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Low voltage area as a predictor of recurrence after a single pulmonary vein isolation procedure: results of the WAVE-MAP AF study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Introduction
Pulmonary vein isolation (PVI) is a recommended approach for atrial fibrillation (AF) ablation procedures. Substrate modification beyond PVI has mixed results but identifying and ablating low voltage zones and ablating those targets in addition to PVI may be beneficial. Electroanatomic mapping is critical to identify subjects that may require further substrate modification. Low voltage area may be predictive of optimal treatment approach.
Purpose
This was a prospective, multicenter, interventional study of a high-density grid-style mapping catheter (HD Grid) to characterize left atrial low voltage substrate during sinus rhythm (SR) and AF and identify associations with 12 month recurrence rates after a single de novo radiofrequency (RF) ablation using a PVI only approach.
Methods
This study (NCT03882021) enrolled 300 subjects at 18 centers in Europe and Israel. Subjects underwent de novo RF ablation for paroxysmal AF (PAF) (N=113), early persistent AF (PsAF; AF sustained 7 days to 3 months) (N=86) or non-early PsAF (AF sustained >3 months to 12 months) (N=101). High density voltage maps were collected with HD Grid. Two pre-ablation maps, in SR and AF, were created for each subject (N=196) followed by PVI only ablation. Low voltage area (using cutoffs of 0.1 mV to 1.5 mV) was investigated in SR and AF. Follow up visits were at 3, 6 and 12 months post-ablation, with a 24-hour Holter monitor at 12 months. A Cox proportional hazards model was used to identify associations between mapping data and 12 month AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence after a single PVI procedure.
Results
At 12 months, 75.5% of subjects were free from AF/AFL/AT recurrence. On average, PsAF subjects had more low voltage area than PAF subjects in SR and AF. However, while univariate analysis found no correlation between recurrence and PAF or PsAF diagnosis (p=0.1261), those with recurrence had a significantly larger percent left atrial low voltage area under 0.5 mV with simultaneous orthogonal bipole wave configuration (HDW) in both AF (p=0.0011) and SR (p=0.0210) than those without recurrence. Using HDW, low voltage area (identified as <0.5 mV) greater than 28% of the left atrium in SR (HR: 4.82, 95% CI: 2.08–11.18, p=0.0003) and greater than 72% in AF (HR: 5.66, 95% CI: 2.34–13.69, p=0.0001) were associated with a higher risk of AF/AFL/AT recurrence at one year.
Conclusion(s)
Using a standard cutoff of 0.5 mV, a larger percent low voltage area was associated with increased risk of recurrence in both SR and AF. Future analyses will explore optimal low voltage cutoffs and thresholds predictive of recurrence that may necessitate additional substrate modification beyond PVI.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Abbott
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High density wave mapping to characterize low voltage substrate in sinus rhythm and atrial fibrillation: acute results from the WAVE-MAP AF study. Europace 2022. [DOI: 10.1093/europace/euac053.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Abbott
Background
Pulmonary vein isolation (PVI) is a recommended approach for all atrial fibrillation (AF) ablation procedures, but PVI alone does not cure all AF. Supplementary substrate modification beyond PVI has mixed results. Identifying low voltage zones and ablating those targets in addition to PVI may be beneficial. Electroanatomic mapping is critical to identify subjects that may require further substrate modification. The amount of low voltage area may be predictive of the optimal treatment approach.
Purpose
This was a prospective, multicenter, interventional study of a high-density grid-style mapping catheter (HD Grid) to characterize left atrial (LA) low voltage substrate during sinus rhythm (SR) and AF in subjects undergoing de novo radiofrequency (RF) ablation for paroxysmal AF (PAF), early persistent AF (PsAF) (7 days-3 months) or non-early PsAF (>3 months-12 months) using a PVI only approach.
Methods
High-density voltage maps were collected with HD Grid during both SR and AF prior to ablation. Differences in low voltage area between (1) SR and AF and (2) simultaneous orthogonal bipole wave configuration (HDW) and standard along-the-spline linear electrode configuration (SD) were investigated.
Results
Three hundred subjects, enrolled at 18 centers in Europe and Israel, underwent PVI only RF ablation for PAF (N=113), early PsAF (N=79), and non-early PsAF (N=108). The average age was 62.0 ± 9.5 years and 70.3% (211/300) were male. SR maps and AF maps were available and evaluated in HDW and SD for 196 subjects (65.3%) (63 PAF, 65 early PsAF, 68 non-early PsAF). Mean LA surface area was 108.8 cm² and mean mapped surface area ranged from 83.2 to 89.5 cm².
HDW maps showed less low voltage area compared to SD in all subgroups, both in AF and in SR (Figure). For example, in AF with a low voltage cutoff of 0.5 mV, mean low voltage area was 49.8 cm² using SD and only 45.6 cm² using HDW (p<.0001). Similarly, in SR with a low voltage cutoff of 0.5 mV, mean low voltage area was 16.1 cm² using SD and only 12.6 cm² using HDW (p<.0001). HDW showed significantly less low voltage area than SD in SR for all measured voltage cutoffs from 0.1 mV to 1.5 mV.
On average, non-early PsAF subjects had a larger low voltage area than early PsAF subjects and PAF subjects in both SR and AF. In SR HDW, non-early PsAF subjects had 15.6 cm² under 0.5 mV, early PsAF subjects had 12.4 cm², and PAF subjects had 9.2 cm² (p=.0316). In AF HDW, non-early PsAF subjects had 56.6 cm² under 0.5 mV, early PsAF had 42.8 cm² and PAF subjects had 35.4 cm² (p<.0001).
Conclusion
Non-early PsAF subjects had the largest low voltage area on average compared to both early PsAF and PAF subjects in this study. Using HD grid, HDW provided better low voltage area characterization compared to SD in both SR and AF. The final results of this study will suggest whether an HDW substrate characterization of low voltage area can predict recurrences after a single PVI-only strategy procedure.
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Enhancing decision-making about adjuvant chemotherapy in ER+, HER2- early breast cancer (EBC) following EndoPredict testing. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx362.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Connexin expression is not altered in omental resistance vessels from women with preeclampsia. Hypertens Pregnancy 2002; 20:119-24. [PMID: 12044320 DOI: 10.1081/prg-100104178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare connexin expression in omental resistance arteries from preeclamptic women and normal gravidas. METHODS Small arteries (approximately 200-400 microm i.d.) were dissected from omental fat biopsies, taken at cesarean delivery from normotensive and preeclamptic women. Vessels were frozen and homogenized, then connexin-43 protein was detected by Western blot and quantitated by comparison with alpha-actin. RESULTS Connexin-43 was detected in all specimens, primarily in its phosphorylated form. Abundance did not differ between vessels from preeclamptic and normotensive gravidas. CONCLUSIONS Phasic activity in omental resistance vessels from preeclamptic women likely depends on abnormal genesis of an oscillatory signal rather than on more extensive gap junctional communication between vascular cells.
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Abstract
Despite minimal model characterisation Langendorff perfused murine hearts are increasingly employed in cardiovascular research, and particularly in studies of myocardial ischaemia and reperfusion. Reported contractility remains poor and ischaemic recoveries variable. We characterised function in C57/BL6 mouse hearts using a ventricular balloon or apicobasal displacement and assessed responses to 10-30 min global ischaemia. We examined the functional effects of pacing, ventricular balloon design, perfusate filtration, [Ca(2+)] and temperature. Contractility was high in isovolumically functioning mouse hearts (measured as the change in pressure with time (+dP/dt), 6000-7000 mmHg s(-1)) and was optimal at a heart rate of approximately 420 beats min(-1), with the vasculature sub-maximally dilated, and the cellular energy state high. Post-ischaemic recovery (after 40 min reperfusion) was related to the ischaemic duration: developed pressure recovered by 82 +/- 5 %, 73 +/- 4 %, 68 +/- 3 %, 57 +/- 2 % and 41 +/- 5 % after 10, 15, 20, 25 and 30 min ischaemia, respectively. Ventricular compliance and elastance were both reduced post-ischaemia. Post-ischaemic recoveries were lower in the apicobasal model (80 +/- 4 %, 58 +/- 7 %, 40 +/- 3 %, 32 +/- 7 % and 25 +/- 5 %) despite greater reflow and lower metabolic rate (pre-ischaemic myocardial O(2) consumption (V(O2,myo)) 127 +/- 15 vs. 198 +/- 17 microl O(2) min(-1) g(-1)), contracture, enzyme and purine efflux. Electrical pacing slowed recovery in both models, small ventricular balloons (unpressurised volumes < 50-60 microl) artificially depressed ventricular function and recovery from ischaemia, and failure to filter the perfusion fluid to < 0.45 microm depressed pre- and post-ischaemic function. With attention to these various experimental factors, the buffer perfused isovolumically contracting mouse heart is shown to be stable and highly energized, and to possess a high level of contractility. The isovolumic model is more reliable in assessing ischaemic responses than the commonly employed apicobasal model.
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5'-Adenosine monophosphate and adenosine metabolism, and adenosine responses in mouse, rat and guinea pig heart. Comp Biochem Physiol A Mol Integr Physiol 2001; 130:615-31. [PMID: 11691599 DOI: 10.1016/s1095-6433(01)00380-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We examined myocardial 5'-adenosine monophosphate (5'-AMP) catabolism, adenosine salvage and adenosine responses in perfused guinea pig, rat and mouse heart. MVO(2) increased from 71+/-8 microl O(2)/min per g in guinea pig to 138+/-17 and 221+/-15 microl O(2)/min per g in rat and mouse. VO(2)/beat was 0.42+/-0.03, 0.50+/-0.03 and 0.55+/-0.04 microl O(2)/g in guinea pig, rat and mouse, respectively. Resting and peak coronary flows were highest in mouse vs. rat and guinea pig, and peak ventricular pressures and Ca(2+) sensitivity declined as heart mass increased. Net myocardial 5'-AMP dephosphorylation increased significantly as mass declined (3.8+/-0.5, 9.0+/-1.4 and 11.0+/-1.6 nmol/min per g in guinea pig, rat and mouse, respectively). Despite increased 5'-AMP catabolism, coronary venous [adenosine] was similar in guinea pig, rat and mouse (45+/-8, 69+/-10 and 57+/-14 nM, respectively). Comparable venous [adenosine] was achieved by increased salvage vs. deamination: 64%, 41% and 39% of adenosine formed was rephosphorylated while 23%, 46%, and 50% was deaminated in mouse, rat and guinea pig, respectively. Moreover, only 35-45% of inosine and its catabolites derive from 5'-AMP (vs. IMP) dephosphorylation in all species. Although post-ischemic purine loss was low in mouse (due to these adaptations), functional tolerance to ischemia decreased with heart mass. Cardiovascular sensitivity to adenosine also differed between species, with A(1) receptor sensitivity being greatest in mouse while A(2) sensitivity was greatest in guinea pig. In summary: (i) cardiac 5'-AMP dephosphorylation, VO(2), contractility and Ca(2+) sensitivity all increase as heart mass falls; (ii) adaptations in adenosine salvage vs. deamination limit purine loss and yield similar adenosine levels across species; (iii) ischemic tolerance declines with heart mass; and (iv) cardiovascular sensitivity to adenosine varies, with increasing A(2) sensitivity relative to A(1) sensitivity in larger hearts.
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Assessing the congruence of nursing models with organizational culture: a quality improvement perspective. J Nurs Care Qual 1996; 10:41-8. [PMID: 8562988 DOI: 10.1097/00001786-199601000-00007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Model-based practice was identified by the Nursing Department at Riverview Health Centre, a 320-bed long-term care facility located in Winnipeg, Manitoba, as having the potential to enhance care quality significantly. To achieve real impact in the clinical setting, however, the model selected would need to reflect closely the culture and values of the department. It was decided to explore these phenomena using cross-method triangulation involving a cultural assessment survey (the Nursing Unit Cultural Assessment Tool) and focus groups. Patient comfort and empathy emerged consistently as core values for staff. Greater appreciation of the depth and complexity of the nursing department culture and values has provided invaluable direction vis-à-vis conceptual model selection.
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Transverse dentofacial structure of young men who have undergone surgical correction of unilateral cleft lip and palate: a posteroanterior cephalometric study. THE INTERNATIONAL JOURNAL OF ADULT ORTHODONTICS AND ORTHOGNATHIC SURGERY 1996; 11:19-28. [PMID: 9046624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The transverse dentofacial structure of 34 young adult males with unilateral cleft lip and palate, studied by means of posteroanterior cephalograms, was compared to that of a normal sample of 102 young adult males. All cleft patients had been treated surgically and orthodontically in accordance with a standardized protocol. Orthognathic surgical treatment was carried out when growth had ended in a few subjects. In studying the posteroanterior cephalograms, eight lengths, 10 ratios, and three angular variables were used. Comparison of the cephalometric values of the subjects with cleft palate and the normal sample of young adult males indicated (1) the absence of any significant differences in angular variables describing the transverse dentoalveolar relationships in the maxillary and mandibular incisal regions as well as the mandibular position; (2) the absence of any significant differences in the ratios of the nasal, maxillary, and mandibular widths to the interorbital width; (3) the presence, in the cleft group of significantly decreased ratios of maxillary intermolar width to interorbital width, mandibular intermolar width to interorbital width, maxillary intermolar width to mandibular intermolar width, and maxillary intermolar width to maxillary width; (4) the presence, in the cleft group, of a significantly increased ratio of innerorbital width to interorbital width; and (5) significant correlations between the maxillary and mandibular molar widths in the cleft group.
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Intra-species characterization of clinical isolates and biotechnologically used strains of Lactobacillus rhamnosus by analysis of the total soluble cytoplasmatic proteins with silver staining. Int J Food Microbiol 1995; 25:263-75. [PMID: 7654512 DOI: 10.1016/0168-1605(94)00141-r] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Lactobacillus rhamnosus is often used in milk products because of its technological properties, however it is supposed to be related to human infections as well. Therefore, 23 L. rhamnosus strains, including the type strain, were investigated. Nine strains resulted from biotechnological sources, 14 isolates had a clinical background, 13 came from a swedish culture collection. Biochemical and physiological properties were proved by classical tests. Analysis of the total soluble cytoplasmatic protein patterns was performed with diamine silver staining, a technique not previously applied to lactobacilli. Classical tests were able to confirm all strains as L. rhamnosus. Analysis of protein patterns allowed to differentiate between three clusters. Cluster I contained the type strain and biotechnologically used strains and one clinical strain isolated in Berlin. The second consisted of both, technological and clinical strains. The third cluster contained clinical isolates alone. SDS-PAGE of proteins together with diamine silver staining seems to be helpful to detect intra-species differences. It was stated, that technologically used strains of L. rhamnosus could clearly be differentiated from each other and also from clinical isolates.
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[Protein fingerprinting as a method for strain-specific differentiation of technologically useful Lactobacillus strains from clinical isolates]. BERLINER UND MUNCHENER TIERARZTLICHE WOCHENSCHRIFT 1994; 107:302-7. [PMID: 7980380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Lactobacilli are often used in products of animal origin because of their technological properties and as protective cultures against pathogenic microorganisms, however they are supposed to be related to human infections as well. Therefore 39 strains of species that are in biotechnological usage, including the type strains, and some clinical isolates were investigated. 9 strains of L. acidophilus, 7 of L. gasseri and 23 strains of L. rhamnosus were tested. Biochemical and physiological properties were proved by classical tests. Analysis of the total soluble cytoplasmatic protein patterns was performed with diamine silver staining, a technique not previously applied to lactobacilli. Classical tests were able to confirm all strains as belonging to one of the three species. Analysis of protein patterns allowed to differentiate between strains of the same species. In case of L. acidophilus biotechnologically used strains and clinical isolates were clustered separately. L. rhamnosus formed three clusters. SDS-PAGE of proteins together with diamine silver staining seems to be helpful to detect intra-species differences. It was stated, that technologically used strains of lactobacilli could clearly be differentiated from another and also from clinical isolates.
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Popliteal arterial injuries associated with fractures or dislocations about the knee as a result of blunt trauma. ORTHOPAEDIC REVIEW 1991; 20:525-30. [PMID: 1876461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A total of 73 patients with popliteal arterial injuries due to blunt trauma were treated at the Los Angeles County/University of Southern California Medical Center between January 1975 and January 1986. The injuries resulted from high-energy trauma (70% were motor-vehicle-related), and were associated with a variety of fractures and dislocations about the knee. Forty-eight of the patients (66%) had open injuries, 27% of which became infected; the infection rate for all injuries was 22%. The average time from injury to anastomosis was 14.6 hours. The overall amputation rate in the series was 15%. Ten of the 11 amputations were associated with open, type III fractures. The amputation rate did not correlate with type of fracture, delay in diagnosis, or delay in surgery of up to 24 hours, but was directly related to the degree of soft-tissue trauma.
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[Quality of dental radiographs. A sample from 52 general practices]. Ned Tijdschr Tandheelkd 1989; 96:580-3. [PMID: 2639266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To assess the quality of dental radiographs in general practice, 1000 radiographs in 52 practices were collected and evaluated. The radiographs were judged by two examiners using standard series of X-ray film, showing different degrees of the nine different types of errors studied. Furthermore, the diagnostic quality was assessed; if the diagnostic value was poor, the cause was registered. Only 3.1% of the investigated radiographs met all the criteria, and the quality of 13.4% was found to be poor. The main causes were filmpositioning, density and errors in the category 'residual'. It also appeared that a combination of errors in one radiograph, which were individually not very serious, resulted in an unacceptable radiograph.
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Abstract
To determine the potential toxicity of prolonged aerosol tobramycin administration, 22 patients with cystic fibrosis were monitored while receiving inhaled tobramycin three times a day for 12 weeks. Prior to, four times during administration and approximately 6 weeks after discontinuation of treatment, we assessed pulmonary function, weight, height, body temperature, eighth cranial nerve function, serum creatinine, blood urea nitrogen, urinary creatinine clearance, plasma iothalamate clearance, urinary beta-2 microglobulin concentration, and Pseudomonas aeruginosa density in sputum. There was no detectable laboratory evidence of nephrotoxicity. Neither a decrease in auditory acuity (range 250-20,000 Hz) nor vestibular dysfunction was detected. Pulmonary function tests significantly improved during the first month in all subjects (P less than 0.05) but returned to enrollment values by the end of the 12th week of administration of tobramycin aerosol. Sputum P. aeruginosa density initially decreased from a mean of 10(7) cfu/gm to a mean of 10(4) cfu/gm after 2 weeks of aerosol tobramycin administration and remained significantly below the enrollment value throughout. Coincident with the reduced bacterial density, a reduction in cough frequency and sputum production, as well as a weight gain was observed. Seventy-three percent of the patients with sputum P. aeruginosa isolates susceptible to tobramycin on enrollment yielded resistant organisms during aerosol administration. However, 1 year later all sputum P. aeruginosa isolates obtained from patients were susceptible to tobramycin. We conclude that thrice daily aerosol tobramycin administration for 3 months is not associated with detectable eighth cranial nerve or renal toxicity. Transient emergence of tobramycin resistant P. aeruginosa may occur.
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