Efficacy and safety of catheter ablation in octogenarians.

OBJECTIVES: To determine whether catheter ablation is safe and effective in patients over the age of 80. BACKGROUND: There is a tendency to withhold invasive therapy in the elderly until it has been proven safe and effective. METHODS: Over a two-year period from February 1, 1996 to February 1, 1998, 695 consecutive patients underwent 744 catheter ablation procedures of supraventricular and ventricular arrhythmias. These patients were divided into three groups based on age: > or =80 years, 60 to 79 years and <60 years. Acute ablation success, using standard criteria and complication rates for these three groups were determined. RESULTS: There were 37 patients > or =80 years, 275 patients 60 to 79 years and 383 patients <60 years old. The overall acute ablation success rate for the entire group was 95% with no difference in rates among the three groups (97%, > or =80 years; 94%, 60-79 years; 95%, <60 years). The percentage of patients undergoing His bundle ablation was greatest in the > or =80-year-old group (43% vs. 19% vs. 2%, p < 0.01), and the percentage of patients undergoing accessory pathway ablation was greatest in the <60-year-old patients (0% vs. 4% vs. 25%, p < 0.01). The overall complication rate for the entire group was 2.6%, and there was only one major/life-threatening complication. There was no difference in complication rates among the groups (0%, > or =80 years; 2.2%, 60 to 79 years; 3.1%, <60 years). Based on the sample size, the 95% confidence interval is 0% to 7.8% for an adverse event in the octogenarian. CONCLUSIONS: Catheter ablative therapy for the arrhythmias attempted in the very elderly appears to be effective with low risk. Ablation results appear to be comparable with those noted in younger patients.

A group II self-splicing intron from the brown alga Pylaiella littoralis is active at unusually low magnesium concentrations and forms populations of molecules with a uniform conformation.

We have investigated the reactivity of three of the seven group II introns encoded by the mitochondrial genome of the brown alga Pylaiella littoralis. While the first intron in the protein-coding cox1 gene could not be induced to self-splice under any of the conditions tested, the first two introns in the gene encoding the large ribosomal subunit are reactive in vitro and splice primarily by the standard group II two-step transesterification pathway. Intron 2 proved to be of exceptional interest, because in contrast to all group II molecules known so far, its optimal magnesium concentration is less than 10 mM and it still carries out accurate splicing at concentrations as low as 0.1 mM magnesium. Analysis of reaction products under optimal conditions showed no evidence of hydrolysis at the 5' splice site and up to 90% of precursor molecules could be converted into excised lariat intron, which migrated as a single band on non-denaturing polyacrylamide gels. Absorbance versus temperature profiles generated from the lariat form of intron 2 reveal the existence of an early melting component, the amplitude of which does not depend on the way the molecules were purified, i.e. with or without a denaturation step. This highly cooperative transition, whose position along the temperature axis changes with the concentration of magnesium, is proposed to consist of the unfolding of the tertiary structure of the molecule. We conclude that group II introns, which are the largest known ribozymes, can form conformationally homogeneous populations of molecules suitable for physical-chemical studies of higher-order structure.

The mitochondrial LSU rDNA of the brown alga Pylaiella littoralis reveals alpha-proteobacterial features and is split by four group IIB introns with an atypical phylogeny.

The mitochondrial DNA region coding for the large ribosomal RNA subunit from the brown alga Pylaiella littoralis (L.) Kjellm was sequenced. The LSU rRNA was folded into a secondary structure and aligned with homologous, mitochondrial and eubacterial sequences. Taking into account the primary and secondary structure levels, the mitochondrial LSU rRNA of P. littoralis shares more structural features with alpha-proteobacterial genes than do those of the green alga Prototheca wickerhamii and land plants. In phylogenetic trees, branches leading to brown algae, red algae, the protozoan Acanthamoeba castellanii and land plants, respectively, emerge approximately at the same time, as they do in nuclear-gene based phylogenies. This suggests that there is only one origin for the mitochondrial rRNA genes found in these lineages. The LSU rDNA is split by four group IIB introns. The first two introns each contain one open reading frame which encodes a reverse transcriptase-like protein. Comparison of their amino acid sequences with those of other reverse transcriptase-like genes contained in group II introns shows that these genes are more closely related to plastid and cyanobacterial homologous genes than to any known mitochondrial intronic reverse transcriptase.

Risk stratification and management of patients with organic heart disease and nonsustained ventricular tachycardia: role of programmed stimulation, left ventricular ejection fraction, and the signal-averaged electrocardiogram.

PURPOSE: Programmed stimulation, left ventricular ejection fraction, and signal-averaged electrocardiography were performed in patients with organic heart disease and spontaneous nonsustained ventricular tachycardia (VT) to determine the role of these techniques in risk stratification and management. PATIENTS AND METHODS: The study consisted of 90 patients: 63 had coronary artery disease and 27 had idiopathic dilated cardiomyopathy. Radionuclide ventriculography, signal-averaged electrocardiography, and programmed electrical stimulation were performed in all patients within 48 hours of index ambulatory electrocardiography. RESULTS: Fifty-three patients (59%) had an ejection fraction less than 40%. Programmed stimulation induced sustained monomorphic VT in 22 patients (24%), ventricular fibrillation (VF) in 10 patients (11%), and no sustained VT/VF in 58 patients (64%). The signal-averaged electrocardiogram (ECG) showed late potentials in 23 patients (26%). Sustained monomorphic VT could be induced in 65% of patients with late potentials and in 10% of those without late potentials. There was no case of inducible sustained monomorphic VT in 33 patients with no late potentials and an ejection fraction of 40% or greater. All patients with induced sustained monomorphic VT received antiarrhythmic therapy guided by the results of programmed stimulation. All 58 patients with no induced sustained ventricular tachyarrhythmias and eight patients with induced VF were discharged without receiving antiarrhythmic drugs. During a follow-up of 30 +/- 10 months, the three-year sudden death rate was 19% in patients with induced sustained VT, 0% in those with induced VF, and 9% in those with no induced sustained VT/VF. The three-year sudden death rate was the same (7%) in patients with no induced sustained VT/VF, both in those with an ejection fraction of 40% or greater or less than 40%. On the other hand, the three-year total cardiac mortality was significantly higher (27%) in those patients with ejection fractions less than 40% compared to those with ejection fractions of 40% or greater (7%). CONCLUSION: It is concluded that the signal-averaged ECG, ejection fraction, and programmed stimulation could be used for the risk stratification and management of patients with organic heart disease and nonsustained VT as follows: (1) Patients with no late potentials and with an ejection fraction of 40% or greater do not require invasive evaluation or antiarrhythmic therapy, since the incidences of induced VT and sudden death are very low. (2) Patients with late potentials as well as patients without late potentials but with an ejection fraction of less than 40% may be advised to undergo electrophysiologic evaluation.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of analyzed signal duration and phase on the results of fast fourier transform analysis of the surface electrocardiogram in subjects with and without late potentials.

A microcomputer-based system capable of performing time- and frequency-domain analysis on the same set of acquired and signal-averaged raw data was used to correlate late potentials detected in the time domain with the results of frequency-domain analysis. Ten patients with spontaneous or inducible sustained ventricular tachycardia (VT) known to have abnormal late potentials in the time-domain signal-averaged electrocardiogram and 10 normal subjects without late potentials were studied. Fast Fourier transform analysis was performed on a segment that comprised the last 40 ms of the QRS and the ST segment up to the onset of the T wave as identified visually. The high-frequency signal content, expressed as the area ratio or the peak magnitude, was found to be markedly dependent on the length of the analyzed QRS-ST segment. A change of as little as 3 ms in the duration of the estimated QRS-ST segment changed the results of the frequency analysis across proposed boundaries of normalcy in normal subjects and in patients with VT. This resulted in both false-negative and false-positive conclusions. Similar results were obtained when the effects of varying analyzed signal length or phase were studied using a pure synthesized sine wave signal. For frequency analysis to be clinically useful and reproducible, standards of normalcy must be established for a signal region of fixed duration or the technique must be modified so as to be insensitive to duration of signal sample.

Value of the signal-averaged electrocardiogram as a predictor of the results of programmed stimulation in nonsustained ventricular tachycardia.

A prospective assessment of several clinical variables, left ventricular function indexes, Holter recording characteristics and signal-averaged electrocardiogram (ECG) for their value in predicting the inducibility of sustained ventricular tachyarrhythmias was carried out in a consecutive series of 105 patients with nonsustained ventricular tachycardia (VT). The patients were divided into 3 groups based on the results of programmed electrical stimulation: group 1, 22 patients with induced sustained monomorphic VT; group 2, 14 patients with induced ventricular fibrillation (VF) and group 3, 69 patients with no induced sustained VT/VF. Left ventricular ejection fraction less than 0.40, history of syncope/presyncope and abnormal signal-averaged ECG were significantly more common in group 1 than in group 3. No significant difference was found between groups 2 and 3. The sensitivity, specificity and predictive accuracy of the signal-averaged ECG for the induction of sustained monomorphic VT were 64, 89 and 84%, respectively. Using stepwise discriminant function analysis, the signal-averaged ECG was found to be the single most accurate screening test to predict the inducibility of sustained VT in patients with nonsustained VT and its value was independent of the etiology of heart disease and the length of spontaneous runs. Because of the very high specificity and negative predictive accuracy, patients with normal signal-averaged ECGs may not require invasive evaluation.

Development of a new technique for explantation of chronic transvenous pacemaker leads: five initial case studies.

Transvenous removal of chronic pacing leads was attempted using a special locking stylet and dilator sheaths. In five initial cases, three of seven leads were infected; six of seven leads were removed. The stylet was inserted into the conductor lumen and locked into the tip to reinforce and control the lead, permitting retraction without stretching the conductor. Sheaths were advanced over the lead to detach and dilate fibrous encapsulation. In one case, force applied exceeded the locking mechanism's strength; no patient complication resulted. It is concluded that transvenous lead removal is facilitated by a locking stylet and dilation of fibrous tissue with sheaths.

[Tilt-table test in the diagnosis of syncope of unknown origin]. / Billenthetö ágyon fejjel fölfelé helyzetben (head up tilt table) végzett teszt alkalmazása az ismeretlen eredetü syncope diagnosztikájában.

71 patients with unexplained syncope was examined by 60 grade of head up tilt table test with or without administration of isoproterenol during 25 minutes interval. The mean age of patients was 71.44 +/- 16.40 (12-86) years. 38 (54%) were female and 33 (46%) were male. The underlying heart disease were 27 (38%) coronary artery disease, 12 (17%) arterial hypertension, 6 (8%) diabetes mellitus, 3 (4%) valvular heart disease and 14 (20%) patients had other diseases. Nine (13%) patients had no organic disease. During head up tilt table test positive reaction was found in 13 (18%) patients. Four (6%) patients were vaso-vagal syncope with classic signs, and 9 (13%) patients were vasodepressor type of syncope, without changes in the heart rate. Isoproterenol was given to 16 (23%) patients, and in 4 (6%) (2 vasodepressor and 2 mixed type of syncope) patients occurred the positive test during isoproterenol administration. Orthostatic reaction occurred during head up tilt table test in 14 (20%) patients. Normal was the result of tilt table test in 42 (59%) patients, and two (3%) patients had autonome neuropathy. The vasovagal syncope was treated by metoprolol, atenolol and disopyramid with success. The head up tilt table testing is a good, simple, useful test for evaluation of syncope patients, especially the diagnosis of vasovagal syndrome.

Evaluation of patients with complex ventricular arrhythmias: current noninvasive and invasive methods.

Ventricular tachycardia (VT) or ventricular fibrillation is the most frequently documented mechanism of sudden cardiac death (SCD) in patients with coronary heart disease. There is no definitive proof that the abolition of complex ventricular ectopy, accomplished conventionally by pharmacologic therapy, results in the prevention of SCD; in the recent Cardiac Arrhythmia Suppression Trial (CAST), patients treated with encainide or flecainide demonstrated a greater incidence of cardiac death and arrhythmic death than a placebo group. Traditionally, the role of invasive electrophysiologic testing has been reserved for the evaluation of patients with complex ventricular ectopy associated with unexplained syncope, presyncope, or SCD, and for those patients who have sustained VT or ventricular fibrillation. Management of patients with complex ventricular arrhythmias by noninvasive methods (such as the 24-hour ambulatory ECG and exercise testing) has been the approach implemented for most patients thought to be at risk of SCD who have not experienced syncope, presyncope, or sustained VT. The CAST results, coupled with the fact that ambulatory ECG may lack sensitivity and overpredict successful therapy, warrant a discussion of noninvasive and invasive methods currently available for the evaluation and management of patients with complex ventricular arrhythmias. Among some of the relatively new techniques are programmed electrical stimulation and signal-averaged electrocardiography, both of which have been shown to be valuable in delineating high- and low-risk SCD groups.

Deforming semistable Galois representations.

Let V be a p-adic representation of Gal(Q/Q). One of the ideas of Wiles's proof of FLT is that, if V is the representation associated to a suitable autromorphic form (a modular form in his case) and if V' is another p-adic representation of Gal(Q/Q) "closed enough" to V, then V' is also associated to an automorphic form. In this paper we discuss which kind of local condition at p one should require on V and V' in order to be able to extend this part of Wiles's methods.

DDD-pacemaker pseudomalfunction during supraventricular tachycardia.

Asynchronous pacing during the presence of electromagnetic interference or other sources of "noise" is a protective mechanism available to prevent pacemaker output inhibition. We describe a patient with a DDD pacemaker who had asynchronous dual chamber or noise reversion pacing as a consequence of repetitive signals (QRS complexes) falling into the noise sampling period (NSP) of the pacemaker ventricular refractory period. During supraventricular tachycardia at a rate of 215 bpm, noise reversion mode pacing occurred when QRS complexes were well detected immediately after the termination of a normal pacemaker ventricular refractory period and treated as a premature ventricular depolarization, resulting in automatic refractory period extension. Recycling of this extended refractory period occurred when consecutive QRS complexes were detected during the NSP and forced asynchronous dual chamber pacing at the programmed lower rate. The mechanism is presented and was supported by subthreshold esophageal pacing simulating the tachycadia and initiating the noise reversion response.

Risk stratification of patients with complex ventricular arrhythmias. Value of ambulatory electrocardiographic recording, programmed electrical stimulation and the signal-averaged electrocardiogram.

Currently, there are three prognostic indicators of ventricular electrical instability: long-term ambulatory ECG recording, programmed electrical stimulation and the signal-averaged electrocardiogram. Several clinical studies have suggested that frequent and complex ventricular premature contractions in patients with organic heart disease may identify future cardiac events, including sudden cardiac death although, with respect to prognosis, it is not likely that any grading system based on the ambulatory ECG will be without meaningful limitations. No study has adequately tested the hypothesis that decreasing ventricular arrhythmias after acute myocardial infarction reduces mortality. The inducibility of ventricular tachycardia during programmed electrical stimulation is regarded as an independent risk factor for sudden death. Predominantly due to the lack of standardized protocol and definitions, the actual relevance of current literature remains somewhat compromised. The indication for antiarrhythmic treatment in those patients in whom ventricular tachycardia can be induced has not been established with certainty since the effects of therapy on the prognosis are unknown. For patients with complex ventricular arrhythmias in whom sustained ventricular tachycardia cannot be induced, antiarrhythmic drug treatment does not appear indicated. Based on a number of studies, the presence of late potentials in the signal-averaged ECG has also been shown to be a meaningful prognostic indicator. The signal-averaged ECG, however, is not only subject to various technical problems but is also encumbered by limitations arising from electrophysiologic considerations. While no relationship could be established between late potentials and complex ventricular arrhythmias in the ambulatory ECG within the first two months after acute myocardial infarction, there was, however, a correlation between late potentials and the inducibility of ventricular tachycardia during programmed electrical stimulation. Consequently, the signal-averaged ECG may serve as a screening test to identify patients who should subsequently undergo programmed electrical stimulation for arrhythmia assessment or guided institution of treatment provided this proves to be effective in reducing the risk of future major arrhythmic events.

Noninvasive assessment of ventriculo-atrial conduction and early experience with the tachycardia termination algorithm in pacemaker-mediated tachycardia.

Since the advent of physiologic dual chamber pacing systems, pacemaker-mediated tachycardia (PMT) has occurred and the need for invasive measurement of ventriculo-atrial conduction (VAC) has arisen. The variability in VAC and the potential for PMT often make it necessary to assess for the presence or absence of VAC at different points in time. We noninvasively evaluated 20 pacemaker patients for the presence or absence of VAC. We compared ventriculo-atrial conduction time (VACT) obtained with the atrial sense event maker with that obtained from Holter monitoring and invasive methods. The incidence of spontaneous (S) and induced (I) PMT and the efficacy of the tachycardia termination algorithm (TTA) was assessed. Fourteen of 20 had VAC with invasive or noninvasive methods. Twelve of 19 had PMT (63%); three were sustained (greater than 15 beats). We conclude that VACT assessed with the atrial sense event marker (ASEM) yielded a high correlation when compared to the Holter monitor data obtained utilizing our methodology. PMT is commonly a nonsustained (less than 15 beats) event, and the TTA is effective in sustained PMT. Myopotential sensing, atrial premature contractions and loss of atrial capture are common mechanisms in the initiation of PMT.

The reverse-transcriptase-like proteins encoded by group II introns in the mitochondrial genome of the brown alga Pylaiella littoralis belong to two different lineages which apparently coevolved with the group II ribosyme lineages.

The mitochondrial genome of the brown alga Pylaiella littoralis contains two different types of group II introns. They each encode complete complex proteins, i.e., with a reverse transcriptase domain, a maturase or X domain, and an endonuclease or H-N-H/zinc finger domain. To our knowledge, this is the first example of the presence in the same genome of introns belonging to subgroups IIA and IIB which both contain multidomained RT-like proteins. We describe the group IIA introns that interrupt the cox1 gene. The RT-like proteins contained in these introns were compared to those of the LSU rDNA group IIB introns. The phylogenetic relationships of these intron ORFs were investigated and the possible evolution of group II introns is discussed.

Ventricular tachycardia: a life-threatening arrhythmia in a patient with congenitally corrected transposition of the great arteries.

Ventricular tachycardia (VT) is an uncommon finding in patients with congenitally corrected transposition of the great arteries (CCTGA). Cardiac death in patients with CCTGA has been attributed to complete heart block, systemic ventricular dysfunction, or severe AV valve regurgitation with heart failure. We describe the case of a patient who presented with palpitations and near-syncope that was associated with clinical episodes of VT. Programmed ventricular stimulation revealed easily inducible sustained VT that immediately degenerated to ventricular fibrillation and subsequently required therapy with an implantable cardioverter defibrillator.

Rapid ventricular pacing in a pacemaker patient undergoing magnetic resonance imaging.

Magnetic resonance imaging (MRI) generates potent electromagnetic forces in the form of a static, gradient, or pulsed radiofrequency magnetic field that can result in pacemaker malfunction. This report documents a case of rapid cardiac pacing during MRI in a patient with a dual chamber pacemaker. Although the mechanism of rapid cardiac pacing is unclear, it was directly related to radiofrequency pulsing. We postulated that the lead acts as an antenna for radiofrequency energy that interacts with the pacemaker's output circuit, thus, causing cardiac pacing at a cycle length representing a multiple of the repetition time; or perhaps rapid pacing is related to induced currents generated between the MRI unit and the pacing lead.

Time course of ventricular arrhythmias and the signal averaged electrocardiogram in the post-infarction period: a prospective study of correlation.

The incidence and time course of complex ventricular arrhythmias and of the abnormal signal averaged electrocardiogram were studied prospectively in 90 patients in the first two months after acute myocardial infarction. Serial recordings of both 24 hour ambulatory and signal averaged electrocardiograms were obtained 0-5 days (phase 1), 6-30 days (phase 2), and 31-60 days (phase 3) after infarction. A total of 264 ambulatory electrocardiograms and 264 signal averaged electrocardiograms were available for analysis. Complex ventricular arrhythmias were seen in 31%, 17%, and 38% of patients during phases 1, 2, and 3 respectively, and abnormal signal averaged electrocardiogram in 13%, 24%, and 16%. The incidence of complex ventricular arrhythmias was not significantly different in patients with or without an abnormal signal averaged electrocardiogram in the entire study period nor in any of the three phases after infarction. During phase 2 when abnormal signal averaged electrocardiograms were most common complex ventricular arrhythmias were least common. This lack of correlation suggests that the abnormal signal averaged electrocardiogram and complex ventricular arrhythmias after infarction have different electrophysiological bases.

Study of the influence of left bundle branch block on the signal-averaged electrocardiogram: a qualitative and quantitative analysis.

UNLABELLED: To study the influence of left bundle branch block (LBBB) on the signal-averaged electrocardiogram (SAECG), quantitative and qualitative analyses of SAECG parameters were undertaken in 48 patients with electrocardiographic evidence of intrinsic LBBB and in 39 patients with a "normal" surface QRS duration (less than 120 msec) who underwent right ventricular pacing-induced LBBB. We assumed pacing of the right ventricular apex to be a suitable model of this conduction defect. Sustained monomorphic ventricular tachycardia (SMVT) was inducible in 16 of 48 patients with intrinsic LBBB and in 23 of 39 patients with pacing-induced LBBB. Utilizing a filter setting of 25 to 250 Hz, late potentials were defined as a total filtered QRS duration greater than or equal to 120 msec, a root mean square voltage in the terminal 40 msec (RMS 40) of less than or equal to 25 microV, and the duration of signals less than 40 microV (LAS 40) of greater than or equal to 38 msec. Only RMS 40 and LAS 40 criteria were used in patients with LBBB. Prolongation of LAS 40 and fragmentation of signals in the terminal portion of the filtered QRS were characteristic of all patients with LBBB aberration. Of those patients with intrinsic LBBB, the mean total filtered QRS duration, RMS 40, and LAS 40 for inducible and noninducible patients were significantly different (170 +/- 28, 16 +/- 10, 55 +/- 24, and 153 +/- 18 msec, 25 +/- 10 microV, 33 +/- 16.9 msec; p = 0.04, 0.009, and 0.007, respectively). Noninducible patients with a normal QRS duration demonstrated a 60% decrement in the mean RMS 40 value during pacing-induced LBBB. These changes resulted in a 59% false positive incidence of late potentials during pacing-induced LBBB. This correlated with a similarly low mean RMS 40 value in patients with intrinsic LBBB and no inducible SMVT, hence giving rise to a false positive incidence of late potentials of 63%. Since "standard" RMS 40 and LAS 40 criteria resulted in low specificity and positive predictive value, new parameters were selected and analyzed. The combination of RMS 40 less than or equal to 17 microV plus LAS 40 greater than or equal to 55 msec yielded the best overall statistical result, with a sensitivity, specificity, and total predictive accuracy of 69%, 81%, and 77%, respectively. IN CONCLUSION: (1) A reduction of RMS 40, prolongation of LAS 40, and fragmentation of signals in the terminal portion of the filtered QRS are characteristics of LBBB.(ABSTRACT TRUNCATED AT 400 WORDS)

The complete sequence of a brown algal mitochondrial genome, the ectocarpale Pylaiella littoralis (L.) Kjellm.

We describe here the complete sequence (58,507 bp) of the mitochondrial genome of the brown alga Pylaiella littoralis (Ectocarpales). This molecule displays an AT content of 62.0% and contains seventy-nine genes, most of them (73) encoded on one strand. They include the usual mitochondrial set of protist genes and a number of rarer genes. Among these, several ribosomal protein genes and the rn5 were identified. Twenty-four tRNA genes are present in this genome, insufficient to decode all genes. The other conspicuous features of this molecule are: a large (3018 nucleotides) in-frame insertion of unknown function in the cox2 gene; the presence of two different lineages of group II introns, including complete reverse transcriptase-like genes, one in the cox1 and the other in the rnl gene; the concomitant occurrence of a T7-like RNA polymerase and of several well-conserved alpha-proteobacterial-type promoters; and a small nad11 gene, coding for the first domain only of this NADH dehydrogenase subunit. Altogether, the mitochondrial genome of P. littoralis exhibits both alpha-proteobacterial characteristics and evidences of the independent integration of several exogenous DNA fragments.