Acute coronary syndrome in patients younger than 30 years--aetiologies, baseline characteristics and long-term clinical outcome

BACKGROUND Coronary atherosclerosis begins early in life, but acute coronary syndromes in adults aged <30 years are exceptional. We aimed to investigate the rate of occurrence, clinical and angiographic characteristics, and long-term clinical outcome of acute coronary syndrome (ACS) in young patients who were referred to two Swiss hospitals. METHODS From 1994 to 2010, data on all patients with ACS aged <30 years were retrospectively retrieved from our database and the patients were contacted by phone or physician's visit. Baseline, lesion and procedural characteristics, and clinical outcome were compared between patients in whom an underlying atypical aetiology was found (non-ATS group; ATS: atherosclerosis) and patients in whom no such aetiology was detected (ATS group). The clinical endpoint was freedom from any major adverse cardiac event (MACE) during follow-up. RESULTS A total of 27 young patients with ACS aged <30 years were admitted during the study period. They accounted for 0.05% of all coronary angiograms performed. Mean patient age was 26.8 ± 3.5 years and 22 patients (81%) were men. Current smoking (81%) and dyslipidaemia (59%) were the most frequent risk factors. Typical chest pain (n = 23; 85%) and ST-segment elevation myocardial infarction (STEMI; n = 18 [67%]) were most often found. The ATS group consisted of 17 patients (63%) and the non-ATS group of 10 patients (37%). Hereditary thrombophilia was the most frequently encountered atypical aetiology (n = 4; 15%). At 5 years, mortality and MACE rate were 7% and 19%, respectively. CONCLUSION ACS in young patients is an uncommon condition with a variety of possible aetiologies and distinct risk factors. In-hospital and 5-year clinical outcome is satisfactory.

Pattern and timing of the coronary sinus activation to guide rapid diagnosis of atrial tachycardia after atrial fibrillation ablation

BACKGROUND Atrial tachycardias (AT) during or after ablation of atrial fibrillation frequently pose a diagnostic challenge. We hypothesized that both the patterns and the timing of coronary sinus (CS) activation could facilitate AT mapping. METHODS AND RESULTS A total of 140 consecutive postpersistent atrial fibrillation ablation patients with sustained AT were investigated by conventional mapping. CS activation pattern was defined as chevron or reverse chevron when the activations recorded on both the proximal and the distal CS dipoles were latest or earliest, respectively. The local activation of mid-CS was timed with reference to Ppeak-Ppeak (P-P) interval in lead V1. A ratio, mid-CS activation time to AT cycle length, was computed. Of 223 diagnosed ATs, 124 were macroreentrant (56%) and 99 were centrifugal (44%). When CS activation was chevron/reverse chevron (n=44; 20%), macroreentries were mostly roof dependent. With reference to P-P interval, mid-CS activation timing showed specific consistency for peritricuspid and perimitral AT. Proximal to distal CS activation pattern and mid-CS activation at 50% to 70% of the P-P interval (n=30; 13%) diagnosed peritricuspid AT with 81% sensitivity and 89% specificity. Distal to proximal CS activation and mid-CS activation at 10% to 40% of the P-P interval (n=44; 20%) diagnosed perimitral AT with 88% sensitivity and 75% specificity. CONCLUSIONS The analysis of the patterns and timing of CS activation provides a rapid stratification of most likely macroreentrant ATs and points toward the likely origin of centrifugal ATs. It can be included in a stepwise diagnostic approach to rapidly select the most critical mapping maneuvers.

Prognostic role of subsequent atrial tachycardias occurring during ablation of persistent atrial fibrillation: a prospective randomized trial

BACKGROUND The role of subsequent atrial tachycardias (AT) in the context of persistent atrial fibrillation (AF) remains undetermined. This study evaluated the prognostic role of subsequent ATs for arrhythmia recurrences after catheter ablation of persistent AF. METHODS AND RESULTS A total of 110 patients with persistent AF (63±9 years; 22 women; 61 long-lasting persistent AF) underwent pulmonary vein isolation followed by electrogram-guided ablation. After AF terminated to AT, patients were separated by the randomization protocol to receive either direct cardioversion (group A) or further ablation of subsequent ATs to sinus rhythm (group B). After a mean follow-up of 20.1±13.3 months after the first procedure, significantly more group B patients were in sinus rhythm as compared with patients in group A (30 [57%] versus 18 [34%]; P=0.02). Moreover, recurrences of AF were significantly less frequent of group B than in group A patients (10 [19%] versus 26 [49%]; P=0.001). After the last procedure (follow-up, 34.0±6.4 months), significantly more group B patients were free of AF as compared with patients of group A (49 [92%] versus 39 [74%]; P=0.01). The proportion of AT recurrences did not differ between the 2 groups after the first and final procedures. The strongest predictor for an arrhythmia-free survival after a single procedure was randomization to the procedural end point of termination to sinus rhythm by elimination of subsequent ATs (P=0.004). CONCLUSIONS Catheter ablation of subsequent ATs increases freedom from AF but not AT, suggesting a contributing role of subsequent ATs in the mechanisms of persistent AF. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01896570.

Validation of multiple-breath washout equipment for infants and young children.

INTRODUCTION The new ATS/ERS consensus report recommends in vitro validation of multiple-breath inert gas washout (MBW) equipment based on a lung model with simulated physiologic conditions. We aimed to assess accuracy of two MBW setups for infants and young children using this model, and to compare functional residual capacity (FRC) from helium MBW (FRCMBW ) with FRC from plethysmography (FRCpleth ) in vivo. METHODS The MBW setups were based on ultrasonic flow meter technology. Sulfur hexafluoride and helium were used as tracer gases. We measured FRC in vitro for specific model settings with and without carbon dioxide and calculated differences of measured to generated FRC. For in vivo evaluation, difference between FRCMBW and FRCpleth was calculated in 20 healthy children, median age 6.1 years. Coefficient of variation (CV) was calculated per FRC. RESULTS In the infant model (51 runs, FRC 80-300 ml), mean (SD) relative difference between generated and measured FRCs was 0.7 (4.7) %, median CV was 4.4% for measured FRCs. In the young child model, one setting (8 runs, FRC 400 ml) showed a relative difference of up to 13%. For the remaining FRCs (42 runs, FRC 600-1,400 ml), mean (SD) relative difference was -2.0 (3.4) %; median CV was 1.4% for measured FRCs. In vivo FRCpleth exceeded FRCMBW values by 37% on average. CONCLUSIONS Both setups measure lung volumes in the intended age group reliably and reproducibly. Characteristics of different techniques should be considered when measuring lung volumes in vivo. Pediatr Pulmonol. © 2014 Wiley Periodicals, Inc.

Functional architecture of mammalian horizontal cells

In the rabbit retina, there are two kinds of horizontal cells (HCs). The A-type HC is a large axonless cell which contacts cones exclusively. The B-type HC is an axon bearing cell. While the somatic dendrites of B-type HCs also contact cones, the axon expands into an elaborately branched structure, the axon terminal (AT), which contacts a large number of rods. It is difficult to label the different HCs selectively by immunochemical methods. Therefore, we developed dye injection methods to label each type of HC. Then it was possible, (1) to describe the detailed structure of the AT (2) to identify the glutamate receptors mediating cone input to A and B-type HCs and rod input to ATs and (3) to test the hypothesis that the B-type HCs are coupled via Cx57 gap junctions. ^ To obtain well filled examples of single HCs, it was necessary to block gap junction coupling to stop the spread of Neurobiotin through the network. We used dye coupling in A-type HCs to screen a series of potential gap junction antagonists. One of these compounds, meclofenamic acid (MFA), was potent, water soluble and easily reversible. This compound may be a useful tool to manipulate gap junction coupling. ^ In the presence of MFA, Neurobiotin passed down the axon of B-type HCs to reveal the detailed structure of the AT. We observed that only one AT ending entered each rod spherule invagination. This observation was confirmed by calculation and two dye injections. ^ Glutamate is the neurotransmitter used by both rods and cones. AMPA receptors were colocalized with the dendrites of A and B-type HCs at each cone pedicle. In addition, AMPA receptors were located on the AT ending at each rod spherule. Thus rod and cone input to HCs is mediated by AMPA receptors. ^ A-type and B-type HCs may express different connexins because they have different dye-coupling properties. Recently, we found that connexin50 (Cx50) is expressed by A-type HCs. B-type HCs and B-type ATs are also independently coupled. Cx57 was expressed in the OPL and double label studies showed that Cx 57 was colocalized with the AT matrix but not with the somatic dendrites of B-type HCs. ^ In summary, we have identified a useful gap junction antagonist, MFA. There is one AT ending at each rod spherule, rods inputs to ATs is mediated by AMPA receptors and coupling in the AT matrix is mediated by Cx57. This confirms that HCs with different properties use distinct connexins. The properties of ATs described in this research are consistent. The connections and properties reported here suggest that ATs functions as rod HCs and provide a negative feedback signal to rods. ^

Composite depth scale, tie points and magnetic susceptibilities of ODP Site 178-1098 sediments

Multiple holes were cored at Ocean Drilling Program Leg 178 Sites 1098 and 1099 in two subbasins of the Palmer Deep in order to recover complete and continuous records of sedimentation. By correlating measured properties of cores from different holes at a site, we have established a common depth scale, referred to as the meters composite depth scale (mcd), for all cores from Site 1098. For Site 1098, distinct similarities in the magnetic susceptibility records obtained from three holes provide tight constraints on between-hole correlation. Additional constraints come from lithologic features. Specific intervals from other data sets, particularly gamma-ray attenuation bulk density, magnetic intensity, and color reflectance, contain distinctive anomalies that correlate well when placed into the preferred composite depth scale, confirming that the scale is accurate. Coring in two holes at Site 1099 provides only a few meters of overlap. None of the data sets within this limited overlap region provide convincing correlations. Thus, the preferred composite depth scale for Site 1099 is the existing depth scale in meters below seafloor (mbsf).

Neogene diatoms from the western Antarctic Peninsula

During Ocean Drilling Program Leg 178 we cored nine sites on the continental rise (Sites 1095, 1096, and 1101), continental shelf (Sites 1097, 1100, 1102, and 1103), and in an inner shelf basin, Palmer Deep (Sites 1098 and 1099), along the Pacific margin of the Antarctic Peninsula. Fossil diatoms are a key group that provides age constraint for these shelf site sediments to allow reconstruction of Antarctic Peninsula glacial history. This paper provides the systematic paleontology of diatoms applied in biostratigraphic and paleoceanographic studies and includes a total of 33 plates. Taxonomic confusion in previous reports, including biostratigraphically useful species such as Thalassiosira inura and Thalassiosira complicata, is discussed. These systematics and taxonomic discussions help to provide a reference for Neogene diatoms in the Southern Ocean.

Opal concentration of ODP Leg 178 holes

Neogene to Quaternary records of biogenic opal contents and opal accumulation rates are presented for Sites 1095, 1096, and 1101, which were drilled during Ocean Drilling Program Leg 178 in the Bellingshausen Sea, a marginal sea in the eastern Pacific sector of the Southern Ocean. The opal records in the drift sediments on the continental rise west of the Antarctic Peninsula provide signals of paleoproductivity, although they are influenced by dissolution in the water column and the sediment column. Opal contents at Sites 1095, 1096, and 1101 show similar long-term trends through the Neogene and Quaternary, whereas the opal accumulation rates exhibit marked discrepancies, which are caused by local differences in opal preservation linked to local variations of bottom current-induced supply of lithogenic detritus. We used a regression describing the relationship between opal preservation and sedimentation rate to extract the signal of primary opal deposition on the seafloor in the Bellingshausen Sea from the opal accumulation in the drift deposits. On long-term timescales, the reconstructed opal depositional rates show patterns similar to those of the opal contents and a much better coherency between the different locations on the Antarctic Peninsula continental rise. Therefore, the estimated opal depositional rates are suggested to represent a suitable proxy for paleoproductivity in the drift setting of the Bellingshausen Sea. Supposing that the sea-ice coverage within the Antarctic Zone was the main factor controlling biological productivity in the Bellingshausen Sea, and thus the estimated opal depositional rates on the continental rise, we reconstructed paleoceanographic long-term changes during the Neogene and Quaternary considering the climatic control on regional and global scales. Slightly enhanced opal depositional rates during the late Miocene are interpreted to indicate warmer climatic conditions in the vicinity of the Antarctic Peninsula than at present. The contribution of heat from the Northern Component Water (NCW) into the Southern Ocean seems only to have played a subordinate role during that time. High opal depositional rates during the early Pliocene document a strong reduction of sea-ice coverage and relatively warm climatic conditions in the Bellingshausen Sea. The early onset of the Pliocene warmth points to a positive feedback of regional Antarctic climate on the global thermohaline circulation. A decrease of opal deposition between 3.1 and 1.8 Ma likely reflects sea-ice expansion in response to reduced NCW flow, caused by the onset and intensification of Northern Hemisphere glaciation. Throughout the Quaternary, a relatively constant level of opal depositional rates in the Bellingshausen Sea indicates stable climatic conditions in the Antarctic Peninsula area.

Grain size analyses of ODP Leg 178 sites

Sites 1095, 1096, and 1101 were drilled on the continental rise west of the Antarctic Peninsula (Fig. F1) to recover a continuous high-resolution record of Antarctic glaciation. Site 1095 is the subject of a short paper in this volume (Pudsey, 2001, doi:10.2973/odp.proc.sr.178.214.2001), whereas mass accumulation rates at the three sites are described by Wolf-Welling (2001, doi:10.2973/odp.proc.sr.178.223.2001) and ice-rafted debris at Site 1101 is discussed by Cowan (2001, doi:10.2973/odp.proc.sr.178.206.2001) This report documents grain-size data (sand and fine fraction) and the proportion of biogenic silica for the upper 300 m at Site 1095, the upper 250 m at Site 1096, and the whole 220 m at Site 1101.