Michael C. Chin

Effects of long-term right ventricular apical pacing on left ventricular perfusion, innervation, function and histology

OBJECTIVES The purpose of this study was to better understand the effects of long-term right ventricular pacing on left ventricular perfusion, innervation, function and histology. BACKGROUND Long-term right ventricular apical pacing is associated with increased congestive heart failure and mortality compared with atrial pacing. The exact mechanism for these changes is unknown. In this study, left ventricular perfusion, sympathetic innervation, function and histologic appearance after long-term pacing were studied in dogs in an attempt to see whether basic changes might be present that might ultimately be associated with the adverse clinical outcome. METHODS A total of 24 dogs were studied. Sixteen underwent radiofrequency ablation of the atrioventricular (AV) junction to produce complete AV block. Seven of these underwent long-term pacing from the right ventricular apex (ventricular paced group), and nine had atrial and right ventricular apical pacing with AV synchrony (dual-chamber paced group). A control group of eight dogs had sham ablations with normal AV conduction. These dogs had atrial pacing only. Regional perfusion and sympathetic innervation were studied in all dogs by imaging with thallium-201 and [I123]metaiodobenzylguanidine, respectively. The degree of innervation was also determined by assay of tissue norepinephrine levels. Left ventricular function was assessed by radionuclide ventriculography. Cardiac histology was studied with both light and electron microscopy. RESULTS Mismatching of perfusion and innervation in the ventricular paced group was noted, with perfusion abnormalities of both the septum and free wall. Regional [I123]metaiodobenzylguanidine distribution was homogeneous. Tissue norepinephrine levels were elevated in both the ventricular and dual-chamber paced groups compared with the control group. No light or electron microscopic findings were noted in any groups. In the dual-chamber paced group, diastolic dysfunction was noted, with normal systolic function. CONCLUSIONS Ventricular pacing resulted in regional changes in tissue perfusion and heterogeneity between perfusion and sympathetic innervation. Both ventricular and dual-chamber pacing were associated with an increase in tissue catecholamine activity. The abnormal activation of the ventricles via right ventricular apical pacing may result in multiple abnormalities of cardiac function, which may ultimately affect clinical outcome.

Radiofrequency catheter ablation: the effect of electrode size on lesion volume in vivo.

Radiofrequency current is a promising alternative to high voltage direct current defibrillator discharges for catheter ablation of arrhythmias. However, lesions produced with radiofrequency current are relatively small and use of high power is limited by the impedance rise that occurs with desiccation of tissue and coagulum formation. The effect of electrode size on radiofrequency ablation was assessed by comparing results of radiofrequency application using a standard 6 French electrode catheter (distal electrode 2 mm in length) to those using catheters modified with longer distal electrodes (3, 4, 6, 8, and 10 mm in length). Radiofrequency ablation was performed at 47 left ventricular endocardial sites in 20 anesthetized dogs. A constant power of 13.3 ± 1.3 watts at 550 kHz was applied between the distal catheter electrode and a skin electrode until a total of 500 joules had been delivered or a rise in impedance occurred. Increasing electrode length from 2 to 4 mm more than doubled lesion volume from a mean of 143 to 326 mm3 (P = 0.025). Increasing electrode length beyond 4 mm produced progressively smaller lesions (157 mm3, 155 mm3, and 67 mm3 for 6‐, 8‐, and 10‐mm electrode lengths, respectively). Impedance rise was significantly less likely with larger electrodes and took longer to occur. Increasing the size of electrodes used for radiofrequency ablation allows application of higher power without an impedance rise. Optimizing electrode size (3 or 4 mm in this study) results in larger lesions and may improve the effectiveness of radiofrequency ablation of arrhythmias.

Radiofrequency catheter ablation guided by intracardiac echocardiography.

BACKGROUND Radiofrequency catheter ablation requires precise positioning of the ablation electrode. Fluoroscopically guided catheter manipulation has limitations, and there are risks of radiation exposure. The purpose of this study was to examine the feasibility of guiding catheter ablation within the right atrium with catheter-based intracardiac echocardiography. METHODS AND RESULTS A 10F, 10-MHz intracardiac imaging catheter was used to direct an ablation electrode at four or five anatomic landmarks in the right atrium. Thirty-eight radiofrequency energy applications were performed in nine anesthetized dogs, and 38 lesions were identified on pathological examination. Lesions were created a mean of 1.9 +/- 2.1 mm from the ultrasound-guided site. Twenty-six of 38 lesions (68%) were less than 2.2 mm from the imaged site. Intracardiac echocardiography also was used to confirm stable electrode-endocardial contact in 37 energy applications (97%) and identified catheter movement in 9 energy applications (24%). Discrete lesions, microcavitations, and thrombi were observed in 13 (34%), 23 (61%), and 19 (50%) of 38 energy applications, respectively. Microcavitations predicted the appearance of thrombus. Fluoroscopy time required to create four or five lesions decreased from 23 minutes in the first study to less than 2 minutes in the last five studies. CONCLUSIONS Catheter-based intracardiac echocardiography can accurately guide catheter ablation directed at anatomic landmarks and potentially reduced ionizing radiation exposure. Intracardiac imaging can be used to confirm endocardial contact, identify electrode movement, and directly visualize lesions. Intracardiac echocardiography also can be used to identify microcavitations, which predict thrombus formation during radiofrequency energy applications.

Biophysical characteristics of radiofrequency lesion formation in vivo: Dynamics of catheter tip–tissue contact evaluated by intracardiac echocardiography

During clinical radiofrequency catheter ablation a wide range of delivered power may be necessary to achieve success despite an apparently stable catheter position on fluoroscopy. The purpose of this study was to use intracardiac echocardiography to characterize the relation between catheter tip-tissue contact and the efficiency of heating during applications of radiofrequency energy in vivo and to determine whether intracardiac echocardiography could be used prospectively to improve tissue contact. A closed-loop temperature feedback control system was used during radio-frequency applications at five anatomic regions in the right atrium of 15 anesthetized dogs to ensure achievement of a predetermined temperature (70 degrees C) at the catheter tip thermistor by automatic adjustment of delivered power (maximum 100 W). The efficiency-of-heating index was defined as the ratio of steady-state temperature (degrees Celsius) to power (watts). Two-dimensional intracardiac echocardiography was used to evaluate movement of the catheter tip relative to the endocardium. Perpendicular contact was scored as good, average, or poor and lateral catheter sliding as < 2, 2 to 5, or > 5 mm. Two groups of animals were included: group 1, in which tissue contact was guided by fluoroscopic and electrographic criteria for stability of contact, with intracardiac echocardiography used simply to observe the application; and group 2, in which tissue contact was guided by intracardiac echocardiography. Of 66 applications, 18 (27.3%) had poor perpendicular contact on echocardiography, and 12 (18.2%) demonstrated lateral sliding of > 5 mm even though they had been considered to have good tissue contact by fluoroscopic and electrographic criteria. Perpendicular catheter contact and anatomic location were shown to be independently related to the efficiency-of-heating index. Applications with good perpendicular contact had a significantly higher efficiency-of-heating index and a significantly greater lesion size than those with average or poor contact. The percentage of applications having good perpendicular tissue contact and the lesion size were significantly greater when tissue contact was guided by intracardiac echocardiography compared with fluoroscopic and electrographic guidance. This study demonstrates that variations in catheter tip-tissue contact account for differences in the efficiency of tissue heating, independently of the anatomic site of the application. Poor tissue contact was observed by intracardiac echocardiography and confirmed by indexes of tissue heating in approximately one third of radiofrequency applications despite a fluoroscopic appearance and electrographic morphologic appearance suggestive of good tissue contact. There was a significant correlation between echocardiographic evaluation of tissue contact, parameters of tissue heating (efficiency-of-heating index), and lesion size. In addition, intracardiac echocardiography could be used prospectively to improve the percentage of good contact applications and increase the lesion size.

Active compression-decompression resuscitation: A novel method of cardiopulmonary resuscitation

Chest compression is an important part of cardiopulmonary resuscitation (CPR), but it only aids circulation during a portion of the compression cycle and has been shown to only minimally increase blood flow to vital organs. The purpose of this study was to quantitate the short-term hemodynamic effects of CPR with a hand-held suction device that incorporates both active compression and decompression of the chest. The suction device was applied to the middle of the sternum and compared with standard manual CPR in eight nonventilated anesthetized dogs. Coronary perfusion pressure, systolic and diastolic aortic pressures, right atrial diastolic pressure, and the velocity time integral (an analog of cardiac output), which were obtained by means of transesophageal pulsed wave Doppler echocardiography from the main pulmonary artery, were measured every 30 seconds during CPR. Minute ventilation was measured over the last minute of each CPR technique. Both active compression-decompression CPR and standard CPR were sequentially performed for 2 minutes in random order 30 seconds after induced ventricular fibrillation. The CPR techniques consisted of 100 compressions per minute, with a compression depth of 1.5 to 2 inches and a 50% duty cycle. Coronary perfusion pressure, velocity time integral (cardiac output analog), minute ventilation, and systolic arterial pressure were all significantly improved by active compression-decompression CPR when compared with standard CPR. We conclude that active compression-decompression CPR is a simple technique that appears to improve coronary perfusion pressure, systolic arterial pressure, cardiac output, and minute ventilation in nonventilated animals when compared with standard CPR.(ABSTRACT TRUNCATED AT 250 WORDS)

Active compression-decompression. A new method of cardiopulmonary resuscitation. Cardiopulmonary Resuscitation Working Group.

OBJECTIVE To describe and compare with standard cardiopulmonary resuscitation (CPR) in humans a new form of CPR that involves both active compression and active decompression of the chest. DESIGN Patients in cardiac arrest in whom standard advanced cardiac life support failed were randomized to receive 2 minutes of either standard or active compression-decompression (ACD) CPR using a custom, hand-held suction device, followed by 2 minutes of the alternate technique. The ACD device was applied midsternum and used to perform CPR according to the guidelines of the American Heart Association: 80 compressions per minute, compression depth of 3.8 to 5 cm, 50% duty cycle, and constant-volume ventilation. Mechanical Thumper CPR was also compared in five patients. End-tidal carbon dioxide (ETCO2) concentrations and hemodynamic variables were measured. Transesophageal Doppler echocardiography was used to assess contractility, the velocity time integral (an analogue of cardiac output), and diastolic myocardial filling times. RESULTS Ten patients were enrolled. The mean +/- SD ETCO2 was 4.3 +/- 3.8 mm Hg with standard CPR and 9.0 +/- 3.9 mm Hg with ACD CPR (P less than .0001). Systolic arterial pressure with standard CPR was 52.5 +/- 14.0 mm Hg and with ACD CPR, 88.9 +/- 24.7 mm Hg (P less than .003). The velocity time integral increased from 7.3 +/- 2.6 cm with standard CPR to 17.5 +/- 5.6 cm with ACD CPR (P less than .0001), and diastolic filling times increased from 0.23 +/- .09 seconds with standard CPR to 0.37 +/- .12 seconds with ACD CPR (P less than .004). Mechanical Thumper CPR consistently underperformed both standard and ACD CPR. Minute ventilation obtained in four patients during ACD CPR without endotracheal ventilation was 6.6 +/- 0.9 L/min. After 1 hour of standard CPR failed, three of 10 patients randomized to ACD CPR rapidly converted to a hemodynamically stable rhythm following 2 minutes of ACD CPR. CONCLUSION ACD CPR is a simple manual technique that improved cardiopulmonary circulation in 10 patients during cardiac arrest. Although ACD CPR may have produced a return of spontaneous circulation in three patients refractory to standard measures, its impact on survival when used early in cardiac arrest remains to be determined.

Radiofrequency Catheter Modification of Sinus Pacemaker Function Guided by Intracardiac Echocardiography

BACKGROUND The sinus P wave arises from a pacemaker complex distributed along the crista terminalis. We investigated the feasibility of modification of sinus pacemaker function using graded applications of radiofrequency energy along the crista terminalis in dogs to achieve sinus rate control. METHODS AND RESULTS Modification of sinus pacemaker function (30 +/- 5% reduction in intrinsic heart rate with retention of a normal P-wave axis) was performed in 11 dogs (group 1). Total sinus pacemaker ablation (> 50% reduction in intrinsic heart rate with development of a low ectopic atrial or a junctional rhythm) was performed in 4 dogs (group 2). Intracardiac echocardiography was used to identify the crista terminalis as an anatomic marker of sinus node location. Sinus pacemaker modification caused a significant decrease in intrinsic heart rate (31% reduction, P < .001), heart rate responsiveness to isoproterenol (30% reduction, P < .0001), and average (20% reduction, P = .0002) and maximal (22% reduction, P = .0007) heart rates during 24-hour Holter monitoring. In 6 of the 11 animals, the targeted rate reduction of 30 +/- 5% was accurately achieved (mean, 31.6 +/- 4.3%; P < .001), and in the other 5, significant reduction of intrinsic heart rate was achieved but with greater variation (28.0 +/- 17.3%, P < .005). Corrected sinus node recovery time was not prolonged. After modification, earliest activation was mapped to the crista terminalis inferior to the lesion in all animals. In long-term follow-up (3.7 +/- 1.0 months), effects were maintained. After total sinus pacemaker ablation, junctional and low atrial escape pacemakers were unstable. CONCLUSIONS This study demonstrates the feasibility of modification of sinus pacemaker function for sinus rate control using catheter-based radiofrequency ablation guided by intracardiac echocardiography. This can be done while pacemaker stability and attenuated responsiveness to autonomic influences are preserved. Intracardiac echocardiography accurately defined the crista terminalis and provided a reliable means to anatomically localize catheter position in relation to the sinus node.

Catheter ablation of the atrioventricular junction using a helical microwave antenna: a novel means of coupling energy to the endocardium.

Catheter ablation with either direct current defibrillator discharges or radiofrequency energy produces tissue injury via current flow from an electrode into the adjacent myocardium. In order to affect tissue at a distance, excessive power density may be produced at the electrode‐tissue interface with the possibility of explosive gas formation or coagulum formation. A novel microwave catheter was developed with a helical antenna distally. This coil, although not in direct contact with the endocardium, radiates an electromagnetic field into the tissue that, in turn, causes thermal injury. The utility of this system for ablation was assessed in six dogs. The antenna catheter was introduced percutaneously and positioned so as to record the largest His electrogram. Microwave power (50 watts at 2,450 MHz) was applied for 114 ± 118 seconds. Complete AV block was produced in all six animals with 1.8 ± 1.2 applications. There was no ventricular ectopy or change in blood pressure during microwave ablation. One dog died 6 days after ablation. The remaining five dogs had persistent, complete AV block during 6 weeks of follow‐up. Pathological analysis at 6 weeks revealed a large (mean 2.8 ± 4.7 mm) fibrovascular scar in the region of the AV junction. Percutaneous microwave ablation of the endocardium appears feasible, By radiating an electromagnetic field without direct contact, this system can produce large lesions without being limited by desiccation of tissue and impedance rise.

Heterogeneous Sympathetic Innervation in German Shepherd Dogs With Inherited Ventricular Arrhythmia and Sudden Cardiac Death

BACKGROUND Recently, a colony of German shepherd dogs with inherited spontaneous cardiac arrhythmias and associated sudden death has been developed and characterized. Due to the median age of onset of the arrhythmia (4.5 months), the tendency for the arrhythmia to occur during REM sleep or after exercise, and the absence of structural heart disease, we hypothesized a developmental abnormality of the sympathetic innervation to the heart. METHODS AND RESULTS We studied 11 dogs from this colony, ranging in age from 6 months to 6 years, and four 7-month-old German shepherd dogs unrelated to the colony as controls. We imaged the distribution of functional myocardial sympathetic innervation and perfusion with [123I]metaiodobenzylguanidine (MIBG) and 201Tl, respectively. Sympathetic nerve distribution was evaluated morphologically by immunocytochemical localization of tyrosine hydroxylase. All of the hearts showed evidence of a regional decrease in MIBG uptake, ranging from 5.3% to 53.4% of the myocardium, whereas control dogs showed homogeneous MIBG uptake. Immunocytochemical studies on sections from regions with decreased MIBG uptake showed a striking paucity of nerves compared with regions with normal MIBG uptake, confirming denervation. When the dogs were grouped into those with (n=6) and without (n=5) evidence of ventricular tachycardia on ambulatory ECG, the group with ventricular tachycardia showed 35+/-16.5% denervation, whereas the group without ventricular tachycardia showed 12+/-5.6% denervation (P<.02). CONCLUSIONS Abnormal heterogeneous sympathetic innervation exists in these dogs with inherited ventricular arrhythmia and sudden cardiac death. Mechanisms relating the presence and extent of regional denervation to the incidence of ventricular arrhythmia remain to be defined.

The Effect of Radiofrequency Catheter Ablation on Permanent Pacemakers: An Experimental Study

Radiofrequency current is being investigated as an alternative to direct current shock for transcatheter abJation of cardiac arrhythmias. Permanent pacemakers are known to be susceptible to high frequency electromagnetic interference. This study was performed to examine the effects of Imnscatheter radiofrequency ablation on permanent pacemakers in a worst‐case scenario. Nineteen pulse generators representing 16 models from seven manufacturers were acutely implanted in 12 dogs to assess (heir function during and after ablation. Pulse generators were implanted subcutaneously in the neck and connected to a transvenous permanent pacing lead positioned in the right ventricular apex. A 6F quadri‐polar electrode catheter was positioned approximately 1 cm from the tip of the permanent pacing lead. Radiofrequency current from an electrosurgical unit was applied between the distal electrode of the catheter and a large diameter skin electrode placed below the left scapula. Three additional ablation sessions were performed with the catheter situated 4‐5 cm from the permanent pacing lead. Each ablation consisted of 35 W of radiofrequency power, delivered for up to 30 seconds. Twelve pulse generators were falsely inhibited during radiofrequency ablation while programmed to (he WI or DDD mode, nine of which continued to be inhibited while programmed to the VOO or DOO mode. Five pulse generators paced at abnormal rates, including three examples of one pulse generator model that displayed pacemaker runaway. Runaway was observed during eight ablations, resulting in two episodes of ventricular fibrillation. Eleven pulse generators reverted to noise mode behavior during ablation. Only three pulse generators were unaffected during ablation. No reprogramming or pacing system malfunctions were observed after cessation of radiofrequency current application or during ablations > 4 cm from the permanent lead. No changes in lead impedance, sensing, or capture threshold were observed. In conclusion, transcatheter radiofrequency ablation within close proximity of a permanent pacing lead may falsely inhibit implanted pulse generators, induce pacemaker runaway, or cause pulse generators to revert to noise mode behavior. Radiofrequency ablation performed in patients with permanent pacemakers requires careful monitoring as well as backup external pacing. A complete pacing system analysis should be performed following each ablation.