[A 68-year-old patient with atrial flutter/fibrillation, inadequate anticoagulation, subacute amaurosis, normal ESR, and lymphadenopathy]. / 68-jähriger Patient mit Vorhofflattern/Vorhofflimmern, inadäquater Antikoagulation, subakuter Amaurosis, normaler BSG und Lymphadenopathie.

We present a rare manifestation of chronic lymphatic leukemia with progressive bilateral visual loss and the typical fundoscopic picture of anterior ischemic optic nerve neuropathy (AION). Clinical symptoms were due to meningeal metastases and tumor cell infiltration of the optic nerve. The diagnostic clue was provided by lumbar puncture with pressure measurement, which made it possible to differentiate AION from papillitis and papilledema. In this case the patient was able to regain his initial visual activity after intrathecal and systemic polychemotherapy.

Characterization of the taurine transport pathway in A6 kidney cells.

We investigated the role of taurine in cell homeostasis and characterized the taurine transport pathway in cultured kidney cells (A6). The taurine concentration in A6 cells varies with the osmolarity of the culture medium, suggesting that taurine participates in cell osmolarity. Under isosmotic conditions, 14C-taurine efflux through the apical membranes (aJtaur) was 6-7 times lower than that through the basolateral membranes (bJtaur). Under hyposmotic conditions, aJtaur remained almost unchanged. On the contrary, bJtaur increased 8 times in comparison with isosmotic conditions. In hyposmotic conditions, bJtaur was inhibited by 500 microM DIDS, 50 microM NPPB, 10 microM of the two oxonol derivatives DISBAC(2)3 and WW-791, and 100 microM ketoconazole. Conversely, 100 microM 1,9-dideoxyforskolin, 10 microM tamoxifen, 100 microM niflumic acid and 50 microM verapamil had no inhibitory effects. Cell volume regulation upon hyposmotic stress was also found to be inhibited by DISBAC(2)3 (K0.5 of 5+/-1 microM) and by ketoconazole. Nystatin was used to permeabilize the apical membranes with the aim to further characterize bJtaur. 14C-taurine transepithelial fluxes in nystatin-treated cells were found to be linear over taurine concentrations ranging from 3.5 microM to 35 mM. Clamping the transepithelial voltage at positive values (serosal side) slightly stimulated the 14C-taurine transport. Similar time courses of 14C-taurine, 36Cl and 86Rb transepithelial fluxes were found under osmotic stimulation followed by DIDS inhibition in nystatin-treated cells. In whole cell patch-clamp experiments, DISBAC(2)3 application resulted in a strong and reversible decrease of the global Cl- current which was stimulated by hyposmotic stress. Our study indicates that taurine participates in the control of A6 cell osmolarity and that the transporting taurine pathway (efflux) is on the basolateral membranes. In addition to usual chloride channel blockers, oxonol was found to be a potent blocker of the taurine transport and of the swelling-activated chloride current. Using a pharmacological approach, we could not distinguish between a common or different pathway for Cl- and taurine.

Cloning and characterisation of amphibian ClC-3 and ClC-5 chloride channels.

Amphibians have provided important model systems to study transepithelial transport, acid-base balance and cell volume regulation. Several families of chloride channels and transporters are involved in these functions. The purpose of this review is to report briefly on some of the characteristics of the chloride channels so far reported in amphibian epithelia, and to focus on recently cloned members of the ClC family and their possible physiological roles. The electrophysiological characterisation, distribution, localisation and possible functions are reviewed and compared to their mammalian orthologs.

Internal atrial defibrillation during electrophysiological studies and focal atrial fibrillation ablation procedures.

Induction of sustained AF during electrophysiological studies requires electrical cardioversion to restore sinus rhythm for continuation of the electrophysiological study and mapping procedure. The study included 104 consecutive patients (age 59 +/- 12 years, 74 men), who were in stable sinus rhythm at the beginning of the electrophysiological study, underwent internal atrial defibrillation (IAD) of AF (> 15 minutes) that was induced during electrophysiological study. In 21 patients, AF was regarded to be the clinical problem (group I), and in the remaining 83 patients other arrhythmias represented the primary target of the electrophysiological study (group II). A 7.5 Fr cardioversion catheter (EP Medical) equipped with a distal array was used and placed in the left pulmonary artery and a proximal array of the same size was located along the lateral right atrial wall. All patients were successfully cardioverted with a mean energy of 6.2 +/- 4.0 1. In 18 (78%) of 21 group I patients and in 12 (14%) of 81 group II patients, AF recurred 3.7 +/- 3.4 and 2.4 +/- 1.4 times during electrophysiological study, respectively. The IAD shock did not suppress focal activity, thus the mapping of atrial foci responsible for AF could be continued even after several IADs. No IAD related complications occurred during the study. In conclusion, (1) IAD can be safely and successfully performed during electrophysiological study without using narcotic drugs or high electric energies; (2) IAD does not suppress focal activity; and (3) even if AF recurs frequently during the electrophysiological study, IAD can be performed several times without significant time delay.

[Problems of electrocardiographic diagnosis of occlusion of the left circumflex coronary artery]. / Probleme der elektrokardiographischen Diagnostik bei Verschluss des Ramus circumflexus der linken Koronararterie.

BACKGROUND AND OBJECTIVE: The electrocardiographic diagnosis of posterior myocardial infarction is difficult. It was the objective of the present study to evaluate ST-segment changes in angiographically documented occlusion of the left RCX in the setting of an acute myocardial infarction and to analyse the value of the posterior chest leads V(7)-V(9). PATIENTS AND METHODS: Data of 120 patients (88 males, on average 61+/-13 years old) with an acute myocardial infarction and angiographically proven occlusion of the left circumflex artery were included in the study. Mean time of pain onset to ECG recording was 5.5 +/- 2.8 hours. The ECGs were analysed for ST-segment changes of > or = 1 mm in two contiguous leads in surface leads I-aVF, > or = 2 mm in the precordial leads V(1)-V(6), and > or = 1 mm in right precordial (V(3)R-V(6)R) and posterior (V(7)-V(9)) leads. These additional leads were recorded only in a subgroup of 36 patients. Maximal creatine kinase activity was determined as a measure of infarct size. RESULTS: Standard leads I-V(6) showed ST-segment elevation in 55 of 120 patients (46 %). In the subgroup of patients with extended chest leads 61 % (11/36) had significant ST-segment elevation, whereas isolated ST-segment elevation in the posterior leads occurred in 8 % (3/36). ST-segment depression in the standard leads was observed in 73 of the 120 patients (54 %), and isolated ST-segment depression was seen in 31 patients (26 %). No significant ST-segment changes in the standard leads were found in 34 patients (28 %). Maximum CK values were not significantly different among the three groups (1107 +/- 815 IU/l vs 953 +/- 651 IU/l vs 816 +/- 553 IU/l; (P = 0.447). CONCLUSION: These findings confirm that the sensitivity of the standard ECG leads is less than 50 % in angiographically documented occlusion of the left RCX. The extended posterior chest leads (V(7)-V(9)) improve sensitivity only marginally (by 8 %). Isolated ST-segment depression or no significant ST-segment depression in the standard leads was observed in 26 % and 28 % respectively. The infarct size - as measured by maximum CK-values - did not differ among the respective groups.

Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel : limitations of ST-segment elevation in standard and extended ECG leads.

STUDY OBJECTIVES: The majority of thrombolysis studies require defined ST-segment elevations as an inclusion criterion for the diagnosis of acute myocardial infarction (AMI). However, depending on the occluded infarct vessel and the criteria applied, the ECG diagnosis of AMI can be difficult to establish. Accordingly, this study was performed to evaluate the sensitivity of ST-segment elevation of standard and extended ECG leads in a cohort of patients with angiographically confirmed diagnosis of AMI. PATIENTS AND METHODS: In 418 patients (mean +/- SD age, 60 +/- 13 years) with AMI (pain onset, 4.8 +/- 3.0 h), coronary angiography with percutaneous transluminal coronary angioplasty/stenting of the culprit lesion was performed. The diagnosis of AMI was confirmed by emergency coronary angiography and laboratory analyses. ST-segment elevation (in two contiguous leads) of 1 mm in standard lead I through aVF and ST-segment elevations of 2 mm (or 1 mm, corresponding values presented in parentheses) in V(1) through V(6) were considered significant. In a subset of 102 AMI patients, additional right precordial leads V(3)R through V(6)R for evaluation of right ventricular infarction and additional chest leads V(7) through V(9) for evaluation of posterior infarction were recorded. ST-segment elevations of 1 mm in the right precordial leads and 1 mm or 0.5 mm in the posterior leads were considered significant. RESULTS: Standard leads I through V(6) showed ST-segment elevation in 85% (96%) of patients with left anterior descending artery occlusion, in 46% (61%) of patients with left circumflex coronary artery (CX) occlusion, and in 85% (90%) of patients with right coronary artery occlusion. On consideration of additional ECG tracings in the subgroup of 102 patients (V(3)R through V(6)R and V(7) through V(9)), the respective numbers increased by 2 to 8% depending on different criteria for ST-segment elevation; in patients with CX occlusion, the increase amounted to 6 to 14%. There was a trend toward an extended infarct size (maximum creatine kinase [CK] values) with concomitant ST-segment elevation in additional ECG leads as assessed by maximum CK levels. CONCLUSIONS: The sensitivity of the ECG diagnosis of AMI is only marginally increased by extended precordial chest leads. There is a trend toward an extended infarct size in those patients with concomitant ST-segment elevation in additional ECG leads.

Tissue-specific N-glycosylation of the ClC-3 chloride channel.

A commercially available polyclonal antibody against a rClC-3/GST fusion protein was used in order to investigate the tissue distribution of the ClC-3 chloride channel protein. The antibody appeared to be specific to rClC-3 since no cross-reaction could be observed with rClC-4 or rClC-5 proteins when overexpressed in Xenopus oocytes. In mouse, mClC-3 was preferentially expressed in the central nervous system, intestine, and kidney. To a lower extent, mClC-3 protein was also detected in liver, lung, skeletal muscle, and heart. Surprisingly, the electrophoretic mobility of mClC-3 differed in the various tissues. After enzymatic digestion of N-linked oligosaccharide residues of membrane proteins from brain, intestine, and kidney, mClC-3 was found to migrate at its calculated molecular mass. This study provides important information regarding the specificity of the used antibody, indicates that ClC-3 is widely expressed in mouse, and that mClC-3 undergoes differential tissue-specific N-glycosylation.

Internal low energy cardioversion of atrial fibrillation using a single lead system: comparison of a left and right pulmonary artery catheter approach.

Internal cardioversion (ICV) has been demonstrated as an effective and safe method for restoring sinus rhythm in patients with AF. Recently, a new single lead system with a balloon-guided cardioversion catheter was introduced. ICV was performed after advancing a 7.5 Fr catheter flow-directed into the left or right pulmonary artery (PA, distal array, cathode). The proximal array (anode) was placed at the lateral RA wall. Synchronized shocks (3/3 ms biphasic impulse) were applied using a stepwise protocol (0.5, 3, 6, 9, 12, 15 J) until sinus rhythm was restored or maximum energy (15 J) was reached. Sixty-five patients (mean age 58 +/- 13 years) with acute and chronic AF were included. Sinus rhythm could be restored in 59 (91%) patients. Cardioversion success was 93% in the left PA compared to 86% in right PA. DFTs for the left and right PA approaches were 7.1 +/- 4.0 J and 10.2 +/- 4.0 J, respectively (P < 0.0001). It was significantly higher in patients with an AF history > 7 days (7.2 +/- 4.1 J) than for those with a recent onset of AF (5.6 +/- 4.1 J), P = 0.0012. Shock impedance differed for the left and right PA lead configuration (53 +/- 11 vs 49 +/- 13 omega, P < 0.05). A right PA lead configuration is as effective compared to a left PA catheter approach when performing ICV for AF. ICV with a single lead system is safe and cardioversion success is comparable to other internal and external cardioversion techniques. In combination with hemodynamic monitoring, flow-directed nonfluoroscopic catheter positioning is feasible and may serve as a valuable therapeutic and diagnostic tool in intensive care units.

Do current dual chamber cardioverter defibrillators have advantages over conventional single chamber cardioverter defibrillators in reducing inappropriate therapies? A randomized, prospective study.

INTRODUCTION: Supraventricular tachyarrhythmias are the main cause of inappropriate therapies in patients with conventional single chamber implantable cardioverter defibrillators (VVI-ICD). It was anticipated that dual chamber cardioverter defibrillators (DDD-ICD), with their capacity to analyze atrial and ventricular rhythm, could substantially reduce inappropriate therapies. METHODS AND RESULTS: Our prospective study included 92 patients (87 men; mean age 61 +/- 12.7 years) who were randomly assigned to a VVI-ICD (45 patients) or a DDD-ICD (47 patients). Both groups were followed for 7.5 +/- 3.5 and 7.6 +/- 4.1 months, respectively. During the follow-up period, overall 725 ventricular tachycardia (VT)/ventricular fibrillation (VF) episodes were recorded in 45 (49%) of 92 patients. Of these episodes, 404 (56%) occurred in the VVI-ICD group and 321 (44%) episodes occurred in the DDD-ICD group. Twenty-three (51%) patients in the VVI-ICD group and 22 (47%) patients in the DDD-ICD group (P = 0.8) developed VT/VF. Overall, 73 (10%) of 725 treated episodes were inappropriate in 6 (13%) patients in the VVI group and in 10 (21%) patients in the DDD-ICD group (P = 0.2). There were 22 (31%) inappropriately treated episodes in the VVI-ICD group and 51 (69%) in the DDD-ICD group. Thirty-two of the 51 inappropriate episodes in the DDD-ICD patients resulted from intermittent atrial sensing problems that led to failure of the respective dual chamber algorithms. Nonfatal complications occurred in 6 (13%) patients in the VVI-ICD group and in 3 (6%) patients in the DDD-ICD group (P = 0.7). CONCLUSION: We conclude that the implanted DDD-ICD and conventional VVI-ICD are equally safe and effective for therapy of life-threatening ventricular tachyarrhythmias. Although DDD-ICDs allow better rhythm classification, the applied detection algorithms do not offer benefits in avoiding inappropriate therapies during supraventricular tachyarrhythmias.

Noncontact mapping-guided ablation of atrial flutter and enhanced-density mapping of the inferior vena caval-tricuspid annulus isthmus.

Three-dimensional visualization of cardiac activation has become important in providing further insights into pathophysiological mechanisms of arrhythmias and to increase the efficacy of catheter ablation. The noncontact mapping enables a single beat analysis in a reconstructed geometry of the cardiac chamber. The aim of the study was to describe three-dimensional activation patterns and inferior vena caval-tricuspid annulus (IVC-TA) isthmus conduction characteristics in patients with atrial flutter and the noncontact guidance of the radiofrequency ablation of this arrhythmia. In 34 patients with atrial flutter, the noncontact probe was deployed in the RA. The global three-dimensional activation and the isthmus conduction (enhanced density mapping) were delineated during ongoing a trial flutter and paced rhythms. Ablation was performed nonfluoroscopically based on reconstructed anatomy and conduction patterns. Noncontact mapping was compared and validated with conventional multielectrode technique. IVC-TA isthmus ablation was completed successfully in 33 (97%) of 34 patients. In one patient a lower loop reentry around the inferior vena cava was depicted as a mechanism of atrial flutter. In another patient with positive flutter waves in inferior leads, an activation pattern typical of counterclockwise flutter was demonstrated in propagation maps. During a follow-up of 15.9 +/- 5.9 months, two atrial flutter recurrences occurred (5.8%). A gap of the resumed conduction through the IVC-TA isthmus was delineated as a mechanism of recurrence and ablated with one and three radiofrequency applications. Noncontact mapping allows construction of the global activation patterns in typical and atypical atrial flutter. It enables the nonfluoroscopic guidance of atrial flutter ablation and a comprehensive evaluation of the ablation results.

Characterization of the putative chloride channel xClC-5 expressed in Xenopus laevis oocytes and comparison with endogenous chloride currents.

1. We recently cloned a putative chloride channel (xClC-5) from the renal cell line A6, which induced the appearance of a Cl- conductance not found in control oocytes after homologous expression in Xenopus oocytes. With the aim of increasing the Xenopus oocyte xClC-5 expression, we constructed a new plasmid in which the native 5' and 3' non-coding regions of xClC-5 were replaced by the non-coding regions of the Xenopus beta-globin sequence and in which a Kozak consensus site was introduced before the initiator ATG. 2. We then compared the induced currents Inative (induced by injection of cRNA presenting the native non-coding regions of xClC-5) and Ibeta-globin (induced by injection of cRNA presenting the non-coding regions of the Xenopus beta-globin sequence) investigating anion selectivity and anion blocker sensitivity. Several differences were found: (1) expression yield and oocyte surviving rate were largely increased by injecting (beta) xClC-5 cRNA, (2) the Ibeta-globin outward rectification score was 2.6 times that of Inative, (3) the anion conductivity sequence was nitrate > bromide > chloride > iodide >> gluconate for Ibeta-globin and iodide > bromide > nitrate > chloride >> gluconate for Inative, (4) 5-nitro-2-(3-phenylpropylamino)-benzoic acid (NPPB), anthracene-9-carboxylic acid (9-AC), DIDS, lanthanum ions, cAMP and ionomycin-induced [Ca2+]i increase inhibited Inative but had no effect on Ibeta-globin, and (5) Inative showed considerable similarity to the previously reported endogenous current appearing after ClC-6 or pICln cRNA injection. 3. Comparison of Inative with the endogenous chloride current ICl,swell which develops under hyposmotic conditions demonstrated several similarities in their electrophysiological and pharmacological characteristics but were nevertheless distinguishable. 4. In vitro translation assays demonstrated that protein synthesis was much greater using the (beta) xClC-5 construct than that of xClC-5. Furthermore, immunoreactivity of membrane preparations of Xenopus oocytes was only observed with the (beta) xClC-5 construct, its intensity being positively correlated with Ibeta-globin levels. 5. In addition, the current induced in (beta) xClC-5 cRNA-injected oocytes presented a very marked pH dependence (inhibition by acid external media) with a pKa value (negative log of the acid dissociation constant) of 5.67. 6. In conclusion, Ibeta-globin may be due to the presence of xClC-5 in the oocyte plasma membrane playing a role as an anion channel whereas Inative may represent an endogenous current induced by xClC-5 cRNA injection. The use of antibodies will facilitate the tissue and subcellular localization of xClC-5 and the identification of its physiological role.

Cloning and functional expression of a ClC Cl- channel from the renal cell line A6.

Cl- channels are important for ion transport and cell volume regulation in A6 renal cells. In the present study, we used reverse transcriptase (RT)-polymerase chain reaction (PCR) and rapid amplification of cDNA ends (RACE) to identify proteins homologous to ClC Cl- channel proteins in A6 cells. Using degenerate primers designed on consensus sequences for members of the ClC family, we amplified an RT-PCR product that had significant homology to the ClC sequences. RACE-PCR was then used to isolate several full-length clones that had total lengths from 2,764 to 3,016 base pairs. Although the coding regions were identical, sequence differences occurred in the 5' noncoding regions. The amino acid sequences of the clones had high homologies to rat and human ClC-5 (85 and 84%, respectively, if the 5th methionine of the open reading frame represents the start codon). Three parts of the protein (53, 80, and 63 amino acids in length) were 97-100% homologous to the mammalian sequences. Ribonuclease protection assay analysis revealed mRNA for this protein in oocytes, kidney, intestine, liver, brain, and blood, with lower amounts in stomach, muscle, and skin. Expression of the clones in Xenopus laevis oocytes resulted in an outwardly rectifying Cl- current that was inhibited by 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid and possessed an anion selectivity of I- > Cl- >> gluconate.

[Superfusion technique for studying the in vitro release of putative neurotransmitters from brain structures]. / Superfusionskammer zur in vitro-Bestimmung der Freisetzung putativer Neurotransmitter aus Hirnstrukturen.

The superfusion technique described enables a stimulus synchronous observation of release mechanisms by reason of the size of the perfusion chamber and by the arrangement of the medium supply. The presentation of the results allows a quantitative comparison of releasing activity also in case of different chemical or electrical stimulation conditions.