Cryoablation of atrial fibrillation in "very severe" obese patients (BMI ≥ 40): Indications, feasibility, procedural safety and efficacy, and clinical outcome (the ICE-Obese Extreme).

BACKGROUND: Management of atrial fibrillation (AF) in very severe obese patients is challenging. Cryoballoon ablation (CBA) represents an effective rhythm control strategy. However, data in this patient group were limited. METHODS: Highly symptomatic AF patients with body mass index (BMI) ≥ 40 kg/m2 who had failed antiarrhythmic drug therapy and electrocardioversion and failure to achieve targeted body-weight-reduction underwent CBA. RESULTS: Data of 72 very severe obese AF patients (Group A) and 129 AF patients with normal BMI (Group B, BMI < 25 kg/m2) were consecutively collected. Group A had significantly younger age (60.6 ± 10.4 vs. 69.2 ± 11.2 years), higher BMI (44.3 ± 4.3 vs. 22.5 ± 1.6 kg/m2). Procedural pulmonary vein isolation (PVI) was successful in all patients (2 touch-up ablation in Group A). Compared to Group B, Group A had similar procedural (61.3 ± 22.6 vs. 57.5 ± 19 min), similar fluoroscopy time (10.1 ± 5.5 vs. 9.2 ± 4.8 min) but significantly higher radiation dose (2852 ± 2095 vs. 884 ± 732 µGym2). We observed similar rates of real-time-isolation (78.6% vs. 78.5%), single-shot-isolation (86.5% vs. 88.8%), but significantly longer time-to-sustained-isolation (53.5 ± 33 vs. 43.2 ± 25 s). There was significantly higher rate of puncture-site-complication (6.9% vs. 1.6%) in Group A. One-year clinical success in paroxysmal AF was (Group A: 69.4% vs. Group B: 80.2%; p < .001), in persistent AF was (Group A: 58.1% vs. Group B: 62.8%; p = .889). In Re-Do procedures Group A had a numerically lower PVI durability (75.0% vs. 83.6%, p = .089). CONCLUSION: For very severe obese AF patients, CBA appears feasible, leads to relatively good clinical outcome.

Long-term performance of ceramic in/-onlays vs. cast gold partial crowns - a retrospective clinical study.

OBJECTIVES: To assess the long-term clinical performance of ceramic in-/onlays (CIOs) and cast gold partial crowns (CGPCs) in posterior teeth in terms of success, survival, complications (biological, technical) and quality. MATERIAL AND METHODS: In a retrospective study, a total of 325 patients were recorded after up to 24.8 years (mean 13.9 ± 3.8 years) having (pre-)molars restored with CIO (Empress I, Ivoclar Vivadent, n = 161) and CGPC (Degunorm, DeguDent, n = 164) by supervised undergraduate students. A total of 296 restorations were assessed clinically and radiologically in healthy and endodontically treated teeth using modified United States Public Health Service (USPHS) criteria. Cumulative success and survival rates of the restorations were calculated using Kaplan-Meier estimates. Biological and technical complications were recorded. Status of oral health comprising caries risk and localized periodontitis were assessed. RESULTS: The cumulative success rates of CIOs were 92.1% and of CGPCs 84.2% after mean service times of 14.5 years. The annual failure rates of total service times were 0.5% in teeth restored with CIO (n = 155) and 0.7% in teeth restored with CGPC (n = 163). The cumulative survival rates of CIOs were 93.9% after a mean service time of 15.2 years and decreased to 91.7% after 23.5 years. The cumulative survival rates of CGPCs were 92.6% after a mean service time of 14.9 years and 91.8% after 23.5 years. Complications in CIOs (n = 149) were ceramic fracture (6.7%), secondary caries (4.7%), endodontic complication (2.7%) and tooth fracture (1.3%) compared to CGPCs (n = 147) with endodontic complication (8.8%), secondary caries (4.8%) and decementation (2.0%). Endodontically treated teeth restored with CIO or CGPC revealed significantly less often success compared with corresponding vital teeth (p = .02). CIOs and CGPCs revealed clinically and radiographically good and excellent qualities with 71.8% (107/149) and 68% (100/147) without any significant differences regarding type of restoration. CONCLUSIONS: Both CIOs and CGPCs achieved high survival rates up to 24.8 years when performed by supervised undergraduate students. The longevity of the restorations may benefit from the intraoral repair of accessible defects and, in case of pulp infection or necrosis, an adequate endodontic management. CLINICAL RELEVANCE: CIOs and CGPCs made by supervised undergraduate students are proper restoration types in posterior teeth in the long-term. An adequate preparation design, meticulous care in the inserting technique and constant biofilm removal due to proper oral hygiene combined with professional maintenance care are substantial. The clinical long-term performance was mostly limited by ceramic fractures in CIOs and endodontic complications in CGPCs.

Impaired Filtering and Hyperfocusing: Neural Evidence for Distinct Selective Attention Abnormalities in People with Schizophrenia.

Although schizophrenia is classically thought to involve impaired attentional filtering, people with schizophrenia (PSZ) exhibit a more intense and more exclusive attentional focus than healthy control subjects (HCS) in many tasks. To resolve this contradiction, this functional magnetic resonance imaging study tested the impact of attentional control demands on the modulation of stimulus-induced activation in the fusiform face area and parahippocampal place area when participants (43 PSZ and 43 HCS) were looking for a target face versus house. Stimuli were presented individually, or as face-house overlays that challenged attentional control. Responses were slower for house than face stimuli and when prioritizing houses over faces in overlays, suggesting a difference in salience. Blood-oxygen-level-dependent activity reflected poorer attentional selectivity in PSZ than HCS when attentional control was challenged most, that is, when stimuli were overlaid and the task required detecting the lower-salience house target. By contrast, attentional selectivity was exaggerated in PSZ when control was challenged least, that is, when stimuli were presented sequentially and the task required detecting the higher-salience face target. These findings are consistent with 2 distinct attentional abnormalities in schizophrenia leading to impaired and exaggerated selection under different conditions: attentional control deficits, and hyperfocusing once attention has been directed toward a stimulus.

Impact of body mass index on cryoablation of atrial fibrillation: Patient characteristics, procedural data, and long-term outcomes.

INTRODUCTION: Ablation of atrial fibrillation in the context of obesity can be challenging. We sought to evaluate the role of cryoballoon pulmonary vein isolation (CB-PVI) in obese patients with symptomatic atrial fibrillation (AF). METHODS: Patients with a BMI ≥ 25 kg/m2 and symptomatic AF who underwent CB-PVI were retrospectively enrolled. Three groups were defined (G1: BMI of 25-29 kg/m2 ; G2: BMI of 30-34 kg/m2 ; G3: BMI ≥ 35 kg/m2 ). RESULTS: 600 patients were included (59% male; 66 ± 11 years old); 337, 149, and 114 were assigned to G1, G2, and G3, respectively. Acute procedural success was recorded in 99.7% of patients. Procedural and fluoroscopy time were comparable but the radiation dose was significantly higher in G3. Procedural complications were 3% in G1, 5.4% in G2, and 8.8% in G3 (p = .01). The overall freedom from AF after 1-year was 77%. G3 had a significantly worse 1-year success rate compared to G1 and G2 (G3: 66.5% vs. G1: 78.4%; p = .015 and vs. G2: 82.5%; p = .008) with reduced 1-year success in paroxysmal AF (G1: 84.0%; G2: 86.3%; and G3: 69.6%) but not in persistent AF (G1: 68.7%; G2: 77.4%; and G3: 62.1%). G3 showed similar success rates irrespective of AF form (PAF: 69.6% vs. persAF 62.1%; p = .501). CONCLUSION: Cryoballoon ablation in obese patients can be effective with an acceptable safety profile, 77% of patients were in stable SR at 1 year. Severe obese patients (BMI ≥ 35) showed reduced procedural safety and 1-year success rate. In association with life style modification, CB ablation may represent a strategy to enhance rhythm control in the context of obesity.

Unexpected large device related thrombus at 12 months follow-up after left atrial appendage closure.

An 89-year-old woman underwent left atrial appendage (LAA) closure (LAAC) in our hospital because of recurrent gastrointestinal bleedings. The first transesophageal echocardiography (TEE) follow-up at six weeks revealed a complete sealing of the LAA and no device related thrombus. In a TEE follow-up at one year after the LAA closure, a large device related thrombus (6 × 3 cm) was found. Treated with oral anticoagulation (apixaban) the thrombus showed a partial resolution one year later.

Catheter ablation of atrial fibrillation using ablation index-guided high-power technique: Frankfurt AI high-power 15-month follow-up.

BACKGROUND: Radiofrequency (RF) high-power ablation appears to be a novel concept in treating atrial fibrillation (AF). The ablation-index (AI) has been linked with the durability of pulmonary vein isolation (PVI). To report the midterm clinical results of a new ablation strategy using AI-guided high-power (50 W) ablation (AI-HP). METHODS AND RESULTS: Symptomatic AF patients were included and underwent wide-area circumferential PVI. Contact-force catheters were used, RF power was set to 50 W targeting AI values (550/400 for anterior/posterior) and interlesion distance 6 mm. Luminal esophageal temperature (LET) was monitored during the procedure; patients with LET ≥39°C underwent post-ablation esophageal-endoscopy. Seventy-two-hour-Holter ECGs were scheduled during follow-up. Procedural PVI was achieved in all (N = 122; mean age, 68.2 years; male, 71.3%) patients, rate of first-pass PVI was 96.7% per patient. Procedural mean RF time was 11.5 min, and mean RF time during posterior wall segment was 3.1 min. Per RF-lesion, the mean contact force, RF duration, AI, and impedance-drop at anterior/posterior wall were 26 ± 14 g/23 ± 12 g, 16.2 ± 7.5 s/8.8 ± 3.6 s, 552 ± 53/438 ± 47, and 13 ± 6 Ω/9 ± 5 Ω, respectively. Mean PVI procedural-time, 55.8 min; mean procedural fluoroscopic time, 5.6 min. Three (2.5%) patients had asymptomatic endoscopic small erosion/erythema esophageal lesions, no serious adverse events were observed. During a 15-month follow-up, overall single-procedure freedom from clinical recurrence of AF/atrial tachycardia (AT) off antiarrhythmic drug after blanking period was 85.2% (89.4% for paroxysmal AF, 80.4% for persistent AF). CONCLUSION: The AI-HP (50 W) appears as an efficient ablation technique in treating AF and leads to a high single-procedure arrhythmia-free survival at 15 months.

Attention-enhancing effects of propranolol and synergistic effects with nicotine.

Nicotine increases the output of every major neurotransmitter. In previous studies designed to identify the secondary neurotransmitter systems mediating nicotine's attention-enhancing effects in a rat model, the ß-adrenoceptor antagonist propranolol blocked these effects. The present study was designed to test whether this mechanism held true in humans, thus guiding development of novel nicotinic agonists for cognitive enhancement. Twenty-six nonsmokers completed a nicotine (7 mg/24 h transdermally) x propranolol (40 mg p.o., body weight-adjusted) interaction study. Over four test days, each participant received double-placebo, nicotine only, propranolol only, and nicotine plus propranolol in randomized sequence before cognitive testing. No drug effects were seen in a visuospatial attention task. In the Rapid Visual Information Processing Task, performed in two 15-min blocks, neither drug alone significantly affected hit rate, but both drugs combined acted synergistically to alleviate its decrement over time in the first block and displayed additive beneficial effects in the second. In a change detection task, propranolol enhanced accuracy and reduced reaction time independent of nicotine presence. Propranolol also enhanced subjective self-reports of vigor. Overall, the findings were contrary to those hypothesized. Propranolol displayed beneficial effects on cognition, especially on sustaining performance over time. ß-adrenoceptor activation by nicotine-induced noradrenaline release appeared to limit performance-enhancing effects of nicotine, because they were unmasked by ß-adrenoceptor antagonism. The results suggest that cognitive effects of changes in ß-adrenoceptor tone are context-dependent; contrary to rodent paradigms, human cognitive paradigms require no physical orienting in space but prolonged periods of remaining stationary while sustaining predictable processing demands.

People with schizophrenia show enhanced cognitive costs of maintaining a single item in working memory.

BACKGROUND: Working memory (WM) deficits are seen as a core deficit in schizophrenia, implicated in the broad cognitive impairment seen in the illness. Here we examine the impact of WM storage of a single item on the operation of other cognitive systems. METHODS: We studied 37 healthy controls (HCS) and 43 people with schizophrenia (PSZ). Each trial consisted of a sequence of two potential target stimuli, T1 and T2. T1 was a letter presented for 100 ms. After delays of 100-800 ms, T2 was presented. T2 was a 1 or a 2 and required a speeded response. In one condition, subjects were instructed to ignore T1 but respond to T2. In another condition, they were required to report T1 after making their speeded response to T2 (i.e. to make a speeded T2 response while holding T1 in WM). RESULTS: PSZ were dramatically slowed at responding to T2 when T1 was held in WM. A repeated measures ANOVA yielded main effects of group, delay, and condition with a group by condition interaction (p's < 0.001). Across delays, the slowing of the T2 response when required to hold T1 in memory, relative to ignoring T1, was nearly 3 times higher in PSZ than HCS (633 v. 219 ms). CONCLUSIONS: Whereas previous studies have focused on reduced storage capacity, the present study found that PSZ are impaired at performing tasks while they are successfully maintaining a single item in WM. This may play a role in the broad cognitive impairment seen in PSZ.

Long-term outcome of adhesive fragment reattachment in crown-root fractured teeth.

BACKGROUND/AIMS: Adhesive fragment reattachment (AFR) is one treatment option for crown-root fractured teeth. However, there are no studies investigating the long-term outcome of this approach. The aim of this retrospective study was to evaluate the long-term outcome of AFR and periodontal health in crown-root fractured teeth by assessing complications and periodontal status. MATERIALS AND METHODS: Data regarding 41 patients with 51 traumatized teeth (TT) were included. Periodontal health was assessed by recording the pocket probing depth (PPD), clinical attachment level (CAL), bleeding on probing (BoP), gingival index (GI), and plaque index (PI) in the TT and in one unaffected control tooth (CT). Complications were classified as "restorative," "endodontic," and "additional root fracture." Based on these complications, the outcome was graded as "success," "partial success," "survival," and "failure." Statistics was performed by t test, chi-square test and logistic regression models. RESULTS: After 8.5 ± 4.6 years, 76.5% (39/51) of the TT had functionally survived. Functional survival of the reattached fragments was 66.7% (26/39) after 9.5 ± 3.7 years. PPD (TT: 4.11 ± 2.03; CT: 2.08 ± 0.65), CAL (TT: 4.78 ± 2.19; CT: 2.42 ± 1.03), and BoP values (TT: 77.4%; CT: 22.6%) were higher in TT than in CT. GI scores > 0 were found in 83.3% of the TT and in 27.8% of the CT. PI scores did not differ between TT and CT. Of the complications, 56.8% were "restorative," 22.7% "endodontic," and 20.5% "additional root fractures." Eleven (27.5%) TT were without complications and rated as "success." CONCLUSIONS: AFR in crown-root fractured teeth showed a high survival rate and occasionally compromised periodontal health. However, due to the high complication rate, it should be considered as a long-term temporary treatment to postpone other invasive therapy options. AFR can be a valuable way to avoid early loss of crown-root fractured teeth, especially in young patients. Moisture control and additional root fractures significantly influenced the outcome.

Posterior Parietal Cortex Dysfunction Is Central to Working Memory Storage and Broad Cognitive Deficits in Schizophrenia.

PFC dysfunction is widely believed to underlie working memory (WM) deficits in people with schizophrenia (PSZ), but few studies have focused on measures of WM storage devoid of manipulation. Research in neurotypical individuals has shown that storage capacity is more closely related to posterior parietal cortex (PPC) than PFC, suggesting that reductions in WM storage capacity in schizophrenia that are associated with broad cognitive deficits may be related to neural activity in PPC. In the present human neuroimaging study, 37 PSZ and 37 matched healthy control subjects of either sex completed a change detection task with varying set sizes while undergoing fMRI. The task was designed to emphasize WM storage with minimal top-down control demands. Whole-brain analysis identified areas in which BOLD activity covaried with the number of items maintained in WM (K), as derived from task performance at a given set size. Across groups, K values independent of set size predicted BOLD activity in PPC, including superior and inferior parietal lobules and intraparietal sulcus, and middle occipital gyrus. Whole-brain interaction analysis found significantly less K-dependent signal modulation in PSZ than healthy control subjects in left PPC, a phenomenon that could not be explained by a narrower K value range. The slope between K and PPC activation statistically accounted for 43.4% of the between-group differences in broad cognitive function. These results indicate that PPC dysfunction is central to WM storage deficits in PSZ and may play a key role in the broad cognitive deficits associated with schizophrenia.SIGNIFICANCE STATEMENT People with schizophrenia exhibit cognitive deficits across a wide range of tasks. Explaining these impairments in terms of a small number of core deficits with clearly defined neural correlates would advance the understanding of the disorder and promote treatment development. We show that a substantial portion of broad cognitive deficits in schizophrenia can be explained by a failure to flexibly modulate posterior parietal cortex activity as a function of the amount of information currently stored in working memory. Working memory deficits have long been considered central to schizophrenia-related cognitive deficits, but the focus has been on paradigms involving some form of top-down control rather than pure storage of information, which may have unduly narrowed the focus on prefrontal dysfunction.

Electrophysiological Evidence for Hyperfocusing of Spatial Attention in Schizophrenia.

A recently proposed hyperfocusing hypothesis of cognitive dysfunction in schizophrenia proposes that people with schizophrenia (PSZ) tend to concentrate processing resources more narrowly but more intensely than healthy control subjects (HCS). The present study tests a key prediction of this hypothesis, namely, that PSZ will hyperfocus on information presented at the center of gaze. This should lead to greater filtering of peripheral stimuli when the task requires focusing centrally but reduced filtering of central stimuli when the task requires attending broadly in the periphery. These predictions were tested in a double oddball paradigm, in which frequent standard stimuli and rare oddball stimuli were presented at central and peripheral locations while event-related potentials were recorded. Participants were instructed to discriminate between the standard and oddball stimuli at either the central location or at the peripheral locations. PSZ and HCS showed opposite patterns of spatial bias at the level of early sensory processing, as assessed with the P1 component: PSZ exhibited stronger sensory suppression of peripheral stimuli when the task required attending narrowly to the central location, whereas HCS exhibited stronger sensory suppression of central stimuli when the task required attending broadly to the peripheral locations. Moreover, PSZ exhibited a stronger stimulus categorization response than HCS, as assessed with the P3b component, for central stimuli when the task required attending to the peripheral region. These results provide strong evidence of hyperfocusing in PSZ, which may provide a unified mechanistic account of multiple aspects of cognitive dysfunction in schizophrenia.SIGNIFICANCE STATEMENT Schizophrenia clearly involves impaired attention, but attention is complex, and delineating the precise nature of attentional dysfunction in schizophrenia has been difficult. The present study tests a new hyperfocusing hypothesis, which proposes that people with schizophrenia (PSZ) tend to concentrate processing resources more intensely but more narrowly than healthy control subjects (HCS). Using electrophysiological measures of sensory and cognitive processing, we found that PSZ were actually superior to HCS in focusing attention at the point of gaze and filtering out peripheral distractors when the task required a narrow focusing of attention. This finding of superior filtering in PSZ supports the hyperfocusing hypothesis, which may provide the mechanism underlying a broad range of cognitive impairments in schizophrenia.

Treatment of an Adolescent Patient with Dentinogenesis Imperfecta Using Indirect Composite Restorations - A Case Report and Literature Review.

PURPOSE: To demonstrate the field of application and prospects of individually modeled indirect composite restorations for the treatment of children and adolescents based on a case of dentinogenesis imperfecta. Dental malformations can affect single or multiple teeth. In most cases, direct composite fillings can be placed. However, in severe cases, these restorations may be more challenging and error-prone, especially when occlusal adjustments are necessary. Since composite materials do not require a specific lamination strength and are easy to repair, they can be applied using the indirect technique, enabling conservation of more sound hard tissue than is possible when conventional restorations are used. PATIENT AND METHODS: A young patient with dentinogenesis imperfecta type II underwent interdisciplinary full-mouth rehabilitation due to massive tooth wear and loss of vertical occlusion. First, a check bite was taken, and vertical occlusion was increased using overdentures. Six months later, a construction bite was taken over the existing overdentures (focusing on the sagittal dimension) to move the mandibular position more towards the anterior, correcting the skeletal Class II malocclusion. This resulted in a Class I intercuspidation with harmonization of the facial proportions. After a further six months, all teeth were restored using individually modeled indirect composite restorations, which preserved most of the sound hard tissue and restored esthetics and function. CONCLUSION: Indirect composite restorations can be a valuable tool for improving occlusion, esthetics and function in the treatment of children and adolescents.

Incidence and characteristics of phrenic nerve palsy following pulmonary vein isolation with the second-generation as compared with the first-generation cryoballoon in 360 consecutive patients.

AIMS: The second-generation cryoballoon (CB2) with increased surface cooling has recently become available. The aim was to investigate the incidence and characteristics of phrenic nerve palsy (PNP) during pulmonary vein isolation (PVI) using the CB2 as compared with the first-generation balloon (CB1). METHODS AND RESULTS: A total of 360 consecutive patients with atrial fibrillation underwent PVI with the CB1 (106 patients) or the CB2 (254 patients). Right PN function was monitored by continuous stimulation and palpation during septal PV ablation. Persistent PNP (present at discharge) occurred in 2.8 and 1.9% (P = 0.63) of patients, transient PNP (full recovery before discharge) in 5.9 and 3.8% (P = 0.41) of patients in the CB2 and CB1 group, respectively. Phrenic nerve palsy during ablation at the right inferior PV was observed in 0% (CB1) and 4.3% (CB2, P = 0.03) of patients. Using the CB2, a trend of reduced incidence of persistent PNP over quartiles of consecutive patients was observed [4.8% (Q1) vs. 0% (Q4); P = 0.077]. At the culprit PV, PNP occurred after 3.5 ± 2.1 (CB1) and 1.1 ± 0.4 applications (CB2; P = 0.036). Complete recovery of PN function occurred after 29 ± 11 (CB1) and 259 ± 137 days (CB2; P = 0.004). CONCLUSIONS: The rate of transient/persistent PNP associated with the use of the CB2 was 5.9 and 2.8%, respectively. Time to restitution of PN function was longer using the CB2.

High rate of durable pulmonary vein isolation after second-generation cryoballoon ablation: analysis of repeat procedures.

AIMS: Pulmonary vein isolation (PVI) using the first-generation cryoballoon (CB1) was characterized by a high rate of recovered pulmonary vein (PV) conduction along with a typical conduction gap pattern in patients with recurrent atrial tachyarrhythmia (ATa). Second generation (CB2) enables more uniform freezing. However, the rate of chronic PVI and PV conduction gap pattern is unknown. METHODS AND RESULTS: All patients with ATa recurrence undergoing a second procedure after CB2 or (historical) CB1 PVI (28 mm) were enrolled. In all patients, a left atrial three-dimensional electronatomic reconstruction was performed. The rates of chronic PVI and localization of PV conduction gaps were determined and compared between CB1 and CB2. Antral PV re-isolation was performed using irrigated-tip radiofrequency current energy ablation. Of 206 patients (CB2), 18 patients underwent the repeat procedure after 192 (75:245) days. In 6 of 18 (33%) patients, all PVs were electrically isolated whereas in the remaining 12 patients (66%) at least one PV demonstrated PV reconduction. Of 71 PVs [1 left common PV (LCPV)], 55 PVs (77%) were chronically isolated. The right superior PV (RSPV) was characterized by the lowest rate of chronic PVI (RSPV: 56%, LSPV: 76%, RIPV: 83%, LIPV: 94%, LCPV: 100%). Compared with CB1, CB2 ablation resulted in a significantly higher rate of chronic PVI (CB2: 77% vs. CB1: 32%; P < 0.0001) with the greatest improvement along both inferior PVs. CONCLUSION: Second-generation cryoballoon atrial fibrillation ablation is associated with a high rate of durable PVI in patients with ATa recurrence. The RSPV represents the PV with the greatest risk for left atrium-pulmonary vein reconnection.

Filling the gap: interventional occlusion of incompletely ligated left atrial appendages.

AIMS: Patients undergoing heart surgery and with history of atrial fibrillation are often treated with intraoperative left atrial appendage (LAA) ligation. Incomplete LAA ligation is often described and can be associated with thrombo-embolic complications. To describe a case series of percutaneous LAA occlusion in patients previously treated with surgical LAA ligation. METHODS AND RESULTS: Over 179 patients treated with implantation of an LAA-occluder system at our centre, 3 (1.6%) were previously treated with a surgical LAA suture exclusion (2 males, age 74 ± 3 years). Patients 1 and 3 presented a 'hammerhead' LAA morphology with an open neck and were successfully treated with an AGA Cardiac Plug (ACP-St Jude Medical) Device. Patient 2 had a conic monolobar LAA with a small neck, and the occlusion could be performed using a Watchman (Boston Scientific) device. After discharge on dual antiplatelet therapy, all the patients could be switched to single aspirin (ASA) therapy after a 6-week transoesophageal echocardiography control. CONCLUSION: Left atrial appendage occlusion in patient with incomplete surgical ligation using percutaneous LAA occluder devices appears to be feasible, and studies including a larger number of patients are needed.

Improved 1-year clinical success rate of pulmonary vein isolation with the second-generation cryoballoon in patients with paroxysmal atrial fibrillation.

BACKGROUND: The second-generation cryoballoon (CB2) has recently been introduced featuring improved surface cooling. Increased procedural efficacy of pulmonary vein isolation (PVI) when compared to the first-generation balloon (CB1) has been reported. The aim of the study was to investigate the clinical outcome of cryoballoon PVI after 1 year using the CB2 as compared to the CB1. METHODS AND RESULTS: A total of 105 consecutive patients with paroxysmal atrial fibrillation (AF) were studied. Cryoballoon PVI (28 mm) was performed in 50 patients using the CB1, and in 55 patients using the CB2. Patients were scheduled for 72-hour Holter ECG recording at 3, 6, 9, and 12 months and every 6 months thereafter. The study endpoint was defined as recurrent AF or atrial tachycardia >30 seconds documented after a blanking period of 90 days after the procedure. Complete PVI was achieved in 49/50 (98%) and 55/55 (100%) patients in the CB1 and CB2 group, respectively. After a mean follow-up of 416 ± 75 days, 21 (CB1 group) and 10 (CB2 group) patients reached the study endpoint. Kaplan-Meier estimates of arrhythmia-free survival after a single procedure without AAD therapy after 1 year were 63.9% versus 83.6% (P = 0.008) in the CB1 and CB2 group, respectively. Persistent phrenic nerve palsy with delayed healing occurred in 2 (CB1 group) and 3 (CB2 group) patients. CONCLUSION: Clinical outcome of PVI using the CB2 was significantly improved when compared to the CB1.

Improved lesion formation using the novel 28 mm cryoballoon in atrial fibrillation ablation: analysis of biomarker release.

AIMS: Recently, a novel second-generation (G2) cryoballoon (CB) was introduced. Comparative analysis of lesion formation in terms of myocardial biomarker release [first-generation CB (G1) vs. G2] has not been studied. To compare myocardial biomarker release using the 28 mm G1 vs. G2 CB. METHODS AND RESULTS: In patients (patients) treated with the simplified single big CB (SBCB) strategy for pulmonary vein isolation (PVI), myocardial biomarkers [troponin T (TnT), creatine kinase, lactic dehydrogenase (LDH)] were measured at 12, 24, and 48 h after PVI. Two groups were defined: Group 1 (G1; freezing time: 300 s), Group 2 (G2; freezing time: 240 s). Mean biomarker peak values were compared. To correct for between-group differences in cumulative freezing time, an index calculated as peak biomarker release divided by cumulative freezing time was calculated. Sixty-six CB PVI procedures (G1: 33 patients, G2: 33 patients) were analysed. Pulmonary vein isolation was achieved in all the patients using the simplified SBCB technique only. Mean freezing time (51 ± 10 vs. 33 ± 6 min, P < 0.01) was significantly shorter in G2. All biomarker levels tended to be higher in G2 vs. G1. The indexed biomarkers values were significantly higher in G2: TnT: 18.8 ± 8.5 vs. 32.3 ± 13.6 pg/L/min (P < 0.01); creatinephosphokinase: 6.7 ± 2.7 vs. 11.7 ± 3.9 U/L/min (P < 0.01); LDH: 5.2 ± 1.0 vs. 9.1 ± 2.7 U/L/min (P < 0.01). On a 6-month follow-up (180 days), G2 revealed a significantly higher success rate (20/33 vs. 28/33; P = 0.027). CONCLUSION: Pulmonary vein isolation using the G2 CB increased the myocardial biomarker release index and is linked to a significantly improved 6 months success rate.

Toward the neural mechanisms of reduced working memory capacity in schizophrenia.

People with schizophrenia (PSZ) demonstrate reliable reductions in working memory (WM) capacity (i.e., the number of objects that can be held in memory). The present study asked whether WM impairments in PSZ can be explained by the same neural mechanisms that underlie individual differences in WM capacity among healthy individuals. Specifically, we examined event-related potentials in PSZ and healthy matched controls during a change detection task that required the storage of multiple objects in WM. The amplitude of contralateral delay activity (CDA), which correlates with WM capacity in healthy individuals, was larger in controls than in PSZ for memory loads of 3 and 5 objects, but larger in PSZ than in controls for a memory load of 1. This same pattern was found in the subgroups of PSZ and controls with an equivalent WM capacity. Moreover, the increase in CDA amplitude was correlated with individual differences in capacity in controls, but not in PSZ. These results demonstrate that WM impairment in PSZ is not associated with the same patterns of neural activity that characterize low WM capacity in healthy individuals. We propose that WM impairment in PSZ instead reflects a specific impairment in the ability to distribute attention broadly.

Improved procedural efficacy of pulmonary vein isolation using the novel second-generation cryoballoon.

INTRODUCTION: The cryoballoon technology has the potential to isolate a pulmonary vein (PV) with a single energy application. However, using the first-generation cryoballoon (CB-1G) repeated freezing or additional focal ablation is often necessary. The novel second-generation cryoballoon (CB-2G) features a widened zone of optimal cooling comprising the whole frontal hemisphere. The aim of this study was to investigate the impact of the novel design on procedural efficacy of cryoballoon PV isolation (CB-PVI). METHODS AND RESULTS: Single transseptal CB-PVI using an endoluminal spiral mapping catheter was performed in 60 consecutive patients (CB-1G, 28 mm, 300 seconds application time: 30 patients; CB-2G, 28 mm, 240 seconds application time: 30 patients). When compared to the CB-1G, using the CB-2G increased single-shot PVI rate from 51% to 84% (P < 0.001) and decreased procedure duration (128 ± 27 vs 98 ± 30 minutes; P < 0.001), and fluoroscopy exposure time (19.5 ± 7.4 vs 13.4 ± 5.3 min; P = 0.001). Effective CB-2G PVI could be performed with increased real-time PVI visualization rate (49% vs 76%; P < 0.001). Time to PVI (T(PVI)) was shorter in the CB-2G group (79 ± 60 vs. 52 ± 36 seconds; P = 0.049). Procedure-related complications occurred in 2 patients in the CB-1G group and 1 patient in the CB-2G group. CONCLUSIONS: The CB-2G significantly improved procedural efficacy compared to the CB-1G and provided reliable T(PVI) measurement. T(PVI) may be used to adjust application time and number individually in future studies. Final conclusions regarding the safety profile of the CB-2G requires additional research.

Comparison of balloon catheter ablation technologies for pulmonary vein isolation: the laser versus cryo study.

INTRODUCTION: Balloon catheters have been developed to facilitate pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF). We sought to compare the safety and efficacy of the cryoballoon (CB) and the laserballoon (LB) in a pilot study. METHODS AND RESULTS: One hundred and forty patients with drug-refractory PAF were prospectively allocated in a 1:1 fashion to undergo a PVI procedure with the 28 mm CB or the LB and were followed for 12 months using 3-day Holter ECG recording. The primary efficacy endpoint was a documented AF recurrence ≥ 30 seconds between 90 and 365 days after the index ablation. In total, 269 of 270 PVs (99.6%) and 270 of 273 PVs (98.9%) were acutely isolated in the CB and LB group, respectively. Mean procedural time was 136 ± 30 minutes for the CB group and 144 ± 33 minutes for the LB group (P = 0.13). Mean fluoroscopy time was longer in the CB group (21 ± 9 minutes vs 15 ± 6 minutes; P < 0.001). During 12 months follow-up, 37% of patients in the CB group and 27% in the LB group experienced an AF recurrence (P = 0.18). Phrenic nerve palsies occurred in 5.7% (CB) and 4.2% (LB) of patients, respectively. CONCLUSION: Balloon catheters are a viable option to safely perform a PVI procedure in patients with drug-refractory PAF. Ninety-nine percent of PVs may be acutely isolated with a single balloon catheter. The AF free survival rate after a single ablation procedure was not statistically different between groups.