Masashi Kamioka

One-Year Clinical Outcome After Pulmonary Vein Isolation Using the Second-Generation 28-mm Cryoballoon

Background—The use of second-generation cryoballoon for pulmonary vein isolation in patients with paroxysmal atrial fibrillation has demonstrated encouraging acute and mid-term results. Long-term outcome data are not yet available. Methods and Results—Fifty patients (18 women; mean age, 61±11 years; mean left atrial diameter, 43±5 mm) with paroxysmal (36 of 50 patients; 72%) or short-standing (<3-month duration) persistent atrial fibrillation (14 of 50 patients; 28%) underwent cryoballoon-based pulmonary vein isolation. Freeze cycle duration was 240 seconds. After successful pulmonary vein isolation, a bonus freeze was applied. Follow-up was based on outpatient clinic visits at 3, 6, and 12 months including Holter-ECGs and telephonic interviews. Recurrence was defined as a symptomatic or documented arrhythmia episode >30 seconds excluding a 3-month blanking period. A total of 192 pulmonary veins were identified, and 191 of 192 (99%) pulmonary veins were successfully isolated. Phrenic nerve palsy occurred in 1 of 50 (2%) patients. Follow-up was available for 49 of 50 (98%) patients with a mean follow-up duration of 440±39 days. Thirty-nine of 49 (80%) patients remained in stable sinus rhythm. Of 8 of 10 patients with arrhythmia recurrence, a second procedure using radiofrequency ablation demonstrated left atrial to pulmonary vein reconduction. Conclusions—The use of second-generation 28-mm cryoballoon for pulmonary vein isolation results in an 80% 1-year success rate.

LOX-1-MT1-MMP axis is crucial for RhoA and Rac1 activation induced by oxidized low-density lipoprotein in endothelial cells

AIMS RhoA and Rac1 activation plays a key role in endothelial dysfunction. Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is a major receptor for oxidized low-density lipoprotein (ox-LDL) in endothelial cells (ECs). Membrane type 1 matrix metalloproteinase (MT1-MMP) has been shown to be involved in atherogenesis. This study was conducted to investigate the role of the LOX-1-MT1-MMP axis in RhoA and Rac1 activation in response to ox-LDL in ECs. METHODS AND RESULTS Ox-LDL induced rapid RhoA and Rac1 activation as well as MT1-MMP activity in cultured human aortic ECs. Inhibition of LOX-1 prevented ox-LDL-dependent RhoA and Rac1 activation. Knockdown of MT1-MMP by small interfering RNA prevented ox-LDL-induced RhoA and Rac1 activation, indicating that MT1-MMP is upstream of RhoA and Rac1. Fluorescent immunostaining revealed the colocalization of LOX-1 and MT1-MMP, and the formation of a complex of LOX-1 with MT1-MMP was detected by immunoprecipitation. Blockade of LOX-1 or MT1-MMP prevented RhoA-dependent endothelial NO synthase protein downregulation and cell invasion, Rac1-mediated NADPH oxidase activity, and reactive oxygen species generation. CONCLUSION The present study provides evidence that the LOX-1-MT1-MMP axis plays a crucial role in RhoA and Rac1 activation signalling pathways in ox-LDL stimulation, suggesting that this axis may be a promising target for treating endothelial dysfunction.

Role of LOX‐1 in monocyte adhesion‐triggered redox, Akt/eNOS and Ca2+ signaling pathways in endothelial cells

This study was conducted to examine the role of lectin‐like oxidized low‐density lipoprotein receptor‐1 (LOX‐1) in monocyte adhesion‐induced redox‐sensitive, Akt/eNOS and Ca2+ signaling pathways in endothelial cells (ECs). LOX‐1 was blocked by an antibody‐neutralizing LOX‐1 TS92 or small interfering RNA. In cultured human aortic ECs, monocyte adhesion activated Rac1 and p47phox, and increased NADPH oxidase activity and reactive oxygen species (ROS) generation within 30 min and NF‐κB phosphorylation within 1 h, resulting in redox‐sensitive gene expression. Akt and eNOS phosphorylation was induced 15 min after adding monocytes and returned to control level after 30 min, whereas NO production was not altered by monocyte adhesion. Blockade of LOX‐1 blunted the monocyte adhesion‐triggered redox‐sensitive signaling pathway and Akt/eNOS phosphorylation in ECs. Both endothelial intracellular Ca2+ mobilization and Ca2+ influx caused by monocyte attachment were markedly attenuated by pretreatment of ECs with TS92. This suggests that LOX‐1 is involved in redox‐sensitive, Akt/eNOS and Ca2+ signaling pathways in monocyte adhesion to ECs independent of oxidized low‐density lipoprotein (ox‐LDL). Furthermore, blockade of Ca2+ inhibited monocyte adhesion‐triggered Rac1 and p47phox activation and ROS generation in ECs, whereas Ca2+ signaling was suppressed by blockade of NADPH oxidase and ROS generation. Finally, TS92 blocked the monocyte adhesion to ECs stimulated with or without tumor necrosis factor‐α or ox‐LDL. We provide evidence that LOX‐1 plays a role in redox‐sensitive, Akt/eNOS and Ca2+ signaling pathways in monocyte adhesion to ECs independent of the ox‐LDL–LOX‐1 axis. J. Cell. Physiol. 220: 706–715, 2009.

Thrombin-induced Rapid Geranylgeranylation of RhoA as an Essential Process for RhoA Activation in Endothelial Cells

RhoA plays a critical signaling role in thrombin-induced endothelial dysfunction. The possible thrombin regulation of geranylgeranylation, a lipid modification, of unprocessed RhoA and the significance of the geranylgeranylation in RhoA activation in endothelial cells (ECs) are not well understood. The amounts of the unprocessed and geranylgeranylated forms of RhoA in non-stimulated cultured human aortic ECs were 31 ± 8 and 69 ± 8% total cellular RhoA, respectively (n = 6, p < 0.0001), as determined by the Triton X-114 partition method. Thrombin-induced rapid conversion of most of the unprocessed RhoA into the geranylgeranylated form within 1 min through stimulating geranylgeranyltransferase I (GGTase I) activity. Thrombin-induced rapid geranylgeranylation was inhibited by acute short term (3 min) pretreatment with atorvastatin as well as by an inhibitor of GGTase I (GGTI-286). Thrombin also rapidly stimulated GTP loading of RhoA, which was blocked by acute pretreatment with either atorvastatin or GGTI-286. These observations indicate the dependence of thrombin stimulation of RhoA on the rapid geranylgeranylation of unprocessed RhoA. Importantly, the addition of geranylgeranylpyrophosphate to ECs pretreated with atorvastatin quickly reversed the atorvastatin inhibition of thrombin stimulation of RhoA. These results suggest that geranylgeranylation of unprocessed RhoA may limit thrombin-induced full activation of RhoA in ECs. Cytoskeleton analysis demonstrated that atorvastatin and GGTI-286 inhibited thrombin-induced stress fiber formation. We provide the evidence that, in thrombin-stimulated ECs, the unprocessed form of RhoA is rapidly geranylgeranylated to become the mature form, which then is converted into GTP-bound active RhoA.

Ventricular Arrhythmias Arising from the Left Ventricular Outflow Tract below the Aortic Sinus Cusps: Mapping and Catheter Ablation via Transseptal Approach and Electrocardiographic Characteristics

Background—Ventricular arrhythmias (VAs) originating from the anterosuperior left ventricular outflow tract (LVOT) represent a challenging location for catheter ablation. This study investigates mapping and ablation of VA from anterosuperior LVOT via a transseptal approach. Methods and Results—This study included 27 patients with symptomatic VA, of which 13 patients had previous failed ablations. LVOT endocardial 3-dimensional mapping via retrograde transaortic and antegrade transseptal approaches was performed. Previous ECG markers for procedure failure were analyzed. In all patients, earliest activation with low-amplitude potentials was identified at the anterosuperior LVOT 5.1±2.8 mm below the aortic cusp and preceded the QRS onset by 39.5±7.7 ms only via an antegrade transseptal approach using a reversed S curve. In all patients, pace mapping failed to demonstrate perfect QRS morphology match. The anatomic location was below the left coronary cusp in 16, below the left coronary cusp/right coronary cusp junction in 8, and below the right coronary cusp in 3 patients. Radiofrequency energy resulted in rapid disappearance of VAs in all patients. ECG analysis showed aVL/aVR Q-wave amplitude ratio >1.4 in 7, lead III/II R-wave amplitude ratio >1.1 in 10, and peak deflection index >0.6 in 11 patients. There were no complications or clinical VA recurrence during a mean follow-up of 8.4±2.5 months. Conclusions—The anterosuperior LVOT can be reached via a transseptal approach with a reversed S curve of the ablation catheter. The rapid effect from radiofrequency energy indicates that the VA is most likely located under the endocardium. Also, previous ECG markers for procedure failure need further investigation.

In vivo left-ventricular contact force analysis: comparison of antegrade transseptal with retrograde transaortic mapping strategies and correlation of impedance and electrical amplitude with contact force

Aims Clinical outcomes following radiofrequency ablation of ventricular tachycardias (VTs) depend on catheter tip-to-tissue contact force (CF). Left-ventricular (LV) mapping is performed via antegrade-transseptal or retrograde-transaortic approaches, and the applied CF may depend on the approach used. This study evaluated (i) the impact of antegrade-transseptal vs. retrograde-transaortic LV-mapping approaches on CF and catheter stability and (ii) the clinical value of the commonly used surrogate markers of catheter–myocardial contact—impedance, unipolar, and bipolar electrogram amplitudes. Methods and results An antegrade-transseptal and a retrograde-transaortic LV-mapping approach was performed in 10 patients undergoing VT ablation by using CF-sensing catheters. Operators were blinded to CF data and data were analysed according to 11 predefined LV segments. Three thousand three hundred and twenty-four mapping points (1577 antegrade, 1747 retrograde) were analysed, including 80 (2.4%) points with maximum CF > 100 g. Median antegrade and retrograde CF were 16.0 g (q1–q3; 8.4–26.2) and 15.3 g (9.8–23.4), respectively. Contact force was significantly higher antegradely in mid-anteroseptum, mid-lateral, and apical segments, and significantly higher retrogradely in basal-anteroseptum, basal-inferoseptum, basal-inferior, and basal-lateral segments. Contact force did correlate with impedance, unipolar, and bipolar electrogram amplitudes; however, there were large overlaps. Conclusions Antegrade vs. retrograde LV-mapping approaches result in different CF. A combined approach to the LV mapping may improve the overall LV mapping, potentially resulting in better clinical outcomes for the left VT catheter ablation. The previous surrogate markers used to assess CF do correlate with in vivo CF; however, due to a larger overlap, their clinical value is limited.

In Vivo Contact Force Analysis and Correlation With Tissue Impedance During Left Atrial Mapping and Catheter Ablation of Atrial Fibrillation

Background—The aim of this study was to evaluate in vivo contact force (CF) and the correlation of CF with impedance during left atrial 3-dimensional electroanatomical mapping and ablation. Methods and Results—CF during point-by-point left atrial mapping was assessed in 30 patients undergoing atrial fibrillation ablation. Operators were blinded to the real-time CF data. Data were analyzed according to 11 predefined areas in the left atrial and 6 segments around the ipsilateral pulmonary veins. A total of 3475 mapping and 878 ablation points were analyzed. Median CF during mapping was 14.0g (6.5–26.2; q1–q3), ranging from 5.1g at the ridge to 29.8g at the roof. Median CF at the ridge and mitral isthmus were 5.1g and 6.9g, respectively. Extremely high CF ≥100g was noted in 24 points (0.7%). Median CFs during ablation around the right and left pulmonary veins were 22.8g (12.6–37.9; q1–q3) and 12.3g (6.9–30.2; q1–q3), respectively. The lowest median CFs were recorded at the anterior–superior and anterior–inferior segments of the left pulmonary veins (7.2g and 7.9g). Impedance values during mapping and impedance fall during ablation correlated with the applied CF (R2=0.16; P<0.001 and R2=0.04; P<0.001) although there was significant overlap. Conclusions—Excessively high and low CF values can be observed during left atrial mapping and ablation. The low CF obtained at the mitral isthmus and anterior segments of the left pulmonary veins may explain why reconnection after ablation occurs more frequently at these sites. CF and impedance do correlate; however, the impedance for a given CF ranges widely, limiting its use in clinical practice.

Endogenous NO Blockade Enhances Tissue Factor Expression via Increased Ca2+ Influx Through MCP-1 in Endothelial Cells by Monocyte Adhesion

Objective—Ca2+ plays an important role in tissue factor (TF) gene expression. We investigated the role of endogenous nitric oxide (NO) in the induction of TF expression in endothelial cells (ECs) by monocyte adhesion and the mechanisms of NO action. Methods and Results—Inhibition of endogenous NO by N&ohgr;-nitro-l-arginine methyl ester (l-NAME) enhanced TF promoter activity and protein expression induced in human coronary ECs by monocyte adhesion, as well as EC surface TF activity. l-NAME also induced monocyte chemoattractant protein-1 (MCP-1) expression, which was blocked by an NO donor, NOC18. Exogenous MCP-1 enhanced TF expression induced by monocyte adhesion, whereas adenovirus-mediated expression of the mutant MCP-1, 7ND, abolished the l-NAME enhancement of TF expression induced by monocyte adhesion. Monocyte attachment to l-NAME–treated ECs increased Ca2+ influx, which was prevented by NOC18, anti–MCP-1 antibody or 7ND. These results indicate that the binding of increased MCP-1 induced by endogenous NO blockade to CCR2 mediated the enhancement of Ca2+ influx only when monocytes adhered to ECs, which upregulated TF expression in ECs triggered by monocyte adhesion. Conclusion—MCP-1/CCR2 may play a role in Ca2+ influx-dependent TF regulation in the monocyte–EC interaction in the impairment of NO synthesis.

Modified energy settings are mandatory to minimize oesophageal injury using the novel multipolar irrigated radiofrequency ablation catheter for pulmonary vein isolation.

AIMS The multipolar irrigated radiofrequency (RF) ablation catheter (nMARQ™) is a novel tool for pulmonary vein isolation (PVI). We investigated the incidence of thermal oesophageal injury (EI) using the nMARQ™ for PVI. METHODS AND RESULTS In the initial six patients (Group 1), RF was delivered at the posterior wall with a maximum duration of 60 s and a maximum power (maxP) of 20 W for unipolar ablation, and a maxP of 10 W for the bipolar ablation. In the latter 15 patients (Group 2), RF application was limited at the posterior wall to a maximum duration of 30 s and a maxP of 15 W for unipolar ablation a max P of 10 W for bipolar ablation. Oesophageal temperature monitoring was performed in all patients and ablation was terminated at a temperature rise >41°C. Endoscopy was carried out within 2 days post-ablation. Pulmonary vein isolation was performed during sinus rhythm and was successfully achieved in 83 of 84 PVs except the septal inferior vein in one patient. Charring was seen in 3 of 21 (14.3%) patients without any evidence of embolism. Phrenic nerve palsy occurred in one patient. Endoscopy revealed severe EI in 3 of 6 (50%) patients in Group 1 and in 1 of 15 patients (6.7%) in Group 2. Procedure times between Groups 1 and 2 were similar (228.3 ± 60.2 min vs. 221.3 ± 51.8 min; P = 0.79). CONCLUSION An unexpectedly high incidence of thermal EI was noted following PVI using the nMARQ™ with the initial ablation protocol. However, the incidence of thermal EI can be sigificantly reduced with limited power and RF application time at the posterior left atrium.

Adaptive servo ventilation improves Cheyne-Stokes respiration, cardiac function, and prognosis in chronic heart failure patients with cardiac resynchronization therapy

BACKGROUND Cheyne-Stokes respiration (CSR-CSA) is often observed in patients with chronic heart failure (CHF). Although cardiac resynchronization therapy (CRT) is effective for CHF patients with left ventricular dyssynchrony, it is still unclear whether adaptive servo ventilation (ASV) improves cardiac function and prognosis of CHF patients with CSR-CSA after CRT. METHODS AND RESULTS Twenty two patients with CHF and CSR-CSA after CRT defibrillator (CRTD) implantation were enrolled in the present study and randomly assigned into two groups: 11 patients treated with ASV (ASV group) and 11 patients treated without ASV (non-ASV group). Measurement of plasma B-type natriuretic peptide (BNP) levels (before 3, and 6 months later) and echocardiography (before and 6 months) were performed in each group. Patients were followed up to register cardiac events (cardiac death and re-hospitalization) after discharge. In the ASV group, indices for apnea-hypopnea, central apnea, and oxyhemoglobin saturation were improved on ASV. BNP levels, cardiac systolic and diastolic function were improved with ASV treatment for 6 months. Importantly, the event-free rate was significantly higher in the ASV group than in the non-ASV group. CONCLUSIONS ASV improves CSR-CSA, cardiac function, and prognosis in CHF patients with CRTD. Patients with CSR-CSA and post CRTD implantation would get benefits by treatment with ASV.