Pre-procedural pacing bias among transcatheter aortic valves with higher post-procedure pacing rates: evidence from the UK TAVI Registry.

Rates of permanent pacemaker (PPM) implantation following transcatheter aortic valve implantation (TAVI) are higher than following surgery and are dependent on patient factors and valve type. There is an increasing trend towards pre-emptive PPM insertion in patients with significant conduction disease prior to TAVI. We report results from the British Cardiovascular Intervention Society (BCIS) on pre- and post-procedural PPM implantation in the TAVI population. All centres in the United Kingdom performing TAVI are required to submit data on all TAVI procedures to the National database which are then reported annually. During 2015, there were 2373 TAVI procedures in the UK. 22.4% of TAVI patients had a PPM implanted either pre-procedure (including the distant past), or during the in-hospital procedural episode. Of these, 7.9% were pre-procedure and 14.5% post-procedure. Overall PPM rates were Edwards Sapien (13.5%), Medtronic CoreValve (28.2%) and Boston Lotus (42.1%; p < 0.01). Pre-procedure pacing rates were Edwards Sapien (6.0%), Medtronic CoreValve (9.1%) and Boston Lotus (12.3%; p < 0.01). Pre-procedural pacing rates for the Boston Lotus valve have risen year-on-year from 5.8% (2013) to 8.6% (2014) to 12.3% (2015). The UK TAVI Registry demonstrates a pre-procedural permanent pacing bias amongst patients receiving transcatheter valves with higher post-procedure pacing rates. Pre-emptive permanent pacing is likely to be responsible for this difference.

Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative).

BACKGROUND: Permanent pacemaker (PPM) requirement is a recognized complication of transcatheter aortic valve implantation. We assessed the UK incidence of permanent pacing within 30 days of CoreValve implantation and formulated an anatomic and electrophysiological model. METHODS AND RESULTS: Data from 270 patients at 10 centers in the United Kingdom were examined. Twenty-five patients (8%) had preexisting PPMs; 2 patients had incomplete data. The remaining 243 were 81.3±6.7 years of age; 50.6% were male. QRS duration increased from 105±23 to 135±29 milliseconds (P<0.01). Left bundle-branch block incidence was 13% at baseline and 61% after the procedure (P<0.001). Eighty-one patients (33.3%) required a PPM within 30 days. Rates of pacing according to preexisting ECG abnormalities were as follows: right bundle-branch block, 65.2%; left bundle-branch block, 43.75%; normal QRS, 27.6%. Among patients who required PPM implantation, the median time to insertion was 4.0 days (interquartile range, 2.0 to 7.75 days). Multivariable analysis revealed that periprocedural atrioventricular block (odds ratio, 6.29; 95% confidence interval, 3.55 to 11.15), balloon predilatation (odds ratio, 2.68; 95% confidence interval, 2.00 to 3.47), use of the larger (29 mm) CoreValve prosthesis (odds ratio, 2.50; 95% confidence interval, 1.22 to 5.11), interventricular septum diameter (odds ratio, 1.18; 95% confidence interval, 1.10 to 3.06), and prolonged QRS duration (odds ratio, 3.45; 95% confidence interval, 1.61 to 7.40) were independently associated with the need for PPM. CONCLUSION: One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a PPM within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM.

Nonlinear Landau damping of plasma waves with orbital angular momentum.

We present, using three-dimensional particle-in-cell simulations, an observation that orbital angular momentum (OAM) is transferred to resonant electrons proportionally to longitudinal momentum when Laguerre-Gaussian plasma waves are subjected to Landau damping. A higher azimuthal mode number leads to a larger net orbital angular momentum transfer to particles traveling close to the phase velocity of the plasma wave, implying a population of electrons that are orbiting the same center of rotation as the plasma wave. This observation has implications on magnetic field excitation as a result of the formation and damping of OAM plasma waves. The energy distributions of electrons in damping Laguerre-Gaussian plasma waves are significantly changed as a function of azimuthal mode number. This leads to larger numbers of lower energy particles tending towards a significant narrowing of the energy distribution of accelerated particles.

Kinetic plasma waves carrying orbital angular momentum.

The structure of Langmuir plasma waves carrying a finite orbital angular momentum is revised in the paraxial approximation. It is shown that the kinetic effects related to higher-order momenta of the electron distribution function lead to coupling of Laguerre-Gaussian modes and result in a modification of the wave dispersion and damping. The theoretical analysis is compared to the three-dimensional particle-in-cell numerical simulations for a mode with orbital momentum l=2. It is demonstrated that propagation of such a plasma wave is accompanied with generation of quasistatic axial and azimuthal magnetic fields which result from the orbital and longitudinal momenta transported with the wave, respectively.

Primary percutaneous coronary intervention for acute ST elevation myocardial infarction--first year's experience of a tertiary referral centre in the UK.

This study evaluated the first year's experience of a large interventional centre in the UK after a primary percutaneous coronary intervention (PCI) programme that runs 24 hours a day and seven days a week was started. Workload, patient outcome, length of stay, and effect on the remainder of the interventional service were analysed. The primary PCI service for a mainly urban population of 800,000 was started in April 2005. All relevant characteristics, details of procedures, outcome, and other data on quality of care were collected and entered prospectively onto a computerised database. Data were analysed with SPSS (version 13.0). Over a 12-month period, 305 patients were diagnosed with ST elevation myocardial infarction (STEMI), of whom 259 (85%) were accepted for primary PCI. Median door-to-balloon time was 98 minutes, which decreased from 106 minutes in the first six months to 93 minutes in the second six months (p < 0.005). In-hospital mortality was 4.5% and 30-day mortality was 4.9%. Median length of stay was three days, which was reduced from the six days previously reported after thrombolysis. Waiting times for other acute and elective PCI procedures did not increase after initiation of the primary PCI programme. Primary PCI can be delivered successfully in a setting in the UK with low mortality and reduced length of stay and without a negative impact on other interventional services.

Micron-scale mapping of megagauss magnetic fields using optical polarimetry to probe hot electron transport in petawatt-class laser-solid interactions.

The transport of hot, relativistic electrons produced by the interaction of an intense petawatt laser pulse with a solid has garnered interest due to its potential application in the development of innovative x-ray sources and ion-acceleration schemes. We report on spatially and temporally resolved measurements of megagauss magnetic fields at the rear of a 50-µm thick plastic target, irradiated by a multi-picosecond petawatt laser pulse at an incident intensity of ~1020 W/cm2. The pump-probe polarimetric measurements with micron-scale spatial resolution reveal the dynamics of the magnetic fields generated by the hot electron distribution at the target rear. An annular magnetic field profile was observed ~5 ps after the interaction, indicating a relatively smooth hot electron distribution at the rear-side of the plastic target. This is contrary to previous time-integrated measurements, which infer that such targets will produce highly structured hot electron transport. We measured large-scale filamentation of the hot electron distribution at the target rear only at later time-scales of ~10 ps, resulting in a commensurate large-scale filamentation of the magnetic field profile. Three-dimensional hybrid simulations corroborate our experimental observations and demonstrate a beam-like hot electron transport at initial time-scales that may be attributed to the local resistivity profile at the target rear.

Filter no reflow during percutaneous coronary interventions using the Filterwire distal protection device.

BACKGROUND: Distal protection devices are increasingly used to prevent embolization during percutaneous coronary interventions (PCI) in saphenous vein grafts (SVG) and native coronary arteries (NV). During interventions with the Filterwire device we have observed reduced flow that is reversible following removal of the filter (filter no reflow, FNR), which might be erroneously interpreted as true no reflow and might be associated with reduced capture efficiency of the basket. METHODS: We analyzed the incidence of FNR in 58 patients (60 lesions) at high risk of embolization undergoing PCI of either a SVG or a NV using the Filterwire (Boston Scientific, Natick, MA). Qualitative and quantitative angiographic analysis was performed, and the volume of collected debris was estimated using a photographic technique. RESULTS: In our population, about 1/3 of the cases showed FNR, which was associated with angiographically visible filling defects within the basket, indicating macroembolism. However some patients (especially those undergoing vein graft interventions) showed filling defects without FNR, and some others FNR without filling defects. Thus we tried to understand the predictors of FNR: FNR was associated with higher amount of collected debris (36.97 +/- 42.98 mm(3) vs. 11.31 +/- 18.47 mm(3), p = 0.005), was neither prevented by abciximab, nor predicted by high thrombotic burden, increasing stent volume or need for predilatation. When patient with and without angiographically evident macroembolisation were separately analyzed, a linear correlation of FNR with the quantity of debris was only apparent in the macroembolization group. CONCLUSIONS: Interventionalists should be aware of the "Filter No Reflow", a common but reversible angiographic complication when the Filterwire device is used. Reduced flow seen during these procedures should be treated conservatively. Mechanical obstruction of the filter, but also other mechanisms (pharmacologically active debris? platelet aggregates?) play a role in this phenomenon.

Endothelium-derived nitric oxide contributes to the regulation of venous tone in humans.

BACKGROUND: Although nitric oxide (NO) is known to play an important part in the regulation of arterial tone, little is known about its role in veins. The aim of this study was to investigate the role of basal and stimulated NO activity in the regulation of tone of the human venous capacitance bed. METHODS AND RESULTS: We measured venous tone using radionuclide forearm venous plethysmography in 24 healthy subjects with no cardiovascular risk factors. In 13 subjects, basal NO activity was assessed by measuring the effects on venous tone of an intra-arterial infusion of the NO synthase inhibitor N-monomethyl-L-arginine (L-NMMA). In the remaining 11 subjects, stimulated NO activity was evaluated by measuring the effects of an intra-arterial infusion of incremental doses of carbachol, followed in a subgroup by coinfusion with L-NMMA. Infusion of carbachol caused dose-dependent venodilation, with a maximal reduction in forearm venous tone of 40.1+/-12.5% (P<0.0001). Carbachol-induced venodilation was inhibited by L-NMMA (48.9+/-6.2% reversal of maximal venodilation, P<0.01). Infusion of L-NMMA alone caused venoconstriction (9.1+/-6.4% increase in venous tone, P=0.002). CONCLUSIONS: Human forearm capacitance veins exhibit both stimulated and basal NO activity, which indicates that NO contributes not only to the regulation of venous tone but also to resting venous tone in healthy human subjects.

Preservation of venous endothelial function in the forearm venous capacitance bed of patients with chronic heart failure despite arterial endothelial dysfunction.

OBJECTIVES: The goal of this study was to assess whether endothelial dysfunction occurs in the forearm venous capacitance bed of patients with chronic heart failure (CHF) and to determine the role of nitric oxide (NO) in modulating venous tone. BACKGROUND: Control of venous tone is crucially important in CHF. More than 70% of blood volume lies in the venous capacitance beds. Therefore, small changes in venous tone may markedly affect cardiac filling pressures and cardiac output. METHODS: Venous tone was measured using radionuclide forearm venous plethysmography in 24 patients with CHF and 16 age-matched controls. The effect of basal NO activity on venous tone was assessed by infusing N-monomethyl-L-arginine 12 mg/min and stimulated NO using carbachol 15 microg/min. Brachial artery flow-mediated dilation was assessed by ultrasonic wall-tracking. RESULTS: Blockade of basal NO release caused a significant and similar venoconstriction in patients (9.6 +/- 1.8%, p < 0.01) and controls (6.6 +/- 1.7%, p < 0.01). Carbachol-induced venodilation was significant and similar in patients (36.8 +/- 3.9%, p < 0.001) and controls (40.7 +/- 3.9%, p < 0.001). Brachial artery flow-mediated dilation was impaired in patients compared with controls (2.0 +/- 0.6% vs. 7.5 +/- 2.5%, p < 0.01). CONCLUSIONS: Our data indicate that, despite marked impairment of the function of the arterial endothelium, there is preservation of both basal and stimulated NO release in the forearm venous capacitance bed. This may provide important insights into mechanisms of endothelial dysfunction in CHF and the potential for novel therapy.

Neutrophil superoxide anion--generating capacity, endothelial function and oxidative stress in chronic heart failure: effects of short- and long-term vitamin C therapy.

OBJECTIVES: First, we sought to study the effects of short- and long-term vitamin C therapy on oxidative stress and endothelial dysfunction in chronic heart failure (CHF), and second, we sought to investigate the role of neutrophils as a cause of oxidative stress in CHF. BACKGROUND: Oxidative stress may contribute to endothelial dysfunction in CHF. Vitamin C ameliorates endothelial dysfunction in CHF, presumably by reducing oxidative stress, but this is unproven. METHODS: We studied 55 patients with CHF (ischemic and nonischemic etiologies) and 15 control subjects. Flow-mediated dilation (FMD) in the brachial artery was measured by ultrasound wall-tracking, neutrophil superoxide anion (O2-) generation by lucigenin-enhanced chemiluminescence and oxidative stress by measurement of free radicals (FRs) in venous blood using electron paramagnetic resonance (EPR) spectroscopy and plasma thiobarbituric acid reactive substances (TBARS). Measurements were performed at baseline in all subjects. The effects of short-term (intravenous) and long-term (oral) vitamin C therapy versus placebo were tested in patients with nonischemic CHF. RESULTS: At baseline, FRs were higher in patients with CHF than in control subjects (p < 0.01), TBARS were greater (p < 0.005), neutrophil O2- -generating capacity was enhanced (p < 0.005) and FMD was lower (p < 0.0001). Compared with placebo, short-term vitamin C therapy reduced FR levels (p < 0.05), tended to reduce TBARS and increased FMD (p < 0.05), but did not affect neutrophil O2- -generating capacity. Long-term vitamin C therapy reduced FR levels (p < 0.05), reduced TBARS (p < 0.05) and improved FMD (p < 0.05), but also reduced neutrophil O2- -generating capacity (p < 0.05). Endothelial dysfunction was not related to oxidative stress, and improvements in FMD with vitamin C therapy did not relate to reductions in oxidative stress. CONCLUSIONS: Oxidative stress is increased in ischemic and nonischemic CHF, and neutrophils may be an important cause. Vitamin C reduces oxidative stress, increases FMD and, when given long term, decreases neutrophil O2- generation, but the lack of a correlation between changes in endothelial function and oxidative stress with vitamin C implies possible additional non-antioxidant benefits of vitamin C.

Determinants of platelet responsiveness to nitric oxide in patients with chronic heart failure.

Congestive heart failure (CHF) is associated with oxidative stress. Platelet responsiveness to nitric oxide (NO) donors, are impaired in patients with angina pectoris, possibly by increasing oxidative stress. We investigated the occurrence of platelet resistance to NO in patients, with ischaemic or non-ischaemic cardiomyopathy compared with normal subjects. Anti-aggregatory effects of sodium nitroprusside (SNP), oxidative stress and whole blood superoxide anion content were determined, with correlates of responsiveness to SNP. Inhibition of platelet aggregation by SNP was 65.4+/-3.55% in controls and 59.3+/-4.1% in CHF (P=ns) despite increased oxidative stress and post-aggregation O2- in CHF patients. However, subsets of CHF patients have NO-resistant platelets: this is associated with increasing age and/or increased oxidative stress (both p<0.05).

Effects of chlordiazepoxide, ripazepam and d-amphetamine on conditioned acceleration of timing behaviour in rats.

The lever-pressing behaviour of three rats was maintained by a schedule in which food reinforcement was obtained by any response which was emitted at least 15 s after the previous response (DRL 15s). When performance on this schedule had stabilised, the animals were presented intermittently with 1-min periods of a white noise stimulus, the termination of which was accompanied by the delivery of a mild electric footshock. This procedure let to reliable increases in response rates furing the stimulus although responding at other times continued to be appropriate to the DRL 15-s schedule. Administration of the benzodiazepine chlordiazepoxide (1, 3, 10, 17 and 30 mg/kg) and of ripazepam (1, 3, 10, 30 and 56 mg/kg), a non-benzodiazepine reported to have anxiolytic properties, increased response rates on the DRL baseline while decreasing the acceleration of responding produced by the preshock stimulus. Baseline response rates were also increased by d-amphetamine (0.25, 0.5, 1.0 and 2.0 mg/kg) and at the higher doses this drug completely abolished the accelerated responding during the preshock stimulus. Although the effects of chlordiazepoxide and ripazepam are consistent with the suggestion that these drugs may attenuate the behavioural effects of aversive stimuli, in this experiment the behavioural effects of d-amphetamine were similar in many respects.

Effects of chlordiazepoxide on the self-regulated duration of lateral hypothalamic stimulation in rats.

Rats were exposed to a fixed-interval 60-s schedule under which responding was maintained by electrical stimulation of the lateral hypothalamus. The duration of stimulation was controlled by the duration of each lever press that initiated reinforcement. The effects of variation in current intensity and administration of several chlordiazepoxide (CDP) doses (2.5--20 mg/kg IP) were investigated. The duration of stimulation was inversely related to current intensity. Administration of CDP resulted in increases in response rate and the durations of reinforced and non-reinforced responses. CDP increased the response duration reliably more with non-reinforced responses than with responses that served to regulate the duration of stimulation. Thus CDP-induced increases in the duration of brain stimulation with the single lever self-regulation procedure may not be attributed to a specific effect of this compound on neural processes underlying reinforcement. The present results indicate the utility of intermittent schedules in establishing the specificity of drug effects on self-regulated duration of brain stimulation in the single-lever condition.

Self-reported Papanicolaou smears and hysterectomies among women in the United States.

OBJECTIVE: To evaluate the potential overuse of Papanicolaou smears among women who have had a hysterectomy. METHODS: We analyzed two surveys of US women aged 18 years or older, the Behavioral Risk Factor Surveillance System (1992-1997) and the National Health Interview Survey (1993-1994), and one survey of US hospitals (National Hospital Discharge Survey, 1980-1997). We examined the number of women who have had a hysterectomy who had a recent (within 3 years) Papanicolaou smear. We also examined trends in the proportions and rates of hysterectomies by diagnoses and type of procedure that potentially could require a Papanicolaou smear. RESULTS: From the Behavioral Risk Factor Surveillance System, an estimated 21.2% of US women have had a hysterectomy. Among women who have had a hysterectomy, 78.3% had a recent Papanicolaou smear. Among those reporting no hysterectomy, 82.1% had a recent Papanicolaou smear. Estimates from the National Health Interview Survey were similar. From the National Hospital Discharge Survey, an estimated 6.7% to 15.4% of women with a history of hysterectomy would require a subsequent Papanicolaou smear because they had a diagnosis related to cervical neoplasia or because they had undergone a supracervical hysterectomy. For an estimated 10.6-11.6 million of the 12.5 million women who had a hysterectomy and a recent Papanicolaou smear, that test could be considered unnecessary. CONCLUSION: Continued Papanicolaou screening of women without an intact uteri may result in excessive use of resources in time and money with minimal impact on decreasing cervical cancer.

Effects of d-amphetamine and of diazepam on non-punished and punished schedule-induced drinking in rats.

Drinking induced in food-deprived rats by a Fixed-Time 1min schedule of food presentation was measured by the amount of water consumed per session and the number of licks per inter-food interval. Subsequently each lick initiated a 10-sec signalled delay in the delivery of food, which led to a decrease in drinking (punishment). With three rats the effects of d-amphetamine (0.25, 0.5, 1.0, 2.0mg/kg) were assessed on non-punished and then on punished drinking. With another three rats, the effects of diazepam (0.5, 1.0, 2.0, 4.0mg/kg) were assessed. The smaller doses of d-amphetamine had no consistent effect on overall measures of non-punished schedule-induced drinking, but the largest dose decreased them. With the signalled delay d-amphetamine increased punished schedule-induced drinking. Non-punished drinking was increased by small doses of diazepam and decreased by the largest dose, but no dose of diazepam affected punished drinking.

Effects of drugs on the temporal distribution of schedule-induced polydipsia in rats.

Drinking was induced in food-deprived rats by a fixed-time 1-min schedule of food presentation. With three rats, d-amphetamine (0.25, 0.5, 1.0, and 2.0 mg/kg) led to a dose-related increase in licking early in the interfood intervals, the peak of the temporal distribution of licking being shifted to earlier values. These effects were seen even when d-amphetamine had no effect on overall rates of licking and drinking. With another three rats, however, diazepam (0.5, 1.0, 2.0, and 4.0 mg/kg) did not shift the peak of the temporal distribution of licks in interfood intervals, even at doses that produced small increases in overall rates of licking and drinking. However, diazepam did reduce the peak of the distributions of licks at doses that did not decrease water intake and licks per minute.

Rate-dependent effects of drugs: a review of the literature.

It has been claimed that the effects of amphetamines on schedule-controlled behavior depend to a large extent on the rate of responding in control conditions. A review of the literature shows that there is considerable support for this hypothesis if the behavior is not suppressed by aversive procedures, is not under the control of powerful external stimuli or is not occurring very infrequently. The extension of a rate-dependency hypothesis to the effects of other drugs has less empirical support, however. It is argued that many of the procedures used for studying rate-dependent drug effects do not provide critical tests of the hypothesis. If it is to be shown unequivocally that it is rate of operant responding which determines the behavioral effects of drugs, procedures are needed in which other varibles such as reinforcement frequency are more adequately controlled.

Effects of diazepam and ripazepam on two measures of adjunctive drinking in rats.

Four rats were maintained at 85% of their pre-experimental body weights and were given daily 1 hr sessions during which they were each placed in a test chamber in which a 45 mg food pellet was delivered regularly every min independently of behavior. During these sessions water spouts were available to the rats and all 4 animals developed high levels of adjunctive drinking, a burst of licking typically following the consumption of each food pellet. This behavior was found to be sensitive to the effects of diazepam and ripazepam. Small doses of both drugs increased the volume of water consumed during a session. The number of licks was not increased to the same extent, however. Larger doses of both drugs resulted in decreased numbers of licks and decreased water intake although licking appeared on several occasions to be more sensitive than water intake to this action of the drugs. A possible explanation of these effects is that the drugs affected the topography of the rats' licking at the water spouts. Whatever the mechanism involved, however, these results suggest that in such experiments measures of both water intake and number of licks should be obtained.

The effects of pimozide and of reward omission on fixed-interval behavior of rats maintained by food and electrical brain stimulation.

Pimozide (0.125 to 2.0 mg/kg) was administered to rats whose behavior was maintained by a fixed-interval schedule in which the reward was either food (Experiment 1) or electrical stimulation of the brain (Experiment 2). The effects of the drug were compared with the effects of withholding reward (i.e., extinction) in both experiments. Reward omission and administration of pimozide both resulted in decreases in overall rates of responding and increases in the time taken by the subjects to complete a specified number of fixed-intervals. The typical patterning of responding during the sessions of reward omission was also characteristic of the effects of pimozide with food reward but not with brain stimulation reward. The duration of trains of brain stimulation which was under the control of the subjects in Experiment 2, was not altered by administration of pimozide. The differences between the effects of pimozide on behavior maintained by intermittent food reward or by intermittent brain stimulation reward limits a global interpretation of the effects of neuroleptics.

Effects of d-amphetamine and of beta-phenylethylamine on fixed interval responding maintained by self-regulated lateral hypothalamic stimulation in rats.

d-Amphetamine sulphate (0.25-4.0 mg/kg) and beta-phenylethylamine hydrochloride (1.25-50 mg/kg) respectively were administered IP to two groups of rats (R1-R4 and R5-R8 respectively) responding on a fixed interval (FI) schedule (R1-R4 FI 60 sec, R5-R8 FI 30 sec) of electrical hypothalamic stimulation. The duration of each train of stimulation was controlled by the duration of each lever press that initiated stimulation. Under these conditions administration of d-amphetamine resulted in a marked increase in overall response rates on the FI 60 sec schedule. This effect was significant at 1, 2 and 4 mg/kg. d-Amphetamine had not significant effect on the duration of hypothalamic stimulation or on the duration of responses occurring during the FI. Administration of beta-phenylethylamine resulted in a decrease in overall response rates on the FI 30 sec schedule. This effect was significant at 50 mg/kg. beta-Phenylethylamine increased the duration of responses occurring during the FI, this effect being significant at 25 and 50 mg/kg, but had no significant effect on the duration of hypothalamic stimulation. These results indicate that the systemic effects of d-amphetamine on response rate, and of beta-phenylethylamine on both response rate and response duration, are dissociable from changes in the self-regulated duration of lateral hypothalamic stimulation.