Successful catheter ablation of persistent electrical storm late post myocardial infarction by targeting purkinje arborization triggers

Drug refractory ventricular tachycardia (VT) occurring as a storm after acute myocardial infarction has grave prognosis. We report a case of a middle-aged lady who presented with drug refractory VT that lead to persistent electrical storm two weeks after an anterior wall myocardial infarction. She underwent a successful catheter ablation of VT followed a few days later by implantation of an AICD. Catheter ablation of the VT could control the persistent electrical storm and the patient was free from a recurrence of VT at three month follow up.     

Acute outcome of treating patients admitted with electrical storm in a tertiary care centre

Background

Electrical storm (ES) is a life threatening emergency. There is little data available regarding acute outcome of ES.

Aims

The study aimed to analyze the acute outcome of ES, various treatment modalities used, and the factors associated with mortality.

Methods

This is a retrospective observational study involving patients admitted with ES at our centre between 1/1/2007 and 31/12/2013.

Results

41 patients (mean age 54.61 ± 12.41 years; 86.7% males; mean ejection fraction (EF) 44.51 ± 16.48%) underwent treatment for ES. Hypokalemia (14.63%) and acute coronary syndrome (ACS) (14.63%) were the commonest identifiable triggers. Only 9 (21.95%) patients already had an ICD implanted. Apart from antiarrhythmic drugs (100%), deep sedation (87.8%), mechanical ventilation (24.39%) and neuraxial modulation using left sympathetic cardiac denervation (21.95%) were the common treatment modalities used. Thirty-three (80.49%) patients could be discharged after a mean duration of 14.2 ± 2.31 days. Eight (19.5%) patients died in hospital. The mortality was significantly higher in those with EF < 35% compared to those with a higher EF (8 (42.11% vs 0 (0%), p = 0.03)). There was no significant difference in mortality between those with versus without a structural heart disease (8 (21.1% vs 0 (0%), p = 0.32)). Comparison of mortality an ACS with ES versus ES of other aetiologies (3 (50%) vs 5 (14.29) %, p = 0.076)) showed a trend towards significance.

Conclusion

With comprehensive treatment, there is reasonable acute survival rate of ES. Hypokalemia and ACS are the commonest triggers of ES. Patients with low EF and ACS have higher mortality.     

Catheter Ablation in Patients with Electrical Storm in Early Post Infarction Period (6 Weeks): A Single Centre Experience

Background

Electrical storm (ES) due to drug refractory ventricular tachycardia (VT) occurring within first few weeks of acute myocardial infarction (MI) has poor prognosis. Catheter ablation has been proposed for treating VT occurring late after MI, but there is limited data on catheter ablation in VT within first few weeks of MI.

Methods and Results

Five patients (4 males, mean age 54.2±12.11 years) between June 2008 to July 2012, referred for VT presenting as ES refractory to antiarrhythmic drugs in the early post infarction period (six weeks following MI) despite revascularization. Three patients had anterior wall MI and two inferior wall MI with left ventricular ejection fraction ranging from 26 to 35%.All underwent catheter ablation within 48 hours of being in VT except one who presented late. Clinical VT was induced in all five patients. Total number of VTs induced were 11 (2.2±1.09 per patient). Two patients needed epicardial ablation via pericardial puncture. Though acute success was 100%, one patient had recurrence of clinical VT the next day of procedure.One patient succumbed to sepsis with multiple organ failure. The remaining four patients are doing well without further clinical recurrence of VT over a period of 3.7 years of follow-up.

Conclusion

Catheter ablation can be a useful adjunctive therapy for patients with recurrent VT in the early post infarction period. This procedure appears to be safe with acceptable success rate.     

Genetic variants in post myocardial infarction patients presenting with electrical storm of unstable ventricular tachycardia

Electrical storm (ES) is a life threatening clinical situation. Though a few clinical pointers exist, the occurrence of ES in a patient with remote myocardial infarction (MI) is generally unpredictable. Genetic markers for this entity have not been studied. In the present study, we carried out genetic screening in patients with remote myocardial infarction presenting with ES by next generation sequencing and identified 25 rare variants in 19 genes predominantly in RYR2, SCN5A, KCNJ11, KCNE1 and KCNH2, CACNA1B, CACNA1C, CACNA1D and desmosomal genes - DSP and DSG2 that could potentially be implicated in electrical storm. These genes have been previously reported to be associated with inherited syndromes of Sudden Cardiac Death. The present study suggests that the genetic architecture in patients with remote MI and ES of unstable ventricular tachycardia may be similar to that of Ion channelopathies. Identification of these variants may identify post MI patients who are predisposed to develop electrical storm and help in risk stratification.     

Electrophysiological Features of Atrial Flutter in Cardiac Sarcoidosis: A Report of Two Cases

We report two cases of systemic sarcoidosis with atrial flutter as the clinical manifestation. In one patient, who had symptoms of shorter duration, the arrhythmia was no longer inducible after a course of glucocorticoid therapy. Electroanatomical mapping in the other case revealed patchy fibrosis of the left atrial myocardium and multiple macro-reentrant circuits. Sinus rhythm could be restored with ablation of these reentrant circuits. To our knowledge, this is the first report on the demonstration of atrial scarring in a patient with sarcoidosis using 3-D electroanatomical mapping. These two cases illustrate that the inflammation of atrial myocardium is the primary mechanism of atrial arrhythmias in patients with cardiac sarcoidosis.     

Unintended Harm and Benefit of the Implantable Defibrillator in an Unfortunate 19-Year-Old Male: Featuring a Sequence of Rare Life-threatening Complications of Cardiac Procedures

All procedures have inherent risk. Our patient endured a sequence of rare life-threatening complications from commonly preformed procedures. The sequence of these complications was; large pericardial effusion post implantable cardioverter-defibrillator (ICD) implantation with echocardiographic signs of tamponade, left main narrowing post radiofrequency ablation, and late stent thrombosis post coronary intervention with a bare metal stent. All these occurred to one unfortunate young man. Furthermore, our patient demonstrated an unintended benefit of ICD which saved his life.     

Intercellular communication inAzolla roots: II. Electrical coupling

Summary There is a predictable and well defined variation in numbers of plasmodesmata in roots ofAzolla. As the apical cell of the root ages, it lays down walls with progressively fewer plasmodesmata, thereby gradually cutting itself off from the rest of the root (Gunning 1978). Electrical coupling was examined between the apical cell and an adjacent merophyte in roots of various lengths. The apical cell becomes increasingly electrically isolated from the rest of the root as it ages. Electrical coupling is strongly correlated with the number of the plasmodesmata between the coupled cells. The resistance of a plasmodesma, as estimated from equivalent electrical circuits, was 150–600 times more resistive than a value based on theoretical considerations. No evidence was found for a change in the physiology of plasmodesmata as the root ages. Coupling experiments, both on root hairs and at the apex, gave some suggestion that plasmodesmata may be less resistive towards the apical cell than away from it.     

（强）热带风暴条件下农田林网对防止棉花倒伏及减产的效应

研究结果表明 ,林带背风面 2 7H范围内 ,林网具有不同程度减轻棉株倒伏及产量损失的功能 ,有效防护范围为 0 .42～ 2 3H ,最大籽棉产量和衣分率效果区为 1 0～ 1 3H .与受灾区相比 ,保护区的籽棉产量增加 45.0 1 % ,皮棉产量增加 52 .69% .整个林网内的籽棉产量增加 2 9 94% ,皮棉产量增加 35 0 6% .     

宁蒙特大沙暴科学考察报告

在对1993年5月5日宁蒙两区发生特大沙暴考察的基础上,系统分析了特大沙暴形成的原因、造成的危害及沙暴的运行规律。结果表明,特大沙暴发生是在大气候条件控制下,由大风、干旱和土地严重沙漠化不断扩大的综合作用结果,这次特大沙暴给人民生命财产造成了极为惨重的损失。沙暴运行规律表明,防护林和治沙工程对防止沙暴的作用是十分显著的。同时针对沙暴易发区的自然、社会和经济特点,提出了预防、整治和合理开发利用该区资源的综合防治对策。     

冰灾后南岭五指山森林树种的受损与早期恢复

应用样带调查法,于2009年调查了2008年冰灾后南岭五指山森林优势种及保护树种的受损及恢复情况。在3条长2～7km、宽15m的样带调查区共记录了2832株胸径>2cm的树木,它们隶属于53科96属141种,其中2072株林木受到损伤,总受损率为73%,61%为轻度受损。灾后一年,约84%的个体能通过萌条恢复生长,但16%未出现萌条而死亡或濒临死亡。群落优势类群壳斗科、樟科、木兰科和金缕梅科优势种的受损率和萌条恢复率均较高。共记录了15种国家级保护树种,以广东松(Pinus kwangtungensis)和福建柏(Fokienia hodginsii)最为常见,除三尖杉(Cephalotaxus fortunei)和穗花杉(Amentotaxus argot-aenia)外,其余种类均有不同程度的受损,其中59%死亡或濒临死亡。此外,在43个具3株以下的小频度种中,25%的个体未见恢复而死亡。本研究结果揭示了2008年冰雪灾害对南岭五指山森林林木造成了严重的伤害,大多数树种具有较强的自然恢复能力,能以快速萌条方式进行恢复,但部分濒危珍稀植物和低密度种的死亡可能会改变原有群落的物种组成,进而影响未来群落的演替进程。     

Electrical stimulation promotes nerve growth factor-induced neurite outgrowth and signaling

Background

Neurotrophins are important regulators for neural development and regeneration. Nerve growth factor (NGF) therapy has been tested in various models of neural injury and degeneration. However, whether NGF can reach target tissues and maintain effective concentration for a certain period of time remains uncertain. To facilitate neural regeneration, we investigate the possibility of combining NGF and electrical stimulation (ES) in promoting neurite outgrowth, an essential process during neural regeneration.

Methods

PC12 cells were seeded on collagen and indium tin oxide (ITO)-coated area on the transparent conductive devices. Cells were then subjected to the combination of ES and NGF treatment. Neurite outgrowth was compared.

Results

Our findings suggest that ES of 100 mV/mm together with NGF provides optimal effect on neurite outgrowth of PC12 cells. ES increases NGF-induced neurite length but reduces neurite branching, indicative of its primary effect on neurite elongation instead of initiation. One mechanism that ES enhances neurite outgrowth is through increasing NGF-induced phosphorylation of ERK1/2 (pERK1/2) and expression of Egr1 gene. ES has previously been demonstrated to increase the activity of protein kinase C (PKC). Our result indicates that activating PKC further increases NGF-induced pERK1/2 and thus neurite outgrowth.

Conclusion

It is likely that ES promotes NGF-induced neurite outgrowth through modulating the activity of ERK1/2.

General significance

Findings from this study suggest that combining ES and NGF provides a promising strategy for promoting neurite outgrowth.     

（强）热带风暴条件下农田林网对防止水稻倒伏及减产的效应

对江苏沿海地区（强）热带风暴条件下农田林网防止水稻倒伏和减产效应的研究表明,有林网农田的水稻倒伏率为１６．２８％,无林网农田为４９．７３％;水稻在灌浆结实期倒伏以后,千粒重减少１３．２４％,产量减少１４．３２％,有林网农田的水稻倒伏减产率为无林网农田的１／３．主林带林木保存率大于９０％的林网抗倒度最大,水稻倒伏减产率最小．     

Incidence,Risk Factors,Treatment and Prognosis of Popliteal Artery Embolization in the Superficial Femoral Artery Interventions

Objective

Percutaneous transluminal angioplasty and stenting (PTA + stent) has gained acceptance as a primary treatment modality for the superficial femoral artery (SFA) diseases. Popliteal artery embolization (PAE) is a severe complication in SFA interventions. The purpose of this study was to evaluate the incidence, risk factors, treatment and prognosis of PAE in primary SFA PTA + stent.

Methods

Chronic SFA arteriosclerosis cases that underwent primary PTA + stent were reviewed from a retrospectively maintained database. Runoff vessels were evaluated in all cases before and after the interventions for PAE detection. The primary patency, secondary patency and limb salvage rates were calculated using Kaplan-Meier analysis and compared using log-rank analysis. Cox multivariate regression was performed to evaluate predictors of patency and limb salvage rates.

Results

There were 436 lesions treated in 388 patients with 10 PAE events (2.3%) in total. PAE rate was significantly higher in Transatlantic Inter-Society Consensus (TASC) C/D group compared with TASC A/B group (OR = 8.91, P = .002), in chronic total occlusion (CTO) lesions compared with stenotic lesions (P<.0001), and in group with history of cerebral ischemic stroke (OR = 6.11, P = .007). PAE rates were not significantly affected by age, sex, smoking, hypertension, diabetes, hyperlipidemia and runoff status. The binary logistic regression showed that only the TASC C/D was an independent predictor of PAE (P = .031). The 12-month and 24-month primary patency, secondary patency and limb salvage rates in PAE group showed no significant differences comparing with non-PAE group.

Conclusions

PAE is a rare event in primary SFA PTA + stent. TASC C/D lesion, CTO and cerebral ischemic stroke history are risk factors for PAE. PAE is typically reversible by comprehensive techniques. If the popliteal flow is restored in time, PAE has no significant effect on long-term patency and limb salvage rates.     

Dual Atrioventricular Nodal Pathways Physiology: A Review of Relevant Anatomy,Electrophysiology, and Electrocardiographic Manifestations

More than half a century has passed since the concept of dual atrioventricular (AV) nodal pathways physiology was conceived. Dual AV nodal pathways have been shown to be responsible for many clinical arrhythmia syndromes, most notably AV nodal reentrant tachycardia. Although there has been a considerable amount of research on this topic, the subject of dual AV nodal pathways physiology remains heavily debated and discussed. Despite advances in understanding arrhythmia mechanisms and the widespread use of invasive electrophysiologic studies, there is still disagreement on the anatomy and physiology of the AV node that is the basis of discontinuous antegrade AV conduction. The purpose of this paper is to review the concept of dual AV nodal pathways physiology and its varied electrocardiographic manifestations.     

Electrical characteristics of the apical and basal-lateral membranes in the turtle bladder epithelial cell layer

(1) The active transport of Na⁺ across the turtle bladder epithelial cell layer consists of a passive entry step through a Na⁺-selective path in the apical membrane and an active extrusion step through Na⁺ pump-containing path in the basal-lateral membrane together with some back-leakage through the paracellular spaces and tight junctions between the epithelial cells. This hypothesis has now been verified qualitatively and to some extent, quantitatively by the use of an intracellularly-located microelectrode in conjunction with a conventional assembly of extracellularly-located macroelectrodes mainly in short-circuited bladders bathed by Na⁺-rich Ringer media. Under these conditions, the intracellular potential (V_sc) averaged 38.4 mV with the cell electronegative; the fractional resistance of the apical membrane ($\text{?R}{}_{\mathrm{<mtext>a</mtext>}}$) averaged 0.55; while the concomitant transepithelial parameters, short circuiting current (I_sc) and electrical conductance (G_t), average 68.6 μA/cm² and 0.98 mS/cm², respectively. (2) The relation between these parameters and the transepithelial flow of Na⁺ (orI_sc) is evoked by blocking Na⁺ entry into the cell (by the mucosal addition of amiloride or removal of mucosal Na⁺). Amiloride-induced blockade of the Na⁺ entry step results in a rapid hyperpolarization of the cell interior during which V_sc = —79.1 mV and $\text{?R}{}_{\mathrm{<mtext>a</mtext>}}\text{= 0.92}$. I_sc and G_t (equivalent to the shunt conductance under these conditions) averaged 5 μA/cm² and 0.35 mS/cm², respectively. The entire process is reversible on re-admission of Na⁺ entry into the cell. (3) A slow depolarization of the cell interior in the period of blocked transapical Na⁺ entry is opposite to that expected from an electroneutral Na⁺-K⁺ exchanging pump; but instead is the predictable response of an electrogenic Na⁺ pump in parallel with a passive K⁺-selective conductance in the basal-lateral membrane. (4) The electrogenicity concept is substantiated after pretreatment of the bladder with serosal ouabain, which changes the response of V_sc to amiloride (from the aforementioned biphasic response) to a step-function response, attributable mainly to the development of a slowly dissipating K⁺ diffusion potential across the basallateral membrane. (5) Under open-circuit conditions, the electronegativity of cell to mucosa (V_a) is a linear inverse function of the electropositivity of serosa to mucosa (V_t). For V_t ? 100 mV, V_a is positive; and for V_t between ?30 and 90 mV, V_a is negative.     

Electrical stimulation of human embryonic stem cells: Cardiac differentiation and the generation of reactive oxygen species

Exogenous electric fields have been implied in cardiac differentiation of mouse embryonic stem cells and the generation of reactive oxygen species (ROS). In this work, we explored the effects of electrical field stimulation on ROS generation and cardiogenesis in embryoid bodies (EBs) derived from human embryonic stem cells (hESC, line H13), using a custom-built electrical stimulation bioreactor. Electrical properties of the bioreactor system were characterized by electrochemical impedance spectroscopy (EIS) and analysis of electrical currents. The effects of the electrode material (stainless steel, titanium-nitride-coated titanium, titanium), length of stimulus (1 and 90 s) and age of EBs at the onset of electrical stimulation (4 and 8 days) were investigated with respect to ROS generation. The amplitude of the applied electrical field was 1 V/mm. The highest rate of ROS generation was observed for stainless steel electrodes, for signal duration of 90 s and for 4-day-old EBs. Notably, comparable ROS generation was achieved by incubation of EBs with 1 nM H₂O₂. Cardiac differentiation in these EBs was evidenced by spontaneous contractions, expression of troponin T and its sarcomeric organization. These results imply that electrical stimulation plays a role in cardiac differentiation of hESCs, through mechanisms associated with the intracellular generation of ROS.     

Electrical fusion of protoplasts from sycamore mutants and hybrid selection on hypoxanthine-aminopterin-thymidine (HAT) medium

Summary An electrical fusion method has been used to form somatic hybrids between protoplasts of two mutant cell lines of sycamore tissue culture cells. Both mutants will not grow in a hypoxanthine-aminopterin-thymidine (HAT) medium. It was possible to select the fused hybrids from homospecific fusion products and nonfused protoplasts by the use of HAT medium. In this way the viability and regeneration of the fused cells during the first few weeks of culture could be evaluated. An electron microscopic examination of the fusion process showed that it occurred at a series of points along the surface of the plasmalemma. Cytoplasmic bridges between the two cells were formed separated by vesicles which later dispersed to give complete cytoplasmic continuity between the cells.     

Hyperglycaemia,Insulin Therapy and Critical Penumbral Regions for Prognosis in Acute Stroke: Further Insights from the INSULINFARCT Trial

Background

Recently, the concept of ‘clinically relevant penumbra’ was defined as an area saved by arterial recanalization and correlated with stroke outcome. This clinically relevant penumbra was located in the subcortical structures, especially the periventricular white matter. Our aims were to confirm this hypothesis, to investigate the impact of admission hyperglycemia and of insulin treatment on the severity of ischemic damages in this area and to study the respective contributions of infarct volume and ischemic damage severity of the clinically relevant penumbra on 3-month outcome.

Methods

We included 99 patients from the INSULINFARCT trial. Voxel-Based Analysis was carried on the Apparent Diffusion Coefficient (ADC) maps obtained at day one to localize the regions, which were more damaged in patients i) with poor clinical outcomes at three months and ii) without arterial recanalization. We determined the intersection of the detected areas, which represents the clinically relevant penumbra and investigated whether hyperglycemic status and insulin regimen affected the severity of ischemic damages in this area. We performed logistic regression to examine the contribution of infarct volume or early ADC decrease in this strategic area on 3-month outcome.

Findings

Lower ADC values were found in the corona radiata in patients with poor prognosis (p< 0.0001) and in those without arterial recanalization (p< 0.0001). The tracking analysis showed that lesions in this area interrupted many important pathways. ADC values in this area were lower in hyperglycemic than in normoglycemic patients (average decrease of 41.6 ± 20.8 x10⁻⁶mm²/s) and unaffected by the insulin regimen (p: 0.10). ADC values in the clinically relevant penumbra, but not infarct volumes, were significant predictors of 3-month outcome.

Conclusion

These results confirm that the deep hemispheric white matter is part of the clinically relevant penumbra and show that hyperglycaemia exacerbates the apparition of irreversible ischemic damage within 24 hours in this area. However, early intensive insulin therapy fails to protect this area from infarction.

Trial Registration

ClinicalTrials.gov NCT00472381