Durability of pulmonary vein isolation for atrial fibrillation: a meta-analysis and systematic review.

AIMS: Pulmonary vein isolation (PVI) plays a central role in the interventional treatment of atrial fibrillation (AF). Uncertainties remain about the durability of ablation lesions from different energy sources. We aimed to systematically review the durability of ablation lesions associated with various PVI-techniques using different energy sources for the treatment of AF. METHODS AND RESULTS: Structured systematic database search for articles published between January 2010 and January 2023 reporting PVI-lesion durability as evaluated in the overall cohort through repeat invasive remapping during follow-up. Studies evaluating only a proportion of the initial cohort in redo procedures were excluded. A total of 19 studies investigating 1050 patients (mean age 60 years, 31% women, time to remap 2-7 months) were included. In a pooled analysis, 99.7% of the PVs and 99.4% of patients were successfully ablated at baseline and 75.5% of the PVs remained isolated and 51% of the patients had all PVs persistently isolated at follow-up across all energy sources. In a pooled analysis of the percentages of PVs durably isolated during follow-up, the estimates of RFA were the lowest of all energy sources at 71% (95% CI 69-73, 11 studies), but comparable with cryoballoon (79%, 95%CI 74-83, 3 studies). Higher durability percentages were reported in PVs ablated with laser-balloon (84%, 95%CI 78-89, one study) and PFA (87%, 95%CI 84-90, 2 studies). CONCLUSION: We observed no significant difference in the durability of the ablation lesions of the four evaluated energies after adjusting for procedural and baseline populational characteristics.

Feasibility and safety of laser balloon pulmonary vein isolation in patients with prior left atrial appendage occlusion device implantation.

INTRODUCTION: With the increasing adoption of left atrial appendage occlusion (LAAO) procedures and the eligibility of patients for pulmonary vein isolation (PVI) post device placement, we examined the feasibility and safety of laser balloon (LB) for PVI in patients with prior LAAO. METHODS: We retrospectively examined consecutive patients with paroxysmal or persistent, drug-resistant atrial fibrillation (AF) who underwent LB PVI, after Watchman FLX device implantation at Rush University Medical Center between January 2020 and December 2021. RESULTS: Seven patients (four persistent and three paroxysmal) with a mean age of 64 ± 11 years, predominantly male sex (86%), were included in the study. Two (29%) patients had prior cryoablation PVI with recurrence of AF. The mean CHA2 DS2 VASc is 2.6 ± 0.5 and the mean HAS-BLED score is 3.4 ± 0.8. The mean follow-up duration was 10 ± 7 months. The mean duration between Watchman FLX device implantation and LB PVI was 592 days. Acute first pass left pulmonary vein (PV) isolation was achieved in 100% of the procedures. There were no periprocedural complications such as death, pericardial tamponade or effusion, phrenic nerve injury, PV stenosis, device perforation or embolization, or worsening peri-device leak in any of the patients. None of the patients had AF recurrence after the blanking period. CONCLUSION: LB PVI was safe and effective with 100% acute isolation of left-sided veins in patients with prior LAAO device.

Two-Dimensional Antiferroelectricity in Nanostripe-Ordered In_{2}Se_{3}.

Two-dimensional (2D) layered materials have been an exciting frontier for exploring emerging physics at reduced dimensionality, with a variety of exotic properties demonstrated at 2D limit. Here, we report the first experimental discovery of in-plane antiferroelectricity in a 2D material ß^{'}-In_{2}Se_{3}, using optical and electron microscopy consolidated by first-principles calculations. Different from conventional 3D antiferroelectricity, antiferroelectricity in ß^{'}-In_{2}Se_{3} is confined within the 2D layer and generates the unusual nanostripe ordering: the individual nanostripes exhibit local ferroelectric polarization, whereas the neighboring nanostripes are antipolar with zero net polarization. Such a unique superstructure is underpinned by the intriguing competition between 2D ferroelectric and antiferroelectric ordering in ß^{'}-In_{2}Se_{3}, which can be preserved down to single-layer thickness as predicted by calculation. Besides demonstrating 2D antiferroelectricity, our finding further resolves the true nature of the ß^{'}-In_{2}Se_{3} superstructure that has been under debate for over four decades.

Semiconductor Seeded Nanorods with Graded Composition Exhibiting High Quantum-Yield, High Polarization, and Minimal Blinking.

Seeded semiconductor nanorods represent a unique family of quantum confined materials that manifest characteristics of mixed dimensionality. They show polarized emission with high quantum yield and fluorescence switching under an electric field, features that are desirable for use in display technologies and other optical applications. So far, their robust synthesis has been limited mainly to CdSe/CdS heterostructures, thereby constraining the spectral tunability to the red region of the visible spectrum. Herein we present a novel synthesis of CdSe/Cd1-xZnxS seeded nanorods with a radially graded composition that show bright and highly polarized green emission with minimal intermittency, as confirmed by ensemble and single nanorods optical measurements. Atomistic pseudopotential simulations elucidate the importance of the Zn atoms within the nanorod structure, in particular the effect of the graded composition. Thus, the controlled addition of Zn influences and improves the nanorods' optoelectronic performance by providing an additional handle to manipulate the degree confinement beyond the common size control approach. These nanorods may be utilized in applications that require the generation of a full, rich spectrum such as energy-efficient displays and lighting.

Fast imaging with inelastically scattered electrons by off-axis chromatic confocal electron microscopy.

We introduce off-axis chromatic scanning confocal electron microscopy, a technique for fast mapping of inelastically scattered electrons in a scanning transmission electron microscope without a spectrometer. The off-axis confocal mode enables the inelastically scattered electrons to be chromatically dispersed both parallel and perpendicular to the optic axis. This enables electrons with different energy losses to be separated and detected in the image plane, enabling efficient energy filtering in a confocal mode with an integrating detector. We describe the experimental configuration and demonstrate the method with nanoscale core-loss chemical mapping of silver (M4,5) in an aluminium-silver alloy and atomic scale imaging of the low intensity core-loss La (M4,5@840 eV) signal in LaB6. Scan rates up to 2 orders of magnitude faster than conventional methods were used, enabling a corresponding reduction in radiation dose and increase in the field of view. If coupled with the enhanced depth and lateral resolution of the incoherent confocal configuration, this offers an approach for nanoscale three-dimensional chemical mapping.

Atomic-level 2-dimensional chemical mapping and imaging of individual dopants in a phosphor crystal.

The ability to visualize and identify individual dopants, as well as measure their local physical and chemical environments in a bulk, provides deep insight for designing new functional materials and predicting their properties. However, a full understanding of dopants inside a solid has been limited by currently available characterization techniques. We demonstrate the first atomic-level 2-dimensional elemental maps of Pr dopants using the electron energy-loss spectroscopy (EELS) technique and we image Al dopants located in a lattice. Based on spectroscopic and imaging evidence we provide plausible local defect configurations of implanted Pr(+) and Al(+) ions within SrTiO3 single crystals. Our results demonstrate the detection of single Pr atoms and the formation of Al-rich nanoscale clusters ranging from 1 to 3 nm in size randomly distributed in the implanted lattice. These results provide insight into the mechanism of red light emission in doped SrTiO3.

Atomic Mechanisms of Cation Adsorption/Exchange in Octahedral Molecular Sieves.

Octahedral molecular sieves (OMSs) based on MnO2 have been widely studied in the fields of deionization, geochemistry, and energy storage due to their microporous tunnel framework capable of adsorbing and exchanging various ions, particularly cations. The understanding of cation adsorption/exchange within OMS tunnels demands atomic-scale exploration, which has been scarcely reported. Here, we disclose how various cations (K+/Ag+/Na+) interplay within the OMS tunnel space on an atomic scale. Not only are the lattice sites for each adsorbed cation species pinpointed but the scenario of dual-cation adsorption within single tunnels is also demonstrated, together with the discovery of characteristic concentration-dependent cation ordering. Moreover, compared with the theoretical parent tunnel phase, the heterogeneous tunnels, though sparsely distributed, exhibit a distinct yet orderly cationic accommodation, highlighting the non-negligible role of tunnel heterogeneity in regulating OMS physiochemistry. Our findings clarify the long-existing ambiguities in nano- and atomic-scale science of the ion adsorption process in OMS materials and are expected to inspire their structural/compositional engineering toward functionality enhancement in various fields.

Imaging high-energy electrons propagating in a crystal.

It has recently become possible to focus a beam of high-energy electrons to a spot smaller than an atom, with vast potential for the study of condensed matter. We devise an experiment that can image, with subangstrom resolution, the distribution of such an electron beam as it scatters within an atomic lattice. Our experiments reveal the acute sensitivity of the scattered electron distribution to 0.1 Å shifts of the impact point. Scattering due to plasmon excitations is also examined. Implications for the study of the atomic and electronic structure of condensed matter are discussed.

Imaging, core-loss, and low-loss electron-energy-loss spectroscopy mapping in aberration-corrected STEM.

High-angle annular dark-field and annular bright-field imaging experiments were carried out on an aberration-corrected transmission electron microscope. These techniques have been demonstrated on thin films of complex oxides Ba3.25La0.75Ti3O12 and on LaB6. The results show good agreement between theory and experiments, and for the case of LaB6 they demonstrate the detection of contrast from the B atoms in the annular bright-field images. Elemental mapping with electron-energy-loss spectroscopy has been used to deduce the distribution of Cr and Fe in a thin film of the complex oxide Bi2(Fe1/2Cr3/2)O6 at the unit cell level and the changes in the near-edge structure within the inequivalent regions in the crystalline unit cell. Energy-filtered images in the low-loss region of the energy-loss spectrum show contrast and resolution consistent with the modulation of the signals from elastic scattering. High-resolution contrast, mediated by phonon scattering, is observed for interband transitions. The limitations in terms of detection and signal are discussed.

Cardiac safety of off-label COVID-19 drug therapy: a review and proposed monitoring protocol.

More than 2,000,000 individuals worldwide have had coronavirus 2019 disease infection (COVID-19), yet there is no effective medical therapy. Multiple off-label and investigational drugs, such as chloroquine and hydroxychloroquine, have gained broad interest due to positive pre-clinical data and are currently used for treatment of COVID-19. However, some of these medications have potential cardiac adverse effects. This is important because up to one-third of patients with COVID-19 have cardiac injury, which can further increase the risk of cardiomyopathy and arrhythmias. Adverse effects of chloroquine and hydroxychloroquine on cardiac function and conduction are broad and can be fatal. Both drugs have an anti-arrhythmic property and are proarrhythmic. The American Heart Association has listed chloroquine and hydroxychloroquine as agents which can cause direct myocardial toxicity. Similarly, other investigational drugs such as favipiravir and lopinavir/ritonavir can prolong QT interval and cause Torsade de Pointes. Many antibiotics commonly used for the treatment of patients with COVID-19, for instance azithromycin, can also prolong QT interval. This review summarizes evidenced-based data regarding potential cardiac adverse effects due to off-label and investigational drugs including chloroquine and hydroxychloroquine, antiviral therapy, monoclonal antibodies, as well as common antibiotics used for the treatment of COVID-19. The article focuses on practical points and offers a point-of-care protocol for providers who are taking care of patients with COVID-19 in an inpatient and outpatient setting. The proposed protocol is taking into consideration that resources during the pandemic are limited.

Resolving hydrogen atoms at metal-metal hydride interfaces.

Hydrogen as a fuel can be stored safely with high volumetric density in metals. It can, however, also be detrimental to metals, causing embrittlement. Understanding fundamental behavior of hydrogen at the atomic scale is key to improve the properties of metal-metal hydride systems. However, currently, there is no robust technique capable of visualizing hydrogen atoms. Here, we demonstrate that hydrogen atoms can be imaged unprecedentedly with integrated differential phase contrast, a recently developed technique performed in a scanning transmission electron microscope. Images of the titanium-titanium monohydride interface reveal stability of the hydride phase, originating from the interplay between compressive stress and interfacial coherence. We also uncovered, 30 years after three models were proposed, which one describes the position of hydrogen atoms with respect to the interface. Our work enables previously unidentified research on hydrides and is extendable to all materials containing light and heavy elements, including oxides, nitrides, carbides, and borides.

Metal-Organic Framework for Transparent Electronics.

Electronics allowing for visible light to pass through are attractive, where a key challenge is to make the core functional units transparent. Here, it is shown that transparent electronics can be constructed by epitaxial growth of metal-organic frameworks (MOFs) on single-layer graphene (SLG) to give a desirable transparency of 95.7% to 550 nm visible light and an electrical conductivity of 4.0 × 104 S m-1. Through lattice and symmetry match, collective alignment of MOF pores and dense packing of MOFs vertically on SLG are achieved, as directly visualized by electron microscopy. These MOF-on-SLG constructs are capable of room-temperature recognition of gas molecules at the ppb level with a linear range from 10 to 108 ppb, providing real-time gas monitoring function in transparent electronics. The corresponding devices can be fabricated on flexible substrates with large size, 3 × 5 cm, and afford continuous folding for more than 200 times without losing conductivity or transparency.

Imaging dopant distribution across complete phase transformation by TEM and upconversion emission.

Correlating dopant distribution to its optical response represents a complex challenge for nanomaterials science. Differentiating the "true" clustering nature from dopant pairs formed in statistical distribution complicates even more the elucidation of doping-functionality relationship. The present study associates lanthanide dopant distribution, including all significant events (enrichment, depletion and surface segregation), to its optical response in upconversion (UPC) at the ensemble and single-nanoparticle level. A small deviation from the Er nominal concentration of a few percent is able to induce clear differences in Er UPC emission color, intensity, excited-state dynamics and ultimately, UPC mechanisms, across tetragonal to monoclinic phase transformation in rationally designed Er doped ZrO2 nanoparticles. Rare evidence of a heterogeneous dopant distribution leading to the coexistence of two polymorphs in a single nanoparticle is revealed by Z- and phase contrast transmission electron microscopy (TEM). Despite their spatial proximity, Er in the two polymorphs are spectroscopically isolated, i.e. they do not communicate by energy transfer. Segregated Er, which is well imaged in TEM, is absent in UPC, while the minor phase content overlooked by X-ray diffraction and TEM is revealed by UPC. The outstanding sensitivity of combined TEM and UPC emission to subtle deviations from uniform doping in the diluted concentration regime renders such an approach relevant for various functional oxides supporting lanthanide dopants as emitters.

Prospects for analyzing the electronic properties in nanoscale systems by VEELS.

Valence electron energy-loss spectroscopy in the scanning transmission electron microscope can provide detailed information on the electronic structure of individual nanostructures. By employing the latest advances in electron optical devices, such as a probe aberration corrector and an electron monochromator, the probe size, spectroscopic resolution, probe current and primary electron energy can be varied over a large range. This flexibility is particularly important for nanostructures where each of these variables needs to be carefully counterbalanced in order to collect spectroscopic data without altering the integrity of the sample. Here the implementation of valence electron energy-loss spectroscopy to the study of nanostructures is discussed, with particular mention to the theoretical understanding of each of the contributions to the overall spectrum.

Association Between Family History and Early-Onset Atrial Fibrillation Across Racial and Ethnic Groups.

Importance: There is a genetic predisposition to early-onset atrial fibrillation (EOAF) in European American individuals. However, the role of family history in the pathogenesis of EOAF in racial and ethnic minorities remains unclear. Objective: To determine whether probands with EOAF across racial and ethnic groups have a higher rate of AF in first-degree family members than racially and ethnically matched control patients with non-early-onset AF (non-EOAF). Design, Setting, and Participants: In this cohort study, patients prospectively enrolled in a clinical and genetic biorepository were administered baseline questionnaires that included questions about family history of AF. Early-onset AF was defined as AF occurring in probands aged 60 years or younger in the absence of structural heart disease. All other forms were categorized as non-EOAF. Recruitment took place from July 2015 to December 2017. Analysis was performed in January 2018. Main Outcomes and Measures: Primary analysis of reported family history of AF in first-degree relatives with sensitivity analysis restricted to those in whom a family history was confirmed by medical record review and electrocardiogram. Results: Of 664 patients enrolled (mean [SD] age, 62 [12] years; 407 [61%] male), 267 (40%) were European American; 258 (39%), African American; and 139 (21%), Hispanic/Latino. There was a family history of AF in 36 probands with EOAF (49%) compared with 128 patients with non-EOAF (22%) (difference, 27%; 95% CI, 14%-40%; P < .001). On multivariable analysis, the adjusted odds of a proband with EOAF who was of African descent (odds ratio [OR], 2.69; 95% CI, 1.06-6.91; P < .001) or Hispanic descent (OR, 9.25; 95% CI, 2.37-36.23; P = .002) having a first-degree relative with AF were greater than those of European descent (OR, 2.51; 95% CI, 1.29-4.87; P = .006). Overall, probands with EOAF were more likely to have a first-degree relative with AF compared with patients with non-EOAF (adjusted OR, 3.02; 95% CI, 1.82-4.95; P < .001) across the 3 racial and ethnic groups. Atrial fibrillation in a first-degree family member was confirmed in 32% of probands with EOAF vs 11% of those with non-EOAF (difference, 21%; 95% CI, 11%-33%; P < .001). Furthermore, African American (28% vs 5%; difference, 23%; 95% CI, 4%-43%; P = .001), European American (35% vs 20%; difference, 15%; 95% CI, 1%-30%; P = .03), and Hispanic/Latino (30% vs 5%; difference, 25%; 95% CI, 4%-54%; P = .02) probands with EOAF were more likely to have a first-degree relative with confirmed AF vs racially and ethnically matched control patients with non-EOAF. The positive and negative predictive values for a family history of confirmed AF were both 89%. Conclusions and Relevance: Probands of African or Hispanic/Latino descent with EOAF were more likely to have a first-degree relative with AF when compared with European American individuals. These findings support genetic predisposition to EOAF across all 3 races.

Comparison of high power, medium power, and irrigated-tip ablation strategies for pulmonary vein isolation in a canine model.

BACKGROUND: We sought to compare the efficacy and collateral damage during pulmonary vein (PV) isolation in a canine model using three different ablation strategies. METHODS: Normal dogs (three each) were randomized to high power (70 W, 20 seconds, 60 degrees C, Hi), medium power (50 W, 60 seconds, 50 degrees C; Med), or irrigated-tip (35 W, 60 seconds, 45 degrees C; Cool) ablation. Two transseptal punctures were performed and right and left superior PV electrical isolation was performed using the assigned ablation strategy. Animals survived for 30 days. RESULTS: There was no difference in the number of lesions required to achieve PV isolation (Hi vs Med vs Cool; 43 vs 38 vs 44 lesions; P = NS). At sacrifice, Hi and Med lesions showed gross evidence of endocardial cratering and eschar formation. Corresponding histopathology showed transmural atrial necrosis with granulation tissue and fibrosis. Cool lesions demonstrated superficial endocardial white patches. The corresponding histopathology was subendocardial fibrosis with full and partial thickness necrosis of the atrial wall. One Hi animal had a large thrombus adherent to the left atrial wall above the left superior PV. PV stenosis was noted in one of three Hi and one of three Med, and none of three Cool. There were visible burns to the lung overlying the left atrial wall in one of three Hi, one of three Med, and none of three Cool. The esophagus demonstrated no evidence of serosal injury. CONCLUSIONS: The Hi and Med power 8-mm-tip ablation strategies for achieving PV isolation appear to result in excessive tissue destruction. Irrigated-tip lesions resulted in less endocardial eschar formation, PV stenosis, and damage to collateral structures.

Real-space mapping of electronic orbitals.

Electronic states are responsible for most material properties, including chemical bonds, electrical and thermal conductivity, as well as optical and magnetic properties. Experimentally, however, they remain mostly elusive. Here, we report the real-space mapping of selected transitions between p and d states on the Ångström scale in bulk rutile (TiO2) using electron energy-loss spectrometry (EELS), revealing information on individual bonds between atoms. On the one hand, this enables the experimental verification of theoretical predictions about electronic states. On the other hand, it paves the way for directly investigating electronic states under conditions that are at the limit of the current capabilities of numerical simulations such as, e.g., the electronic states at defects, interfaces, and quantum dots.