Assessment of ablation catheter contact on valve annulus: Implications on accessory pathway ablation

BackgroundCatheter-tissue contact force is an important factor influencing lesion size and efficacy and thereby potential for arrhythmia recurrence following accessory pathway (AP) radiofrequency ablation. We aim to evaluate adequacy and perception of catheter contact on the tricuspid and mitral annuli.MethodsData were collected from 42 patients undergoing catheter ablation. Operators were blinded to contact force information and reported perceived contact (poor, moderate, or good) while positioning the catheter at four tricuspid annular sites (12, 9, 6 and 4 o'clock positions; abbreviated as TA12, TA9, TA6 and TA4) and three mitral annular sites (3, 5 and 7 o'clock positions; abbreviated as MA3, MA5 and MA7) through long vascular sheaths.ResultsThe highest and lowest mean contact forces were obtained at MA7 (13.3 ± 1.7 g) and TA12 (3.6 g ± 1.3 g) respectively. Mean contact force on tricuspid annulus (6.1 g ± 0.9 g) was lower than mitral annulus (9.8 ± 0.9 g) locations (p = 0.0036), with greater proportion of sites with <10 g contact force (81.7% vs 60.4%; p = 0.0075). Perceived contact had no impact on measured mean contact force for both mitral and tricuspid annular positions (p = 0.959 and 0.671 respectively). There was correlation of both impedance and atrial electrogram amplitude with contact force, though insufficient to be clinically applicable.ConclusionA high proportion of annular catheter applications have low contact force despite being performed with long vascular sheaths in the hands of experienced operators. In addition, there was no impact of operator perceived contact force on actual measured contact force. This may carry implications for success of AP ablation.     

Field trial detects incomplete barstar attenuation of vegetative cytotoxicity in Populus trees containing a poplar LEAFY promoter::barnase sterility transgene

We tested the efficacy of an attenuation system developed to preclude the deleterious effects of floral promoter::cytotoxin genes on vegetative growth of transgenic sterile plants. We tested the promoter (2.6 kb 5′ region) of the poplar LEAFY gene PTLF driving barstar, combined on the same T-DNA with barstar driven by either the CaMV 35S basal promoter +5 to −72 fragment (35SBP), 35SBP fused to the TMV omega element (35SBP omega), or the NOS promoter. The unattenuated pPTLF::barnase construct failed to give rise to any transgenic events, suggesting substantial non-reproductive expression from this promoter. The barstar-attenuated constructs enabled transformation, but the rate was reduced by nearly one-third. Four events (7% of attenuated events) had highly abnormal morphology, and were identified during the early phases of propagation; these events had significantly higher barnase:barstar expression ratios based on quantitative RT-PCR. A greenhouse study showed that phenotypically normal attenuated plants grew at the same rate as wild-type and barnase-lacking transgenic plants. A statistically significant positive linear association was found between relative growth rate (RGR) and barstar:barnase ratio in the attenuated events, and graphical analysis suggested a threshold for barstar attenuation of barnase, above which additional levels of barstar did not provide further attenuation. Surprisingly, the appearance and growth rate of the nearly all of the attenuated events were substantially reduced after one or two growing seasons in the field, and the extent of growth reduction was associated with barstar:barnase expression ratio. These results demonstrate the importance of field testing during early phases of research to identify pleiotropic effects of transgenic sterility genes in trees.     

Ablation of the secondary heart field leads to tetralogy of Fallot and pulmonary atresia

Recent studies in chick and mouse embryos have identified a previously unrecognized secondary heart field (SHF), located in the ventral midline splanchnic mesenchyme, which provides additional myocardial cells to the outflow tract as the heart tube lengthens during cardiac looping. In order to further delineate the contribution of this secondary myocardium to outflow development, we labeled the right SHF of Hamburger-Hamilton (HH) stage 14 chick embryos via microinjection of DiI/rhodamine and followed the fluorescently labeled cells over a 96-h time period. These experiments confirmed the movement of the SHF into the outflow and its spiraling migration distally, with the right side of the SHF contributing to the left side of the outflow. In contrast, when the right SHF was labeled at HH18, the fluorescence was limited to the caudal wall of the lengthening aortic sac. We then injected a combination of DiI and neutral red dye, and ablated the SHF in HH14 or 18 chick embryos. Embryos were allowed to develop until day 9, and harvested for assessment of outflow alignment. Of the embryos ablated at HH14, 76% demonstrated cardiac defects including overriding aorta and pulmonary atresia, while none of the sham-operated controls were affected. In addition, the more severely affected embryos demonstrated coronary artery anomalies. The embryos ablated at HH18 also manifested coronary artery anomalies but maintained normal outflow alignment. Therefore, the myocardium added to the outflow by the SHF at earlier stages is required for the elongation and appropriate alignment of the outflow tract. However, at later stages, the SHF contributes to the smooth muscle component of the outflow vessels above the pulmonary and aortic valves which is important for the development of the coronary artery stems. This work suggests a role for the SHF in a subset of congenital heart defects that have overriding aorta and coronary artery anomalies, such as tetralogy of Fallot and double outlet right ventricle.     

Ventricular Tachycardia Storm in Cardiac Sarcoidosis: A 76-Day-ICU-Nightmare

Ventricular Tachycardia (VT) is a life threatening complication in a patient with Cardiac Sarcoidosis. The management becomes extremely challenging when it is refractory to traditional anti-arrhythmic drugs. Herein, we describe a case where a 33-year-old patient with VT storm, with an implantable cardioverter defibrillator (ICD), was managed by medications, sedation, ventilator support and multiple Radio-Frequency (RF) ablation procedures over 76- days ICU stay period.     

Cryoballoon ablation for atrial fibrillation

Focal point-by-point radiofrequency catheter ablation has shown considerable success in the treatment of paroxysmal atrial fibrillation. However, it is not without limitations. Recent clinical and preclinical studies have demonstrated that cryothermal ablation using a balloon catheter (Artic Front©, Medtronic CryoCath LP) provides an effective alternative strategy to treating atrial fibrillation. The objective of this article is to review efficacy and safety data surrounding cryoballoon ablation for paroxysmal and persistent atrial fibrillation. In addition, a practical step-by-step approach to cryoballoon ablation is presented, while highlighting relevant literature regarding: 1) the rationale for adjunctive imaging, 2) selection of an appropriate cryoballoon size, 3) predictors of efficacy, 4) advanced trouble-shooting techniques, and 5) strategies to reduce procedural complications, such as phrenic nerve palsy.     

Balloon Catheter Position and its Relationship with Esophageal Temperature during Pulmonary Vein Isolation using High-Intensity Focused Ultrasound

BackgroundHIFU can achieve PVI, but severe esophageal complications have happened. We analyzed relative position of HIFU balloon catheter (BC) to esophageal temperature (ET) probe and correlated it to ET changes.Methods and ResultsBefore each ablation relative position of HIFU BC to ET probe was recorded in RAO 30° and LAO 40°. We compared ablations where ET at end of ablation was < 38.5°C or ≥ 38.5°C and < 40.0°C or ≥ 40.0°C.A total of 600 images from 311 ablations in 28 patients (18 male, age 63 ± 7 years), were analyzed. ET ≥ 38.5°C was reached when distance from BC to ET probe was: < 20 mm in LAO for RSPV and < 29 mm in LAO for RIPV. For RIPV ET ≥ 38.5°C was reached when angle between BC and ET probe was significantly smaller in LAO and RAO. ET ≥ 40.0°C was reached when distance of BC to ET probe was: < 20 mm in LAO for RIPV, < 14 mm in RAO for RIPV, < 18 mm in RAO for LIPV. ET increased to ≥ 40.0°C when distance from BC to ET probe was significantly longer in LAO for LIPV. For RIPV ET ≥ 40.0°C was reached when angle between BC and ET probe was significantly smaller in LAO.ConclusionsThere is a relationship between distance/angle of HIFU BC to ET probe and ET: shorter distances and smaller angles can cause higher ET.     

Early regulative ability of the neuroepithelium to form cardiac neural crest

The cardiac neural crest (arising from the level of hindbrain rhombomeres 6–8) contributes to the septation of the cardiac outflow tract and the formation of aortic arches. Removal of this population after neural tube closure results in severe septation defects in the chick, reminiscent of human birth defects. Because neural crest cells from other axial levels have regenerative capacity, we asked whether the cardiac neural crest might also regenerate at early stages in a manner that declines with time. Accordingly, we find that ablation of presumptive cardiac crest at stage 7, as the neural folds elevate, results in reformation of migrating cardiac neural crest by stage 13. Fate mapping reveals that the new population derives largely from the neuroepithelium ventral and rostral to the ablation. The stage of ablation dictates the competence of residual tissue to regulate and regenerate, as this capacity is lost by stage 9, consistent with previous reports. These findings suggest that there is a temporal window during which the presumptive cardiac neural crest has the capacity to regulate and regenerate, but this regenerative ability is lost earlier than in other neural crest populations.     

Catheter Ablation of Hemodynamically Unstable Ventricular Tachycardia in a Patient with Dextro - Transposition of the Great Arteries and Mustard's Repair

Introduction

A patient with D-TGA and surgical repair (Mustard''s procedure) presented with appropriate ICD shocks due to monomorphic ventricular tachycardia, refractory to antiarrhythmic medications.

Methods and Results

The patient underwent an electrophysiological study and catheter ablation for the VT. Substrate and pace mapping techniques, with the help of an electroanatomical mapping system, was used to localize and ablate the tachycardia successfully.

Conclusions

In patients with D-TGA and Mustard''s repair, scar tissue resulting from VSD repair can act as a substrate for recurrent VT. Catheter ablation of VT is useful in management of VT that occurs despite antiarrhythmic therapy and/or when it is unstable.     

Dual energy computed tomography thermometry during hepatic microwave ablation in an ex-vivo porcine model

BackgroundMicrowave thermoablation (MTA) is a treatment method used to destroy hepatic tumors.ObjectiveTo investigate temperature changes during MTA of ex-vivo porcine liver using dual-energy computed tomography (DECT) imaging.MethodsThree MTA experiments were performed using ex-vivo porcine liver (15 × 15 × 15 cm³) and DECT imaging with 80/Sn140 kVp spectral and 0.5-weighted reconstructions. Images were acquired from basic organ temperature to 100 °C with 10 °C difference during microwave heating and cooling phases. Three fluoro-optic thermometers were used for temperature measurements; two were placed at 1 cm and third one positioned at 2 cm distance from the applicator. Tissue temperature, ablation-region-conspicuity (ARC), ablation-region dimensions and image quality were determined. Regression analysis was performed determining thermal sensitivity during heating and cooling phases.ResultsDetermined thermal sensitivities during heating phase were: −0.59 Hounsfield Unit/°C (80 kVp), −0.60HU/°C (0.5-weighted) and −0.59HU/°C (140 kVp); furthermore, during cooling: −0.56HU/°C (80 kVp), −0.55HU/°C (0.5-weighted) and −0.55HU/°C (140 kVp). ARC showed significantly higher (all P < 0.05) values for thermometer positions −1 and −2 compared to −3; however, comparison between positions −1 and −2 was insignificant (P > 0.05). Signal-to-noise ratios were higher for 0.5-weighted but ARC values were higher for 80 kVp images.ConclusionMicrowave thermal sensitivity on tissue was inversely linear with DECT image datasets. Heating phase showed higher influence of temperature on HU compared to cooling; ARC and ablation-region were increased with increase in temperature.     

Acute Right Coronary artery Occlusion During Cooled-Tip Radiofrequency Ablation of the Cavotricuspid Isthmus

Cooled-tip radiofrequencycatheter ablation of the cavotricuspid isthmus, performed after pulmonary vein isolation, resulted in acute occlusion of the posterolateral branch of the right coronary artery in a 49-year-old male with previously known right coronary artery disease. The occlusion was successfully stented. It is conceivable that previously diseased coronary arteries are more prone to be damaged during ablation.