Incidence of phrenic nerve injury during pulmonary vein isolation using different cryoballoons: data from a large prospective ablation registry.

AIMS: Phrenic nerve injury (PNI) is the most common complication during cryoballoon ablation. Currently, two cryoballoon systems are available, yet the difference is unclear. We sought to compare the acute procedural efficacy and safety of the two cryoballoons. METHODS: This prospective observational study consisted of 2,555 consecutive atrial fibrillation (AF) patients undergoing pulmonary vein isolation (PVI) using either conventional (Arctic Front Advance) (AFA-CB) or novel cryoballoons (POLARx) (POLARx-CB) at 19 centers between January 2022 and October 2023. RESULTS: Among 2,555 patients (68.8 ± 10.9 years, 1,740 men, paroxysmal AF[PAF] 1,670 patients), PVIs were performed by the AFA-CB and POLARx-CB in 1,358 and 1,197 patients, respectively. Touch-up ablation was required in 299(11.7%) patients. The touch-up rate was significantly lower for POLARx-CB than AFA-CB (9.5% vs. 13.6%, p = 0.002), especially for right inferior PVs (RIPVs). The touch-up rate was significantly lower for PAF than non-PAF (8.8% vs. 17.2%, P < 0.001) and was similar between the two cryoballoons in non-PAF patients. Right PNI occurred in 64(2.5%) patients and 22(0.9%) were symptomatic. It occurred during the right superior PV (RSPV) ablation in 39(1.5%) patients. The incidence was significantly higher for POLARx-CB than AFA-CB (3.8% vs. 1.3%, P < 0.001) as was the incidence of symptomatic PNI (1.7% vs. 0.1%, P < 0.001). The difference was significant during RSPV (2.5% vs. 0.7%, P < 0.001) but not RIPV ablation. The PNI recovered more quickly for the AFA-CB than POLARx-CB. CONCLUSIONS: Our study demonstrated a significantly higher incidence of right PNI and lower touch-up rate for the POLARx-CB than AFA-CB in the real-world clinical practice.

Successful visualization of pulmonary embolism using fluoroscopic video analysis in a patient with iodine contrast allergy: a case report.

Background: Contrast-enhanced computed tomography (CT) is commonly used to diagnose pulmonary embolism (PE). However, a history of iodine contrast allergy presents a dilemma in the management of patients with PE. As an alternative approach, X-ray fluoroscopic video analysis has been recently reported to be useful in diagnosing PE. Case summary: A 78-year-old man with dyspnoea of 1-month duration visited our hospital. His oxygen saturation was 89%, and echocardiography demonstrated right heart strain. We could not perform contrast-enhanced CT because the patient had a history of contrast allergy and refused to undergo premedicated contrast CT with anti-histamine and/or corticosteroid. Therefore, a video analysis of pulmonary circulation using dynamic chest X-ray (DCR) was performed. The reconstructed pseudo-colour video showed defects of pulmonary circulation in both lung areas. We diagnosed PE and started anticoagulant therapy. Multiple segmental defects were also observed in pulmonary perfusion scintigraphy on Day 3, which confirmed the diagnosis of PE. He was discharged on Day 9, and an improvement of the pulmonary circulation as assessed with DCR was observed. He had no symptoms at the last follow-up visit at 1 year after discharge. Discussion: We describe the successful visualization of PE using DCR in a patient with iodine contrast allergy.

Cardiac tamponade due to ruptured coronary-pulmonary artery fistula aneurysm: a case report.

BACKGROUND: Coronary artery fistulas are rare and most commonly asymptomatic; however, they can become enlarged and rupture in some cases. CASE SUMMARY: We report a case of a 51-year-old woman who was brought to our hospital unconscious in an ambulance. Cardiac tamponade caused by the rupture of an aneurismal coronary-pulmonary artery fistula (CPAF) was detected by contrast-enhanced computed tomography and confirmed by invasive coronary angiography. Due to prompt diagnosis and subsequent surgical intervention, the patient's condition was rapidly improved, and she was discharged from the hospital. DISCUSSION: Coronary-pulmonary artery fistula aneurysm rupture requires rapid diagnosis and treatment, and thus, in cases with cardiac tamponade and coronary aneurysm, CPAF aneurysm rupture should be considered.

The radio frequency catheter ablation of inter-fascicular reentrant tachycardia: new insights into the electrophysiological and anatomical characteristics.

INTRODUCTION: Macro-reentrant ventricular tachycardias (VT) utilizing the bundle branches and Purkinje fibers have been reported as verapamil sensitive VT (idiopathic left VT), bundle branch reentrant VT (BBRT) and inter-fascicular reentrant tachycardia (inter-fascicular VT). However, diagnostic confusion exists with these VTs due to the difficulty in differentiating between them with conventional electrophysiological (EP) studies. The aim of this study was to clarify the EP and anatomical entity of inter-fascicular VT, and provide successful methods for the radio frequency catheter ablation (RFCA) of inter-fascicular VT. METHODS AND RESULTS: A total of nine patients were included in this study. All patients were diagnosed with idiopathic left VT in the first session, and underwent a second session after a failed RFCA. Detailed EP studies guided by a three-dimensional (3D) mapping system were performed to further analyze the VTs. All VTs were finally diagnosed as inter-fascicular VT. They were successfully cured with RFCA targeting the left anterior or posterior fascicle, which was regarded as a requisite part of the reentrant circuit of the inter-fascicular VT, using 3D and fluoroscopic images combined with a detailed EP investigation instead of the conventional RFCA method targeting Purkinje potentials for the RFCA of idiopathic left VT. CONCLUSIONS: Inter-fascicular VT could be misdiagnosed as idiopathic left VT due to the limitations of the conventional EP study. Failed RFCA in presumptive idiopathic left VT cases has to be carefully investigated by further analysis, and a tailored RFCA strategy targeting the requisite portions of the left fascicles in the inter-fascicular VT reentrant circuit will be required for the successful elimination of the inter-fascicular VT.

Control of Bacterial Seedling Rot and Seedling Blight of Rice by Bacteriophage.

In Japan, rice seed are immersed in pesticide solutions to prevent seedborne diseases that attack greenhouse seedlings. However, disposal of large quantities of waste pesticide solutions after treatment is costly. As an alternative treatment, bacteriophages (phages) that are highly specific to the target bacteria are considered as potential biocontrol agents. Here, we isolated three phage strains that lyse Burkholderia glumae and B. plantarii, the causative pathogens of seedling rot and seedling blight, respectively. Two phages could lyse both bacteria and clearly suppress these diseases. One of these phages (BGPP-Ar) suppressed these diseases more effectively than existing pesticides: the ratio of seedlings exhibiting disease to the total number of seedlings examined after treatment with BGPP-Ar 1.0 × 108 plaque-forming units (PFU)/ml was 0.0 for seedling rot and 2.0 for seedling blight; after treatment with ipconazole/copper (II) hydroxide, the ratios were 14.3 and 15.0, respectively. BGPP-Ar was highly effective in suppressing seedling rot of rice, even at the low concentration of 1.0 × 105 PFU/ml. The best phage treatment effect for sterilizing seed is achieved indoors to avoid phage inactivation by UV irradiation. Treatment effect was demonstrated on seed infected with pathogens. Therefore, we consider that phage treatment was effective in this study.

Erwinia uzenensis sp. nov., a novel pathogen that affects European pear trees (Pyrus communis L.).

Bacteria were isolated from black lesions on shoots of European pear trees (Pyrus communis L.) in an orchard in Japan. Previous characterization of this novel pathogen by phenotypic and genotypic methods suggested that it should belong to the genus Erwinia but might not correspond to either Erwinia amylovora or Erwinia pyrifoliae. Here, phylogenetic analyses of the 16S rRNA gene, gyrB, and rpoD gene sequences indicated that it could not be assigned to any recognized species of the genus Erwinia. DNA-DNA hybridization confirmed that the bacterial strains represented a novel species. The DNA G+C contents, the fatty acid profile and phenotypic characteristics resembled those previously reported for members of the genus Erwinia. On the basis of these and previous results, the pathogen represents a novel species of the genus Erwinia, for which the name Erwinia uzenensis sp. nov. (type strain: YPPS 951(T) = LMG 25843(T) = NCPPB 4475(T)) is proposed.

GMC oxidoreductase, a highly expressed protein in a potent biocontrol agent Fusarium oxysporum Cong:1-2, is dispensable for biocontrol activity.

A spontaneous non-pathogenic variant (Cong:1-2) derived from Fusarium oxysporum f. sp. conglutinans (Cong: 1-1), a causal agent of cabbage yellows, carries biocontrol activity for cabbage yellows. We found a GMC oxidoreductase (ODX1) among the proteins expressed much more in Cong:1-2 than Cong:1-1 by 2D-DIGE comparison. GMC oxidoreductases have been reported to be involved in biocontrol activity of several plant pathogenic fungi. The gene encoding ODX1 in Cong:1-2 was cloned, and targeted disruption of the gene in Cong:1-2 did not affect its biocontrol activity, suggesting that GMC oxidoreductase is dispensable for biocontrol activity in the fungal biocontrol agent.

Factors leading to failure to diagnose acute aortic dissection in the emergency room.

BACKGROUND: Acute aortic dissection (AAD) is often missed on initial assessment. PURPOSE: The aim of our study was to identify features associated with misdiagnosis of AAD. METHODS AND RESULTS: We examined a total of 109 emergency room (ER) patients who were ultimately diagnosed with AAD. Misdiagnosis of AAD was defined as failure to diagnose AAD at the end of the initial assessment in the ER, and occurred in 17 patients (16%). The alternate diagnosis consisted of acute coronary syndrome (n=10), other cardiovascular disease (n=3), abdominal disease (n=3), and cerebral infarction (n=1). In the misdiagnosed patients, walk-in mode of admission to the ER (29% vs. 10%, p=0.042) and anterior chest pain (71% vs. 41%, p=0.025) were more frequent, and widened mediastinum (25% vs. 55%, p=0.023) was less frequent than in diagnosed patients. The number of imaging studies performed per patient was also fewer in misdiagnosed patients than in diagnosed patients (0.82 ± 0.81 vs. 1.53 ± 0.52, p<0.001). However, there was no significant difference in in-hospital mortality (18% vs. 15%, p=0.520). Multivariate analysis showed that the strongest predictor of misdiagnosis was walk-in mode of admission (odds ratio 4.777; 95% confidence interval 1.267-18.007; p=0.021). CONCLUSIONS: Both diversity of symptoms and variability of the severity of symptoms, especially walk-in mode of admission lead ER physicians to miss AAD in about 1 in 6 cases of AAD. It is therefore important to keep AAD as a differential diagnosis in mind, even when patients present with mild enough symptoms that allow them to walk into the ER.

Clinical study of the electrophysiological effects of ischemic post-conditioning in patients with acute myocardial infarctions.

BACKGROUND: Ischemic "pre"-conditioning has been shown to have antiarrhythmic effects. The aim of this study was to investigate whether ischemic "post"-conditioning (post-CON) also has antiarrhythmic effects in ST-segment elevation myocardial infarction (STEMI) patients undergoing coronary angioplasty (PCI) as a clinical model of post-CON. METHODS AND RESULTS: A total of 61 patients suffering from an acute myocardial infarction (AMI) were included. The QT dispersion (QTd) was measured before each balloon inflation (BI) and after deflation (BD) during PCI. The hemodynamic parameters and electrocardiogram were also assessed during PCI. All data were analyzed using a logistic regression analysis. A total of 36 of 61 STEMI patients could be analyzed according to the protocol. The QTd shortened significantly as the BI and BD were repeated (p<0.05). Prior to the PCI, frequent premature ventricular contractions (PVCs) were observed in 5 patients, and the PVCs were remarkably suppressed or disappeared entirely as the BI and BD were repeated. Non-sustained ventricular tachycardia was observed prior to the PCI in 2 patients; this also disappeared as the BI and BD were repeated. Ventricular fibrillation (VF) occurred in 1 patient prior to PCI, necessitating D-C cardioversion. After repeating the BI and BD during PCI, VF no longer recurred. CONCLUSIONS: In the majority of the AMI patients studied, post-CON exhibited significant antiarrhythmic effects as assessed by the change in the QTd. The ventricular dysarrhythmias were also suppressed during the PCI.

Reduction of the PaO2/FiO2 ratio in acute aortic dissection ­ relationship between the extent of dissection and inflammation ­.

BACKGROUND: Acute aortic dissection (AAD) often accompanies acute respiratory failure. The aim of this study was to clarify the relationship between the incidence of oxygenation impairment and the extent of distal type AAD. METHODS AND RESULTS: A total of 49 patients with medically treated distal type AAD were retrospectively examined. AAD% was defined as the percentage of the volume of false lumen to that of aorta in the descending aorta. AAD% was measured by computed tomography. C-reactive protein (CRP) levels, white blood cell (WBC) counts, body temperature and arterial partial pressure of oxygen/fraction of inspired oxygen (PaO(2)/FiO(2)) ratio were measured serially. Oxygenation impairment was defined as a PaO(2)/FiO(2) ratio ≤ 200. This occurred in 19 patients (39%). In patients with oxygenation impairment, AAD% (50.8 ± 10.9% vs 28.0 ± 11.9%, P<0.001), peak CRP levels (15.2 ± 6.5 mg/dl vs 9.6 ± 4.6 mg/dl, P<0.001), peak WBC counts (13,600 ± 3,700/µl vs 10,400 ± 2,800 /µl, P=0.001) and body temperature (38.1 ± 0.5°C vs 37.8 ± 0.4°C, P=0.045) were higher than those without oxygenation impairment. It was found that there were inverse correlations between the PaO(2)/FiO(2) ratio and AAD% (r=-0.604, P<0.001), and between peak CRP levels and the PaO(2)/FiO(2) ratio (r=-0.635, P<0.001). Multivariate analysis demonstrated that the only independent predictor of oxygenation impairment was AAD% (odds ratio, 1.323; 95% confidence interval, 1.035-1.691, P=0.026). CONCLUSIONS: Respiratory failure in AAD appears to be closely correlated with the amount of aortic injury, possibly mediated by the magnitude of the systemic inflammatory reaction to the aortic injury.

Sudden cardiac death associated with Churg-Strauss syndrome.

A 60-year-old man who had serious chest and arm pain died suddenly during hospitalization. He suffered from coronary vasospastic angina complicated by a fatal acute fulminant-type of myocarditis associated with Churg-Strauss syndrome (CSS). The diagnosis at autopsy was acute progressive eosinophilic myocarditis associated with CSS.

A novel mesh electrode catheter for mapping and radiofrequency delivery at the left atrium-pulmonary vein junction: a single-catheter approach to pulmonary vein antrum isolation.

BACKGROUND: Electrical isolation of pulmonary veins (PV) by radiofrequency (RF) ablation is often performed in patients with atrial fibrillation (AF). Current catheter technology usually requires the use of a multielectrode catheter for mapping in addition to the ablation catheter. PURPOSE: We evaluated the feasibility and safety of using a single, expandable electrode catheter (MESH) to map and to electrically isolate the PV. METHODS AND RESULTS: Nineteen closed-chest mongrel dogs, weighing 23-35 kg, were studied under general anesthesia. Intracardiac echocardiography (ICE) was used to guide transseptal puncture and to assess PV dimensions and contact of the MESH with PV ostia. ICE and angiography of RSPV were obtained before and after ablation, and prior to sacrifice at 7-99 days. An 11.5 Fr steerable MESH was advanced and deployed at the ostium of the RSPV. Recordings were obtained via the 36 electrodes comprising the MESH. For circumferential ablation, RF current was delivered at a target temperature of 62-65 degrees C (4 thermocouples) and maximum power of 70-100 W for 180 to 300 seconds. Each animal received 1-4 RF applications. Entrance conduction block was obtained in 13/19 treated RSPVs. Pathological examination confirmed circumferential and transmural lesions in 13 of 19 RSPV. LA mural thrombus was present in 3 animals. There was no significant PV stenosis. CONCLUSION: Based on this canine model, a new expandable MESH catheter may safely be used for mapping and for PV antrum isolation. This approach may decrease procedure time without compromising success rate in patients undergoing AF ablation.

Successful catheter ablation of focal left atrial tachycardia originating from the mitral annulus aorta junction.

Focal left atrial tachycardias (AT) originating from the mitral annulus-aorta (MA-Ao) junction are rare and their mechanisms are unclear. We report a 35-year-old male with successful ablation of an exercise-induced focal AT due to triggered activity originating from the MA-Ao junction. The AT occurred spontaneously during treadmill exercise testing and was easily induced by an atrial extrastimulus and atrial burst pacing after intravenous administration of isoproterenol. The AT was terminated by an atrial extrastimulus as well as a bolus of 5 mg of adenosine 5'-triphosphate. The coupling intervals of the extrastimuli that induced the AT were positively correlated with the interval between the extrastimuli and the first beat of the AT, suggesting the triggered activity as a tachycardia mechanism. The AT was successfully eliminated by a focal ablation at the MA-Ao junction with the earliest atrial activation where fractionated atrial potentials were recorded. The MA-Ao junction should be recognized as an important arrhythmogenic region.

Spatial resolution of pacemapping and activation mapping in patients with idiopathic right ventricular outflow tract tachycardia.

BACKGROUND: The purpose of this study was to compare the spatial resolution of activation mapping and pacemapping in patients undergoing ablation of idiopathic ventricular tachycardia (VT) arising from the right ventricular outflow tract (RVOT). A direct comparison of the two techniques has not been undertaken. METHODS AND RESULTS: Electroanatomical activation maps of the RVOT were obtained during VT in 15 patients. Pacemaps were obtained from multiple sites, tagged on the activation map, and scored according the degree of concordance between the paced QRS configuration and that of VT. The site of successful ablation was considered the VT site of origin. Initial endocardial activation away from the site of origin was rapid; the mean area of myocardium activated within the first 10 msec (early activation area, EAA) was 3.0 +/- 1.6 cm(2) (range: 1.3-6.4 cm(2)). Best pacemap scores were always obtained adjacent to the site of origin. Pacemap concordance, and the probability of an exact pacemap match significantly decreased with increasing distance of the pacing site from the site of origin (P < 0.01). All patients had more than one pacing site yielding a best pacemap score. The greatest distance between such sites in an individual patient ranged from 11 to 26 mm (mean: 18 +/- 5 mm), and was strongly correlated with the size of the EAA (r = 0.77, P < 0.001). CONCLUSIONS: Pacemapping and activation mapping provide similar localizing information. The spatial resolution of each technique is modest, varies between patients, and may be optimized by three-dimensional data display.

Effect of Iron Limitation on "Pseudomonas plantarii" Growth and Tropolone and Protein Production.

The addition of iron to an iron-deficient medium markedly enhanced the growth of "Pseudomonas plantarii" and the production of red crystals. However, it markedly reduced the amount of dissolved tropolone, a product of the bacterium and an iron chelator, and the production of an iron-regulated protein (78 kilodaltons). The red crystal was complex, composed of tropolone and iron, the ratio being 3:1.