Lesion index: a novel guide in the path of successful pulmonary vein isolation.

PURPOSE: Previous studies indicate force time integral (FTI) as a radiofrequency (RF) lesion quality marker, while not considering power supply. Tacticath™ Quartz catheter provides Lesion index (LSI), a lesion quality marker derived by contact force (CF), power supply, and RF time combined. Our aim is to assess LSI and FTI correlation and a LSI-related cutoff of atrial fibrillation (AF) recurrences 12 months after pulmonary vein isolation (PVI). METHODS: We retrospectively enrolled 37 patients who underwent RF ablation using Tacticath™ Quartz catheter. AF recurrence rate was evaluated 3, 6, and 12 months after PVI procedure. RESULTS: AF recurrence was detected in 32% of patients. FTI mean value was significantly lower in left superior pulmonary vein (LSPV: 256 ± 86 gs vs 329 ± 117 gs, p = 0.05) and right inferior pulmonary vein (RIPV: 253 ± 128 gs vs 394 ± 123 gs p = 0.006) in patients with AF recurrences; no significant differences were found in right superior pulmonary vein (RSPV) and left inferior pulmonary vein (LIPV). LSI instead was significantly higher for all veins in patients without AF recurrences: LSPV (5.2 ± 0.7 vs 4.6 ± 0.8, p = 0.03), LIPV (5.0 ± 0.8 vs 4.5 ± 0.6, p = 0.04), RSPV (5.5 ± 0.6 vs 5.1 ± 0.6, p = 0.05), and RIPV (5.5 ± 0.7 vs 4.7 ± 0.8, p = 0.006). Receiver operator characteristic curve suggests 5.3 as LSI overall cutoff value predicting freedom from disease at 1-year follow-up. CONCLUSIONS: Our preliminary data suggest that a LSI mean value higher than 5.3 can be considered a good predictor of AF freedom at 1-year follow-up.

Temporal Trends and Temperature-Related Incidence of Electrical Storm: The TEMPEST Study (Temperature-Related Incidence of Electrical Storm).

BACKGROUND: The occurrence of ventricular tachyarrhythmias seems to follow circadian, daily, and seasonal distributions. Our aim is to identify potential temporal patterns of electrical storm (ES), in which a cluster of ventricular tachycardias or ventricular fibrillation, negatively affects short- and long-term survival. METHODS AND RESULTS: The TEMPEST study (Circannual Pattern and Temperature-Related Incidence of Electrical Storm) is a patient-level, pooled analysis of previously published data sets. Study selection criteria included diagnosis of ES, absence of acute coronary syndrome as the arrhythmic trigger, and ≥10 patients included. At the end of the selection and collection processes, 5 centers had the data set from their article pooled into the present registry. Temperature data and sunrise and sunset hours were retrieved from Weather Underground, the largest weather database available online. Total sample included 246 patients presenting with ES (221 men; age: 65±9 years). Each ES episode included a median of 7 ventricular tachycardia/ventricular fibrillation episodes. Fifty-nine percent of patients experienced ES during daytime hours (P<0.001). The prevalence of ES was significantly higher during workdays, with Saturdays and Sundays registering the lowest rates of ES (10.4% and 7.2%, respectively, versus 16.5% daily mean from Monday to Friday; P<0.001). ES occurrence was significantly associated with increased monthly temperature range when compared with the month before (P=0.003). CONCLUSIONS: ES incidence is not homogenous over time but seems to have a clustered pattern, with a higher incidence during daytime hours and working days. ES is associated with an increase in monthly temperature variation. CLINICAL TRIAL REGISTRATION: https://www.crd.york.ac.uk. Unique identifier: CRD42013003744.

Comparison between First- and Second-Generation Cryoballoon for Paroxysmal Atrial Fibrillation Ablation.

Introduction. Cryoballoon (CB) ablation has emerged as a novel treatment for pulmonary vein isolation (PVI) for patients with paroxysmal atrial fibrillation (PAF). The second-generation Arctic Front Advance (ADV) was redesigned with technical modifications aiming at procedural and outcome improvements. We aimed to compare the efficacy of the two different technologies over a long-term follow-up. Methods. A total of 120 patients with PAF were enrolled. Sixty patients underwent PVI using the first-generation CB and 60 patients with the ADV catheter. All patients were evaluated over a follow-up period of 2 years. Results. There were no significant differences between the two groups of patients. Procedures performed with the first-generation CB showed longer fluoroscopy time (36.3 ± 16.8 versus 14.2 ± 13.5 min, resp.; p = 0.00016) and longer procedure times as well (153.1 ± 32 versus 102 ± 24.8 min, resp.; p = 0.019). The overall long-term success was significantly different between the two groups (68.3 versus 86.7%, resp.; p = 0.017). No differences were found in the lesion areas of left and right PV between the two groups (resp., p = 0.61 and 0.57). There were no significant differences in procedural-related complications. Conclusion. The ADV catheter compared to the first-generation balloon allows obtaining a significantly higher success rate after a single PVI procedure during the long-term follow-up. Fluoroscopy and procedural times were significantly shortened using the ADV catheter.

Level of neurotoxic metals in amyotrophic lateral sclerosis: A population-based case-control study.

The association between exposure to toxic metals and amyotrophic lateral sclerosis (ALS) was explored in a population-based case-control study in the Sardinia island (Italy), a region characterized by elevated rates of ALS cases. In 34 patients with ALS (mean age, 62 ± 10 years) and 30 controls (mean age, 65 ± 11 years), Al, Cd, Hg, Mn and Pb were determined in blood, hair and urine by sector field inductively coupled mass spectrometry. Results indicated that, in blood, concentrations of Al (p=0.045) and Pb were higher (p=0.026) in ALS patients than in control subjects. In hair, a depletion of Al (p=0.006) and Mn (p=0.032) concentrations in ALS subjects respect to controls was found. In urine, no significant differences between cases and controls were observed. Thus, some metals seemed to be associated with ALS degeneration, but a definitive conclusion is still far considering the multiple risk factors (genetic mutations, environmental toxicants and stressors) involved in the disease. Finally, the interpretation that deregulated metal concentrations can be a consequence of the degenerative process, rather than a cause, is also valid.

Electrical storm: A clinical and electrophysiological overview.

Electrical storm (ES) is a clinical condition characterized by three or more ventricular arrhythmia episodes leading to appropriate implantable cardioverter-defibrillator (ICD) therapies in a 24 h period. Mostly, arrhythmias responsible of ES are multiple morphologies of monomorphic ventricular tachycardia (VT), but polymorphic VT and ventricular fibrillation can also result in ES. Clinical presentation is very dramatic in most cases, strictly related to the cardiac disease that may worsen electrical and hemodynamic decompensation. Therefore ES management is challenging in the majority of cases and a high mortality is the rule both in the acute and in the long-term phases. Different underlying cardiomyopathies provide significant clues into the mechanism of ES, which can arise in the setting of structural arrhythmogenic cardiomyopathies or rarely in patients with inherited arrhythmic syndrome, impacting on pharmacological treatment, on ICD programming, and on the opportunity to apply strategies of catheter ablation. This latter has become a pivotal form of treatment due to its high efficacy in modifying the arrhythmogenic substrate and in achieving rhythm stability, aiming at reducing recurrences of ventricular arrhythmia and at improving overall survival. In this review, the most relevant epidemiological and clinical aspects of ES, with regard to the acute and long-term follow-up implications, were evaluated, focusing on these novel therapeutic strategies of treatment.

An easy-to-use, operator-independent, clinical model to predict the left vs. right ventricular outflow tract origin of ventricular arrhythmias.

AIMS: To identify clinical characteristics able to predict a left ventricular outflow tract (LVOT) origin in outflow tract ventricular arrhythmias (OTVAs). METHODS AND RESULTS: We included 117 consecutive patients (training sample) with successful radiofrequency ablation of OTVA in one centre. A predictive model for LVOT origin was obtained using clinical data. The model was prospectively validated in a second population (testing sample) of 143 patients from two additional centres. In training sample, mean age was 54 ± 17 years, 72 patients (61%) were male, and 63 (54%) had cardiovascular risk factors. Sixty (51%) patients had LVOT origin. Independent predictors for LVOT origin were the presence of hypertension [odds ratio (OR) 2.17, confidence interval (CI) 0.91-6.20, P = 0.09], male gender (OR 4.83, 95% CI 1.89-12.33, P < 0.001), and age >50 years (OR 4.46, 95% CI 1.57-12.7, P = 0.005). A simple score was constructed with these three variables to predict LVOT origin (mean predicted probability of 15% for score 0, 26% for score 1, 60% for score 2, and 87% for score 3, P < 0.001) and reached 80% sensitivity and 75% specificity. The score was validated in the testing sample and was not inferior to previously described electrocardiogram algorithms. CONCLUSION: Patients currently referred for OTVA ablation are older, more frequently men, and with a higher probability for LVOT origin than previously described. A LVOT origin is associated with the presence of hypertension, male gender, and older age, and can be anticipated by using a simple clinical score.

Right Ventricular Outflow Tract Arrhythmias: Benign Or Early Stage Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia?

Ventricular arrhythmias (VAs) arising from the right ventricular outflow tract (RVOT) are a common and heterogeneous entity. Idiopathic right ventricular arrhythmias (IdioVAs) are generally benign, with excellent ablation outcomes and long-term arrhythmia-free survival, and must be distinguished from other conditions associated with VAs arising from the right ventricle: the differential diagnosis with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is therefore crucial because VAs are one of the most important causes of sudden cardiac death (SCD) in young individuals even with early stage of the disease. Radiofrequency catheter ablation (RFCA) is a current option for the treatment of VAs but important differences must be considered in terms of indication, purposes and procedural strategies in the treatment of the two conditions. In this review, we comprehensively discuss clinical and electrophysiological features, diagnostic and therapeutic techniques in a compared analysis of these two entities.

Comparisons of predictors of fluid responsiveness in major surgery.

The majority of studies on fluid responsiveness is focused on volume expansion maneuvers in intensive care unit (ICU), while fewer studies have analyzed the same problem during major surgery. Among them, the results are contrasting. The aim of this work was to compare the performance of different hemodynamic indices in the prediction of cardiac output variations following fast fluid infusion. The study was limited to a particular type of major surgery, i.e. liver transplantation and hepatectomy. Our results showed that pulse pressure variation (PPV) estimated according to the definition, i.e. within single respiratory cycles, and PPV estimated by PiCCO monitor system are coherent and very similar. Moreover, PPV and stroke volume variation (SVV) produced good values of sensitivity and specificity in separating the subjects into responsive and non responsive to maneuvers.

Human papillomavirus-32-positive extragenital Bowenoid papulosis (BP) in a HIV patient with typical genital BP localization.

OBJECTIVES: Bowenoid papulosis (BP) is characterized by multiple maculopapular lesions of the genitalia; extragenital localization is rarely found. Human papillomavirus (HPV) type 16 has been found in most cases of BP, but the other HPV genotypes associated with BP had been poorly characterized. GOAL: We describe an extragenital BP with concomitant genital involvement in an HIV-positive woman. STUDY: Several HPV gene-specific amplifications and sequencing were performed on DNA extracted from biopsy samples. RESULTS: The presence of HPV-16 DNA in anogenital and HPV-32 DNA in lip lesions was demonstrated in the absence of any other HPV type and with no coinfection. Semiquantitative polymerase chain reaction analysis revealed that HPV-16 and -32 DNA sequences are in the episomal state. CONCLUSIONS: This is the first report of BP associated with HPV-32 (the causative agent of a benign hyperplasia) and a rare case of BP associated with 2 HPV types in the same patient. The immune depression could have modified the normal benign progression of the extragenital lesions.