Coved-type ST-elevation during ablation of ischemic ventricular tachycardia.

A coved-type electrocardiogram (ECG) change in Brugada syndrome is suggested to be the result of abnormally delayed depolarization over the right ventricular outflow tract; however, ischemia of the conus branch of the right coronary artery presents the same ECG change. A 63-year-old man with a history of myocardial infarction demonstrated a transient coved-type ECG change during catheter ablation of ventricular tachycardia. The ECG change appeared during left ventricular mapping without any chest symptoms, and recovered spontaneously. A pilsicainide test was negative and a coved-type ECG did not appear during the perioperative or follow-up period.

A potential pitfall of the modified 12 lead electrocardiogram (Mason-Likar modification) in catheter ablation of idiopathic ventricular arrhythmias originating from the outflow tract.

AIMS: The Mason-Likar modified electrocardiogram (ML-ECG) can be interchanged with standard 12 lead ECG electrode positions (standard ECG) without affecting the diagnostic interpretation during sinus rhythm, but the morphological differences during ventricular arrhythmias have not been sufficiently evaluated. This study aimed to elucidate the morphological changes in the ML-ECG precordial leads. METHODS AND RESULTS: In 53 consecutive patients with premature ventricular contractions predicted to originate from the outflow tract (OT-PVCs), the arrhythmias were analysed by those two ECG methods. The OT-PVC origin sites, which were predicted by currently published criteria with the respective ECG methods prior to catheter ablation, were compared with the successful ablation sites. Compared with the standard-ECG, S-waves in the ML-ECG became shallower in leads V1-4 (P < 0.05 in lead V1; P < 0.001 in leads V2-4), and pseudo-R-waves in lead V1 appeared in seven patients. The precordial leads transition zone shifted counter-clockwise in 18 patients in the ML-ECG. In leads I and aVL, the negative deflection amplitudes of the ML-ECG were greater than those of the standard ECG (P < 0.001), and polarity reversals in lead I appeared in 18 patients. The R-wave amplitudes in all ML-ECG inferior leads were greater than those in the standard-ECG leads (all for P < 0.001). Those changes had an effect on the diagnostic indexes for the localization, and the specificity of the criteria for the ML-ECG was poorer than that for the standard-ECG. CONCLUSION: Great differences were found between those two ECG methods. Predicting OT-PVC origins by diagnostic criteria with the ML-ECG might result in a misdiagnosis and inefficient ablation.

The influence of the external structures in atrial fibrillation patients: Relationship to focal low voltage areas in the left atrium.

INTRODUCTION: Left atrial (LA) low voltage areas (LVAs) are suggested as an important factor for maintaining atrial fibrillation (AF). The relationship between focal LVAs and anatomical contact is still unclear. METHODS: Thirty paroxysmal AF (PAF) and 30 persistent AF (PsAF) patients underwent high density voltage mapping during sinus rhythm before any radiofrequency applications were performed. The relationship between the LVA (<0.5mV) and contact area (CoA) demonstrated by enhanced CT and the distance to near external structures were investigated. RESULTS: The anterior region, posterior wall and left pulmonary vein (LPV) antrum were the three most frequent LVA sites that corresponded to CoA sites, and LVAs mostly overlapped with CoAs (PAF 47/61: 77%, PsAF 63/74: 85%). In the PAF group, patients with posterior-LVAs had a shorter distance to the vertebrae than those without (2.8 ± 1.1 vs. 4.4 ± 1.9 mm; P=0.0086). The distance to the vertebrae was the only predictive factor of the existence of a posterior-LVA and the cut-off value was ≤2.9 mm (P<0.0001). Similarly, an LPV-LVA also had the same results (2.0 ± 0.5 vs. 2.7 ± 0.8mm, P=0.0127) and the cut-off value was ≤2.6mm (P=0.0391). In contrast, the PsAF patients had no difference in the distance when compared to the existence of an LVA. CONCLUSIONS: Anatomical CoAs demonstrated a spatial relationship to the LVAs in AF patients. In PAF patients, the distance to near external structures in the posterior region was a predictive factor for the existence of an LVA and may have had some influence on maintaining AF, while in PsAF patients no relationship was suggested.

Influence of left atrium anatomical contact area in persistent atrial fibrillation-relationship between low-voltage area and fractionated electrogram.

BACKGROUND: Atrial low-voltage areas are suggested to be related to maintenance of atrial fibrillation (AF). The influence of the left atrium (LA) contact area (CoA) has not been investigated. METHODS AND RESULTS: Twenty-two persistent AF patients underwent high-density mapping during AF and sinus rhythm (SR). Three representative CoA regions in the LA (ascending aorta: anterior wall; descending aorta: left inferior pulmonary vein [LIPV]; and vertebrae: posterior wall) were identified. Electrogram analysis of both high dominant frequency (high-DF; >8 Hz) and complex fractionated atrial electrogram (con-CFAE; <50 ms) regions during SR was done. The anatomical relationship between CoA and both the very low-voltage areas (vLVA; <0.2 mV) and high-frequency sources was determined. Forty-seven vLVA (194.4 cm(2)) and 60 CoA (337.0 cm(2)) were documented, and 32 vLVA directly overlapped CoA. The vLVA were preferentially found in the anterior (45%) and posterior (13%) walls of the LA, and in the LIPV (13%), and corresponded to CoA sites. The mean voltage during SR at high-DF sites was significantly lower than that at con-CFAE sites (0.62 vs.1.54 mV; P<0.0001). Seventy-two percent of high-DF sites overlapped CoA, while 54% of con-CFAE did. Furthermore, 44% of high-DF surface area directly overlapped CoA, while only 19% of con-CFAE did. CONCLUSIONS: Very low-voltage regions had a strong association with CoA. Sites with CoA had a higher incidence of fractionated electrograms both during SR and AF.

Palladium-catalyzed α-ketocyclopropanation of norbornenes with propargyl acetates.

Propargyl acetates reacted with norbornene in the presence of a catalytic amount of tetrakis(tripheylphosphine)palladium to give cyclopropyl ketones. The reaction proceeded with high stereoselectivity, affording a single stereoisomer. The reaction of various substituted norbornenes gave the corresponding cyclopropanes in moderate to good yields.

Substrate modification by adding ablation of localized complex fractionated electrograms after stepwise linear ablation in persistent atrial fibrillation.

PURPOSE: Linear left atrial (LA) ablation in patients with persistent atrial fibrillation (PsAF) resulting in the elimination of most complex fractionated electrogram (CFE) sites has been demonstrated. This study was designed to evaluate the impact of a localized CFE ablation in addition to a representative linear LA ablation in patients with PsAF. METHODS: A total of 40 consecutive patients with PsAF underwent construction of CFE and dominant frequency (DF) maps using NavX. A stepwise linear ablation including at the PV antra, septum, roof, mitral annulus, and ridge of the appendage was performed followed by additional ablation of localized CFEs detected by an automatic algorithm. RESULTS: A significant reduction in the continuous CFE burden (<50 ms) after the linear ablation (69 vs. 21 %; P < 0.0001) was confirmed, and localized CFEs (40-120 ms) were observed with a significant predilection for the anterior (30 %), posterior (30 %), and inferior LA (38 %) regions (P < 0.01). Comparing the localized CFEs with higher frequency sources, 45 % (70/156) of the localized CFE sites included continuous CFE regions, and 59 % (92/156) of those sites overlapped with the high-DF sites (>8 Hz). Additional localized CFE-targeted ablation further terminated PsAF in 20 % of the patients and further increased the mean CFE cycle length (110 ± 31 to 125 ± 39 ms; P = 0.0033) and decreased the DF (6.0 ± 0.8 to 5.7 ± 0.7 Hz; P = 0.0013) within the CS. CONCLUSIONS: The presence of localized CFE sites with a predilection for particular LA regions after a representative linear LA ablation could provide the optimal sites for selective substrate modification of the atrial fibrillation substrate in patients with PsAF.

Optimal observation time after completion of circumferential pulmonary vein isolation for atrial fibrillation to prevent chronic pulmonary vein reconnections.

PURPOSE: To identify predictors of chronic pulmonary vein (PV) reconnection (CPVR) after successful circumferential PV isolation (CPVI) for atrial fibrillation (AF). MATERIALS AND METHODS: A total of 718 PVs from 181 consecutive AF patients (141 males, median age 61 years, 92 paroxysmal AF) who underwent a second ablation procedure for recurrent AF were retrospectively analyzed. RESULTS: During the second procedure, a CPVR was observed in 477 PVs (66.4%) among 169 patients. In a multiple logistic regression analysis, the observation time after the final completion of the PVI (OT-final) was a significant negative predictor (odds ratio 0.980; P<0.001). A receiver operating characteristic analysis demonstrated that the greatest area under the curve was for the OT-final (0.670). At an optimal cutoff of 35 min, the sensitivity and specificity for predicting a CPVR were 66.9% and 60.6%, respectively. By Kaplan Meier analysis, CPVR was more frequent in PVs with an OT-final of <35 min than ≥35 min (log-rank test, P=0.018). In a vessel-by-vessel analysis, the OT-final at all PV sites was a significant negative predictor, while male gender in the right PVs and left-inferior PV, number of RF applications for the ipsilateral CPVI in the right PVs and left-superior PV, and major PV diameter in the left-superior PV were significant positive predictors of a CPVR (all P<0.05). CONCLUSIONS: An optimal observation time (≥35 min in this study) to determine whether PVI is successfully completed during the initial CPVI for AF may be needed to prevent a CPVR and subsequent AF recurrence thereafter.

Efficacy and safety of periprocedural dabigatran in patients undergoing catheter ablation of atrial fibrillation.

BACKGROUND: Periprocedural anticoagulation using uninterrupted warfarin could reduce the risk of thromboembolic complications of atrial fibrillation (AF) ablation. Few studies, however, have evaluated the efficacy and safety of periprocedural dabigatran in AF ablation. METHODS AND RESULTS: A total of 211 consecutive patients who underwent AF ablation, including 110 patients who received 110mg dabigatran twice daily (group D) and 101 patients who received dose-adjusted warfarin (international normalized ratio, 2.0-3.0; group W), were evaluated. Dabigatran was discontinued on the morning of the procedure, and resumed on the next morning. Warfarin was continued throughout the procedure. During the procedure, heparin infusion was maintained to achieve an activated clotting time of >300s. Postprocedural cerebral magnetic resonance imaging (MRI) was performed in 60 patients (group D, n=31; group W, n=29). No periprocedural deaths or symptomatic thromboembolic complications were observed in either group. MRI indicated a silent cerebral infarction in 1 patient in each group. Five patients in group D and 11 in group W had minor bleeding (P=0.12). Cardiac tamponade occurred in 2 patients in group W, but in none in group D. Total bleeding complications occurred less frequently in group D (4.5%) than in group W (12.9%; P<0.05). CONCLUSIONS: Dabigatran at a dose of 110mg twice daily was safe for AF ablation in patients with a relatively low risk of thromboemboli, suggesting that it may become an alternative to warfarin in those patients.

Palladium-catalyzed selective cross-addition of triisopropylsilylacetylene to internal and terminal unactivated alkynes.

Dinuclear and mononuclear palladium complexes having N,N'-bis[2-(diphenylphosphino)phenyl]amidinate (DPFAM) as a ligand catalyzed the cross-addition of triisopropylsilylacetylene (TIPSA) to unactivated internal alkynes, giving enynes selectively. When palladium catalysts having PPh3, TDMPP, dppe, or dppf were used, dimers of TIPSA were obtained as major products. The reactions of TIPSA with several terminal alkynes also gave cross-adducts selectively, although the yields were moderate.

Intermolecular and intramolecular, platinum-catalyzed, acceptorless dehydrogenative coupling of hydrosilanes with aryl and aliphatic methyl C-H bonds.

Intermolecular acceptorless dehydrogenative coupling of silanes with arene C-H bonds and intramolecular coupling of silanes with aryl and alkyl C-H bonds occur in good yield in the presence of 5 mol % of TpMe2PtMe2H (TpMe2 = hydridotris(3,5-dimethylpyrazolyl)borate) and related platinum(IV) complexes. The intermolecular reactions of arenes occurred with both trialkyl and dialkylaryl silanes. Intramolecular reactions of dialkylsilylalkylarenes occurred at aryl C-H bonds, and reactions of tributylsilane or dibutylphenylsilane occurred intramolecularly at the aliphatic, primary C-H bond. The reactions of arenes occurred preferentially at the least sterically hindered C-H bonds and preferentially with more electron-poor arenes. Crossover experiments and the lack of reactivity of the arylsilanes with H2 imply that the dehydrogenative silylation of arenes can be irreversible, even in a closed reaction vessel.

Palladium-catalyzed allylic alkenylation of allylic alcohols with n-butyl acrylate.

Various allylic alcohols reacted with n-butyl acrylate in the presence of p-toluenesulfonic anhydride and palladium catalysts to yield the corresponding n-butyl 2,5-dienoates with high regioselectivity.

Stereoselective cis-addition of aromatic C-H bonds to alkynes catalyzed by dinuclear palladium complexes.

Reactions of alkynes with arenes proceeded in the presence of dinuclear palladium complexes and trialkylboranes to yield alkyne hydroarylation products with high stereoselectivity. In the reactions of monosubstituted benzenes, meta and para products were formed in statistical ratios, while no ortho isomers were detected.

Palladium-catalyzed benzannulation from alkynes and allylic compounds.

Various alkynes reacted with allyl tosylates in the presence of palladium catalysts, giving polysubstituted benzenes with good to high regioselectivity. Pentasubstituted and trisubstituted benzenes were readily prepared by reaction of internal alkynes and terminal alkynes, respectively. The combination of allyl alcohols and p-toluenesulfonic anhydride could be utilized in place of isolated allyl tosylates. The cyclization of diynes with allyl tosylate afforded bicyclic compounds containing an aromatic ring.