Intermediate septal accessory pathways: Electrocardiographic characteristics, electrophysiologic observations and their surgical implications

AbstractIntermediate septal accessory pathways are located in close proximity to the atrioventricular (AV) node and His bundle, have unique features that distinguish them from typical anterior and posterior accessory pathways and have been associated with a high risk for unsuccessful pathway division and the production of complete AV block after surgery. Between July 1986 and May 1990, 4 of 70 patients (3 men and 1 woman; mean age 33 ± 13 years) undergoing surgery for accessory pathway division were found to have an intermediate septal accessory pathway. The presenting arrhythmia was atrial fibrillation with rapid anterograde conduction over the accessory pathway in two patients and recurrent orthodromic reciprocating tachycardia in two patients.In all patients, the delta wave on the electrocardiogram (ECG) was inversed in lead V1, but two patterns of delta wave configuration were observed. In three patients (type 1 intermediate septal accessory pathway), the delta wave was upright in lead II, inverted in lead III and isoelectric in lead aVF; the transition from a negative to an upright delta wave occurred in lead V2. The fourth patient exhibited a different delta wave pattern (type 2 intermediate septal accessory pathway). The delta wave was upright in each of leads II, III and aVF; the transition from a negative to an upright delta wave occurred at lead V3.Intraoperative electrophysiologic study localized the atrial insertion of type 1 pathways to the midpoint of Koch's triangle close to the AV node. In the one patient with a type 1 pathway in which both anterograde and retrograde accessory pathway conduction was present, preoperative catheter mapping demonstrated that earliest retrograde atrial activation occurred near the foramen ovale. Intraoperative mapping during anterograde conduction over the type 1 pathway demonstrated earliest epicardial ventricular activation to occur simultaneously at the crux and the base of the aorta. The atrial insertion of the type 2 intermediate septal accessory pathway was localized to the apex of Koch's triangle in close proximity to the bundle of His. Preoperative catheter mapping revealed that earliest retrograde atrial activation occurred on the His bundle electrogram. Intraoperative mapping during anterograde conduction over the type 2 pathway demonstrated that earliest epicardial ventricular activation occurred anteriorly at the base of the aorta.Intraoperative ablation of the intermediate septal accessory pathway was accomplished by cooling the endocardium at the site of pathway insertion on the atrial side of the tricuspid anulus with a 5 mm cryoprobe. Patients with a type 1 intermediate septal accessory pathway had preservation of AV conduction, but the patient with the type 2 pathway did not and required permanent pacing. At late follow-up study, no patient has had return of intermediate septal accessory pathway conduction. Distinguishing an intermediate septal accessory pathway close to the AV node (type 1) from one close to the His bundle (type 2) is useful to predict both surgical success and success without the production of permanent complete AV block

Microplastic contamination has limited effects on coral fertilisation and larvae

Microplastics are ubiquitous throughout the world's oceans and contaminate coral reef ecosystems. There is evidence of microplastic ingestion by corals and passive contact with coral tissues, causing adverse health effects that include energy expenditure for particle removal from the tissue surface, as well as reduced growth, tissue bleaching, and necrosis. Here, it was examined whether microplastic contamination impairs the success of gamete fertilisation, embryo development and larval settlement of the reef-building coral Acropora tenuis. Coral gametes and larvae were exposed to fifteen microplastic treatments using two types of plastic: (1) weathered polypropylene particles and (2) spherical polyethylene microbeads. The treatments ranged from five to 50 polypropylene pieces L-1 and 25 to 200 microbeads L-1. Fertilisation was only negatively affected by the largest weathered microplastics (2 mm2), but the effects were not dose dependent. Embryo development and larval settlement were not significantly impacted by either microplastic type. The study shows that moderate-high levels of marine microplastic contamination, specifically particles <2 mm2, will not substantially interfere with the success of critical early life coral processes

Influence of healthy candidate bias in assessing clinical effectiveness for implantable cardioverter-defibrillators: cohort study of older patients with heart failure

Objective: To assess the potential contribution of unmeasured general health status to patient selection in assessments of the clinical effectiveness of implantable cardioverter-defibrillator (ICD) therapy. Design: Retrospective cohort study. Setting: Linked data from an ICD registry, heart failure registry, and Medicare claims data for ICDs implanted in 2005 through 2009. Participants: 29 426 patients admitted to hospital with heart failure aged 66 years or older and eligible for ICD therapy for primary prevention. Main outcome measures Non-traumatic hip fracture, admission to a skilled nursing facility, and 30 day mortality—outcomes unlikely to be improved by ICD therapy. Results: Compared with 17 853 patients without ICD therapy, 11 573 patients with ICD therapy were younger and had lower ejection fraction and more cardiac admissions to hospital but fewer non-cardiac admissions to hospital and comorbid conditions. Patients with ICD therapy had greater freedom from unrelated events after adjusting for age and sex: hip fracture (hazard ratio 0.77, 95% confidence interval 0.64 to 0.92), skilled nursing facility admission (0.53, 0.50 to 0.55), and 30 day mortality (0.12, 0.10 to 0.15). Conclusions: Lower risks of measured outcomes likely reflect unmeasured differences in comorbidity and frailty. The findings highlight potential pitfalls of observational comparative effectiveness research and support physician consideration of general health status in selecting patients for ICD therapy

In-hospital versus out-of-hospital presentation of life-threatening ventricular arrhythmias predicts survival Results from the AVID registry

AbstractOBJECTIVESThis study describes the outcomes of patients from the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study Registry to determine how the location of ventricular arrhythmia presentation influences survival.BACKGROUNDMost studies of cardiac arrest report outcome following out-of-hospital resuscitation. In contrast, there are minimal data on long-term outcome following in-hospital cardiac arrest.METHODSThe AVID Study was a multicenter, randomized comparison of drug and defibrillator strategies to treat life-threatening ventricular arrhythmias. A Registry was maintained of all patients with sustained ventricular arrhythmias at each study site. The present study includes patients who had AVID-eligible arrhythmias, both randomized and not randomized. Patients with in-hospital and out-of-hospital presentations are compared. Data on long-term mortality were obtained through the National Death Index.RESULTSThe unadjusted mortality rates at one- and two-year follow-ups were 23% and 31.1% for patients with in-hospital presentations, and 10.5% and 16.8% for those with out-of-hospital presentations (p < 0.001), respectively. The adjusted mortality rates at one- and two-year follow-ups were 14.8% and 20.9% for patients with in-hospital presentations, and 8.4% and 14.1% for those with out-of-hospital presentations (p < 0.001), respectively. The adjusted long-term relative risk for in-hospital versus out-of-hospital presentation was 1.6 (95% confidence interval [CI] 1.3–1.9).CONCLUSIONSCompared with patients with out-of-hospital presentations of life-threatening ventricular arrhythmias not due to a reversible cause, patients with in-hospital presentations have a worse long-term prognosis. Because location of ventricular arrhythmia presentation is an independent predictor of long-term outcome, it should be considered as an element of risk stratification and when planning clinical trials

Henipavirus Infection in Fruit Bats (Pteropus giganteus), India

We tested 41 bats for antibodies against Nipah and Hendra viruses to determine whether henipaviruses circulate in pteropid fruit bats (Pteropus giganteus) in northern India. Twenty bats were seropositive for Nipah virus, which suggests circulation in this species, thereby extending the known distribution of henipaviruses in Asia westward by >1,000 km

Hijacking ZIP codes: posttanscriptional regulation of CCN2 by nucleophosmin

CCN2 (connective tissue growth factor [CTGF]/hypertrophic chondrocyte-specific gene product 24 [Hcs24]) is regulated at the transcriptional and posttranscriptional level. For example, an element in the its 3′ untranslated region (3′-UTR) of the CCN2 mRNA controls message stability in chondrocytes. In a recent study, Mukudai et al. (Mol Cell Biol 28:6134-6147, 2008) purified and identified a trans-factor protein binding to the minimal repressive cis element in the 3′-UTR of ccn2 mRNA and identify this protein as the multifunctional nucleolar phosphoprotein nucleophosmin (NPM) This commentary summarizes these observations

The Disconnect Between the Guidelines, the Appropriate Use Criteria, and Reimbursement Coverage Decisions The Ultimate Dilemma

Recently, the American College of Cardiology Foundation in collaboration with the Heart Rhythm Society published appropriate use criteria (AUC) for implantable cardioverter-defibrillators and cardiac resynchronization therapy. These criteria were developed to critically review clinical situations that may warrant implantation of an implantable cardioverter-defibrillator or cardiac resynchronization therapy device, and were based on a synthesis of practice guidelines and practical experience from a diverse group of clinicians. When the AUC was drafted, the writing committee recognized that some of the scenarios that were deemed “appropriate” or “may be appropriate” were discordant with the clinical requirements of many payers, including the Medicare National Coverage Determination (NCD). To charge Medicare for a procedure that is not covered by the NCD may be construed as fraud. Discordance between the guidelines, the AUC, and the NCD places clinicians in the difficult dilemma of trying to do the “right thing” for their patients, while recognizing that the “right thing” may not be covered by the payer or insurer. This commentary addresses these issues. Options for reconciling this disconnect are discussed, and recommendations to help clinicians provide the best care for their patients are offered