Early safety and efficacy of percutaneous left atrial appendage suture ligation: results from the U.S. transcatheter LAA ligation consortium

BACKGROUND

Transcatheter left atrial appendage (LAA) ligation may represent an alternative to oral anticoagulation for stroke prevention in atrial fibrillation.

OBJECTIVES

This study sought to assess the early safety and efficacy of transcatheter ligation of the LAA for stroke prevention in atrial fibrillation.

METHODS

This was a retrospective, multicenter study of consecutive patients undergoing LAA ligation with the Lariat device at 8 U.S. sites. The primary endpoint was procedural success, defined as device success (suture deployment and <5 mm leak by post-procedure transesophageal echocardiography), and no major complication at discharge (death, myocardial infarction, stroke, Bleeding Academic Research Consortium bleeding type 3 or greater, or cardiac surgery). Post-discharge management was per operator discretion.

RESULTS

A total of 154 patients were enrolled. Median CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism [doubled]) was 3 (interquartile range: 2 to 4). Device success was 94%, and procedural success was 86%. A major complication occurred in 15 patients (9.7%). There were 14 major bleeds (9.1%), driven by the need for transfusion (4.5%). Significant pericardial effusion occurred in 16 patients (10.4%). Follow-up was available in 134 patients at a median of 112 days (interquartile range: 50 to 270 days): Death, myocardial infarction, or stroke occurred in 4 patients (2.9%). Among 63 patients with acute closure and transesophageal echocardiography follow-up, there were 3 thrombi (4.8%) and 13 (20%) with residual leak.

CONCLUSIONS

In this initial multicenter experience of LAA ligation with the Lariat device, the rate of acute closure was high, but procedural success was limited by bleeding. A prospective randomized trial is required to adequately define clinical efficacy, optimal post-procedure medical therapy, and the effect of operator experience on procedural safety.

Horse species symposium: a novel approach to monitoring pathogen progression during uterine and placental infection in the mare using bioluminescence imaging technology and lux-modified bacteria

Uterine and placental infections are the leading cause of abortion, stillbirth, and preterm delivery in the mare. Whereas uterine and placental infections in women have been studied extensively, a comprehensive examination of the pathogenic processes leading to this unsatisfactory pregnancy outcome in the mare has yet to be completed. Most information in the literature relating to late-term pregnancy loss in mares is based on retrospective studies of clinical cases submitted for necropsy. Here we report the development and application of a novel approach, whereby transgenically modified bacteria transformed with lux genes of Xenorhabdus luminescens or Photorhabdus luminescens origin and biophotonic imaging are utilized to better understand pathogen-induced preterm birth in late-term pregnant mares. This technology uses highly sensitive bioluminescence imaging camera systems to localize and monitor pathogen progression during tissue invasion by measuring the bioluminescent signatures emitted by the lux-modified pathogens. This method has an important advantage in that it allows for the potential tracking of pathogens in vivo in real time and over time, which was hitherto impossible. Although the application of this technology in domestic animals is in its infancy, investigators were successful in identifying the fetal lungs, sinuses, nares, urinary, and gastrointestinal systems as primary tissues for pathogen invasion after experimental infection of pregnant mares with lux-modified Escherichia coli. It is important that pathogens were not detected in other vital organs, such as the liver, brain, and cardiac system. Such precision in localizing sites of pathogen invasion provides potential application for this novel approach in the development of more targeted therapeutic interventions for pathogen-related diseases in the equine and other domestic species.

Postmortem photonic imaging of lux-modified Salmonella Typhimurium within the gastrointestinal tract of swine after oral inoculation in vivo

The study objective was to monitor Salmonella progression by photonic detection through segments of the gastrointestinal tract after oral inoculation. Pigs (~80 kg) were inoculated orally with 3.1 or 4.1 x 10(10) cfu of Salmonella Typhimurium transformed with plasmid pAK1-lux for a 6-h (n = 6) or 12-h (n = 6) incubation in vivo and then were killed for tissue harvest. Intestinal regions (duodenum, jejunum, ileum, large intestine) were divided into 5 replicates of 4 segments (5 cm) each for imaging. For each replicate, n = 2 segments of each region were intact, whereas n = 2 segments were opened to expose the digesta. Subsamples of digesta were analyzed to determine actual colony-forming units, and images were analyzed for relative light units per second. At 6 h, a greater (P < 0.05) concentration of emitting bacteria, and consequently a greater (P < 0.05) detection of photonic emissions, was observed in the small intestine than in the large intestine. The correlations (6 h) of photonic emissions in exposed segments to bacterial colony-forming units were r = 0.73, 0.62, 0.56, and 0.52 (P < 0.05) in duodenum, jejunum, ileum, and large intestine, respectively. Photonic emissions were greater (P < 0.05) in intact jejunum, ileum, and large intestine than in the duodenum after a 6-h incubation. At 12 h, a greater (P < 0.05) concentration of emitting bacteria in jejunum and ileum of exposed segments was observed than in duodenum and large intestine of exposed segments. Photonic emissions were greater in ileum than duodenum, jejunum, and large intestine of exposed segments (P < 0.05). The correlations (12 h) of photonic emissions in exposed segments to bacterial colony-forming units were r = 0.71 and 0.62 for jejunum and ileum, respectively (P < 0.05). At 12 h, a greater (P < 0.05) concentration of emitting bacteria in jejunum and ileum of intact segments was observed than in duodenum and large intestine. These data indicate that colony-forming units of introduced bacteria remained greater in the small intestine after 6- and 12-h incubations; we have determined that a minimum of 2.0 x 10(5) cfu generates detection through these tissues (~1.0 to 21.0 relative light units/s). This study demonstrates the feasibility of using biophotonics in research models ex vivo for monitoring the pathogenicity of Salmonella in swine, in place of, or in conjunction with, traditional microbiological assessments and whether a greater level of sensitivity of detection and correlation to actual bacterial concentrations can be achieved.

Use of tissue-fluid correlations to estimate gentamicin residues in kidney tissue of Holstein steers

Gentamicin continues to be one of the most effective antibiotics for the treatment of gram-negative infections. Greater than 90% of the drug is rapidly eliminated from the body in <2 days, however, a small residue remains bound to the kidney cortex tissue for many months. In beef steers, the gentamicin residue is unacceptable and its presence is monitored by the FAST (Fast Antimicrobial Screen Test) applied to the kidney at the time of slaughter. The sensitivity of the FAST to gentamicin in the kidney cortex is reported to be 100 ng/g, therefore, this level of gentamicin defines the acceptable limit of gentamicin drug residue in the bovine kidney. In the present study, three doses of 4 mg/kg gentamicin was administered intramuscularly to eight steers. Gentamicin was allowed to deplete from the kidneys for a range of times from 7 to 10 months. At slaughter the level of gentamicin in the kidney cortex varied from 91 to 193 ng/g, but a total of 160 FAST tests performed on the kidneys were negative. Blood and urine samples were collected at varying times following the last dose of gentamicin. Kidney tissue samples were collected by laparoscopic surgery in the live steers as well as the final sample obtained at slaughter. Plasma levels of gentamicin declined rapidly to nondetectable within 3 days, while measurable urine persisted for 75 days before the concentration of gentamicin declined to levels too low to quantitate by the available liquid chromatography tandem mass spectrometry (LC/MS/MS) technique. An estimated correlation between an extrapolation of urine gentamicin concentration to the corresponding kidney tissue sample suggests a urine to kidney tissue relationship of 1:100. A test system sufficiently sensitive to a urine gentamicin concentration of 1 ng/mL will correlate with the estimated 100 ng/g gentamicin limit of the FAST applied to the fresh kidney of the recently slaughtered bovine.

Combinatorial interactions between AP-1 and ets domain proteins contribute to the developmental regulation of the macrophage scavenger receptor gene

Macrophage development is regulated by a complex set of hormone-like molecules and cell adhesion events that control the growth and differentiation of progenitor cells. The macrophage scavenger receptor (SR) gene becomes markedly upregulated during the final stages of monocyte-to-macrophage differentiation and provides a model for the identification and characterization of transcription factors that control this process. In this report, we have identified three genomic regulatory elements that are required for transactivation of the SR gene in the THP-1 monocytic leukemia cell line following induction of macrophage differentiation by tetradecanoyl phorbol acetate. Each of these regulatory elements contains a near-consensus binding site for members of the AP-1 gene family, while the two most quantitatively important elements also contain juxtaposed binding sites for ets domain transcription factors. We demonstrate that tetradecanoyl phorbol acetate treatment results in a marked and prolonged increase in AP-1 binding activity on these elements, which can be accounted for almost entirely by c-jun and junB. These proteins in turn form ternary complexes with additional factors that bind to the adjacent ets recognition motifs. Several indirect lines of evidence indicate that ets2 represents a component of this ternary complex. The combined expression of c-jun, ets2, and a constitutive form of ras result in synergistic increases in transcription from promoters containing the SR regulatory elements. These observations suggest that SR gene expression is regulated via a signal transduction pathway involving ras, AP-1, and ets domain proteins and imply that at least some of the signalling components involved in ras-dependent growth are also utilized to promote the expression of genes involved in terminal differentiation.

Radiofrequency catheter ablation for AV nodal reentry: a technique for rapid transection of the slow AV nodal pathway

Selective radiofrequency (RF) catheter ablation of the slow AV nodal pathway has shed new light on the anatomy and physiology of the atrioventricular junction. The recording of "slow pathway potentials" facilitates localization of the slow pathway and has led to a concept of multiple pathway components with atrial insertion sites covering a potentially broad region surrounding the coronary sinus os. The critical area for complete interruption of the slow pathway may be larger than lesion size produced by ablation at a single site, resulting in multiple RF applications with lengthy sessions and prolonged radiation exposure. Information from both old and recent literature suggests that the slow AV nodal pathway is represented by a group of fibers originating from the posteroinferior interatrial septum and coursing anterosuperiorly near the tricuspid annulus before converging upon the compact AV node. Based on this anatomical arrangement, the present study was conducted to evaluate a technique designed to transect the slow pathway by producing a linear RF lesion perpendicular to the orientation of the slow pathway within the mid-portion of Koch's triangle. Using this technique, 30 of 30 patients with common AV nodal reentry were rendered noninducible using 1 to 3 RF applications. Total procedure time averaged 3.4 +/- 1.1 hours and fluoroscopy time averaged 14.8 +/- 4.6 minutes. As a marker of efficacy, episodic nonsustained atrial tachycardia (NSAT) during RF delivery occurred in 28 of 30 (93%) successful applications. Three patients experienced tachycardia recurrence and were successfully ablated by repeat procedure. Conduction characteristics and refractoriness of the fast pathway were unchanged in 23 of 23 patients reevaluated at a mean of 7.2 weeks postablation.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiofrequency catheter ablation for supraventricular tachycardia

Radiofrequency catheter-mediated ablation is a recently developed technique of achieving cure of certain rhythm disorders, notably supraventricular tachycardia. In less than a decade, it has evolved from a theoretic concept to first line therapy for many patients, including those in the pediatric age group. The most common types of arrhythmias amenable to catheter ablation include supraventricular tachycardia due either to an accessory pathway or A-V nodal reentry and atrial fibrillation with a rapid ventricular response refractory to medical therapy. Before the development of the technique, the only therapeutic options included either lifelong antiarrhythmic drugs or open heart surgery. The initial experiences with catheter ablative techniques used direct current shocks of up to 400 J, delivered to an intracardiac catheter from a standard defibrillator. This energy source has largely been replaced by radiofrequency current because of the substantially lower morbidity and greater efficacy. The treatment of patients with these tachyarrhythmias is evolving from a palliative approach to a curative one. With the current worldwide experience, complications are relatively rare and do not appear to differ from those associated with routine electrophysiologic testing or cardiac catheterization. The success rate is high, usually exceeding a 90% efficacy, but is dependent on the skill and experience of the operator. The technique, arrhythmias amenable to treatment, and the nursing implications before, during, and after the procedure are discussed in this article.

Catheter ablation of atrioventricular junction using radiofrequency current in 17 patients. Comparison of standard and large-tip catheter electrodes

BACKGROUND

Two catheter electrode systems were compared for delivering radiofrequency current for ablation of the atrioventricular junction. Seventeen patients with drug-resistant supraventricular tachyarrhythmias were studied.

METHODS AND RESULTS

A 6F or 7F catheter with six or eight standard electrodes (1.25 mm wide, 2.5-mm spacing) was used in the first seven patients (group 1). A 7F quadripolar catheter with a large-tip electrode (4 mm long; surface area, 27 mm2) was used in the final 10 patients (group 2). Both ablation catheters were positioned to record a large atrial potential and a small but sharp His bundle potential from the distal bipolar electrode pair. Radiofrequency current was applied between a large skin electrode on the left posterior chest and either 1) each individual electrode on the standard-tip electrode catheter at 40 V (group 1) or 2) the large-tip electrode at 50-60 V (group 2). Radiofrequency current was limited to 40 V in group patients because of the strong potential for an early impedance rise when higher voltage is applied through standard electrodes. Complete atrioventricular block was achieved in six of seven group 1 patients and all 10 group 2 patients. A junctional escape rhythm followed ablation in five or six group 1 patients (mean cycle length, 1,066 +/- 162 msec) and eight of 10 group 2 patients (mean cycle length, 1,281 +/- 231 msec). Atrioventricular block was produced in a mean of 4.7 +/- 4.6 radiofrequency current applications delivered over a period of 42 +/- 45 minutes using the large-tip electrode (group 2) compared with 46 +/- 22 applications using standard electrodes (15.9 +/- 10.2 applications delivered through the standard-tip electrode) over a period of 147 +/- 59 minutes (group 1). For the application producing atrioventricular block, the large-tip electrode used higher voltage (58 +/- 17 versus 38 +/- 5 V, p less than 0.03) and had lower impedance (103 +/- 22 versus 148 +/- 40 omega, p less than 0.01), resulting in greater power (33.0 +/- 13.0 versus 10.2 +/- 0.6 W, p less than 0.003) and shorter time to block (8 +/- 3 versus 22 +/- 3 seconds, p less than 0.001). Current delivery through standard electrodes was limited by an impedance rise occurring 7 +/- 7 seconds after the onset of one or more radiofrequency current applications at 10 +/- 1 W in six of seven patients. Using the large-tip electrode, an impedance rise occurred in five of 10 patients, but at 25 +/- 10 W and after 21 +/- 9 seconds. Atrioventricular block occurred before the impedance rise in three of these five patients. Complete atrioventricular block persisted in 15 of 16 patients at a mean follow-up of 8.7 months. Atrioventricular conduction returned at 1 month in one group 2 patient and was successfully ablated by a second procedure. Three group 1 patients died 0.5-2 months after ablation, and a fourth patient underwent cardiac transplantation after 10 months. Pathological examination of the heart in two of these patients showed necrosis of the atrioventricular node and origin of the His bundle, without injury to the middle or distal His bundle. All 10 group 2 patients are alive and subjectively improved after ablation.

CONCLUSIONS

We conclude that catheter-delivered radiofrequency current effectively produces complete atrioventricular block (94%) without requiring general anesthesia or the risk of ventricular dysfunction or cardiac perforation. The large-tip electrode allows a threefold increase in delivered power and markedly decreases the number of pulses and time required to produce atrioventricular block.