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Multiple groups have reported on the usefulness of ablating in atrial regions exhibiting abnormal electrograms during atrial fibrillation (AF). Still, previous studies have suggested that ablation outcomes are highly operator- and center-dependent. This study sought to evaluate a novel machine learning software algorithm named VX1 (Volta Medical), trained to adjudicate multipolar electrogram dispersion.This study was a prospective, multicentric, nonrandomized study conducted to assess the feasibility of generating VX1 dispersion maps. In 85 patients, 8 centers, and 17 operators, we compared the acute and long-term outcomes after ablation in regions exhibiting dispersion between primary and satellite centers. We also compared outcomes to a control group in which dispersion-guided ablation was performed visually by trained operators.The study population included 29% of long-standing persistent AF. AF termination occurred in 92% and 83% of the patients in primary and satellite centers, respectively, p = 0.31. The average rate of freedom from documented AF, with or without antiarrhythmic drugs (AADs), was 86% after a single procedure, and 89% after an average of 1.3 procedures per patient (p = 0.4). The rate of freedom from any documented atrial arrhythmia, with or without AADs, was 54% and 73% after a single or an average of 1.3 procedures per patient, respectively (p 0.001). No statistically significant differences between outcomes of the primary versus satellite centers were observed for one (p = 0.8) or multiple procedures (p = 0.4), or between outcomes of the entire study population versus the control group (p 0.2). Interestingly, intraprocedural AF termination and type of recurrent arrhythmia (i.e., AF vs. AT) appear to be predictors of the subsequent clinical course.VX1, an expertise-based artificial intelligence software solution, allowed for robust center-to-center standardization of acute and long-term ablation outcomes after electrogram-based ablation.

This article examines the presence and uses of plants attested in the Chinese medical tradition in the materia medica literature of classical antiquity. It is based on the consultation of the major ancient compilations on materia medica of Chinese medicine and classical antiquity, specifically Bencao Gangmu by Li Shizhen (16th cent.) and De materia medica by Dioscorides (1st cent. A.D.). The article is divided in three major parts: the identification of plants used in the Chinese medical tradition in the medicine of the Mediterranean World in Antiquity; the analysis of the knowledge of these plants and their origin in classical antiquity; a comparison of the uses of these plants in the Bencao Gangmu and De materia medica. It traces the presence of plants of the Chinese medical tradition in Classical antiquity. Although their exact origin was not known, they were reputed at that time to be native to either India or the Black Sea, two areas that correspond to the ending points of the Silk Road. As for their uses in both traditions, they correspond for some plants, whereas they do not for others because either the uses attested in the Chinese tradition were not preserved on the Mediterranean or different uses appeared in the Mediterranean tradition. These differentiated uses hint at both continuities and ruptures, with the latter resulting from the long journey of the plants from the Chinese World to the Mediterranean and, at the same time, attempts aimed to diversify and optimize the applications of non-native medicinal substances.

Mapping of Scar-Related VTBackground Substrate-based VT ablation is mostly based on maps acquired with ablation catheters. We hypothesized that multipolar mapping catheters are more effective for identification of scar and local abnormal ventricular activity (LAVA). Methods and results Phase1: In a sheep infarction model (2 months postinfarction), substrate mapping and LAVA tagging (CARTO®3) was performed, using a Navistar (NAV) versus a PentaRay (PR) catheter (Biosense Webster). Phase2: Consecutive VT ablation patients from a single center underwent NAV versus PR mapping. Point pairs were defined as a PR and a NAV point located within a 3D-distance of ≤3 mm. Agreement was defined as both points in a pair being manually tagged as normal or LAVA. Four sheep (4 years, 50 ± 4.8 kg) and 9 patients were included (53 ± 14 years, 8 male, 6 ischemic cardiomyopathy). Mapping density was higher within the scar with PR versus NAV (3.2 vs. 0.7 points/cm2, P = 0.001) with larger bipolar scar area (68 ± 55 cm2 vs. 58 ± 48 cm2, P = 0.001). In total, 818 point pairs were analyzed. Using PR, far-field voltages were smaller (PR vs. NAV; bipolar: 1.43 ± 1.84 mV vs. 1.64 ± 2.04 mV, P = 0.001; unipolar; 4.28 ± 3.02 mV vs. 4.59 ± 3.67 mV, P < 0.001). More LAVA were also detected with PR (PR vs. NAV; 126 ± 113 vs. 36 ± 29, P = 0.001). When agreement on LAVA was reached (overall: 72%; both LAVA, 40%; both normal, 82%) higher LAVA voltages were recorded on PR (0.48 ± 0.33 mV vs. 0.31 ± 0.21 mV, P = 0.0001). Conclusion Multipolar mapping catheters with small electrodes provide more accurate and higher density maps, with a higher sensitivity to near-field signals. Agreement between PR and NAV is low.

Unipolar Signal and Atrial Flutter AblationIntroduction Complete elimination of the negative component of the unipolar atrial electrogram recently proved predictive of lesions transmurality. We prospectively assessed its relevance as a real-time local ablative endpoint for each individual lesion created across the cavotricuspid isthmus (CTI) in order to constitute a line of bidirectionnal block during common atrial flutter (AFL) ablation. Methods and Results Sixty-two consecutive patients underwent common AFL ablation following an electrophysiological approach guided by real-time electrogram modification analysis. In 31 patients (unipolar group), the local ablative endpoint was complete elimination of the negative component of the unipolar atrial electrogram, while the other 31 patients (control group) were treated following our standard approach based on the currently used local ablative endpoint defined by a ≥50% amplitude decrease of the bipolar atrial electrogram. Bidirectional block was achieved in all patients (mean age 67.9 ± 11.5 with 80.6% of men). Mean ablation time (164.3 ± 88.3 seconds vs 332.8 ± 151.5 seconds; P < 0.001) and mean energy delivery (7.5 ± 4.1 kJ vs 14.2 ± 6 kJ; P < 0.001) were significantly shorter in the unipolar group compared to the control group. No statistical differences were seen in procedure time (68.5 ± 22.6 min vs 77.5 ± 20.2 min; P = 0.10). Conclusion Real-time unipolar electrogram modification is a relevant local endpoint during common AFL ablation and leads to a substantial reduction of ablation time and energy delivery compared to a standard ablative approach while displaying a similar short- and long-term success rate.

Background— It has been experimentally shown that elimination of the negative component of the unipolar atrial electrogram (R morphology completion) during radiofrequency applications reflects transmural lesions creation. Subsequently, it has been clinically suggested that such a transmurality can be either irreversible or reversible. The present study is aimed to determine, at the histological level, whether transmural lesions, assessed by R morphology completion, might indeed be reversible in some circumstances or not. Methods and Results— In 6 Mongrel hound dogs, superior and inferior vena cavae were isolated and individual lesions were created in the right atrium using radiofrequency energy (30 W/48°C/17 mL/min as presettings and 10 g of force in average) under CARTO guidance. Five types of lesions were created; R + 0: termination of ablation at the time of R morphology completion; R + 5, R + 10, or R + 20: extension of ablation for 5, 10, or 20 seconds, respectively, after R morphology achievement; and conventional: radiofrequency applications lasting 30 seconds irrespective of the atrial electrogram modification. All conventional, R + 5, R + 10, and R + 20 lesions were necrotic and transmural, whereas some R + 0 lesions were not (comprising a part of necrosis and a part of reversible cell damage). Interestingly, surrounding organ injuries were observed after conventional, R + 10, and R + 20 radiofrequency applications but were not observed after R + 0 and R + 5 applications. Conclusions— Elimination of the negative component of the unipolar atrial electrogram reflects, in general, irreversible transmural necrosis creation. In some cases, however, it translates transmural lesion only (with potential reversibility) likely related to transient cell damage creation.

Ethnopharmacological relevance : Transmission of ethnopharmacological knowledge over a long period of time and across a vast area or between botanically or culturally/scientifically unrelated regions of the world is a fundamental issue in ethnopharmacology, as it traces continuity and transformation(s) of the data to be submitted to analysis for evaluation. In the context of present interest in Eastern medicine (particularly Indian and Chinese), we ask questions about the transmission of knowledge from the East to the Mediterranean. In the first part, we survey available literature on trade between the two areas and, in the second, we present preliminary micro-cases (data, analysis and interpretation) in order to verify the feasibility of a comparative study. Materials and methods Based on the assumption of native areas of origin and/or domestication of plants and one other natural product (musk), we have screened relevant sources (pharmacological literature) in the original language searching for explicit information about Indian and/or Chinese materia medica. We have concentrated our attention on knowledge of the origin of the materia medica under study, their therapeutic applications, the explanations provided for their activity, and the knowledge of the living plants and animals as demonstrated through their representations. Results Relevant data come from the Hippocratic Collection in ancient Greece (5th century B.C.E.) to the Renaissance in the 16th century. The corpus of materia medica and drugs collected in this preliminary study include pepper and myrrh (5th century B.C.E.), ginger (1st century C.E.), a dozen plants and drugs in the period 9th to 13th century (e.g. camphor, clove, galanga, nutmeg), cinnamon (11th century and later), eggplant, banana tree and musk (13th–16th century). Whereas the Eastern origin of such products was known, the exact area was not always. Judging from their representations, the plants and animals producing the drugs studied here were not necessarily known. Compared therapeutic uses of the drugs did not correspond to those in the area of origin, even though some knowledge of such original uses was preserved. Conclusions This study warrants the very possibility of a comparative analysis of different historical pharmacological traditions. It highlights both continuities and innovations in the transmission of information from the East (India and China) to the Mediterranean, suggests interpretations on the processes brought to light and opens the door to a further systematic study that will expand the documentary corpus, collect additional material, and also confirm and refine our interpretations. Such an approach is expected to play a fundamental role in the collection of historical ethnopharmacological data and to be applicable to traditions other than the Eastern and Mediterranean ones.

Complete elimination of the negative component of the unipolar atrial electrogram recently proved predictive of lesions transmurality. We prospectively assessed its relevance as a real-time local ablative endpoint for each individual lesion created across the cavotricuspid isthmus (CTI) in order to constitute a line of bidirectionnal block during common atrial flutter (AFL) ablation.Sixty-two consecutive patients underwent common AFL ablation following an electrophysiological approach guided by real-time electrogram modification analysis. In 31 patients (unipolar group), the local ablative endpoint was complete elimination of the negative component of the unipolar atrial electrogram, while the other 31 patients (control group) were treated following our standard approach based on the currently used local ablative endpoint defined by a ≥50% amplitude decrease of the bipolar atrial electrogram. Bidirectional block was achieved in all patients (mean age 67.9 ± 11.5 with 80.6% of men). Mean ablation time (164.3 ± 88.3 seconds vs 332.8 ± 151.5 seconds; P0.001) and mean energy delivery (7.5 ± 4.1 kJ vs 14.2 ± 6 kJ; P0.001) were significantly shorter in the unipolar group compared to the control group. No statistical differences were seen in procedure time (68.5 ± 22.6 min vs 77.5 ± 20.2 min; P = 0.10).Real-time unipolar electrogram modification is a relevant local endpoint during common AFL ablation and leads to a substantial reduction of ablation time and energy delivery compared to a standard ablative approach while displaying a similar short- and long-term success rate.

The aims of the present study are (i) to develop a predictive model, using discriminant analysis to forecast the solvency of Italian firms and (ii) to compare the ability of this model with that of a second one in which static ratios have been replaced by values that take account of their own trends. The results obtained by considering the trends of ratios over three years are encouraging and indicate that the second model not only performed better than the first, but also better than any other model using the balance sheet data of Italian firms.