When Is Cardiac Resynchronization Therapy with a Defibrillator Indicated in Patients with Heart Failure, Especially Elderly Patients?

One benefit of an implantable cardioverter-defibrillator is the prevention of sudden cardiac death (SCD). It is recommended for patients with a low left ventricular ejection fraction (LVEF). However, the choice of cardiac resynchronization therapy (CRT) with or without a defibrillator (CRT-D and CRT-P) in elderly patients is controversial. To understand the current situation for proper device selection, we investigated the impact of defibrillators on mortality in elderly patients with heart failure.Consecutive patients who underwent CRT implantation were retrospectively recruited. Baseline characteristics, all-cause mortality, cardiac death, and defibrillator implantation rates were investigated in patients aged > 75 or ≤ 75 years.A total of 285 patients (79 patients aged > 75 years) were analyzed. Elderly patients had more comorbidities, but a lower proportion had ventricular arrhythmia. During the mean follow-up of 47 months, 109 patients died (67 due to cardiac death). Kaplan-Meier analysis showed higher mortality in elderly patients (P = 0.0428) but no significant difference in cardiac death by age group (P = 0.7472). There were no significant differences in mortality between patients with CRT-D versus CRT-P (P = 0.3386).SCD was rare. A defibrillator had no significant impact on mortality. In elderly patients, comorbidities are common and related to mortality. The selection of CRT-D versus CRT-P should take those factors into account.

Rapid movements in plants.

Plant movements are generally slow, but some plant species have evolved the ability to move very rapidly at speeds comparable to those of animals. Whereas movement in animals relies on the contraction machinery of muscles, many plant movements use turgor pressure as the primary driving force together with secondarily generated elastic forces. The movement of stomata is the best-characterized model system for studying turgor-driven movement, and many gene products responsible for this movement, especially those related to ion transport, have been identified. Similar gene products were recently shown to function in the daily sleep movements of pulvini, the motor organs for macroscopic leaf movements. However, it is difficult to explain the mechanisms behind rapid multicellular movements as a simple extension of the mechanisms used for unicellular or slow movements. For example, water transport through plant tissues imposes a limit on the speed of plant movements, which becomes more severe as the size of the moving part increases. Rapidly moving traps in carnivorous plants overcome this limitation with the aid of the mechanical behaviors of their three-dimensional structures. In addition to a mechanism for rapid deformation, rapid multicellular movements also require a molecular system for rapid cell-cell communication, along with a mechanosensing system that initiates the response. Electrical activities similar to animal action potentials are found in many plant species, representing promising candidates for the rapid cell-cell signaling behind rapid movements, but the molecular entities of these electrical signals remain obscure. Here we review the current understanding of rapid plant movements with the aim of encouraging further biological studies into this fascinating, challenging topic.

Narrower QRS may be enough to respond to cardiac resynchronization therapy in lightweight patients.

A prolonged QRS duration (QRSd) is promising for a response to cardiac resynchronization therapy (CRT). The variation in human body sizes may affect the QRSd. We hypothesized that conduction disturbances may exist in Japanese even with a narrow (< 130 ms)-QRS complex; such patients could be CRT candidates. We investigated the relationships between QRSd and sex and body size in Japanese. We retrospectively analyzed the values of 338 patients without heart failure (HF) (controls) and 199 CRT patients: 12-lead electrocardiographically determined QRSd, left ventricular diastolic and systolic diameters (LVDd and LVDs), body surface area (BSA), body mass index (BMI), and LVEF. We investigated the relationships between the QRSd and BSA, BMI, and LVD. The men's and women's BSA values were 1.74 m2 and 1.48 m2 in the controls (p < 0.0001), and 1.70 m2 and 1.41 m2 in the CRT patients (p < 0.0001). The men's and women's QRSd values were 96.1 ms and 87.4 ms in the controls (p < 0.0001), and 147.8 ms and 143.9 ms in the CRT group (p = 0.4633). In the controls, all body size and LVD variables were positively associated with QRSd. The CRT response rate did not differ significantly among narrow-, mid-, and wide-QRS groups (83.6%, 91.3%, 92.4%). An analysis of the ROC curve provided a QRS cutoff value of 114 ms for CRT responder. The QRSd appears to depend somewhat on body size in patients without HF. The CRT response rate was better than reported values even in patients with a narrow QRSd (< 130 ms). When patients are considered for CRT, a QRSd > 130 ms may not be necessary, and the current JCS guidelines appear to be appropriate.

Benefit of Rate Response with Closed-Loop Stimulation in Patients with Difficult Hemodialysis.

Rate-responsive pacing is known to improve quality of life (QOL) in patients with sick sinus syndrome and chronotropic incompetence. However, the sensors for rate response include accelerometers, closed-loop stimulation (CLS), and minute ventilation sensors (MV sensors), each of which has a different mode of action. For this reason, it is important to select appropriate sensors that match the daily habits and behavioral patterns of the patient. For example, young and active patients are expected to have a rate increase when an accelerometer is used, while elderly patients and patients with a physical disability who are only able to move slowly often have a poor response to the accelerometer. MV sensors are therefore better suited to these patients. Furthermore, CLS is considered effective for patients who require an increase in heart rate when at rest, for example, patients undergoing maintenance dialysis.We describe a representative case, demonstrating the effectiveness of closed-loop stimulation in a patient with hypotension during dialysis.

Thermosensory Perceptual Learning Is Associated with Structural Brain Changes in Parietal-Opercular (SII) Cortex.

The location of a sensory cortex for temperature perception remains a topic of substantial debate. Both the parietal-opercular (SII) and posterior insula have been consistently implicated in thermosensory processing, but neither region has yet been identified as the locus of fine temperature discrimination. Using a perceptual learning paradigm in male and female humans, we show improvement in discrimination accuracy for subdegree changes in both warmth and cool detection over 5 d of repetitive training. We found that increases in discriminative accuracy were specific to the temperature (cold or warm) being trained. Using structural imaging to look for plastic changes associated with perceptual learning, we identified symmetrical increases in gray matter volume in the SII cortex. Furthermore, we observed distinct, adjacent regions for cold and warm discrimination, with cold discrimination having a more anterior locus than warm. The results suggest that thermosensory discrimination is supported by functionally and anatomically distinct temperature-specific modules in the SII cortex.SIGNIFICANCE STATEMENT We provide behavioral and neuroanatomical evidence that perceptual learning is possible within the temperature system. We show that structural plasticity localizes to parietal-opercular (SII), and not posterior insula, providing the best evidence to date resolving a longstanding debate about the location of putative "temperature cortex." Furthermore, we show that cold and warm pathways are behaviorally and anatomically dissociable, suggesting that the temperature system has distinct temperature-dependent processing modules.

Pain: a distributed brain information network?

Understanding how pain is processed in the brain has been an enduring puzzle, because there doesn't appear to be a single "pain cortex" that directly codes the subjective perception of pain. An emerging concept is that, instead, pain might emerge from the coordinated activity of an integrated brain network. In support of this view, Woo and colleagues present evidence that distinct brain networks support the subjective changes in pain that result from nociceptive input and self-directed cognitive modulation. This evidence for the sensitivity of distinct neural subsystems to different aspects of pain opens up the way to more formal computational network theories of pain.

Impact of Sinus Node Recovery Time after Long-Standing Atrial Fibrillation Termination on the Long-Term Outcome of Catheter Ablation.

Atrial electrical and structural remodeling is related to the perpetuation of atrial fibrillation (AF) subsequent to sinus node dysfunction. We investigated the relationship between AF recurrence after catheter ablation and sinus node dysfunction in long-standing persistent AF patients using the sinus node recovery time (SNRT) after defibrillation.Fifty-one consecutive patients who underwent a first ablation for long-standing persistent AF were enrolled. Intracardiac cardioversion was applied before ablation in the absence of any antiarrhythmic drugs, and the power required to defibrillate, number, and SNRT after defibrillation were measured. All patients underwent the same designed radiofrequency catheter ablation procedure.No patient required permanent pacemaker implantation due to sinus dysfunction after the ablation. During the follow-up period of 28.4 months (3.6-43.7), 35 out of 51 patients (69%) experienced an AF recurrence. The AF recurrence was significantly associated with an older age (60 ± 11 versus 52 ± 12 years in the non-recurrence group, P = 0.0196), longer SNRT after defibrillation (1722 [1410-2656] versus 1295 [676-1651] msec, P = 0.0125), and larger left atrial (LA) volume (59 ± 25 versus 41 ± 15 mL, P = 0.0119). There were no significant differences in the AF duration, AF cycle length, and right and total atrial conduction times between the 2 groups. A longer SNRT after defibrillation (adjusted HR 2.13, 95%CI 1.16-3.71, P = 0.0152) and larger LA volume (adjusted HR 1.03, 95%CI 1.01-1.04, P = 0.0054) were independent predictors of AF recurrence after ablation.Assessment of the SNRT after defibrillation may help to predict a successful ablation in patients with long-standing persistent AF.

Redox alters yellow dragonflies into red.

Body color change associated with sexual maturation--so-called nuptial coloration--is commonly found in diverse vertebrates and invertebrates, and plays important roles for their reproductive success. In some dragonflies, whereas females and young males are yellowish in color, aged males turn vivid red upon sexual maturation. The male-specific coloration plays pivotal roles in, for example, mating and territoriality, but molecular basis of the sex-related transition in body coloration of the dragonflies has been poorly understood. Here we demonstrate that yellow/red color changes in the dragonflies are regulated by redox states of epidermal ommochrome pigments. Ratios of reduced-form pigments to oxidized-form pigments were significantly higher in red mature males than yellow females and immature males. The ommochrome pigments extracted from the dragonflies changed color according to redox conditions in vitro: from red to yellow in the presence of oxidant and from yellow to red in the presence of reductant. By injecting the reductant solution into live insects, the yellow-to-red color change was experimentally reproduced in vivo in immature males and mature females. Discontinuous yellow/red mosaicism was observed in body coloration of gynandromorphic dragonflies, suggesting a cell-autonomous regulation over the redox states of the ommochrome pigments. Our finding extends the mechanical repertoire of pigment-based body color change in animals, and highlights an impressively simple molecular mechanism that regulates an ecologically important color trait.

Dramatic Response to Cardiac Resynchronization Therapy With AV Delay Optimization in Narrow QRS Heart Failure.

Cardiac resynchronization therapy (CRT) has been shown to be effective for heart failure. However, as outlined in the AHA/ACC/HRS Appropriate Use Criteria, CRT is not strongly recommended for patients with a narrow QRS complex. We describe a case of dilated cardiomyopathy and narrow QRS complex in which we obtained a dramatic response to CRT by optimizing the atrioventricular (AV) delay. The patient was a 61-year-old man with intractable heart failure. Echocardiography showed a low ejection fraction of 22% but no dyssynchrony. Because he had been hospitalized many times for congestive heart failure despite ß-blocker and diuretic treatment, we decided to use CRT. However, after implantation of the CRT device, the QRS complex widened abnormally, and his symptoms worsened. He was re-admitted 2 months after CRT implantation. We examined the pacemaker status and optimized the AV delay to obtain a "narrow" QRS complex. The patient's condition improved dramatically after the AV delay optimization. His clinical status has been good, and there has been no subsequent hospitalization. Our case points to the effectiveness of CRT in patients with a narrow QRS complex and to the importance of AV optimization for successful CRT.

Activity in early visual areas predicts interindividual differences in binocular rivalry dynamics.

When dissimilar images are presented to the two eyes, binocular rivalry (BR) occurs, and perception alternates spontaneously between the images. Although neural correlates of the oscillating perception during BR have been found in multiple sites along the visual pathway, the source of BR dynamics is unclear. Psychophysical and modeling studies suggest that both low- and high-level cortical processes underlie BR dynamics. Previous neuroimaging studies have demonstrated the involvement of high-level regions by showing that frontal and parietal cortices responded time locked to spontaneous perceptual alternation in BR. However, a potential contribution of early visual areas to BR dynamics has been overlooked, because these areas also responded to the physical stimulus alternation mimicking BR. In the present study, instead of focusing on activity during perceptual switches, we highlighted brain activity during suppression periods to investigate a potential link between activity in human early visual areas and BR dynamics. We used a strong interocular suppression paradigm called continuous flash suppression to suppress and fluctuate the visibility of a probe stimulus and measured retinotopic responses to the onset of the invisible probe using functional MRI. There were ∼130-fold differences in the median suppression durations across 12 subjects. The individual differences in suppression durations could be predicted by the amplitudes of the retinotopic activity in extrastriate visual areas (V3 and V4v) evoked by the invisible probe. Weaker responses were associated with longer suppression durations. These results demonstrate that retinotopic representations in early visual areas play a role in the dynamics of perceptual alternations during BR.

Tissue velocity imaging-based atrial fibrillatory cycle length and wall motion for predicting atrial structural remodeling in patients undergoing catheter ablation.

BACKGROUND: Atrial fibrillation (AF) causes atrial electrical and structural remodeling, which are linked to recurrence of AF after ablation. Atrial fibrillatory cycle length (AFCL) and AF wall motion velocity (AFW-V) obtained by tissue velocity imaging (TVI) might characterize such atrial electrical and structural remodeling. The purpose of this study was to assess the clinical and electrophysiologic correlates of these parameters and their relation to ablation outcomes. METHODS AND RESULTS: The study group comprised 80 patients who underwent transthoracic echocardiography followed by AF ablation. Atrial TVI traces were used to determine AFCL-tvi and AFW-V-tvi at the left atrial septal wall. AFCL that was measured from intracardiac electrograms correlated well with AFCL-tvi (R=0.6094; P=0.0002). AFW-V-tvi was significantly lower and AFCL-tvi was significantly shorter in patients with non-paroxysmal AF than in those with paroxysmal AF (1.63±0.76 cm/s vs. 2.85±1.00 cm/s, respectively, P<0.0001; and 118.2±23.0 ms vs. 145.0±35.0 ms, respectively, P=0.0001). These findings held true for patients with and without post-ablation recurrence. Upon multivariate analysis, a reduced AFW-V-tvi remained the strongest predictor of post-ablation recurrence (hazard ratio for +1-cm/s change, 0.573; 95% confidence interval, 0.337-0.930; P=0.0234). CONCLUSIONS: TVI of atrial fibrillatory wall motion might enhance the non-invasive characterization of atrial remodeling in patients with AF and thus be used for predicting AF recurrence after ablation.

Effect of catheter tip-tissue surface contact on three-dimensional left atrial and pulmonary vein geometries: potential anatomic distortion of 3D ultrasound, fast anatomical mapping, and merged 3D CT-derived images.

UNLABELLED: Anatomic Distortion of 3D Mapping. BACKGROUND: Although catheter tip-tissue contact is known as a reliable basis for mapping and ablation of atrial fibrillation (AF), the effects of different mapping methods on 3-dimensional (3D) map configuration remain unknown. METHODS AND RESULTS: Twenty AF patients underwent Carto-based 3D ultrasound (US) evaluation. Left atrium (LA)/pulmonary vein (PV) geometry was constructed with the 3D US system. The resulting geometry was compared to geometries created with a fast electroanatomical mapping (FAM) algorithm and 3D US merged with computed tomography (merged 3D US-CT). The 3D US-derived LA volumes were smaller than the FAM- and merged 3D US-CT-derived volumes (75 ± 21 cm(3) vs 120 ± 20 cm(3) and 125 ± 25 cm(3) , P < 0.0001 for both). Differences in anatomic PV orifice fiducials between 3D US- and FAM- and merged 3D US-CT-derived geometries were 6.0 (interquartile range 0-9.3) mm and 4.1 (0-7.0) mm, respectively. Extensive encircling PV isolation guided by 3D US images with real-time 2D intracardiac echocardiography-based visualization of catheter tip-tissue contact generated ablation point (n = 983) drop-out at 1.9 ± 3.8 mm beyond the surface of the 3D US-derived LA/PV geometry. However, these same points were located 1.5 ± 5.4 and 0.4 ± 4.1 mm below the FAM- and merged 3D US-CT-derived surfaces. CONCLUSIONS: Different mapping methods yield different 3D geometries. When AF ablation is guided by 3D US-derived images, ablation points fall beyond the 3D US surface but below the FAM- or merged 3D US-CT-derived surface. Our data reveal anatomic distortion of 3D images, providing important information for improving the safety and efficacy of 3D mapping-guided AF ablation. (J Cardiovasc Electrophysiol, Vol. 24, pp. 259-266, March 2013).

The brain structural hub of interhemispheric information integration for visual motion perception.

We investigated the key anatomical structures mediating interhemispheric integration during the perception of apparent motion across the retinal midline. Previous studies of commissurotomized patients suggest that subcortical structures mediate interhemispheric transmission but the specific regions involved remain unclear. Here, we exploit interindividual variations in the propensity of normal subjects to perceive horizontal motion, in relation to vertical motion. We characterize these differences psychophysically using a Dynamic Dot Quartet (an ambiguous stimulus that induces illusory motion). We then tested for correlations between a tendency to perceive horizontal motion and fractional anisotropy (FA) (from structural diffusion tensor imaging), over subjects. FA is an indirect measure of the orientation and integrity of white matter tracts. Subjects who found it easy to perceive horizontal motion showed significantly higher FA values in the pulvinar. Furthermore, fiber tracking from an independently identified (subject-specific) visual motion area converged on the pulvinar nucleus. These results suggest that the pulvinar is an anatomical hub and may play a central role in interhemispheric integration.

Rate-dependent electrophysiologic effects of the class III antiarrhythmic drugs nifekalant, amiodarone, and ibutilide on the atrium in patients with persistent atrial fibrillation.

Persistent atrial fibrillation (AF) is characterized by electrical remodeling, ie, marked decreases in the atrial effective refractory period (ERP), ERP rate adaptation, and atrial conduction velocity. Little information is available on the effects of class III antiarrhythmic drugs on the remodeled atrium. We studied the effects of the class III antiarrhythmic drugs nifekalant, ibutilide, and amiodarone on rate-dependent changes in atrial action potential duration in patients with persistent AF. Right atrial (RA) monophasic action potential duration (MAPD) and intra-atrial conduction time (IACT) were measured at pacing cycle lengths (CLs) of 800, 700, 600, 500, 400, 350, 300, and 250 ms before and after administration of nifekalant (0.4 mg/kg + 0.3 mg/kg/hr, iv), amiodarone (5 mg/kg, iv), or ibutilide (0.01 mg/kg, iv) in 31 patients after successful internal cardioversion of chronic AF of > 2 months duration. Nifekalant and ibutilide significantly increased RA MAPD and the ERP at each CL in a reverse rate-dependent manner. Amiodarone did not affect RA MAPD. Nifekalant did not affect IACT, whereas amiodarone increased IACT at each CL in a rate-dependent manner, and ibutilide increased IACT at CLs ≤ 350 ms. The atrial electrophysiologic effects of the class III antiarrhythmic drugs nifekalant, amiodarone, and ibutilide differ, depending on the degree of electrical and structural remodeling and the effects of the drugs on the depolarizing and repolarizing currents.

Three-dimensional high-density bipolar contact mapping of left atrial endocardial activation during sinus rhythm in patients with atrial fibrillation.

Non-contact array mapping studies have demonstrated the existence of a line of conduction block along the septopulmonary bundle area and the posterior left atrial (LA) roof during sinus rhythm (SR). However, little is known of the global LA activation pattern during SR using a high-density contact bipolar mapping system. High-density contact bipolar isochronal mapping (bipolar mapping sites: 292 [IQR 250-348] points) of the LA was performed during SR with the NavX mapping system in 20 patients with paroxysmal atrial fibrillation (AF) and 11 patients with non-paroxysmal AF. The earliest endocardial breakthrough in the the LA from the right atrium (RA) during SR occurred in the anterosuperior LA (77%) or anterior to the right pulmonary veins (23%), and the breakthrough site did not differ between patients with paroxysmal and non-paroxysmal AF. Regardless of the site of breakthrough, the LA activation pattern was homogeneous, and no line of functional block was observed in any patient. Total LA activation time was significantly longer in non-paroxysmal AF patients than in paroxysmal AF patients (95.1 ± 4.3 ms versus 78.3 ± 3.2 ms, P = 0.0040). Contact-based bipolar LA endocardial activation mapping revealed a homogeneous LA activation pattern during SR, regardless of the between-group difference in activation time and the between-patient difference in sites of earliest LA endocardial breakthrough from the RA.

Inconsistency and uncertainty of the human visual area loci following surface-based registration: Probability and Entropy Maps.

Here we created two different multisubject maps (16 subjects) to characterize interindividual variability in the positions of human visual areas (V1, dorsal and ventral parts of V2/3, V3A, V3B, V7, LOc, MT+, and hV4 [or V4v and V8]), which were localized using fMRI and coregistered using a surface-based method. The first is a probability map representing the degree of alignment inconsistency for each area, in which each point in space is associated with the probability affiliated with a given area. The second, a novel map termed an entropy map in which each point is associated with Shannon entropy computed from the probabilities, represents the degree of uncertainty regarding the area that resides there, and is maximal when all areas are equally probable. The overall average probability and entropy values were about 0.27 and 1.15 bits, respectively, with dependencies on the visual areas. The probability and entropy maps generated here will benefit any application which requires predictions of areas that are most likely present at an anatomical point and know the uncertainty associated with such predictions.

Epicardial ablation with irrigated electrodes: ­ effect of bipolar vs. unipolar ablation on lesion formation ­.

BACKGROUND: Ablation of ventricular tachycardia originating from the left ventricular (LV) epicardium is often limited by the radiofrequency power delivery. We compared the effect of bipolar vs. unipolar epicardial ablation on lesion size. METHODS AND RESULTS: Eleven excised pig hearts were superfused with saline (2 L/min). Unipolar ablation (25 or 30 W for 120 s) was performed between the LV epicardial saline-irrigated electrode and an indifferent electrode (n = 33 lesions). Bipolar ablation (25 or 30 W for 120 s) was performed between a 4-mm saline-irrigated-tip (20 ml/min) electrode on the LV epicardium and an opposing 10-mm non-irrigated-tip electrode on the LV endocardium (n = 38 lesions). Wall thickness did not differ between experiments (15.4 ± 2.4 vs. 15.3 ± 2.1 mm). Impedance was lower at the beginning and end of unipolar ablation than at the beginning and end of bipolar ablation (163.2 ± 20.3Ω and 109.9 ± 16.0Ω vs. 194.6 ± 23.3Ω and 127.1 ± 16.4Ω, respectively) (P<0.001). Epicardial lesion width did not differ between unipolar and bipolar ablation (10.1 ± 2.7 vs. 10.2 ± 2.4 mm), but lesion depth was greater with bipolar ablation (10.6 ± 2.7 vs. 7.5 ± 1.0 mm) (P<0.001). Unipolar ablation produced no transmural lesion, but bipolar ablation produced 15 (46%) (P<0.001). Steam pop occurred in 11 (29%) and 3 (9%) cases, respectively (P = 0.036). CONCLUSIONS: Bipolar ablation of the LV free wall is highly effective at creating an appropriately deep epicardial lesion.

Pharmacologic atrial defibrillation by drug delivery into the temporarily occluded coronary sinus. A canine study.

Venous blood draining from the left atrium (LA) flows into the coronary sinus (CS) through the Marshall vein which has no valvular apparatus, thus allowing LA retroperfusion if reflow in the right atrium is hindered. We investigated pharmacologic atrial defibrillation via the CS in dogs with chronic atrial fibrillation (AF). Chronic AF was induced by rapid atrial pacing for 4-16 weeks in 6 mongrel dogs. A 7F occlusion balloon catheter was introduced into the proximal CS. Boluses of low doses of the class Ic antiarrhythmic drug, pilsicainide (2, 4, 6, and 8 mg as needed) or class III antiarrhythmic drug, nifekalant (0.5, 1, 2, and 4 mg) were infused directly within 3-4 seconds at 10 minute intervals into the temporarily balloon occluded CS near its orifice. In 4 of the 5 dogs (balloon catheter could not be placed in the CS in 1 dog), the cumulative dose of 11.5 ± 7.4 mg of pilsicainide was effective in restoring sinus rhythm; the venous concentration of pilsicainide was 1.23 ± 0.79 µg/mL. A cumulative dose of 7.5 mg nifekalant restored sinus rhythm in only 1 of the 6 dogs. Our results in dogs with sustained AF indicate that delivery of a class Ic or III antiarrhythmic drug near the CS ostium via the temporarily occluded CS is feasible and effective for pharmacologic atrial defibrillation; however, the effect may be related to the elevation of the serum concentration of the drug to the therapeutic range rather than to the delivery method itself.

Linear catheter ablation of the right atrium for rapid atrial pacing-induced sustained atrial fibrillation in dogs.

Catheter ablation of persistent/long-persistent atrial fibrillation (AF) has been shown to be less effective by pulmonary vein isolation (PVI) and additional left atrial (LA) complex fractionated atrial electrograms and long linear lesions are often required. Recent reports have demonstrated right atrial (RA) ablation increases the success rate of maintaining sinus rhythm in persistent/long-persistent AF. The aim of this study was to investigate whether effective RA linear lesions can terminate AF and render it noninducible in a canine model of rapid atrial pacing-induced sustained AF. Sustained AF was induced by rapid atrial pacing in 20 dogs. AF duration was 21-126 days (median, 50 days). Four RA linear lesions (superior vena cava-inferior vena cava, septal line, transverse line, and cavo-tricuspid line) were created with the use of 1 of 3 different ablation catheters (large-tip [8-mm tip], coil-tip, and cooled-tip catheters). AF was terminated with the large-tip catheter in 4/7 dogs (1 dog died of ventricular fibrillation [VF]), with the coil-tip catheter in 3/7 dogs (1 dog died of VF), and with the cooled-tip catheter in 1/6 dogs. In 6 dogs in which AF could not be terminated acutely by RA ablation, AF terminated spontaneously at 7-78 days (median, 14 days) after ablation. RA linear ablation terminated AF with limited success in our dog model of rapid atrial pacing-induced AF, but late AF termination was noted in the surviving dogs. Therefore, RA linear lesions in addition to the PVI and LA lesions may have additional effects on the catheter ablation for the persistent AF.

A novel technique for improved lesions in the coronary sinus. comparison of bipolar and unipolar ablation.

The stepwise approach to radiofrequency (RF) ablation of atrial fibrillation (AF) can include ablation of the coronary sinus (CS) by RF delivery at the left atrium (LA) and/or within the CS. In both cases, the energy is applied between the tip electrode of a percutaneous catheter and a dispersive electrode on the body surface. We explored the feasibility of using the electrode rings of a diagnostic catheter placed in the CS as dispersive electrode(s) for RF delivery within the LA and compared this technique to an established CS ablation method.Excised pig hearts were superfused with a pulsatile saline flow. Bipolar ablation was performed between a saline-irrigated (20 mL/minute) 4-mm tip electrode placed in the LA adjacent to the CS and 7 electrode rings of a 6F, septapolar, 4-mm nonirrigated electrode placed within the CS adjacent to the LA endocardial electrode. Unipolar ablation was performed between the endocardial electrode and dispersive electrode. A continuous transmural lesion was produced in 6/8 (75%) attempts with bipolar ablation, but in 0/6 (0%) attempts with unipolar ablation. However, the incidence of steam pop tended to be increased with bipolar ablation.Bipolar ablation of the CS appears to be highly effective for creating a transmural LA-CS lesion.