Knotting of a flow-directed catheter about a cardiac structure

A new ganglion identified as the bursal ganglion is described from male Moniliformis moniliformis. This ganglion is located adjacent to the pseudocoel and longitudinal muscle fibers and medial to the dorsal lacunar canal about 1 mm from the posterior end of males with non-everted bursa. The ganglion consists of four large club-shaped cells with single nuclei and bipolar neurons. The ganglion cells are paired with one neuron from each cell innervating the opposite side of the worm.     

Effect of a single element subcutaneous array electrode added to a transvenous electrode configuration on the defibrillation field and the defibrillation threshold

Even with the use of biphasic shocks, up to 5% of patients need an additional subcutaneous lead to obtain a defibrillation safety margin of at least 10 J. The number of patients requiring additional subcutaneous leads may even increase, because recent generation devices have a < 34 J maximum output in order to decrease their size. In 20 consecutive patients, a single element subcutaneous array lead was implanted in addition to a transvenous lead system consisting of a right ventricular (RV) and a vena cava superior lead using a single infraclavicular incision. The RV lead acted as the cathode; the subcutaneous lead and the lead in the subclavian vein acted as the anode. The biphasic defibrillation threshold was determined using a binary search protocol. Patients were randomized as to whether to start them with the transvenous lead configuration or the combination of the transvenous lead and the subcutaneous lead. In addition, a simplified assessment of the defibrillation field was performed by determining the interelectrode area for the transvenous lead only and the transvenous lead in combination with the subcutaneous lead from a biplane chest X ray. The intraoperative defibrillation threshold was reconfirmed after 1 week, after 3 months, and after 12 months. The mean defibrillation threshold with the additional subcutaneous lead was significantly (P = 0.0001) lower (5.7 +/- 2.9 J) than for the transvenous lead system (9.5 +/- 4.6 J). With the subcutaneous lead, the impedance of the high voltage circuit decreased from 48.9 +/- 7.4 omega to 39.2 +/- 5.0 omega. In the frontal plane, the interelectrode area increased by 11.3% +/- 5.5% (P < 0.0001) and in the lateral plane by 29.5% +/- 12.4% (P < 0.0001). The defibrillation threshold did not increase during follow-up. Complications with the subcutaneous electrode were not observed during a follow-up of 15.8 +/- 2 months. The single finger array lead is useful in order to lower the defibrillation threshold and can be used in order to lower the defibrillation threshold.     

Boundary layer drug delivery using a helical catheter

BACKGROUND: A catheter-based approach for local endovascular drug delivery has been developed. The catheter is deployed percutaneously, while the end of the catheter is in the form of a helix that is placed just proximal to the vascular site to be treated. The helices are in contact with the vessel wall. A number of small holes is drilled in the coils of the catheter through which drug is infused, so that the infused drug remains within the blood fluid 'boundary layer' adjacent to the vessel wall. This approach is expected to be highly efficient for administration of antithrombotic and antiproliferative agents that target processes leading to vascular occlusion, heart attacks, and strokes. METHODS: The helical catheter was qualitatively evaluated using optical dye density measurements of Evans blue dye infused using an in vitro steady flow system under a physiologic range of conditions. To further demonstrate the efficiency of the technique, its capacity to inhibit thrombosis was evaluated in a baboon thrombosis model. The catheter was inserted into a femoral arteriovenous shunt (blood flow rate = 100 ml/min) and placed proximal to a segment of highly thrombogenic Dacron vascular graft (4.0 mm i.d.). Integrelin (an inhibitor of platelet glycoprotein IIb/IIIa; doses: 0.25-1.0 microg/min) and hirudin (an antithrombin; doses: 10-100 microg/min) were used to inhibit thrombus formation. RESULTS: Experimental flow visualization studies demonstrated that high concentrations of the infused Evans blue dye were retained near the vessel wall. In the animal experiments, platelet deposition on the Dacron graft surface was reduced by 82-97% (Integrelin) and 68-92% (hirudin) over 1-2 h of blood exposure. The local antithrombotic effects produced were found to be 200-fold and 30-fold more efficient than systemic administration of the same agents. CONCLUSIONS: Local drug infusion using the helical catheter approach can achieve high drug concentration levels at target sites, may avoid systemic effects, and can reduce cost of therapy by reducing total drug requirements.     

Electrical stimulation of cardiac tissue by a bipolar electrode in a conductive bath

A three-dimensional (3-D) computer simulation of the electrical stimulation of passive cardiac tissue from a bipolar electrode placed within a conductive bath is presented. Through the bidomain model, the syncytial and anisotropic properties of cardiac tissue are taken into account; tissues with equal anisotropy and no transverse coupling are also considered. The membrane is represented by a capacitor and passive resistor in parallel. Located within an isotropic bath, the bipolar electrode is oriented either perpendicular or parallel to the tissue surface. For anisotropic tissue with a small cathode-tissue separation, the tissue surface is highly depolarized under the cathode with the depolarization persisting a considerable distance from the electrode in the transverse fiber direction. Adjacent to this region in the longitudinal direction, areas of hyperpolarization exist. At large distances from the cathode, the tissue surface is hyperpolarized in all directions when the electrode axis is perpendicular to the tissue. In the parallel case, surface depolarization creates buried regions of hyperpolarization. For the perpendicular configuration, the ratio of the steady-state maximum depolarization to steady-state maximum hyperpolarization, an estimate of the ratio of anodal to cathodal threshold, decreases rapidly with increasing cathode-tissue separation. In the parallel case, the depth of the conductive bath significantly affected the transmembrane potential distribution in the tissue. The use of a 3-D model more realistically simulates real-life electrical stimulation (such as stimulation with an implantable pacemaker) and provides insight into the effect of the volume conductor adjacent to the tissue.     

Primary cardiac angiosarcoma of the right atrium undiagnosed by transvenous endocardial tumor biopsy

A 50-year-old man was admitted with acute pericarditis. Echocardiography demonstrated a large mass on the right atrial free wall along with a pericardial effusion. We performed transvenous biopsy of this mass under transesophageal echocardiographic guidance. Though the biotome obtained the mass, the pathological findings were of organized thrombus. Two weeks later, a new precordial mass appeared around the left third rib and was suspected to be a metastasis. Incisional biopsy of this mass gave the diagnosis of angiosarcoma.     

Effects on cardiac performance of atrioventricular node catheter ablation using radiofrequency current for drug-refractory atrial arrhythmias

Patients with atrial fibrillation or atrial flutter (AF) are candidates for radiofrequency (RF) catheter ablation of the atrioventricular (AV) node with the aim being to control heart rate. As patients with AF can have markedly impaired ventricular function, information concerning the hemodynamic effects of AV node ablation using RF current would be valuable. Fourteen consecutive patients (mean age 65 +/- 3 years) with drug-resistant AF underwent AV node catheter ablation with RF current and had permanent pacemaker implantation. The mean left ventricular ejection fraction (EF) by two-dimensional echocardiography immediately before ablation was 42 +/- 3% (range 14%-54%) and their mean exercise time was 4.4 +/- 0.4 minutes. Complete AV block was achieved in all 14 patients with 6 +/- 2 RF applications (range 1-18). There was no evidence of any acute cardiodepressant effect associated with delivery of RF current, and EF 3 days after ablation was 44 +/- 4%. By 6 weeks after ablation, the left ventricular EF was significantly improved compared to baseline (47 +/- 4% postablation vs 42 +/- 3% preablation; P < 0.05), and this modest increase in EF was accompanied by an improvement in exercise time (5.4 +/- 0.4 min). In conclusion, delivery of RF current for AV node catheter ablation in patients with AF and reduced ventricular function is not associated with any acute cardiodepressant effect. On the contrary, improved control of rapid heart rate following successful AV node ablation is associated with a modest and progressive improvement in cardiac performance.     

Nonsustained reentry following successive stimulation of cardiac tissue through a unipolar electrode

INTRODUCTION: Using numerical simulations, we predict that nonsustained reentry occurs following a strong, premature stimulus through a unipolar electrode. METHODS AND RESULTS: Our simulations were based on the bidomain model of cardiac tissue, and the active membrane properties were represented by the Beeler-Reuter model. An outwardly propagating wavefront was excited by an initial stimulus (S1). A second stimulus (S2) was then applied through the same electrode. Nonsustained reentry or reentrant-like behavior followed the S2 stimulus for both cathodal and anodal stimulation, and were associated with "break" stimulation but not with "make" stimulation. The direction of spiral-wave rotation was reversed when the polarity of the stimulus was reversed. These complex dynamics occur only for a narrow window of S1-S2 intervals. During anodal S2 stimulation, two different modes of reentry exist. Our simulations also explain the "no response" phenomenon. CONCLUSION: Our mathematical model predicts that both anodal and cathodal unipolar S2 stimulation results in reentry. This behavior arises from an interaction of virtual anodes and cathodes surrounding the stimulating electrode.     

A multicenter evaluation of a new continuous cardiac output pulmonary artery catheter system

OBJECTIVE: To validate a new system of continuous cardiac output monitoring. DESIGN: Multicenter, prospective, nonrandomized clinical study. SETTING: Four university hospitals. PATIENTS: Forty-seven adult intensive care unit patients. INTERVENTIONS: Pulmonary artery catheterization. MEASUREMENTS AND MAIN RESULTS: Continuous and bolus cardiac output measurements were obtained over 72 hrs. The 327 continuous cardiac output measurements compared favorably with bolus cardiac output measurements (bias = 0.12 L/min, precision = +/-0.84). The continuous cardiac measurement was not adversely affected by temperatures of <37 degrees C or >38 degrees C, high (>7.5 L/min) or low (<4.5 L/min) cardiac output values, or duration (72 hrs) of the study. CONCLUSIONS: This continuous cardiac output system provides a reliable estimate of cardiac output for clinical use if applied in conditions similar to this study. The combination of a continuous measure of cardiac output with other continuous physiologic monitoring (arterial and mixed venous oxygen saturation, oxygen consumption, etc.) may provide important information that no single parameter could achieve.     

Clinical shock tolerability and effect of different right atrial electrode locations on efficacy of low energy human transvenous atrial defibrillation using an implantable lead system

OBJECTIVES: The objectives of this study were 1) to evaluate the effect of different right atrial electrode locations on the efficacy of low energy transvenous defibrillation with an implantable lead system; and 2) to qualitate and quantify the discomfort from atrial defibrillation shocks delivered by a clinically relevant method. BACKGROUND: Biatrial shocks result in the lowest thresholds for transvenous atrial defibrillation, but the optimal right atrial and coronary sinus electrode locations for defibrillation efficacy in humans have not been defined. METHODS: Twenty-eight patients (17 men, 11 women) with chronic atrial fibrillation (AF) (lasting > or = 1 month) were studied. Transvenous atrial defibrillation was performed by delivering R wave-synchronized biphasic shocks with incremental shock levels (from 180 to 400 V in steps of 40 V). Different electrode location combinations were used and tested randomly: the anterolateral, inferomedial right atrium or high right atrial appendage to the distal coronary sinus. Defibrillation thresholds were defined in duplicate by using the step-up protocol. Pain perception of shock delivery was assessed by using a purpose-designed questionnaire; sedation was given when the shock level was unacceptable (tolerability threshold). RESULTS: Sinus rhythm was restored in 26 of 28 patients by using at least one of the right atrial electrode locations tested. The conversion rate with the anterolateral right atrial location (21 [81%] of 26) was higher than that with the inferomedial right atrial location (8 [50%] of 16, p < 0.05) but similar to that with the high right atrial appendage location (16 [89%] of 18, p > 0.05). The mean defibrillation thresholds for the high right atrial appendage, anterolateral right atrium and inferomedial right atrium were all significantly different with respect to energy (3.9 +/- 1.8 J vs. 4.6 +/- 1.8 J vs. 6.0 +/- 1.7 J, respectively, p < 0.05) and voltage (317 +/- 77 V vs. 348 +/- 70 V vs. 396 +/- 66 V, respectively, p < 0.05). Patients tolerated a mean of 3.4 +/- 2 shocks with a tolerability threshold of 255 +/- 60 V, 2.5 +/- 1.3 J. CONCLUSIONS: Low energy transvenous defibrillation with an implantable defibrillation lead system is an effective treatment for AF. Most patients can tolerate two to three shocks, and, when the starting shock level (180 V) is close to the defibrillation threshold, they can tolerate on average a shock level of 260 V without sedation. Electrodes should be positioned in the distal coronary sinus and in the high right atrial appendage to achieve the lowest defibrillation threshold, although other locations may be suitable for certain patients.     

Fragmentation of massive pulmonary embolism using a pigtail rotation catheter

STUDY OBJECTIVES: The purpose of this study was the evaluation of the efficacy and safety of mechanical fragmentation of acute massive pulmonary emboli with a rotatable pigtail catheter. MATERIAL AND METHODS: Ten patients (4 female, 6 male, age 53.8+/-9.5 years) with acute massive pulmonary embolism with hemodynamic impairment were included in the study. The fragmentation catheter device (William Cook Europe A/S; Bjaerverskov, Denmark) consisted of a 5F catheter embedded in a flexible 5.5F sheath. Pulmonary emboli were fragmented by mechanical action of the recoiled rotating pigtail, while the guide wire was exiting an oval side hole proximal to the pigtail tip. In eight cases, an additional thrombolysis was performed. RESULTS: Fragmentation was successful in 7 of 10 patients. Average percentage of recanalization by fragmentation was 29.2+/-14.0%, and 36.0+/-10.0% exclusively of the seven successful cases. Average shock index decreased significantly prefragmentation to postfragmentation from 1.52 to 1.22 (p = 0.03) and to 0.81 48 h later (p < 0.001). Decrease of the average mean arterial pulmonary pressure prefragmentation to postfragmentation was insignificant (from 33 to 31 mm Hg, p = 0.14); further decrease within the 48 h follow-up was highly significant (from 31 to 21 mm Hg, p < 0.001) due to a synergy of fragmentation and thrombolysis (average dose 63+/-25 mg plasminogen activator). There were no procedure-related complications. Overall mortality rate was 20%. CONCLUSION: Fragmentation of massive pulmonary emboli with the pigtail rotation catheter achieved rapid partial recanalization in most cases, with ease of instrumentation, and without complications. Hemodynamic stabilization was completed in synergy with thrombolysis.     

Intracoronary stent implantation using a single high-pressure perfusion balloon catheter

INTRODUCTION: A factory producing lead ingots, located in Ca?apava, caused lead and cadmium contamination of the environment, in the Paraiba Valley region of Southeastern, Brazil, through the discharge of industrial waste and the recycling of batteries. The factory, set in a rural, dairy cattle breeding area, worried sanitary authorities who envisaged the possibility of these metals' having entered the food chain. For the purpose of assessing the levels of contamination of the milk produced in the region, due to the cattle's possible consumption of contaminated grass and water, the amounts of cadmium and lead present in the milk were verified. MATERIAL AND METHOD: Major producers, covering an area of up to 20 km from the contaminated source, authorized collection of 218 samples of both pasteurized and non-pasteurized milk, which were analysed. Lead and cadmium levels were determined by flame atomic absorption spectrophotometry, the lead being pre-concentrated by complexation with APDC (ammonium 1-pyrrolidinecarbodithioate) and further extraction with isobutyl methylketone. RESULTS AND CONCLUSIONS: Of the total number of samples, 43 presented lead levels over the maximum limit of 0.05 mg/kg established by Brazilian legislation. The median value found for lead was 0.04 mg/L. The variance analysis, with 95% confidence level, found no significant difference among the types of milk studied with regard to lead levels. As for cadmium, all samples showed levels below the 0.02 mg/L quantification limit of the method. In spite of the environmental contamination, the levels of cadmium found in the milk were below the 1.0 mg/kg limit established by Brazilian legislation.     

Real-time continuous measurement of right ventricular volume using a conductance catheter

The authors propose using a multi-electrode conductance catheter to measure continuous right ventricular volume. True ventricular volume measurements are affected by four main sources of error. 1) field non-uniformity, 2) catheter curvature, 3) blood conductivity changes, and 4) leakage of current through surrounding tissues. Three-dimensional finite-element models were developed to investigate the effects of these sources of error and to devise schemes for correcting them. The models include an axisymmetric cylindrical model, a rectangular block model, and a heart model with left and right ventricular chambers. The heart model is built from conical primitives, with major dimensions derived from the literature. Finite-element simulations showed that volume measurements were underestimated due to field nonuniformity to as much as 1/25th actual volume in segments near the exciting electrodes. The extent of underestimation in a segment decreased with increasing distance of the segment from the exciting electrodes and increased for larger segmental volumes. Catheter curvature overestimated measured volume by as much as 4.5 times when the curvature was increased from 0.0 to 1.25 (from a straight catheter to a very curved one). The leakage of current through surrounding tissues overestimated volume by nearly 30%. The sensitivity of volume measurement to blood resistivity changes was found to be very high, at 70%. Correction factors established with the computer models compensate for field nonuniformity. Mathematical mapping of the curved catheter onto a fictitious straight catheter corrects for the catheter curvature error. Correction for both nonuniform field and catheter curvature allowed measurement of total ventricular volume with an error of 7%. Leakage current is determined by using different frequencies to build the catheter electric field and to separate tissue and blood resistance paths. Using this scheme, the percentage overestimation in volume measurement due to leakage could be determined with an accuracy of 85%. The proposed correction scheme for blood conductivity changes involves the in-vivo measurement of blood conductivity with the catheter itself. It was found that blood conductivity could be determined with insignificant error (< 0.5%) so long as the blood volume around the exciting electrodes had a radius of more than the electrode spacing.     

Simultaneous determination of maltose and glucose using a screen-printed electrode system

A screen-printed sensor system consisting of a glucose oxidase (GOD) electrode and an amyloglucosidase/glucose oxidase (A/G) electrode was constructed to determine maltose and glucose simultaneously in a mixture. Sensor construction was optimised so that it contained 20 units of GOD/40 units of amyloglucosidase and 0.2 mM 1,1'-ferrocenedimethanol. These components were deposited onto a screen-printed carbon electrode and an outer membrane was printed from 3.5% hydroxyethyl cellulose (HEC) solution. The optimum pH was 4.8. The linear range of the system was up to 40 mM glucose or 20 mmol/L maltose with coefficients of variation (CVs) ranging from 3.5% to 5.29%. The results obtained by using the enzyme electrode system agreed well with those obtained by the Fehling titration method. When stored dry, especially at 4 degrees C, the enzyme electrodes showed good stability over four months.     

Endocardial activation mapping of ventricular tachycardia in patients : first application of a 32-site bipolar mapping electrode catheter

BACKGROUND: Localization of early activated endocardial areas during ventricular tachycardia (VT) is mandatory for performance of surgical or radiofrequency catheter interventions. The use of a multielectrode catheter may shorten the procedure time and increase the accuracy of the procedure compared with single-electrode mapping techniques. This study was performed to evaluate the safety and efficacy of a 32-bipolar-electrode mapping catheter in patients. METHODS AND RESULTS: The basket-shaped mapping catheter (BMC), integrated with a computerized mapping system, allowed on-line reconstruction of endocardial activation maps. Twenty patients with VT were studied before surgery (n=4) or radiofrequency catheter ablation (n=16). End-diastolic left ventricular (LV) volume was 280+/-120 mL, with an LV ejection fraction of 33+/-14%. The volume encompassed by the BMC was 164+/-27 mL (130 to 200 mL); the deployment time was 46+/-11 minutes. Endocardial activation time during sinus rhythm was 105+/-34 ms; 14+/-5 electrodes could be used to stimulate the heart. Cycle length of VT was 325+/-83 ms. Earliest endocardial activation was recorded 58+/-42 ms before the onset of the surface ECG. Complications were pericardial effusion (n=2) and transient cerebral disorientation (n=1). CONCLUSIONS: Percutaneous multielectrode endocardial mapping in patients with VT is feasible and relatively safe. The use of this technique shortens the time patients have to endure VT.