Important factors in left atrial posterior wall isolation using 28-mm cryoballoon ablation for persistent atrial fibrillation-Block line or isolation area?

INTRODUCTION: Left atrial (LA) roof ablation using the cryoballoon technique, combined with pulmonary vein isolation (PVI), has been reported to be beneficial for ablation therapy in patients with persistent atrial fibrillation (AF). Left posterior wall ablation also results in improved patient outcomes. However, the contribution of these techniques to the success of cryoballoon ablation (CBA) treatment of AF is not known. The present study examined the influence of the roofline block and isolation area on outcomes after CBA. METHODS AND RESULTS: We enrolled 78 patients with persistent AF. LA roof ablation was performed using a 28-mm cryoballoon with a single freezing of 3 minutes at each region (median number of freezes: 4) after PVI. After CBA, bipolar voltage amplitude mapping was performed during sinus rhythm using the NavX mapping system. Patients were divided into two subgroups according to the voltage and activation map: the roof-conduction (n = 46) and roofline-block groups (n = 32). Atrial tachyarrhythmia recurred in 20 patients of the conduction group and 4 patients of the roofline-block group. The rate of 12-month freedom from tachyarrhythmia after a single ablation procedure was 78% (95% confidence interval [CI], 60%-89%) in the roofline-block group and 45% (95% CI, 30%-60%) in the conduction group (P = .048). Cox proportional hazard analysis revealed that the isolated area was not a significant predictor of recurrence (hazard ratio, 0.94; 95% CI, 0.86-1.02; P = .15). CONCLUSION: Creating a complete roofline block is the major factor predicting the maintenance of sinus rhythm in patients with persistent AF.

Novel use of a 3-dimensional mapping system in cryoablation of right-sided and septal accessory pathways: playback ablation.

PURPOSE: Despite recent advances in the treatment of eliminating accessory pathways (APs), catheter-induced mechanical block (bump) of APs has been reported to result in a less favorable outcome with high primary failure and recurrence rates. The real bump site cannot always be precisely reapproached under fluoroscopy so physicians can perform ablation to a location different from where the mechanical block was encountered. In this paper, we describe this novel use of a 3-dimensional (3D) mapping system (playback ablation) with a case series. METHODS: The EnSite Velocity system (St. Jude Medical, St. Paul, MN, USA), a 3D mapping system, has a unique function that records the positional information of catheters in a 3D geometric map and the local potential of catheters continuously. This function enables physicians to specify the bump site in a 3D geometric map and apply ablation to the bump site even if the catheter moves away from the bump site. RESULTS: This technique helped us eliminate APs in two patients with bump of APs, and they have been free of preexcitation and arrhythmias without the use of anti-arrhythmic drugs for more than 3 months. CONCLUSIONS: This technique may contribute to improving long-term success in patients with mechanical block of APs.

A relation between ablation area and outcome of ablation using 28-mm cryoballon ablation: Importance of carina region.

INTRODUCTION: Pulmonary vein isolation (PVI) with wide antral ablation leads to better outcomes in atrial fibrillation ablation therapy, but the ablation area is relatively small during cryoballoon ablation (CBA). The present study tested the hypothesis that wide ablation can lead to better outcomes in CBA. METHODS AND RESULTS: Ninety-six patients with atrial fibrillation were enrolled (paroxysmal 76%, 64.1 ± 11.7 years). All patients underwent preprocedural computed tomography and the PV diameter at left atrial PV junction was measured. PV isolation was performed using a 28-mm CB for 3 minutes with single freezing. Sinus rhythm bipolar voltage amplitude maps with the NavX mapping system were generated after ablation. According to the voltage map, patients were divided into 3 subgroups (68 in the extensive isolation group, 17 in the individual isolation group, and 10 in the incomplete isolation group). Atrial tachyarrhythmias recurred in 9 patients of the extensive isolation group and 6 in the individual isolation group. The rate of 12-month freedom from tachyarrhythmia after a single ablation procedure was 84% (95% confidence interval [C.I.], 72%-91%) in the extensive group and 57% (95% C.I., 28%-78%) in the individual group (P = 0.048). Multiple logistic regression analyses revealed that maximal PV diameter was the only predictor to achieve extensive PVI (odds ratio, 1.57; 95% C.I. 1.08-2.29 P = 0.018). CONCLUSION: Extensive isolation is superior to individual isolation for achieving freedom from atrial arrhythmia in long term follow-up by CBA. Evaluating PV diameter at the left atrial PV junction is essential for applying CBA.

Heavy alcohol consumption and risk of atrial fibrillation. The Circulatory Risk in Communities Study (CIRCS).

BACKGROUND: Evidence regarding the relationship between different levels of alcohol consumption and the risk of atrial fibrillation (AF) is currently limited in Asian populations. METHODS AND RESULTS: Between 1991 and 1995, a total of 8,602 Japanese men and women aged 30-80 years took part in the first examination of the Circulatory Risk in Communities Study (CIRCS), a population-based cohort study in Japanese communities. An interviewer obtained detailed information on weekly alcohol intake. During the follow-up period, the incidence of AF was ascertained from annual ECG records, the subject's medical history of AF, and cardiovascular disease surveillance. The hazard ratios (HRs) of incident AF and the 95% confidence intervals (CIs) relative to the never-drinking group were calculated with adjustment for potential confounding factors by using the Cox proportional hazard model. During a median follow-up period of 6.4 years, 296 incidents of AF occurred. A higher incidence of AF was observed among participants with an ethanol intake >69g/day, compared with never-drinkers. Compared with the never-drinkers, the multivariable-adjusted HRs (CIs) of past, light (<23g/day), light-moderate (23-46g/day), moderate (46-69g/day), and heavy (>69g/day) drinkers were 1.30 (0.68-2.49), 0.89 (0.60-1.32), 1.19 (0.73-1.95), 1.36 (0.79-2.35), and 2.90 (1.61-5.23), respectively. CONCLUSIONS: Heavy alcohol consumption is associated with a higher risk of AF.

Nicorandil prevents microvascular dysfunction resulting from PCI in patients with stable angina pectoris: a randomised study.

AIMS: Nicorandil, an ATP sensitive potassium channel opener, may reduce the incidence of microvascular dysfunction after percutaneous coronary intervention (PCI) by dilating coronary resistance vessels. The aim of the study was evaluation of the impact of the administration of intravenous nicorandil on measuring the index of microcirculatory resistance (IMR) in PCI to patients with stable angina pectoris (SAP). METHODS AND RESULTS: Intravascular ultrasound (IVUS), fractional flow reserve (FFR), IMR and blood examination (CK-MB), cardiac troponin I (cTnI) immediately post-PCI (and 24 hours later) were performed in 62 consecutive patients with SAP undergoing PCI. FFR and IMR were measured simultaneously with a single coronary pressure wire. IMR was defined as Pd/coronary flow (or Pd* mean transit time) at peak hyperaemia. Patients were randomised to the control (n=29), or nicorandil group (n=33). In the nicorandil group, nicorandil was intravenously administered as a 6 mg bolus injection just before PCI and as a constant infusion at 6 mg/hour for 24 hours thereafter. All volumetric IVUS parameters and FFR were similar between the two groups both pre- and post-PCI. However, IMR immediately post-PCI and cTnI 24 hours post-PCI were significantly higher in the control group compared to the nicorandil group (IMR: 25.4±12.1 vs. 17.9±9.1 units, and cTnI: 0.21±0.13 vs. 0.12±0.08 ng/mL, for control vs. nicorandil). The incidence for cTnI elevation more than fivefold the normal range (>0.20 ng/mL) was significantly larger in the control group than in the nicorandil group (41% vs. 12%, p<0.01). Additionally, the control group showed a closer correlation between plaque volume reduction during stenting as assessed by volumetric IVUS, and cTnI elevation than the nicorandil group (r=0.55 vs. 0.42, p<0.001 for control vs. nicorandil). CONCLUSIONS: In patients undergoing successful coronary stenting for stable angina, administration of nicorandil is associated with reduced microvascular dysfunction induced by PCI.

Four-year clinical outcomes of the OLIVUS-Ex (impact of Olmesartan on progression of coronary atherosclerosis: evaluation by intravascular ultrasound) extension trial.

BACKGROUND: The previous OLIVUS trial reported a positive role in achieving a lower rate of coronary atheroma progression through the administration of olmesartan, an angiotension-II receptor blocking agent (ARB), for stable angina pectoris (SAP) patients requiring percutaneous coronary intervention (PCI). However, the benefits between ARB administration on long-term clinical outcomes and serial atheroma changes by IVUS remain unclear. Thus, we examined the 4-year clinical outcomes from OLIVUS according to treatment strategy with olmesartan. METHODS: Serial volumetric IVUS examinations (baseline and 14 months) were performed in 247 patients with hypertension and SAP. When these patients underwent PCI for culprit lesions, IVUS was performed in their non-culprit vessels. Patients were randomly assigned to receive 20-40mg of olmesartan or control, and treated with a combination of ß-blockers, calcium channel blockers, glycemic control agents and/or statins per physician's guidance. Four-year clinical outcomes and annual progression rate of atherosclerosis, assessed by serial IVUS, were compared with major adverse cardio- and cerebrovascular events (MACCE). RESULTS: Cumulative event-free survival was significantly higher in the olmesartan group than in the control group (p=0.04; log-rank test). By adjusting for validated prognosticators, olmesartan administration was identified as a good predictor of MACCE (p=0.041). On the other hand, patients with adverse events (n=31) had larger annual atheroma progression than the rest of the population (23.8% vs. 2.1%, p<0.001). CONCLUSIONS: Olmesartan therapy appears to confer improved long-term clinical outcomes. Atheroma volume changes, assessed by IVUS, seem to be a reliable surrogate for future major adverse cardio- and cerebrovascular events in this study cohort.

Ecotoxicity by the biodegradation of alkylphenol polyethoxylates depends on the effect of trace elements.

The bacteria Sphingomonas sp. strain BSN22, isolated from bean fields, degraded octylphenol polyethoxylates (OPEO(n)) to octylphenol (OP) under aerobic conditions. This biodegradation mechanism proceeded by the following two-step degradation process: (1) degradation of OPEO(n) to octylphenol triethoxylate (OPEO(3)), (2) degradation from OPEO(3) to OP via octylphenoxy acetic acid (OPEC(1)). The chemical structure of OPEC(1) was confirmed by analysis using (18)O-labeled water. Quantitative studies revealed that magnesium (Mg(2+)) and calcium (Ca(2+)) ions were essential for the biodegradation of OPEO(n). Furthermore, the rate of biodegradation was especially accelerated by ferric ions (Fe(3+)), and the accumulated amounts of endocrine active chemicals, such as OP, OPEO(1), and OPEC(1), significantly increased to the concentration of 22.8, 221.7, and 961.1 microM in the presence of 37.0 microM Fe(3+), respectively. This suggests that environmental elements significantly influence the resultant ecotoxicity as well as the rate of their biodegradation in the environment. This study on the mechanism of OPEO(n) biodegradation may play an important role in understanding and managing environmental safety, including drinking water safety.

Comparison of the growth performances of offspring produced by a pair of cloned cattle and their nuclear donor animals.

In the present study, the growth performance of a calf produced by mating a somatic cell cloned dam and sire was compared with that of its full siblings produced by mating the cattle used as nuclear donors for the cloned animals. The somatic cell cloned dam and sire were derived from cultured cumulus cells and ear cells, respectively. The cloned dam was artificially inseminated with semen from the cloned sire. A female calf was produced that was reared under general group feeding conditions. The calf was subjected to a clinical examination and to hematology, serum biochemistry, and telomere length analyses; all of these tests indicated that the calf was normal. The growth characteristics (body weight and shoulder height) of the calf fell within the range of the full siblings of the same sex produced by mating the animals used as the nuclear donors of clones. These findings suggest that the same breeding performance is expected from mating a cloned dam and sire as from mating the animals used as nuclear donors for the clones.

Purification and properties of a new Brevibacterium sterolicum cholesterol oxidase produced by E. coli MM294/pnH10.

A gene encoding a cholesterol oxidase from Brevibacterium sterolicum nov. sp. ATCC21387 was isolated by an expression cloning method and highly expressed by a recombinant strain Escherichia coli MM294/pnH10. The purified cholesterol oxidase was a typical flavoprotein with a molecular mass of 46.5 kDa, absorption peaks at 280, 360, and 450 nm. Optimum pH and temperature were found at pH 6.5 and 55 degrees C, respectively. The enzyme acted on 3beta-hydroxysteroids such as cholesterol, pregnenolone, and beta-sitosterol at high rates, but on dehydro-epi-androsterone to a lesser degree. The molecular and catalytic properties were different from those of cholesterol oxidase I, which was initially discovered in B. sterolicum nov. sp. ATCC21387. The new enzyme, designated cholesterol oxidase II, was distinguished by its high affinity toward cholesterol (K(m)=30 microM).