All-Microwave Leakage Reduction Units for Quantum Error Correction with Superconducting Transmon Qubits

Minimizing leakage from computational states is a challenge when using many-level systems like superconducting quantum circuits as qubits. We realize and extend the quantum-hardware-efficient, all-microwave leakage reduction unit (LRU) for transmons in a circuit QED architecture proposed by Battistel et al. This LRU effectively reduces leakage in the second- and third-excited transmon states with up to 99% efficacy in 220 ns, with minimum impact on the qubit subspace. As a first application in the context of quantum error correction, we show how multiple simultaneous LRUs can reduce the error detection rate and suppress leakage buildup within 1% in data and ancilla qubits over 50 cycles of a weight-2 stabilizer measurement.

High-Fidelity Controlled-Z Gate with Maximal Intermediate Leakage Operating at the Speed Limit in a Superconducting Quantum Processor

Simple tuneup of fast two-qubit gates is essential for the scaling of quantum processors. We introduce the sudden variant (SNZ) of the net zero scheme realizing controlled-Z (CZ) gates by flux control of transmon frequency. SNZ CZ gates realized in a multitransmon processor operate at the speed limit of transverse coupling between computational and noncomputational states by maximizing intermediate leakage. Beyond speed, the key advantage of SNZ is tuneup simplicity, owing to the regular structure of conditional phase and leakage as a function of two control parameters. SNZ is compatible with scalable schemes for quantum error correction and adaptable to generalized conditional-phase gates useful in intermediate-scale applications.

Protecting quantum entanglement from leakage and qubit errors via repetitive parity measurements

Protecting quantum information from errors is essential for large-scale quantum computation. Quantum error correction (QEC) encodes information in entangled states of many qubits and performs parity measurements to identify errors without destroying the encoded information. However, traditional QEC cannot handle leakage from the qubit computational space. Leakage affects leading experimental platforms, based on trapped ions and superconducting circuits, which use effective qubits within many-level physical systems. We investigate how two-transmon entangled states evolve under repeated parity measurements and demonstrate the use of hidden Markov models to detect leakage using only the record of parity measurement outcomes required for QEC. We show the stabilization of Bell states over up to 26 parity measurements by mitigating leakage using postselection and correcting qubit errors using Pauli-frame transformations. Our leakage identification method is computationally efficient and thus compatible with real-time leakage tracking and correction in larger quantum processors.

Fast, High-Fidelity Conditional-Phase Gate Exploiting Leakage Interference in Weakly Anharmonic Superconducting Qubits

Conditional-phase (cz) gates in transmons can be realized by flux pulsing computational states towards resonance with noncomputational ones. We present a 40 ns cz gate based on a bipolar flux pulse suppressing leakage (0.1%) by interference and approaching the speed limit set by exchange coupling. This pulse harnesses a built-in echo to enhance fidelity (99.1%) and is robust to long-timescale distortion in the flux-control line, ensuring repeatability. Numerical simulations matching experiment show that fidelity is limited by high-frequency dephasing and leakage by short-timescale distortion.

Evolution of Nanowire Transmon Qubits and Their Coherence in a Magnetic Field

We present an experimental study of flux- and gate-tunable nanowire transmons with state-of-the-art relaxation time allowing quantitative extraction of flux and charge noise coupling to the Josephson energy. We evidence coherence sweet spots for charge, tuned by voltage on a proximal side gate, where first order sensitivity to switching two-level systems and background 1/f noise is minimized. Next, we investigate the evolution of a nanowire transmon in a parallel magnetic field up to 70 mT, the upper bound set by the closing of the induced gap. Several features observed in the field dependence of qubit energy relaxation and dephasing times are not fully understood. Using nanowires with a thinner, partially covering Al shell will enable operation of these circuits up to 0.5 T, a regime relevant for topological quantum computation and other applications.

Direct Oral Anticoagulants Vs. Enoxaparin for Prevention of Venous Thromboembolism Following Orthopedic Surgery: A Dose-Response Meta-analysis

We carried out a dose–response model‐based meta‐analysis to assess venous thromboembolism (VTE) and bleeding with factor Xa (FXa) inhibitors (apixaban, edoxaban, rivaroxaban) and a thrombin inhibitor (dabigatran) compared with European (EU) (40 mg q.d.) and North American (NA) (30 mg Q12H) dose regimens of a low molecular weight heparin (enoxaparin) following orthopedic surgery. Statistically significant differences in both VTE and bleeding outcomes were found between the NA and EU doses of enoxaparin, with odds ratios (95% confidence interval) for the NA vs. EU dose of 0.73 (0.71–0.76) and 1.20 (1.14–1.29) for total VTE and major bleeding, respectively. At approved doses, estimated odds ratios vs. both doses of enoxaparin for the three FXa inhibitors (range: 0.35–0.75 for VTE; 0.76–1.09 for bleeding) compared with those for dabigatran (range: 0.66–1.21 for VTE; 1.10–1.38 for bleeding) suggested generally greater efficacy and less bleeding for the FXa inhibitors.

Realization of Microwave Quantum Circuits Using Hybrid Superconducting-Semiconducting Nanowire Josephson Elements

We report the realization of quantum microwave circuits using hybrid superconductor-semiconductor Josephson elements comprised of InAs nanowires contacted by NbTiN. Capacitively shunted single elements behave as transmon circuits with electrically tunable transition frequencies. Two-element circuits also exhibit transmonlike behavior near zero applied flux but behave as flux qubits at half the flux quantum, where nonsinusoidal current-phase relations in the elements produce a double-well Josephson potential. These hybrid Josephson elements are promising for applications requiring microwave superconducting circuits operating in a magnetic field.

Detecting bit-flip errors in a logical qubit using stabilizer measurements

Quantum data are susceptible to decoherence induced by the environment and to errors in the hardware processing it. A future fault-tolerant quantum computer will use quantum error correction to actively protect against both. In the smallest error correction codes, the information in one logical qubit is encoded in a two-dimensional subspace of a larger Hilbert space of multiple physical qubits. For each code, a set of non-demolition multi-qubit measurements, termed stabilizers, can discretize and signal physical qubit errors without collapsing the encoded information. Here using a five-qubit superconducting processor, we realize the two parity measurements comprising the stabilizers of the three-qubit repetition code protecting one logical qubit from physical bit-flip errors. While increased physical qubit coherence times and shorter quantum error correction blocks are required to actively safeguard the quantum information, this demonstration is a critical step towards larger codes based on multiple parity measurements.

Future quantum computers will employ error correction to protect quantum data from decoherence and faulty hardware. Here, using a quantum processor with five superconducting qubits, the authors demonstrate how to protect one logical qubit from bitflip errors using multi-qubit, stabilizer measurements.

Digital quantum Rabi and Dicke models in superconducting circuits

We propose the analog-digital quantum simulation of the quantum Rabi and Dicke models using circuit quantum electrodynamics (QED). We find that all physical regimes, in particular those which are impossible to realize in typical cavity QED setups, can be simulated via unitary decomposition into digital steps. Furthermore, we show the emergence of the Dirac equation dynamics from the quantum Rabi model when the mode frequency vanishes. Finally, we analyze the feasibility of this proposal under realistic superconducting circuit scenarios.

Entanglement genesis by ancilla-based parity measurement in 2D circuit QED

We present an indirect two-qubit parity meter in planar circuit quantum electrodynamics, realized by discrete interaction with an ancilla and a subsequent projective ancilla measurement with a dedicated, dispersively coupled resonator. Quantum process tomography and successful entanglement by measurement demonstrate that the meter is intrinsically quantum nondemolition. Separate interaction and measurement steps allow the execution of subsequent data-qubit operations in parallel with ancilla measurement, offering time savings over continuous schemes.

Partial-measurement backaction and nonclassical weak values in a superconducting circuit

We realize indirect partial measurement of a transmon qubit in circuit quantum electrodynamics by interaction with an ancilla qubit and projective ancilla measurement with a dedicated readout resonator. Accurate control of the interaction and ancilla measurement basis allows tailoring the measurement strength and operator. The tradeoff between measurement strength and qubit backaction is characterized through the distortion of a qubit Rabi oscillation imposed by ancilla measurement in different bases. Combining partial and projective qubit measurements, we provide the solid-state demonstration of the correspondence between a nonclassical weak value and the violation of a Leggett-Garg inequality.

Probing dynamics of an electron-spin ensemble via a superconducting resonator

We study spin relaxation and diffusion in an electron-spin ensemble of nitrogen impurities in diamond at low temperature (0.25-1.2 K) and polarizing magnetic field (80-300 mT). Measurements exploit field-controlled coupling of the ensemble to two modes of a transmission-line resonator. The observed temperature-independent spin relaxation time indicates that spin outdiffusion across the mode volume dominates over spin-lattice relaxation. Depolarization of one hyperfine-split subensemble by pumping of another indicates fast cross relaxation, with implications for the use of subensembles as independent quantum memories.

Millisecond charge-parity fluctuations and induced decoherence in a superconducting transmon qubit

The tunnelling of quasiparticles across Josephson junctions in superconducting quantum circuits is an intrinsic decoherence mechanism for qubit degrees of freedom. Understanding the limits imposed by quasiparticle tunnelling on qubit relaxation and dephasing is of theoretical and experimental interest, particularly as improved understanding of extrinsic mechanisms has allowed crossing the 100 microsecond mark in transmon-type charge qubits. Here, by integrating recent developments in high-fidelity qubit readout and feedback control in circuit quantum electrodynamics, we transform a state-of-the-art transmon into its own real-time charge-parity detector. We directly measure the tunnelling of quasiparticles across the single junction and isolate the contribution of this tunnelling to qubit relaxation and dephasing, without reliance on theory. The millisecond timescales measured demonstrate that quasiparticle tunnelling does not presently bottleneck transmon qubit coherence, leaving room for yet another order of magnitude increase.

Feedback control of a solid-state qubit using high-fidelity projective measurement

We demonstrate feedback control of a superconducting transmon qubit using discrete, projective measurement and conditional coherent driving. Feedback realizes a fast and deterministic qubit reset to a target state with 2.4% error averaged over input superposition states, and allows concatenating experiments more than 10 times faster than by passive initialization. This closed-loop qubit control is necessary for measurement-based protocols such as quantum error correction and teleportation.

Cost comparison of wirelessly vs. directly observed therapy for adherence confirmation in anti-tuberculosis treatment

SETTING

A US clinic treating patients entering the continuation phase of treatment for Mycobacterium tuberculosis.

OBJECTIVE

To compare the costs of direct confirmation of treatment using wirelessly observed therapy (WOT) vs. standard of care utilizing World Health Organization-recommended 7-day and 3-day directly observed therapy (DOT).

DESIGN

A model was created comparing the costs between the two types of DOT and WOT, using data from public sources of treatment, personnel costs, patient spending, and interview responses. The model considered public health facility's cost-to-treat and patient's cost-to-be-treated. Cost drivers for M. tuberculosis treatment monitoring were identified, and four univariate sensitivity analyses were conducted on selected variables.

RESULTS

The cost of WOT was estimated to be 36% of 7-day DOT, and 71% of 3-day DOT in public health facility's cost-to-treat. The patient's cost-to-be-treated with WOT was estimated to be 4% of 7-day DOT and 8% of 3-day DOT. Sensitivity analyses indicated that WOT was likely to provide immediate cost savings over a range of WOT costs, time spent on WOT monitoring, WOT-related treatment failure rates and clinician compensations.

CONCLUSION

Under several potential cost scenarios, the immediate cost of M. tuberculosis treatment by WOT appears to be substantially less than DOT. Further WOT development for M. tuberculosis treatment appears warranted.

Initialization by measurement of a superconducting quantum bit circuit

We demonstrate initialization by joint measurement of two transmon qubits in 3D circuit quantum electrodynamics. Homodyne detection of cavity transmission is enhanced by Josephson parametric amplification to discriminate the two-qubit ground state from single-qubit excitations nondestructively and with 98.1% fidelity. Measurement and postselection of a steady-state mixture with 4.7% residual excitation per qubit achieve 98.8% fidelity to the ground state, thus outperforming passive initialization.

Measurements of quasiparticle tunneling dynamics in a band-gap-engineered transmon qubit

We have engineered the band gap profile of transmon qubits by combining oxygen-doped Al for tunnel junction electrodes and clean Al as quasiparticle traps to investigate energy relaxation due to quasiparticle tunneling. The relaxation time T1 of the qubits is shown to be insensitive to this band gap engineering. Operating at relatively low-E(J)/E(C) makes the transmon transition frequency distinctly dependent on the charge parity, allowing us to detect the quasiparticles tunneling across the qubit junction. Quasiparticle kinetics have been studied by monitoring the frequency switching due to even-odd parity change in real time. It shows the switching time is faster than 10  μs, indicating quasiparticle-induced relaxation has to be reduced to achieve T1 much longer than 100  μs.

High-fidelity readout in circuit quantum electrodynamics using the Jaynes-Cummings nonlinearity

We demonstrate a qubit readout scheme that exploits the Jaynes-Cummings nonlinearity of a superconducting cavity coupled to transmon qubits. We find that, in the strongly driven dispersive regime of this system, there is the unexpected onset of a high-transmission "bright" state at a critical power which depends sensitively on the initial qubit state. A simple and robust measurement protocol exploiting this effect achieves a single-shot fidelity of 87% using a conventional sample design and experimental setup, and at least 61% fidelity to joint correlations of three qubits.

High-cooperativity coupling of electron-spin ensembles to superconducting cavities

Electron spins in solids are promising candidates for quantum memories for superconducting qubits because they can have long coherence times, large collective couplings, and many qubits could be encoded into spin waves of a single ensemble. We demonstrate the coupling of electron-spin ensembles to a superconducting transmission-line cavity at strengths greatly exceeding the cavity decay rates and comparable to the spin linewidths. We also perform broadband spectroscopy of ruby (Al₂O₃:Cr(3+)) at millikelvin temperatures and low powers, using an on-chip feedline. In addition, we observe hyperfine structure in diamond P1 centers.

Noise correlations in a Coulomb-blockaded quantum dot

We report measurements of current noise auto- and cross correlation in a tunable quantum dot with two or three leads. As the Coulomb blockade is lifted at finite source-drain bias, the autocorrelation evolves from super- to sub-Poissonian in the two-lead case, and the cross correlation evolves from positive to negative in the three-lead case, consistent with transport through multiple levels. Cross correlations in the three-lead dot are found to be proportional to the noise in excess of the Poissonian value in the limit of weak output tunneling.

Neoadjuvant chemoradiation for rectal cancer: A 5-year institutional experience at Sparrow Hospital

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Continued efforts to improve local control and to maximize sphincter preservation in patients with rectal carcinoma led to consideration of preoperative chemoradiation. The purpose of this retrospective study is to examine clinical outcomes and find out which prognostic factors are related to survival in patients treated with neoadjuvant chemoradiation in Sparrow Hospital from 1998–2003. Forty two patients with biopsy proven rectal carcinoma without evidence of extra pelvic spread were treated in this fashion. Radiation therapy was administered for a total dose of 5.00 cGy. Chemotherapy used was 5-FU in 37 patients, and in combination with leucovorin in additional 5 patients. Surgical treatments performed were abdominoperineal resection (23 pts), low anterior resection in 13 pts., transanal excisions (2 pts), 2 patients had only exploratory laparotomy and for 2 patients records were not available. Cox proportional hazards regression techniques were used to estimate survival rates. Univariate and multivariate Cox proportional hazards analyses were used to evaluate relationship between risk factors and the survival. The SAS system (V9.1.3, Cary NC) was used for all analyses. Out of 42 patients analyzed 25 were males and 17 females. Mean age was 65 years (range 31 - 85). Median follow-up time was 57 months with a range from 7 to 98 months. After the surgery 4 patients had complete response, 12 were stage I, 10 stage II, 12 patients stage III, one patient had metastatic disease and for 2 patients records were inadequate. Analysis of disease free survival showed actuarial 5-year disease free survival to be 59%. Actuarial 5-year overall survival was 67%. Median overall survival was still not reached, while median disease-free survival is 78 months . Univariate and multivariate analyses showed that only postoperative stage was associated significantly with overall survival. Specifically, there was an increase in the risk of mortality of just over 3-fold for each increment in post-operative stage. In conclusion, in the community settings preoperative chemoradiation seem to provide good overall and disease free survival for patients with rectal cancer. Postoperative stage appears to be the most important prognostic factor for the survival.

No significant financial relationships to disclose.

Shot-noise signatures of 0.7 structure and spin in a quantum point contact

We report simultaneous measurement of shot noise and dc transport in a quantum point contact as a function of source-drain bias, gate voltage, and in-plane magnetic field. Shot noise at zero field exhibits an asymmetry related to the 0.7 structure in conductance. The asymmetry in noise evolves smoothly into the symmetric signature of spin-resolved electron transmission at high field. Comparison to a phenomenological model with density-dependent level splitting yields good quantitative agreement.

Differential charge sensing and charge delocalization in a tunable double quantum dot

We report measurements of a tunable double quantum dot, operating in the quantum regime, with integrated local charge sensors. The spatial resolution of the sensors allows the charge distribution within the double dot system to be resolved at fixed total charge. We use this readout scheme to investigate charge delocalization as a function of temperature and strength of tunnel coupling, demonstrating that local charge sensing can be used to accurately determine the interdot coupling in the absence of transport.

Photocurrent, rectification, and magnetic field symmetry of induced current through quantum dots

We report mesoscopic dc current generation in an open chaotic quantum dot with ac excitation applied to one of the shape-defining gates. For excitation frequencies large compared to the inverse dwell time of electrons in the dot (i.e., GHz), we find mesoscopic fluctuations of induced current that are fully asymmetric in the applied perpendicular magnetic field, as predicted by recent theory. Conductance, measured simultaneously, is found to be symmetric in field. In the adiabatic (i.e., MHz) regime, in contrast, the induced current is always symmetric in field, suggesting its origin is mesoscopic rectification.

Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death. Multicenter Unsustained Tachycardia Trial Investigators

BACKGROUND

The mortality rate among patients with coronary artery disease, abnormal ventricular function, and unsustained ventricular tachycardia is high. The usefulness of electrophysiologic testing for risk stratification in these patients is unclear.

METHODS

We performed electrophysiologic testing in patients who had coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias could be induced were randomly assigned to receive either antiarrhythmic therapy guided by electrophysiologic testing or no antiarrhythmic therapy. The primary end point was cardiac arrest or death from arrhythmia. Patients without inducible tachyarrhythmias were followed in a registry. We compared the outcomes of 1397 patients in the registry with those of 353 patients with inducible tachyarrhythmias who were randomly assigned to receive no antiarrhythmic therapy in order to assess the prognostic value of electrophysiologic testing.

RESULTS

Patients were followed for a median of 39 months. In a Kaplan-Meier analysis, two-year and five-year rates of cardiac arrest or death due to arrhythmia were 12 and 24 percent, respectively, among the patients in the registry, as compared with 18 and 32 percent among the patients with inducible tachyarrhythmias who were assigned to no antiarrhythmic therapy (adjusted P<0.001). Overall mortality after five years was 48 percent among the patients with inducible tachyarrhythmias, as compared with 44 percent among the patients in the registry (adjusted P=0.005). Deaths among patients without inducible tachyarrhythmias were less likely to be classified as due to arrhythmia than those among patients with inducible tachyarrhythmias (45 and 54 percent, respectively; P=0.06).

CONCLUSIONS

Patients with coronary artery disease, left ventricular dysfunction, and asymptomatic, unsustained ventricular tachycardia in whom sustained ventricular tachyarrhythmias cannot be induced have a significantly lower risk of sudden death or cardiac arrest and lower overall mortality than similar patients with inducible sustained tachyarrhythmias.

Nonsustained ventricular tachycardia in coronary artery disease: relation to inducible sustained ventricular tachycardia. MUSTT Investigators

BACKGROUND

Many physicians believe that electrocardiographic characteristics of nonsustained ventricular tachycardia correlate with the risk for sudden death in survivors of myocardial infarction. Sustained ventricular tachycardia induced by programmed electrical stimulation has also been shown to predict sudden death.

OBJECTIVE

To determine whether electrocardiographic characteristics of spontaneous nonsustained ventricular tachycardia can predict the inducibility of sustained ventricular tachycardia by programmed electrical stimulation in patients with coronary artery disease having abnormal ventricular function.

DESIGN

Observational cohort study.

SETTING

70 clinical electrophysiology laboratories in the United States and Canada.

PATIENTS

1480 consecutive patients with coronary artery disease, left ventricular ejection fraction of 0.40 or less, and asymptomatic nonsustained ventricular tachycardia.

INTERVENTION

Electrophysiologic study attempting to induce sustained monomorphic ventricular tachycardia.

MEASUREMENTS

Daily frequency, duration, and cycle length of spontaneous episodes of nonsustained ventricular tachycardia, measured by standard electrocardiographic recordings.

RESULTS

No statistically significant difference in the frequency or duration of spontaneous nonsustained ventricular tachycardia was seen between patients with and those without inducible sustained ventricular tachycardia. Rates of spontaneous tachycardia were slightly slower in patients with inducible ventricular tachycardia than in patients without inducible ventricular tachycardia (P = 0.047), but the difference was not clinically significant.

CONCLUSION

Electrocardiographic characteristics of spontaneous nonsustained ventricular tachycardia do not predict which patients with coronary artery disease will have inducible sustained ventricular tachycardia.

Tachycardia detection by antitachycardia devices: present limitations and future strategies

Early experience with three generations of implantable devices has demonstrated the need to further refine the accuracy of automated rhythm analysis. Although initial experience with commercially utilized morphological waveform analysis has been disappointing, other time and frequency domain electrogram features have been developed and show potential promise for future devices. While single chamber algorithms for rate and rate variations have theoretical appeal because of their limited power demands, practical experience has demonstrated that inaccurate arrhythmia diagnosis continues to occur by antitachycardia devices that utilize them. Technological advancement in hardware manufacturing and the design of increasingly more efficient software algorithms for tachycardia detection will continue to yield lower power digital circuitry, to increase device battery power and life, and to permit more and more accurate automated arrhythmia diagnosis and treatment by antitachycardia devices. Two chamber sensing has been available for decades in dual chamber antibradycardia pacemakers. The introduction of this technology into antitachycardia devices is not only inevitable but should dramatically improve the precision of diagnosis in future generation devices.

Prevention of sudden death in patients with coronary artery disease: the Multicenter Unsustained Tachycardia Trial (MUSTT)

This trial will significantly advance our understanding of the prognostic and therapeutic usefulness of electrophysiologic studies in patients with coronary artery disease. Several features of this trial are worth emphasizing. First, the protocol for performing programmed stimulation and serial drug testing is designed to mirror those currently in use by many practicing electrophysiologists. While practice patterns vary, the procedures used in the trial reflect what is considered "usual and standard" practice. Second, because half of the patients with inducible sustained ventricular tachycardia will be given no antiarrhythmic therapy, we will be able to ascertain the true risk of sudden death in this patient population without the influence of these agents. Third, this trial will assess the usefulness of a method of guiding antiarrhythmic therapy (electrophysiologic testing) to reduce mortality in this high-risk population. It will not evaluate the efficacy of a specific type of antiarrhythmic therapy.

Long-term results of catheter ablation of idiopathic right ventricular tachycardia

Ten consecutive patients with recurrent episodes of symptomatic, idiopathic, sustained monomorphic ventricular tachycardia (VT) originating in the right ventricle underwent an attempt at catheter ablation of the ventricular tachycardia. There were seven women and three men, with a mean age of 39 +/- 14 years (+/- SD). None of the patients had any evidence of structural heart disease. The VT had a left bundle branch block configuration and an inferior axis in each patient, and the mean cycle length was 313 +/- 75 msec. Based on the methods of induction of the VT and the response of the VT to verapamil, the VT mechanism was presumed to be reentry in six patients, triggered activity in three patients, and catecholamine-sensitive automaticity in one patient. Sites for ablation were guided by pace mapping, and an appropriate target site was identified in the right ventricular outflow tract in each patient. From one to three shocks of 100-360 J (mean total, 336 +/- 195 J) were delivered from a defibrillator between the tip of the ablation catheter (cathode) and a patch electrode on the anterior chest (anode). An electrophysiology test 7-9 days after ablation demonstrated that VT was still inducible in only one patient, who was treated with amiodarone. One other patient had a recurrence of VT 3 weeks after ablation and was treated with verapamil. Eight of 10 patients were not treated with antiarrhythmic medications and have had no episodes of symptomatic VT during 15-68 months of follow-up (mean follow-up, 33 +/- 18 months). There were no acute or long-term complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of flecainide acetate on prevention of electrical induction of ventricular tachycardia and occurrence of ischemic ventricular fibrillation during the early postmyocardial infarction period: evaluation in a conscious canine model of sudden death

The antiarrhythmic and antifibrillatory effects of flecainide acetate during the early postinfarction period were evaluated in a conscious canine model of sudden cardiac death. Ventricular tachycardia remained inducible early after infarction in eight of nine dogs receiving an intravenous loading dose of flecainide (2.0 mg/kg body weight) and seven of eight dogs receiving saline vehicle. In both the drug and vehicle groups, there was no significant change in the ventricular refractory period or in the cycle length of the induced ventricular tachycardia. With a maintenance intravenous infusion of flecainide, 1.0 mg/kg per h for 4 hours, the subsequent occurrence of acute posterolateral ischemia resulted in the development of ventricular fibrillation and sudden death in seven of eight flecainide-treated and eight of eight vehicle-treated dogs. Seven additional postinfarction dogs with noninducible tachycardia during pretreatment programmed stimulation, and thereby considered to be at "low risk" for the development of ischemic ventricular fibrillation, were also given flecainide in an intravenous loading and maintenance dosing regimen. The subsequent occurrence of posterolateral ischemia resulted in the development of ventricular fibrillation in three of these seven dogs. These findings suggest that flecainide acetate may not possess pharmacologic properties useful in managing ventricular tachycardia or in preventing ischemic ventricular fibrillation in the presence of recent myocardial damage.

Prognostic usefulness of programmed ventricular stimulation in idiopathic dilated cardiomyopathy without symptomatic ventricular arrhythmias

Twenty-four patients, mean age 42 years, with idiopathic dilated cardiomyopathy (DC) and no history of symptomatic ventricular arrhythmias underwent right ventricular programmed stimulation with up to 3 extrastimuli. Ventricular tachycardia (VT) was induced in 8 patients and ventricular fibrillation (VF) in 2. The VT was unimorphic in 2 and polymorphic in 6. No significant differences were noted between patients in whom arrhythmias were inducible and and those in whom they were not with regard to age, symptomatic class, arrhythmia severity or hemodynamic indexes. Over a mean follow-up of 12 months, 4 patients died, 3 suddenly and 1 with progressive heart failure. Only 1 of the 3 who died suddenly had inducible VT. One other patient with induced sustained unimorphic VT later presented with spontaneous sustained VT similar in rate and configuration to induced VT. In conclusion, VT or VF may be induced in approximately 40% of patients with DC and no history of symptomatic VT or VF. Inducibility of polymorphic VT or VF does not correlate with clinical or hemodynamic variables or with the risk of sudden death. However, induction of unimorphic VT may predict later occurrence of spontaneous unimorphic VT.

Histologic changes and arrhythmogenicity after discharge through transseptal catheter electrode

Ventricular tachycardia commonly arises within the intraventricular septum and successful catheter ablation of septal tachycardia might be enhanced by transseptal electrode placement. We have evaluated the safety of a transseptal ablation procedure. Arrhythmogenicity and histology were examined after high-energy capacitor discharges were delivered to an intracavitary cathode-anode pair placed on opposite sides of the interventricular septum in pentobarbital-anesthetized dogs. After two discharges of 200 or 100 J proved lethal, paired discharges of 30 or 50 J (10 dogs) or a single discharge of 100 J (four dogs) was used to induce 28 lesions. Acute rhythm changes and risk of induction of ventricular tachycardia by programmed stimulation were measures of arrhythmogenicity. Gross and histologic examination of the hearts after 20 min to 28 days allowed characterization of the evolution of lesions. The conduction system in nearby and remote locations was extensively examined in four dogs. Refractory ventricular fibrillation developed with paired shocks at 200 or 100 J. At lower energy levels, acute ventricular fibrillation occurred with 12 of 20 shocks (60%), but defibrillation was consistently achieved. After ablation, no dog had ventricular tachycardia or fibrillation induced with programmed stimulation. Matching anodal and cathodal lesions spanned the septum without perforation in 10 of 16 dogs, and the lesions were of similar histology. Each contained central areas of hemorrhage surrounded by a region of coagulation necrosis merging with normal myocytes peripherally. There was necrosis and edema without inflammation at 20 min, acute inflammatory cell infiltration at 1 to 2 days, and myocyte replacement by granulation tissue after 6 days.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical features and prognosis of patients with out of hospital cardiac arrest and a normal electrophysiologic study

Nineteen patients survived a cardiac arrest not associated with an acute myocardial infarction, and had a normal electrophysiologic study with no inducible ventricular tachycardia despite programmed stimulation with one to three extrastimuli at two or more ventricular sites. Among 14 patients who had obstructive coronary artery disease, cardiac arrest occurred during exertion or an episode of angina pectoris in 11; 24 hour ambulatory electrocardiographic recordings demonstrated infrequent or no premature ventricular complexes in 10 and an ischemic response occurred during stage I or II (Bruce protocol) in 6 of 9 patients who underwent exercise testing. Treatment of these patients consisted of myocardial revascularization (eight patients) or antianginal medications (six patients). Only three patients were also treated with an antiarrhythmic drug. Over a follow-up period of 26 +/- 15 months (mean +/- standard deviation), only one patient died suddenly. Two patients who had coronary artery spasm were treated with coronary vasodilator medications and had no recurrence of cardiac arrest over 7 and 36 months of follow-up, respectively. Three patients who had cardiomyopathy or no identifiable structural heart disease were treated with nadolol or amiodarone and had no recurrence of cardiac arrest over 3 to 27 months of follow-up. Among patients who survive a cardiac arrest and have a normal electrophysiologic study, those with obstructive coronary artery disease or coronary artery spasm generally have an excellent prognosis with treatment directed primarily at the underlying heart disease. The clinical features of these patients suggest that cardiac arrest was related to ischemia rather than a primary arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective comparison of triple extrastimuli and left ventricular stimulation in studies of ventricular tachycardia induction

One hundred and one patients with sustained unimorphic ventricular tachycardia underwent programmed ventricular stimulation with one of two protocols. Fifty patients underwent programmed stimulation with protocol A, which consisted of burst overdrive pacing, single, double, and triple extrastimuli at the right ventricular apex, right ventricular outflow tract, or septum, and then at the left ventricular apex. Fifty-one patients underwent programmed stimulation with protocol B, which consisted of burst overdrive pacing, single and double extrastimuli at the right ventricular apex, right ventricular outflow tract or septum, and at the left ventricular apex, followed by triple extrastimuli at these sites. The stimulation protocol was continued until sustained ventricular tachycardia or rapid, polymorphic ventricular tachycardia greater than 10 sec in duration was induced. With protocol A, clinical and nonclinical ventricular tachycardia was induced in 76% and 36% of patients, respectively; with protocol B, clinical and nonclinical ventricular tachycardia was induced in 85% and 38% of patients, respectively. Direct-current countershock for sustained polymorphic ventricular tachycardia was required in 10% of patients studied under protocol A, compared with in 2% of patients studied under protocol B. With protocol A, near-maximal yield of induced clinical (72%) and nonclinical ventricular tachycardia (30%) was attained after the use of triple extrastimuli at the first stimulation site. The yield of stimulation at a second right ventricular site and of left ventricular stimulation was only an additional 2% each. With protocol B, triple extrastimuli increased the yield of induced clinical ventricular tachycardia from 61% to 85%.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrophysiologic and hemodynamic effects of intravenous propafenone in patients with recurrent ventricular tachycardia

Electrophysiologic and hemodynamic studies were performed before and after intravenous infusion of a new antiarrhythmic agent, propafenone, in 28 patients with recurrent ventricular tachycardia. Propafenone was given at a loading dose of 2 mg/kg in all patients. Subsequently, group A, the first 14 patients, received 1 mg/min and group B, the second 14 patients, received 2 mg/min continuous infusion. Propafenone exerted no effect on sinus nodal recovery time and sinoatrial conduction time, but significantly prolonged atrioventricular (AV) nodal and His-Purkinje conduction time and the QRS duration (respectively, 95 +/- 19, 48 +/- 10 and 120 +/- 23 ms before, and 110 +/- 28, 53 +/- 10 and 135 +/- 27 ms after; p less than 0.001). Propafenone did not change the mean arterial blood pressure but slightly increased right atrial, pulmonary artery and capillary wedge pressures resulting in mild depression of the cardiac index (2.6 +/- 0.8 liters/min per m2 before and 2.3 +/- 0.7 liters/min per m2 after; p less than 0.001). None of the patients were symptomatic from these changes. In group A, propafenone did not affect the inducibility of ventricular tachycardia except for one patient whose arrhythmia was sustained before and become nonsustained after propafenone. In group B, sustained ventricular tachycardia became noninducible in three patients and nonsustained in two patients, and nonsustained ventricular tachycardia became noninducible in one patient after propafenone. Therefore, an appropriate loading dose of intravenous propafenone such as 2 mg/kg followed by 2 mg/min infusion may be given safely and may suppress ventricular tachycardia. Propafenone may be a useful addition to currently available antiarrhythmic agents.

Enalapril: a new angiotensin-converting enzyme inhibitor in chronic heart failure: acute and chronic hemodynamic evaluations

Hemodynamic effects of the new oral angiotensin-converting enzyme inhibitor, enalapril, were evaluated acutely in 15 patients with chronic heart failure and in 7 patients after 4 weeks of maintenance therapy. Initial hemodynamic effects were characterized by a significant increase in cardiac index (from 2.1 +/- 0.7 to 2.6 +/- 0.7 liters/min per m2) and a decrease in pulmonary capillary wedge pressure (from 30 +/- 6 to 24 +/- 7 mm Hg), right atrial pressure (from 14 +/- 5 to 11 +/- 4 mm Hg), mean arterial pressure (from 96 +/- 16 to 80 +/- 17 mm Hg) and systemic vascular resistance (from 1,820 +/- 480 to 1,200 +/- 410 dynes . s . cm-5) without any significant change in heart rate, pulmonary artery pressure and pulmonary vascular resistance. During maintenance therapy, the dose of diuretic drugs had to be increased because of systemic venous hypertension. Repeat hemodynamic study showed that after chronic therapy, cardiac index (2.1 +/- 0.7 vs. 3.0 +/- 0.08 liters/min per m2) and stroke volume index (24 +/- 10 vs. 36 +/- 7 ml/m2) remained elevated and pulmonary capillary wedge pressure was lower than control (30 +/- 6 vs. 16 +/- 6 mm Hg), indicating sustained improvement in left ventricular performance. Plasma renin activity increased and plasma norepinephrine levels decreased after enalapril therapy and these humoral changes persisted during maintenance therapy. All patients receiving chronic therapy had symptomatic improvement. Significant hypotension, which occurred in five patients at the initiation of therapy, appears to be the major side effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous amiodarone in the acute treatment of recurrent symptomatic ventricular tachycardia

Fifteen patients aged 59.3 +/- 11.5 years (mean +/- standard deviation [SD]) had recurrent symptomatic ventricular tachycardia (VT) refractory to at least 2 conventional antiarrhythmic drugs. All patients had organic heart disease; 4 had an acute myocardial infarction. The mean ejection fraction was 0.30 +/- 0.09. TWelve patients had overt congestive heart failure. Five had bundle branch block. Before treatment with intravenous amiodarone, the patients had had 6 to 40 episodes of symptomatic VT over 1 to 8 days of hospitalization. All patients received an initial bolus of 5 mg of amiodarone/kg over 15 minutes. Seven patients also received a continuous infusion of 600 to 1,000 mg of amiodarone over 12 to 24 hours. Additional doses depended on the patients' clinical responses. In 11 of 15 patients, antiarrhythmic drugs that had failed to suppress VT were continued during administration of amiodarone. In 12 of 15 patients acute control of VT was obtained with intravenous administration of amiodarone either alone or in combination with previously ineffective drugs. Three patients continued to have frequent episodes of VT while being treated with intravenous amiodarone. Mobitz type I atrioventricular block developed in 1 patient. No patient had high degree atrioventricular block, symptomatic hypotension, or a clinically apparent worsening of congestive heart failure. The use of intravenous amiodarone represents a significant advance in the acute treatment of frequent life-threatening VT refractory to other drugs. With appropriate monitoring, it can be used safely in patients with congestive heart failure, bundle branch block, or acute myocardial infarction.