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BUNDLE-branch block, VENTRICULAR tachycardia, VENTRICULAR arrhythmia, SODIUM, and INTRAVENOUS therapy

Lithium intoxication induces Brugada-pattern ECG, ventricular arrhythmia, and sudden death with the predominant preference for the male over the female gender. This study investigated the mechanisms of gender difference in lithium-induced arrhythmogenesis. The ECG parameters were recorded in male and female rabbits before and after the intravenous administration of lithium chloride (LiCl) (1, 3, 10 mmol/kg). Patch clamps were used to study the sodium current (INa) and late sodium current (INa-late) in the isolated single male and female right ventricular outflow tract (RVOT) cardiomyocytes before and after LiCl. Male rabbits (n = 9) were more prone to developing lithium-induced Brugada-pattern ECG changes (incomplete right bundle branch block, ST elevation and QRS widening) with fatal arrhythmia (66.7% vs. 0%, p = 0.002) than in female (n = 7) rabbits at 10 mmol/kg (but not 1 or 3 mmol/kg). Compared to those in the female RVOT cardiomyocytes, LiCl (100 μM) reduced INa to a greater extent and increased INa-late in the male RVOT cardiomyocytes. Moreover, in the presence of ranolazine (the INa-late inhibitor, 3.6 mg/kg iv loading, followed by a second iv bolus 6.0 mg/kg administered 30 min later, n = 5), LiCl (10 mmol/kg) did not induce Brugada-pattern ECG changes (p < 0.005). The male gender is much predisposed to lithium-induced Brugada-pattern ECG changes with a greater impact on INa and INa-late in RVOT cardiomyocytes. Targeting INa-late may be a potential therapeutic strategy for Brugada syndrome-related ventricular tachyarrhythmia. [ABSTRACT FROM AUTHOR]

PULMONARY arterial hypertension, ATRIAL arrhythmias, SINOATRIAL node, ENDOTHELIN receptors, PREPROENDOTHELIN, RIGHT heart atrium, CONNEXIN 43, and WESTERN immunoblotting

Atrial arrhythmias are considered prominent phenomena in pulmonary arterial hypertension (PAH) resulting from atrial electrical and structural remodeling. Endothelin (ET)-1 levels correlate with PAH severity and are associated with atrial remodeling and arrhythmia. In this study, hemodynamic measurement, western blot analysis, and histopathology were performed in the control and monocrotaline (MCT, 60 mg/kg)-induced PAH rabbits. Conventional microelectrodes were used to simultaneously record the electrical activity in the isolated sinoatrial node (SAN) and right atrium (RA) tissue preparations before and after ET-1 (10 nM) or BQ-485 (an ET-A receptor antagonist, 100 nM) perfusion. MCT-treated rabbits showed an increased relative wall thickness in the pulmonary arterioles, mean cell width, cross-sectional area of RV myocytes, and higher right ventricular systolic pressure, which were deemed to have PAH. Compared to the control, the spontaneous beating rate of SAN–RA preparations was faster in the MCT-induced PAH group, which can be slowed down by ET-1. MCT-induced PAH rabbits had a higher incidence of sinoatrial conduction blocks, and ET-1 can induce atrial premature beats or short runs of intra-atrial reentrant tachycardia. BQ 485 administration can mitigate ET-1-induced RA arrhythmogenesis in MCT-induced PAH. The RA specimens from MCT-induced PAH rabbits had a smaller connexin 43 and larger ROCK1 and phosphorylated Akt than the control, and similar PKG and Akt to the control. In conclusion, ET-1 acts as a trigger factor to interact with the arrhythmogenic substrate to initiate and maintain atrial arrhythmias in PAH. ET-1/ET-A receptor/ROCK signaling may be a target for therapeutic interventions to treat PAH-induced atrial arrhythmias. [ABSTRACT FROM AUTHOR]

HEART metabolism, DIABETES, ATRIAL fibrillation, ATRIAL arrhythmias, ENERGY metabolism, FATTY acid oxidation, and THERAPEUTICS

Atrial fibrillation (AF) is the most common type of sustained arrhythmia in diabetes mellitus (DM). Its morbidity and mortality rates are high, and its prevalence will increase as the population ages. Despite expanding knowledge on the pathophysiological mechanisms of AF, current pharmacological interventions remain unsatisfactory; therefore, novel findings on the underlying mechanism are required. A growing body of evidence suggests that an altered energy metabolism is closely related to atrial arrhythmogenesis, and this finding engenders novel insights into the pathogenesis of the pathophysiology of AF. In this review, we provide comprehensive information on the mechanistic insights into the cardiac energy metabolic changes, altered substrate oxidation rates, and mitochondrial dysfunctions involved in atrial arrhythmogenesis, and suggest a promising advanced new therapeutic approach to treat patients with AF. [ABSTRACT FROM AUTHOR]

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Insuffisance cardiaque, oedème pulmonaire cardiogène, hypertrophie cardiaque, Heart failure, cardiogenic pulmonary edema, cardiac enlargement, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Cardiopathie, Heart disease, Cardiopatía, Electrodiagnostic, Electrodiagnosis, Electrodiagnóstico, Electrophysiologie, Electrophysiology, Electrofisiología, Trouble de l'excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble du rythme cardiaque, Arrhythmia, Arritmia, Cardiologie, Cardiology, Cardiología, Fibrillation auriculaire, Atrial fibrillation, Fibrilación auricular, Insuffisance cardiaque, Heart failure, Insuficiencia cardíaca, Pathologie de l'appareil circulatoire, Cardiovascular disease, Aparato circulatorio patología, Potentiel action, Action potential, Potencial acción, Protéine choc thermique, Heat shock protein, Proteína choque térmico, Substrat, Substrate, Substrato, GGA, and Monophasic action potential

Background: Geranylgeranylacetone (GGA) has been reported up-regulating heat shock protein (HSP) expression, and protecting against atrial remodeling. This study aimed to investigate the effects of GGA on atrial electrophysiology and inducibility of atrial fibrillation (AF) in heart failure (HF) model. Methods and results: HF rabbits were created 4 weeks after coronary artery ligation. Monophasic action potential recordings and multielectrode array were used to record the electrophysiological characteristics of left atrium (LA) in normal, or HF rabbits with (HF-GGA) and without (HF-control) oral administration of GGA (200 mg/kg, 24 h before experiments). The mRNA and protein expressions of ionic channels were measured by Western blot and PCR. HF-GGA LA (n = 10), similar to normal LA (n = 10) had a shorter action potential duration (APD) and effective refractory period than HF-control LA (n = 10). HF-GGA LA had less triggered activity and APD alternans (20% vs. 100%, P = 0.001), lower maxima slope of restitution curve of APD (0.94 ± 0.04 vs.1.69 ± 0.04, P < 0.001), and less inducibility of AF (50% vs. 100%, P = 0.033) than HF-control LA. HF-GGA LA had a shorter activation time and higher conduction velocity than HF-control LA. HF-GGA LA had a higher mRNA expression of Cav1.2, Nav1.5, Kir2.1, Kv1.4, Kv7.1, Kv11.1, sarcoplasmic reticulum Ca2+-ATPase, and higher phosphorylation of phospholamban than HF-control LA. Conclusions: GGA decreases triggered activity, dispersion of APD and inducibility of AF in failing heart through induction of HSP, and modulation of ionic channels and calcium homeostasis.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences biologiques fondamentales et appliquees. Psychologie, Fundamental and applied biological sciences. Psychology, Genetique des eucaryotes. Evolution biologique et moleculaire, Genetics of eukaryotes. Biological and molecular evolution, Génétique classique, génétique quantitative, hybrides, Classical genetics, quantitative genetics, hybrids, Homme, Human, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Cardiopathie, Heart disease, Cardiopatía, Pathologie de l'appareil circulatoire, Cardiovascular disease, Aparato circulatorio patología, Trouble de l'excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble du rythme cardiaque, Arrhythmia, Arritmia, Ablation, Ablación, Age, Edad, Analyse, Analysis, Análisis, Caractère dominant, Dominant character, Carácter dominante, Caractéristique, Characteristic, Característica, Caractéristiques, Characteristics, Características, Carte génétique, Genetic mapping, Mapa genético, Cartographie, Cartography, Cartografía, Cathéter, Catheter, Catéter, Complexe, Complexes, Complejo, Donnée, Data, Dato, Electrique, Electric, Eléctrico, Fibrillation auriculaire, Atrial fibrillation, Fibrilación auricular, Fréquence, Frequency, Frecuencia, Homme, Human, Hombre, Intervalle, Interval, Intervalo, Isolement, Isolation, Aislamiento, Malade, Patient, Enfermo, Mécanisme, Mechanism, Mecanismo, Méthode, Method, Método, OMS, WHO, Oreillette gauche, Left atrium, Orejuela izquierda, Organisation, Organization, Organización, Résultat, Result, Resultado, Substrat, Substrate, Substrato, Système, System, Sistema, Technique, Técnica, Veine pulmonaire, Pulmonary vein, Vena pulmonar, atrial fibrillation, electrogram frequency analysis, and left atrium

Background―There is a paucity of data regarding the mechanism of maintaining atrial fibrillation (AF) after pulmonary vein isolation (PVI) in patients with AF. The aim of this study was to examine the impact of circumferential PVI on the left atrial (LA) substrate characteristics. Methods and Results―Seventy-two AF patients (age, 53±11 years) underwent mapping and catheter ablation using an NavX system. The biatrial characteristics such as the complex fractionated atrial electrograms (CFEs; based on fractionated intervals) and frequency analysis (based on dominant frequencies) were mapped before and after PVI. PVI with electric isolation was performed in all patients. In the 45 patients who did not respond to PVI, the continuous CFEs (>8 seconds, 18±18% and 12±17% of the LA sites, before and after PVI, respectively, P=0.02), degree of LA fractionation (mean fractionated interval: 75.6±14.3 msec versus 87.3±16.7 msec, P=0.001), and mean LA dominant frequencies (6.92±0.88 Hz versus 6.58±0.91 Hz, P=0.001) decreased after PVI. Complete PVI altered the distribution of the CFEs toward the LA anteroseptum, mitral annulus, and LA appendage regions. A persistent presence of continuous CFEs in the vicinity of the dominant frequencies sites (observed in 53% patients) correlated with a higher procedural AF termination rate for the CFE ablation (63% versus 23%, P<0.05). Conclusions―Complete PVI eliminated some CFEs in the LA and altered the distribution of the CFEs. The persistent presence of CFEs before and after PVI in the vicinity of the high frequency sites is important for AF maintenance after PVI.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Cardiopathie, Heart disease, Cardiopatía, Pathologie de l'appareil circulatoire, Cardiovascular disease, Aparato circulatorio patología, Trouble de l'excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble du rythme cardiaque, Arrhythmia, Arritmia, Appareil circulatoire, Circulatory system, Aparato circulatorio, Caractéristique, Characteristic, Característica, Caractéristiques, Characteristics, Características, Cardiologie, Cardiology, Cardiología, Etude comparative, Comparative study, Estudio comparativo, Sexe, Sex, Sexo, Tachycardie auriculaire, Atrial tachycardia, and Taquicardia auricular

Gender differences of supraventricular tachycardias such as atrioventricular nodal re-entry, atrioventricular re-entry, and atrial fibrillation have been reported. There is little evidence of the effect of gender on focal atrial tachycardia (FAT). The study consisted of 298 patients who were referred to this institution for radiofrequency catheter ablation of FAT from October 1992 to April 2008 and included 156 men (52%) and 142 women (48%). Men were significantly older than women (57.9 ± 18.2 vs 47.2 ± 19.0 years old, p <0.001). Women had more associated arrhythmias (17.0% vs 28.9%, p = 0.01), mostly due to an increased incidence of atrioventricular nodal re-entrant tachycardia. Men had more cardiovascular co-morbidities (19.9% vs 9.9%, p = 0.02), a mechanism of increased automaticity (19.1% vs 8.1%, p = 0.01), and nonparoxysmal tachycardia (14.7% vs 4.4%, p = 0.01). No gender differences were noted among FAT number, left atrial involvement, shortest tachycardia cycle, success rate of catheter ablation, or recurrence rate of FAT. Mean duration of follow-up was 63.2 ± 47.5 months. Premenopausal women had a lesser cardiovascular co-morbidity (15.3% vs 4.3%, p = 0.04) and a greater incidence of a mechanism of increased automaticity (13.4% vs 2.9%, p = 0.03). In conclusion, gender differences in electrophysiologic characteristics were noted in FAT.

Brugada syndrome, gender, lithium intoxication, sodium current dysregulation, right ventricular outflow tract, Biology (General), and QH301-705.5

Lithium intoxication induces Brugada-pattern ECG, ventricular arrhythmia, and sudden death with the predominant preference for the male over the female gender. This study investigated the mechanisms of gender difference in lithium-induced arrhythmogenesis. The ECG parameters were recorded in male and female rabbits before and after the intravenous administration of lithium chloride (LiCl) (1, 3, 10 mmol/kg). Patch clamps were used to study the sodium current (INa) and late sodium current (INa-late) in the isolated single male and female right ventricular outflow tract (RVOT) cardiomyocytes before and after LiCl. Male rabbits (n = 9) were more prone to developing lithium-induced Brugada-pattern ECG changes (incomplete right bundle branch block, ST elevation and QRS widening) with fatal arrhythmia (66.7% vs. 0%, p = 0.002) than in female (n = 7) rabbits at 10 mmol/kg (but not 1 or 3 mmol/kg). Compared to those in the female RVOT cardiomyocytes, LiCl (100 μM) reduced INa to a greater extent and increased INa-late in the male RVOT cardiomyocytes. Moreover, in the presence of ranolazine (the INa-late inhibitor, 3.6 mg/kg iv loading, followed by a second iv bolus 6.0 mg/kg administered 30 min later, n = 5), LiCl (10 mmol/kg) did not induce Brugada-pattern ECG changes (p < 0.005). The male gender is much predisposed to lithium-induced Brugada-pattern ECG changes with a greater impact on INa and INa-late in RVOT cardiomyocytes. Targeting INa-late may be a potential therapeutic strategy for Brugada syndrome-related ventricular tachyarrhythmia.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Trouble excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble rythme cardiaque, Arrhythmia, Arritmia, Ablation, Ablación, Appareil circulatoire pathologie, Cardiovascular disease, Aparato circulatorio patología, Caractérisation, Characterization, Caracterización, Cardiopathie, Heart disease, Cardiopatía, Flutter auriculaire, Atrial flutter, Flutter auricular, Homme, Human, Hombre, Radiofréquence, Radiofrequency, and Radiofrecuencia

OBJECTIVES The aim of the study was to investigate the conduction properties and anisotropy of the crista terminalis (CT) in patients with atrial flutter (AFL) using non-contact mapping. BACKGROUND The CT is a posterior barrier during typical AFL. However, the CT has transverse conduction capabilities in patients with upper loop re-entry (ULR). METHODS Twenty-two patients (16 males, 63 ± 15 years) with typical AFL and ULR were included. Non-contact mapping of the right atrium during AFL and pacing from coronary sinus (CS) and low anterolateral right atrium (LARA) was performed to evaluate transverse conduction across the CT. During ULR, the longitudinal (CVL) and transverse (CVT) conduction velocity along and across the CT were measured. The width of the CT conduction gap was evaluated to guide radiofrequency ablation (RFA). RESULTS No transverse CT gap conduction was found during typical AFL. Transverse CT gap conduction was found in three patients during CS pacing and in three patients during LARA pacing. During ULR, CVL was greater than CVT (1.28 ± 0.43 vs. 0.73 ± 0.30 m/s, p < 0.001). The CVL/CVT ratio was 1.95 ± 0.77, which was inversely related to the CT gap width (15.7 ± 6.8 mm) (p < 0.001). The RFA of the CT gap was successful in 18 patients. Four patients had recurrence of arrhythmias during the follow-up of 11 ± 3 months. CONCLUSIONS Most of the CT conduction gaps were functional and only appeared during ULR. The width of the CT gap was inversely related to the anisotropic ratio of the CT. The RFA of the CT gap was effective in eliminating ULR.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Appareil circulatoire pathologie, Cardiovascular disease, Aparato circulatorio patología, Cardiopathie, Heart disease, Cardiopatía, Trouble excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble rythme cardiaque, Arrhythmia, Arritmia, Appareil circulatoire, Circulatory system, Aparato circulatorio, Atypique, Atypical, Atípico, Cardiologie, Cardiology, Cardiología, Carte génétique, Genetic mapping, Mapa genético, Cartographie, Cartography, Cartografía, Conduction, Conducción, Endocarde, Endocardium, Endocardio, Flutter auriculaire, Atrial flutter, Flutter auricular, Homme, Human, Hombre, Oreillette droite, Right atrium, Orejuela derecha, Phlébologie, Phlebology, Flebología, Substrat, Substrate, and Substrato

OBJECTIVES The purpose of this study was to investigate the relationship between the abnormal substrate and peak negative voltage (PNV) in the right atrium (RA) with atypical flutter. BACKGROUND The impact of a local abnormally low voltage electrogram on the local activation pattern and velocity of atrial flutter (AFL) remains unclear. METHODS Twelve patients with clinically documented AFL were included to undergo noncontact mapping of the RA. The atrial substrate was characterized by the: 1) activation mapping; 2) high-density voltage mapping; and 3) conduction velocity along the flutter re-entrant circuit. The normalized PNV (i.e., the relative ratio to the maximal PNV) in each virtual electrode recording was used to produce the voltage maps of the entire chamber. The protected isthmus was bordered by low voltage zones. RESULTS Atypical AFL of the RA was induced by atrial pacing in 12 patients, including 10 upper loop re-entry and 2 RA free wall re-entry flutter. These protected isthmuses were located near the crista terminalis. The mean width of the protected isthmus was 1.7 ± 0.3 cm and mean voltage at the isthmus was -0.91 ± 0.39 mV. The conduction velocities within these paths were significantly slower than outside the path (0.30 ± 0.18 m/s vs. 1.14 ± 0.41 m/s, respectively; p = 0.004). The ratiometric PNV of 37.6% of the maximal PNV had the best cut-off value to predict slow conduction, with a high sensitivity (92.3%) and specificity (85.7%). CONCLUSIONS Characterization of the RA substrate in terms of the unipolar PNV is an effective predictor of the slow conduction path within the critical isthmus of the re-entrant circuit.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Appareil circulatoire pathologie, Cardiovascular disease, Aparato circulatorio patología, Cardiopathie, Heart disease, Cardiopatía, Trouble excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble rythme cardiaque, Arrhythmia, Arritmia, Analyse, Analysis, Análisis, Appareil circulatoire, Circulatory system, Aparato circulatorio, Cardiologie, Cardiology, Cardiología, Fibrillation auriculaire, Atrial fibrillation, Fibrilación auricular, Fréquence, Frequency, Frecuencia, Phlébologie, Phlebology, Flebología, Type, and Tipo

OBJECTIVES This study sought to investigate the regional frequency distribution from multiple bi-atrial sites in different types of paroxysmal atrial fibrillation (AF). BACKGROUND A previous study showed a left atrium (LA) to right atrium (RA) frequency gradient in patients with paroxysmal AF. METHODS Forty-four patients (age = 60 ± 16, male patients = 27) with paroxysmal AF originating from the pulmonary veins (PVs) (n = 31) or superior vena cava (SVC) (n = 13) were included. Frequency analysis was performed on the intracardiac electrograms (7 s, 1 kHz/channel) recorded from PV, posterior LA, coronary sinus (CS), posterolateral RA, and SVC. The largest peak frequency was identified as the dominant frequency (DF). RESULTS In the PV-AF patients, there was a frequency gradient from the PV ostium to the LA, RA, and SVC (8.5 ± 3.3 Hz vs. 5.9 ± 1.1 Hz vs. 5.2 ± 0.85 Hz vs. 5.5 ± 0.48 Hz, respectively, p < 0.001). The highest DFs were mostly located at the arrhythmogenic PV ostium (58%). The DFs of the arrhythmogenic PV and PV ostium were significantly higher than those of the non-arrhythmogenic PVs and PV ostia (p < 0.05). In the SVC-AF patients, there was a frequency gradient from the SVC to the RA, LA, and PV (8.0 ± 2.4 Hz vs. 5.9 ± 1.1 Hz vs. 5.9 ± 0.7 Hz vs. 5.8 ± 0.7 Hz, respectively, p = 0.001). The highest DFs were mostly located inside the SVC (77%) instead of the SVC ostium (as compared with PV-AF patients, p = 0.035). CONCLUSIONS The location of the highest DF depended on the arrhythmogenic PV or SVC. A frequency gradient was present between the arrhythmogenic thoracic vein and atrium in all patients.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Pharmacologie. Traitements medicamenteux, Pharmacology. Drug treatments, Système cardiovasculaire, Cardiovascular system, Vasodilatateurs périphériques. Vasorégulateurs cérébraux, Vasodilator agents. Cerebral vasodilators, Métabolisme général et cellulaire. Vitamines, General and cellular metabolism. Vitamins, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Vaisseaux sanguins et lymphatiques, Blood and lymphatic vessels, Maladies vasculaires des membres. Pathologie de la veine cave. Maladies vasculaires diverses, Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous, Cardiopathie, Heart disease, Cardiopatía, Trouble excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble rythme cardiaque, Arrhythmia, Arritmia, Ablation, Ablación, Appareil circulatoire pathologie, Cardiovascular disease, Aparato circulatorio patología, Cathéter, Catheter, Catéter, Fibrillation auriculaire, Atrial fibrillation, Fibrilación auricular, Homme, Human, Hombre, Oreillette droite, Right atrium, Orejuela derecha, ablation, atrial fibrillation, and atrium

Background-Catheter ablation of the right atrial (RA) substrate has had variable efficacy in curing paroxysmal atrial fibrillation (PAF), suggesting that RA substrate ablation can play an important role in the treatment of atrial fibrillation (AF) in some patients. The aim of this study was to investigate the electrophysiological characteristics and ablation strategy and its results in a specific group of patients with paroxysmal RA-AF. Methods and Results-The study population consisted of 13 patients (8 men; age, 64± 15 years) with drug-refractory (2± 1 drugs), frequent episodes of PAF. Provocation maneuvers did not reveal any ectopic beat-initiating AF. However, rapid atrial pacing easily induced AF. Activation mapping during sinus rhythm, atrial pacing, and AF was visualized by using a noncontact mapping system. Noncontact mapping revealed RA reentry (6 patients with single-loop circuits and 7 with double-loop circuits) with conduction through channels between lines of block, crista terminalis gaps, and the cavotricuspid isthmus, which could be identified during sinus rhythm and atrial pacing, resulting in fibrillatory conduction in other parts of the RA. The consistency of wavefront activation was confirmed by frequency analysis from equally distributed mapping sites in the RA. Short lines of ablation lesions were aimed at the conduction channels between the lines of block, crista terminalis gaps, and the cavotricuspid isthmus, resulting in bidirectional block. AF was eliminated in 11 (85%) of 13 patients, and those 11 patients with acute success were free of AF without any antiarrhythmic drugs during the long-term follow-up period (16±6 months). Conclusions-RA ablation still can cure selected patients with PAF. Linear ablation of the RA substrate guided by the electrophysiological characteristics of RA-AF is an effective approach for treating this specific group of patients with AF.

Anesthesia, intensive care, Anesthésie, réanimation, Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Pneumology, Pneumologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Pneumologie, Pneumology, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Cardiopathie, Heart disease, Cardiopatía, Trouble excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble rythme cardiaque, Arrhythmia, Arritmia, Ablation, Ablación, Anatomie, Anatomy, Anatomía, Appareil circulatoire pathologie, Cardiovascular disease, Aparato circulatorio patología, Appareil respiratoire pathologie, Respiratory disease, Aparato respiratorio patología, Cathéter, Catheter, Catéter, Fibrillation auriculaire, Atrial fibrillation, Fibrilación auricular, Oesophage, Esophagus, Esófago, Oreillette gauche, Left atrium, Orejuela izquierda, ablation, esophagus, and left atrium

Study objectives: Atrioesophageal fistulas have been reported to be a lethal complication following catheter ablation of atrial fibrillation (AF). The purpose of this study was to investigate the relationship between the esophagus and posterior left atrium (LA) and provide the anatomic information necessary to minimize the risk of esophageal injury during AF ablation. Methods and results: Forty-eight patients (43 men; mean ± SD age, 59 ± 12 years) with drug-refractory paroxysmal AF and 32 control subjects (26 men; mean age, 60 ± 9 years) were included. All underwent a CT scan for delineation of the relationship between the esophagus and posterior LA. In the paroxysmal AF group, two major types of esophageal routes were demonstrated. Type 1 routes were found in 42 patients with the lower portion of esophagus close to the ostium of the left inferior pulmonary vein (LIPV), including three subtypes of courses according to the proximity to the left superior pulmonary vein (PV) and LIPV. Type 2 routes were found in six patients with the lower portion of esophagus close to the ostium of the right inferior pulmonary vein (RIPV), including three subtypes of courses according to the proximity to the right superior PV and RIPVs. The mean shortest distance of the esophagus to the four individual PVs significantly differed between type 1 and type 2: 28.4 ± 6.1 mm vs 10.5 ± 5.7 mm (to the right superior), 19.6 ± 7.0 mm vs 3.7 ± 3.4 mm (to the right inferior), 10.1 ± 3.4 mm vs 22.8 ± 4.2 mm (to the left superior), and 2.8 ± 2.5 mm vs 18.7 ± 5.2 mm (to the left inferior), respectively (p < 0.001 for all). Contact of the esophagus and middle part of posterior LA was observed in each patient. However, direct contact of the aorta with the posterior LA wall was more frequent in type 2 than in type 1 (p = 0.001). The clinical characteristics, type of esophageal routes, distance from the esophagus to the four PVs, and diameter of the thoracic cage, LA, and aorta in the control group were similar to those in the AF group (p > 0.05 for all). Conclusion: Although the anatomic relationship between the esophagus and LA posterior wall varied widely, two major patterns of esophageal routes could be depicted. This information is important for deciding the location of the ablation lesions around the PV ostia and LA and for avoiding the potential risk of esophageal injury.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Coeur, Heart, Trouble du rythme et de la conduction, Cardiac dysrhythmias, Appareil circulatoire pathologie, Cardiovascular disease, Aparato circulatorio patología, Cardiopathie, Heart disease, Cardiopatía, Electrodiagnostic, Electrodiagnosis, Electrodiagnóstico, Trouble excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble rythme cardiaque, Arrhythmia, Arritmia, Algorithme, Algorithm, Algoritmo, Appareil circulatoire, Circulatory system, Aparato circulatorio, Cardiologie, Cardiology, Cardiología, Electrocardiographie, Electrocardiography, Electrocardiografía, Flutter auriculaire, Atrial flutter, Flutter auricular, Phlébologie, Phlebology, and Flebología

OBJECTIVES This study was performed to differentiate upper loop re-entry (ULR) from reverse typical atrial flutter (AFL). BACKGROUND Right atrial ULR and reverse typical AFL have different mechanisms and ablation strategies, but similar electrocardiographic characteristics. METHODS This study included 26 patients with reverse typical AFL and 20 patients with ULR. The noncontact mapping system (EnSite-3000, Endocardial Solutions, St. Paul, Minnesota) was used to confirm diagnosis and guide successful radiofrequency ablation. Flutter wave polarity and amplitude in the 12-lead surface electrocardiogram were determined by two independent electrophysiologists. RESULTS The flutter wave polarity in leads I and aVL was significantly different between the reverse typical AFL and ULR groups (p £ 0.001). Voltage measurement revealed significant differences between reverse typical AFL and ULR in leads I, II, aVR, aVF, V1, and V2 (p < 0.001). A new diagnostic algorithm based on negative or isoelectric/flat flutter wave polarity and amplitude ≤0.07 mV in lead I was useful for diagnosis of ULR, with an accuracy of 90% to 97%, a sensitivity of 82% to 100%, and a specificity of 95%. CONCLUSIONS Polarity and voltage measurement of flutter wave in lead I can differentiate reverse typical AFL from ULR.

Cardiology, blood circulation, phlebology, Cardiologie, appareil circulatoire, phlébologie, Sciences biologiques et medicales, Biological and medical sciences, Sciences medicales, Medical sciences, Cardiologie. Appareil circulatoire, Cardiology. Vascular system, Vaisseaux sanguins et lymphatiques, Blood and lymphatic vessels, Maladies vasculaires des membres. Pathologie de la veine cave. Maladies vasculaires diverses, Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous, Cardiopathie, Heart disease, Cardiopatía, Trouble excitabilité, Excitability disorder, Trastorno excitabilidad, Trouble rythme cardiaque, Arrhythmia, Arritmia, Ablation, Ablación, Appareil circulatoire pathologie, Cardiovascular disease, Aparato circulatorio patología, Cartographie, Cartography, Cartografía, Cathéter, Catheter, Catéter, Tachycardie auriculaire, Atrial tachycardia, and Taquicardia auricular

Background-This study investigated the electrophysiologic characteristics, atrial activation pattern, and effects of radiofrequency (RF) catheter ablation guided by noncontact mapping system in patients with focal atrial tachycardia (AT). Methods and Results-In 13 patients with 14 focal ATs, noncontact mapping system was used to map and guide ablation of AT. AT origins were in the crista terminalis (n=8), right atrial (RA) free wall (n=3), Koch triangle (n=1), anterior portion of RA-inferior vena cava junction (n= 1), and superior portion of tricuspid annulus (n=1); breakout sites were in the crista terminalis (n=5), RA free wall (n=5), middle cavotricuspid isthmus (n=2), and RA-superior vena cava junction (n=2). ATs arose from the focal origins (11 ATs inside or at the border of low-voltage zone), with preferential conduction, breakout, and spread to the whole atrium. After applications of RF energy on the earliest activation site or the proximal portion of preferential conduction from AT origin, 13 ATs were eliminated without complication. During the follow-up period (8±5 months), 11 (91.7%) of the 12 patients with successful ablation were free of focal ATs. Conclusions-Focal AT originates from a small area and spreads out to the whole atrium through a preferential conduction. Application of RF energy guided by noncontact mapping system was effective and safe in eliminating focal AT.