Trends and patterns in electrophysiologic and ablation catheter reuse in the United States.

In a survey of 140 electrophysiologic laboratories in the USA, 49% reuse catheters to some extent. Catheter reuse is associated with significant reductions in cost but is not conducted in a standardized fashion.

Safety and efficacy of hydrogen peroxide plasma sterilization for repeated use of electrophysiology catheters.

OBJECTIVES: The purpose of this study was to evaluate a new technique for sterilizing nonlumen electrophysiology catheters that uses hydrogen peroxide gas plasma. BACKGROUND: The reuse of electrophysiology catheters may potentially result in a significant cost savings. While ethylene oxide sterilization appears to be safe and effective from a clinical standpoint, toxic ethylene oxide residuals, which exceed Food and Drug Administration standards, have been reported. METHODS: Ten nonlumen electrophysiology catheters were extensively evaluated. Each catheter was used five times and resterilized after each use with hydrogen peroxide gas plasma. Tests for sterility, mechanical and electrical integrity, chemical residuals and standard and electron microscopic inspection were performed. RESULTS: Loss of electrical integrity or mechanical integrity was not observed in any catheter. No evidence of microbial contamination was found. Surface integrity was preserved except for one ablation catheter that exhibited fraying of the insulation at the insulation-electrode interface. Surface inspection using standard magnification and electron microscopy revealed no significant change in surface characteristics associated with the sterilization process. Hydrogen peroxide was the only chemical residual noted, with an average concentration of 0.22% by weight, which is within accepted American Association for the Advancement of Medical Instrumentation limits. The cost for a standard electrophysiology catheter ranges from $200 to $800, and one sterilization cycle costs $10. If electrophysiology catheters are used five times, resterilization could potentially result in a savings of $2,000 per catheter, or $9,000 for five ablation procedures. CONCLUSIONS: Hydrogen peroxide gas plasma sterilization may provide a cost-effective means of sterilizing nonlumen electrophysiology catheters without the problem of potentially harmful chemical residuals. However, careful visual inspection of catheters, particularly at the insulation-electrode interface, is required if catheter reuse is performed.

Radiofrequency catheter ablation versus medical therapy for initial treatment of supraventricular tachycardia and its impact on quality of life and healthcare costs.

We prospectively compared the impact on quality of life and cost effectiveness between ablation and medication as an initial strategy for patients with paroxysmal supraventricular tachycardia (SVT). Seventy-nine consecutive patients with newly documented paroxysmal SVT were treated with either ablation or medication. Health surveys (SF-36 and disease-specific questions) were obtained at baseline and after 12 months of follow up. Cost of health care utilization for the 6 months before and after treatment were measured. Both medication and ablation improved quality of life. However, ablation improved quality of life in more general health categories than medication. At follow up, ablation was associated with significantly improved quality of life in the bodily pain (63+/-24 vs 81+/-20, p <0.005), general health (69+/-21 vs 79+/-21, p <0.05), vitality (55+/-21 vs 66+/-22, p <0.05), and role emotion (78+/-36 vs 94+/-17, p <0.05) categories when compared with medication. Although both medication and ablation decreased frequency of disease-specific symptoms, ablation resulted in complete amelioration of symptoms in more patients (33% vs 74%). Potential long-term costs were similar for medication and ablation. In conclusion, ablation improves health-related quality of life to a greater extent, and in more aspects of general and disease-specific health than medication.

A left free-wall, decrementally conducting, atrioventricular (Mahaim) fiber: diagnosis at electrophysiological study and radiofrequency catheter ablation guided by direct recording of a Mahaim potential.

A 64-year-old female with Wolff-Parkinson-White syndrome and an ECG demonstrating a right posterolateral accessory pathway was referred for electrophysiological study. During electrophysiological testing two AV pathways were identified: a right posterolateral pathway that displayed conventional electrophysiological properties: and a left free-wall pathway that conducted only anterogradely and demonstrated decremental properties. Two separate wide complex tachycardias were induced that utilized the left free-wall pathway anterogradely and either the AV node or the right posterolateral accessory pathway retrogradely. A discrete electrical potential on the free wall of the mitral annulus was identified during tachycardia and was utilized to facilitate mapping and ablation.

Cardiac pacing in patients with dilated cardiomyopathy.

Studies of both the acute and chronic effects of permanent cardiac pacing in patients with dilated cardiomyopathy have produced contradictory results. Similarly, theoretically promising novel pacing techniques such as multisite, His bundle, and right ventricular outflow tract pacing have also yielded mixed results in preliminary studies. In general, at the present time, pacing therapy should be considered investigational for patients with dilated cardiomyopathy who do not have traditional bradycardia indications; nevertheless, pacing therapy may be useful in a small population of patients with dilated cardiomyopathy who have inappropriate timing of left ventricular and left atrial contraction. The beneficial effects of cardiac pacing in some patients with DCM cannot be dismissed out of hand; they must be explained. What is needed is clarification of the best methods to measure any benefits of this therapy: among the options are echocardiographically determined parameters of forward flow and AV valve function, exercise test parameters such as duration and O2 consumption, global and regional ejection fraction, functional classification, quality of life questionnaires, neurohumoral parameters such as plasma atrial natriuretic peptide and catecholamines, and, finally, disease progression and survival.

Responses to calcium and binding of 3H-nimodipine in the atrioventricular node, atria, and ventricles of mature and old male Fischer 344 rats.

To determine whether aging alters cardiac calcium dose responses or dihydropyridine receptor density or affinity, we performed (a) calcium (Ca2+) dose-response studies (3-5 mM) in Langendorff perfused hearts from 12 mature (4-7 month) and 12 old (23-27 month) Fischer 344 rats, and (b) quantitative autoradiography experiments with 3H-nimodipine (50-3,000 pM) in 20-microns tissue sections containing the compact AV node from hearts of eight mature and eight old F344 rats. Baseline AA interval, AV conduction time, AV Wenckebach block cycle length, and QRS duration were prolonged in isolated hearts from old compared with mature rats. In contrast, neither left ventricular developed pressure nor peak dP/dt was altered by age. Perfusion with increasing concentrations of Ca2+ produced decreased coronary perfusion (p < 0.001) without age-related alterations in AA intervals, AV conduction times, dP/dt, or left ventricular developed pressure. No age-related differences in AV node 3H-nimodipine binding (Bmax: mature, 1.35 +/- 0.41 fmol/mm2; old, 1.33 +/- 0.43 fmol/mm2) or affinity (Kd: mature, 915 +/- 375 pM; old, 973 +/- 369 pM) were detected. Similarly, no age-related differences in 3H-nimodipine receptor number or affinity were detected in left and right ventricular or atrial tissue. Total protein in atrial and ventricular tissue was unchanged with age. However, left atrial and left ventricular isolated membrane protein was significantly lower in senescent compared with mature rat hearts (left ventricle: mature, 49.4 +/- 8.7 mg/g; old, 40.9 +/- 3.5 mg/g; p < 0.05; left atria: mature, 36 +/- 9 mg/g; old, 28 +/- 3 mg/g; p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of aging on AV nodal and ventricular beta-adrenergic receptors in the Fischer 344 rat.

The effects of aging on atrioventricular (AV) nodal and right and left ventricular beta-adrenergic receptor (beta-AR) characteristics were studied in Fischer 344 rat hearts using quantitative autoradiography. Twenty-micrometer-thick cardiac sections containing the compact AV node from 16 mature (4-6 mo old) rats, 6 middle-aged (12 mo old) rats, and 16 old (24 mo old) rats were incubated with [125I]iodocyanopindolol, [125I]iodocyanopindolol plus atenolol, or ICI 118551. Saturation experiments revealed a significant age-related decrease in AV nodal beta-AR density (mature: 190 +/- 46, middle-aged: 165 +/- 27, old: 133 +/- 34 amol/mm2; P < 0.01), with no change in affinity (mature: 106 +/- 62, middle-aged: 132 +/- 46, old: 128 +/- 66 pM). No age-related changes in AV nodal beta-AR subtype ratio (55% beta 1, 45% beta 2) or estimated compact AV node volume were detected (mature: 66 +/- 17, old: 65 +/- 23 microns 3). No difference in beta-AR density or affinity was detected between mature and old rats in either left (LV) or right (RV) ventricular tissue (LV, mature: 60 +/- 11, middle-aged: 59 +/- 11, old: 62 +/- 11 amol/mm2; RV, mature: 65 +/- 9, middle-aged: 65 +/- 11, old: 58 +/- 10 amol/mm2). beta-AR subtype ratios for the left ventricle (64% beta 1, 36% beta 2) and right ventricle (63% beta 1, 37% beta 2) did not significantly differ between mature and old rats. To summarize, aging from 4 to 24 mo in the Fischer 344 rat is associated with 1) a decrease in AV nodal beta-AR density with no change in affinity; 2) no change in volume of the compact region of the AV node; 3) no change in beta-AR subtype ratio in the AV node, left ventricle, or right ventricle; and 4) no change in either RV or LV beta-AR density.

Response of the interatrial septum to transatrial pressure gradients and its potential for predicting pulmonary capillary wedge pressure: an intraoperative study using transesophageal echocardiography in patients during mechanical ventilation.

OBJECTIVES: We hypothesized that the directional movement of the interatrial septum and its curvature may reflect the pressure relations between the left and right atria. BACKGROUND: Interventricular septal shape is primarily dependent on the pressure gradient between the left and the right ventricle. No analogous study has carefully evaluated the determinants of interatrial septum shape and motion. METHODS: Patients (n = 52) undergoing cardiac or vascular surgery were studied intraoperatively at multiple intervals with transesophageal echocardiography and simultaneous measurement of central venous pressure, pulmonary capillary wedge pressure and airway pressure. RESULTS: Overall interatrial septum shape, which usually curved toward the right atrium, changed concordantly with the interatrial pressure gradient (pulmonary capillary wedge pressure-central venous pressure difference). The degree of interatrial septum curvature was also primarily dependent on the interatrial pressure gradient and, to a lesser extent, was affected by changes in left atrial size (F = 130.4 vs. F = 14.1). During passive mechanical expiration, the interatrial pressure gradient, usually positive, often reverses transiently and the interatrial septum momentarily bows toward the left atrium. Midsystolic reversal was seen in 64 of 72 episodes when the pulmonary capillary wedge pressure was < or = 15 mm Hg but in only 2 of 40 episodes when it was > 15 mm Hg (sensitivity = 0.89, specificity = 0.95, positive predictive value = 0.97). CONCLUSIONS: These findings suggest that overall interatrial septum shape depends on the pressure gradient between the left and right atria. Midsystolic reversal of the interatrial septum, which probably reflects the increased venous return in the right relative to the left atrium during mechanical expiration, may be a useful indicator of the pulmonary capillary wedge pressure.

Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow.

To determine whether pulmonary venous flow and mitral inflow measured by transesophageal pulsed Doppler echocardiography can be used to estimate mean left atrial pressure (LAP), we prospectively studied 47 consecutive patients undergoing cardiovascular surgery. We correlated Doppler variables of pulmonary venous flow and mitral inflow with simultaneously obtained mean LAP and changes in pressure measured by left atrial or pulmonary artery catheters. Among the pulmonary venous flow variables, the systolic fraction (i.e., the systolic velocity-time integral expressed as a fraction of the sum of systolic and early diastolic velocity-time integrals) correlated most strongly with mean LAP (r = -0.88). Of the mitral inflow variables, the ratio of peak early diastolic to peak late diastolic mitral flow velocity correlated most strongly with mean LAP (r = 0.43), but this correlation was not as strong as that with the systolic fraction of pulmonary venous flow. Similarly, changes in the systolic fraction correlated more strongly with changes in mean LAP (r = -0.78) than did changes in the ratio of peak early diastolic to peak late diastolic mitral inflow velocity (r = 0.68). We conclude that in the surgical setting observed, pulmonary venous flow from transesophageal pulsed Doppler echocardiography can be used to estimate mean LAP. This technique may provide a rapid, simple, and relatively noninvasive means of gauging this variable in patients undergoing intraoperative transesophageal echocardiography.

Streptococcal endocarditis temporally related to transesophageal echocardiography.

A case of streptococcal sanguis endocarditis temporally related to a transesophageal echocardiogram is reported; and the literature on the incidence of bacteremia occurring during transesophageal echocardiography is reviewed. On the basis of this case and review of the literature, a reevaluation of the current guidelines for endocarditis prophylaxis during this procedure is recommended.