Economic recession, illicit drug use and the young population: a systematic literature review and meta-analysis.

AIMS: Economic recessions impact on drug use through different channels, with potential conflicting outcomes. Previous studies have reached mixed outcomes, and a clear and comprehensive picture is difficult to depict. METHODS: We use a systematic review of literature - conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines - and a hierarchical mixed-effects meta-analysis to provide a comprehensive quantitative assessment of the relationship between business cycle and the use of drugs by young populations. The heterogeneity of studies was assessed by the I2 statistic, and the publication bias was evaluated with contour-enhanced funnel plots. RESULTS: We identify 25 studies, published over the period 2008-2020. These articles carried out an empirical analysis of the impact of the business cycle on illegal drug consumption in Organisation for Economic Co-operation Development (OECD) countries. Most of the studies (17 studies) covered the 2007 financial crisis. Among the outcomes, 9 studies traced a countercyclical relationship between economic recessions and drug use, 3 showed a procyclical relationship and 13 studies found mixed results. Unemployment was the most widely used variable to assess macroeconomic conditions in most of the studies (21 studies). The meta-analysis shows a partial correlation of .03 (95% confidence interval (CI): .0147-.0453) between the unemployment rate and drug use among young individuals. Therefore, we conclude that, on average, recessions tend to boost drug use. This impact is more marked with cannabis use than it is with cocaine, opioids or other drugs. CONCLUSION: This study provides robust evidence that in periods of economic downturns, the young populations tend to increase the use of illegal drugs, with cannabis as their main preference. Therefore, in periods of economic severity, society may particularly benefit from implementing widely reaching public prevention programmes and demand reduction interventions, targeting this subgroup of the population.

Role of infarct scar dimensions, border zone repolarization properties and anisotropy in the origin and maintenance of cardiac reentry.

Cardiac ventricular tachycardia (VT) is a life-threatening arrhythmia consisting of a well organized structure of reentrant electrical excitation pathways. Understanding the generation and maintenance of the reentrant mechanisms, which lead to the onset of VT induced by premature beats in presence of infarct scar, is one of the most important issues in current electrocardiology. We investigate, by means of numerical simulations, the role of infarct scar dimension, repolarization properties and anisotropic fiber structure of scar tissue border zone (BZ) in the genesis of VT. The simulations are based on the Bidomain model, a reaction-diffusion system of Partial Differential Equations, discretized by finite elements in space and implicit-explicit finite differences in time. The computational domain adopted is an idealized left ventricle affected by an infarct scar extending transmurally. We consider two different scenarios: i) the scar region extends along the entire transmural wall thickness, from endocardium to epicardium, with the exception of a BZ region shaped as a central sub-epicardial channel (CBZ); ii) the scar region extends transmurally along the ventricular wall, from endocardium to a sub-epicardial surface, and is surrounded by a BZ region (EBZ). In CBZ simulations, the results have shown that: i) the scar extent is a crucial element for the genesis of reentry; ii) the repolarization properties of the CBZ, in particular the reduction of IKs and IKr currents, play an important role in the genesis of reentrant VT. In EBZ simulations, since the possible reentrant pathway is not assigned a-priori, we investigate in depth where the entry and exit sites of the cycle of reentry are located and how the functional channel of reentry develops. The results have shown that: i) the interplay between the epicardial anisotropic fiber structure and the EBZ shape strongly affects the propensity that an endocardial premature stimulus generates a cycle of reentry; ii) reentrant pathways always develop along the epicardial fiber direction; iii) very thin EBZs rather than thick EBZs facilitate the onset of cycles of reentry; iv) the sustainability of cycles of reentry depends on the endocardial stimulation site and on the interplay between the epicardial breakthrough site, local fiber direction and BZ rim.

Apelin plasma levels predict arrhythmia recurrence in patients with persistent atrial fibrillation.

Low levels of the regulatory peptide apelin have been reported in patients with lone atrial fibrillation (AF). We evaluate the potential utility of assessing apelin plasma levels as a predictor of AF recurrence in individuals presenting for electrical cardioversion. Plasma levels of apelin, brain natriuretic peptide (BNP) and high-sensitivity C-reactive protein were measured in 93 patients, with persistent AF before successful external electrical cardioversion. Significantly lower apelin plasma levels were found in patients with AF recurrence as respect to population with persistence of sinus rhythm during a six months follow-up. The hazard increased with duration of AF, left atrial dimension, BNP concentrations. Subjects with apelin levels below the median had a hazard ratio of 3.1 of arrhythmia recurrence with respect to those with high apelin levels (p<0.05). A significant difference in BNP levels was found between patients with and without AF recurrence during the follow-up. After adjusting for potential confounders, both BNP and apelin retained their statistical significance as independent predictors of arrhythmia recurrence. Patients with both low apelin and elevated BNP had a worse prognosis compared with those with either low apelin or elevated BNP alone. Low plasma apelin levels before external electrical cardioversion are an independent prognostic factor for arrhythmia recurrence in patients with AF treated with antiarrhythmic drugs. Apelin may be of particular value for the identification of high-risk patients in addition to BNP.

Catheter ablation and antiarrhythmic drugs for haemodynamically tolerated post-infarction ventricular tachycardia; long-term outcome in relation to acute electrophysiological findings.

AIMS: Radiofrequency catheter ablation is effective at terminating ventricular tachycardia, but the overall clinical role of the technique in patients with a prior myocardial infarction is still debated, due to the uncertainties of the long-term reliability of the procedure. The purpose of this study was to prospectively investigate the relationship between acute results obtained by catheter ablation and long-term outcome in a homogeneous population of patients with post-myocardial infarction ventricular tachycardia. METHODS AND RESULTS: One hundred and twenty-four consecutive patients with recurrent, drug-refractory, haemodynamically tolerated ventricular tachycardia were included in the study. This population accounted for 30% of the patients with post-myocardial infarction ventricular tachycardia admitted between April 1992 and September 1997 to the investigating centres. The ablation was successful in eliminating sustained ventricular tachycardia in 91 of them (73%); a partial result was obtained in 21 (17%) and failure in 12 (10%). Low dose amiodarone and/or beta-blockers were maintained in 86% of the patients. Over a median follow-up of 41.5 months (interquartile range 30.5-59.5 months), there were 15 deaths (12%), three of which were sudden (2.4%); the 12 remaining patients died of heart failure. Event-free survival analysis showed a significantly lower ventricular tachycardia recurrence rate in patients with a successful procedure as compared to those with failure or a partial result (19% vs 53% at one year and 27% vs 60% at 3 years, P=0.003). A repeat procedure was performed in 15 patients with early recurrences and was followed in all by long-term success. Of those who submitted to a second procedure, 93/124 patients (75%) are free of ventricular tachycardia recurrences. An implantable cardioverter-defibrillator (ICD), following procedure failure, was implanted in 13 patients (11%) of the study population. CONCLUSIONS: Radiofrequency catheter ablation is effective in a wide population of patients with recurrent tolerated ventricular tachycardia, with very low sudden death and cardiac mortality rates over the long-term. Persistent ventricular tachycardia inducibility after catheter ablation requires an ICD implant and/or repeat ablation.

Radiofrequency ablation in two patients with typical and atypical atrioventricular nodal reentrant tachycardias, associated with atrioventricular reentrant tachycardias.

The incidence of dual atrioventricular nodal physiology in patients with Wolff-Parkinson-White syndrome is quite frequent, but arrhythmia related to an accessory pathway and atrioventricular nodal reentrant tachycardia (AVNRT) in a single patient is less common. Two of our cases (patients aged 24 and 19 yrs) presented the rare evidence of both typical and atypical AVNRTs, associated in the first case with two other atrioventricular reentrant tachycardias (AVRTs), and in the second case with a single AVRT. Both underwent radiofrequency catheter ablation of the slow nodal pathway and of the accessory pathways in a single session, without any complications. After a 3-month follow-up, they were free from symptoms suggestive of tachycardia, without any antiarrhythmic treatment.

Trans-septal catheterization for radiofrequency catheter ablation of cardiac arrhythmias. Results and safety of a simplified method.

AIM: This study reports on the results and safety of a simplified method of trans-septal catheterization for radiofrequency catheter ablation of cardiac arrhythmias. METHODS AND RESULTS: Over 5 years, 411 patients underwent trans-septal catheterization for radiofrequency catheter ablation: 388 patients had a left-sided accessory pathway, 19 a left-sided focal atrial tachycardia, two atrial fibrillation and two post-infarction ventricular tachycardia. All but one patient with ventricular tachycardia underwent elective trans-septal catheterization. In the absence of a patent foramen ovale, puncture of the atrial septum was performed by using an 8F Mullins sheath and a Brockenbrough needle, according to the simplified method described in this paper. Trans-septal catheterization was accomplished in 383/388 patients (98.7%); in 41 patients a second trans-septal catheterization and radiofrequency catheter ablation was performed for initial failure or recurrence. Radiofrequency catheter ablation was successful in 96% of accessory pathway patients, 90% of atrial tachycardia patients, in both patients with atrial fibrillation and in both patients with ventricular tachycardia. No complication related to trans-septal catheterization was observed. CONCLUSION: In experienced hands and according to the method described in this paper, the elective use of transseptal catheterization for radiofrequency catheter ablation in a large cohort of patients with cardiac arrhythmias is feasible, safe and allows successful ablation in the vast majority of the patients.

Fast pathway ablation in a patient with iterative atrioventricular nodal reentrant tachycardia and prolonged PR interval.

A safe approach to radiofrequency catheter ablation is still unclear and not well defined in patients with AV nodal reentrant tachycardia and prolonged PR interval. In our study, a patient with iterative AV nodal reentrant tachycardia and prolonged PR interval underwent fast pathway radiofrequency catheter ablation. By mapping Koch's triangle, the earliest retrograde atrial activation area was localized. Radiofrequency energy was delivered here with the interruption of tachycardia with no complications.

[Transcatheter radiofrequency bundle branch ablation in bundle branch reentry ventricular tachycardia: report of a case]. / Ablazione transcatetere con radiofrequenza della tachicardia ventricolare da rientro tra le branche: descrizione di due casi.

Two patients with branch to branch ventricular tachycardia (BBVT) are reported: successful radiofrequency catheter ablation of BBVT was performed in both, delivering energy distally to the point where the maximum amplitude of His deflection occurred, so that a wide ventricular deflection was obtained without any atrial electrogram. No significant conduction delay appeared but a right bundle branch block. HV intervals during BBVT resulted equal or longer than in sinus rhythm: whether this was secondary to anatomical or functional variations or to the possibility that the His bundle may be "bystander" in BBVT, is discussed.

The role of catheter ablation in atrial tachycardia, flutter, and fibrillation.

The first experiences of nonpharmacological treatment of ectopic atrial tachycardia (EAT), common atrial flutter (AFl), and atrial fibrillation (AF) were performed by surgical techniques. Many studies reported a very high success rate on the use of catheter ablation with radiofrequency current for the treatment of supraventricular arrhythmias; and recently, various preliminary reports are dedicated to the treatment of EAT, AFl, and AF with that source of energy. To our knowledge 108 cases of EAT treated by catheter ablation of the ectopic focus are reported in the literature with a success rate superior to 90%. On the basis of our personal experience regarding 11 cases (4 of right atrium EAT and 7 of left) we discuss here the essential role of unipolar leads derived from the mapping catheter to select the target for radiofrequency applications. Two hundred and one cases of AFl tested by catheter ablation were previously reported. The majority of them (> 80%) were successfully treated with radiofrequency. Some working groups performed the procedure as the basis of electrophysiological findings, while others preferred an anatomical approach applying radiofrequency energy at the isthmus lying between the coronary sinus ostium and the tricuspid ring, near the vena cava orifice. On the basis of these assumptions, we obtained 83% of final success in 12 cases of AFl treated by radiofrequency. Finally, we discuss the problem related to the modulation of atrioventricular (AV) nodal conduction during AF. In our laboratory, five cases with chronic AF and very fast ventricular response were treated with radiofrequency with a posterior septal approach. In all patients, we obtained very encouraging results with a constant decrease of ventricular rate (from 137 +/- 33 to 69 +/- 14 beats per minute). All cases treated by modulation of AV nodal conduction demonstrated an appropriate chronotropic response to the variations of the functional state that persists during the follow-up. More experience with longer follow-up and accurate pre- and postprocedure evaluations are needed to finalize the most appropriate technique of radiofrequency applications in these cases.

Spontaneous incessant AV reentrant tachycardia related to left bundle branch block and concealed left-sided accessory AV pathway.

Three patients in whom permanent AV reentrant tachycardia became the clinical manifestation of Wolff-Parkinson-White syndrome are described. The substrate for the arrhythmia was created by coexistence of a concealed left-sided accessory pathway and an ipsilateral bundle branch block. Pharmacologic therapy in all three patients failed to control the tachycardia, which in two cases led to severe left ventricular failure. After successful radiofrequency ablation of the accessory pathway (in two) or AV junction (in one), left ventricular function gradually returned to normal.

[Atrioventricular reciprocating tachycardia with QRS type left branch block in patients undergoing radiofrequency catheter ablation: analysis of the substrate and mechanism of tachycardia]. / Tachicardia reciprocante atrioventricolare con QRS tipo blocco di branca sinistra in soggetti da sottoporre ad ablazione transcatetere mediante radiofrequenza: analisi del substrato e del meccanismo della tachicardia.

BACKGROUND: Among patients (pts) with atrioventricular accessory pathway (AP), some cases show wide complex arrhythmias with different QRS morphology. In a subset of these pts, an atrioventricular reentrant tachycardia with left bundle branch block morphology (LBBBM-AVRT) is observed. The aim of this study is: 1) to identify the substrate and the reentrant mechanism underlying the LBBBM-AVRT in pts undergoing radiofrequency catheter ablation (RFCA) of AP; 2) to report the results achieved by RFCA of the identified substrate. METHODS: From May 1991 to April 1993, among the 168 pts who underwent RFCA for arrhythmias related to an AP, 12 (7.1%) (8M, 4F, mean age 35 +/- 21 yrs, range 8-65) showed LBBBM-AVRT, alone or associated with other arrhythmias. Pts, in whom LBBBM was rate-related during orthodromic AVRT, were excluded from this study. During sinus rhythm, QRS complex was normal in 1 pt, while ventricular preexcitation due to a right-sided Kent bundle (KB) was present in 4 pts; among the other pts without preexcitation, 3 showed left bundle branch block (LBBB) and 4 right bundle branch block. In 2 pts, an Ebstein disease was present, while dilated cardiomyopathy was observed in another. The LBBBM-AVRT was iterative in 3 pts and in 6 pts it was the only arrhythmia observed; the mean tachycardia cycle length was 341 +/- 49 msec (range 250-428). In 1 pt, the LBBBM-AVRT was induced only after successful RFCA of a right-sided AP, responsible for orthodromic AVRT. All pts underwent diagnostic electrophysiologic study and RFCA during the same session. RESULTS: In 6/12 pts one or more KBs were observed, while in the remaining 6 an atrioventricular or atriofascicular "Mahaim like" bundle (MB) was present; the patient population was divided into 4 groups on the basis of the substrate and the reentrant mechanism responsible for LBBBM-AVRT. In Group 1, 3 pts were included: the LBBBM-AVRT was an orthodromic AVRT involving the nodal conduction antegradely (showing LBBB also during sinus rhythm) and a left-sided unidirectional KB, retrogradely. In all the 3 pts, the LBBBM-AVRT was iterative and not controlled by antiarrhythmic agents and RFCA of the KB abolished the arrhythmia. Two further pts were included in Group 2: in these pts with multiple bilateral KBs, the LBBBM-AVRT involved a right-sided KB antegradely and a left-sided one, retrogradely. In these 2 pts both KBs were successfully ablated. In 1 pt, considered in Group 3, the LBBBM-AVRT was sustained by an antidromic circuit involving a right-sided KB antegradely and the nodal conduction retrogradely; in this pt the KB was completely interrupted after two RFCA procedures. The remaining 6 pts with MB were included in Group 4: at least one associated electrophysiologic abnormality was present in all (dual A-V nodal pathway in 4/6 and a right-sided KB in 4/6); Ebstein disease was also observed in 2 of them. In 4/6 pts the LBBBM-AVRT was an antidromic tachycardia involving the nodal conduction retrogradely and the MB antegradely; in 3/4 pts the MB was ablated (along with a nodal reentrant tachycardia in 1 pt), while in the remaining pt in whom the non-sustained LBBBM-AVRT, inducible only after RFCA of a right-sided KB, had not been clinically observed, no further ablation was mandatory. In the remaining 2 pts in Group 4, the LBBBM-AVRT was due to the involvement of MB in other arrhythmias such as an AVRT due to a right-sided KB and a "slow-slow" nodal reentrant tachycardia, respectively; the LBBBM-AVRT were abolished by RFCA of these two underlying arrhythmias. All pts are asymptomatic during a 7.9 +/- 6.9 months follow-up. CONCLUSIONS: The LBBBM-AVRT is observed in a minority (7.1%) of the cases referred for RFCA of AP. (ABSTRACT TRUNCATED)

[Radiofrequency catheter ablation in patients with Mahaim-type slow-conduction accessory right atrioventricular pathway]. / Ablazione transcatetere mediante radiofrequenza in pazienti con via anomala atrioventricolare destra a conduzione lenta tipo Mahaim.

In some cases undergoing radiofrequency catheter ablation (RFCA) of accessory pathway (AP), a Mahaim-like right-sided atrioventricular AP (M-AP) showing slow and decremental conduction is observed. Among 200 consecutive patients referred to our Institution up to September 1993 for arrhythmias related to an AP and undergoing RFCA, 8 patients (6 males, 2 females; mean age 24 +/- 8 years, range 8-35) showed a M-AP. Seven out of 8 patients have been complaining episodes of palpitation for 13 +/- 7 years (range 1-20), while 1 subject was an asymptomatic young athlete. In 2/8 patients an Ebstein disease (Eb) was present and they had previously undergone right-sided Kent bundle (Kb) ablation elsewhere. During sinus rhythm, QRS was normal in 1 patient, while it showed ventricular preexcitation due to right-sided Kb in 3 patients and right bundle branch block in another 4 patients. A left bundle branch block morphology (LBBBM) reentrant tachycardia (RT) was observed in 7 patients (in 1, only after RFCA of a right-sided Kb); 3 showed also orthodromic RT. In the asymptomatic young athlete, a preexcitation atrial fibrillation with very rapid ventricular response was inducible. All patients underwent diagnostic electrophysiologic (EP) study and RFCA in the same session. In 2/8 patients M-AP was manifest only after right-sided Kb RFCA. In all patients, associated EP abnormalities were noted: in 5/8 patients a dual A-V node pathway was present and in 5/8 patients 6 right-sided Kbs were associated. Patients have been divided in 3 groups, according to the mechanism involving the M-AP in the RT. In the 2 Group I patients showing also Eb, antidromic LBBBM RT and orthodromic RT involving the M-AP anterogradely and retrogradely, respectively, were observed; both arrhythmias were abolished by ablating the M-AP. The 3 Group II patients showed only antidromic LBBBM RT, involving a fast A-V node pathway retrogradely; also in these patients, the M-AP was the target of RFCA. This was performed only in 1 patient, in whom A-V node RT was also observed and ablated after RFCA of M-AP; as to the other 2 patients, in 1 the ablation of M-AP was not considered mandatory, since it was responsible for inducible not sustained LBBBM RT observed only after RFCA of a Kb in the same EP session, while in the other it was not possible because of a prolonged traumatic conduction block through the M-AP.(ABSTRACT TRUNCATED AT 400 WORDS)

[New perspectives in the ablation of ectopic atrial tachycardia and atrial flutter]. / Nuove prospettive dell'ablazione nella tachicardia atriale ectopica e nel flutter atriale.

The first experiences on non-pharmacological treatment of ectopic atrial tachycardia (EAT) and common atrial flutter (AFl) were performed by surgical techniques. The surgical abolition of EAT comprised the isolation, the excision or the cryoablation of the ectopic atrial foci using electromapping guide. The AFl was treated by extensive cryoablation of the slow conduction area responsible for the macroreentrant process located in the infero-posterior part of the right atrium (RA). Transcatheter ablation with DC-shock for the treatment of EAT was proposed in 1985 but the technique did not gain wide acceptance due to its risks. The same method was utilized for the treatment of AFl since 1987. Many preliminary studies reported on the use of transcatheter ablation with radiofrequency (RF) current as an energy source since 1992 and no major complications were encountered. According with our knowledge, 81 cases of permanent or iterative EAT were treated by RF in the world with a primary success rate superior than 90%. The low rates of recurrence are reported very early (within 24-48 hours) after the procedure; recurrencies are very easy to recognise and they are successfully ablated in a second session. Cases of EAT due to an ectopic focus localized in the RA are ablated from the superior or inferior vena cava approaches and cases of EAT related to a left atrial (LA) ectopic focus by a trans-septal approach (persistent foramen ovale or atrial septum puncture). On the basis of our personal experience regarding 7 cases (4 LA and 3 RA foci) the role of unipolar leads derived from the mapping catheter appears essential to select the target for RF applications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Radiofrequency transcatheter ablation of anomalous left atrioventricular pathways: the role of the transseptal approach]. / Ablazione transcatetere mediante radiofrequenza delle vie anomale atrioventricolari sinistre: ruolo dell'approccio transettale.

BACKGROUND AND METHODS: In this study we used two different approaches in radiofrequency catheter ablation (RFCA) of the left free wall atrioventricular accessory pathway (AP): the retrograde transaortic (TAo) approach and the transseptal (TSA) one. Our aim was to evaluate the success rate and the duration of the two procedures. From May 1, 1991 to April 30, 1992, 33 pts (23 M, 10 F; mean age 38 +/- 16 years, range 14-66) with left free wall atrioventricular AP were selected among a 57 patient population, in which RFCA was performed for arrhythmias related to the AP. In 20/33 pts (61%) stable ventricular pre-excitation was present, while in 4/33 (12%) it was intermittent; in the remaining 9/33 pts (27%) only retrograde conduction through the AP was documented. In the majority of the pts (26/33) a diagnostic electrophysiologic study was performed immediately before the ablation procedure, during the same EP test. A 7 F steerable large tip catheter was used for energy delivery. In 8/33 pts, RFCA was performed by using only the TAo approach; other 7/33 pts underwent RFCA with a TSA technique after one completely unsuccessful retrograde TAo ablation and, in the remaining 18/33 pts, the TSA approach was used electively and continuously from January 1992. Overall, the TAo procedure has been carried out in 15 cases, while the TSA one in 25 cases. In the latter group, the ablation catheter was positioned against the left atrioventricular groove through a patent foramen ovale in 5/25 cases (20%), while a TSA puncture was needed in the remaining 20 cases. After successful ablation, the observation period was prolonged up to 60 min. RESULTS: Complete AP ablation was achieved in 31/33 pts (94%), while the remaining 2 pts underwent surgical cryo-ablation after unsuccessful TAo procedure. Among the three different subsets of pts, the success rate was as follows: 40% (6/15 cases) by using TAo technique, 100% (7/7 cases) by TSA after one unsuccessful attempt with the TAo technique, and 94% (17/18 cases) after single elective TSA; in the only case where the first elective TSA procedure failed, a second attempt was successful. The duration of the whole electrophysiologic test was 4.0 +/- 1.3 hours for the TAo approach vs 3.3 +/- 0.9 hours for the TSA one (p < 0.05). The mean fluoroscopy time was significantly (p < 0.05) shorter in pts who underwent elective TSA (43 +/- 27 min), than in pts who underwent only TAo approach (68 +/- 42 min) or both TAo and TSA approach (157 +/- 54 min). No complication during or after the procedure was observed in any case. CONCLUSIONS: In RFCA of left free wall atrioventricular APs, the TSA approach seems to be as safe as the TAo approach. In this preliminary experience, the success rate and the short duration of single elective TSA procedure suggest that this can be used as a first-choice approach in these pts.

[Transcatheter radiofrequency modulation and ablation of the atrioventricular junction in supraventricular arrhythmias refractory to medical therapy]. / Modulazione e ablazione transcatetere mediante radiofrequenza della giunzione atrioventricolare in aritmie sopraventricolari refrattarie alla terapia medica.

In patients with supraventricular tachyarrhythmias refractory to medical therapy, transcatheter ablation (TA) is necessary. From January 1990, in 27 patients with nodal tachycardia and 6 with atrial fibrillation or flutter, referred to our institution for electrophysiologic evaluation, TA by radiofrequency (RF) was performed, respectively for atrioventricular (AV) junction modulation and total AV junction ablation. In all these cases, a total refractoriness to several antiarrhythmic drugs alone or in combination had been observed. The RF current, generated by the Osypka HAT 100 device, was administered through a tripolar USCI 7 F catheter. The ideal site for energy delivery was defined on the basis of a mapping, performed in the AV junction area to find out the most premature retrograde atrial activation. Local atrial activation time was evaluated during nodal tachycardia by delivering a premature ventricular extrastimulus to discover the atrial deflection from the ventricular one. In the selected area, 5 applications (range 1-12) of 20-25 W power RF energy for 5-30 s were delivered on average. A complete prevention of nodal tachycardia was achieved in 26/27 patients (96.2%). Only in 2 patients (7.4%) a total AV block was induced. The pre- and post-procedure values are as follows: AH = pre 71 +/- 18, post 113.2 +/- 53; HV = pre 46.4 +/- 8, post 48 +/- 7; anterograde Wenckebach point = pre 352 +/- 56, post 389 +/- 91; retrograde Wenckebach point = pre 338 +/- 75, post 419 +/- 61. In 13/27 cases the AH interval was normal after RF application. The retrograde conduction was worsened in all patients and totally abolished in 12/27.(ABSTRACT TRUNCATED AT 250 WORDS)

[Indications and results of transcatheter ablation and surgery in paroxysmal reentry nodal tachycardia]. / Indicazioni e risultati dell'ablazione transcatetere e della chirurgia nelle tachicardie parossistiche da rientro "nodale".

In patients with nodal tachycardia refractory to medical therapy, transcatheter or surgical ablation is necessary. From January 1989 to December 1990, in 26/42 patients with nodal tachycardia, referred to our institution for electrophysiologic evaluation, transcatheter ablation by radiofrequency (20 patients) or surgical ablation by perinodal cryo (6 patients) was performed. In all these cases, a total refractoriness to several antiarrhythmic drugs alone or in association had been observed. The radiofrequency current, generated by the Osypka HAT 100 device, was administered through a tripolar USCI 7 F catheter. The ideal site for energy delivery was defined on the basis of a mapping, performed in the A-V junction area. In order to find out the most premature retrograde atrial activation, the following areas were explored: right bundle, atrial His bundle, peri-nodal region, proximal His bundle and coronary sinus ostium. Local atrial activation time was evaluated during nodal tachycardia by delivering a premature ventricular extrastimulus to discover the atrial deflection from the ventricular one. In the selected area, 5 applications (range 1-12) of 20-25 W power radiofrequency energy for 5-30 s were delivered on average. A complete prevention of nodal tachycardia was achieved in 18/20 patients (90%). Only in 2 patients a total A-V block was induced. The pre- and post-procedure values are as follows: AH: pre 71 +/- 19, post 113.6 +/- 50; HV: pre 45.5 +/- 8, post 47 +/- 6; aWP: pre 353 +/- 57, post 391 +/- 87; rWP: pre 322 +/- 58, post 411 +/- 58. In 10/18 cases the AH interval was normal after radiofrequency application.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperventilation and ergonovine tests in Prinzmetal's variant angina: comparative sensitivity and relation with the activity of the disease.

Hyperventilation (HV) and ergonovine (E) tests were carried out in a group of 32 patients with variant angina to compare their sensitivity and to correlate the results with the activity of the disease. The HV test was positive in 84% of the patients and E in 94% of them; the percentage of positive responses to HV was similar to that to E (96% vs 100%) in the patients with daily attacks, while it was lower (55% vs 77%) in those with sporadic attacks. All 27 patients with a positive HV also had a positive response to E, while of the five patients with a negative HV, two also had a negative response to E and the other three had a positive E at a higher dose than that of the patients with daily attacks. The incidence of chest pain and of ST-segment elevation or depression or T-wave positivization was similar during the two tests; however, spontaneous remission of ischaemia was more frequent after HV than after E and ventricular arrhythmias less frequent during the HV test. At the onset of myocardial ischaemia pH was significantly higher compared with basal values (7.51 +/- 0.07 vs 7.38 +/- 0.05, P less than 0.001), while double product was not significantly different compared with basal (10.0 +/- 2.4 vs 9.2 +/- 2.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrinopeptide A levels in patients with acute ischaemic heart disease.

Fibrinopeptide A (FPA) levels were determined in 40 consecutive patients admitted to the coronary care unit with a typical history of chest pain: in 24 of them a diagnosis of acute myocardial infarction (AMI) and in 16 a diagnosis of angina was made. Seven of the patients with AMI suffered from recurrent episodes of early post-infarctional angina. FPA levels were determined in each patient on admission and every 4 h for 48 h. On admission in patients with both angina and AMI the FPA levels were significantly higher than in normal controls; these levels were higher in patients with AMI than in those with angina, but this difference was not significant. In patients with angina the values decreased progressively after 12 h to baseline values, while in those with AMI the high levels of FPA persisted throughout the 48-hour observation period. In many instances, particularly after 24 h, the differences between the two groups were statistically significant. In patients with early post-infarctional angina the episode of angor was preceded by or corresponded to a new great elevation of FPA levels. These data suggest that the thrombin generation is higher and more prolonged in patients with AMI than in those with angina; the determination of FPA levels, which are an index of 'in vivo' thrombin generation, can be useful to follow the clinical course of ischaemic heart disease.