Modélisation de l’activité électrique des oreillettes avant et après ablation par cathéter

- Réalisé au centre de recherche de l'hospital du Sacré-Coeur de Montréal. - Programme conjoint entre Université de Montréal et École Polytechnique de Montréal.

Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation.

UNLABELLED Topography of the esophagus in atrial fibrillation ablation. INTRODUCTION The close anatomic relationship of the posterior wall of the left atrium (LA) and the thermosensitive esophagus creates a potential hazard in catheter ablation procedures. METHODS AND RESULTS In 30 patients (pts) with atrial fibrillation (AF) undergoing catheter ablation, we prospectively studied the course and contact of the esophagus in relation to LA and the topographic proximity to ablation lines encircling the right-sided and left-sided pulmonary veins (PV) as well as to the posterior line connecting the encircling lines using the electromagnetic mapping system for reconstruction of LA and for tagging of the esophagus. This new technique of anatomic tagging of the esophagus was validated against the CT scan as a standard imaging procedure. The esophageal course was highly variable, extending from courses in direct vicinity to the left- or right-sided PV as well as in the midportion of the posterior LA. In order to avoid energy application in direct proximity to the esophagus, adjustments of the left and right PV encircling lines were necessary in 14/30 pts (47%) and 3/30 (10%). In 30 pts (100%), the mid- to inferior areas of the posterior LA revealed contact with the esophagus. Therefore, posterior and inferior linear ablation lines were abandoned and shifted to superior in 29 pts (97%). CONCLUSIONS Anatomic tagging of esophagus revealed a highly variable proximity to different areas of the posterior LA suggesting individual adjustment of encircling and linear ablation lines in AF ablation procedures to avoid the life threatening complication of esophagus perforation.

Modélisation de l’activité électrique des oreillettes avant et après ablation par cathéter

- Réalisé au centre de recherche de l'hospital du Sacré-Coeur de Montréal. - Programme conjoint entre Université de Montréal et École Polytechnique de Montréal.

Late recurrent arrhythmias after ablation of atrial fibrillation: incidence, mechanisms, and treatment.

OBJECTIVES The aim of the study was to determine the incidence of atrial flutter and other arrhythmia recurrences (other than atrial fibrillation [AF]) during long-term follow-up after left atrial substrate modification by percutaneous radiofrequency (RF) ablation of AF. BACKGROUND RF ablation is an effective treatment for patients with AF. However, late recurrent arrhythmias may complicate the patient's course. METHODS One hundred fifty consecutive patients with paroxysmal or persistent AF were included in this prospective study. The incidence of arrhythmia recurrences after AF ablation was analyzed during long-term follow-up using repetitive 7-day ECG recording. RESULTS In 28 of 150 patients (18.7%), stable regular arrhythmias other than AF were detected during follow-up. Left atrial flutter observed in 10 patients (6.7%) was treated by recompletion of the ablation lines in all 10 patients. Left atrial flutter was associated with recurrence of AF in all 10 patients. Nine of 10 patients (90%) were free from atrial flutter and 6 of 10 patients were free from AF after the second intervention. Typical right atrial flutter occurred in 10 patients (6.7%) and was treated successfully by percutaneous RF ablation without recurrence in all patients. Additionally, atrial flutter was documented during follow-up in 7 patients (4.7%); however, invasive electrophysiologic evaluation was not performed due to various reasons. CONCLUSIONS Left atrial flutter is a relevant complication after RF catheter ablation of AF and was always associated with AF recurrence in our study population. Prevention of left atrial flutter can be achieved by induction of ablation lines as continuous and transmural as possible. However, left atrial flutter that does occur late after ablation is amenable to interventional treatment with good prospects of success.

Pulmonary Vein Isolation Versus Defragmentation: The CHASE-AF Clinical Trial

BACKGROUND Long-term success rates using ablation for persistent atrial fibrillation (AF) are disappointing and usually do not exceed 60%. OBJECTIVES This study sought to compare arrhythmia-free survival between pulmonary vein isolation (PVI) and a stepwise approach (full defrag) consisting of PVI, ablation of complex fractionated electrograms, and additional linear ablation lines in the setting of atrial tachycardias (AT) in patients with persistent AF after PVI. METHODS From November 2010 to February 2013, 205 patients (151 men; 61.7 ± 10.2 years of age) underwent de novo ablation for persistent AF. Subsequently, patients were prospectively randomized to either PVI alone (n = 78) or full defrag (n = 75), with 52 patients not randomized due to AF termination with the original PVI. The primary endpoint was recurrence of any AT after a blanking period of 3 months. RESULTS During the entire study, 241 ablations were performed (mean: 1.59 in the PVI-alone group, 1.55 in the full-defrag group). With the stepwise approach, termination of AF occurred in 45 (60%) patients. However, arrhythmia-free survival did not differ whether patients underwent single or multiple procedures (p = 0.468). Procedure duration, fluoroscopy time, and radiofrequency duration were significantly longer in the full-defrag group (all p < 0.001). CONCLUSIONS A stepwise approach aimed at AF termination does not seem to provide additional benefit over PVI alone in patients with persistent AF, but it is associated with significantly longer procedural and fluoroscopic duration as well as radiofrequency application time. (The Randomized Catheter Ablation of Persist End Atrial Fibrillation Study [CHASE-AF]; NCT01580124).

The role of magnetic reconnection on jet/accretion disk systems

Context. It was proposed earlier that the relativistic ejections observed in microquasars could be produced by violent magnetic reconnection episodes at the inner disk coronal region (de Gouveia Dal Pino & Lazarian 2005). Aims. Here we revisit this model, which employs a standard accretion disk description and fast magnetic reconnection theory, and discuss the role of magnetic reconnection and associated heating and particle acceleration in different jet/disk accretion systems, namely young stellar objects (YSOs), microquasars, and active galactic nuclei (AGNs). Methods. In microquasars and AGNs, violent reconnection episodes between the magnetic field lines of the inner disk region and those that are anchored in the black hole are able to heat the coronal/disk gas and accelerate the plasma to relativistic velocities through a diffusive first-order Fermi-like process within the reconnection site that will produce intermittent relativistic ejections or plasmons. Results. The resulting power-law electron distribution is compatible with the synchrotron radio spectrum observed during the outbursts of these sources. A diagram of the magnetic energy rate released by violent reconnection as a function of the black hole (BH) mass spanning 10(9) orders of magnitude shows that the magnetic reconnection power is more than sufficient to explain the observed radio luminosities of the outbursts from microquasars to low luminous AGNs. In addition, the magnetic reconnection events cause the heating of the coronal gas, which can be conducted back to the disk to enhance its thermal soft X-ray emission as observed during outbursts in microquasars. The decay of the hard X-ray emission right after a radio flare could also be explained in this model due to the escape of relativistic electrons with the evolving jet outburst. In the case of YSOs a similar magnetic configuration can be reached that could possibly produce observed X-ray flares in some sources and provide the heating at the jet launching base, but only if violent magnetic reconnection events occur with episodic, very short-duration accretion rates which are similar to 100-1000 times larger than the typical average accretion rates expected for more evolved (T Tauri) YSOs.

Tyrosinase-Cre mice for tissue-specific gene ablation in neural crest and neuroepithelial-derived tissues

This study describes the derivation of two new lines of transgenic mice that express Cre recombinase under the control of tyrosinase transcriptional elements. To determine the suitability of the Tyrosinase-Cre transgene for tissue-specific gene ablation studies, a fate map of Cre expression domains was determined using the Z/AP reporter strain. It was shown that Cre-expressing cells contribute to a wide array of neural crest and neuroepithelial-derived lineages. The melanocytes of the harderian gland and eye choroid, sympathetic cephalic ganglia, leptomeninges of the telencephalon, as well as cranial nerves (V), (VII), and (IX) are derived either fully or partly from Cre-expressing cephalic crest. The cells contributing to the cranial nerves were the first to exhibit Cre expression at E10.5 as they were migrating into the branchial arches. The melanocytes, chromaffin cells of the adrenal medulla, and dorsal root ganglia are derived from trunk neural crest that either express Cre or were derived from Cre-expressing precursors. An array of brain tissue including the basal forebrain, hippocampus, olfactory bulb, and the granule cell layer of the lateral cerebellum, as well as the retinal pigmented epithelium and glia of the optic nerve originate from Cre-expressing neuroepithelial cells. (C) 2003 Wiley-Liss, Inc.

Colorectal cancer metastasis: the DNA repair inhibitor Dbait increases sensitivity to hyperthermia and improves efficacy of radiofrequency ablation.

PURPOSE: To assess the usefulness of combining hyperthermia with a DNA repair inhibitor (double-strand break bait [Dbait]) and its potential application to radiofrequency ablation (RFA) in a preclinical model of human colorectal cancer. MATERIALS AND METHODS: The local ethics committee of animal experimentation approved all investigations. First, the relevance was assessed by studying the survival of four human colorectal adenocarcinoma cell cultures after 1 hour of hyperthermia at 41°C or 43°C with or without Dbait. Human colon adenocarcinoma cells (HT-29) were grafted subcutaneously into nude mice (n = 111). When tumors reached approximately 500 mm(3), mice were treated with Dbait alone (n = 20), sublethal RFA (n = 21), three different Dbait schemes and sublethal RFA (n = 52), or a sham treatment (n = 18). RFA was performed to ablate the tumor center alone. To elucidate antitumor mechanisms, 39 mice were sacrificed for blinded pathologic analysis, including assessment of DNA damage, cell proliferation, and tumor necrosis. Others were monitored for tumor growth and survival. Analyses of variance and log-rank tests were used to evaluate differences. RESULTS: When associated with mild hyperthermia, Dbait induced cytotoxicity in all tested colon cancer cell lines. Sublethal RFA or Dbait treatment alone moderately improved survival (median, 40 days vs 28 days for control; P = .0005) but combination treatment significantly improved survival (median, 84 days vs 40 days for RFA alone, P = .0004), with approximately half of the animals showing complete tumor responses. Pathologic studies showed that the Dbait and RFA combination strongly enhances DNA damage and coagulation areas in tumors. CONCLUSION: Combining Dbait with RFA sensitizes the tumor periphery to mild hyperthermia and increases RFA antitumor efficacy.

A biophysical model of atrial fibrillation ablation: what can a surgeon learn from a computer model?

AIMS: Surgical ablation procedures for treating atrial fibrillation have been shown to be highly successful. However, the ideal ablation pattern still remains to be determined. This article reports on a systematic study of the effectiveness of the performance of different ablation line patterns. METHODS AND RESULTS: This study of ablation line patterns was performed in a biophysical model of human atria by combining basic lines: (i) in the right atrium: isthmus line, line between vena cavae and appendage line and (ii) in the left atrium: several versions of pulmonary vein isolation, connection of pulmonary veins, isthmus line, and appendage line. Success rates and the presence of residual atrial flutter were documented. Basic patterns yielded conversion rates of only 10-25 and 10-55% in the right and the left atria, respectively. The best result for pulmonary vein isolation was obtained when a single closed line encompassed all veins (55%). Combination of lines in the right/left atrium only led to a success rate of 65/80%. Higher rates, up to 90-100%, could be obtained if right and left lines were combined. The inclusion of a left isthmus line was found to be essential for avoiding uncommon left atrial flutter. CONCLUSION: Some patterns studied achieved a high conversion rate, although using a smaller number of lines than those of the Maze III procedure. The biophysical atrial model is shown to be effective in the search for promising alternative ablation strategies.

In situ signatures of interchange reconnection between magnetic clouds and open magnetic fields: a mechanism for the erosion of polar coronal holes?

We outline a method to determine the direction of solar open flux transport that results from the opening of magnetic clouds (MCs) by interchange reconnection at the Sun based solely on in-situ observations. This method uses established findings about i) the locations and magnetic polarities of emerging MC footpoints, ii) the hemispheric dependence of the helicity of MCs, and iii) the occurrence of interchange reconnection at the Sun being signaled by uni-directional suprathermal electrons inside MCs. Combining those observational facts in a statistical analysis of MCs during solar cycle 23 (period 1995 – 2007), we show that the time of disappearance of the northern polar coronal hole (1998 – 1999), permeated by an outward-pointing magnetic field, is associated with a peak in the number of MCs originating from the northern hemisphere and connected to the Sun by outward-pointing magnetic field lines. A similar peak is observed in the number of MCs originating from the southern hemisphere and connected to the Sun by inward-pointing magnetic field lines. This pattern is interpreted as the result of interchange reconnection occurring between MCs and the open field lines of nearby polar coronal holes. This reconnection process closes down polar coronal hole open field lines and transports these open field lines equatorward, thus contributing to the global coronal magnetic field reversal process. These results will be further constrainable with the rising phase of solar cycle 24.

Inner plasma structure of the low-latitude reconnection layer

We report a clear transition through a reconnection layer at the low-latitude magnetopause which shows a complete traversal across all reconnected field lines during northwestward interplanetary magnetic field (IMF) conditions. The associated plasma populations confirm details of the electron and ion mixing and the time history and acceleration through the current layer. This case has low magnetic shear with a strong guide field and the reconnection layer contains a single density depletion layer on the magnetosheath side which we suggest results from nearly field-aligned magnetosheath flows. Within the reconnection boundary layer, there are two plasma boundaries, close to the inferred separatrices on the magnetosphere and magnetosheath sides (Ssp and Ssh) and two boundaries associated with the Alfvén waves (or Rotational Discontinuities, RDsp and RDsh). The data are consistent with these being launched from the reconnection site and the plasma distributions are well ordered and suggestive of the time elapsed since reconnection of the field lines observed. In each sub-layer between the boundaries the plasma distribution is different and is centered around the current sheet, responsible for magnetosheath acceleration. We show evidence for a velocity dispersion effect in the electron anisotropy that is consistent with the time elapsed since reconnection. In addition, new evidence is presented for the occurrence of partial reflection of magnetosheath electrons at the magnetopause current layer.

Reconnection at the high-latitude magnetopause during northward interplanetary magnetic field conditions

The Polar spacecraft had a prolonged encounter with the high-latitude dayside magnetopause on May 29, 1996. This encounter with the magnetopause occurred when the interplanetary magnetic field was directed northward. From the three-dimensional electron and ion distribution functions measured by the Hydra instrument, it has been possible to identify nearly all of the distinct boundary layer regions associated with high-latitude reconnection. The regions that have been identified are (1) the cusp; (2) the magnetopause current layer; (3) magnetosheath field lines that have interconnected in only the Northern Hemisphere; (4) magnetosheath field lines that have interconnected in only the Southern Hemisphere; (5) magnetosheath field lines that have interconnected in both the Northern and Southern Hemispheres; (6) magnetosheath that is disconnected from the terrestrial magnetic field; and (7) high-latitude plasma sheet field lines that are participating in magnetosheath reconnection. Reconnection over this time period was occurring at high latitudes over a broad local-time extent, interconnecting the magnetosheath and lobe and/or plasma sheet field lines in both the Northern and Southern Hemispheres. Newly closed boundary layer field lines were observed as reconnection occur-red first at high latitudes in one hemisphere and then later in the other. These observations establish the location of magnetopause reconnection during these northward interplanetary magnetic field conditions as being at high latitudes, poleward of the cusp, and further reinforce the general interpretation of electron and ion phase space density signatures as indicators of magnetic reconnection and boundary layer formation.

Coordinated Cluster and ground-based instrument observations of transient changes in the magnetopause boundary layer during an interval of predominantly northward IMF: relation to reconnection pulses and FTE signatures

We study a series of transient entries into the low-latitude boundary layer (LLBL) of all four Cluster spacecraft during an outbound pass through the mid-afternoon magnetopause ([X(GSM), Y(GSM), Z(GSM)] approximate to [2, 7, 9] R(E)). The events take place during an interval of northward IMF, as seen in the data from the ACE satellite and lagged by a propagation delay of 75 min that is well-defined by two separate studies: (1) the magnetospheric variations prior to the northward turning (Lockwood et al., 2001, this issue) and (2) the field clock angle seen by Cluster after it had emerged into the magnetosheath (Opgenoorth et al., 2001, this issue). With an additional lag of 16.5 min, the transient LLBL events cor-relate well with swings of the IMF clock angle (in GSM) to near 90degrees. Most of this additional lag is explained by ground-based observations, which reveal signatures of transient reconnection in the pre-noon sector that then take 10-15 min to propagate eastward to 15 MLT, where they are observed by Cluster. The eastward phase speed of these signatures agrees very well with the motion deduced by the cross-correlation of the signatures seen on the four Cluster spacecraft. The evidence that these events are reconnection pulses includes: transient erosion of the noon 630 nm (cusp/cleft) aurora to lower latitudes; transient and travelling enhancements of the flow into the polar cap, imaged by the AMIE technique; and poleward-moving events moving into the polar cap, seen by the EISCAT Svalbard Radar (ESR). A pass of the DMSP-F15 satellite reveals that the open field lines near noon have been opened for some time: the more recently opened field lines were found closer to dusk where the flow transient and the poleward-moving event intersected the satellite pass. The events at Cluster have ion and electron characteristics predicted and observed by Lockwood and Hapgood (1998) for a Flux Transfer Event (FTE), with allowance for magnetospheric ion reflection at Alfvenic disturbances in the magnetopause reconnection layer. Like FTEs, the events are about 1 R(E) in their direction of motion and show a rise in the magnetic field strength, but unlike FTEs, in general, they show no pressure excess in their core and hence, no characteristic bipolar signature in the boundary-normal component. However, most of the events were observed when the magnetic field was southward, i.e. on the edge of the interior magnetic cusp, or when the field was parallel to the magnetic equatorial plane. Only when the satellite begins to emerge from the exterior boundary (when the field was northward), do the events start to show a pressure excess in their core and the consequent bipolar signature. We identify the events as the first observations of FTEs at middle altitudes.

Predicted signatures of pulsed reconnection in ESR data

Early in 1996, the latest of the European incoherent-scatter (EISCAT) radars came into operation on the Svalbard islands. The EISCAT Svalbard Radar (ESR) has been built in order to study the ionosphere in the northern polar cap and in particular, the dayside cusp. Conditions in the upper atmosphere in the cusp region are complex, with magnetosheath plasma cascading freely into the atmosphere along open magnetic field lines as a result of magnetic reconnection at the dayside magnetopause. A model has been developed to predict the effects of pulsed reconnection and the subsequent cusp precipitation in the ionosphere. Using this model we have successfully recreated some of the major features seen in photometer and satellite data within the cusp. In this paper, the work is extended to predict the signatures of pulsed reconnection in ESR data when the radar is pointed along the magnetic field. It is expected that enhancements in both electron concentration and electron temperature will be observed. Whether these enhancements are continuous in time or occur as a series of separate events is shown to depend critically on where the open/closed field-line boundary is with respect to the radar. This is shown to be particularly true when reconnection pulses are superposed on a steady background rate.

Ion populations on open field lines within the dayside low-latitude boundary layer: theory and observations during a transient event

We analyze of ion populations observed by the NOAA-12 satellite within dayside auroral transients. The data are matched with an open magnetopause model which allows for the transmission of magnetosheath ions across one or both of the two Alfvén waves which emanate from the magnetopause reconnection site. It also allows for reflection and acceleration of ions of magnetospheric origin by these waves. From the good agreement found between the model and the observations, we propose that the events and the low-latitude boundary precipitation are both on open field lines.