Combined pulsed field ablation with ultra-low temperature cryoablation: A preclinical experience.

BACKGROUND: Combining pulsed field ablation (PFA) with ultra-low temperature cryoablation (ULTC) represents a novel energy source which may create more transmural cardiac lesions. We sought to assess the feasibility of lesions created by combined cryoablation and pulsed field ablation (PFCA) versus PFA alone. METHODS: Ablations were performed using a custom PFA generator, ULTC console, and an ablation catheter with insertable stylets. PFA was delivered in a biphasic, bipolar train. PFCA precooled the tissue for 30 s followed by a concurrent PFA train. Benchtop testing using Schlieren imaging and microbubble volume assessment were used to compare PFA and PFCA. PFA and PFCA lesions using pre-optimized and optimized ablation protocols were studied in 6 swine. Pre and post-ECGs were recorded for each ablation and a gross necropsy was performed at 14 days. RESULTS: Consistent with benchtop comparisons of heat and microbubble generation, PFA deliveries in the animals were accompanied by muscle contractions and significant microbubbles (Grade 2-3) visible on intracardiac echo while neither occurred during PFCA at higher voltage levels. Both PFA and PFCA acutely eliminated or highly attenuated (>80%) local atrial electrograms. Histology of PFA and PFCA lesions indicated depth up to 6-7 mm and nearly all lesions were transmural. Optimized PFCA produced wider cavotricuspid isthmus lesions with evidence of tissue selectivity. CONCLUSION: A novel technology combining PFA and ULTC into one energy source demonstrated in-vivo feasibility for PFCA ablation. PFCA had a more favorable thermal profile and did not produce muscle contraction or microbubbles while extending lesion depth beyond cryoablation.

Prolonged effects of DPP-4 inhibitors on steato-hepatitic changes in Sprague-Dawley rats fed a high-cholesterol diet.

OBJECTIVE: Sitagliptin and other dipeptidyl peptidase (DPP)-4 inhibitors/gliptins are antidiabetic drugs known to improve lipid profile, and confer anti-inflammatory and anti-fibrotic effects, which are independent of their hypoglycemic effects. However, in our previous short-term (35 days) studies, we showed that sitagliptin accentuates the hepato-inflammatory effects of high dietary cholesterol (Cho) in male Sprague-Dawley rats. Since most type 2 diabetics also present with lipid abnormalities and use DPP-4 inhibitors for glucose management, the present study was conducted to assess the impact of sitagliptin during long-term (98 days) feeding of a high Cho diet. An additional component of the present investigation was the inclusion of other gliptins to determine if hepatic steatosis, necro-inflammation, and fibrosis were specific to sitagliptin or are class effects. METHODS: Adult male Sprague-Dawley rats were fed control or high Cho (2.0%) diets, and gavaged daily (from day 30 through 98) with vehicle or DPP-4 inhibitors (sitagliptin or alogliptin or saxagliptin). On day 99 after a 4 h fast, rats were euthanized. Blood and liver samples were collected to measure lipids and cytokines, and for histopathological evaluation, determination of hepatic lesions (steatosis, necrosis, inflammation, and fibrosis) using specific staining and immunohistochemical methods. RESULTS: Compared to controls, the high Cho diet produced a robust increase in NASH like phenotype that included increased expression of hepatic (Tnfa, Il1b, and Mcp1) and circulatory (TNFα and IL-1ß) markers of inflammation, steatosis, necrosis, fibrosis, and mononuclear cell infiltration. These mononuclear cells were identified as macrophages and T cells, and their recruitment in the liver was facilitated by marked increases in endothelium-expressed cell adhesion molecules. Importantly, treatment with DPP-4 inhibitors (3 tested) neither alleviated the pathologic responses induced by high Cho diet nor improved lipid profile. CONCLUSIONS: The potential lipid lowering effects of DPP-4 inhibitors were diminished by high Cho (a significant risk factor for inducing liver damage). The robust inflammatory responses induced by high Cho feeding in long-term experiment were not exacerbated by DPP-4 inhibitors and a consistent hepatic inflammatory environment persisted, implying a prospective physiological adaptation.

The incretin enhancer, sitagliptin, exacerbates expression of hepatic inflammatory markers in rats fed a high-cholesterol diet.

OBJECTIVE: Hypercholesterolemia is associated with the development of a pro-inflammatory state and is a documented risk factor for progression to insulin resistance, nonalcoholic fatty liver and cardiovascular diseases. Sitagliptin is an incretin enhancer that improves glucose tolerance by inhibiting dipeptidyl peptidase-4, but it also has reported anti-inflammatory effects. The current study was thus undertaken to examine the interactions of dietary Cholesterol (Cho) and sitagliptin on markers of inflammation. METHODS: Male Sprague-Dawley rats were provided diets high in Cho and gavaged with vehicle or an aqueous suspension of sitagliptin (100 mg/kg/day) from day 10 through day 35. Molecular methods were used to analyze the lipid profile and inflammatory markers in liver and serum samples. H&E-stained liver sections were used for histopathological evaluation. Hepatic influx of mononuclear cells and necrosis were assessed by immunohistochemistry. RESULTS: Sitagliptin reduced triglyceride and Cho levels in serum of rats on the control diet but these effects were abrogated in rats on the high-Cho diet. Sitagliptin produced a significant increase in the expression of hepatic inflammatory markers (Tnfa, Il1b, and Mcp1) and a corresponding increase in serum TNFα and IL-1ß in rats on the high-Cho diet, but it had no effect on rats on the control diet. Additionally, sitagliptin had no effect on liver morphology in rats on the control diet, but it produced hepatic histopathological changes indicative of necrosis and mononuclear cell infiltration in rats on the high-Cho diet. These mononuclear cells were identified as macrophages and T cells. CONCLUSION: When provided in the context of a high-Cho diet, these findings reveal previously unrecognized hepato-inflammatory effects of sitagliptin that are accompanied by evidence of hepatic necrosis and mononuclear cell infiltration.

Cryoelectrolysis; an acute case study in the pig liver.

We report results from an acute, single case study in the pig liver on the effects of a tissue ablation protocol (we named cryoelectrolysis) in which 10 min of cryosurgery, with a commercial cryosurgical probe, are delivered after 10 min of electrolysis generated by a current of about 60 mA. The histological appearance of tissue treated with cryoelectrolysis is compared with the appearance of tissue treated with 10 min of cryosurgery alone and with 10 min of electrolysis alone. Histology done after 3 h survival shows that the mixed rim of live and dead cells found around the ablated lesion in both cryosurgery and electrolytic ablation is replaced by a sharp margin between life and dead cells in cryoelectrolysis. The appearance of the dead cells in each, cryoelectrolysis, cryosurgery and electrolytic ablation is different. Obviously, this is an acute study and the results are only relevant to the conditions of this study. There is no doubt that additional acute and chronic studies are needed to strengthen and expand the findings of this study.

Tissue Ablation by a Synergistic Combination of Electroporation and Electrolysis Delivered by a Single Pulse.

A synergistic combination of electroporation and electrolysis (SEE) has been found with distinct advantages over tissue ablation by electrolysis or electroporation alone. Minimally invasive tissue ablation by electrolysis uses a low magnitude direct electric current to produce a lesion due to the creation of chemical products that result in cell death. Electroporation creates permeabilizations in the cell membrane which may lead to loss of cell homeostasis and cell death. When these two modes of tissue ablation are combined, a more effective method of cell death is achieved, likely due to the ability of electrolytic products to access the cell interior through the permeabilized cell membrane. Here, a new method of achieving SEE tissue ablation is obtained through the application of a single exponential decay pulse. This parametric study explores the mechanisms of damage as a function of the initial electric field and amount of delivered charge. It is seen that treatment parameters can dictate the mode of tissue ablation, either by SEE or by irreversible electroporation alone.

Combining Electrolysis and Electroporation for Tissue Ablation.

Electrolytic ablation is a method that operates by delivering low magnitude direct current to the target region over long periods of time, generating electrolytic products that destroy cells. This study was designed to explore the hypothesis stating that electrolytic ablation can be made more effective when the electrolysis-producing electric charges are delivered using electric pulses with field strength typical in reversible electroporation protocols. (For brevity we will refer to tissue ablation protocols that combine electroporation and electrolysis as E(2).) The mechanistic explanation of this hypothesis is related to the idea that products of electrolysis generated by E(2) protocols can gain access to the interior of the cell through the electroporation permeabilized cell membrane and therefore cause more effective cell death than from the exterior of an intact cell. The goal of this study is to provide a first-order examination of this hypothesis by comparing the charge dosage required to cause a comparable level of damage to a rat liver, in vivo, when using either conventional electrolysis or E(2) approaches. Our results show that E(2) protocols produce tissue damage that is consistent with electrolytic ablation. Furthermore, E(2) protocols cause damage comparable to that produced by conventional electrolytic protocols while delivering orders of magnitude less charge to the target tissue over much shorter periods of time.

Ethanol-mediated perivascular renal sympathetic denervation: preclinical validation of safety and efficacy in a porcine model.

AIMS: We report the use of a novel endovascular approach using chemical neurolysis, via periadventitial injection of dehydrated ethanol (EtOH) to perform renal artery denervation. METHODS AND RESULTS: A novel, three-needle delivery device was introduced into the renal arteries of adult swine using fluoroscopic guidance. EtOH was injected bilaterally with one injection per artery, via the three needles into the adventitial and periadventitial space, using EtOH doses 0.15 ml/artery; n=3, 0.30 ml/artery; n=3, and 0.60 ml/artery; n=3, with saline injection as a sham control (0.4 ml/artery; n=3), and naive subjects (n=7) as a true negative control. The renal parenchymal norepinephrine (NE) concentration at two-week follow-up was the primary efficacy endpoint. The mean renal NE reduction was 54%, 78% and 88% at doses of 0.15 ml, 0.30 ml and 0.60 ml, respectively (p<0.0001 vs. controls). Histological examination revealed marked, and deep, circumferential renal nerve injury at depths of 2-8 mm from the intimal surface. There was no evidence of device-related or EtOH-induced injury to the intimal layers. In some samples at the higher EtOH doses, there was focal loss of smooth muscle cells in the outer media. Angiography at 45 days demonstrated normal appearing renal arteries with no detectable stenoses (n=8). CONCLUSIONS: Circumferential adventitial delivery of very low doses of EtOH may be a promising alternative to energy-based systems to achieve dose-dependent, and predictable renal denervation. Further study is warranted.

Structured data system for a breast cancer medical record.

We have developed software for an Electronic Medical Record (EMR) to be used by oncologists and researchers. It has rapid, structured data entry, visualization of clinical information and a searchable data base. Interactive, rules-based forms were designed for structured data entry. The web-based forms have been customized for the clinical staff who enter the data. The forms have been tested by oncologists and their office assistants. Modules have been added to upload images and add legends, metadata, and code classifications such as ICD and CPT. Other features include a search interface and a permission system that controls user access. Oncologists enter detailed information during a patient's visit to the clinic. The electronic forms capture diagnoses, stage and history, which includes social, family, and medical history. A time map provides a graphical summary of a patient's record. Visualization of complex clinical information with intuitive navigation increases clarity while retaining the detail necessary for clinical information. Customized data entry forms and automatic coding speed the workflow. The system can potentially interface with multi-institutional data-sharing systems such as Cancer Bioinformatics Grid (CaBig).

Histopathological evaluation of a novel radiofrequency surgical ablation system.

PURPOSE: : Using a porcine model, this feasibility study was undertaken to evaluate the histopathological characteristics of lesions created in the proximity of the pulmonary veins after ablation with a new endoscopic-guided radiofrequency device. METHODS: : Five adult female swine underwent endoscopic surgical ablation on the epicardial surface of the beating heart. Histologic sections taken from around the pulmonary vein pedicle, representing 10 separate anatomic sites, underwent independent qualitative histopathological evaluation as well as quantitative histomorphometric measurement of lesion depth and section thickness. RESULTS: : Sections from all five animals had histologically identical lesions, with the majority of ablation foci having pronounced thermal injury characterized by deep and extensive zones of acute myocardial necrosis in the absence of tissue charring. Fifty-seven percent (13 of 23) of the lesions were completely transmural and 91% (21 of 23) of the sections demonstrated ≥70% transmurality. No collateral injuries were noted. CONCLUSIONS: : This irrigated, suction-stabilized unipolar radiofrequency device can produce histologically transmural lesions around the pulmonary veins and is amenable to endoscopic-guided application on the beating heart.

Absence of biological damage from prolonged exposure to intravascular ultrasound: a swine model.

Ultrasound (US) has been used in IMS II (intravascular US) and CLOTBUST (transcranial US) clinical trials for thrombolysis. During the treatment, in addition to the targeted thrombus, other biological components, such as blood and vessel walls are subjected to long durations of US exposure. In this study we explored evidence of biological damage due to mechanical forces or thermal effects of US exposure at the frequency, intensity and duration employed for thrombolysis treatment. Biological effects were investigated by exposing swine ilio-femoral arteries bilaterally to an intravascular US generating catheter and a conventional catheter. A total of 12 animals each underwent 8h of exposure to intravascular pulsed US with a frequency of 2.2MHz and spatial peak time average intensity (I(SPTA)) of 6W/cm(2) per transducer (a total of six transducers per catheter) while the ultrasonic device surface temperature was maintained at 43 degrees C. The animals were euthanized either 24+/-3h or 28+/-3 days post treatment. A range of physiological and hematological parameters were evaluated pre-, post-, and during US exposure. The vascular diameter was determined pre- and post-US exposure using angiograms. Following euthanasia, each animal underwent a gross pathological examination, and the treated vessels and an unexposed vessel were excised for comparative histopathological evaluation. No evidence of biological damage was found at the end of 8h exposure to intravascular US.