Tricuspid valve-in-valve jailing right ventricular lead is not free of risk.

Transcatheter tricuspid valve in valve (TViV) is increasingly performed on patients with degenerated bioprosthetic valves and elevated surgical risk. Jailing a right ventricular (RV) pacer lead at the time of TViV implantation has been achieved without causing lead dysfunction; however, device-related complications that require lead extraction raise the need for better periprocedural strategies for TViV, in pacer-dependent patients. We describe a case of device pocket infection with incomplete lead extraction, due to a jailed RV lead at the time of TViV.

Nonenhanced MR angiography of the pulmonary arteries using single-shot radial quiescent-interval slice-selective (QISS): a technical feasibility study.

BACKGROUND: For evaluation of the pulmonary arteries in patients suspected of pulmonary embolism, CT angiography (CTA) is the first-line imaging test with contrast-enhanced MR angiography (CEMRA) a potential alternative. Disadvantages of CTA include exposure to ionizing radiation and an iodinated contrast agent, while CEMRA is sensitive to respiratory motion and requires a gadolinium-based contrast agent. The primary goal of our technical feasibility study was to evaluate pulmonary arterial conspicuity using breath-hold and free-breathing implementations of a recently-developed nonenhanced approach, single-shot radial quiescent-interval slice-selective (QISS) MRA. METHODS: Breath-hold and free-breathing, navigator-gated versions of radial QISS MRA were evaluated at 1.5 Tesla in three healthy subjects and 11 patients without pulmonary embolism or arterial occlusion by CTA. Images were scored by three readers for conspicuity of the pulmonary arteries through the level of the segmental branches. In addition, one patient with pulmonary embolism was imaged. RESULTS: Scan time for a 54-slice acquisition spanning the pulmonary arteries was less than 2 minutes for breath-hold QISS, and less than 3.4 min using free-breathing QISS. Pulmonary artery branches through the segmental level were conspicuous with either approach. Free-breathing scans showed only mild blurring compared with breath-hold scans. For both readers, less than 1% of pulmonary arterial segments were rated as "not seen" for breath-hold and navigator-gated QISS, respectively. In subjects with atrial fibrillation, single-shot radial QISS consistently depicted the pulmonary artery branches, whereas navigator-gated 3D balanced steady-state free precession showed motion artifacts. In one patient with pulmonary embolism, radial QISS demonstrated central pulmonary emboli comparably to CEMRA and CTA. The thrombi were highly conspicuous on radial QISS images, but appeared subtle and were not prospectively identified on scout images acquired using a single-shot bSSFP acquisition. CONCLUSIONS: In this technical feasibility study, both breath-hold and free-breathing single-shot radial QISS MRA enabled rapid, consistent demonstration of the pulmonary arteries through the level of the segmental branches, with only minimal artifacts from respiratory motion and cardiac arrhythmias. Based on these promising initial results, further evaluation in patients with suspected pulmonary embolism appears warranted.

Concomitant treatment of sustained ventricular tachycardia and hypertrophic cardiomyopathy with transcoronary ethanol ablation: a case report.

Background: The recommended treatment for recurrent ventricular tachycardia in patients with hypertrophic cardiomyopathy that is not amenable to defibrillator implantation due to shock burden is radiofrequency ablation. In patients with deeply intramural foci of ventricular tachycardia, traditional unipolar ablation has a lower probability of success. Case summary: A 66-year-old Caucasian man was admitted with ventricular tachycardia, which recurred despite antiarrhythmic drugs. On cardiac magnetic resonance imaging, he was discovered to have septal hypertrophic cardiomyopathy, which was not significant on echocardiogram. The focus of ventricular tachycardia was suspected to be buried deeply within the hypertrophic segment as localized by late gadolinium enhancement. The patient underwent transcoronary ethanol ablation, which abated the ventricular tachycardia while also completely decreasing his invasively measured left ventricular outflow tract obstruction gradient from 45 to 17 mmHg. Discussion: Transcoronary ethanol ablation may be successfully applied to simultaneously treat ventricular arrhythmia superimposed within a segment of hypertrophic cardiomyopathy. Further data are needed to evaluate long-term success of this strategy vs. traditional radiofrequency ablation.

Real-world data of radiofrequency catheter ablation in paroxysmal atrial fibrillation: Short- and long-term clinical outcomes from the prospective multicenter REAL-AF Registry.

BACKGROUND: The safety and long-term efficacy of radiofrequency (RF) catheter ablation (CA) of paroxysmal atrial fibrillation (PAF) has been well established. Contemporary techniques to optimize ablation delivery, reduce fluoroscopy use, and improve clinical outcomes have been developed. OBJECTIVE: The purpose of this study was to assess the contemporary real-world practice approach and short and long-term outcomes of RF CA for PAF through a prospective multicenter registry. METHODS: Using the REAL-AF (Real-world Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation; ClincalTrials.gov Identifier: NCT04088071) Registry, patients undergoing RF CA to treat PAF across 42 high-volume institutions and 79 experienced operators were evaluated. The procedures were performed using zero or reduced fluoroscopy, contact force sensing catheters, wide area circumferential ablation, and ablation index as a guide with a target of 380-420 for posterior and 500-550 for anterior lesions. The primary efficacy outcome was freedom from all-atrial arrhythmia recurrence at 12 months. RESULTS: A total of 2470 patients undergoing CA from January 2018 to December 2022 were included. Mean age was 65.2 ±11.14 years, and 44% were female. Most procedures were performed without fluoroscopy (71.5%), with average procedural and total RF times of 95.4 ± 41.7 minutes and 22.1±11.8 minutes, respectively. At 1-year follow-up, freedom from all-atrial arrhythmias was 81.6% with 89.7% of these patients off antiarrhythmic drugs. No significant difference was identified comparing pulmonary vein isolation vs pulmonary vein isolation plus ablation approaches. The complication rate was 1.9%. CONCLUSION: Refinement of RF CA to treat PAF using contemporary tools, standardized protocols, and electrophysiology laboratory workflows resulted in excellent short- and long-term clinical outcomes.

High-Frequency Low-Tidal Volume Ventilation Improves Long-Term Outcomes in AF Ablation: A Multicenter Prospective Study.

BACKGROUND: High-frequency, low-tidal-volume (HFLTV) ventilation is a safe and simple strategy to improve catheter stability and first-pass isolation during pulmonary vein (PV) isolation. However, the impact of this technique on long-term clinical outcomes has not been determined. OBJECTIVES: This study sought to assess acute and long-term outcomes of HFLTV ventilation compared with standard ventilation (SV) during radiofrequency (RF) ablation of paroxysmal atrial fibrillation (PAF). METHODS: In this prospective multicenter registry (REAL-AF), patients undergoing PAF ablation using either HFLTV or SV were included. The primary outcome was freedom from all-atrial arrhythmia at 12 months. Secondary outcomes included procedural characteristics, AF-related symptoms, and hospitalizations at 12 months. RESULTS: A total of 661 patients were included. Compared with those in the SV group, patients in the HFLTV group had shorter procedural (66 [IQR: 51-88] minutes vs 80 [IQR: 61-110] minutes; P < 0.001), total RF (13.5 [IQR: 10-19] minutes vs 19.9 [IQR: 14.7-26.9] minutes; P < 0.001), and PV RF (11.1 [IQR: 8.8-14] minutes vs 15.3 [IQR: 12.4-20.4] minutes; P < 0.001) times. First-pass PV isolation was higher in the HFLTV group (66.6% vs 63.8%; P = 0.036). At 12 months, 185 of 216 (85.6%) in the HFLTV group were free from all-atrial arrhythmia, compared with 353 of 445 (79.3%) patients in the SV group (P = 0.041). HLTV was associated with a 6.3% absolute reduction in all-atrial arrhythmia recurrence, lower rate of AF-related symptoms (12.5% vs 18.9%; P = 0.046), and hospitalizations (1.4% vs 4.7%; P = 0.043). There was no significant difference in the rate of complications. CONCLUSIONS: HFLTV ventilation during catheter ablation of PAF improved freedom from all-atrial arrhythmia recurrence, AF-related symptoms, and AF-related hospitalizations with shorter procedural times.

Regulation of p53 tetramerization and nuclear export by ARC.

Inactivation of the transcription factor p53 is central to carcinogenesis. Yet only approximately one-half of cancers have p53 loss-of-function mutations. Here, we demonstrate a mechanism for p53 inactivation by apoptosis repressor with caspase recruitment domain (ARC), a protein induced in multiple cancer cells. The direct binding in the nucleus of ARC to the p53 tetramerization domain inhibits p53 tetramerization. This exposes a nuclear export signal in p53, triggering Crm1-dependent relocation of p53 to the cytoplasm. Knockdown of endogenous ARC in breast cancer cells results in spontaneous tetramerization of endogenous p53, accumulation of p53 in the nucleus, and activation of endogenous p53 target genes. In primary human breast cancers with nuclear ARC, p53 is almost always WT. Conversely, nearly all breast cancers with mutant p53 lack nuclear ARC. We conclude that nuclear ARC is induced in cancer cells and negatively regulates p53.

A case of Takotsubo cardiomyopathy mimicking an acute coronary syndrome.

BACKGROUND: A 71-year-old woman presented with severe chest pain after an episode of acute emotional distress. Her serum levels of cardiac enzymes were slightly elevated and electrocardiography revealed anterior ST-segment elevations. Significant coronary stenoses were excluded. A left ventriculogram revealed apical ballooning and a hypercontractile basal segment. INVESTIGATIONS: Serum cardiac enzyme measurements, echocardiography, coronary angiography and left ventriculography. DIAGNOSIS: Takotsubo cardiomyopathy. MANAGEMENT: Treatment with beta-blockers, aspirin, angiotensin-converting-enzyme inhibitors, and intravenous diuretics.

Cardiac sarcoidosis detected by late gadolinium enhancement and prevalence of atrial arrhythmias.

Cardiovascular magnetic resonance (CMR) imaging is being increasingly used to help identify patients with cardiac sarcoidosis (CS). Whereas ventricular arrhythmias have been well studied in this population, atrial arrhythmias have not been thoroughly investigated. We sought to better characterize the arrhythmia burden of a cohort of patients diagnosed with CS by CMR imaging. Patients with biopsy-proven extracardiac sarcoidosis were referred to the University of Chicago for evaluation of the presence of CS. CMR imaging was used to categorize the patients into 2 groups; those with and those without late gadolinium enhancement (LGE) for comparison of arrhythmic events. Arrhythmic evaluation included Holter monitor, event recorder, electrophysiology testing, or implantable cardioverter-defibrillator (ICD) interrogation; 192 consecutive patients were evaluated with CMR imaging, 57 of whom did not have ambulatory monitoring results and thus were excluded. LGE was present in 44 patients. Atrial arrhythmias were documented in 16 patients (36%) with myocardial LGE and in 11 patients (12%) without myocardial LGE (p = 0.002). Ventricular arrhythmias were documented in 27% of patients with myocardial LGE and 2.2% of LGE-negative patients (p = 0.00076). Of 26 LGE-positive patients with ICDs, 8 (30.8%) received therapies, 3 (11.5%) of which were inappropriate for atrial arrhythmias. In conclusion, atrial arrhythmias were documented more frequently than ventricular arrhythmias in patients with sarcoidosis with cardiac involvement and were 3 times more prevalent than in patients with sarcoidosis without cardiac involvement. Risk-benefit assessment of anticoagulation for primary prevention of stroke should be performed for patients with CS. In patients receiving implantable defibrillators, programming to minimize inappropriate ICD shocks for atrial arrhythmias must be considered.