Catheter ablation of atrial fibrillation in patients with cor triatriatum sinister; case series and review of literature.

INTRODUCTION: Cor triatriatum sinister (CTS) is a rare congenital heart defect characterized by fibromuscular septation of the left atrium associated with atrial fibrillation (AF). The incidence of hemodynamically insignificant CTS in the AF ablation population and effect on ablation success are not known. Furthermore, little is known about the potential effect of CTS on arrhythmogenic substrate. OBJECTIVE: We define the incidence of hemodynamically insignificant CTS in patients undergoing AF ablation with RF and cryoballoon ablation, the technical challenges created by the left atrial partitioning, and the potentially arrhythmogenic effects of the membrane. We also review the literature of CA in patients with CTS. METHODS: First-time AF ablation cases at our institution over a 10-year period were screened to identify patients with CTS. Retrospective review was performed to obtain clinical characteristics and ablation data. RESULTS: Of the 3953 consecutive patients undergoing initial AF ablation during the study period, four patients (0.10%) had CTS. Ablation was successful acutely in all patients. One patient had recurrent AF and required repeat ablation for a single procedure success rate of 75% and multi-procedure success rate of 100%. The CTS membrane was associated with low voltage zones in the two patients in whom it was measured and with substrate for macro-reentrant atrial tachycardia in one of these patients. CONCLUSION: The incidence of hemodynamically insignificant CTS in patients undergoing CA for AF is very low, but does not serve as a significant barrier to successful ablation as long as directed access to the superoposterior chamber is obtained.

Electrical delays in quadripolar leads with cardiac resynchronization therapy.

BACKGROUND: Pacing at sites of late intraventricular activation (QLV) or long interventricular conduction (right ventricle [RV]-left ventricular [LV]) have been associated with improved cardiac resynchronization therapy (CRT) outcomes. Quadripolar leads improve CRT outcomes by allowing for electrical repositioning to optimize pacing sites. However, little is known regarding the effect of such repositioning on electrical delay. OBJECTIVE: Determine the relationship between different electrical bipoles from a quadripolar lead and measures of electrical delay. METHODS: Forty-six patients underwent CRT with a quadripolar lead. The RV-LV and QLV intervals were measured for both the proximal and distal bipoles and the difference (Δ) between bipoles for each measure were calculated. Multivariate analyses were performed to identify predictors of electrical delays. RESULTS: This was a typical CRT population with a mean age of 65 years and ejection fraction of 27%, with left bundle branch block (LBBB) present in 70%. The regression model for ΔQLV was significant (p = .05), with both gender (p = .008) and LBBB status (p = .020) significant predictors. The overall regression model for ΔRV-LV was not significant. ΔQLV and ΔRV-LV were significant among LBBB patients. Among non-LBBB, only ΔRV-LV was significant (mean: 7.2 ms, p = .006). ΔRV-LV versus ΔQLV were strongly correlated in LBBB (R2 = .92) but not non-LBBB (R2 = .06). CONCLUSION: In LBBB, ΔRV-LV and ΔQLV are closely correlated suggesting that the proximal bipole and thus basal LV pacing sites should be selected when feasible. Greater variation in activation pattern is present in non-LBBB, so pacing sites should be individualized.

The effect of posture, exercise, and atrial pacing on atrioventricular conduction in systolic heart failure.

BACKGROUND: Optimization of atrioventricular (AV) intervals for cardiac resynchronization therapy (CRT) programming is typically performed in supine patients at rest, which may not reflect AV timing in other conditions. OBJECTIVE: To evaluate the effects of posture, exercise, and atrial pacing on intrinsic AV intervals in patients with CRT devices. METHODS: Rate-dependent A-V delay by exercise was a multicenter, prospective trial of patients in sinus rhythm following CRT implantation. Intracardiac electrograms were recorded to analyze atrial to right ventricular (ARV), atrial to left ventricular (ALV), and RV to LV (VV) time intervals. Heart rate was increased with incremental atrial pacing in different postures, followed by an exercise treadmill test. RESULTS: This study included 36 patients. At rest, AV intervals changed minimally with posture. With atrial pacing, AV interval immediately increased compared with sinus rhythm, with ARV slopes being 8.1 ± 7.7, 8.8 ± 13.4, and 6.8 ± 6.5 milliseconds per beat per minute (ms/bpm) and ALV slopes being 8.2 ± 7.7, 9.1 ± 12.8, and 7.0 ± 6.5 ms/bpm for supine, standing and sitting positions, respectively. As the paced heart rate increased, ARV and ALV intervals increased more gradually with similar trends. Interventricular conduction times changed less than 0.2 ms/bpm with atrial pacing. During exercise, the direction of change of intrinsic ARV intervals, as heart rate increased, was variable between patients with relatively small overall group changes (0.1 ± 1.4 and 0.2 ± 1.2 ms/bpm for ARV and ALV, respectively). CONCLUSION: Posture and exercise have a smaller effect on AV timing compared with atrial pacing. However, individualized optimization and dynamic rate related changes may be needed to maintain optimal fusion with left ventricular (LV) stimulation.

Biventricular pacemaker/defibrillators versus biventricular pacemakers in patients with non-ischemic cardiomyopathy.

The decision to employ defibrillator therapy in patients with non-ischemic cardiomyopathy is driven by reduction in mortality. The strength of data supporting this therapy has led to its incorporation in medical guidelines and general practice across the world. Cardiac resynchronization therapy has also been proven to reduce heart failure hospitalization and improve quality of life. Although trends toward reduction in arrhythmic events have been observed, results in multicenter, randomized controlled trials have not been compelling for stand-alone use in most patients who currently meet criteria for defibrillator therapy.

A comparison of the effects of prenatal exposure of CD-1 mice to three imidazolium-based ionic liquids.

BACKGROUND: Ionic liquids (ILs; salts with melting points below 100 degrees C) exhibit wide liquid ranges, non-flammability, and thermal stability among other properties. These unique salts are best known as "green" alternatives to traditional volatile organic solvents, which are utilized in both academia and industry. Our current study compares the developmental toxicity potential of three representative ionic liquids, with various chain lengths: 1-ethyl-3-methylimidazolium chloride ([C(2)mim]Cl), 1-butyl-3-methylimidazolium chloride ([C(4)mim]Cl), and 1-decyl-3methylimidazolium chloride ([C(10)mim]Cl). METHODS: From gestation days (GD) 6-16, mated CD-1 mice were orally dosed with one of the following: 1,000, 2,000, or 3,000 mg/kg/day [C(2)mim]Cl; 113, 169, or 225 mg/kg/day [C(4)mim]Cl; 50, 75, or 100 mg/kg/day [C(10)mim]Cl; or the vehicle only. Dams were sacrificed on GD 17, and their litters were examined for adverse effects. RESULTS: Fetal weight was significantly decreased in the two highest dosage groups exposed to [C(4)mim]Cl and [C(10)mim]Cl in comparison with their controls, but the [C(2)mim]Cl treated groups were not affected. An apparent teratogenic effect was associated with both [C(4)mim]Cl and [C(10)mim]Cl, as the offspring exhibited certain uncommon morphological defects. However, the incidences of malformations were low and no correlation between incidence and dosage could be made. No morphological defects were observed in any of the [C(2)mim]Cl-treated groups, despite maternal morbidity at the highest dosage level. CONCLUSIONS: This study indicates that [C(4)mim]Cl and [C(10)mim]Cl may have adverse effects on development at high maternal exposures and strongly supports the supposition that the toxicity of imidazolium-based ILs is influenced by alkyl chain length.

Acute hemodynamic effects of atrial pacing with cardiac resynchronization therapy.

BACKGROUND: Chronotropic incompetence is common among patients with advanced heart failure (HF), thus atrial pacing (AP) is frequently utilized in this population. The hemodynamic effects of AP during cardiac resynchronization therapy (CRT) have not been well studied. OBJECTIVE: The purpose of this study was to compare the acute hemodynamic response during CRT of AP with that during atrial sensing (AS). METHODS: This study included 26 patients undergoing CRT. At implant, invasive left ventricular (LV) dP/dt was measured by a micromanometer catheter during biventricular pacing in AS and AP modes at 5 different atrioventricluar delays (AVD), tested in randomized order. Postimplant, echocardiography was performed to obtain aortic and mitral flow velocity integrals at baseline (no CRT) and during CRT. RESULTS: Compared with intrinsic rhythm, CRT increased LV dP/dt by 11 +/- 11% during AS (heart rate: 74 +/- 13 bpm) and by 17 +/- 11% during AP (heart rate: 86 +/- 12 bpm, P < 0.001). The AVD associated with maximal hemodynamic response (AVD(max)) during AP was 72 +/- 40 ms longer than during AS. However, aortic and mitral flow velocity integrals decreased by 15-20% during AP. The aortic and mitral flow velocities at AVD(max) for LV dP/dt(max) were highly correlated with their maximum values (r > 0.98). CONCLUSION: AP increases LV dP/dt during CRT, but requires a substantially longer AV delay. However, AP results in modest reductions of LV filling and stoke volume. Further studies are needed to assess the long-term impact of AP on HF functional status and LV remodeling.

Effects of pre- and postnatal exposure to chromium picolinate or picolinic acid on neurological development in CD-1 mice.

Chromium picolinate, Cr(pic)3, a popular dietary supplement marketed as an aid in fat loss and lean muscle gain, has also been suggested as a therapy for women with gestational diabetes. The current study investigated the effects of maternal exposure to Cr(pic)3 and picolinic acid during gestation and lactation on neurological development of the offspring. Mated female CD-1 mice were fed diets from implantation through weaning that were either untreated or that contained Cr(pic)3 (200 mg kg(-1) day(-1)) or picolinic acid (174 mg kg(-1) day(-1)). A comprehensive battery of postnatal tests was administered, including a modified Fox battery, straight-channel swim, open-field activity, and odor-discrimination tests. Pups exposed to picolinic acid tended to weigh less than either control or Cr(pic)3-exposed pups, although the differences were not significant. Offspring of picolinic acid-treated dams also appeared to display impaired learning ability, diminished olfactory orientation ability, and decreased forelimb grip strength, although the differences among the treatment groups were not significant. The results indicate that there were no significant effects on the offspring with regard to neurological development from supplementation of the dams with either Cr(pic)3 or picolinic acid.