Role of CMR-derived atrial deformation analysis in the prediction of atrial fibrillation recurrence rate after pulmonary vein isolation.

PURPOSE: Left atrial (LA) dimensions have been identified as anatomical predictors for atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). The value of LA function compared to pure LA anatomical risk prediction for AF recurrence after PVI is not well investigated. Cardiovascular magnetic resonance (CMR) is able to simultaneously assess LA anatomical, tissue and functional markers within one examination. The hypothesis of this explorative study was that CMR-derived LA strain has incremental value for the prediction of AF recurrence after PVI. METHOD: Fifty-two patients with paroxysmal or persistent AF were retrospectively enrolled for CMR (1.5T) prior to PVI. Strain-analysis was derived from standard cine images in 4-, 3- and 2-chamber view. LA function was divided into LA reservoir strain and strain rate (εs and SRs), LA conduit (εe and SRe) and LA booster pump function (εa and SRa). The primary endpoint was recurrence of AF within one year after PVI. RESULTS: Twelve patients (23 %) presented with AF recurrence. There was no difference in age, LA size as well as LA sphericity index between the groups. Patients with AF recurrence (68.3 ± 5.5 years, 66 % male) showed significantly reduced LA booster pump function compared to the patients without AF recurrence (66.3 ± 10.5 years, 50 % male) (εa: p = 0.015; SRa: p = 0.036). In binomial logistic regression analyses, the only predictor for AF recurrence after PVI was εa (p = 0.033). CONCLUSIONS: In this descriptive study, impaired LA booster pump function predicted AF recurrence one year after PVI. Compared to further LA strain and anatomical parameters, LA booster pump might serve as additional predictor of AF recurrence.

CMR-guidance of passively tracked endomyocardial biopsy in an in vivo porcine model.

Endomyocardial biopsy (EMB) is considered to be the diagnostic gold-standard in detection of myocardial-inflammation. EMB is usually conducted under fluoroscopy without any specific target information. Specific target-information provided by cardiovascular magnetic resonance (CMR) may improve specificity of EMB. The aim was to investigate feasibility and safety of CMR-guided and targeted EMB in a preclinical-model using passively-tracked devices. Procedures were performed on a MRI-System equipped with an Interventional Software-Platform for real-time imaging. Ex vivo experiments were conducted to optimize visibility of the guide-sheath. In vivo experiments were conducted in 2 pigs for technical feasibility assessment and in 4 pigs after acute myocardial infarction to test feasibility of guided and lesion targeted EMB. For anatomical real-time imaging a single-shot-balanced-SSFP-sequence was applied. Myocardial targets were identified under real-time imaging (single-shot-T2 (sshT2) and single-shot Late-Gadolinium-Enhancement (sshLGE) sequences). Ex vivo experiments demonstrated best visibility of continuously labelled guide-sheath. CMR-guided EMB was feasible in all cases without major complications. Likewise, lesion-targeting endomyocardial biopsy was feasible in two cases. Biopsies exhibited appropriate sizes and qualities. Real-time lesion sequences revealed comparable CNR values to clinical-protocols. Real-time imaging of lesions showed following signal- and contrast-to-noise ratios (SNR/CNR): SNR of sshT2- and sshLGE was 124 ± 35 and 67 ± 51 respectively, whereas CNR was 81 ± 30 and 57 ± 44. This study demonstrates feasibility and safety of CMR-guided and basically targeted EMB with passively-tracked devices. Signal-to-noise ratios of real-time sequences is non-inferior to standard sequences for lesion detection. CMR-guidance may improve diagnostic accuracy of EMB since CMR can detect myocardial-targets under real-time-imaging.

Role of T2 mapping in left ventricular reverse remodeling after TAVR.

BACKGROUND: Patients with severe aortic stenosis (AS) are subjected to left ventricular hypertrophy (LVH) with increasing morbidity and mortality. Transcatheter aortic valve replacement (TAVR) induces reverse left ventricular remodeling which can be monitored by cardiovascular magnetic resonance (CMR). CMR is able to analyze myocardial tissue properties by magnetic relaxation times (parametric CMR). The objective of this study was to study myocardial T2 relaxation in reverse ventricular remodeling after TAVR. METHODS: Forty-three patients with severe AS (19 males, 81.9 ±â€¯4.9 years) underwent CMR with T2 mapping before and 6 months after TAVR. A cohort of age- and gender-matched volunteers served as controls. Analyzed parameters included left ventricular ejection fraction (LV-EF), mass indexed to body surface area (LVMi), interventricular septum thickness (IVS), end-diastolic volume (LVEDV), global longitudinal strain (GLS), peak diastolic strain rate (SRe) and myocardial T2 values. RESULTS: CMR characteristics for patients with AS displayed LVH concomitant to elevated myocardial T2 values, reduced GLS and SRe. Patients with T2 values above 70.2 ms at baseline were characterized by eccentric hypertrophy with reduced LV-EF. T2 values decreased after TAVR (67.4 ±â€¯3.4 to 63.3 ±â€¯4.2 ms, p < 0.01) during left ventricular remodeling. Patients with T2 values above 70.2 ms at baseline exhibited pronounced reverse remodeling which proved to be a significant predictor of LV-EF improvement and LVEDV reduction in uni- and multivariate analyses. CONCLUSIONS: Multiparametric CMR can be used to characterize myocardial hypertrophy due to severe AS and to monitor myocardial adaptations after TAVR. It may provide additional information in the prediction of left ventricular remodeling after TAVR.

T2 mapping cardiovascular magnetic resonance identifies the presence of myocardial inflammation in patients with dilated cardiomyopathy as compared to endomyocardial biopsy.

Aims: The aim of this study was to determine the value of T2 mapping for the non-invasive assessment of myocardial inflammation in different stages of systolic left ventricular dysfunction in dilated cardiomyopathy (DCM) in comparison with endomyocardial biopsy (EMB). Methods and results: A total of 132 subjects were enrolled between 2013 and 2016 (62 controls and 70 patients with DCM). All patients underwent CMR at 1.5 T and received coronary angiogram and EMB. CMR applied standard protocols including T2 mapping with Gradient And SpinEcho sequence (GRASE). Global T2 relaxation time was significantly increased in patients with DCM compared to the healthy controls (T2 time DCM vs. controls: 65.9 ± 6.2 vs. 60.0 ± 4.2 ms; P < 0.001). Of note, patients with the presence of inflammatory cells in EMB exhibited further elevation of T2 values (T2 time in patients with the presence of inflammatory cells vs. T2 time in patients without: 68.8 ± 5.8 vs. 64.7 ± 5.9 ms; P = 0.02). Receiver operating characteristic analysis of our data deciphered a global myocardial T2 time >65.3 ms as the best cut-off for distinction between the healthy controls and patients with myocardial inflammation [sensitivity 93%, specificity 90%, P < 0.01, area under the curve (AUC) 0.95]. In patients with DCM, this threshold identified patients with biopsy-proven inflammation with a sensitivity of 79% and specificity 58% (AUC 0.72). Conclusion: In patients with DCM and presence of inflammatory cells in the myocardium, myocardial T2 relaxation times may help to non-invasively detect myocardial inflammation. Although there is an overlap of T2 values between patients and healthy controls, T2 mapping may facilitate the identification of patients who may benefit from EMB for therapeutic decision-making.

Magnetic resonance guided renal denervation using active tracking: first in vivo experience in Swine.

Interventional cardiovascular magnetic resonance (iCMR) might evolve as a technique to improve procedural success rates in cardiovascular interventions by combining intraprocedural guidance and simultaneous lesion imaging. The objective of the present study was to prove feasibility and estimate safety of renal sympathetic denervation guided by real-time iCMR using active tracking. Six pigs were examined in a 1.5 T MRI-System (Achieva, Philips Healthcare, Best, Netherlands) equipped with non-invasive hemodynamic control and in-room monitors displaying an interventional software platform [Interventional MRI Suite (iSuite), Philips Research, Hamburg, Germany]. MR-guided renal denervation was performed using a MR conditional non-irrigated ablation catheter with active tracking (Imricor, Burnsville, MN, USA). Real-time imaging for device guidance was performed with a TFE sequence, vessel patency was assessed with a 3D non-contrast angiography and velocity encoded imaging. Oedema of the renal artery was visualized by a high-resolution T2 SPIR sequence. Renal sympathetic denervation was feasible in all cases with survival of all animals. Non-contrast angiography displayed renal artery patency accompanied by equal flow conditions before and after the ablation in all cases as measured by velocity encoded imaging. Oedema imaging displayed a significant increase in relative signal intensity at renal artery ablations sites pre and post intervention (p < 0.05). The histologic examination revealed no signs of perforation or bleeding, while sufficient ablation lesions could be depicted. MR-guided renal sympathetic denervation using active tracking is feasible and the initial data suggest safety of this procedure. MR-guided renal sympathetic denervation offers the inherent strength of high soft tissue contrast thereby providing target information without the use of iodinated contrast agents or radiation.

Monocyte imaging after myocardial infarction with 19F MRI at 3 T: a pilot study in explanted porcine hearts.

AIM: Inflammation is a hallmark of cardiac healing after myocardial infarction and it determines subsequent cardiovascular morbidity and mortality. The aim of the present study was to explore whether inflammation imaging with two perfluorocarbon (PFC) nanoemulsions and fluorine magnetic resonance imaging ((19)F MRI) is feasible at 3.0 T with sufficient signal-to-noise ratio (SNR) using explanted hearts, an (19)F surface coil and dedicated MR sequences. METHODS AND RESULTS: Acute myocardial infarction (AMI) was induced by balloon angioplasty (50 min) of the distal left anterior descending artery in 12 pigs. One day thereafter, PFCs were injected intravenously to label circulating monocytes. Either emulsified perfluoro-15-crown-5 ether or already clinically applied perfluorooctyl bromide (PFOB) was applied. Four days after AMI and immediately after gadolinium administration, hearts were explanted and imaged with a 3.0 T Achieva MRI scanner. (19)F MRI could be acquired with an SNR of >15 using an in-plane resolution of 2 × 2 mm(2) within <20 min for both agents. Combined late gadolinium enhancement (LGE) and (19)F MRI revealed that (19)F signal was inhomogenously distributed across LGE myocardium reflecting patchy macrophage infiltration as confirmed by histology. In whole hearts, we found an apico-basal (19)F gradient within LGE-positive myocardium. The (19)F-positive volume was always smaller than LGE volume. Ex vivo experiments on isolated monocytes revealed that pig and human cells phagocytize PFCs even more avidly than mouse monocytes. CONCLUSION: This pilot study demonstrates that (19)F MRI at 3.0 T with clinically applicable PFOB is feasible, thus highlighting the potential of (19)F MRI to monitor the inflammatory response after AMI.

Sedation with target-controlled propofol infusion during shoulder surgery under interscalene brachial plexus block in the sitting position: report of a series of 140 patients.

BACKGROUND AND OBJECTIVE: The aim of this study was to assess target-controlled propofol infusion as a technique of sedation for shoulder surgery under interscalene brachial plexus block in the sitting position and to evaluate the effect of sedation on hypotensive/bradycardic events during this procedure. METHODS: One hundred and forty patients undergoing elective shoulder surgery in the sitting position under interscalene brachial plexus block (with 30 mL of ropivacaine 0.75%) were prospectively enrolled. All patients were premedicated with hydroxyzine 1 mg kg(-1), none received beta-blockers. No patients were given atropine except for the patients who experienced a vasovagal event either during the block procedure or intravenous catheter placement. The target-controlled propofol infusion was started immediately after positioning the patient on the operating table. The initial target concentration was 1 microg mL(-1). The infusion rate was adjusted every 15 min by increasing or decreasing the target concentration by 0.2 microg mL(-1) steps to maintain the patient rousable to verbal commands (score of 3 on Wilson sedation scale). The following parameters were assessed: minimal, maximal, optimal target concentration, respiratory and haemodynamic parameters, total propofol dose, additional alfentanil needs, occurrence of hypotensive/bradycardic events, complications. Results are mean +/- SD. Statistical analysis used t-test and chi2-tests. RESULTS: The optimal propofol target concentration was 0.8 mug mL(-1). No respiratory complications or conversion to general anaesthesia was reported. Two patients experienced transient and inconsequential intraoperative agitation. The incidence of hypotensive/bradycardic events during the procedure was 5.7% (eight patients). CONCLUSION: Target-controlled propofol infusion (0.8-0.9 microg mL(-1)) following hydroxyzine premedication is a safe and effective technique for sedation when combined with interscalene brachial plexus block during shoulder surgery in the sitting position.

Lyme neuroborreliosis mimics stroke: a case report.

Lyme neuroborreliosis is diagnostically challenging because of its diverse manifestations. The well-documented neurologic spectrum includes lymphocytic meningitis, cranial neuropathy, and radiculoneuritis in the early disseminated stage; and peripheral neuropathy, chronic encephalomyelitis, and mild encephalopathy in the late persistent stage. This case report describes a 74-year-old man who developed progressive left hemiparesis and facial palsy. The patient was hospitalized to rule out a cerebral vascular accident. The diagnosis of Lyme borreliosis was established with serologic studies. The patient was treated with intravenous ceftriaxone and responded with rapid clinical and functional recovery. Lyme neuroborreliosis presenting as hemiparesis has rarely been reported. Prompt diagnosis and treatment appear to facilitate symptomatic relief and prevent persistent neurologic deficits.

Correlation between two-point discrimination and median nerve sensory response.

Static two-point discrimination (2PD) has been relied upon clinically to gauge the extent of median neuropathy in patients with carpal tunnel syndrome (CTS). Correlation with median nerve sensory conduction findings has not been well-established. We determined the median sensory nerve action potential parameters from the first and third digits of 83 hands referred primarily for suspected CTS. These results were compared to 2PD carried out in a standardized fashion by a group of hand surgeons. A lack of correlation was found in most electrodiagnostic parameters, with the exception of peak and onset latencies to the thumb; on further analysis, 2PD to the thumb was found to be useful if abnormal, but contributed nothing if negative. We conclude that static 2PD results may correlate with latency, but do not overall adequately predict the findings on sensory nerve conduction examination of the median nerve.

1H NMR spectroscopic and histopathological studies on propyleneimine-induced renal papillary necrosis in the rat and the multimammate desert mouse (Mastomys natalensis).

The renal papillary toxin, propyleneimine (PI), was administered at 20 or 30 microliters/kg i.p. to male Sprague Dawley (SD) rats (n = 5), Fischer 344 (F344) rats (n = 4), and to multimammate desert mice (Mastomys natalensis, n = 4). Urine was collected at time points up to 4 days p.d. and the toxicological response of the different animal models to PI compared using 1H NMR spectroscopy of urine, renal histopathology, and urinary assays for alkaline phosphatase (ALP), lactate dehydrogenase (LDH), and gamma-glutamyl transpeptidase (gamma GT). The renal papillae of both F344 and SD rats showed extensive necrotic lesions 4 days post-dosing and in some cases sloughing of the papilla. However, only slight renal papillary necrosis (RPN) was observed in Mastomys treated with 20 microliters/kg PI and, although slight to moderate damage was observed at 30 microliters/kg, PI-treated Mastomys showed substantially less RPN than either group of PI-treated rats. 1H NMR urinalysis showed that PI treatment caused a decrease in the urinary concentrations of succinate (0-24 hr p.d.) and citrate (24-48 hr p.d.) and an increase in creatine (0-48 hr p.d.) in all animal models. Trimethylamine-N-oxide (24-48 hr) and 2-oxoglutarate concentrations decreased initially following the administration of PI and then rose above control levels. The 1H NMR-detected urinary biochemical effects of PI in all three models were similar. However, taurine concentrations were elevated in the urine of Mastomys following PI treatment, perhaps indicating a degree of liver damage, whereas taurinuria was not seen in either SD or F344 rats. These observations are discussed in relation to the potential mechanism of PI-toxicity.

Comparative biochemical effects of low doses of mercury II chloride in the F344 rat and the multimammate mouse (Mastomys natalensis).

The biochemical effects and comparative nephroxicity of mercury II chloride (HgCl2) dosed at 0.75 mg/kg i.p. was investigated in the Fisher 344 rat (F344) and Mastomys natalensis using high resolution 1H nuclear magnetic resonance (NMR) spectroscopy of urine, histopathology and clinical chemical techniques. The effects of HgCl2 treatment were followed for up to 4 days post-dosing (p.d.). In F344 rats there was extensive proximal tubular damage and renal cortical necrosis together with elevated levels of urinary gamma-glutamyl transpeptidase (gamma GT), alkaline phosphatase (ALP) and lactate dehydrogenase (LDH). The 1H NMR spectra of urine obtained from Hg-treated F344 rats also showed increased levels of glucose, alanine, lactate, valine and hippurate (0-48h p.d.) with decreased levels of citrate, succinate and 2-oxoglutarate (24-48h p.d.). Mastomys were found to be highly resistant to HgCl2 toxicity at 0.75 mg/kg and the histological appearance of the renal cortex of treated animals was virtually identical to controls. There were no elevations in urinary ALP, gamma GT and LDH activities in HgCl2-treated Mastomys and there were no biochemical abnormalities in low MW components of Mastomys urine following HgCl2-treatment, as shown by 1H NMR spectroscopy. Urinary gamma GT activity was found to be much higher in F344 rats than Mastomys. Since gamma GT activity is involved in the tubular reabsorption of Hg2+, the lower levels of gamma GT in Mastomys might partially account for the lower toxicity of Hg2+ in this species.

A study of the nephrotoxicity of three cephalosporins in rabbits using 1H NMR spectroscopy.

Male New Zealand White rabbits received a single intravenous injection of 125 mg/kg cephaloridine, 500 mg/kg cefoperazone or 1000 mg/kg cephalothin. Histological examination of kidneys at 48 h post-dose confirmed the presence of bilateral necrosis of the proximal convoluted tubules in the cephaloridine-treated animals. 1H-NMR urinalysis of cephaloridine-treated rabbits detected drug-related resonances, decreased hippurate and increased glucose at 0-24 h post-dose accompanied by elevated levels of lactate, glycine, citrate, glutamine/glutamate and alanine at 24-48 h post-dose. No histopathological changes were observed following administration of cefoperazone or cephalothin. 1H-NMR spectra of urine collected from these animals showed drug-related resonances and decreased hippurate levels at 0-24 h post-dose, and increased glucose levels at 24-48 h post-dose. Analysis of urine by conventional clinical-chemistry failed to reveal any statistically significant differences between the treatment groups. Under the conditions of this study, the nephrotoxic effects of cephaloridine and the minimal effects of cefoperazone and cephalothin could be clearly distinguished by 1H-NMR urinalysis but not by conventional urinalysis.

AAEM minimonograph #45: the early development of electromyography.

The use of electricity for therapeutic purposes began in the first century and became more refined as the properties of electricity became more understood. The works of Franklin, Galvani, Volta, and others contributed to this body of knowledge. Development of the string galvanometer, the advent of the vacuum tube, the introduction of concentric needle electrodes, and the development of the cathode-ray oscilloscope occurred during the first half of the 20th century. The science of electromyography and electrodiagnosis grew in its sophistication, leading to the formation of the American Association of Electromyography and Electrodiagnosis (now the American Association of Electrodiagnostic Medicine) with James Golseth, MD, as its first president in 1953.

Mechanism research of cryoanalgesia.

The sciatic nerves of rabbits were frozen at different temperatures (-20 degrees C, -60 degrees C, -100 degrees C, -140 degrees C, and -180 degrees C). The morphology and function of the frozen nerves were examined with light microscopy (hematoxylin and eosinophilin stain and a histochemical thiocholine method) and electron microscopy. The function of the nerve after freezing was assessed using short latency somatosensory evoked potentials, sensory conduction velocity, and electromyogram at various intervals after freezing. There were no changes in morphology or function of nerves cryolesioned at -20 degrees C. The nerve fibers cryolesioned at -60 degrees C showed signs of freezing degeneration and lost their conductive function although, these nerves all recovered. Approximately half of nerve fibers cryolesioned at -100 degrees C showed Wallerian degeneration, and although the time to remyelination was delayed, nerve regeneration was still complete. At -140 degrees C and -180 degrees C the nerve fibers showed immediate necrosis, with destruction of basal membranes and proliferation of collagen fibers. The results explained the mechanism of cryoanalgesia. Our study demonstrates that cryo-temperatures lower than -140 degrees C will cause permanent alterations in nerve morphology and function, whereas warmer temperatures do not result in permanent nerve damage and are therefore not likely to provide long-term analgesia to patients.

Comparative studies on the nephrotoxicity of 2-bromoethanamine hydrobromide in the Fischer 344 rat and the multimammate desert mouse (Mastomys natalensis).

Renal papillary necrosis (RPN) was induced in Fischer 344 (F344) rats (n = 4) using 2-bromoethanamine hydrobromide (BEA) dosed at 150 mg/kg, and in multimammate desert mice (Mastomys natalensis) at 150 and 250 mg/kg (n = 4 per group). Control rats and Mastomys were dosed with 0.9% saline (n = 4 per group). Urine was collected at regular intervals for up to 4 days post-dosing and analysed for low MW metabolites using high resolution 1H NMR spectroscopy. The urinary activity of lactate dehydrogenase, gamma-glutamyl transpeptidase and alkaline phosphatase was determined using conventional biochemical assays. On termination, histopathological examination of papillae was performed showing the development of extensive lesions in F344 rats at 150 mg/kg BEA. Mastomys appeared much more resistant to BEA and showed normal renal histology at 150 mg/kg and patchy lesions at 250 mg/kg BEA. Enzyme analysis of control urine showed F344 rats to have > 1000% higher gamma-glutamyl transpeptidase activity than Mastomys. 1H NMR spectroscopic analysis showed that BEA caused a substantial decrease in urinary concentrations of succinate and citrate (0-24 h p.d.) and an increase in creatine (0-96 h p.d.) in both animal models. A decrease in the urinary concentration of 2-oxoglutarate with a subsequent increase by 72-96 h p.d. was also noted in both animal models. Glutaric and adipic aciduria were also induced in both F344 rats and Mastomys 0-24 h post-BEA treatment, indicative of an enzyme deficiency in the acyl CoA dehydrogenases. Urinary taurine levels were elevated in Mastomys following the administration of BEA, indicating some degree of liver toxicity. Urinary taurine was not elevated in F344 rats following BEA administration, demonstrating further species difference in BEA toxicity.

The relative hypolipidaemic activity and hepatic effects of ciprofibrate enantiomers in the rat.

The aim of this study was to establish whether the individual enantiomers of racemic ciprofibrate, a potent hypolipidaemic agent and peroxisome proliferator, differ significantly in either pharmacological potency or toxic potential. After a single oral dose to male Fischer F344 rats at dosages below 10 mg/kg, S(-) ciprofibrate produced slightly, but statistically significantly, greater reductions in plasma concentrations of cholesterol than R(+) ciprofibrate. Similarly, at low concentrations in F344 rat hepatocyte cultures, S(-) ciprofibrate produced slightly, but statistically significantly, greater inductions of peroxisomal beta-oxidation activity than R(+) ciprofibrate. However, after seven daily doses, the differences in pharmacological effects of the two enantiomers were no longer apparent. Furthermore, in contrast to its effects in vitro, R(+) ciprofibrate produced slightly, but statistically significantly, greater inductions of peroxisomal beta-oxidation activity in vivo than S(-) ciprofibrate. These observations may be possibly explained on the basis that following multiple dosing, plasma concentrations of R(+) ciprofibrate 24 hr post-dose were greater than those of its optical antipode. Thus the slightly greater potency of the S(-) enantiomer after a single dose may have been overcome by the greater plasma concentrations of the less potent enantiomer. Both enantiomers produced similar reductions in plasma concentrations of thyroxine. The data indicate that at low dosages S(-) ciprofibrate is a slightly more potent hypolipidaemic agent after a single dose in rats and a slightly more potent peroxisome proliferator at low concentrations in vitro. However, following multiple dosing, both enantiomers produced changes in plasma concentrations of lipids, hepatic enzyme activities and plasma concentrations of thyroxine which were of comparable magnitude to those produced by the racemate. Since these early changes have been linked mechanistically to the chronic toxicity of the racemate in the rat, it could be predicted that the individual enantiomers of ciprofibrate under conditions employed in chronic safety studies, would produce the same spectrum of rodent toxicity as the racemate.