The usefulness of ventricular pacing during atrial fibrillation ablation in a persistent left superior vena cava: A case report

A 69-year-old woman with palpitations was referred to our hospital for a second session of atrial fibrillation (AF) catheter ablation. She had a history of AF ablation including pulmonary vein (PV) isolation and persistent left superior vena cava (PLSVC) isolation. Electrophysiologic studies showed the veno-atrial connections that had recovered. After PV isolation was performed, AF was induced by atrial premature contraction (APC) from the PLSVC, and AF storm occurred. During PLSVC isolation, AF was not induced by APC from the PLSVC. PLSVC isolation continued during sinus rhythm. The elimination of the PLSVC potential was difficult to confirm because of the far-field potential of the left ventricle. Then, we performed right ventricular pacing. The remaining PLSVC potential was identified. After that, the PLSVC isolation was successful during right ventricular pacing. Complications were not observed. The patient had no recurrence of AF thereafter.     

Cardiac resynchronization therapy device implantation in a patient with persistent left superior vena cava without communicating innominate vein - should we proceed from the same side? - A dilemma revisited

Persistent left superior vena cava (PLSVC) is an uncommon congenital anomaly. We report a case of implantation of cardiac resynchronization therapy - pacemaker (CRT-P) device in a 38-year-old lady with idiopathic dilated cardiomyopathy. After left axillary vein puncture, we faced an unexpected entry of left subclavian to PLSVC draining into the coronary sinus (CS). The target posterolateral vein which had been identified before, seemed to have an acute angle at its entry into the CS. Hence, at this stage we were in a dilemma, whether to switch to the right side or to continue from the same side. We continued the procedure from the left side and completed it successfully after some manipulation and improvisation.     

Cryoablation for atrioventricular nodal re-entrant tachycardia associated with persistent left superior vena cava

Catheter ablation for atrioventricular nodal re-entrant tachycardia (AVNRT) in patients with persistent left superior vena cava (PLSVC) is challenging because of anatomical abnormalities of Koch's triangle associated with the enlarged coronary sinus ostium. We present the Case of successful ablation in a patient with PLSVC using the cryoablation technique. The ablation was successfully performed without damaging the conduction system by virtue of “cryomapping” and “cryoadhesion.” Cryoablation is a safe and efficacious alternative to radiofrequency catheter ablation for the treatment of AVNRT associated with PLSVC.     

An unusual ‘bow tie’ image in pacemaker implantation

Upper venous system anatomic variations may cause difficulties during cardiac pacemaker implantation. Persistent left superior vena cava (PLSVC) and absent right superior vena cava could be an arrhythmogenic source of atrial arrhythmias and cardiac conduction disease. We represent dual-chamber pacemaker implantation in a patient with a very rare upper venous system anomaly, paroxysmal atrial fibrillation, sick sinus syndrome, that cause unusual fluoroscopic image.     

Natural history and management of chronic aortic valve disease.

Chronic aortic valve disease involving stenosis, regurgitation or both is insidious and progressive. Severe valvular dysfunction may be present for years without symptoms, but functional deterioration is often rapid once congestive heart failure, angina or syncope with effort is present. As the severity of aortic stenosis may not be easy to assess clinically, the relative usefulness of various tests is considered in this paper. The difficulty with chronic aortic regurgitation lies not in diagnosing the problem but in detecting early left ventricular dysfunction in time to perform the surgery that can prevent further functional deterioration. Patients with significant aortic valve disease should undergo surgery when the important symptoms of dyspnea, angina or syncope with effort first appear. Surgery should also be considered in selected patients with aortic regurgitation in whom left ventricular function has diminished even without symptoms.     

Postfire forest management and Mediterranean birds: the importance of the logging remnants

Fire is a crucial element needed to understand the biodiversity patterns of forest landscapes in most Mediterranean countries. However, little is known about the quantitative responses of bird communities to postfire forest management in this region, in which the logging of burnt trees is a common practice. Several studies have already described the negative effects of felling burnt trees on birds but none has focussed on the remaining wood remnants. We investigated this question in a large burnt area located in north-east Iberian Peninsula. The amount of logging remnants left on the ground had positive linear and negative quadratic relationships with the indices of bird abundance and bird richness. The results obtained at a species level were similar, since 36% of the most abundant species revealed the same type of relations with logging remnants, whereas none showed an opposite pattern. Thus, birds in general seem to be positively influenced by the amount of wood remnants left on the ground to a certain point, from which the relation reverses. The results of this study indicate that a moderate amount of wood remnants left on the ground may be positive for the overall bird community. We suggest that management plays a role in the recovery of the bird community after fire and, therefore, biodiversity criteria should be incorporated in the guidelines driving postfire actions.     

Right‐ and left‐handed three‐helix proteins. I. Experimental and simulation analysis of differences in folding and structure

Despite the large number of publications on three‐helix protein folding, there is no study devoted to the influence of handedness on the rate of three‐helix protein folding. From the experimental studies, we make a conclusion that the left‐handed three‐helix proteins fold faster than the right‐handed ones. What may explain this difference? An important question arising in this paper is whether the modeling of protein folding can catch the difference between the protein folding rates of proteins with similar structures but with different folding mechanisms. To answer this question, the folding of eight three‐helix proteins (four right‐handed and four left‐handed), which are similar in size, was modeled using the Monte Carlo and dynamic programming methods. The studies allowed us to determine the orders of folding of the secondary‐structure elements in these domains and amino acid residues which are important for the folding. The obtained data are in good correlation with each other and with the experimental data. Structural analysis of these proteins demonstrated that the left‐handed domains have a lesser number of contacts per residue and a smaller radius of cross section than the right‐handed domains. This may be one of the explanations of the observed fact. The same tendency is observed for the large dataset consisting of 332 three‐helix proteins (238 right‐ and 94 left‐handed). From our analysis, we found that the left‐handed three‐helix proteins have some less‐dense packing that should result in faster folding for some proteins as compared to the case of right‐handed proteins.Proteins 2013; © 2013 Wiley Periodicals, Inc.     

Laterality patterns in infants with external birth defects.

The lateral distribution of external birth defects has not been reported in a comprehensive way, and patterns in this distribution have not been examined. This study presents the lateral distribution of 6,390 unilateral defects from among 102 defect categories in data collected by the Metropolitan Atlanta Congenital Defects Program. Among all defects, 49% (95% CI 48-51%) were right-sided. Among males and females, 51% (95% CI 50-53%) and 47% (95% CI 46-49%) of the defects, respectively, were right-sided. Of the 102 defect types, 57 had an excess of defects on the right side of the body; 39 had an excess of defects on the left side; and 6 were equally distributed. The excess on the right side was statistically significant for inguinal hernia, incarcerated inguinal hernia, microtia, preauricular sinus, talipes calcaneovalgus, and lambdoidal craniosynostosis. For the left side, the excess was statistically significant for preauricular tags, cleft lip, fused lip and cleft gum, cleft lip with cleft palate, congenital hip dysplasia, unstable hip, absent forearm or hand, anomaly of the knee, and skin tags. The percentage of right-sided defects among case subjects with unilateral defects was correlated with the percentage of males among all case subjects (r = 0.24, P < 0.05). Among male case subjects with unilateral defects, the correlation coefficient was 0.31 (P < 0. 01), and among females with unilateral defects, it was 0.11 (P > 0. 10). Differences in the lateral distribution of specific birth defects may be due to subtle differences in morphogenesis on the left and right sides of the embryo brought about by establishment of left-right asymmetry prior to organogenesis. The fact that more defect categories were right-sided than left-sided may be related to the observation that mitochondrial maturation in rat embryos is delayed on the right side. The right side, therefore, may be more susceptible than the left to defects caused by prenatal hypoxia. The significant correlation between the percentage right-sided and percentage male may then also be related to the observation that male sex hormones lower the mitochondrial respiration rate in rats and increase rat sensitivity to chemical hypoxia. Investigators should consider reporting the laterality of specific defects in both laboratory and epidemiological studies of birth defects. Right- and left-sided defects should perhaps be considered separately in etiologic studies of birth defects. Teratology 60:265-271, 1999. Published 1999 Wiley-Liss, Inc.     

Cardiac remodelling: concentric versus eccentric hypertrophy in strength and endurance athletes

Cardiac remodelling is commonly defined as a physiological or pathological state that may occur after conditions such as myocardial infarction, pressure overload, idiopathic dilated cardiomyopathy or volume overload. When training excessively, the heart develops several myocardial adaptations causing a physiological state of cardiac remodelling. These morphological changes depend on the kind of training and are clinically characterised by modifications in cardiac size and shape due to increased load. Several studies have investigated morphological differences in the athlete’s heart between athletes performing strength training and athletes performing endurance training. Endurance training is associated with an increased cardiac output and volume load on the left and right ventricles, causing the endurance-trained heart to generate a mild to moderate dilatation of the left ventricle combined with a mild to moderate increase in left ventricular wall thickness. Strength training is characterised by an elevation of both systolic and diastolic blood pressure. This pressure overload causes an increase in left ventricular wall thickness. This may or may not be accompanied by a slight raise in the left ventricular volume. However, the development of an endurancetrained heart and a strength-trained heart should not be considered an absolute concept. Both forms of training cause specific morphological changes in the heart, dependent on the type of sport. (Neth Heart J 2008;16:129-33.)     

DOES PROFESSIONAL AUTONOMY PROTECT MEDICAL FUTILITY JUDGMENTS?

Despite substantial controversy, the use of futility judgments in medicine is quite common, and has been backed by the implementation of hospital policies and professional guidelines on medical futility. The controversy arises when health care professionals (HCPs) consider a treatment futile which patients or families believe to be worthwhile: should HCPs be free to refuse treatments in such a case, or be required to provide them? Most physicians seem convinced that professional autonomy protects them from being forced to provide treatments they judge medically futile, given the lack of patient benefit as well as the waste of medical resources involved. The argument from professional autonomy has been presented in a number of articles, but it has not been subjected to much critical scrutiny. In this paper I distinguish three versions of the argument: 1) that each physician should be free to exercise his or her own medical judgment; 2) that the medical profession as a whole may provide futility standards to govern the practice of its members; and 3) that the moral integrity of each physician serves as a limit to treatment demands. I maintain that none of these versions succeeds in overcoming the standard objection that futility determinations involve value judgments best left to the patients, their designated surrogates, or their families. Nor do resource considerations change this fact, since they should not influence the properly patient‐centered judgment about futility.     

Severe upper airway obstruction due to delayed retropharyngeal hematoma formation following blunt cervical trauma

Background

We report a case of severe upper airway obstruction due to a retropharyngeal hematoma that presented nearly one day after a precipitating traumatic injury. Retropharyngeal hematomas are rare, but may cause life-threatening airway compromise.

Case presentation

A 50 year-old man developed severe dyspnea with oropharyngeal airway compression due to retropharyngeal hematoma 20 hours after presenting to the emergency department. The patient also had a fractured first cervical vertebra and was diagnosed with a left brachial plexopathy. The patient underwent emergent awake fiberoptic endotracheal intubation to provide a definitive airway.

Conclusion

Retropharyngeal hematoma with life-threatening airway compromise can develop hours or days after a precipitating injury. Clinicians should be alert to the potential for this delayed airway collapse, and should also be prepared to rapidly secure the airway in this patient population likely to have concomitant cervical spinal or head injuries.     

The effects of cross-fiber deformation on axial fiber stress in myocardium.

We incorporated a three-dimensional generalization of the Huxley cross-bridge theory in a finite element model of ventricular mechanics to examine the effect of nonaxial deformations on active stress in myocardium. According to this new theory, which assumes that macroscopic tissue deformations are transmitted to the myofilament lattice, lateral myofilament spacing affects the axial fiber stress. We calculated stresses and deformations at end-systole under the assumption of strictly isometric conditions. Our results suggest that at the end of ejection, nonaxial deformations may significantly reduce active axial fiber stress in the inner half of the wall of the normal left ventricle (18-35 percent at endocardium, depending on location with respect to apex and base). Moreover, this effect is greater in the case of a compliant ischemic region produced by occlusion of the left anterior descending or circumflex coronary artery (26-54 percent at endocardium). On the other hand, stiffening of the remote and ischemic regions (in the case of a two-week-old infarct) lessens the effect of nonaxial deformation on active stress at all locations (9-32 percent endocardial reductions). These calculated effects are sufficiently large to suggest that the influence of nonaxial deformation on active fiber stress may be important, and should be considered in future studies of cardiac mechanics.     

Isolation of persistent left superior vena cava during atrial fibrillation ablation

Persistent left superior vena cava is a rarely seen anomaly but it may be an arrhythmogenic source for paroxysmal atrial fibrillation. Furthermore, the complex anatomicregion between the left superior vena cava and the pulmonary veins may leads to misinterpretation of the pulmonary vein recordings during atrial fibrillation ablation. Approaches that might be helpful to overcome these problems are discussed in this case report.     

Pregnancy in women with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is increasingly being diagnosed in pregnant women. Women with HCM generally tolerate pregnancy well. The risk is however higher in women who are symptomatic before pregnancy or in those with severe left ventricular outflow tract obstruction. The incidence of arrhythmias does not appear to be increased during pregnancy and maternal mortality is low. Prior to conception, women with HCM should have a risk assessment as well as genetic counselling. During pregnancy beta-blockers should be continued and the judicious use of diuretics may be required to treat symptoms of dyspnoea. A vaginal delivery with regional anaesthesia is usually appropriate. Women should be managed by a specialist multidisciplinary team.     

Experiments with an apparatus for lyophile desiccation of micro-organisms

Summary Lyophyle desiccation is an extremely valuable method of preserving micro-organisms. The apparatus described above proves satisfactory. The material should be frozen as rapidly as possible at a temperature of −35°C. or lower, and the apparatus should be constructed in such a way that the pressure remains approximatively constant. During the sealing of the ampoules care should be taken that no dry material passes from the latter to the apparatus. A time limit for the desiccation process is hard to fix. When water has condensed on the outside surface of the ampoules, the apparatus is left untouched for about an hour. This brings the total duration of the desiccation as a rule up to 1 1/2 to 2 hours. A volume of 0.25 ml skimmed milk suffices for the preservation of a strain. It is advisable to start from a fresh culture that has been grown on a solid medium and to suspend the required amount in skimmed milk at a pH of 7.4–7.8. The suspension should directly be frozen in a thin layer. Bofore the frozen ampoules are submitted to the desiccation process, they may be kept for some time at a temperature of −35°C. For this as well as for many valuable indications we are greatly indebted to the Staff of the Kamerlingh Onnes Laboratory.     

Selection of Patients for Coronary Artery Bypass Operations

Bypass operations have proved to be an effective treatment for advanced coronary artery disease. Randomized clinical trials have now shown that compared with medical treatment, bypass operations enhance survival in patients who have three-vessel disease or left main coronary stenosis. The goals of both medical and surgical treatment should be to improve a patient''s quality of life, extend survival and reduce medical care costs. Preliminary data suggest that bypass operations may be less costly than medical treatment in patients with severe angina that requires repeated or prolonged stays in hospital.     

The distribution and density of ET-1 and its receptors are different in human right and left ventricular endocardial endothelial cells

Evidence suggests that endocardial endothelial cells (EECs) may play a role in the regulation of cardiac function by releasing ET-1. Furthermore, reports in the literature suggested that differences may exist in peptide receptor distribution between the left and right EECs. In this study, we verified if the distribution and density of ET-1 and its receptors could be different in right as compared to left ventricular EECs, and whether this difference may affect ET-1-induced increase of intracellular calcium. Using immunofluorescence and 3D confocal microscopy, our results showed that in both cell types, the ET(A) receptor is present and is homogeneously distributed throughout the two cell types. The relative density of the ET(A) receptor is similar in both right and left ventricular EECs. The ET(B) receptor is also present in right and left ventricular EECs, however, the relative density of the ET(B) receptor is higher in the nucleus as compared to the cytosol. In addition, the ET(B) receptor density was found to be higher in left EECs as compared to right EECs. In addition, our results showed that ET-1 is present in the cytosol and the nucleus of both types of cells and that the relative density of ET-1 is higher in right as compared to left ventricular EECs. Moreover, using the Fura-2 calcium measurement technique, our results showed that in left ventricular EECs, both ET(A) and ET(B) receptor activation mediated the effect of ET-1 on intracellular calcium, whereas in right ventricular EECs, this effect was solely mediated by the ET(A) receptor. In conclusion, our results showed that ET-1 and its receptors are present in both right and left ventricular EECs. However, the distribution and relative density of ET-1 and its receptors seem to be different in right EECs as compared to left EECs.     

Modifying oligoalanine conformation by replacement of amide to ester linkage

Oligo(lactic acid) is an ester‐analogue of short oligoalanine sequence and adopts a rigid left‐handed helical structure. In this study, oligo(lactic acid) was incorporated into oligoalanine sequences and their conformations were studied by vibrational circular dichroism and electronic circular dichroism spectroscopy. The results suggested that oligo(lactic acid) moiety in these sequences maintains a left‐handed helix and increases the conformational propensity of the oligoalanine moiety to form a left‐handed polyproline type II‐like helix. The importance of the chirality of oligo(lactic acid) moiety for the oligoalanine conformation was also studied. The results obtained in this study should be useful in developing ester‐containing oligopeptides that function better than normal peptides.     

Management of pheochromocytoma during pregnancy.

To reduce the high maternal and fetal mortality in pheochromocytoma of pregnancy, therapy is advocated with phenoxybenzamine and propranolol to obtain adequate alpha- and beta-adrenergic receptor blockade. In early pregnancy control of symptoms may be difficult, but the patient may be carried to term with such medical therapy. Delivery should be by cesarean section before the onset of labour, with, if possible, simultaneous removal of the tumour. Additional preoperative preparation with phenoxybenzamine and propranolol and careful intraoperative management are essential. During her third pregnancy a 29-year-old woman was found to have a pheochromocytoma of the left adrenal gland. After the medical therapy and preparation described, the infant was delivered by cesarean section and the mother''s left adrenal gland excised. Eight-year follow-up, including during a fourth pregnancy, showed no recurrence of tumour in the mother and only mild hypertension. The infant developed normally.