Review of Atrioventricular Node Ablation Combined with Permanent His-Purkinje Conduction System Pacing in Patients with Atrial Fibrillation with Heart Failure.

With the advancement of pacing technologies, His-Purkinje conduction system pacing (HPCSP) has been increasingly recognized as superior to conventional right ventricular pacing (RVP) and biventricular pacing (BVP). This method is characterized by a series of strategies that either strengthen the native cardiac conduction system or fully preserve physical atrioventricular activation, ensuring optimal clinical outcomes. Treatment with HPCSP is divided into two pacing categories, His bundle pacing (HBP) and left bundle branch pacing (LBBP), and when combined with atrioventricular node ablation (AVNA), can significantly improve left ventricular (LV) function. It effectively prevents tachycardia and regulates ventricular rates, demonstrating its efficacy and safety across different QRS wave complex durations. Therefore, HPCSP combined with AVNA can alleviate symptoms and improve the quality of life in patients with persistent atrial fibrillation (AF) who are unresponsive to multiple radiofrequency ablation, particularly those with concomitant heart failure (HF) who are at risk of further deterioration. As a result, this "pace and ablate" strategy could become a first-line treatment for refractory AF. As a pacing modality, HBP faces challenges in achieving precise localization and tends to increase the pacing threshold. Thus, LBBP has emerged as a novel approach within HPCSP, offering lower thresholds, higher sensing amplitudes, and improved success rates, potentially making it a preferable alternative to HBP. Future large-scale, prospective, and randomized controlled studies are needed to evaluate patient selection and implantation technology, aiming to clarify the differential clinical outcomes between pacing modalities.

Left bundle branch area pacing: A new era of cardiac resynchronization therapy?

The recent systematic review and meta-analysis provided a comprehensive focus on the current state of cardiac resynchronization therapy (CRT). The authors determined the feasibility of physiological left bundle branch area pacing (LBBAP) in patients indicated for CRT through a careful analysis of trials. They found that LBBAP was associated with significant reductions in QRS duration, New York Heart Association functional class, B-type natriuretic peptide levels, and pacing thresholds as well as improvements in echocardiographic parameters compared to biventricular pacing.

Right ventriculography to guide left bundle branch pacing in pacing-induced cardiomyopathy: a novel case report.

Background: There is emerging evidence for the potential utility of left bundle branch area pacing (LBBAP), as an alternative to conventional cardiac resynchronization therapy (CRT). The utility of right ventriculography by way of power injector to facilitate lead placement has not yet been reported in the literature. Case summary: A 79-year-old female, with a background of poorly rate-controlled atrial fibrillation, presented with worsening dyspnoea. She had recently undergone single-chamber pacemaker insertion prior to an atrioventricular nodal (AVN) ablation, owing to failure in achieving successful CRT coronary sinus lead placement. She had clinical evidence of volume overload, and her electrocardiogram demonstrated right ventricular pacing. Echocardiography demonstrated left ventricular (LV) impairment, with an ejection fraction (EF) of 35%, and severe functional mitral regurgitation (MR). Her diagnosis was overall consistent with pacing-induced cardiomyopathy (PIC). In this patient, the use of right ventriculography, using power-injector-delivered contrast, successfully facilitated placement of an LBBAP lead, with confirmation of good threshold and sensing parameters. Following an upgrade to conduction system pacing, the patient recovered well. On recent follow-up, repeat echocardiography (24 months post initial presentation) demonstrated improved LV function (EF 45% from 35%) and only mild-to-moderate MR. Discussion: In conclusion, we demonstrate the utility of right ventriculography to facilitate placement of an LBBAP lead, successfully treating a patient who developed PIC from chronic right ventricular pacing following AVN ablation.

Predictive Factors for Functional and Anatomical Outcomes After Anti-VEGF Treatment for Macular Edema in Patients with Branch Retinal Vein Occlusion.

Purpose: This study aimed to identify predictive factors for the improvement of best-corrected visual acuity (BCVA) and reduction of central macular thickness (CMT) after treatment of macular edema (ME) due to branch retinal vein occlusion (BRVO) in a real-world setting. Methods: This retrospective study included patients with ME secondary to BRVO who were treated with intravitreal injection of bevacizumab as the first-line therapy and were followed up for 12 months. Demographic and clinical data, in addition to baseline spectral domain optical coherence tomography (SD-OCT) features, were considered as possible biomarkers of final BCVA and CMT. We also collected the data concerning the need for additional treatment including sectorial laser photocoagulation, change to another anti-VEGF agent, or intravitreal corticosteroid injection. Results: A total of 161 eyes were analyzed. BCVA significantly improved from baseline to 12-month follow-up (0.6 and 0.4 logMAR, respectively; P < 0.01). CMT decreased significantly during the follow-up period (from 498.0 to 325.0 µ m; P < 0.01). Final BCVA correlated positively with baseline BCVA (P < 0.01, r = 0.57). Older age at diagnosis and baseline SD-OCT findings including CMT, disruption of the retinal inner layers, retinal pigment epithelium (RPE) damage, and impairment of the ellipsoid zone and external limiting membrane negatively affected final BCVA (P < 0.01). Multiple regression analysis identified age and BCVA at baseline as the only independent predictors of final BCVA (P = 0.001 and P < 0.01, respectively). No association was found between clinical data, SD-OCT parameters, and final CMT. Conclusion: Various clinical and SD-OCT parameters are prognostically relevant for visual improvement in ME secondary to BRVO. Age at diagnosis and baseline BCVA were found to be independent predictors of visual outcome.

Branch retinal artery occlusion in a patient with COVID-19 infection: A case report.

We report here, a case of branch retinal artery occlusion (BRAO) in the left eye of a 76-year-old man that involved three arteries which was considered to be related to a COVID-19 infection due to high levels of blood cytokines and coagulation factors. Although the patient had hypertension and atherosclerosis, his hypertension had been well controlled for the past five years by regular antihypertensive medication. Twenty-five days after starting treatment with anti-inflammatory, anticoagulant and conservative therapy, the patient's biomarkers of inflammation and coagulation returned to normal and his vision improved. However, some visual field defects remained and were probably a consequence of low oxygen saturation.

New generalized metric based on branch length distance to compare B cell lineage trees.

The B cell lineage tree encapsulates the successive phases of B cell differentiation and maturation, transitioning from hematopoietic stem cells to mature, antibody-secreting cells within the immune system. Mathematically, this lineage can be conceptualized as an evolutionary tree, where each node represents a distinct stage in B cell development, and the edges reflect the differentiation pathways. To compare these lineage trees, a rigorous mathematical metric is essential. Analyzing B cell lineage trees mathematically and quantifying changes in lineage attributes over time necessitates a comparison methodology capable of accurately assessing and measuring these changes. Addressing the intricacies of multiple B cell lineage tree comparisons, this study introduces a novel metric that enhances the precision of comparative analysis. This metric is formulated on principles of metric theory and evolutionary biology, quantifying the dissimilarities between lineage trees by measuring branch length distance and weight. By providing a framework for systematically classifying lineage trees, this metric facilitates the development of predictive models that are crucial for the creation of targeted immunotherapy and vaccines. To validate the effectiveness of this new metric, synthetic datasets that mimic the complexity and variability of real B cell lineage structures are employed. We demonstrated the ability of the new metric method to accurately capture the evolutionary nuances of B cell lineages.

A New Dimension in Cardiac Imaging: 3D Exploration of the Atrioventricular Conduction Axis with Hierarchical Phase-contrast Tomography.

Much of our understanding of the atrioventricular conduction axis has been derived from early 20th-century histological investigations. These studies, while foundational, are constrained by their two-dimensional representation of complex, three-dimensional anatomy. The variability in the course of the atrioventricular conduction axis, and its relationship to surrounding cardiac structures, necessitates a more advanced imaging approach. Utilizing hierarchical phase-contrast tomography (HiP-CT) of an autopsied heart specimen with cellular resolution, this review provides a contemporary understanding of the atrioventricular conduction axis. By correlating these findings with three-dimensional computed tomographic reconstructions in living patients, we offer clinicians the insights needed accurately to predict the location of the atrioventricular conduction axis. This novel approach overcomes the inherent limitations of two-dimensional histology, enhancing our ability to understand and visualize the intricate relationships of the conduction axis within the heart.

Small cyst size and lack of growth as negative predictors of malignant transformation in low-risk intraductal papillary mucinous neoplasms of the pancreas: A systematic review and meta-analysis.

BACKGROUND AND AIM: For branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) without worrisome features (WFs) or high-risk stigmata (HRS), current guidelines recommend surveillance. However, these intraductal papillary mucinous neoplasm (IPMNs), especially the small and stable-sized ones, carry a low risk of malignant transformation. Our aim was to assess whether small cyst size and absence of rapid growth provide reassurance against the development of WFs/HRS and malignancy (high-grade dysplasia (HGD) or pancreatic cancer (PC)). METHODS: PubMed/Medline, Embase, the Cochrane Library and the Web of Science Core Collection were systematically searched from inception to May 2023 to identify studies investigating surveillance outcomes of low-risk BD-IPMNs. Studies assessing baseline cyst size and/or growth in relation to WFs/HRS and/or HGD/PC were included. The Newcastle-Ottawa scale tool was used to assess study quality. RESULTS: Of the 1937 identified manuscripts, 21 studies were eligible for inclusion. The quality of these studies was considered reasonable. A negative association between cyst size and WFs/HRS development was found in 11 out of 13 relevant studies, but only one out of nine studies reported a negative association between size and malignancy. Regarding cyst growth, four out of six studies described a negative association with the development of WFs/HRS, and all six reported a negative association with malignancy. The pooled relative risk (RR) of developing WFs/HRS or malignancy for cysts ≤15 mm was 0.37 (95% CI 0.25-0.57) and the RR of developing malignancy for cyst growth <2-2.5 mm/year was 0.04 (95% CI 0.02-0.09)). CONCLUSION: This systematic review and meta-analysis shows that small and stable-sized low-risk BD-IPMNs are associated with a markedly low progression rate, with stable cyst size being the most reassuring feature. Because of substantial heterogeneity in definitions and reported outcome measures, prospective studies are needed to confirm that surveillance of small and stable sized cyst can be de-intensified or even discontinued.

Overlooked branch turnover creates a widespread bias in forest carbon accounting.

Most measurements and models of forest carbon cycling neglect the carbon flux associated with the turnover of branch biomass, a physiological process quantified for other organs (fine roots, leaves, and stems). Synthesizing data from boreal, temperate, and tropical forests (184,815 trees), we found that including branch turnover increased empirical estimates of aboveground wood production by 16% (equivalent to 1.9 Pg Cy-1 globally), of similar magnitude to the observed global forest carbon sinks. In addition, reallocating carbon to branch turnover in model simulations reduced stem wood biomass, a long-lasting carbon storage, by 7 to 17%. This prevailing neglect of branch turnover suggests widespread biases in carbon flux estimates across global datasets and model simulations. Branch litterfall, sometimes used as a proxy for branch turnover, ignores carbon lost from attached dead branches, underestimating branch C turnover by 38% in a pine forest. Modifications to field measurement protocols and existing models are needed to allow a more realistic partitioning of wood production and forest carbon storage.

Quadrifurcation of the Facial Artery Near the Inferior Mandibular Border with a Bilateral Premasseteric Artery Component.

During the dissection of the cervicofacial area in a donated male cadaver, an asymmetrical division of the facial artery (FA) and a premasseteric artery (PA) were identified. Specifically, on the left side, the FA stem is divided into four branches (quadrifurcation) 4.26 mm below the lower border of the mandible. In contrast, it is divided into two branches (bifurcation) on the right side. Whether symmetrical or asymmetrical, these variants can have significant implications for rhinoplastic, maxillofacial, or reconstructive surgery. This finding underscores the crucial role of surgeons in exercising caution and paying close attention during these procedures to avoid potential damage.

Predictors of success in left bundle branch area pacing with stylet-driven pacing leads: a multicenter investigation.

Purpose: Although left bundle branch area pacing (LBBAP) is an emerging conduction system pacing modality, it is unclear which parameters predict procedural success and how many implant attempts are acceptable. This study aimed to assess predictors of successful LBBAP, left bundle branch (LBB) capture, and factors associated with the number of LBBAP implant attempts. Methods: This retrospective observational multicenter study was conducted in Korea. LBBAP was attempted in 119 patients; 89.3% of patients had bradyarrhythmia (atrioventricular block 82.4%), and 10.7% of patients had heart failure (cardiac resynchronization therapy) indication. Procedural success and electrophysiological and echocardiographic parameters were evaluated. Results: The acute success rate of lead implantation in LBBAP was 95.8% (114 of 119 patients) and that of LBB capture was 82.4% (98 of 119 patients). Fewer implant attempts were associated with LBBAP success (three or fewer vs. over three times, p = 0.014) and LBB capture (three or fewer vs. over three times, p = 0.010). In the multivariate linear regression, the patients with intraventricular conduction delay (IVCD) required a greater number of attempts than those without IVCD [estimates = 2.33 (0.35-4.31), p = 0.02], and the larger the right atrial (RA) size, the more the attempts required for LBBAP lead implantation [estimates = 2.08 (1.20-2.97), p < 0.001]. Conclusion: An increase in the number of implant attempts was associated with LBBAP procedural failure and LBB capture failure. The electrocardiographic parameter IVCD and the echocardiographic parameter RA size may predict the procedural complexity and the number of lead implant attempts for LBBAP.

Stylet-driven Leads or Lumenless Leads for Conduction System Pacing.

Stylet-driven leads have been recently introduced for conduction system pacing, while most of the previous experience has been obtained with lumenless leads. Design and structural characteristics of both lead types are significantly different, resulting in different implant techniques and independent learning curves. Lead performance appears to be comparable, whereas data on direct comparison of clinical outcomes are scarce. Currently, there are no specific clinical scenarios favouring the use of one lead type over another and the decision should rely on the individual experience of the implanter.

A New Bailout Maneuver to Manage Type IIIa Endoleak Due to Displaced Renal Bridging Stent Graft in Narrow Aorta.

PURPOSE: To present endovascular management of an intraoperative type IIIc endoleak (EL) in a patient with migration of the right renal artery (RRA) bridging stent graft (BSG) during branched aortic aneurysm repair. TECHNIQUE: The technique is demonstrated in an 80-year-old woman who underwent branched endograft repair of a symptomatic 6-cm type II TAAA. The t-Branch thoracoabdominal stent graft was positioned without difficulty. A "partial graft deployment" was performed, with the distal portion of the device remaining inside the delivery system and the right renal and superior mesenteric arteries were stented. When the constraining wires were removed, the RRA BSG migration from the branch was displayed, due to endograft twisting resulting in a horizontal rotation of the t-Branch. The RRA BSG remained oriented upward with the proximal edge positioned above the distal edge of the directional branch, making cannulation very difficult. This bailout technique uses a balloon placed at the level of the RRA BSG through the celiac artery (CA) directional branch; keeping the balloon inflated and in thrust, the edge of the BSG has moved downward making it possible to engage it and relining through the RRA directional branch. CONCLUSIONS: This paper describes an endovascular bailout technique for relining a displaced bridging stent graft, oriented upwards with the proximal edge positioned above the distal edge of the directional branch. CLINICAL IMPACT: This sophisticated technique adds to the spectrum of bailout techniques that can be applied in cases of type IIIa EL with migration and complete separation of BSG.

Seasonal changes in hydraulic functions of eight temperate tree species: divergent responses to freeze-thaw cycles in spring and autumn.

Freeze-thaw cycles (FTCs) are the major seasonal environment stress in the temperate and boreal forests, which induces hydraulic dysfunction and limits tree growth and distribution. There are two types of FTCs in the field: FTCs with increasing temperature from winter to spring (spring FTCs); and FTCs with decreasing temperature from autumn to winter (autumn FTCs). While previous studies have evaluated the hydraulic function during the growing season, its seasonal changes and how it adapts to different types of FTCs remain unverified. To fill this knowledge gap, the eight tree species from three wood types (ring- and diffuse-porous, tracheid) were selected in a temperate forest undergoing seasonal FTCs. We measured the branch hydraulic traits in spring, summer, autumn, and early, middle, and late winter. Ring-porous trees always showed low native hydraulic conductance (Kbranch), and high percentage loss of maximum Kbranch (PLCB) and water potential that loss of 50% maximum Kbranch (P50B) in non-growing seasons (except summer). Kbranch decreased, and PLCB and P50B increased in diffuse-porous trees after several spring FTCs. In tracheid trees, Kbranch decreased after spring FTCs while the P50B did not change. All sampled trees gradually recovered their hydraulic functions from spring to summer. Kbranch, PLCB, and P50B of diffuse-porous and tracheid trees were relatively constant after autumn FTCs, indicating almost no effect of autumn FTCs on hydraulic functions. These results suggested that hydraulic functions of temperate trees showed significant seasonal changes, and spring FTCs induced more hydraulic damage (except ring-porous trees) than autumn FTCs, which should be determined by the number of FTCs and trees' vitality before FTCs. These findings advance our understanding of seasonal changes in hydraulic functions and how they cope with different types of freeze-thaw cycles in temperate forests.

Impact of Combining Iliac Branch Endoprosthesis and Physician-Modified Fenestrated-Branched Endovascular Repair for Complex Abdominal and Thoracoabdominal Aortic Aneurysms with Concomitant Iliac Artery Aneurysms.

OBJECTIVES: Treatment of iliac artery aneurysms (IAA) with the Iliac Branch Endoprosthesis (IBE) during endovascular repair of infrarenal abdominal aortic aneurysm (EVAR) has been well-documented as effective. However, limited data exists evaluating the safety and efficacy of treating complex abdominal (cAAA) and thoracoabdominal aortic aneurysms (TAAA) with associated IAA with combined physician-modified fenestrated branched endovascular aortic repair (PM-FBEVAR) and IBE. Moreover, limited studies exist assessing the impact of adding IBE on the outcomes following PM-FBEVAR. Therefore, we compared the clinical outcomes of patients who underwent PM-FBEVAR with and without IBE for the treatment of cAAA and TAAA. METHODS: A single institution retrospective review of consecutive patients who underwent PM-FBEVAR between September 2015 and February 2021 was conducted. Patients with both unilateral and bilateral IBE implantation were included. Infected aneurysms and pseudoaneurysms were excluded. Demographics, technical success, and operative factors were analyzed. Primary outcomes were incidence of pelvic ischemia including buttock and thigh claudication, bowel and spinal cord ischemia, patency of internal and external limbs of IBE, and target vessel instability. Secondary outcomes included technical success, 30-day major adverse events (MAE), 30-day and all-cause mortality, and endoleaks. RESULTS: Among 183 patients identified who underwent PM-FBEVAR, 22 patients underwent PM-FBEVAR and IBE with 3 patients treated with bilateral IBEs. There was no pelvic ischemia in the PM-FBEVAR and IBE group. Technical success, fluoroscopy time, and procedure time were comparable between the two groups. Contrast usage was higher in the PM-FBEVAR and IBE group (p=0.01). Thirty-day MAE and mortality were not statistically different between the two groups. At mean follow-up of 23 months, all-cause mortality was similar for both groups (21% vs 27%; p=0.47). Patency of internal iliac artery limb and external iliac artery limb of the IBE were 96% (24 of 25) and 100%, respectively, during mean follow-up of 23 months. The patient with occlusion of internal iliac limb was asymptomatic and received no re-intervention. CONCLUSION: Treatment of cAAA and TAAA associated with IAA using combined PM-FBEVAR and IBE is feasible with high efficacy and safety, and without adverse effect on outcomes. Long-term follow-up is planned to assess durability of repair with PM-FBEVAR and IBE.

Ultrasound-guided renal artery balloon catheter occluded hybrid partial nephrectomy (UBo-HPN) with branch renal artery occlusion: a single arm trial.

BACKGROUND: One key focus of partial nephrectomy is preserving renal function. Segmental renal artery occlusion with microdissection at the renal hilum confines ischemia, effectively reducing warm ischemic injury. Ultrasound-Guided Renal Artery Balloon Catheter Occluded Hybrid Partial Nephrectomy (UBo-HPN) can achieve branch occlusion without the need for dissecting the renal hilum. OBJECTIVE: To investigate the feasibility and safety of UBo-HPN of branch renal artery occlusion in the treatment of localized renal tumors. SUBJECT AND METHODS: A prospective single-arm analysis involving 20 patients with renal localized tumors underwent robot assisted UBo-HPN with branch renal artery occlusion from August 2021 to July 2023, with an average follow-up of 12 months. RESULTS: All patient was successfully operated on without conversion to conventional arterial clamping or radical nephrectomy. One case (5%) of minor complication occurred in the whole cohort, which was bruising around the puncture site. The mean total operative time was 95.8 min, with a mean operative time of 21.25 min for vascular intervention. The mean warm ischemia time was 20.35 min, and the median estimated blood loss was 50 ml. The median eGFR preservation percentage at postoperative 48 h, 30 days, and the latest follow-up were 87.52%, 91.47%, and 92.2%, respectively. After a median follow-up of 10.2 (2.3-19.2) months, no patients had radiological tumor recurrence or died from tumor-related causes. CONCLUSIONS: UBo-HPN with renal artery branch occlusion emerges as an efficient alternative to partial nephrectomy (PN), which achieved branch artery occlusion without dissecting the renal hilum. Long-term follow-up is expected for functional outcomes.

Coal-gangue sound recognition using hybrid multi-branch CNN based on attention mechanism fusion in noisy environments.

The coal-gangue recognition technology plays an important role in the intelligent realization of fully mechanized caving face and the improvement of coal quality. Although great progress has been made for the coal-gangue recognition in recent years, most of them have not taken into account the impact of the complex environment of top coal caving on recognition performance. Herein, a hybrid multi-branch convolutional neural network (HMBCNN) is proposed for coal-gangue recognition, which based on improved Mel Frequency Cepstral Coefficient (MFCC) as well as Mel spectrogram, and attention mechanism. Firstly, the MFCC and its smooth feature matrix are input into each branch of one-dimensional multi-branch convolutional neural network, and the spliced features are extracted adaptively through multi-head attention mechanism. Secondly, the Mel spectrogram and its first-order derivative are input into each branch of the two-dimensional multi-branch convolutional neural network respectively, and the effective time-frequency information is paid attention to through the soft attention mechanism. Finally, at the decision-making level, the two networks are fused to establish a model for feature fusion and classification, obtaining optimal fusion strategies for different features and networks. A database of sound pressure signals under different signal-to-noise ratios and equipment operations is constructed based on a large amount of data collected in the laboratory and on-site. Comparative experiments and discussions are conducted on this database with advanced algorithms and different neural network structures. The results show that the proposed method achieves higher recognition accuracy and better robustness in noisy environments.

Coronary bifurcation lesion treatment with the BioMime™ Branch sirolimus-eluting coronary side-branch stent system: A single-center experience.

BACKGROUND: Coronary bifurcation lesions (CBL) comprise 15 %-20 % of percutaneous coronary procedures and remain a challenge despite advances in stent and interventional techniques. The BioMime™ Branch sirolimus-eluting coronary side-branch stent (BBSES) is specifically designed for CBL treatment in conjunction with a standard drug-eluting stent (DES). We report the first single-center experience of treating complex CBL with the novel BBSES. METHODS: This is a retrospective, single-center study involving consecutive prospectively identified patients who underwent treatment of true CBL with the BBSES. The protocol included BBSES+DES implantation in the CBL and simultaneous final kissing balloon inflation. RESULTS: Fifty-eight CBL were treated in 58 consecutive patients (89.6 % men, mean age 69.0 ± 9.5 years) presenting primarily with stable angina (84.4 %) and true (Medina 1,1,1,) CBL. Procedural success was 100 % without major adverse cardiac events (MACE). At a median follow-up of 18 months, one sudden death was reported that was accounted as possible late stent thrombosis. One patient had spontaneous myocardial infarction due to subacute thrombosis of a DES implanted in the main vessel proximally to the BBSES before the index procedure. Another patient was hospitalized for atrial fibrillation. CONCLUSIONS: This is the first clinical experience to date of true CBL treatment with the BBSES demonstrating high procedural success, no in-hospital MACE and sustained clinical results at a median follow-up of 18 months.