Radiofrequency multielectrode catheter ablation in the atrium.

We developed a temperature-controlled radiofrequency (RF) system which can ablate by delivering energy to up to six 12.5 mm long coil electrodes simultaneously. Temperature feedback was obtained from temperature sensors placed at each end of coil electrodes, in diametrically opposite positions. The coil electrodes were connected in parallel, via a set of electronic switches, to a 150 W 500 kHz temperature-controlled RF generator. Temperatures measured at all user-selected coil electrodes were processed by a microcontroller which sent the maximum value to the temperature input of the generator. The generator adjusted the delivered power to regulate the temperature at its input within a 5 degrees C interval about a user-defined set point. The microcontroller also activated the corresponding electronic switches so that temperatures at all selected electrodes were controlled within a 5 degrees C interval with respect to each other. Physical aspects of tissue heating were first analysed using finite element models and current density measurements. Results from these analyses also constituted design input. The performance of this system was studied in vitro and in vivo. In vitro, at set temperatures of 70 degrees C, 85% of the lesions were contiguous. All lesions created at set temperatures of 80 and 90 degrees C were contiguous. The lesion length increased almost linearly with the number of electrodes. Power requirements to reach a set temperature were larger as more electrodes were driven by the generator. The system impedance decreased as more electrodes were connected in the ablation circuit and reached a low of 45.5 ohms with five coil electrodes in the circuit. In vivo, right atrial lesions were created in eight mongrel canines. The power needed to reach 70 degrees C set temperature varied between 15 and 114 W. The system impedance was 105+/-16 ohms, with one coil electrode in the circuit, and dropped to 75+/-12 ohms when two coil electrodes were simultaneously powered. The length and the width of the lesion set varied between 17.6+/-6.1 and 59.2+/-11.7 mm and 5.9+/-0.7 and 7.1+/-1.2 mm respectively. No sudden impedance rises occurred and 75% of the lesions were contiguous. From the set of contiguous lesions, 90% were potentially therapeutic as they were transmural and extended over the entire target region. The average total procedure and fluoroscopy times were 83.4 and 5.9 min respectively. We concluded that the system can safely perform long and contiguous lesions in canine right atria.

Transcutaneous multielectrode basket catheter for endocardial mapping and ablation of ventricular tachycardia in the pig.

BACKGROUND: Endocardial mapping using standard electrode catheters is often technically limited in ventricular tachycardia and constitutes a major obstacle to successful ablation. We wished to examine the utility of a basket-shaped multielectrode mapping catheter (MMC) in the mapping and ablation of ventricular tachycardia. METHODS AND RESULTS: This study of sustained monomorphic ventricular tachycardia (SMVT) was conducted in two phases in the postinfarction pig model. In the first phase, the utility of the MMC in providing adequate localization of potential ablation site(s) of SMVT by different techniques (presystolic potentials, pace mapping, and concealed entrainment) was assessed in 21 pigs. In the second phase, ablation of induced SMVT was attempted in 10 pigs. Mapping of SMVT was performed after percutaneous introduction of the MMC to the LV. Comprehensive mapping was performed in 90 episodes of SMVT and required 2.0 to 25 seconds. Diastolic potentials were recorded during 86 episodes; good or identical pace maps (> or = 9 of 12 paced surface ECG leads identical to ventricular tachycardia surface ECG leads) were obtained in 25 of 31 maps, and entrainment was achieved during 28 of 42 SMVTs. In 10 pigs, 10 SMVTs were recorded at least twice and were considered for radiofrequency ablation. An 8-mm tip ablation catheter was advanced to potential ablation sites with a specially designed "homing" device, requiring a median time of 120 seconds. In these 10 pigs, either identical pace map (> or = 11 of 12, 6 SMVTs) or concealed entrainment (4 SMVTs) guided the ablation procedure. After ablation, 8 of 10 SMVTs were rendered noninducible, while 2 pigs died during energy application of degeneration of SMVT to ventricular fibrillation. CONCLUSIONS: The MMC allows rapid, comprehensive, and reliable endocardial mapping during SMVTs, which facilitates successful ablation in the porcine post-myocardial infarction model.

Percutaneous multielectrode endocardial mapping during ventricular tachycardia in the swine model.

BACKGROUND: Identification of critical areas within the ventricular tachycardia circuit is a prerequisite for catheter ablation. Currently, mapping during ventricular tachycardia, usually performed with standard catheters, is difficult and time-consuming and can be used only in patients with hemodynamically stable tachycardia. METHODS AND RESULTS: A total of 43 pigs underwent closed-chest induction of myocardial infarction. A basket-shaped catheter carrying 64 electrodes was deployed in the left ventricle during normal sinus rhythm. Unipolar pacing at 3 mA was successful in 78% of the basket catheter electrodes, demonstrating good electrode-tissue contact. Hemodynamic and echocardiographic measurements did not reveal any significant interference with myocardial or valvular function during or after catheter deployment. One hundred eighteen episodes of monomorphic ventricular tachycardia were induced in 28 pigs through right ventricular stimulation, 81 of which were mapped and analyzed. Ventricular tachycardia mapping was rapid, requiring only several beats and < 10 seconds to complete. Presystolic potentials, a possible target for ablation, were identified in 58% of the tachycardia episodes mapped. Pathological examination revealed only minor valvular and endocardial catheter-induced lesions immediately after mapping and none a month later. CONCLUSIONS: The multielectrode catheter enables rapid and safe percutaneous endocardial mapping of ventricular tachycardia in the swine model. Exploration of the clinical potential of the multielectrode catheter seems warranted.

Three-dimensional finite element analysis of current density and temperature distributions during radio-frequency ablation.

This study analyzed the influence of electrode geometry, tissue-electrode angle, and blood flow on current density and temperature distribution, lesion size, and power requirements during radio-frequency ablation. We used validated three-dimensional finite element models to perform these analyses. We found that the use of an electrically insulating layer over the junction between electrode and catheter body reduced the chances of charring and coagulation. The use of a thermistor at the tip of the ablation electrodes did not affect the current density decreased more slowly with distance from the electrode surface. We analyzed the effects of three tissue-electrode angles: 0, 45, and 90 degrees. More power was needed to reach a maximal tissue temperature of 95 degrees C after 120 s when the electrode-tissue angle was 45 degrees. Consequently, the lesions were larger and deeper for a tissue-electrode angle of 45 degrees than for 0 and 90 degrees. The lesion depth, volume, and required power increased with blood flow rate regardless of the tissue-electrode angle. The significant changes in power with the tissue-electrode angle suggest that it is safer and more efficient to ablate using temperature-controlled RF generators. The maximal temperature was reached at locations within the tissue, a fraction of a millimeter away from the electrode surface. These locations did not always coincide with the local current density maxima. The locations of these hottest spots and the difference between their temperature and the temperature read by a sensor placed at the electrode tip changed with blood flow rate and tissue-electrode angle.

A closed-chest pig model of sustained ventricular tachycardia.

The goal of this study was to develop and explore a closed-chest animal model of sustained VT. Seven of 11 domestic pigs had successful induction of myocardial infarction by injection of agarose gel microbeads into the left anterior descending coronary artery through an inflated balloon angioplasty catheter. Four of the first five pigs died and seem to represent a "learning experience." During a 3- to 50-day follow-up period, each pig underwent 1-3 electrophysiological studies. Sustained, monomorphic VT was induced 1-4 times in 5 of the 7 pigs (a total of 19 episodes), was reproducible during the same study in all pigs, and could be repetitively induced during successive studies in some. Ventricular fibrillation was induced less frequently (nine episodes) and was successfully terminated by DC shock in eight episodes. We conclude that a closed-chest pig model of VT is feasible and is associated with a relatively high induction rate of sustained, monomorphic, and reproducible VT and a relatively low mortality rate.

Is the second phase of a biphasic defibrillation waveform the defibrillating phase?

Why some biphasic waveforms defibrillate with lower energies than monophasic waveforms of similar duration is unknown. One hypothesis is that the first phase of a biphasic waveform acts as a conditioning, hyperpolarizing prepulse to prepare for defibrillation by a second depolarizing phase. To test whether the second phase of a biphasic waveform is the defibrillating phase, three monophasic waveforms, an ascending ramp (A), a square wave (S), and a descending ramp (D), were compared to three biphasic waveforms with A, S, or D in the first phase (biphasic first phase) and three biphasic waveforms with A, S, or D in the second phase (biphasic second phase). Two defibrillation thresholds for each waveform were performed in 18 open chest pigs and mean defibrillation thresholds were compared. In nine pigs 16-msec monophasic and 16/16-msec biphasic waveforms were ranked by mean current and energy at defibrillation threshold. The ranks were the same for monophasic and biphasic second phase waveforms: for mean current A < S = D and for energy A < S < D. The ranks were different for the biphasic first phase waveforms: for mean current S < A = D and for energy S < A = D. Although ranks for the 16-msec monophasic waveforms matched those for the 16/16-msec biphasic second phase waveforms, the biphasic waveforms had higher mean currents and energies at defibrillation threshold. In nine pigs defibrillation thresholds for 6-msec monophasic and 6/6-msec biphasic waveforms were ranked. For mean current the ranks were monophasic: A < S = D; biphasic first phase: A = S = D; and biphasic second phase: S = D < A. For energy the ranks were monophasic: A = S < D; biphasic first phase: A = S = D; and biphasic second phase: S = D < A. Thus, ranks for the 6-msec monophasic waveforms differed from those for the 6/6-msec biphasic second phase waveforms. For 16/16-msec biphasic waveforms, less effective for defibrillation than corresponding 16-msec monophasic waveforms, these results support the hypothesis that the second phase of a biphasic waveform defibrillates since the defibrillation efficacy of a 16/16-msec biphasic waveform is related to the defibrillation efficacy of its second phase waveshape. However, for clinically useful 6/6-msec biphasic waveforms, more effective for defibrillation than 6-msec monophasic waveforms, the hypothesis is not supported because the ability of a 6/6-msec biphasic waveform to defibrillate is unrelated to the defibrillation efficacy of its second phase waveshape.

Estimating the 95% effective defibrillation dose.

Minimum squared error (MinSE) testing protocols and a MinSE estimator are presented which accurately estimate the voltage that defibrillates 95% of the time (the ED95). The MinSE experimental procedures, presented in the form of lookup tables, detail the response to successful and unsuccessful trials. The lookup tables also show the ED95 estimates calculated from the observed results using the MinSE estimator. Two assumptions are required to develop the look-up tables: 1) the dose-response curve, chosen using a statistical analysis of a retrospective sample, and 2) the distribution of the ED95's in the population. The MinSE estimator and experimental procedure are examined in a prospective study of five dogs (19-25 kg, heart weights 139.3-236.9 gm) using nonthoracotomy implantable defibrillator electrodes and a biphasic defibrillation waveform (3.5 ms first phase, 2.0 ms second phase). Employing an ED95 population distribution assumption applicable to most implantable defibrillator electrodes and waveforms, e.g., the ED95 is between 0.0 and 800.0 V, the measured rms error was 15% of the mean measured ED95 for the MinSE, four test shock, ED95 estimates. If the protocols are designed with an ED95 population distribution assumption for animals of the same species and size, and defibrillation is constrained to one electrode configuration and waveform, the estimates improve by 3.8%. Using techniques from the Bayesian statistics literature, the MinSE approach can be extended to a variety of defibrillation parameter estimation problems.

Effects of oxygenated cardioplegic solutions on myocardial aerobic metabolism.

Oxygenated cardioplegic solutions can deliver sufficient oxygen to support aerobic metabolism of heart tissue during cardiac arrest, but little is known about oxygen use after cardioplegic solution infusion. Exhaustion of myocardial oxygen stores after infusion of oxygenated crystalloid cardioplegic solution or Krebs-Henseleit buffer was measured in rat hearts. Since nicotinamide adenine dinucleotide accumulates when mitochondria become anaerobic, the epicardium was monitored during perfusion and ischemia. As ischemia progressed, nicotinamide adenine dinucleotide fluorescence increased, indicating exhaustion of oxygen. After buffer perfusion, at 37 degrees C, 50% of peak fluorescence was seen at 13 +/- 1 seconds and 90% at 37 +/- 3 seconds. Oxygenated cardioplegic solution increased these intervals to 57 +/- 6 and 114 +/- 9 seconds, respectively. Oxygenated cardioplegic solution at 10 degrees C increased the time to 50% fluorescence to 238 +/- 12 seconds and to 90% to 320 +/- 14 seconds. Differences between buffer and cardioplegic solution were less at 10 degrees C. Aerobic metabolism was completely abolished 6 minutes after infusion of 10 degrees C oxygenated cardioplegic solution. Maintenance of continuous aerobic metabolism during surgical cardiac arrest would require frequent administration of oxygenated crystalloid cardioplegic solution.

Myocardial metabolism during fixed-rate pulsatile left ventricular bypass.

Fixed-rate pulsatile cardiopulmonary bypass may improve subendocardial perfusion during ventricular fibrillation and has been employed during intermittent aortic cross-clamping. Variable-rate pulsatile left heart bypass that is governed by venous inflow and is asynchronous to the electrical activity of the heart is currently used in clinical practice. To study the effect of fixed-rate pulsation on myocardial metabolism during left heart bypass, six adult pigs underwent alternating periods of pulsatile (PLS) and nonpulsatile (NPLS) centrifugal pump left atrial-to-aortic bypass in randomized block design. Coronary sinus, aortic, and bypass circuit flows were recorded. Oxygen content and lactate concentration of coronary sinus and aortic blood were measured. Pulsatility index and pulse power index during pulsatile bypass were 4.4 and 4.7 (cycles/s)2, respectively. Percent bypass was maximal at a mean pulsation rate of 41.3 and averaged 92.2 and 91.3 for PLS and NPLS, respectively. Myocardial oxygen consumption per minute was reduced 14.3% during NPLS but was unchanged during PLS compared to control (CTRL). Percent lactate extraction was significantly lower than CTRL during NPLS only. Competition for inflow with the ejecting heart appeared to limit circuit pulsation rate and pulse power index. Fixed-rate pulsation is ineffective in reducing myocardial metabolism and should be avoided in left heart bypass.

Improved heart preservation with UW preservation solution.

Despite the good clinical results obtained with the current heart preservation techniques, these methods need to be improved. The UW solution has provided excellent preservation for the pancreas, kidney, and liver after extended cold ischemic storage times. We have tested the ability of the UW solution to store hearts for 5 and 12 hours and compared the results with those obtained from hearts preserved by either Stanford or modified Collins' solutions. Three groups of five canine hearts each underwent 5 hours, and three groups of five canine hearts underwent 12 hours of ischemia at 4 degrees C. Then the hearts were reperfused in an isolated working canine heart preparation. Those hearts preserved for 5 hours had nearly normal ventricular function and adenosine triphosphate contents and were able to maintain normal tissue electrolyte concentration and water contents. After 12 hours of storage time only adenosine triphosphate contents were similar among the groups. Hearts preserved with the UW solution rapidly recovered, reaching nearly normal left ventricular function by 60 minutes of reperfusion; hearts preserved by the modified Collins' solution recovered more slowly, but function was good after 120 minutes of reperfusion. Hearts preserved by the Stanford solution never attained adequate function. The three groups of hearts preserved for 12 hours did not differ in their ability to utilize lactate or in their rates of oxygen utilization. Tissue water and sodium contents were considerably lower in the hearts preserved with the UW solution after 150 minutes of reperfusion compared with hearts stored in the modified Collins' or Stanford solutions. Hearts stored 12 hours in the UW solution under cold ischemic conditions recovered left ventricular function rapidly after reperfusion with normal blood, utilized lactate and oxygen at normal rates, and were able to regulate tissue water and sodium contents to nearly normal levels. Because of the superior preservation obtained by the UW solution, the solution deserves further evaluation for possible future use in clinical heart transplant programs.

Quantitation of absolute flow in coronary artery bypass grafts using digital subtraction angiography.

Coronary angiography defines the location and size of obstructive lesions, but does not assess their physiological significance. To assess a new method to measure the blood-flow waveform, reversed saphenous vein grafts from the left subclavian artery to the left anterior descending coronary artery were placed in five mongrel dogs. Contrast material was injected selectively into the vein graft while obtaining fluoroscopic images from AP and 45 degrees LAO projections. Blood flow was measured under baseline, low-flow, and hyperemic conditions using an electromagnetic flow probe (EM). Seventeen radiographic determinations of mean blood flow (range 18-130 ml/min) were linearly correlated to simultaneous EM measurements (r = 0.91 and 0.88, respectively). Contrast material injections changed EM flow measurements by an average of 35%, which though large, is less than with other radiographic methods. The computed blood-flow waveforms had a time resolution of 1/30 sec and were in good agreement with EM waveforms measured simultaneously. Clinical application of this radiographic method for determining the blood-flow waveform may allow early prediction of coronary artery bypass graft closure.

Pump-induced hemolysis in a rabbit model of neonatal ECMO.

There is no significant difference in hemolysis between pediatric centrifugal pumps and roller pumps during ECMO of 8 hours duration in rabbits or in comparable 24 hour isolated pump circuits. There is also no significant difference in heat production by either pump. Reports of severe hemolysis using the centrifugal pump in neonatal ECMO are likely due to other factors. Proper cannula selection and positioning are important measures to reduce hemolysis by minimizing circuit pressure and maximizing venous return. Avoidance of inadvertently high rotor speed in the centrifugal pump is also recommended.

A comparison of blood and crystalloid cardioplegia during heart transplantation after 5 hours of cold storage.

Four methods of protecting the heart during implantation were compared. All hearts were arrested in situ by perfusing 4 degrees C cardioplegic solution into the aortic root and were stored by a nonperfused cold storage technique for 5 hours at 4 degrees C. The hearts were then transplanted orthotopically with the use of topical iced slush alone or with infusions of either blood cardioplegic solution or one of two crystalloid cardioplegic solutions after each atrial anastomosis. Five dog hearts were included in each group. Biopsy samples to test for adenylates were taken before the arrest, at the end of storage, before cross-clamp removal, and 3.5 hours after cross-clamp removal. The dogs were removed from cardiopulmonary bypass, and with the chest open, left ventricular function curves were measured at 1, 2, and 3 hours after cross-clamp removal. At 3.5 hours of reperfusion time, a full-width section was obtained from the left ventricle for measurement of tissue sodium and water content. No differences in tissue water, sodium, or potassium content were found among the groups. Left ventricular function was significantly better in the blood cardioplegia group than in any other groups. Adenosine triphosphate levels were significantly reduced 3.5 hours after reperfusion in the crystalloid cardioplegia groups but were not significantly depressed at any other measurement time. Excellent early graft function was observed after crystalloid cardioplegic arrest and blood cardioplegic reperfusion during graft implantation.

Arterial blood-flow waveform measurement in intact animals: new digital radiographic technique.

With a new radiographic method to determine the pulsatile flow pattern in an imaged artery, flow velocity is determined by tracking the movement of contrast material along the artery over time. Flow velocity is multiplied by an automatically determined cross-sectional area of the artery to determine blood flow. Pulsatile blood-flow waveforms were determined by radiographic and electromagnetic techniques in each femoral artery of four dogs while flow conditions were varied. Peak and average blood flows measured by the two techniques were highly correlated (r = .97 and .95, respectively). The closest agreement between the flow waveforms measured by the electromagnetic and radiographic techniques was found under normal flow conditions. The radiographically derived flow waveforms tended to be noisy at low blood-flow rates, and instantaneous blood-flow rates exceeding 700 ml/min were underestimated.

Paranoid disorder: the Soviet viewpoint.

The Russian-language psychiatric literature on the paranoid disorders was reviewed for a recent 10-year period. The authors were from a variety of facilities and geographic locations. Bibliography references were primarily European, although 41% of the articles included references to American publications. The paranoid patient population was similar to that in the United States. There was extensive longitudinal study of the disorders; epidemiologic investigations, diagnostic classification, pharmacotherapy, treatment outcome, and etiologic theories allowed comparison with these issues in the United States.

The effects of cardioplegia washout on myocardial preservation.

Preservation of the myocardium in vitro is more effective than preservation in vitro when preservation conditions are apparently the same. The washout of cardioplegia from the myocardium by noncoronary blood flow has been implicated as a probable cause of the poorer myocardial preservation seen in vivo. Isolated dog hearts were used to study the effects of cardioplegia washout by low flow perfusion (0.05 ml/min/g LV weight) during a 2-hr preservation period. Six experimental groups of five hearts each underwent 2 hr of myocardial preservation at temperatures of 20 degrees C (three groups) or 30 degrees C (three groups). The three groups for each temperature consisted of retrograde coronary sinus perfusion (to simulate cardioplegia washout by collateral flow) with blood cardioplegia (BC), normal blood (NB), or no perfusion at all (No CSP). The quality of preservation in each group was assessed by measuring recovery of left ventricular function, tissue water and electrolyte content, and myocardial high-energy phosphate and adenylate content prior to, during, and following preservation. In hearts maintained at 20 degrees C, cardioplegia washout did not significantly affect left ventricular function or myocardial levels of H2O, Na, K, ATP, or total adenylates. When myocardial temperature was allowed to increase to 30 degrees C, preservation was better with low flow perfusion during the preservation period. Hearts warmed to 30 degrees C with no cardioplegia washout experienced a 50% loss of tissue ATP levels and recovered less than 30% of normal left ventricular function during a 150-min reperfusion period. In contrast, hearts slowly perfused during the preservation period maintained nearly normal levels of ATP and returned to normal function by 150 min of reperfusion. Although myocardial warming by noncoronary perfusion has a detrimental effect on myocardial preservation, the slow washout of cardioplegia per se has no apparent detrimental effect on preservation.