Discrimination of thoracic vein potentials facilitated by atrial pacing during the isolation.

BACKGROUND: Although electrical thoracic vein (TV) isolation is an established strategy during atrial fibrillation (AF) ablation, discriminating TV potentials from far-field signals is critical for the achievement. METHODS AND RESULTS: One hundred consecutive drug-refractory symptomatic paroxysmal AF patients who underwent AF catheter ablation were included. All patients underwent circumferential pulmonary vein (PV) isolation during distal coronary sinus (CS) pacing with a cycle length of 600 ms. A superior vena cava (SVC) isolation was added during high right atrial (HRA) pacing with the same cycle length in 79 patients in whom SVC potentials were identified. The interval between the near-field PV potentials and far-field atrial signals significantly prolonged more during distal CS pacing than sinus rhythm (SR) in the left superior (26.0 [18.5-32.8] ms to 36.0 [24.3-55.5] ms, P < 0.01) and left inferior PVs (21.0 [14.0-30.0] ms to 40.0 [23.0-56.0] ms, P < 0.01), but not in the right superior (34.0 [20.0-40.0] ms to 23.0 [18.0-36.0] ms, P = 0.13) and right inferior PVs (22.0 [16.0-28.0] ms to 25.0 [18.0-38.0] ms, P = 0.05). The interval between the SVC potentials and far-field atrial signals significantly prolonged more during HRA pacing than SR (20.0 [0-32.0] ms to 34.0 [24.0-46.0] ms, P < 0.01). Electrical isolation was successfully achieved in all TVs without any complications except for transient right phrenic nerve palsy in two patients. CONCLUSIONS: Discrimination of ipsilateral left PVs and SVC potentials is facilitated by pacing from the distal CS and HRA, respectively. Better recognition of TV potentials would help to achieve electrical isolation.

Clinical implication of adenosine test at repeat atrial fibrillation ablation procedure: the importance of detecting dormant thoracic vein conduction.

BACKGROUND: Pulmonary vein reconnection after electrical isolation is commonly observed in the context of atrial fibrillation ablation and is associated with recurrent atrial tachyarrhythmias. Adenosine test was been performed to identify acute dormant conduction immediately after pulmonary vein isolation at index procedure. However, the utility of adenosine test at repeat procedure has not been reported. METHODS AND RESULTS: We report 5 paroxysmal atrial fibrillation cases without any structural heart disease in which dormant thoracic vein conduction was associated with recurrent atrial tachyarrhythmias. All patients had undergone circumferential ipsilateral pulmonary vein isolation at the index procedure. Superior vena cava isolation was performed if superior vena cava-triggered atrial fibrillation was identified. At the index procedure, adenosine test did not provoke venous reconduction. At the repeat procedure, adenosine provoked clinical arrhythmia in 4 out of 5 cases after transient reconnection between culprit thoracic vein and atrium despite absence of reconnection at the start of the procedure. After the elimination of the dormant conduction gaps, all patients were free from recurrent arrhythmia. CONCLUSIONS: Adenosine provokes dormant thoracic vein conduction associated with the late recurrence of atrial tachyarrhythmias after previous thoracic vein isolation. Thus, adenosine provocation test can specifically help identify and target the cause of recurrent atrial arrhythmia.

A randomized clinical trial comparing advanced pneumatic truncal, chest, and arm treatment to arm treatment only in self-care of arm lymphedema.

Treatment of the truncal lymphatics prior to treatment of the lymphedematous arm is an accepted, although not empirically tested, therapeutic intervention delivered during decongestive lymphatic therapy (DLT). Breast cancer survivors with arm lymphedema are encouraged to use these techniques when performing simple lymphatic drainage as part of their life-long lymphedema self-care. Self-massage is at times difficult and pneumatic compression devices are used by many patients to assist with self-care. One such device, the Flexitouch(®) System, replicates the techniques used during DLT; however, the need for application of pneumatic compression in unaffected truncal areas to improve self-care outcomes in arm only lymphedema is not established. The objective of this study was to compare the therapeutic benefit of truncal/chest/arm advanced pneumatic compression therapy (experimental group) verses arm only pneumatic compression (control group) in self-care for arm lymphedema without truncal involvement using the Flexitouch(®) System. Outcomes of interest were self-reported symptoms, function, arm impedance ratios, circumference, volume, and trunk circumference. Forty-two breast cancer survivors, (21 per group), with Stage II lymphedema completed 30 days of home self-care using the Flexitouch(®) System. Findings revealed a statistically significant reduction in both the number of symptoms and overall symptom burden within each group; however, there were no statistically significant differences in these outcomes between the groups. There was no statistically significant overall change or differential pattern of change between the groups in function. A statistically significant reduction in bioelectrical impedance and arm circumference within both of the groups was achieved; however, there was no statistically significant difference in reduction between groups. These findings indicate that both configurations are effective, but that there may be no added benefit to advanced pneumatic treatment of the truncal lymphatics prior to arm massage when the trunk is not also affected. Further research is indicated in a larger sample.

[Explaining syndromes of decoction for removing blood stasis in chest].

Decoction for removing blood stasis in the chest is Wang Qingren's famous formula for promoting blood circulation, the syndromes of which is composed of Sini powder syndrome, Taohong Siwu decoction syndrome, balloonflower syndrome and achyranthes root syndrome. According to many years' research on formula-syndrome and clinical practice of decoction for removing blood stasis in the chest, the syndromes of decoction for removing blood stasis in the chest is analysised from founder decoction, herb-syndrome, original record and constitutional characteristics in order to provide reference for further study.

Therapeutic massage of the neck and shoulders produces changes in peripheral blood flow when assessed with dynamic infrared thermography.

OBJECTIVE: This study's objective was to determine the effect of therapeutic massage on peripheral blood flow utilizing dynamic infrared thermography in a constant temperature/humidity thermal chamber to assess noncontact skin temperature. DESIGN: The design was a repeated-measures crossover experimental design; the independent variable was treatment condition (massage, light touch, control). SETTING: The study setting was a university research laboratory. SUBJECTS: Seventeen (17) healthy volunteers (8 males/9 females; age = 23.29 +/- 3.06) took part in the study. INTERVENTIONS: One (1) 20-minute neck and shoulder therapeutic massage treatment was performed for each of the three treatment conditions. OUTCOME MEASURES: The dependent variable was noncontact, mean skin temperature in 15 regions measured at 6 time points (pretest and 15, 25, 35, 45, and 60 minutes post-test) for each treatment condition. RESULTS: The massage treatment produced significant elevations in temperature in five regions: anterior upper chest (p = 0.04), posterior neck (p = 0.0006), upper back (p = 0.0005), posterior right arm (p = 0.03), and middle back (p = 0.02). Massage therapy produced significant increases in temperature over time, compared to the other conditions, in the anterior upper chest, and posterior neck, upper back, right arm, and the middle back. Additionally, the temperatures remained above baseline levels after 60 minutes. Interestingly, the massage treatment produced significant temperature elevations in two nonmassaged areas posterior right arm and middle back. CONCLUSIONS: These changes in temperature suggest corresponding changes in peripheral blood flow in the treated areas as well as in adjacent not-massaged areas. Moreover, the results suggest dynamic infrared thermography as a useful tool to measure noninvasive, noncontact changes in peripheral blood flow for massage therapy research.

Interleukin-6 enhancement after direct autologous retransfusion of shed thoracic blood does not influence haemodynamic stability following coronary artery bypass grafting.

BACKGROUND: Direct autologous retransfusion of shed thoracic blood is carried out to reduce homologous transfusion after cardiac surgery, but it contains high concentrations of inflammatory mediators. The purpose of the study was to investigate whether retransfusion of shed thoracic blood induces plasma interleukin-6 (IL-6) expression and influences haemodynamics. METHODS: Following uncomplicated coronary artery bypass graft surgery, forty-four patients were randomised in case postoperative blood loss via thoracic drains exceeded 350 ml. The course of plasma IL-6 levels and haemodynamics including cardiac output, extravascular lung water and intrathoracic blood volume were investigated prior to (T0), 30 minutes (T1), 1 (T2), 3 (T3) and 12 hours (T4) after retransfusion of 350 ml shed blood in comparison to 350 ml saline. RESULTS: Plasma IL-6 levels at T1 (1892 +/- 202 vs. 485 +/- 30 pg/ml) and T2 (1059 +/- 119 vs. 413 +/- 30 pg/ml) were significantly higher in the verum group (n = 20) compared to controls (n = 24) ( P < 0.01). Severe haemodynamic side effects were not detected. CONCLUSION: This study found significantly elevated plasma IL-6 levels following direct autologous retransfusion of shed thoracic blood but failed to show severe adverse effects affecting haemodynamic stability.

Embolization therapy as an alternative to thoracotomy in vascular injuries of the chest wall.

Hemothorax and persistent thoracic bleeding is frequently an indication for thoracotomy after trauma. Unfortunately, the source of the hemorrhage is often not identified. Presently, selective arteriography and transcatheter embolization (SATE) offers a good and safe alternative to localize and control hemorrhage from arterial injuries in selected patients. The records of eight patients who underwent SATE were reviewed. There were six blunt and two penetrating chest injuries. Four patients had significant preexisting medical comorbidities. Three patients with blunt injuries had undergone exploratory thoracotomy, but continued to bleed postoperatively. In three patients, angiography was indicated for associated thoracic and pelvic injuries, and five patients had SATE specifically due to thoracic hemorrhage. In all patients, SATE was effective to diagnose and control the hemorrhage. There were no complications related to the SATE procedure. Two patients died secondary to severe cerebral injuries. Given hemodynamic stability, SATE can be considered in patients who have already had a thoracotomy, have significant associated medical conditions, or those in need of other angiographic studies. Careful technique and a readiness to abandon SATE in unstable patients or when a suitable catheter position cannot be achieved are important technical points.

Changes in muscle sympathetic nerve activity and effect of breathing maneuvers during microgravity induced by parabolic flight in humans.

UNLABELLED: This study aimed to clarify how muscle sympathetic nerve activity (MSNA) in humans, which plays an important role in blood pressure control against gravity, is altered under microgravity (microG) conditions, and how the MSNA change is modified by breathing maneuvers. Ten subjects seated themselves in a jet aircraft with their knees extended. MSNA was recorded microneurographically from the left tibial nerve with simultaneous monitoring of ECG, blood pressure, respiration, and intrathoracic blood volume estimated by the impedance method during parabolic flight in a jet aircraft. In half of the parabolas, their respiration was controlled at 0.25 Hz by a metronome. RESULTS: MSNA was enhanced under hypergravity just before microG entry, and immediately suppressed by microG induced by parabolic flight. The suppression was more marked with controlled than with uncontrolled respiration (51.6 +/- 7.2 vs 82.8 +/- 2.5%, mean +/- SE, 1G=100%). MSNA changes during microG correlated significantly to changes in blood pressure and intrathoracic blood volume. The blood pressure fall 10 to 15 sec after microG entry was less prominent with controlled than with uncontrolled respiration. We conclude that changes in arterial blood pressure and intrathoracic blood volume modulate MSNA during microG induced by parabolic flight, depending largely on breathing maneuvers.

Incentive spirometry to prevent acute pulmonary complications in sickle cell diseases.

BACKGROUND: This study was designed to determine the incidence of thoracic bone infarction in patients with sickle cell diseases who were hospitalized with acute chest or back pain above the diaphragm and to test the hypothesis that incentive spirometry can decrease the incidence of atelectasis and pulmonary infiltrates. METHODS: We conducted a prospective, randomized trial in 29 patients between 8 and 21 years of age with sickle cell diseases who had 38 episodes of acute chest or back pain above the diaphragm and were hospitalized. Each episode of pain was considered to be an independent event. At each hospitalization, patients with normal or unchanged chest radiographs on admission were randomly assigned to treatment with spirometry or to a control nonspirometry group. Each patient in the spirometry group took 10 maximal inspirations using an incentive spirometer every two hours between 8 a.m. and 10 p.m. and while awake during the night until the chest pain subsided. A second radiograph was obtained three or more days after admission, or sooner if clinically necessary, to determine the incidence of pulmonary complications. Bone scanning was performed no sooner than two days after hospital admission to determine the incidence of thoracic bone infarction. RESULTS: The incidence of thoracic bone infarction was 39.5 percent (15 of 38 hospitalizations). Pulmonary complications (atelectasis or infiltrates) developed during only 1 of 19 hospitalizations of patients assigned to the spirometry group, as compared with 8 of 19 hospitalizations of patients in the nonspirometry group (P = 0.019). Among patients with thoracic bone infarction, no pulmonary complications developed in those assigned to the spirometry group during a total of seven hospitalizations, whereas they developed during five of eight hospitalizations in the nonspirometry group (P = 0.025). CONCLUSIONS: Thoracic bone infarction is common in patients with sickle cell diseases who are hospitalized with acute chest pain. Incentive spirometry can prevent the pulmonary complications (atelectasis and infiltrates) associated with the acute chest syndrome in patients with sickle cell diseases who are hospitalized with chest or back pain above the diaphragm.

Total excision of a giant angiolipoma of chest wall with A-V malformation and with the use of an autotransfusion system.

An 18 year old girl suffering from a giant angiolipoma of back and chest wall with A-V malformation underwent total excision of the tumor in 4 stages. The first two stages included surgical ligation of the arterial blood supply to the tumor. In the third and fourth stages the tumor was resected with the use of an autotransfusion system. The last stage was complicated with massive bleeding and disseminated intravascular clotting. Control of bleeding was achieved by the use of autotransfusion system, right thoracotomy and massive transfusion of blood and its components. After long convalescence period associated with renal and respiratory failure the patient recovered completely without sequellae. This case demonstrates the complexity associated with the treatment of these rare tumors.