Long-term course of phrenic nerve injury after cryoballoon ablation of atrial fibrillation.

While phrenic nerve palsy (PNP) due to cryoballoon pulmonary vein isolation (PVI) of atrial fibrillation (AF) was transient in most cases, no studies have reported the results of the long-term follow-up of PNP. This study aimed to summarize details and the results of long-term follow-up of PNP after cryoballoon ablation. A total of 511 consecutive AF patients who underwent cryoballoon ablation was included. During right-side PVI, the diaphragmatic compound motor action potential (CMAP) was reduced in 46 (9.0%) patients and PNP occurred in 29 (5.7%) patients (during right-superior PVI in 20 patients and right-inferior PVI in 9 patients). PNP occurred despite the absence of CMAP reduction in 0.6%. The PV anatomy, freezing parameters and the operator's proficiency were not predictors of PNP. While PNP during RSPVI persisted more than 4 years in 3 (0.6%) patients, all PNP occurred during RIPVI recovered until one year after the ablation. However, there was no significant difference in the recovery duration from PNP between PNP during RSPVI and RIPVI. PNP occurred during cryoballoon ablation in 5.7%. While most patients recovered from PNP within one year after the ablation, PNP during RSPVI persisted more than 4 years in 0.6% of patients.

Compositional dependence of the apatite formation ability of Ti-Zr alloys designed for hard tissue reconstruction.

Ti-Zr alloys are expected to be novel biomaterials with low stress shielding owing to their lower Young's moduli than pure Ti. The drawback of metallic biomaterials is that their bone-bonding abilities are relatively low. NaOH and heat treatments have been performed to provide Ti-50Zr with apatite-forming ability in the body environment, which is essential for bone bonding. However, the systematic compositional dependence of apatite formation has not been revealed. In the present study, NaOH treatment of Ti-Zr alloys with various compositions and bone-bonding abilities was assessed in vitro by apatite formation in simulated body fluid (SBF). The corrosion current density in NaOH aqueous solution and the amount of Na incorporated into the surface tended to decrease with increasing Zr content. The apatite-forming ability of the treated alloy significantly decreased when the Zr content was ≥60 atom%. This phenomenon is attributed to the (1) low OH content on the surface, (2) low Na incorporation into the treated alloy surface, which enhances apatite formation, and (3) low ability of P adsorption to the Ti-Zr alloy in SBF following Ca adsorption to trigger apatite nucleation. Although the adhesion of the titanate/zirconate layer formed on the surfaces to the substrates increased as Zr content increased, the adhesion between the apatite and the substrate was still low.

Effect of metallographic structure and machining process on the apatite-forming ability of sodium hydroxide- and heat-treated titanium.

Although titanium (Ti) is clinically used for hard tissue reconstruction, it has low bone-bonding ability, i.e. bioactivity. Materials able to deposit apatite on their surfaces within the body is considered to exhibit bioactivity. Effects of the metallographic structure and machining process of Ti on its apatite-forming ability remains unclear. In this study, Ti substrates subjected to various preheating and machining processes were then subjected to NaOH and heat treatments. The apatite-forming abilities of resulting Ti were examined in simulated body fluid (SBF). Preheating of the Ti decreased its reactivity with NaOH solution. When quenched or annealed Ti was subjected to NaOH and heat treatments, the induction period for apatite formation in SBF slightly increased. This was attributed to a decrease in sodium titanate and increase in rutile on the Ti surface after the treatments. Substrates subjected to wire-electrical-discharge machining did not form apatite. This was attributed to the inhibition of PO43- adsorption on their surfaces following Ca2+ adsorption, which is an essential process for apatite nucleation. Contamination of Ti surface by components of the brass wire used in the machining contributed to the inhibition. The bioactivity of surface-modified Ti was therefore significantly affected by its thermal treatment and machining process.

Influence of the concomitant use of heparin on the effects of warfarin during catheter ablation for atrial fibrillation.

Warfarin is widely used to perform catheter ablation for atrial fibrillation (AF). Heparin is usually administered during this procedure to prevent thromboembolic events, while protamine is used to reduce the incidence of bleeding complications. The purpose of this study was to investigate the influence of heparin and protamine administration on the effects of warfarin and its safety. The subjects included 226 AF patients (206 males, 54.9 ± 9.1 years, paroxysmal/persistent AF: 118/108) undergoing AF ablation with the discontinuation of warfarin administration over 2 days. Heparin was administered to achieve an activated clotting time (ACT) above 300 s during the procedure. Several parameters of the coagulation status, including the prothrombin time international normalized ratio (PT-INR) and ACT values, measured immediately before and after protamine infusion were compared. The mean value of PT-INR prior to ablation was 1.9 ± 0.6. At the end of the procedure, the mean ACT and PT-INR values were 348.0 ± 52.9 and 2.9 ± 0.7, respectively. Following the infusion of 30 mg of protamine, both the ACT and PT-INR values significantly decreased, to 159.6 ± 31.0 (p < 0.0001) and 1.6 ± 0.3 (p < 0.0001), respectively. No cases of symptomatic cerebral infarction were observed, although femoral hematomas developed in 17 (7.5 %) of the patients without further consequence. The concomitant use of heparin augments the effect of warfarin. Meanwhile, protamine administration immediately reverses both the ACT and PT-INR, indicating the applicability of protamine for AF ablation in patients under the mixed administration of heparin and warfarin.

Predictors of ectopic firing from the superior vena cava in patients with paroxysmal atrial fibrillation.

PURPOSE: Although catheter ablation targeting the pulmonary vein (PV) is a well-known therapy for patients with paroxysmal atrial fibrillation (PAF), ectopic firings from the superior vena cava (SVC) can initiate PAF. The purpose of this study was to investigate predictors of SVC firing. METHODS: The subjects included 336 consecutive PAF patients (278 males, age 56.1 ± 10.8 years) undergoing atrial fibrillation (AF) ablation. The appearance of SVC firing was monitored throughout the procedure using a decapolar catheter with multiple electrodes to record electrograms of the coronary sinus and SVC. In addition to PV isolation, SVC isolation was performed only in patients with documented SVC firing. RESULTS: SVC firing was observed in 43/336 (12.8 %) of the patients, among whom complete isolation of the SVC was achieved in 40/43 (93 %) patients. A lower body mass index (BMI) (22.8 ± 2.8 vs 24.1 ± 3.1 kg/m(2), p = 0.007) and higher prevalence of prior ablation procedures (58 vs 18 %, p = 0.0001) were related to the presence of SVC firing. In a multivariate analysis, a lower BMI (p = 0.012; odds ratio 0.83, 95 % CI 0.72 to 0.96) and history of prior ablation procedures (p < 0.0001; odds ratio 5.37, 95 % CI 2.71 to 10.63) were found to be independent predictors of the occurrence of SVC firing. Among 96 patients undergoing repeat ablation procedures, less PV-left atrial re-conduction was observed in patients with SVC firing than in those without (2.7 ± 1.2 vs 3.2 ± 0.8, p = 0.02). CONCLUSIONS: The presence of SVC firing in patients with PAF is associated with a history of repeat ablation procedures and lower BMI values.

The role of successful catheter ablation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses: outcome during a 5-year follow-up.

AIMS: Although patients with paroxysmal atrial fibrillation (AF) and prolonged sinus pauses [tachycardia-bradycardia syndrome (TBS)] are generally treated by permanent pacemaker, catheter ablation has been reported to be a curative therapy for TBS without pacemaker implantation. The purpose of this study was to define the potential role of successful ablation in patients with TBS. METHODS AND RESULTS: Of 280 paroxysmal AF patients undergoing ablation, 37 TBS patients with both AF and symptomatic sinus pauses (age: 62 ± 8 years; mean maximum pauses: 6 ± 2 s) were analysed. During the 5.8 ± 1.2 years (range: 5-8.7 years) follow-up, both tachyarrhythmia and bradycardia were eliminated by a single procedure in 19 of 37 (51%) patients. Repeat procedures were performed in 14 of 18 patients with tachyarrhythmia recurrence (second: 12 and third: 2 patients). During the repeat procedure, 79% (45 of 57) of previously isolated pulmonary veins (PVs) were reconnected to the left atrium. Pulmonary vein tachycardia initiating the AF was found in 46% (17 of 37) and 43% (6 of 14) of patients during the initial and second procedure, respectively. Finally, 32 (86%) patients remained free from AF after the last procedure. Three patients (8%) required pacemaker implantation, one for the gradual progression of sinus dysfunction during a period of 6.5 years and the others for recurrence of TBS 3.5 and 5.5 years after ablation, respectively. CONCLUSION: Catheter ablation can eliminate both AF and prolonged sinus pauses in the majority of TBS patients. Nevertheless, such patients should be continuously followed-up, because gradual progression of sinus node dysfunction can occur after a long period of time.

Inhibition of hydrogen embrittlement of Ni-Ti superelastic alloy in acid fluoride solution by hydrogen peroxide addition.

Inhibition of the hydrogen embrittlement of Ni-Ti superelastic alloy in an acidulated phosphate fluoride (APF) solution has been attempted by adding various amounts of H(2)O(2). In a 0.2% APF solution, hydrogen absorption is markedly inhibited by adding H(2)O(2), although corrosion is slightly enhanced by increasing the amount of added H(2)O(2). By adding a small amount of H(2)O(2) (0.001 M), in the early stage of immersion, hydrogen embrittlement is inhibited and corrosion is only slightly enhanced. Upon adding H(2)O(2), it appears that the dominant cathodic reactions change from hydrogen evolution to H(2)O(2) reduction reactions, or the surface conditions of the alloy are changed by H(2)O(2) with a high oxidation capability, thereby inhibiting hydrogen absorption. The present study clearly indicates that infinitesimal addition of H(2)O(2) into acid fluoride solutions is effective for the inhibition of the hydrogen embrittlement of the alloy.

Fracture of Ni-Ti superelastic alloy under sustained tensile load in physiological saline solution containing hydrogen peroxide.

The fracture of Ni-Ti superelastic alloy has been investigated by a sustained tensile-loading test in physiological saline solution containing hydrogen peroxide (0.15M NaCl + 0.3M H(2)O(2)). The fracture always occurs when the applied stress exceeds the critical stress for martensite transformation. In contrast, under a low applied stress, the fracture does not always occur within 1000 h. The fracture is probably mainly caused by localized corrosion associated with the preferential dissolution of nickel ions. In 0.3M H(2)O(2) solution without NaCl, the fracture does not occur even under a high applied stress. The results of the present study imply that one reason for the fracture of the Ni-Ti superelastic alloy in vivo is localized corrosion due to the synergistic effects of hydrogen peroxide and sodium chloride under applied stress.

Hydrogen absorption of titanium and nickel-titanium alloys during long-term immersion in neutral fluoride solution.

Hydrogen absorption of biomedical titanium and Ni-Ti alloys in a neutral fluoride (2.0% NaF) solution for up to 10,000 h at 37 degrees C has been evaluated by means of hydrogen thermal desorption analysis. For alpha titanium (commercial pure titanium), the amount of absorbed hydrogen was, at most, 10-30 mass ppm, and the corrosion product and hydride formation were revealed on the surface of the specimen by X-ray diffraction analysis. Ni-Ti superelastic alloy absorbed approximately 150 mass ppm of hydrogen, which was probably sufficient to result in the pronounced degradation of the mechanical properties, although corrosion was hardly observed. In contrast, hydrogen absorption of alpha-beta titanium (Ti-6Al-4V) and beta titanium (Ti-11.3Mo-6.6Zr-4.3Sn) alloys was negligible, although general corrosion was observed. The results of the present study indicate that the susceptibility of titanium and Ni-Ti alloys to hydrogen absorption in the neutral fluoride solution is different from that in the acidic fluoride solution reported previously.

Hydrogen embrittlement of work-hardened Ni-Ti alloy in fluoride solutions.

Hydrogen embrittlement of work-hardened Ni-Ti alloy has been examined in acidulated phosphate fluoride (APF) solutions. Upon immersion in a 2.0% APF solution with a pH of 5.0, tensile strength decreased markedly with immersion time. Moreover, the fracture mode changed from ductile to brittle due to brittle layer formation at the peripheral part of the cross section of the specimen. The amount of absorbed hydrogen increased linearly with immersion time, and it reached above 5000 mass ppm after 24 h. The hydrogen desorption temperature of the immersed specimens shifted from 450 degrees C to a lower temperature with immersion time. As the amount of absorbed hydrogen was larger than 500 mass ppm, the degradation of mechanical properties was recognized. Although the tensile properties and fracture mode scarcely change in a 0.2% APF solution, the slight reduction in hardness and hydrogen absorption of several hundreds mass ppm were observed. The results of the present study imply that work-hardened Ni-Ti alloy is less sensitive to hydrogen embrittlement compared with Ni-Ti superelastic alloy.

Degradation in performance of orthodontic wires caused by hydrogen absorption during short-term immersion in 2.0% acidulated phosphate fluoride solution.

The purpose of this study was to investigate the degradation in performance of four major alloys of orthodontic wires, namely nickel-titanium, beta titanium, stainless steel, and cobalt-chromium-nickel, caused by hydrogen absorption during short-term immersion in an acid fluoride solutions. The hydrogen-related degradation of orthodontic wires after immersion in 2.0% acidulated phosphate fluoride solution at 37 degrees C for 60 minutes was evaluated by a tensile test, scanning electron microscope observation, and hydrogen thermal desorption analysis. Upon immersion, the tensile strengths of the nickel-titanium and beta titanium wires decreased. Particularly, the nickel-titanium wire fractured before yielding, and the fracture mode changed from ductile to brittle. The amounts of absorbed hydrogen in the nickel-titanium and beta titanium wires were 200 and 100 mass ppm, respectively. On the other hand, the tensile strengths of the stainless steel and cobalt-chromium-nickel wires were only slightly affected by immersion. The results of this study suggest that degradation in performance of orthodontic wires of titanium alloys occurs because of hydrogen absorption even after a short-term immersion in fluoride solutions.

Delayed fracture of Ni-Ti superelastic alloys in acidic and neutral fluoride solutions.

Hydrogen-related degradation of the mechanical properties of a Ni-Ti superelastic alloy has been examined by means of delayed fracture tests in acidic and neutral fluoride solutions and hydrogen thermal desorption analysis. Delayed fracture took place in both solutions; the time to fracture was shorter in the acidic solutions than in the neutral solutions with the same fluoride concentration. The time to fracture was reduced in both solutions when applied stress exceeded the critical stress for martensite transformation. In the acidic solutions, Ni-Ti superelastic alloy underwent general corrosion and absorbed substantial amounts of hydrogen. Fractographic features suggested that the delayed fracture in the acidic solutions was attributable to hydrogen embrittlement, whereas in the neutral solutions, a different fracture mode appeared associated with localized corrosion only in the vicinity of the fracture initiation area. In the neutral solutions, the amount of absorbed hydrogen was much less than that in the acidic solutions, and the delayed fracture was likely to be induced by active path corrosion accompanying hydrogen absorption. The results of the present study imply that the hydrogen-related degradation of performance of Ni-Ti superelastic alloys occurs in the presence of fluoride.

Hydrogen absorption behavior of beta titanium alloy in acid fluoride solutions.

Hydrogen absorption behavior of a beta titanium alloy in acid fluoride solutions has been analyzed by hydrogen thermal desorption. The amount of absorbed hydrogen increased with immersion time in a 2.0% acidulated phosphate fluoride (APF) solution. In the case of an immersion time of 60 h, the amount of absorbed hydrogen exceeded 10000 mass ppm. In contrast, the amount of hydrogen absorbed in the 0.2% APF solution was several times smaller than that in the 2.0% APF solution for the same immersion time. For immersion in a 0.2% APF solution, hydrogen absorption saturated after 48 h. The surface topography and corrosion products on the surface of the specimen immersed in the 2.0% APF solution were different from those in the 0.2% APF solution. During the later stage of immersion, the amount of absorbed hydrogen markedly increased under higher applied stress, although the applied stress did not enhance hydrogen absorption during the early stage of immersion. These results of hydrogen absorption behavior are consistent with the delayed fracture characteristics of the beta titanium alloy.

Fracture associated with hydrogen absorption of sustained tensile-loaded titanium in acid and neutral fluoride solutions.

The fracture of commercial pure titanium in acid and neutral fluoride solutions has been examined by a sustained tensile-loading test and hydrogen thermal desorption analysis. It was found that the fracture of titanium occurred in neutral 2.0% NaF solution as well as in 2.0% acidulated phosphate fluoride (APF) solution. The time to fracture decreased with increasing applied stress in both 2.0% APF and 2.0% NaF solutions. In the case of the same applied stress, the time to fracture in the 2.0% APF solution was shorter than that in the 2.0% NaF solution. General corrosion was exhibited on the side surface of the tested specimens. The formation of sodium titanium fluoride was observed on the surface of the immersed specimens in the 2.0% APF solution. Hydrogen desorption of the tested specimen in the 2.0% APF solution was observed with a peak at approximately 600 degrees C. The amount of absorbed hydrogen was >300 mass ppm in the 2.0% APF solution under an applied stress for 24 h. The results of the present study imply that applying stress to titanium by immersing in fluoride solutions leads to the degradation of its mechanical properties.

Hydrogen embrittlement of Ni-Ti superelastic alloy in fluoride solution.

Hydrogen embrittlement of Ni-Ti superelastic alloy in a fluoride solution (0.2% APF) has been investigated by means of a tensile test (after immersion) and hydrogen thermal desorption analysis. Upon immersion, the tensile strength of the alloy decreased to the critical stress level of martensite transformation. Hydrogen desorption of the immersed specimens appeared with a peak at around 500 degrees C. The amount of absorbed hydrogen in the alloy ranged from 100 to 1000 mass ppm when immersed in the fluoride solution for 2 to 24 h. The immersion in the fluoride solution led to the degradation of mechanical properties due to hydrogen embrittlement. The results of the present study imply that one reason that Ti and its alloys fracture in the oral cavity is the fact that hydrogen is absorbed in a fluoride solution, such as prophylactic agents.

Delayed fracture of beta titanium orthodontic wire in fluoride aqueous solutions.

Hydrogen embrittlement of a beta titanium orthodontic wire has been examined by means of a delayed-fracture test in acid and neutral fluoride aqueous solutions and hydrogen thermal desorption analysis. The time to fracture increased with decreasing applied stress in 2.0% and 0.2% acidulated phosphate fluoride (APF) solutions. The fracture mode changed from ductile to brittle when the applied stress was lower than 500MPa in 2.0% APF solution. On the other hand, the delayed fracture did not occur within 1000h in neutral NaF solutions, although general corrosion was also observed similar to that in APF solutions. Hydrogen desorption of the delayed-fracture-tested specimens was observed with a peak at approximately 500 degrees C. The amount of absorbed hydrogen was 5000-6500 mass ppm under an applied stress in 2.0% APF solution for 24h. It is concluded that the immersion in fluoride solutions leads to the degradation of the mechanical properties and fracture of beta titanium alloy associated with hydrogen absorption.

Fracture mechanisms of retrieved titanium screw thread in dental implant.

Titanium and its alloy are increasingly attracting attention for use as biomaterials. However, delayed fracture of titanium dental implants has been reported, and factors affecting the acceleration of corrosion and fatigue have to be determined. The fractured surface of a retrieved titanium screw and metallurgical structures of a dental implant system were analyzed. The outer surface of the retrieved screw had a structure different from that of the as-received screw. It was confirmed that a shear crack initiated at the root of the thread and propagated into the inner section of the screw. Gas chromatography revealed that the retrieved screw had absorbed a higher amount of hydrogen than the as-received sample. The grain structure of a titanium screw, immersed in a solution known to induce hydrogen absorption, showed features similar to those of the retrieved screw. It was concluded that titanium in a biological environment absorbs hydrogen and this may be the reason for delayed fracture of a titanium implant.

Hydrothermal modification of titanium surface in calcium solutions.

Hydrothermal modification of a titanium surface in calcium solutions was performed. The apatite precipitation on the modified surface in Hanks' solution, as a simulated body fluid, was evaluated and the surface microstructure changes after the modification were characterized by thin-film X-ray diffractometry (TF-XRD) and X-ray photoelectron spectroscopy (XPS). Hydrothermal modification in CaO solution enhanced the precipitation of apatite on the titanium surface. High pH, high pressure and high temperature of the CaO solution increased the thickness of the surface-modified layer and enhanced the synthesis of calcium titanate which possibly promoted the precipitation of apatite in Hanks' solution. Hydrothermal modification in CaCl2 solution, on the other hand, showed reverse effects. The modification of titanium in CaO solution with hydrothermal treatment is expected to result in excellent osteointegration and can be easily performed by using an autoclave, a clinical apparatus widely used.