Association between Toll-like receptor 4 Asp299Gly polymorphism and coronary heart disease susceptibility.

Published data on the association between Toll-like receptor 4 (TLR4) Asp299Gly polymorphism and coronary heart disease (CHD) susceptibility are inconclusive. To derive a more precise estimation of the relationship, a meta-analysis was performed. English-language studies were identified by searching PubMed and Embase databases (up to November 2016). All epidemiological studies were regarding Caucasians because no TLR4 Asp/Gly and Gly/Gly genotypes have been detected in Asians. A total of 20 case-control studies involving 14,416 cases and 10,764 controls were included in the meta-analysis. Overall, no significant associations were found between TLR4 Asp299Gly polymorphism and CHD susceptibility in the dominant model (OR=0.89; 95%CI=0.74 to 1.06; P=0.20) pooled in the meta-analysis. In the subgroup analysis by CHD, non-significant associations were found in cases compared to controls. When stratified by control source, no significantly decreased risk was found in the additive model or dominant model. The present meta-analysis suggests that the TLR4 Asp299Gly polymorphism was not associated with decreased CHD risk in Caucasians.

HLA-DR3 antigen in the resistance to idiopathic dilated cardiomyopathy.

Idiopathic dilated cardiomyopathy (IDC) has been hypothesized as a multifactorial disorder initiated by an environment trigger in individuals with predisposing human leukocyte antigen (HLA) alleles. Published data on the association between HLA-DR3 antigen and IDC risk are inconclusive. To derive a more precise estimation of the relationship, a meta-analysis was performed. Studies were identified by searching the PUBMED and Embase database (starting from June 2015). A total of 19 case-control studies including 1378 cases and 10383 controls provided data on the association between HLA-DR3 antigen and genetic susceptibility to IDC. Overall, significantly decreased frequency of HLA-DR3 allele (OR=0.72; 95%CI=0.58-0.90; P=0.004) was found in patients with IDC compared with controls. When stratified by myocardial biopsy or non-biopsy cases, statistically decreased risk was found for IDC in myocardial biopsy cases (OR=0.69; 95%CI=0.57-0.84; P=0.0003). In the subgroup analysis by ethnicity, borderline statistically significantly decreased risk was found among Europeans from 12 case-control studies (OR=0.76; 95%CI=0.58-1.00; P=0.05). In conclusion, our results suggest that individuals with HLA-DR3 antigen may have a protective effect against IDC.

HLA-DR3 antigen in the resistance to idiopathic dilated cardiomyopathy

Idiopathic dilated cardiomyopathy (IDC) has been hypothesized as a multifactorial disorder initiated by an environment trigger in individuals with predisposing human leukocyte antigen (HLA) alleles. Published data on the association between HLA-DR3 antigen and IDC risk are inconclusive. To derive a more precise estimation of the relationship, a meta-analysis was performed. Studies were identified by searching the PUBMED and Embase database (starting from June 2015). A total of 19 case-control studies including 1378 cases and 10383 controls provided data on the association between HLA-DR3 antigen and genetic susceptibility to IDC. Overall, significantly decreased frequency of HLA-DR3 allele (OR=0.72; 95%CI=0.58-0.90; P=0.004) was found in patients with IDC compared with controls. When stratified by myocardial biopsy or non-biopsy cases, statistically decreased risk was found for IDC in myocardial biopsy cases (OR=0.69; 95%CI=0.57-0.84; P=0.0003). In the subgroup analysis by ethnicity, borderline statistically significantly decreased risk was found among Europeans from 12 case-control studies (OR=0.76; 95%CI=0.58-1.00; P=0.05). In conclusion, our results suggest that individuals with HLA-DR3 antigen may have a protective effect against IDC.

High levels of LDL-C combined with low levels of HDL-C further increase platelet activation in hypercholesterolemic patients

High levels of low-density lipoprotein cholesterol (LDL-C) enhance platelet activation, whereas high levels of high-density lipoprotein cholesterol (HDL-C) exert a cardioprotective effect. However, the effects on platelet activation of high levels of LDL-C combined with low levels of HDL-C (HLC) have not yet been reported. We aimed to evaluate the platelet activation marker of HLC patients and investigate the antiplatelet effect of atorvastatin on this population. Forty-eight patients with high levels of LDL-C were enrolled. Among these, 23 had HLC and the other 25 had high levels of LDL-C combined with normal levels of HDL-C (HNC). A total of 35 normocholesterolemic (NOMC) volunteers were included as controls. Whole blood flow cytometry and platelet aggregation measurements were performed on all participants to detect the following platelet activation markers: CD62p (P-selectin), PAC-1 (GPIIb/IIIa), and maximal platelet aggregation (MPAG). A daily dose of 20 mg atorvastatin was administered to patients with high levels of LDL-C, and the above assessments were obtained at baseline and after 1 and 2 months of treatment. The expression of platelets CD62p and PAC-1 was increased in HNC patients compared to NOMC volunteers (P<0.01 and P<0.05). Furthermore, the surface expression of platelets CD62p and PAC-1 was greater among HLC patients than among HNC patients (P<0.01 and P<0.05). Although the expression of CD62p and PAC-1 decreased significantly after atorvastatin treatment, it remained higher in the HLC group than in the HNC group (P<0.05 and P=0.116). The reduction of HDL-C further increased platelet activation in patients with high levels of LDL-C. Platelet activation remained higher among HLC patients regardless of atorvastatin treatment.

High levels of LDL-C combined with low levels of HDL-C further increase platelet activation in hypercholesterolemic patients.

High levels of low-density lipoprotein cholesterol (LDL-C) enhance platelet activation, whereas high levels of high-density lipoprotein cholesterol (HDL-C) exert a cardioprotective effect. However, the effects on platelet activation of high levels of LDL-C combined with low levels of HDL-C (HLC) have not yet been reported. We aimed to evaluate the platelet activation marker of HLC patients and investigate the antiplatelet effect of atorvastatin on this population. Forty-eight patients with high levels of LDL-C were enrolled. Among these, 23 had HLC and the other 25 had high levels of LDL-C combined with normal levels of HDL-C (HNC). A total of 35 normocholesterolemic (NOMC) volunteers were included as controls. Whole blood flow cytometry and platelet aggregation measurements were performed on all participants to detect the following platelet activation markers: CD62p (P-selectin), PAC-1 (GPIIb/IIIa), and maximal platelet aggregation (MPAG). A daily dose of 20 mg atorvastatin was administered to patients with high levels of LDL-C, and the above assessments were obtained at baseline and after 1 and 2 months of treatment. The expression of platelets CD62p and PAC-1 was increased in HNC patients compared to NOMC volunteers (P<0.01 and P<0.05). Furthermore, the surface expression of platelets CD62p and PAC-1 was greater among HLC patients than among HNC patients (P<0.01 and P<0.05). Although the expression of CD62p and PAC-1 decreased significantly after atorvastatin treatment, it remained higher in the HLC group than in the HNC group (P<0.05 and P=0.116). The reduction of HDL-C further increased platelet activation in patients with high levels of LDL-C. Platelet activation remained higher among HLC patients regardless of atorvastatin treatment.

Wire network behavior in superconducting Nb films with diluted triangular arrays of holes.

We present results of transport measurements on superconducting Nb films with diluted triangular arrays (honeycomb and kagomé) of holes. The patterned films have large disk-shaped interstitial regions even when the edge-to-edge separations between nearest neighboring holes are comparable to the coherence length. Changes in the field interval of two consecutive minima in the field dependent resistance R(H) curves are observed. In the low field region, fine structures in the R(H) and T(c)(H) curves are identified in both arrays. Comparison of experimental data with calculation results reveals that these structures observed in honeycomb and kagomé hole arrays resemble those in wire networks with triangular and T(3) symmetries, respectively. The findings suggest that even in these specified periodic hole arrays with very large interstitial regions, the low field fine structures are determined by the connectivity of the nanostructures.

Effect of phenylephrine on focal atrial fibrillation originating in the pulmonary veins and superior vena cava.

OBJECTIVES: This study was aimed at evaluating the effects of phenylephrine infusion on the occurrence of focal atrial fibrillation (AF). BACKGROUND: Paroxysmal AF can be initiated by ectopic atrial beats originating in the pulmonary vein (PV) or superior vena cava (SVC). The effect of change in autonomic tone on this focal AF is unknown. METHODS: This study included 12 patients with frequent bursts of AF documented by 24-h Holter monitoring. The number and coupling interval of spontaneous ectopic activity and bursts of AF were evaluated for 1 min before and after phenylephrine (2 to 3 microg/kg) injection. RESULTS: After detailed mapping, four patients had a focus located in the left superior PV, six in the right superior PV and two in the SVC. In 10 patients with AF foci originating in the PVs, the frequency of ectopic activity (19.5 +/- 27.4 vs. 11.4 +/- 22.9 beats/min, p = 0.059) was reduced as well as AF bursts (14 +/- 3 vs. 1.8 +/- 2.7 bursts/min, p = 0.005) before versus after phenylephrine injection; the minimal coupling interval of ectopic activity and AF bursts became longer compared with baseline. The maximal percent increase in sinus cycle length after phenylephrine injection was significantly greater in patients with complete suppression of AF compared with those with partial suppression (43 +/- 19 vs. 14 +/- 5%, p = 0.01). However, no significant effect of phenylephrine on AF originating in the SVC was found. CONCLUSIONS: Change in autonomic tone induced by phenylephrine injection was effective in suppressing focal AF originating in the PVs but not in the SVC.

Alterations of heart rate variability after radiofrequency catheter ablation of focal atrial fibrillation originating from pulmonary veins.

BACKGROUND: Transient sinus bradycardia and hypotension have been reported as complications during radiofrequency (RF) ablation of focal atrial fibrillation (AF) originating from pulmonary veins (PVs). This study used heart rate variability (HRV) to evaluate the effects of focal PVs ablation on autonomic function. METHODS AND RESULTS: Thirty-seven patients with paroxysmal AF were referred for ablation. The study group included 30 patients who underwent transseptal ablation of PVs, and the control group included 7 patients who underwent the transseptal procedure without ablation. The mean sinus rate and time-domain (standard deviation of RR intervals and root-mean-square of differences of adjacent RR intervals) and frequency-domain (low frequency, high frequency, and low-frequency/high-frequency ratio) analyses of HRV were obtained by use of 24-hour Holter monitoring before and 1 week, 1 month, and 6 months after ablation. All the triggering points of AF were from PVs, and they were successfully ablated. Severe bradycardia and hypotension were noted during ablation of PVs in 6 patients (group IA); 24 patients without the above complication belonged to group IB. Compared with preablation values, a significant increase in mean sinus rate and low-frequency/high-frequency ratio and a significant decrease in standard deviation of RR intervals, root-mean-square of differences of adjacent RR intervals, low frequency, and high frequency were noted in groups IA and IB patients 1 week after ablation. The changes in HR and HRV recovered spontaneously in the 2 subgroups by 1 month later. These parameters of HRV did not change in the control group after the transseptal procedure. CONCLUSIONS: Transient autonomic dysfunction with alterations in HR and HRV occurred after ablation of focal AF originating from PVs.

Inducibility of atrial fibrillation during atrioventricular pacing with varying intervals: role of atrial electrophysiology and the autonomic nervous system.

INTRODUCTION: Patients receiving VVI pacemakers have a higher incidence of paroxysmal atrial fibrillation (AF) than those receiving DDD pacemakers. However, the mechanism behind the difference is not clear. The purpose of this study was to investigate whether atrial electrophysiology and the autonomic nervous system play a role in the occurrence of AF during AV pacing. METHODS AND RESULTS: The study population consisted of 28 patients who had (group I, n = 15) or did not have (group II, n = 13) AF induced by a single extrastimulus during pacing with different AV intervals. Atrial pressure, atrial size, atrial effective refractory periods, and atrial dispersion were evaluated during pacing with different AV intervals. Twenty-four-hour heart rate variability and baroreflex sensitivity also were examined. Atrial pressure, atrial size, effective refractory periods in the right posterolateral atrium and distal coronary sinus, and atrial dispersion increased as the AV interval shortened from 160 to 0 msec. During AV pacing, group I patients had greater minimal (52+/-17 vs 25+/-7 msec; P < 0.005) and maximal (76+/-16 vs 36+/-9 msec; P < 0.005) atrial dispersion than group II patients. The differences in atrial size and atrial dispersion among different AV intervals were greater in patients with AF than in those without AF. Baroreflex sensitivity (6.6+/-1.7 vs 3.9+/-1.0; P < 0.00005), but not heart rate variability, was higher in patients with AF than in those without AF. CONCLUSION: Abnormal atrial electrophysiology and higher vagal reflex activity can play important roles in the genesis of AF in patients receiving pacemakers.

Electrophysiological mechanisms and determinants of vagal maneuvers for termination of paroxysmal supraventricular tachycardia.

BACKGROUND: The vagal maneuvers used for termination of paroxysmal supraventricular reentrant tachycardia (PSVT) appear to involve more complex mechanisms than we have known, and further study should be done to explore the possible mechanisms. METHODS AND RESULTS: In this study, 133 patients with PSVT and 30 age- and sex-matched control subjects were included. We assessed the effects of different vagal maneuvers on termination of PSVT and compared baroreflex sensitivity and beta-adrenergic sensitivity between the patients with PSVT and control subjects. Out of 85 patients with atrioventricular reciprocating tachycardia (AVRT), vagal maneuvers terminated in 45 (53%). Of these, 28 (33%) terminated in the antegrade limb and 17 (20%) terminated in the retrograde limb. Out of 48 patients with atrioventricular nodal reentrant tachycardia (AVNRT), vagal maneuvers terminated the tachycardia in the antegrade slow pathway (14%) or in the retrograde fast pathway (19%). Baroreflex sensitivity was poorer but isoproterenol sensitivity test better in patients with AVNRT. Poorer antegrade atrioventricular node conduction properties and better vagal response determined successful antegrade termination of AVRT by vagal maneuvers. Poorer retrograde accessory pathway conduction property but better vagal response determined successful retrograde termination of AVRT. Better sympathetic and vagal response associated with poorer retrograde atrioventricular node conduction determined retrograde termination of AVNRT by the Valsalva maneuver. CONCLUSIONS: Both the vagal response and conduction properties of the reentrant circuit determine the tachycardia termination by vagal maneuvers. Improved understanding of the interaction of autonomic and electrophysiological mechanisms in maintaining or terminating PSVT may provide important insight into the pathophysiology of these two tachycardias.

Effects of procainamide and dl-sotalol on the changes of atrial electrophysiology induced by high current stimulation.

The relation between high current atrial stimulation and antiarrhythmic drugs was not clear. We evaluated the effects of procainamide and dl-sotalol on the electrophysiological changes induced by high current stimulation. Effects of high current atrial stimulation on effective refractory period, dispersion of refractoriness, conduction velocity, and wavelength of the earliest atrial premature beat were evaluated at baseline and after infusion of procainamide (10 patients) and dl-sotalol (10 patients). High current atrial stimulation shortened effective refractory period locally (-12% +/- 4.0%, -7.0% +/- 3.0%, -5.1 +/- 3.3%, and -3.0 +/- 2.0%, at 0, 7, 14, and 21 mm from the S1 stimulation site, respectively; P < 0.001); increased the dispersion of refractoriness (from 17.8 +/- 8.5 to 27.4 +/- 12.5 ms, P < 0.001); decreased conduction velocity of the earliest premature beat (from 0.58 +/- 0.10 to 0.52 +/- 0.09 ms, P = 0.01); and decreased wavelength of the earliest atrial premature beat (from 10.9 +/- 2.4 to 8.8 +/- 2.1 cm, P < 0.001). These effects of high current stimulation persisted after procainamide infusion. However, after dl-sotalol infusion, high current atrial stimuli did not change the dispersion of refractoriness (23.1 +/- 10 ms vs 26.4 +/- 10.4 ms; P > 0.05, twice diastolic threshold vs 10 mA); conduction velocity of the earliest premature beat (0.54 +/- 0.06 ms vs 0.50 +/- 0.06 ms, P > 0.05); or wavelength of the earliest premature atrial beat (11.5 +/- 1.6 m/s vs 10.1 +/- 1.7 cm; P > 0.05). Although high current atrial stimulation shortened effective refractory period locally, increased dispersion of refractoriness, and decreased the wavelength of the earliest premature atrial impulse, these effects were abolished by dl-sotalol but not procainamide.

Radiofrequency ablation of idiopathic left ventricular tachycardia with changing ECG morphology.

Idiopathic left ventricular tachycardia is a distinct clinical entity with a typical ECG of right bundle branch block and left axis deviation. We presented a 39-year-old man with idiopathic left ventricular tachycardia, which demonstrated change in the configuration of QRS complex during successive radiofrequency catheter ablation. We proposed that this idiopathic left ventricular tachycardia may have alternative pathways within the reentrant circuit leading to different exits.

Role of atrial electrophysiology and autonomic nervous system in patients with supraventricular tachycardia and paroxysmal atrial fibrillation.

OBJECTIVES: The purposes of this study were to evaluate the atrial electrophysiology and autonomic nervous system in patients who had paroxysmal supraventricular tachycardia (PSVT) associated with paroxysmal atrial fibrillation (PAF). BACKGROUND: PAF frequently appeared in patients with PSVT. However, the critical determinants for the occurrence of PAF were not clear. METHODS: This study population consisted of 50 patients who had PSVT with (n=23) and without (n=27) PAF. Atrial pressure, atrial size, atrial effective refractory periods (AERPs), and AERP dispersion were evaluated during baseline and PSVT, respectively. Twenty-four hour heart rate variability and baroreflex sensitivity (BRS) were also examined. RESULTS: There was greater baseline AERP dispersion in patients with PAF than in those without PAF. The atrial pressure, atrial size, AERPs in the right posterolateral atrium and distal coronary sinus, and AERP dispersion were increased during PSVT as compared with those during baseline. Patients with PAF had greater AERP dispersion than those without PAF during PSVT. The differences of atrial size, right posterolateral AERP, and AERP dispersion between baseline and PSVT were greater in patients with PAF than in those without PAF. BRS, but not heart rate variability, was higher in patients with PAF than in those without PAF. Univariate analysis showed that higher BRS (>4.5 ms/mm Hg, p=0.0002, odds ratio=16.1), AERP dispersion during PSVT (>40 ms, p=0.0008, odds ratio=9.7), and increase of right atrial area during PSVT (>2 cm2, p=0.016, odds ratio=10.7) were significantly correlated with the occurrence of PAF in patients with PSVT. CONCLUSIONS: Disturbed atrial electrophysiology and higher vagal reflex could play important roles in the genesis of PAF in patients with PSVT.

Effects of antiarrhythmic drugs on variability of ventricular rate and exercise performance in chronic atrial fibrillation complicated with ventricular arrhythmias.

For conversion of atrial fibrillation to sinus rhythm and management of ventricular arrhythmias, antiarrhythmic drugs were frequently used. However, the effects of antiarrhythmic drugs on exercise performance and on the variability of ventricular rate were not available. This study included 37 patients who had chronic atrial fibrillation complicated with symptomatic ventricular arrhythmias. The patients were divided into three groups and received sotalol, propafenone, and procainamide, respectively. Before and after taking the drugs for 14 days, these patients received treadmill exercise test, 24 h Holter electrocardiogram, and tilt table test for evaluation of the exercise performance and the variability of ventricular rate (including the mean RR intervals, mRR, the standard deviation of RR intervals, SDRR, and the root mean square of the difference in successive RR intervals, rMSSD). All these antiarrhythmic drugs could suppress ventricular arrhythmia but only sotalol could significantly increase the exercise duration (374+/-50 to 476+/-55 s, P=0.02), and reduce the maximal heart rate (186+/-23 to 136+/-16 beats/min, P=0.01) during exercise test. Furthermore, only sotalol increased the mRR (777+/-60 to 885+/-66 ms, P=0.02), SDRR (190+/-40 to 216+/-48 ms, P=0.04) and rMSSD (223+/-48 to 253+/-40 ms, P=0.03) during 24 h Holter electrocardiogram. With head-up tilt, the mRR, SDRR and rMSSD all decreased significantly before drug therapy, and these changes were still present only after propafenone therapy. Therefore, comparisons among sotalol, propafenone and procainamide showed that sotalol increased the exercise performance and the variability of ventricular rate in patients who had chronic atrial fibrillation complicated with symptomatic ventricular arrhythmias.

Intracardiac stimulation of human parasympathetic nerve fibers induces negative dromotropic effects: implication with the lesions of radiofrequency catheter ablation.

INTRODUCTION: The dromotropic effects of intracardiac parasympathetic nerve stimulation have not been well studied; furthermore, the effects of radiofrequency ablation lesions on parasympathetic nerve stimulation are not clear. METHODS AND RESULTS: Group I: intracardiac electrical stimulation in the right posteroseptal and anteroseptal areas under different stimulation strengths; group II: intracardiac electrical stimulation before and 10 minutes after intravenous propranolol; group III: intracardiac electrical stimulation before and 5 minutes after intravenous atropine. Among the 10 patients with AV nodal reentrant tachycardia (group IV) and the 10 patients with atrial flutter (group V), atrial fibrillation was induced before and after successful ablation, and intracardiac electrical stimulation in the right posteroseptal area was performed before and after successful ablation. The maximal response and complete decay of the response occurred within 2 to 6 seconds of initiation or termination of parasympathetic nerve stimulation. This negative dromotropic effect disappeared after atropine was administered, but not after propranolol. After successful ablation, parasympathetic stimulation still induced negative dromotropic effects. CONCLUSION: Electrical stimulation of parasympathetic nerve fibers near the posteroseptal and anteroseptal areas could induce a negative dromotropic effect, and this effect was preserved after successful radiofrequency ablation of slow pathway and isthmus conduction.

Role of autonomic tone in facilitating spontaneous onset of typical atrial flutter.

OBJECTIVES: This study sought to study the change in autonomic tone that precedes the initiation of paroxysmal atrial flutter. BACKGROUND: An abrupt change in the autonomic tone of the heart is an important initiating factor in the pathogenesis of ventricular tachyarrhythmias and paroxysmal atrial fibrillation. Whether the autonomic tone has a role in the initiation of paroxysmal atrial flutter has not been reported. METHODS: Holter electrocardiographic recording was used to investigate the changes in heart rate variability before the onset of paroxysmal atrial flutter. RESULTS: A total of 12 patients with paroxysmal atrial flutter were analyzed. An increase in the normalized value of the low frequency (LF) component and the LF/high frequency (HF) ratio and a decrease in the normalized value of the HF component began at 6 min before the onset of episodes of paroxysmal atrial flutter, which indicated that sympathovagal balance had shifted to more sympathetic predominance. CONCLUSIONS: An increase in sympathetic modulation or vagal withdrawal, or both, may facilitate the initiation of atrial flutter.

Comparisons of quality of life and cardiac performance after complete atrioventricular junction ablation and atrioventricular junction modification in patients with medically refractory atrial fibrillation.

OBJECTIVES: This study compared the long-term effects of complete atrioventricular junction (AVJ) ablation with those of AVJ modification in patients with medically refractory atrial fibrillation (AF). BACKGROUND: Comparisons between the long-term effects of AVJ ablation with those of AVJ modification in patients with medically refractory AF have not been systematically studied. METHODS: Sixty patients with medically refractory AF were randomly assigned to receive complete AVJ ablation with permanent pacing or AVJ modification. Subjective perception of quality of life (QOL) was assessed by a semiquantitative questionnaire before and 1 and 6 months after ablation. Cardiac performance was evaluated by echocardiography and radionuclide angiography within 24 h (baseline) and at 1 and 6 months after ablation. RESULTS: Both methods were associated with significant improvement in general QOL and a significant reduction in the frequency of major symptoms and symptoms during attacks. The frequency of hospital admission and emergency room visits and antiarrhythmic drug trials significantly decreased after ablation in both groups. However, patients after complete AVJ ablation had a significantly greater improvement in general QOL and a significantly reduced frequency of major symptoms and symptoms during attacks (including palpitation, dizziness, chest oppression, blurred vision and syncope). Left ventricular (LV) systolic function and the ability to perform activities of daily life significantly improved after ablation in patients with depressed LV function in both groups. All improvements after ablation or modification were maintained over the 6-month follow-up period. CONCLUSIONS: AVJ ablation with permanent pacing, as compared with AVJ modification, had a significantly greater ability to decrease the frequency of attacks and the extent of symptoms of AF, and the patients who received this procedure were more satisfied with their general well-being.

Long-term outcome of radiofrequency catheter ablation for typical atrial flutter: risk prediction of recurrent arrhythmias.

INTRODUCTION: Little is known about the predictors of recurrent atrial flutter or fibrillation after successful radiofrequency ablation of typical atrial flutter. In addition, there is only limited evidence suggesting that elimination of atrial flutter would modify the natural history of atrial fibrillation in patients who experienced both of these arrhythmias. The aims of the present study were to investigate the long-term results of radiofrequency catheter ablation and to examine the predictors for late occurrence of atrial fibrillation in a large population with typical atrial flutter. METHODS AND RESULTS: The study population consisted of 144 patients (mean age 56 +/- 18 years) with successful ablation of clinically documented typical atrial flutter. In the first 50 patients, successful ablation was defined as termination and noninducibility of atrial flutter; for the subsequent 94 patients, successful ablation was defined as achievement of bidirectional isthmus conduction block and no induction of atrial flutter. The clinical and echocardiographic variables were analyzed in relation to the late occurrence of atrial flutter or fibrillation. Over the follow-up period of 17 +/- 13 months, 14 (9.7%) patients had recurrence of typical atrial flutter. In the first 50 patients, 8 (16%) had recurrence of atrial flutter, compared with only 6 (6%) of the following 94 patients. Patients with incomplete isthmus block had a significantly higher incidence of recurrent atrial flutter than those with complete isthmus block (6/16 vs 0/78, P < 0.0001) in the following 94 patients. There was no predictor for recurrence of atrial flutter after successful ablation as determined by univariate and multivariate analysis. Although successful ablation of atrial flutter eliminated atrial fibrillation in 45% of patients with a prior history of atrial fibrillation, 31 (21.5%) of 144 patients undergoing this procedure developed atrial fibrillation during the follow-up period. Univariate analysis revealed that three clinical variables were related to the occurrence of atrial fibrillation: (1) the presence of structural heart disease; (2) a history of atrial fibrillation before ablation; and (3) inducible sustained atrial fibrillation after ablation. By multivariate analysis, only a history of atrial fibrillation and inducible sustained atrial fibrillation could predict the late development of atrial fibrillation after atrial flutter ablation. CONCLUSION: Radiofrequency catheter ablation of typical atrial flutter is highly effective and associated with a low recurrence rate of atrial flutter, but atrial fibrillation continues to be a long-term risk for patients undergoing this procedure. The presence of structural heart disease and prior spontaneous or inducible sustained atrial fibrillation increases the risk of developing atrial fibrillation.

Changes of autonomic tone before the onset of paroxysmal atrial fibrillation.

The relationship between autonomic nerve system and the onset of paroxysmal atrial fibrillation (PAF) is still controversial. Furthermore, no prior studies have compared heart rate variability (HRV) between PAF patients with (organic) or without (idiopathic) underlying cardiac diseases. The purpose of this study was to assess the alteration of autonomic tone by analyzing HRV immediately before the onset of atrial fibrillation. This study included 57 patients (M/F: 34/23, 66+/-22 years) with frequent attacks of PAF. All cases underwent 24-h ambulatory Holter monitoring; each patient had one or more episodes of sustained PAF (>30 s). A period of sinus rhythm 40 min was allowed for accurate assessment of HRV over these periods. Spectral HRV was expressed as low (0.04-0.15 Hz) and high (0.15-0.40 Hz) frequency components (LF, HF), and L/H ratio at 2-min intervals over a 40-min period before the onset of PAF. According to HRV, three subtypes were classified; onset of PAF accompanied with increased HF component and decreased L/H ratio was designated as vagal type; decreased HF component and increased L/H ratio was designated as sympathetic type, and the other episodes which did not belong to vagal or sympathetic type were designated as non-related type. In group I (idiopathic PAF, n=30): 63 episodes of PAF were found and vagal type was predominant (41/63, 63.5%); HF increased significantly before the onset of AF. In group II (organic PAF, n=27): 58 episodes of PAF were found and sympathetic type was predominant (39/58, 67.2%); L/H ratio increased before AF onset. None of the three subtypes showed significant circadian distributions in group I and II patients. Changes of HRV before the onset of PAF were not universal; most of the patients with idiopathic PAF were vagal dependent and most of the patients with organic PAF were sympathetic dependent.

Atrioventricular node reentrant tachycardia in patients with a long fast pathway effective refractory period: clinical features, electrophysiologic characteristics, and results of radiofrequency ablation.

Twenty-two patients (group 1) with AV node reentrant tachycardia and a baseline fast pathway effective refractory period (ERP) > or = 500 msec were compared with 30 consecutive patients (group 2) with AV node reentrant tachycardia and a fast pathway ERP < 500 msec. Both groups underwent slow pathway ablation. In the patients with complete elimination of slow pathway, the fast pathway ERP and shortest 1:1 conduction cycle length shortened significantly after ablation but was greater in group 1 (n = 14) than in group 2 (n = 21) (125 +/- 78 msec vs 48 +/- 29 msec, p < 0.001 and 103 +/- 72 msec vs 52 +/- 30 msec, p < 0.001, respectively). In group 1, the shortening of fast pathway ERP was correlated to baseline difference between anterograde fast and anterograde slow ERP (r = 0.806, p < 0.001, slope = 1.08), and the shortening of fast pathway shortest 1:1 conduction cycle length was correlated to baseline difference between anterograde fast and anterograde slow shortest 1:1 conduction cycle length (r = 0.885, p < 0.001, slope = 1.47). During follow-up bradycardia did not develop in any patient and no one required pacing. This shortening of the fast pathway ERP and shortest 1:1 conduction cycle length after complete elimination of slow pathway reduced the concern of subsequent impairment of AV node conduction.