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  • 1
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Pathology of Slow Pathway Ablation. Introduction: AV nodal reentrant tachycardia is routinely cured using radiofrequency catheter ablation techniques. However, there remains controversy as to whether the reentrant circuit for this tachycardia exists solely in the AV node or whether perinodal atrial tissues are vital to the circuit. In addition, the effects of radiofrequency ablation of the slow pathway of AV nodal reentrant tachycardia on the AV node are not known. We examined an autopsy specimen to determine the anatomical location and extent of AV nodal damage of radiofrequency slow pathway ablation for cure of AV nodal reentrant tachycardia. Methods and Results: A 64-year-old woman with confirmed AV nodal reentrant tachycardia underwent a successful “slow pathway” AV modification with a single radiofrequency application. Five months after the procedure, the patient died from a spontaneous intracranial hemorrhage. Postmortem gross pathological examination of the heart was performed. The heart was then sectioned and stained for histologic examination. On gross examination, a pale lesion 0.5 cm in diameter was seen on the endocardial surface adjacent to the tricuspid annulus. approximately 0.85 cm anterior to the coronary sinus os and 1.15 cm from the apex of the triangle of Koch where the AV node resides. Histologic examination revealed a right atrial lesion composed of connective tissue and fat. The compact AV node and surrounding transitional cells were unaffected histologically, with normal atrial cells lying between the AV node and the lesion. Conclusion: Ablation of the slow pathway to cure AV nodal reentrant tachycardia does not produce any gross or histologic damage to the AV node, suggesting that the AV nodal reentrant circuit does not exist in its entirety in the AV node.
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  • 2
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Type of Medium: Electronic Resource
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  • 3
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Unusual Resetting Patterns in AV Junctional Reentry. Introduction: Two unusual resetting patterns were observed in two patients with slow-fast AV junctional reentrant tachycardia (AVJRT) submitted to an electrophysiologic study. Methods and Results: After AVJRT induction, resetting was evaluated by introducing single extrastimuli at progressively shorter coupling intervals from the high right atrium (HRA) and the proximal coronary sinus (CS). An alteration in the return cycle length duration allowed demonstration of resetting. In the first patient, during an AVJRT with a large excitable gap, properly timed extrastimuli delivered both from the HRA and CS simultaneously reset the tachycardia and advanced the H electrogram of the preceding tachycardia beat. In the second patient, both HRA and CS stimulation apparently failed to reset AVJRT (return cycle length unchanged), but, at critical coupling intervals, the cycle length duration of the tachycardia beat following the return cycle was consistently shortened. Conclusions: During slow-fast AVJRT, single atrial stimulation from sites remote to the reentrant circuit may result in unusual resetting patterns. Further studies are required to evidence the full spectrum of resetting in AVJRT.
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  • 4
    Electronic Resource
    Electronic Resource
    Oxford, UK : Blackwell Publishing Ltd
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Atomic Force Microscopy. The promise of atomic (scanning) force microscopy (AFM) for cardiovascular research is enormous. The AFM images by using a sharp cantilever tip to sense the repulsive and attractive forces between the tip and the sample surface. The force of interaction is kept constant while raster scanning, resulting in images of the surface contours with molecular and, on hard inorganic surfaces, even atomic resolution. Movement of the cantilever in the Z plane is detected by a laser beam reflected off the cantilever to a photodiode system, a piezotube allows an X and Y raster, and a three-dimensional image results. Its capabilities include: (1) the three-dimensional imaging of membranes and biomolecules with molecular and submolecular resolution; (2) such imaging not only of dry specimens but of specimens in a physiologic solution, thereby allowing the investigation of dynamic processes in both viable biomolecules and living cells; (3) the sensing of charge and intermolecular interaction forces; (4) the chemical or biochemical modification of the cantilever tip, which allows the identification of specific structures and the measurement of specific interactions (e.g., a ligand-receptor interaction); (5) nanometer control of the position and force of the cantilever, which, in turn, allows the physical manipulation of biomolecules, the dissection of biological structures (e.g., the separation of one gap junctional hemichannel from its neighbor, thereby revealing normally inaccessible surfaces), the delivery of ligands, drugs, or other materials to specific locations, and the precise measurement of interacting forces at specific sites; and (6) the modification of the apparatus by adding complementary methodologies (e.g., magnetic resonance imaging, fluorescence microscopy, confocal microscopy, and perhaps electrophysiology). AFM, however, is only now being applied to biological research, many technical and methodologic problems exist, and a number of them are considered in this review. Little work has been done in cardiovascular research, and the purpose of this review is to introduce this new and exciting approach to investigation.
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  • 5
    Electronic Resource
    Electronic Resource
    Oxford, UK : Blackwell Publishing Ltd
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
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  • 6
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Antiarrhythmic Drug Therapy. Pharmacologic therapy for ventricular arrhythmias has undergone a remarkable change recently. Recognition of the importance of underlying structural heart disease on prognostic implications of ventricular arrhythmias has resulted in the refinement of the clinical classification of these arrhythmias. With refinement of techniques of risk stratification, it is now possible to identify patients with ventricular arrhythmias at high risk for sudden death. Retrospective analyses of prior antiarrhythmic drug trials and new data from prospective randomized trials are now available and can more directly define the risks and benefits of antiarrhythmic therapy. Prevention of sudden death, reduction in total mortality, or improvement in symptoms remain the only benefits of antiarrhythmic drugs. With inclusion of total mortality as the major endpoint for assessment of pharmacologic interventions in high-risk patients, the potential for excess mortality due to antiarrhythmic agents is now recognized. The pharmacologic diversity of newly released antiarrhythmic agents and others under development has resulted in a re-evaluation of the traditional classification of these drugs. Multiple ongoing clinical trials will define the risks and benefits of antiarrhythmic therapy and other nonpharmacologic interventions in patients with ventricular arrhythmias.
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  • 7
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Lack of AVNRT Induction. Introduction: AV nodal reentrant tachycardia (AVNRT) is not always reproducibly inducible. The purpose of this study was to determine the mechanisms responsible for the lack of reproducible induction of AVNRT. Methods and Results: The induction of AVNRT was assessed with atrial burst pacing, and with atrial and ventricular programmed stimulation, each with one and two extrastimuli, in 103 patients with AVNRT. The stimulation protocol was repeated 10 times in the baseline state, during isoproterenol infusion, and after atropine administration, or until AVNRT was induced in 7 of 10 attempts. The mechanisms responsible for 〈 7 of 10 inductions were classified as: (1) the inability to achieve critical AH prolongation; (2) fast pathway block; and (3) slow pathway block. The induction endpoint was achieved in 90 patients: 55 in the baseline state, 34 during isoproterenol infusion, and 1 after atropine. Tbe mechanism of noninducibility in the baseline state (n = 48) was the inability to achieve a critical AH interval in 20%, fast pathway block in 49%, and slow pathway block in 31% (P = 0.02). During isoproterenol administration (n = 14) and after atropine administration (n = 13), the three mechanisms were equally responsible for nonreproducible induction of AVNRT. Conclusions: The induction of AVNRT is poorly reproducible in approximately 10% of patients. In the baseline state, the most common reason for the inability to reproducibly induce AVNRT is fast pathway block. In the presence of isoproterenol or atropine, each of the three mechanisms was equally responsible for noninducibility of AVNRT.
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  • 8
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: DFT Rise with Nonthoracotomy Lead Systems. introduction: In patients with nonthoracotomy defibrillation lead (NTL) systems coupled with monophasic shock waveforms, the defibrillation threshold (DFT) rises early after implantation. There is little information regarding features predictive of the DFT rise, or DFT changes early after implantation of NTL systems coupled with biphasic shock waveforms. Methods and Results: DFT measurements were performed serially at implantation, prior to hospital discharge (mean 4 ± 3 days), and at follow-up (mean 49 ± 22 days) in 146 patients with an NTL system. Factors were assessed for association with a “clinically important” early postimplantation DFT rise, defined as a rise of ≥ 2 energy steps (2 to 4 J per step; ≥ 5 J total). A clinically important early postimplantation DFT rise occurred in 48 patients (33%). Univariate predictors of the rise included the monophasic shock waveform, the Medtronic Transvene lead system, the presence of a subcutaneous defibrillation patch, and the number of shocks delivered during the implantation procedure. However, the only independent predictor of a clinically important DFT rise was the monophasic shock waveform (F = 18, P 〈 0.001). For the monophasic patient group (n = 79), the incidence of a DFT rise was 53% (n = 42). For the biphasic patient group (n = 67), the incidence of a DFT rise was 9% (n = 6). The clinical characteristics of the monophasic and biphasic groups were not significantly different, nor were their DFTs at implantation. Among a subgroup of 18 consecutive patients who underwent serial DFT testing utilizing both monophasic and biphasic waveforms, the incidence of a clinically important DFT rise with monophasic (n = 9, 50%) was higher than with biphasic shocks (n = 3, 17%; P = 0.05). Conclusion: NTL systems coupled with biphasic shock waveforms have an attenuated incidence of a clinically important DFT rise early after implantation, relative to patients with NTL systems coupled to monophasic waveforms.
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  • 9
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: M Cells in the Guinea Pig. Introduction: Recent studies have described the presence of M cells in the deep layers of the canine and human ventricle displaying electrophysiologic and pharmacologic features different from those of epicardial (EPI) and endocardial (ENDO) cells. The M cell is distinguished electrophysiologically by the ability of its action potential to prolong disproportionately to that of other myocardial cells with slowing of the stimulation rate and pharmacologically by its unique sensitivity to Class III antiarrhythmic agents. The present study was designed to test the hypothesis that similar cells are present in the guinea pig ventricle. Methods and Results: We used a dermatome to obtain thin strips of left ventricular free wall from the hearts of guinea pigs (8 to 14 weeks old) and standard microelectrode techniques to record transmembrane activity. Action potential duration measured at 90% repolarization (APD90) was significantly longer in mid-myocardial (MID) cells than in surface EPI or ENDO cells at all basic cycle lengths (BCLs) tested. At a BCL of 300 msec, APD90 was 102 ± 21, 136 ± 9, and 95 ± 15 msec in EPI, MID, and ENDO cells (mean ± SD; n = 12). At a BCL of 5000 msec, APD90 was 133 ± 14, 185 ± 24, and 135 ± 13 msec in EPI, MID, and ENDO cells ([K+]0= 4 mM). Thus, APD-rate relations were more pronounced in the MID cells. MID cells were also more sensitive to agents with Class III actions (e.g., d,I-sotalol: 10 to 100 μM), exhibiting a greater APD prolongation than EPI or ENDO. d,I-Sotalol also induced early afterdepolarizations in MID cells hut not in EPI or ENDO cells. The rate of rise of the action potential upstroke (Vmax) was significantly greater in MID cells: 129 ± 13, 240 ± 42, and 192 ± 28 V/sec in EPI, MID, and ENDO cells (n = 10 to 18). Conclusion: Our results demonstrate the existence of important transmural electrical heterogeneity in guinea pig ventricular myocardium. The study provides data in support of the existence of M cells in the mid-myocardial layers of the guinea pig ventricle exhibiting longer APDs and a greater sensitivity to agents with Class III antiarrhythmic action.
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  • 10
    ISSN: 1540-8167
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Activation and Repolarization Patterns. Introduction: Substantial progress has been made in our understanding of transmural activation across ventricular muscle through studies of excitation patterns and potential distributions. In contrast, repolarization sequences are poorly understood because of experimental difficulties in mapping action potential durations (APDs) using extracellular electrodes. Methods and Results: Langendorff-perfused guinea pig hearts and isolated coronaryperfused left ventricular sheet preparations were stained with the voltage-sensitive dye RH-421 and optical APs were recorded with a photodiode array. Epicardial maps were constructed using a triangulation method applied to matrices of activation and repolarization times determined from (dF/dt)max and (d2F/dt2)max′ respectively. Numerical simulations were carried out based on: (1) a modified Luo-Rudy model; (2) the three-dimensional architecture of ventricular fibers; and (3) the intrinsic spatial distribution of APDs. In ventricular sheets, epicardial stimulation elicited elliptical activation patterns with the major axis aligned with the longitudinal axis of epicardial fibers. When the pacing electrode was progressively inserted from epicardium to endocardium, the major axes rotated gradually, clockwise by 45°, and the eccentricity decreased from 2 to 1.14. Repolarization showed a relatively uniform pattern, independent of pacing site, beginning at the apex and spreading to the base. Conclusion: In experiments and simulations, the helical rotation of epicardial excitation isochrones caused by pacing at increasing depth in the myocardium correlated with the helical three-dimensional architecture of ventricular fibers. In contrast, repolarization was independent of the activation sequence and was mainly guided by spatial differences in APDs between apex and base.
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