Convergent ablation for persistent atrial fibrillation: outcomes from a single-centre real-world experience.

OBJECTIVES: Atrial fibrillation (AF) is common and can cause significant morbidity and detriment to quality of life. Success rates for conventional catheter ablation are suboptimal in persistent AF (PsAF), especially when longstanding. Convergent hybrid ablation combines endoscopic surgical epicardial and endocardial catheter ablation. It offers promise in treating PsAF. We aimed to evaluate outcomes at our centre following convergent ablation. METHODS: We conducted an observational study of patients undergoing ablation from 2012 to 2019 at a London cardiac centre. Sixty-seven patients underwent convergent ablation entailing epicardial ablation, mostly via sub-xiphoid access, followed by endocardial left atrial catheter ablation. Baseline and follow-up data were obtained retrospectively from clinical records. Primary outcome was freedom from AF on/off anti-arrhythmic drugs after 12-month follow-up. Secondary outcomes included freedom from AF over the entire follow-up, freedom from anti-arrhythmic drugs, freedom from atrial arrhythmias, symptom status, repeat ablation and complications. RESULTS: At baseline, 80.6% had PsAF >1 year (80.6%), 49.3% had body mass index >30 kg/m2 at baseline and 19.4% had left ventricular ejection fraction of 40% or less. The median follow-up was 2.3 (1.4-3.7) years. Freedom from AF recurrence was 81.3% at 1 year and 61.5% over overall follow-up. Eleven patients (16.4%) required redo AF ablation. Prolonged AF duration was associated with increased recurrence at 12 months and duration >5 years with a shorter time to recurrence on Kaplan-Meier analysis, but this and other factors did not significantly impact the AF recurrence during the overall follow-up period. CONCLUSIONS: Convergent ablation had good 1-year and overall success rates for treating PsAF. Our results in a diverse, real-world population support the potential of convergent ablation in patients with challenging to treat PsAF.

Cardiac stereotactic ablative radiotherapy for control of refractory ventricular tachycardia: initial UK multicentre experience.

BACKGROUND: Options for patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or catheter ablation remain limited. Stereotactic radiotherapy has been described as a novel treatment option. METHODS: Seven patients with recurrent refractory VT, deemed high risk for either first time or redo invasive catheter ablation, were treated across three UK centres with non-invasive cardiac stereotactic ablative radiotherapy (SABR). Prior catheter ablation data and non-invasive mapping were combined with cross-sectional imaging to generate radiotherapy plans with aim to deliver a single 25 Gy treatment. Shared planning and treatment guidelines and prospective peer review were used. RESULTS: Acute suppression of VT was seen in all seven patients. For five patients with at least 6 months follow-up, overall reduction in VT burden was 85%. No high-grade radiotherapy treatment-related side effects were documented. Three deaths (two early, one late) occurred due to heart failure. CONCLUSIONS: Cardiac SABR showed reasonable VT suppression in a high-risk population where conventional treatment had failed.

Importance of operator training and rest perfusion on the diagnostic accuracy of stress perfusion cardiovascular magnetic resonance.

BACKGROUND: Clinical evaluation of stress perfusion cardiovascular magnetic resonance (CMR) is currently based on visual assessment and has shown high diagnostic accuracy in previous clinical trials, when performed by expert readers or core laboratories. However, these results may not be generalizable to clinical practice, particularly when less experienced readers are concerned. Other factors, such as the level of training, the extent of ischemia, and image quality could affect the diagnostic accuracy. Moreover, the role of rest images has not been clarified. The aim of this study was to assess the diagnostic accuracy of visual assessment for operators with different levels of training and the additional value of rest perfusion imaging, and to compare visual assessment and automated quantitative analysis in the assessment of coronary artery disease (CAD). METHODS: We evaluated 53 patients with known or suspected CAD referred for stress-perfusion CMR. Nine operators (equally divided in 3 levels of competency) blindly reviewed each case twice with a 2-week interval, in a randomised order, with and without rest images. Semi-automated Fermi deconvolution was used for quantitative analysis and estimation of myocardial perfusion reserve as the ratio of stress to rest perfusion estimates. RESULTS: Level-3 operators correctly identified significant CAD in 83.6% of the cases. This percentage dropped to 65.7% for Level-2 operators and to 55.7% for Level-1 operators (p < 0.001). Quantitative analysis correctly identified CAD in 86.3% of the cases and was non-inferior to expert readers (p = 0.56). When rest images were available, a significantly higher level of confidence was reported (p = 0.022), but no significant differences in diagnostic accuracy were measured (p = 0.34). CONCLUSIONS: Our study demonstrates that the level of training is the main determinant of the diagnostic accuracy in the identification of CAD. Level-3 operators performed at levels comparable with the results from clinical trials. Rest images did not significantly improve diagnostic accuracy, but contributed to higher confidence in the results. Automated quantitative analysis performed similarly to level-3 operators. This is of increasing relevance as recent technical advances in image reconstruction and analysis techniques are likely to permit the clinical translation of robust and fully automated quantitative analysis into routine clinical practice.

Chronic subthreshold subdural cortical stimulation for the treatment of focal epilepsy originating from eloquent cortex.

Medically refractory epilepsy remains a major medical problem worldwide. Although some patients are eligible for surgical resection of seizure foci, a proportion of patients are ineligible for a variety of reasons. One such reason is that the foci reside in eloquent cortex of the brain and therefore resection would result in significant morbidity. This retrospective study reports our experience with a novel neurostimulation technique for the treatment of these patients. We identified three patients who were ineligible for surgical resection of the intracranially identified seizure focus because it resided in eloquent cortex, who underwent therapeutic trial of focal cortical stimulation delivered through the subdural monitoring grid. All three patients had a significant reduction in seizures, and two went on to permanent implantation, which resulted in long-term reduction in seizure frequency. In conclusion, this small case report provides some evidence of proof of concept of the role of targeted continuous neocortical neurostimulation in the treatment of medically refractory focal epilepsy, and provides support for ongoing investigations into this treatment modality.

Amyloid-ß-related angiitis presenting as a uveomeningeal syndrome.

A 59-year-old man had a 2-month history of nonfluctuating encephalopathy. He initially presented acutely with fevers, headaches, and word-finding difficulties. The sedimentation rate was elevated with a bland CSF and normal MRI head. Body CT showed diffuse pulmonary interstitial thickening with patchy opacification. Following treatment for pneumonia, there was resolution of fevers. No infectious etiology was identified. Within days of discharge, he developed bilateral uveitis, which was successfully treated with corticosteroid eyedrops and oral acyclovir. One month later, he developed confusion and unsteadiness. Repeat MRI was reportedly normal; body CT showed resolution of lung changes but diffuse lymphadenopathy persisted. A lymph node biopsy, reviewed at our institution, showed nonspecific reactive changes and fibrosis. Due to progressive encephalopathy and worsening headaches 2 months after symptom onset, the patient presented to our institution. On examination, he scored 30/38 on the Kokmen short test of mental status,(1) losing points for attention and immediate and delayed recall. Funduscopy revealed bilateral disc edema. He had mild appendicular ataxia and impaired tandem walk. The remainder of the examination was normal.

Mystery case: Cowden syndrome presenting with partial epilepsy related to focal cortical dysplasia.

A 55-year-old man presented with seizures characterized by "tightening" of the right side and variable loss of awareness. EEG showed focal epileptogenic abnormalities over left and midline central regions. MRI showed left frontal focal cortical dysplasia (figure 1). He had multiple skin lesions (figure 2) and colonoscopy revealed gastrointestinal mucosal ganglioneuromas. Genetic testing of PTEN gene confirmed a diagnosis of Cowden syndrome (CS).

Is cardiac magnetic resonance imaging assessment of myocardial viability useful for predicting which patients with impaired ventricles might benefit from revascularization?

A best evidence topic in cardiac magnetic resonance imaging (MRI) was written according to a structured protocol. The question addressed was: what is the role of cardiac magnetic resonance (CMR) imaging in viability assessment of ischaemic cardiomyopathy? Altogether more than 164 papers were found using the reported search; of which, 6 represented the best available evidence to answer the clinical question and an additional 4 were found by crosschecking the reference lists for further 'best available evidence' papers. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Using late-gadolinium enhancement-cardiac magnetic resonance (LGE-CMR) imaging, infarcted myocardium can be identified by the presence of hyperenhanced signal. The extent of myocardial hyperenhancement correlates inversely with improved myocardial contractility following surgical or percutaneous revascularization. Furthermore, CMR is able to assess not only viability, but also make gold-standard assessment of ventricular function and volume as well as identify stress perfusion deficits, each of which is relevant to estimating patient prognosis. National bodies have also begun to formally recommend CMR imaging for cardiac viability assessment. For example, the Canadian Cardiovascular Society (CCS) has stated that 'assessment of myocardial viability in patients with left ventricle dysfunction or akinetic segments for predicting recovery of ventricular function following revascularization is a class I indication for the use of LGE-CMR'. We conclude that cardiac MRI is an excellent tool for predicting myocardial viability, in the context of acute and chronic ischaemic heart disease whether subsequent revascularization is achieved by surgical or percutaneous means. In addition, the versatility of CMR imaging makes it an increasingly attractive tool for the complete assessment of the patient with ischaemic cardiomyopathy.

New Zealand National Acute Stroke Services Audit 2009: organisation of acute stroke services in New Zealand.

AIMS: To characterise the nature of acute stroke services provided by District Health Boards (DHBs) in New Zealand. METHODS: An audit of all 21 DHBs was carried out in 2009 via an online survey examining the structural and process elements of acute stroke service provision. A clinical audit involving a retrospective review of consecutive admitted stroke patients is reported separately. RESULTS: The organisational survey found that most patients (82%) are admitted to hospitals in the 13 large and medium DHBs. Only 8 DHBs had stroke units and 5 of the large and medium DHBs did not have stroke units. On audit day, only 39% of all New Zealand patients were being managed in a stroke unit, compared with 51% of all Australian patients. Even in the 8 DHBs with stroke units, only 64% of patients were actually being managed in the stroke unit on the day of the audit. New Zealand compared favourably with Australia in aspects of TIA management and in access to brain imaging. CONCLUSION: There is significant regional variation in the provision of organised stroke care and the level of stroke unit care is low by international standards. This audit provides a benchmark against which to compare future changes in the delivery of stroke care.

Mortality in adult intensive care patients with severe systemic inflammatory response syndromes is strongly associated with the hypo-immune TNF -238A polymorphism.

The systemic inflammatory response syndrome (SIRS) is associated with activation of innate immunity. We studied the association between mortality and measures of disease severity in the intensive care unit (ICU) and functional polymorphisms in genes coding for Toll-like receptor 4 (TLR4), macrophage migratory inhibitory factor (MIF), tumour necrosis factor (TNF) and lymphotoxin-alpha (LTA). Two hundred thirty-three patients with severe SIRS were recruited from one general adult ICU in a tertiary centre in the UK. DNA from patients underwent genotyping by 5' nuclease assay. Genotype was compared to phenotype. Primary outcome was mortality in ICU. Minor allele frequencies were TLR4 +896G 7%, MIF 173C 16%, TNF -238A 10% and LTA +252G 34%. The frequency of the hypoimmune minor allele TNF -238A was significantly higher in patients who died in ICU compared to those who survived (p = 0.0063) as was the frequency of the two haplotypes LTA +252G, TNF -1031T, TNF -308G, TNF -238A and LTA +252G, TNF-1031T, TNF-308A and TNF-238A (p = 0.0120 and 0.0098, respectively). These findings re-enforce the view that a balanced inflammatory/anti-inflammatory response is the most important determinant of outcome in sepsis. Genotypes that either favour inflammation or its counter-regulatory anti-inflammatory response are likely to influence mortality and morbidity.