is highly but not fully conserved; natural substitutions are Ala, Asn, Gln, or Ser. Such substitutions, when engineered, in M. smegmatis enzyme caused the following. 1) For oxaloacetate synthesis, V(max) decreased 1.4-4-fold. K(m) values for PEP and Mn(2+) increased 3-9- and 1.2-10-fold, respectively. K(m) values for GDP and bicarbonate changed little. 2) For PEP formation, V(max) increased 1.5-2.7-fold. K(m) values for oxaloacetate increased 2-2.8-fold. The substitutions did not change the secondary structure of protein significantly. The kinetic effects are rationalized as follows. In E83A the loss of Glu(83)-Arg(81) interaction affected Arg(81)-PEP association. D78A change altered the Tyr(220)-PEP interaction. These events perturbed PEP-Mn(2+) interaction and consequently affected catalysis severely. In contrast, substitutions at Asp(75), a site far from bound PEP, brought subtle effects, lowering oxaloacetate formation rate but enhancing PEP formation rate. It is likely that Asp(75) substitutions affected PEP-Mn(2+) interaction by changing the positions of Asp(78), Arg(81), and Glu(83), which translated to differential effects on two directions.

Substrates for sudden cardiac death

Pre-event identification of a specific cardiac substrate abnormality in a patient is an important step in preventing sudden cardiac death (SCD) in the pediatric and adult population. Certain cardiac substrate abnormalities can render the patient "at risk" for SCD and strategies for prevention of SCD in children must involve the identification and subsequent modification of these cardiac substrates.

Effect of feeding organic and inorganic sources of additional zinc on growth performance and zinc balance in nursery pigs

Three experiments were conducted to evaluate the effect of feeding pharmacological concentrations of zinc (Zn), from organic and inorganic sources, on growth performance, plasma and tissue Zn accumulation, and Zn excretion of nursery pigs. Blood from all pigs was collected for plasma Zn determination on d 14 in Exp. 1, d 7 and 28 in Exp. 2, and d 15 in Exp. 3. In Exp. 1, 2, and 3, 90, 100, and 15 crossbred (GenetiPorc USA, LLC, Morris, MN) pigs were weaned at 24+/-0.5, 18, and 17 d of age (6.45, 5.47, and 5.3 kg avg initial BW), respectively, and allotted to dietary treatment based on initial weight, sex, and litter. A Phase 1 nursery diet was fed as crumbles from d 0 to 14 in Exp. 1, 2, and 3, and a Phase 2 nursery diet was fed as pellets from d 15 to 28 in Exp. 1 and 2. The Phase 1 and Phase 2 basal diets were supplemented with 100 ppm Zn as ZnSO4. Both dietary phases contained the same five dietary treatments: 150 ppm additional Zn as zinc oxide (ZnO), 500 ppm added Zn as ZnO, 500 ppm added Zn as a Zn-amino acid complex (Availa-Zn 100), 500 ppm added Zn as a Zn-polysaccharide complex (SQM-Zn), and 3,000 ppm added Zn as ZnO. Overall in Exp. 1, pigs fed 500 ppm added Zn as SQM-Zn or 3,000 ppm added Zn as ZnO had greater ADG (P < 0.05) than pigs fed 150 ppm, 500 ppm added Zn as ZnO, or 500 ppm added Zn as Availa-Zn 100 (0.44 and 0.46 kg/d vs 0.35, 0.38, and 0.33 kg/d respectively). Overall in Exp. 2, pigs fed 3,000 ppm added Zn as ZnO had greater (P < 0.05) ADG and ADFI than pigs fed any other dietary treatment. On d 14 of Exp. 1 and d 28 of Exp. 2, pigs fed 3,000 ppm added Zn as ZnO had higher (P < 0.05) plasma Zn concentrations than pigs on any other treatment. In Exp. 3, fecal, urinary, and liver Zn concentrations were greatest (P < 0.05) in pigs fed 3,000 ppm added Zn as ZnO. On d 10 to 15 of Exp. 3, pigs fed 3,000 ppm added Zn as ZnO had the most negative Zn balance (P < 0.05) compared with pigs fed the other four dietary Zn treatments. In conclusion, feeding 3,000 ppm added Zn as ZnO improves nursery pig performance; however, under certain nursery conditions the use of 500 ppm added Zn as SQM-Zn may also enhance performance. The major factor affecting nutrient excretion appears to be dietary concentration, independent of source.

Atrioventricular block in a newborn with acquired long QT syndrome

We report a case of 2:1 atrioventricular block associated with acquired long QT syndrome. A newborn presented to our neonatal intensive care unit with intermittent bradycardia due to 2:1 atrioventricular block. Initial evaluation showed QT prolongation and significant electrolytic abnormalities. After correction of the electrolytic imbalance, the QT interval normalized and atrioventricular block resolved. Compared to congenital long QT syndrome with 2:1 atrioventricular block, acquired long QT syndrome with comparable atrioventricular block has a benign prognosis, provided treatment is initiated quickly.

Differential developmental effects of acute hypoxia on the rabbit atrioventricular conduction axis

The differential developmental effects of hypoxia on antegrade fast and slow and retrograde conduction through the atrioventricular junction are unknown. This study describes the effects of hypoxia on fast and slow antegrade atrioventricular node, infra-Hisian and retrograde conduction in immature and mature hearts during premature pacing protocols in excise, perfused adult and neonatal rabbits. The results are: (1) antegrade conduction delay through the atrioventricular node is the same developmentally, but delay through the His-Purkinje system is greater in adults; (2) hypoxia reduces the extra delay in the His-Purkinje system in adults; (3) fast atrioventricular node conduction is more sensitive to hypoxia in neonates than in adults, and slow atrioventricular node conduction is more sensitive to hypoxia in adults than in neonates, and (4) retrograde atrioventricular node conduction is more resistant to hypoxia in neonates than in adults.

Diagnosis and treatment of pediatric arrhythmias

The work up of arrhythmias encountered in the pediatric patient is usually initiated by primary care providers. Proper treatment of pediatric arrhythmias necessitates recording the suspected rhythm disturbance and an evolution of the underlying cardiac structure and function.

JT dispersion in Wolff-Parkinson-White syndrome: effect of eccentric ventricular depolarization on the dispersion of repolarization

There is much interest in QT dispersion for noninvasive risk stratification of patients at risk of arrhythmias. However, little is known about the genesis of abnormal QT dispersion. In particular, whether eccentric ventricular depolarization, as seen in preexcitation, can lead to abnormal dispersion of repolarization is unknown. We studied 24 children aged 1-19 years (mean +/- SD, 11 +/- 5 years) with manifest preexcitation due to Wolff-Parkinson-White syndrome who had successful catheter ablation. Standard ECGs done preablation, early postablation (< 1 week), mid postablation (> 1 week, < 2 months), and late postablation (> 2 months) were reviewed. The QRS duration prior to ablation ranged from 90-160 ms (mean +/- SD, 123 +/- 21 ms). On the preablation ECG, the JT and JTc dispersions showed no relationship to the QRS duration (r = 0.04 and 0.07, respectively). There was no change in JT dispersion when the preablation (42 +/- 15 ms) ECG was compared to early (43 +/- 15 ms), mid (44 +/- 13 ms), and late postablation (48 +/- 19 ms) ECGs. There was no significant change in JTc dispersion as well. Thus, JT dispersion is unrelated to QRS duration and unaffected by catheter ablation in patients with Wolff-Parkinson-White syndrome. Eccentric ventricular depolarization does not lead to abnormal dispersion of repolarization.

Different effects of flecainide on atrioventricular conduction properties in the adult and immature rabbit heart

The influence of flecainide (0.1, 0.5, 1.0, and 2.0 micrograms/mL) on atrioventricular (AV) conduction was studied in neonatal and adult perfused rabbit hearts using extracellular bipolar surface electrograms and premature atrial and ventricular pacing. Flecainide produced a concentration and rate-related increase in the steady-state nodal conduction (AHmin) and an increase in slow AH conduction (AHmax) in both age groups. The drug produced significant increases in the refractory periods of the atrium, AV node, His-Purkinje system, and ventricular myocardium. The neonatal refractory periods were significantly greater at lower or the same drug concentrations than those of the adult. The neonatal Wenckebach cycle length was significantly greater with a lower concentration of drug (0.5 microgram/mL) than was the adult Wenckebach cycle length. The His-Purkinje system steady-state conduction time (HVmin) was increased by a lower concentration of drug in the neonate (0.5 microgram/mL) as compared with 2.0 micrograms/mL in the adult. These data show that across a wide range of AV conduction parameters, the neonatal preparations responded to a lower concentration of flecainide than did the adult preparations. These findings may, in part, be the basis for the reported greater efficacy of the drug in children than in adults.

Radiofrequency ablation of a posteroseptal accessory pathway via the middle cardiac vein in a six-year-old child

Although radiofrequency ablation is highly successful in patients with the Wolff-Parkinson-White syndrome, certain pathways remain refractory to ablation. In particular, subepicardial pathways often fail ablation via an endocardial approach. In adult patients, left-sided subepicardial pathways have been treated successfully using energy delivery within the coronary sinus. To document the safety and efficacy of this approach in children, we present the case of a 6-year-old boy who underwent radiofrequency ablation of a posteroseptal pathway via energy delivery within the middle cardiac vein. Follow-up study showed no evidence of recurrence or gross coronary vascular injury.

QRS prolongation is associated with inducible ventricular tachycardia after repair of tetralogy of Fallot

Prolonged QRS duration on the electrocardiogram has been found to predict adverse arrhythmic events in patients late after repair of tetralogy of Fallot. Whether QRS duration can also predict inducible ventricular tachycardia (VT) at electrophysiologic study is unknown. Between 1984 and 1995 we studied 135 survivors of tetralogy of Fallot surgery whose age at surgery was 34 days to 37 years (3.7 +/- 3.9, median 2.5) and age at electrophysiologic study was 1.4 to 43 years (9.7 +/- 8.2, median 6.7). QRS duration was 80 to 240 ms (137 +/- 29) and > or = 180 ms in 9 patients. Sustained VT was induced in 22 patients (monomorphic in 17). Induced sustained monomorphic VT was related to QRS duration, right ventricular dimension, H-V interval, and presence of symptoms. QRS duration was also related to induced sustained monomorphic VT by multivariate analysis. QRS duration > or = 180 ms was 35% sensitive and 97% specific for induced sustained monomorphic VT. QRS duration was related to induced sustained monomorphic VT even when only asymptomatic patients were analyzed. A QRS duration > or = 180 ms was 100% sensitive and 96% specific for detecting clinical VT. Prolonged QRS duration on the electrocardiogram is associated with induced sustained monomorphic VT on electrophysiologic study. The finding of prolonged QRS duration should suggest the need for further testing to determine the risk of adverse arrhythmic events in patients after repair of tetralogy of Fallot, even if they are asymptomatic.

Incidence of femoral vein occlusion after catheter ablation in children: evaluation with magnetic resonance angiography

Catheter ablation in children requires placement of multiple large femoral venous sheaths and catheters. Magnetic resonance angiography (MRA) was used to evaluate the effect of indwelling lines on femoral venous blood flow. Between October 1993 and February 1994 a total of 17 patients scheduled for catheter ablation underwent venous MRA. Two-dimensional time-of-flight MRA was performed 12-70 hours after catheterization on all patients. All patients received intravenous heparin during the procedure and had aspirin therapy instituted after ablation. Eighteen catheter ablations and MRA studies were performed on the 17 patients (one patient underwent repeat ablation). There were 7 females and 10 males, with a mean age of 14.8 +/- 4.2 years (range 8-21 years). Patients had three venous sheaths inserted in the left femoral vein (5F, 6F, and 7F with external diameters measuring 1.7, 2.0, and 2.3 mm, respectively) and one sheath in the right femoral vein (7F). Four patients (22%) had altered venous flow (two complete obstructions and two partial obstructions) following catheterization. None of these patients experienced symptoms or complications. It was concluded that there is an increased incidence (22%) of venous obstruction following catheter ablation, but there are no related complications. Venous MRA provides a rapid, noninvasive method for evaluating venous flow abnormalities and possibly detects patients at risk for complications.

Catheter ablation treatment of supraventricular tachycardia-induced cardiomyopathy

OBJECTIVE

To investigate the efficacy of radiofrequency catheter ablation (RFCA) as an alternative nonpharmacological therapy for tachycardia-induced cardiomyopathy.

DESIGN

A retrospective study of 8 pediatric patients (age range, 10 months to 21 years) who underwent RFCA for an incessant supraventricular tachycardia-induced cardiomyopathy. A patient's tachycardia was considered incessant if the tachycardia was present more than 75% of the time. The left ventricular shortening fraction, as measured by echocardiography, before and after ablation, was used as the index of cardiac function. Cardiomyopathy was defined as a left ventricular shortening fraction of 28% or less.

RESULTS

Following RFCA, 7 patients had total resolution of their tachycardia and were discharged from the hospital with no antiarrhythmic medications. The remaining patient's tachycardia was modified by the catheter ablation and was subsequently controlled with flecainide acetate. With follow-up ranging from 9 months to 3 years, all patients have normal cardiac function as documented by echocardiography. No significant morbidity resulted from the catheter ablations.

CONCLUSIONS

Tachycardia-induced cardiomyopathy is amenable to "curative" therapy with RFCA. Ventricular function returns to normal after the successful catheter ablation procedure.

Beta2-agonist induced ventricular dysrhythmias secondary to hyperexcitable conduction system in the absence of a long QT syndrome

BACKGROUND

The use of inhaled beta 2-agonists for bronchodilation in the treatment of lower airway obstruction is accepted worldwide. These agents are used for symptomatic relief of lower airway obstruction and, as well, can be employed prophylactically in exercise-induced bronchospasm. Cardiac dysrhythmias, specifically the long QT syndrome, have been associated with cardiac events precipitated by sympathomimetics. There are reports of documented long QT syndrome in association with syncope in children; however, there are no reports of beta 2-agonist-induced syncope in the absence of long QT syndrome.

OBJECTIVE

To determine predisposing cardiac factors resulting in syncope associated with inhaled beta 2-agonist use.

METHOD

Case report. The index case was evaluated for cardiac pathology through non-invasive techniques, cardiac catheterization, and electrophysiologic studies. Electrophysiologic studies included provocative challenge with parenteral adrenergic agents.

RESULTS

Non-invasive studies were unremarkable. There was no evidence of prolonged QT syndrome or support for vasopressor syncope. Electrophysiologic studies revealed reproducible polymorphic ventricular tachycardia. This predisposition required a ventricular stimulation program of higher intensity while on mexilitine.

CONCLUSIONS

This case of syncope associated with inhaled, short-acting beta 2-agonist resulted from a hyperexcitable conduction system rather than the presence of a long QT syndrome.

Late endocardial pacing lead body migration compromising Fontan physiology

Migration of intracardiac transvenous pacing leads may occur. There is a known risk of intrapulmonary ventricular pacing lead migration in patients with endocardial lead systems. In the current report we present the late intrapulmonary migration of an endocardial atrial pacing lead body. The patient had undergone antitachycardia pacemaker placement to control recurrent atrial tachyarrhythmias following the Fontan procedure. Although the lead electrode remained in place and continued to pace, the lead body migrated, causing severe obstruction to blood flow. This resulted in severe cardiac decompensation, which was ultimately ameliorated by lead repositioning.

Changes in atrioventricular conduction properties with refractory-period modulation

Dofetilide, clofilium, and risotilide, three drugs known to prolong cardiac action potentials and refractory periods, were studied by using a perfused isolated rabbit heart preparation with intermittent premature pacing and bipolar surface electrograms. The rate-related effects of these drugs on atrioventricular (AV) conduction were tested by pacing at a long (400 ms) and a short (250 ms) basic cycle length (BCL). All three drugs increased refractory periods in a concentration-dependent manner in most segments of the AV axis. The maximal atrio-His (AH) conduction interval (AHmax) and delta AH (AHmax - AHmin) produced by premature pacing was decreased by the highest concentration of each drug at the 400-ms BCL, whereas only clofilium reduced AHmax and delta AH at the 250-ms BCL. Changes in delta AH correlated best with changes in the atrial functional refractory period. The His-Purkinje system conduction interval (HV), represented by delta HV, was unaffected by any drug at either BCL. These results show that if atrial or nodal refractory periods are increased sufficiently, AHmax but not AHmin was decreased at the 400-ms BCL. Because dofetilide and risotilide did not affect AHmax at the 250-ms BCL, these drugs may be less effective at preventing AV nodal reentrant tachycardias than a drug such as clofilium that displays less rate dependency.

Interatrial septal aneurysms and atrial arrhythmias in infants

Studies have suggested that interatrial septal aneurysms (IASAs) may be the initiating mechanism of supraventricular tachycardia (SVT) in newborns and infants. A retrospective study was performed to determine the incidence of IASAs in 30 infants with atrial arrhythmias (SVT, atrial flutter, or frequent premature atrial contractions) and their possible relation to the mechanism of atrial arrhythmias. An IASA was defined as dilation of the septum > 5 mm beyond the plane of the atrial septum and associated with redundant tissue and abnormal mobility. The study patients were compared with age and sex-matched control subjects. Four (13%) of the 30 study patients and 2 (7%) of 30 control subjects had an IASA (difference not significant). In contrast to previous reports, this study demonstrates that there is not a significant relation between the presence of IASAs and the onset and recurrence of atrial arrhythmias.

High prevalence of repolarization abnormalities in children with simple ventricular ectopy

BACKGROUND

Premature ventricular contractions (PVCs) may occur in 0.3 to 2.2% of routine resting electrocardiograms (ECGs) in children with structurally normal hearts.

HYPOTHESIS

This study tests the hypothesis that repolarization abnormalities are present more frequently on the surface ECG in pediatric patients with benign ventricular ectopy.

METHODS

A retrospective study was performed examining 32 children with benign ventricular ectopy and structurally normal hearts. The surface ECG was carefully reviewed, concentrating on repolarization abnormalities as evidenced by a prolonged QTc, a prolonged JTc, and/or an abnormal T-wave vector. QTc was calculated using Bazett's formula and considered prolonged if > 440 ms, and the JTc was calculated using a formula analogous to Bazett's formula and considered prolonged if > 340 ms. The T-wave vector was considered normal if between 0 to +90 degrees, concordant with the frontal QRS axis and within 60 degrees of the QRS axis. There were 13 females (41%) and 19 males (59%) with an average age of 9.1 years (range 1-16.1 years). These patients were then compared with age- and gender-matched controls. Fourteen of 32 study patients (44%) and 2 of 32 controls (6%) had evidence of repolarization abnormalities.

RESULTS

Using chi 2 analysis, there was a significant difference between groups (p = 0.0005). No patient had an abnormal T-wave vector and there were no other significant ECG abnormalities. There was no significant relationship between repolarization abnormalities and patient gender or age.

CONCLUSION

A significant percentage (44%; P = 0.0005) of children with benign ventricular ectopy have associated repolarization abnormalities as evidenced by a prolonged QTc and/or JTc. This finding suggests that children with "benign PVCs" may have repolarization changes indicative of underlying substrate abnormalities.

Lack of proarrhythmia as assessed by Holter monitor after atrial radiofrequency ablation of supraventricular tachycardia in children

The purpose of this study was to assess the short-term arrhythmogenicity of atrial radiofrequency (RF) ablation lesions in children. Patients with the greatest exposure to RF energy comprised the study group. Holter data on 35 RF ablation procedures in 31 patients with a median age of 13.2 years (range 3 months to 20 years) was retrospectively analyzed. Patients received an average of 19.9 (SD = 13.6) RF lesions, all delivered by an atrial approach. Supraventricular ectopy and ventricular ectopy were compared immediately before and after and 4 to 9 weeks after RF ablation by serial Holter monitoring. Factors thought to possibly predispose patients to a proarrhythmic effect were used to define subgroups for separate analysis. No increase in ambient supraventricular ectopy or ventricular ectopy was observed either immediately after or 4 to 9 weeks after RF ablation compared with the baseline Holter recordings. Children exposed to relatively large doses of RF energy may demonstrate transient and asymptomatic nonsustained tachycardias in the short term. However, no new sustained tachycardias and no increase in supraventricular or ventricular ambient ectopy are detected by short-term Holter monitoring.

Learning curve for radiofrequency catheter ablation in pediatrics at a single institution

We examined the learning curve for radiofrequency ablation in pediatrics at a single institution. The first 146 cases were retrospectively reviewed, including patients < or = 21 years old with a single tachycardia diagnosis who were undergoing radiofrequency ablation for the first time. Data regarding demographics, electrophysiologic properties of the tachycardia, and procedural characteristics were tabulated. Data were then analyzed for evidence of association between these characteristics, success, and experience. Results revealed that success rates improved significantly with experience, reaching 85% success for all cases after < 100 cases attempted. Success for accessory pathway tachycardias alone reached > 93%. The number of cases of nonpathway tachycardias undertaken significantly increased as experience was gained. Fluoroscopy time improved to 34 +/- 27 minutes after < 100 cases. In conclusion, as experience was gained, (1) success rates showed a steep improvement; (2) the population undergoing radiofrequency ablation clearly shifted to include more difficult diagnoses; and (3) fluoroscopy time significantly decreased.

Developmental effects of d-sotalol on anterograde and retrograde atrioventricular conduction in the rabbit

INTRODUCTION

These experiments investigate the developmental effects of d-sotalol on standard electrophysiologic parameters of anterograde and retrograde AV conduction in the rabbit.

METHODS AND RESULTS

Using bipolar electrograms and standard pacing techniques, the effects of graded concentrations of d-sotalol on anterograde and retrograde conduction in mature and immature perfused rabbit hearts were compared. Also, a quantitative assessment of the drug's effects on a rate-dependent property of anterograde AV node (AVN) conduction, termed the "recovery process," was compared in mature and immature rabbit hearts. The main developmental electrophysiologic findings of this investigation are: (1) in both the mature and immature rabbit heart, d-sotalol increases the anterograde conduction time and prolongs refractoriness of the AVN, yet the minimal concentrations of d-sotalol that produce these changes are lower in the neonate; (2) d-sotalol increases the anterograde refractory period of the His-Purkinje system in both age groups, but increases anterograde infra-Hisian conduction only in the neonate; (3) 1 x 10-4 M d-sotalol significantly changes the time constant of the AVN recovery process in the neonate, but not in the adult; (4) for retrograde conduction, slow conduction through the AVN (HAmax) and infra-Hisian region (VHmax) are increased by d-sotalol in the neonate, but not in the adult.

CONCLUSIONS

The findings of this study illustrate that d-sotalol has different effects on parameters of the developing AV conduction system. This implies that there may be maturational changes in the ionic currents that are responsible for anterograde and retrograde AVN and His-Purkinje conduction.

Radiofrequency catheter ablation of right ventricular outflow tachycardia in children and adolescents

OBJECTIVES

The current study reviews the safety and efficacy of radiofrequency catheter ablation for the treatment of right ventricular outflow tachycardia in children and adolescents and describes a modified method for mapping the tachycardia focus.

BACKGROUND

Although radiofrequency catheter ablation has proved highly effective for the treatment of supraventricular tachycardia during childhood and adolescence, its application in children with idiopathic right ventricular outflow tachycardia has been limited.

METHODS

Six children (mean [+/- SD] age 10.6 +/- 2.4 years, range 6 to 16) with right ventricular outflow tachycardia underwent seven radiofrequency catheter ablation procedures. The mean tachycardia cycle length was 323 +/- 24 ms (range 300 to 360). Two multipolar catheters were positioned in the right ventricular outflow tract to map the tachycardia focus.

RESULTS

Radiofrequency catheter ablation was successful in five (83%) of the six children (95% confidence interval 36% to 99%). At successful ablation sites, local endocardial activation time preceded the surface QRS onset by 46 +/- 5 ms (range 37 to 57), and there was concordance of the 12-lead pace map and the electrocardiogram (ECG) in 11 (one patient) to 12 ECG leads (four patients). One patient developed complete right bundle branch block during radiofrequency catheter ablation. There were no additional complications and no clinical recurrences over a mean follow-up period of 12.7 +/- 3.8 months (range 9 to 22).

CONCLUSIONS

These results suggest that radiofrequency catheter ablation is a safe and effective treatment for right ventricular outflow tachycardia during childhood and adolescence. In addition, tachycardia mapping may be enhanced by use of a multipolar right ventricular outflow catheter technique.

The JT interval as a depolarization independent measurement of repolarization: lessons from catheter ablation of the Wolff-Parkinson-White syndrome

In patients with Wolff-Parkinson-White syndrome (WPW), preexcitation precludes accurate assessment of the ventricular repolarization by the QTc. In patients with long QT syndrome, it has been demonstrated that the JTc does not change when depolarization abnormalities develop. We hypothesized that this phenomenon should also be applicable to WPW patients. To test this, we assessed the surface ECG of 29 patients (16 males, 13 females) with WPW pre- and postablation. The QRS, QT, and JT intervals were measured pre- and postablation at 50 mm/s paper speed in leads II and V2. QTc and JTc were calculated according to Bazett's formula. The average age was 12.8 +/- 4.9 years (range 1.5-21). All patients had no residual preexcitation on postablation ECG. Early and late follow-up ECGs were obtained at 32 +/- 34 days and 388 +/- 197 days postablation, respectively. Both the QRS and the QTc intervals shortened significantly on the postablation versus preablation ECGs (QRS: 115 +/- 23 ms vs 89 +/- 15 ms, respectively; P < 0.0001), QTc: 454 +/- 26 vs 423 +/- 23, respectively; P < 0.0001). The preablation JTc interval did not change, postablation (319 +/- 21 vs 323 +/- 23, respectively; P > 0.2). Also, the JTc interval did not change between early and late follow-up, postablation. JTc is an independent measure of repolarization, not related to depolarization. JTc may be a useful tool in assessing repolarization in patients with WPW and other depolarization abnormalities.

Pulmonary/systemic flow ratio in children after cavopulmonary anastomosis

OBJECTIVES

This study attempted to provide a formula for calculation of the pulmonary/systemic flow ratio in children after bidirectional cavopulmonary anastomosis.

BACKGROUND

With the bidirectional cavopulmonary anastomosis, only the superior vena cava blood is oxygenated by the lungs. The inferior vena cava flow recirculates into the systemic circulation. The ratio of these flows will determine systemic arterial saturation.

METHODS

According to the Fick principle, 1) Systemic cardiac output (liters/min) = Pulmonary venous flow + Inferior vena cava flow; 2) Systemic blood oxygen transport (ml/min) = Pulmonary venous blood oxygen transport + Inferior vena cava blood oxygen transport. By substituting the first equation into the second, Pulmonary/systemic flow ratio = (Systemic saturation - Inferior vena cava saturation)/(Pulmonary venous saturation - Inferior vena cava saturation).

RESULTS

We applied the third formula to data obtained from 34 catheterizations in 29 patients after bidirectional cavopulmonary anastomosis. Mean [+/- SD] age at operation was 1.70 +/- 1.43 years, and mean age at catheterization was 2.95 +/- 1.65 years. The pulmonary/systemic flow ratio calculated for all 29 patients was 0.58 +/- 0.09. Of 17 patients with aortography, 10 had systemic to pulmonary collateral vessels. Patients with collateral vessels had a significantly higher pulmonary/systemic flow ratio (0.61 +/- 0.07 vs. 0.53 +/- 0.07, respectively, p < 0.02) and systemic saturation (88 +/- 4% vs. 82 +/- 4%, respectively, p < 0.002) than those without collateral vessels. The pulmonary/systemic flow ratio in those patients with no collateral vessels was similar to the previously reported echocardiographically derived superior vena cava/systemic flow ratio in normal children.

CONCLUSIONS

The pulmonary/systemic flow ratio after bidirectional cavopulmonary anastomosis can be calculated. Pulmonary blood flow in these patients determines systemic saturation and accounts for the majority of venous return in young children.

Successful radiofrequency catheter ablation of atrial muscle reentry tachycardia in a young adult

Atrial muscle reentry as a mechanism of tachycardia has been well illustrated in isolated animal atrial muscle. It has infrequently been reported as an etiology of supraventricular tachycardia in young patients. A case of atrial muscle reentry tachycardia and its successful elimination using radiofrequency catheter ablation is reported.

Radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia in children

Radiofrequency (RF) catheter ablation has been widely used in the treatment of cardiac arrhythmias. In atrioventricular nodal reentrant tachycardia (AVNRT), the experience has been predominantly in adults. The cardiac electrophysiological records of 18 consecutive children undergoing RF catheter AV node modification for AVNRT were reviewed. The patients (10 females, 8 males) were 8.2-17.9 years of age (mean 13.6 +/- 3.0), weight 15.2-88.1 kg (mean 52.2 +/- 20.8), and height 103-190 cm (mean 157.1 +/- 21.7). Thirteen were on antiarrhythmic medications (1-3, average 1.5 drugs/day). All drugs were discontinued 48 hours prior to the ablations. The procedures were performed under sedation and local anesthesia. Pre- and post-AV node modification electrophysiological studies were performed in all procedures. The 18 patients underwent a total of 25 procedures (1.39 +/- 0.61 per patient): the anterior approach aimed at the antegrade fast pathway in the first four patients and the posterior approach aimed at the slow pathway in the remainder. The number of energy applications was 8-54 (19.8 +/- 10.7) per procedure. The maximum energy used in each procedure was 30-50 watts (33.8 +/- 8.4). The average energy was 24-50 watts (33.0 +/- 6.8). The fluoroscopy time was 7.1-73.4 minutes (29.9 +/- 20.0) per procedure, for a total catheterization time of 228-480 minutes (300.3 +/- 59.1). Preablation spontaneous or induced AVNRT (cycle length 310.4 +/- 55.0 msec) was seen in all except one who had the arrhythmia (cycle length 270 msec) on surface ECG.(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose narcotic anesthesia using sufentanil in swine for cardiac catheterization and electrophysiologic studies

A protocol for high-dose narcotic anesthesia using sufentanil by intravenous infusion was developed in swine undergoing cardiac catheterization and intracardiac electrophysiologic studies. In experiments involving cardiac conduction system ablation, nine swine received intramuscular ketamine, 33 mg/kg, and intramuscular acepromazine, 1.1 mg/kg, as premedication. An infusion of sufentanil (15 mcg/kg/h) was started followed by a loading dose of sufentanil (7 mcg/kg) given as a bolus intravenously. A continuous infusion of sufentanil (15-30 mcg/kg/h) was used for maintenance anesthesia. Since the development of this protocol, we have been able to achieve stable hemodynamics and cardiac rhythms for intracardiac electrophysiologic studies.

Management of atrial flutter after the Fontan procedure

OBJECTIVES

The purpose of this study was to review the management of atrial flutter occurring after the Fontan procedure.

BACKGROUND

Atrial flutter occurs frequently after the Fontan procedure and is often hemodynamically poorly tolerated.

METHODS

The patients' charts were reviewed for relevant information.

RESULTS

Between 1984 and 1992, 18 patients had atrial flutter after the Fontan procedure. The underlying heart defect was tricuspid atresia in nine, mitral atresia in six and double inlet left ventricle in three. All but three patients had undergone previous palliative surgery. The time interval from Fontan operation to atrial flutter was < 1 day to 16 years (mean 3.7 years). Seven had early atrial flutter before leaving the hospital. Electrophysiologic study in 15 showed sinus node dysfunction in 12. Atrial flutter was inducible in all patients, and 13 had > 1 flutter configuration. Digoxin and a variety of other antiarrhythmic agents (mean 2.7 drugs/patient) were tried with poor results. Only digoxin, amiodarone, flecainide and propafenone showed some benefit when used alone or in combination. Antitachycardia pacemakers were implanted in 16 patients (endocardial 14, epicardial 2) and, with drugs, were useful in 8 (50%). Because atrial flutter was resistant to treatment, right atriectomy was performed in three patients (with benefit in two, one death), successful radiofrequency catheter His bundle ablation in one patient and catheter ablation of atrial flutter in three patients (two failed, one partial success). One patient underwent heart transplantation, and two died suddenly. Another died of complications after an elective epicardial pacemaker replacement procedure.

CONCLUSIONS

Atrial flutter after the Fontan procedure is difficult to control. Aggressive drug and antitachycardia pacemaker therapy help about half of the patients. When these measures fail, other options, such as atriectomy, His bundle ablation or catheter ablation of atrial flutter, need consideration. The risk of sudden death justifies the use of such aggressive treatment methods.