Strategy to achieve mitral isthmus flutter ablation by radiofrequency: the SHERIFF plan.

BACKGROUND: Achieving mitral isthmus (MI) block can be challenging. This prospective study evaluated the feasibility and efficacy of a systematic strategy comprising three consecutive steps to achieve MI block. METHODS: Twenty consecutive patients (mean (± SD) age 71.4 ± 6.98 years) undergoing ablation of perimitral atrial tachycardia (PMAT) between December 2019 and November 2021 were included. MI was ablated using a systematic strategy comprising up to three consecutive steps: (1) endocardial ablation from the superolateral mitral annulus to the left pulmonary veins; (2) additional epicardial ablation in the coronary sinus (CS) on the opposite side of the endocardial line; and (3) ablation of early activation sites between endocardial and epicardial breakthroughs. RESULTS: MI block was successfully achieved in 19/20 patients (95%). MI block after endocardial radiofrequency ablation alone (step 1) was observed in 7/20 patients (35%). Epicardial ablation within the CS on the other side of the endocardial line (step 2) resulted in bidirectional MI block in three more patients. Endocardial ablation of epicardial conduction was successful for nine additional patients (95% success). At the 12-month follow-up, five patients (25%) displayed recurrence of arrhythmia after a single procedure. One patient had electrical cardioversion for persistent atrial fibrillation. Four patients had a redo procedure for left atrial flutter and only two patients (10%) had conduction across the MI and showed recurrence of PMAT. No complications occurred. CONCLUSIONS: The three-step ablation strategy resulted in a high rate of acute and durable MI block. PMAT recurrence after a single procedure was 10% at 1-year follow-up.

GluK2 Is a Target for Gene Therapy in Drug-Resistant Temporal Lobe Epilepsy.

OBJECTIVE: Temporal lobe epilepsy (TLE) is characterized by recurrent seizures generated in the limbic system, particularly in the hippocampus. In TLE, recurrent mossy fiber sprouting from dentate gyrus granule cells (DGCs) crea an aberrant epileptogenic network between DGCs which operates via ectopically expressed GluK2/GluK5-containing kainate receptors (KARs). TLE patients are often resistant to anti-seizure medications and suffer significant comorbidities; hence, there is an urgent need for novel therapies. Previously, we have shown that GluK2 knockout mice are protected from seizures. This study aims at providing evidence that downregulating KARs in the hippocampus using gene therapy reduces chronic epileptic discharges in TLE. METHODS: We combined molecular biology and electrophysiology in rodent models of TLE and in hippocampal slices surgically resected from patients with drug-resistant TLE. RESULTS: Here, we confirmed the translational potential of KAR suppression using a non-selective KAR antagonist that markedly attenuated interictal-like epileptiform discharges (IEDs) in TLE patient-derived hippocampal slices. An adeno-associated virus (AAV) serotype-9 vector expressing anti-grik2 miRNA was engineered to specifically downregulate GluK2 expression. Direct delivery of AAV9-anti grik2 miRNA into the hippocampus of TLE mice led to a marked reduction in seizure activity. Transduction of TLE patient hippocampal slices reduced levels of GluK2 protein and, most importantly, significantly reduced IEDs. INTERPRETATION: Our gene silencing strategy to knock down aberrant GluK2 expression demonstrates inhibition of chronic seizure in a mouse TLE model and IEDs in cultured slices derived from TLE patients. These results provide proof-of-concept for a gene therapy approach targeting GluK2 KARs for drug-resistant TLE patients. ANN NEUROL 2023;94:745-761.

Early pacemaker insertion after aortic valve replacement with an Edwards Intuity sutureless valve.

BACKGROUND: Postoperative conduction disorders are serious adverse events in patients undergoing aortic valve replacement, and may prolong the duration of hospitalization and require pacemaker insertion. AIM: Our aim was to evaluate the rate of pacemaker insertion after implantation of an Edwards Intuity sutureless aortic valve (Edwards Lifesciences, Irvine, CA, USA) compared with a standard surgical bioprosthesis. METHODS: This retrospective single-centre study included patients who underwent aortic valve replacement with an Intuity sutureless aortic valve or a standard bioprosthetic valve between 4 June 2014 and 27 June 2016. The main outcome criterion was the rate of postoperative pacemaker insertion. Secondary outcome criteria included the rate of new conduction disorders, the rate of atrial arrhythmia or paroxysmal conduction disorders, mortality and duration of hospital stay. RESULTS: Ninety-three patients received an Intuity sutureless aortic valve (median age 76 years, interquartile range 71-80 years), and 176 were implanted with a standard biological aortic valve (median age 73 years, interquartile range 68-79 years; P=0.007). The rate of postoperative pacemaker insertion, after adjustment, was 22.44% in the Intuity group and 5.66% in the standard aortic valve group (P=0.030). The main indications for postoperative pacemaker insertion were complete atrioventricular block and left bundle branch block with prolongation of the H-V interval. The rate of new postoperative left bundle branch block conduction disorders was significantly higher in patients implanted with an Intuity valve (odds ratio 5.28, 95% confidence interval 1.59 to 23.05; P=0.012). CONCLUSION: Higher rates of pacemaker insertion and new conduction disorders were observed in patients implanted with an Intuity sutureless bioprosthesis compared with those who received a standard surgical aortic valve.

Micra AV leadless pacemaker implantation after transcatheter aortic valve implantation.

BACKGROUND: Transvenous pacemaker (PM) implantation is a complication in patients undergoing transcatheter aortic valve implantation (TAVI). Recently, a second generation of leadless PMs able of atrioventricular (AV) synchronous pacing has been introduced and could be an alternative when ventricular pacing is required after TAVI. Real-world data on Micra AV after TAVI are still lacking. Our aim was to determine the per- and post-procedural outcomes in patients with Micra AV leadless PM implantation after TAVI. METHODS: A total of 20 consecutive patients underwent Micra AV leadless PM implantation after TAVI between November 2020 and June 2021. RESULTS: The main indication for ventricular pacing was high-degree AV block (55% of patients) and left bundle branch block (LBBB) associated with prolonged HV interval (45% of patients). At discharge, mean (SD) ventricular pacing threshold was 0.397 ± 0.11 V at 0.24 ms and ventricular impedance was 709.4 ± 139.1 Ω. At 1-month follow-up, 95% of patients were programmed in VDD pacing mode. Mean (SD) ventricular pacing threshold was 0.448 ± 0.094 V at 0.24 ms. In patients with ventricular> pacing > 90% (n = 5), mean AM-VP was 72.5% ± 8.3%. Pacing threshold at 1 month was not significantly different compared to discharge (p = .1088). Mean (SD) impedance was 631.0 ± 111.9 Ω, which remained stable at discharge (p = .0813). No procedural complications occurred during implantation. At 1-month follow-up, two patients displayed atrial under-sensing. CONCLUSIONS: Micra AV leadless PM implantation after TAVI is associated with a low complication rate and good device performance at 1-month post-implantation.

An improved window of interest for electroanatomical mapping of atrial tachycardia.

PURPOSE: Diagnosis of atrial tachycardia (AT) with 3D mapping system remains challenging due to fibrosis or previous ablation. This study aims to evaluate a new electroanatomical mapping annotation setting using a window of interest adjusted at the end of the P wave (WOIp wave) to identify the AT mechanism more accurately. METHODS: Twenty patients with successful ablation of left AT using navigation system CARTO3 were evaluated. Two maps for each patient were generated offline using either conventional settings of WOI (WOIconv.) or WOIp wave. Three investigators from two centres analysed the maps blindly. RESULTS: Mechanisms of AT were macroreentrant in 14/20 patients (70%) and focal in 6/20 (30%). WOIp wave resulted in a significant increase in the percentage of correct identification of the mechanism based on mapping alone (93.3 ± 13.7% vs 58.3 ± 33.9%; p = 0.0003) compared with WOIconv.. Diagnoses based on mapping were arrived at faster (27.8 ± 16.4 s vs 38.97 ± 13.64 s, respectively; p = 0.0231) and with a greater confidence in the diagnosis (confidence index 2.57 ± 0.45 vs 2.12 ± 0.45, respectively; p = 0.0024). With perimitral re-entry specifically "early meets late" was closer to the anatomical region of the mitral isthmus (15.9 ± 20.9 mm vs 48.77 ± 23.23 mm, respectively; p = 0.0028). CONCLUSIONS: This study found that electroanatomical mapping acquisition with a window of interest set at the end of the P wave improves the ability to diagnose the arrhythmia mechanism based on the initial map. It is particularly beneficial in identifying area of interest for ablation in perimitral AT.

Dentate Granule Cells Recruited in the Home Environment Display Distinctive Properties.

The dentate granule cells (DGCs) play a crucial role in learning and memory. Many studies have described the role and physiological properties of these sparsely active neurons using different behavioral contexts. However, the morpho-functional features of DGCs recruited in mice maintained in their home cage (without training), considered as a baseline condition, have not yet been established. Using fosGFP transgenic mice, we observed ex vivo that DGCs recruited in animals maintained in the home cage condition are mature neurons that display a longer dendritic tree and lower excitability compared with non-activated cells. The higher GABAA receptor-mediated shunting inhibition contributes to the lower excitability of DGCs activated in the home environment by shifting the input resistance towards lower values. Remarkably, that shunting inhibition is neither observed in non-activated DGCs nor in DGCs activated during training in virtual reality. In short, our results suggest that strong shunting inhibition and reduced excitability could constitute a distinctive neural signature of mature DGCs recruited in the context of the home environment.

Depolarizing γ-aminobutyric acid contributes to glutamatergic network rewiring in epilepsy.

OBJECTIVE: Rewiring of excitatory glutamatergic neuronal circuits is a major abnormality in epilepsy. Besides the rewiring of excitatory circuits, an abnormal depolarizing γ-aminobutyric acidergic (GABAergic) drive has been hypothesized to participate in the epileptogenic processes. However, a remaining clinically relevant question is whether early post-status epilepticus (SE) evoked chloride dysregulation is important for the remodeling of aberrant glutamatergic neuronal circuits. METHODS: Osmotic minipumps were used to infuse intracerebrally a specific inhibitor of depolarizing GABAergic transmission as well as a functionally blocking antibody toward the pan-neurotrophin receptor p75 (p75NTR ). The compounds were infused between 2 and 5 days after pilocarpine-induced SE. Immunohistochemistry for NKCC1, KCC2, and ectopic recurrent mossy fiber (rMF) sprouting as well as telemetric electroencephalographic and electrophysiological recordings were performed at day 5 and 2 months post-SE. RESULTS: Blockade of NKCC1 after SE with the specific inhibitor bumetanide restored NKCC1 and KCC2 expression, normalized chloride homeostasis, and significantly reduced the glutamatergic rMF sprouting within the dentate gyrus. This mechanism partially involves p75NTR signaling, as bumetanide application reduced SE-induced p75NTR expression and functional blockade of p75NTR decreased rMF sprouting. The early transient (3 days) post-SE infusion of bumetanide reduced rMF sprouting and recurrent seizures in the chronic epileptic phase. INTERPRETATION: Our findings show that early post-SE abnormal depolarizing GABA and p75NTR signaling fosters a long-lasting rearrangement of glutamatergic network that contributes to the epileptogenic process. This finding defines promising and novel targets to constrain reactive glutamatergic network rewiring in adult epilepsy. Ann Neurol 2017;81:251-265.

Impaired neuronal operation through aberrant intrinsic plasticity in epilepsy.

OBJECTIVE: Patients with temporal lobe epilepsy often display cognitive comorbidity with recurrent seizures. However, the cellular mechanisms underlying the impairment of neuronal information processing remain poorly understood in temporal lobe epilepsy. Within the hippocampal formation neuronal networks undergo major reorganization, including the sprouting of mossy fibers in the dentate gyrus; they establish aberrant recurrent synapses between dentate granule cells and operate via postsynaptic kainate receptors. In this report, we tested the hypothesis that this aberrant local circuit alters information processing of perforant path inputs constituting the major excitatory afferent pathway from entorhinal cortex to dentate granule cells. METHODS: Experiments were performed in dentate granule cells from control rats and rats with temporal lobe epilepsy induced by pilocarpine hydrochloride treatment. Neurons were recorded in patch clamp in whole cell configuration in hippocampal slices. RESULTS: Our present data revealed that an aberrant readout of synaptic inputs by kainate receptors triggered a long-lasting impairment of the perforant path input-output operation in epileptic dentate granule cells. We demonstrated that this is due to the aberrant activity-dependent potentiation of the persistent sodium current altering intrinsic firing properties of dentate granule cells. INTERPRETATION: We propose that this aberrant activity-dependent intrinsic plasticity, which lastingly impairs the information processing of cortical inputs in dentate gyrus, may participate in hippocampal-related cognitive deficits, such as those reported in patients with epilepsy.

Contribution of aberrant GluK2-containing kainate receptors to chronic seizures in temporal lobe epilepsy.

Kainate is a potent neurotoxin known to induce acute seizures. However, whether kainate receptors (KARs) play any role in the pathophysiology of temporal lobe epilepsy (TLE) is not known. In TLE, recurrent mossy fiber (rMF) axons form abnormal excitatory synapses onto other dentate granule cells that operate via KARs. The present study explores the pathophysiological implications of KARs in generating recurrent seizures in chronic epilepsy. In an in vitro model of TLE, seizure-like activity was minimized in mice lacking the GluK2 subunit, which is a main component of aberrant synaptic KARs at rMF synapses. In vivo, the frequency of interictal spikes and ictal discharges was strongly reduced in GluK2(-/-) mice or in the presence of a GluK2/GluK5 receptor antagonist. Our data show that aberrant GluK2-containing KARs play a major role in the chronic seizures that characterize TLE and thus constitute a promising antiepileptic target.

Normotopic cortex is the major contributor to epilepsy in experimental double cortex.

OBJECTIVE: Subcortical band heterotopia (SBH) is a cortical malformation formed when neocortical neurons prematurely stop their migration in the white matter, forming a heterotopic band below the normotopic cortex, and is generally associated with intractable epilepsy. Although it is clear that the band heterotopia and the overlying cortex both contribute to creating an abnormal circuit prone to generate epileptic discharges, it is less understood which part of this circuitry is the most critical. Here, we sought to identify the origin of epileptiform activity in a targeted genetic model of SBH in rats. METHODS: Rats with SBH (Dcx-KD rats) were generated by knocking down the Dcx gene using shRNA vectors transfected into neocortical progenitors of rat embryos. Origin, spatial extent, and laminar profile of bicuculline-induced interictal-like activity on neocortical slices were analyzed by using extracellular recordings from 60-channel microelectrode arrays. Susceptibility to pentylenetetrazole-induced seizures was assessed by electrocorticography in head-restrained nonanesthetized rats. RESULTS: We show that the band heterotopia does not constitute a primary origin for interictal-like epileptiform activity in vitro and is dispensable for generating induced seizures in vivo. Furthermore, we report that most interictal-like discharges originating in the overlying cortex secondarily propagate to the band heterotopia. Importantly, we found that in vivo suppression of neuronal excitability in SBH does not alter the higher propensity of Dcx-KD rats to display seizures. INTERPRETATION: These results suggest a major role of the normotopic cortex over the band heterotopia in generating interictal epileptiform activity and seizures in brains with SBH.

Synaptic kainate receptors in interplay with INaP shift the sparse firing of dentate granule cells to a sustained rhythmic mode in temporal lobe epilepsy.

Dentate granule cells, at the gate of the hippocampus, use coincidence detection of synaptic inputs to code afferent information under a sparse firing regime. In both human patients and animal models of temporal lobe epilepsy, mossy fibers sprout to form an aberrant glutamatergic network between dentate granule cells. These new synapses operate via long-lasting kainate receptor-mediated events, which are not present in the naive condition. Here, we report that in chronic epileptic rat, aberrant kainate receptors in interplay with the persistent sodium current dramatically expand the temporal window for synaptic integration. This introduces a multiplicative gain change in the input-output operation of dentate granule cells. As a result, their sparse firing is switched to an abnormal sustained and rhythmic mode. We conclude that synaptic kainate receptors dramatically alter the fundamental coding properties of dentate granule cells in temporal lobe epilepsy.