Relationship between the upper limit of vulnerability determined in normal sinus rhythm and the defibrillation threshold in patients with implantable cardioverter defibrillators

The upper limit of vulnerability is the strength above which ventricular fibrillation is no longer inducible with a shock delivered during the vulnerable phase of the cardiac cycle. It has been demonstrated that the upper limit of vulnerability correlates with the defibrillation threshold in a paced rhythm. The purpose of this study is to evaluate the correlation of the upper limit of vulnerability determined in normal sinus rhythm with the defibrillation threshold using a simplified protocol in patients undergoing placement of an ICD. We studied 28 patients who underwent ICD implantation. CPI generators and Endotak leads were used in all patients. Device-based testing was used to determined the defibrillation threshold and the upper limit of vulnerability. The upper limit of vulnerability was tested with three shocks delivered at 0, 20, and 40 ms before the peak of the T wave during normal sinus rhythm. The defibrillation threshold was determined by a simple step up-down protocol. The upper limit of vulnerability (9.0 +/- 4.5 J) did not significantly differ from the defibrillation threshold (9.9 +/- 4.0 J), P = NS. A close correlation was present, correlation coefficient = 0.75, P < 0.0001. The upper limit of vulnerability was within 5 J of the defibrillation threshold in 27 (96%) of the 28 patients. The upper limit of vulnerability underestimated the defibrillation threshold by 10 J in one patient who had a defibrillation threshold of 15 J. The upper limit of vulnerability determined in normal sinus rhythm correlates significantly with the defibrillation threshold in patients undergoing ICD implantation. The protocol is simple and easily implemented clinically.

Intraarticular findings after gunshot wounds through the knee

OBJECTIVES

To compare the radiographic findings in patients with a low-velocity gunshot wound through the knee with the intraarticular pathology as documented by arthroscopy, and to evaluate arthroscopic management of these injuries.

STUDY DESIGN

Retrospective review of a protocol.

MATERIALS AND METHODS

Thirty-three patients with low-velocity gunshot wounds through the knee, no significant soft tissue injury, and no fracture requiring repair were studied. Radiographs were evaluated for bullet fragments, loose bodies, and debris. All patients were treated with arthroscopic evaluation and management of intraarticular pathology. The arthroscopic findings were compared with the radiographic findings.

RESULTS

Five chondral injuries and fourteen meniscal injuries not suspected on the basis of plain films were found during arthroscopic evaluation. Seven patients had no radiographic evidence of debris, loose bodies, or bullet or bone fragments in the joint. Five of these seven (71%) had debris and meniscal damage. Debridement of all loose bodies was possible using arthroscopy and occasional miniarthrotomy. No patient in the series had an infection.

CONCLUSIONS

Patients who sustain a low-velocity gunshot through the knee have soft tissue injuries not visible on plain radiographs in most cases, and therefore operative treatment is warranted. Arthroscopic management of these injuries appears to be a safe and effective method of treatment.

Regulation of intracellular free Mg2+ and contraction in single adult mammalian cardiac myocytes

Studies in isolated cardiac myocytes have increased our understanding of intracellular Ca2+ regulation. Because less is known about Mg2+ regulation, adult rat ventricular myocytes were loaded with the Mg(2+)-sensitive fluorescent probe mag-indo 1, and changes in intracellular Mg2+ concentration ([Mg2+]i) and cell length were examined under a variety of conditions. The fluorescent signal was calibrated intracellularly and found to differ slightly from that for the probe in solution. Roughly 40% of the signal was intramitochondrial; the remainder was localized in the cytosol. Basal [Mg2+]i averaged 1.02 +/- 0.03 mM (n = 53 cells). No change in [Mg2+]i was observed during a single electrically stimulated contraction, and only a minor increase was seen during rapid electrical stimulation, which was expected to raise intracellular Ca2+ concentration ([Ca2+]i) to approximately 1 microM. An acid shift in intracellular pH of approximately 1 pH unit was accompanied by a small change in [Mg2+]i (0.34 +/- 0.03 mM, n = 6, P < 0.05). No change in [Mg2+]i was observed when cells were superfused with 15 mM Mg2+, despite marked changes in contraction. [Mg2+]i more than doubled when cells were depleted of ATP by exposure to hypoxia or metabolic inhibitors. The increase in [Mg2+]i was abrupt and occurred at the time of the failure of contraction, plateauing as rigor contracture developed. Reoxygenation was accompanied by a gradual fall in [Mg2+]i in cells that recovered mechanical function, and in a subset of cells that underwent hypercontracture. Studies in cell suspensions confirmed that rapid cellular energy depletion was accompanied by increases in [Mg2+]i and parallel decreases in ATP. Thus [Mg2+]i was largely insensitive to changes in [Ca2+]i or pHi and extracellular [Mg2+] but was rapidly altered by changes in energy state in a manner that was related to specific changes in cell morphology and contractile function.