Impact of high frequency stimulation to confirm a complete box isolation in catheter ablation of non-paroxysmal atrial fibrillation.

INTRODUCTION: Pulmonary vein (PV) isolation (PVI) including the left atrial posterior wall (LAPW) (Box-PVI) is proposed as an additional strategy for non-paroxysmal atrial fibrillation (NPAF), however, the efficacy remains controversial. The more reliable and durable the Box-PVI we can create, the better the rhythm outcomes might be than with a conventional PVI alone. This study focused on the potential exit conduction of the box lesion and investigated whether the conventional Box-PVI would be sufficient. METHODS AND RESULTS: We enrolled 350 consecutive patients with NPAF that underwent a conventional encircling Box-PVI and examined whether latent exit conduction and dormant "exit" conduction independently remained on the LAPW and in the PVs using high frequency stimulation (HFS) and an adenosine triphosphate (ATP) injection. All electrograms inside the box lesion were eliminated in all cases, however, HFS inside the box propagated outward in 23 cases (6.6%) without any exit conduction by conventional burst stimulation, and 24 cases (6.9%) exhibited only dormant "exit" conduction of the LAPW. Additional ablation where positive HFSs were observed created a complete bidirectional Box-PVI in 43 (41.3%) of the cases without a first pass Box-PVI. The recurrence rates depended on the groups classified according to the HFS response. CONCLUSION: HFS delivered with an ATP injection on the LAPW and in the PVs following a Box-PVI could not only elucidate true exit block but also identified possible incomplete lesions or connections outside the ablation line, whose elimination could achieve a complete Box-PVI leading to a better rhythm outcome.

Potential complications in patients undergoing an ethanol injection into the vein of Marshall.

BACKGROUND: Ethanol injections into the vein of Marshall (VOM) (EIM) are considered to be a good therapeutic option for atrial tachyarrhythmias, however, the safety remains to be determined. To elucidate what would affect the safety and potential complications of an EIM, we investigated the anatomical features of the VOM and patient background. METHODS: We performed the EIM before the conventional pulmonary vein isolation for drug-resistant atrial fibrillation in 88 patients and evaluated the anatomical features of the VOM and their background. RESULTS: All procedures were completed, however, other than myocardial staining, trivial contrast medium leaked out of the VOM into the pericardial space, that is, extravasation of contrast medium with capillary rupture, during the EIM in 20 patients (22.7%) regardless of the features of the VOM. No pericardial effusions requiring further intervention developed after the extravasation, which resolved by the next day on echocardiography in 18 of those patients. However, two patients who had extravasation other than during the initial contrast injection required additional therapeutic intervention for nonnegligible pericardial effusions. Their body weights were significantly lower and the latter two patients were also small lean women with heart failure and a preserved ejection fraction. CONCLUSIONS: The physical constitution, regardless of the characteristics of the VOM, could be strongly associated with adverse events during the EIM. We must take extreme care in smaller patients with poor compliant hearts during the EIM.

Limb Salvage With Continuous Intra-Arterial Infusion for Below-the-Ankle Arterial Occlusions in Acute Limb Ischemia.

A 79-year-old man presented with acute-onset coldness and severe pain in his left foot 4 hours prior. His foot (distal to the left Lisfranc joint) was pale and cold with slight motor and sensory deficits. Angiography demonstrated occlusion of the lateral plantar artery and plantar metatarsal arteries (PMAs). Angioplasty using balloons for each PMA and lateral plantar artery was conducted, but failed to achieve satisfactory blood flow. The foot condition subsequently worsened. A 22-gauge cannula was then inserted into the dorsalis pedis artery, and continuous local intra-arterial infusion of heparin, alprostadil, and nicorandil was administered. A marked reduction in the cyanotic areas of the foot was observed, with improved motor and sensory deficits post-continuous local intra-arterial infusion therapy. Follow-up angiography via the cannula on day 3 of hospitalization demonstrated significant flow improvement in the first to third PMAs. Foot salvage was achieved without tissue necrosis or amputation.

Successful chemical ablation for intraventricular septal ventricular tachycardia-An alternative approach to the septal branch.

Trans-coronary ethanol ablation for ventricular tachycardia originating from the ventricular septum is effective, but there are cases with no septal perforator from left anterior descending artery. CT and angiography can reveal the optimal vessel.

Efficacy of the Stripped AFX Aortic Cuff as a Scaffolding Bare Stent to Facilitate the Expansion of the Thoracoabdominal and Visceral Aorta during Thoracic Endovascular Aortic Repair for Complicated Stanford Type B Aortic Dissection.

Purpose: During thoracic endovascular aortic repair for complicated Stanford type B aortic dissection, large bare stent placement for the abdominal aorta is sometimes necessary. In smaller abdominal aortic diameter cases, we used the stripped AFX aortic cuff as a scaffolding bare stent rather than the Zenith Dissection Endovascular Stent, which is a commercially available, large bare stent. In this study, we evaluated the feasibility of the stripped AFX aortic cuff and experiments were conducted to compare the stripped AFX and the Zenith Dissection Endovascular Stent. Material and Method: The type B aortic dissection patients treated with thoracic endovascular aortic repair using stripped AFX at three institutions between January 2014 and December 2017 were retrospectively reviewed. Clinical data, including technical success, perioperative complication, and overall survival, were evaluated. The experiment assessed the chronic outward force that reflected the load acting on the artery wall from the stent. Result: Eight cases (seven males) were reviewed. The median (interquartile range, IQR) age of the patients was 60 years (46.3-70.3). The technical success rate was 100%, and no perioperative complications were observed. The median (IQR) follow-up period was 28.9 months (17.5-31.5). During the follow-up, one patient died of septic shock unrelated to aortic events. The median (IQR) diameter of the stripped AFX on the last follow-up CT was 23.5 mm (21.9-25.0). The chronic outward force of the Zenith Dissection Endovascular Stent was two to three times that of the stripped AFX. Conclusions: The stripped AFX aortic cuff is feasible and safe as a scaffolding stent during thoracic endovascular aortic repair for Stanford Type B aortic dissection.

Novel TSURECOMI Bailout Technique for Transcatheter Heart Valve Implantation After Accidental Wire Withdrawal During TAVR.

This study introduces a case in which our novel "Transarterial Snare-Upholding REcovery technique for COMpletely pulled out LV wire for TAVR valve Insert system (TSURECOMI) technique" with snares was successfully performed for bailout of a transcatheter heart valve during transcatheter aortic valve replacement. (Level of Difficulty: Advanced.).

Isolated internal iliac artery aneurysm causing rectal necrosis due to compression early after endovascular repair: A case report.

INTRODUCTION: Recently, endovascular repair has become the first-line treatment for internal iliac artery aneurysm (IIAA). However, rectal necrosis due to the compression of the residual IIAA early after endovascular repair is rare. PRESENTATION OF CASE: We present a rare case of a huge, isolated left IIAA that severely compressed the rectum and ureter. The patient underwent emergency endovascular repair; however, rectal necrosis occurred 10 days later because the repair failed to shrink the size of the aneurismal sac. DISCUSSION: We hypothesize that the compression of the residual IIAA caused rectal necrosis. During open surgery, endovascular repair disrupted blood flow within the IIAA, which probably allowed for aneurysm dissection and residual hematoma removal. CONCLUSION: Endovascular repair alone could not immediately release compression on the surrounding organs; however, open surgical removal of aneurysms after successful endovascular repair may be a useful option for IIAAs with compression of surrounding organs.

Transarterial Embolization With Complementary Surgical Ligation of Gastroduodenal Artery for Ruptured Pancreaticoduodenal Artery Aneurysm.

The association between pancreaticoduodenal artery aneurysm (PDAA) and local hemodynamic changes in pancreaticoduodenal arcades is well established. However, there are few case reports of PDAA associated with acute aortic dissection. In this article, we outline and discuss the case of a 61-year-old man diagnosed with a type A acute aortic dissection who underwent emergency surgery and developed sudden-onset severe abdominal pain and shock 10 days later. Contrast-enhanced computed tomography showed a ruptured PDAA with feeding vessels from the gastroduodenal and superior mesenteric arteries, with evidence that the celiac artery was diverged from a false lumen. Transarterial embolization via the superior mesenteric artery alone was not expected to achieve hemostasis, so we performed a hybrid procedure involving transarterial embolization cannulated from superior mesenteric artery with complementary surgical ligation of the gastroduodenal artery. The postoperative course was uneventful, and follow-up contrast-enhanced computed tomography showed no persistence of the aneurysm 8 days after the second operation. This case proposed that visceral arterial malperfusion due to acute aortic dissection can cause PDAA in the early postoperative period. Although previous reports suggest that endovascular treatment is preferable, it may not always be feasible. Since ruptured PDAAs are often not detected during surgery, surgical treatment can be overly invasive. Whereas, transarterial embolization with complementary clamping or ligation of the gastroduodenal artery for ruptured PDAA is less invasive and can control hemorrhage, especially when cannulation to the celiac artery is impossible. Notably, the technique did not cause organ ischemia, presumably because the small collateral vessels of the pancreaticoduodenal arcades permitted sufficient blood flow. If endovascular treatment is unable to achieve rapid hemostasis, this technique may be a useful option for ruptured PDAA.

Fistula between the Thoracic Duct and an Unusual Vessel Aneurysm Branching Off the Abdominal Aorta Revealed by Aneurysm Rupture: A Case Report.

Fistulas between an aneurysm branching off the abdominal aorta and the thoracic duct are rare. We report a case of aneurysmal-thoracic duct fistula diagnosed by angiography when aneurysm ruptured, and we successfully treated by catheter embolization. A 42-year-old man was referred to our hospital with a chief complaint of sudden back and chest pain. Computed tomography showed both post-mediastinal and retroperitoneal hematomas, with the aneurysm from the aorta being connected to the thoracic duct. After confirming the aneurysmal-thoracic duct fistula by angiography, we performed embolization of the aneurysm. The patient has remained well for 3 postoperative months, to date.

Analysis of expressed sequence tags from the fungus Aspergillus oryzae cultured under different conditions.

We performed random sequencing of cDNAs from nine biologically or industrially important cultures of the industrially valuable fungus Aspergillus oryzae to obtain expressed sequence tags (ESTs). Consequently, 21 446 raw ESTs were accumulated and subsequently assembled to 7589 non-redundant consensus sequences (contigs). Among all contigs, 5491 (72.4%) were derived from only a particular culture. These included 4735 (62.4%) singletons, i.e. lone ESTs overlapping with no others. These data showed that consideration of culture grown under various conditions as cDNA sources enabled efficient collection of ESTs. BLAST searches against the public databases showed that 2953 (38.9%) of the EST contigs showed significant similarities to deposited sequences with known functions, 793 (10.5%) were similar to hypothetical proteins, and the remaining 3843 (50.6%) showed no significant similarity to sequences in the databases. Culture-specific contigs were extracted on the basis of the EST frequency normalized by the total number for each culture condition. In addition, contig sequences were compared with sequence sets in eukaryotic orthologous groups (KOGs), and classified into the KOG functional categories.

Ethanol injection into the Marshall vein provoking a pericardial effusion resulting in a fatal complication in a patient with persistent atrial fibrillation.

An EIM (ethanol infusion into the vein of Marshall [VOM]) provoked a fatal complication in a chronic hemodialysis patient. Autopsy revealed a lacerated VOM covered with thrombi as the only potential cause. The EIM caused vascular damage and clots resulting in myocardial necrosis and interstitial bleeding around the lacerated VOM.

Isolation of genes encoding novel transcription factors which interact with the Hap complex from Aspergillus species.

The Saccharomyces cerevisiae CCAAT-binding factor is composed of four subunits Hap2p, Hap3p, Hap4p and Hap5p. Three subunits, Hap2/3/5p, are required for DNA-binding and Hap4p is involved in transcriptional activation. Although homologues of Hap2/3/5p (in the case of Aspergillus nidulans; HapB/C/E, respectively) were found in many eukaryotes, no Hap4p homologues have been found except for the other yeast, Kluyveromyces lactis. With the lexA-hap2, -hapB, -hapC, or -hapE fusion gene, we evaluated the ability of interaction between Aspergillus Hap subunits and S. cerevisiae Hap4p subunit in S. cerevisiae. Using the system with lexA-hapB, a gene encoding a novel transcriptional activator, which interacted with the Hap complex, was isolated from A. nidulans and designated hapX.

Structural features of the glycogen branching enzyme encoding genes from aspergilli.

A maltose binding protein, p78, was purified to homogeneity from Aspergillus nidulans by a single column chromatography step on cross-linked amylose. The partial amino acid sequence was highly homologous to the glycogen branching enzymes (GBEs) of human and yeast, and p78 did show branching enzyme activity. The genomic gene and its cDNA encoding GBE (p78) were isolated from the A. nidulans genomic and cDNA libraries. Furthermore, a cDNA encoding A. oryzae GBE was entirely sequenced. A. nidulans GBE shared overall and significant amino acid sequence identity with GBEs from A. oryzae (83.9%), Saccharomyces cerevisiae (61.1%) and human (63.0%), and with starch branching enzymes from green plants (55-56%).

The region in a subunit of the Aspergillus CCAAT-binding protein similar to the HAP4p-recruiting domain of Saccharomyces cerevisiae Hap5p is not essential for transcriptional enhancement.

The CCAAT-binding complex in Aspergillus species, known as the Hap complex, consists of at least three subunits, HapB, HapC, and HapE. Each Hap subunit contains an evolutionarily conserved core domain. In this study, a series of the truncated gene, which encodes the HapE subunit of Aspergillus oryzae, was constructed to survey the regions essential for the transcriptional enhancement of fungal genes. It was revealed that the non-conserved regions and the conserved region similar to the Hap4p recruiting domain of Saccharomyces cerevisiae were not necessary for Hap complex-mediated transcriptional enhancement.

A transcriptional activator, AoXlnR, controls the expression of genes encoding xylanolytic enzymes in Aspergillus oryzae.

By deletion across the promoter region of the xynF1 gene encoding the major Aspergillus oryzae xylanase, a 53-bp DNA fragment containing the XlnR binding sequence GGCTAAA as well as two similar sequences was shown to confer xylan inducibility on the gene. Complementary and genomic DNAs encoding the Aspergillus niger xlnR homologous gene, abbreviated AoxlnR, were cloned from A. oryzae and sequenced. AoXlnR comprised 971 amino acids with a zinc binuclear cluster domain at the N-terminal region and revealed 77.5% identity to the A. niger XlnR. Recombinant AoXlnR protein encompassing the zinc cluster region of the N-terminal part bound to both the consensus binding sequence and its cognate sequence, GGCTGA, with an approximately 10 times lower affinity. GGCTA/GA is more appropriate as the XlnR consensus binding sequence. Both sequences functioned independently in vivo in XlnR-mediating induction of the xynF1 gene. This was further confirmed by using an AoxlnR disruptant. Neither the xynF1 nor the xylA gene was expressed in the disruptant, suggesting that the xylan-inducible genes in A. oryzae may also be controlled in the same manner as described for A. niger.