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Background— Although percutaneous left ventricular assist devices (pLVADs) facilitate mapping and ablation of hemodynamically unstable ventricular tachycardia (VT), there is limited data whether clinical outcomes are improved. We sought to retrospectively compare the outcomes of patients undergoing scar-related VT ablation with and without pLVAD support. Methods and Results— The study population comprised 194 patients (109 pLVAD and 85 non-pLVAD). The pLVAD group more often had dilated cardiomyopathy (33% versus 13%; P =0.001), New York Heart Association heart failure class ≥III (51% versus 25%; P P P =0.04). Procedure times (422±112 versus 330±92 minutes; P P =0.02), and length of subsequent hospitalization (median 6 versus 4 days; P =0.001) were all higher in the pLVAD group. During median follow-up of 215 days, the primary end point (recurrent VT, heart transplantation, or death) occurred in 36% of the pLVAD versus 26% of the non-pLVAD groups ( P =0.14). After propensity matching for differences between groups, no differences were seen between groups for both acute procedural outcomes and the primary end point. Conclusions— In this large single-center scar-related VT ablation experience, despite the worse clinical status of the patients selected for pLVAD support, clinical outcomes were better than expected and were similar to healthier patients not receiving hemodynamic support. Patients with dilated cardiomyopathy presenting with electrical storm, advanced heart failure, and severe left ventricular dysfunction most frequently received hemodynamic support during VT ablation.

Defibrillation testing (DT) does not improve shock efficacy or reduce the risk for arrhythmic death in patients undergoing routine transvenous implantable cardioverter-defibrillator (ICD) placement and is no longer compulsory for left pectoral transvenous ICDs [(1)][1]. The subcutaneous ICD (S-ICD)

This review discusses the role of hemodynamic support for catheter ablation of unstable ventricular tachycardia, using commercially available mechanical circulatory support devices (intra-aortic balloon pump, Impella, TandemHeart, extracorporeal membrane oxygenation) and analyzes the published clinical experience of the safety and efficacy of these devices during ventricular tachycardia ablation. Appropriate selection of patients, device-specific characteristics, and hemodynamic monitoring is also discussed.

Background— Alternative techniques to the traditional 3-incision subcutaneous implantation of the subcutaneous implantable cardioverter-defibrillator may offer procedural and cosmetic advantages. We evaluate 4 different implant techniques of the subcutaneous implantable cardioverter-defibrillator. Methods and Results— Patients implanted with subcutaneous implantable cardioverter-defibrillators from 2 hospitals between 2009 and 2016 were included. Four implantation techniques were used depending on physician preference and patient characteristics. The 2- and 3-incision techniques both place the pulse generator subcutaneously, but the 2-incision technique omits the superior parasternal incision for lead positioning. Submuscular implantation places the pulse generator underneath the serratus anterior muscle and subfascial implantation underneath the fascial layer on the anterior side of the serratus anterior muscle. Reported outcomes include perioperative parameters, defibrillation testing, and clinical follow-up. A total of 246 patients were included with a median age of 47 years and 37% female. Fifty-four patients were implanted with the 3-incision technique, 118 with the 2-incision technique, 38 with submuscular, and 37 with subfascial. Defibrillation test efficacy and shock lead impedance during testing did not differ among the groups; respectively, P =0.46 and P =0.18. The 2-incision technique resulted in the shortest procedure duration and time-to-hospital discharge compared with the other techniques ( P P =0.21). All infections occurred in subcutaneous implants (3-incision, n=3; 2-incision, n=4). In the 2-incision group, there were no lead displacements. Conclusions— The presented implantation techniques are feasible alternatives to the standard 3-incision subcutaneous implantation, and the 2-incision technique resulted in shortest procedure duration.

Background Pericardial suture ligation of the left atrial appendage (LAA) may be an alternative to endoluminal devices for stroke prevention in patients with atrial fibrillation, but multicenter safety and efficacy data in high-risk patients with contraindications to oral anticoagulation are lacking. Objective The purpose of this study was to report the outcomes of consecutive cases of pericardial suture ligation of the LAA in high-risk patients performed at 4 centers. Methods The cohort included 41 consecutive patients who underwent LAA closure with the LARIAT system. Epicardial and transeptal access was obtained, and the epicardial snare was advanced over an endo–epicardial magnetic-tipped guidewire to close the LAA. Transesophageal echocardiography was used to confirm LAA exclusion. Results Mean age was 75 ± 10 years, mean CHADS 2 score was 3.0 ± 1.3, and mean HAS-BLED score was 4.4 ± 1.4. These patients accumulated 24.6 person-years of follow-up. Acute LAA closure was achieved in 38 patients (93%). Transesophageal echocardiography or computerized tomographic angiography performed up to 3.3 ± 0.8 months after the procedure demonstrated LAA leakage in 24% of patients. One patient (2%) had a transient ischemic attack, and 8 (20%) developed pericardial effusions requiring pericardiocentesis. Four cases (9%) were complicated by perforation of the LAA, with 2 of these patients requiring open surgical correction. Conclusion This multicenter experience revealed that pericardial suture ligation with the LARIAT system is technically feasible and acutely efficacious. However, additional improvements are required to minimize the rate of pericardial complications. A randomized study is warranted to accurately define the long-term efficacy and safety profile of percutaneous epicardial suture ligation.

In this article current stakeholder collaboration in tourism development was investigated in the area Veerse Meer, a lake area situated in the southwest of the Netherlands. Since four local public organizations are involved in its development as well as multiple private stakeholders, it presents an interesting case to analyze options for collaboration. Through interviews and a discussion group with stakeholder representatives the research indicates that, despite an awareness of the importance of collaboration in tourism planning, collaboration is not seen as an effective strategy for the tourism development process in Veerse Meer. Different viewpoints, as well as the missing “sense of urgency,” are seen as major constraints for collaboration.

The organizing theme of the 7th International Coastal and Marine Tourism Congress was “Planning, Designing, and Managing the Destination.” This editorial begins with a commentary on how “destination” has been conceptualized and defined over the last several decades in the multidisciplinary tourism literature. Six articles presented at CMT '12 are introduced in this special double issue. Taken together they illustrate a variety of research questions and results bearing on the condition and future of coastal and marine tourism destinations.

Bipolar Ablation for Outflow Tract VTIntroduction Standard unipolar radiofrequency ablation (RFA) is typically successful in eliminating premature ventricular contractions (PVCs) originating from the ventricular outflow tract region. In a minority of cases, this approach may be ineffective. We report 4 cases where bipolar RFA was attempted after failed unipolar RFA. Methods From a total of 73 consecutive PVC ablations, 4 patients underwent bipolar RFA after failed unipolar ablation. Three-dimensional electroanatomic activation mapping of the right and left ventricular outflow (RVOT and LVOT), coronary sinus, and aortic root was performed. Results Mean age was 53 ± 22 years, 3 male. The mean 24-hour PVC burden in these patients was 33,107 ± 8,712. In 3 of 4 patients, the RVOT activation was earlier than the left side. The earliest activation on the left was in the right coronary cusp in 2 patients and left coronary cusp in 2. Unipolar RFA delivered sequentially at the site of earliest RVOT and then earliest aortic cusp sites failed to eradicate the PVCs in all 4 patients. Subsequently, bipolar RFA was applied between irrigated catheters placed at the earliest RVOT and aortic root sites. This approach eliminated PVCs in 3 of 4 (75%) cases. At a median follow-up of 4 months, those with successful bipolar RFA had no recurrence of clinical PVCs. Conclusions This report demonstrates the potential utility of bipolar RFA in patients with outflow tract PVCs that fail unipolar RFA.

A total of 30% to 40% of patients with congestive heart failure eligible for cardiac resynchronization therapy (CRT) either do not respond to conventional CRT or remain untreated due to an inability or impediment to coronary sinus (CS) lead implantation. The WiSE-CRT system (EBR Systems, Sunnyvale, California) was developed to address this at-risk patient population by performing biventricular pacing via a wireless left ventricular (LV) endocardial pacing electrode.The SELECT-LV (Safety and Performance of Electrodes implanted in the Left Ventricle) study is a prospective multicenter non-randomized trial assessing the safety and performance of the WiSE-CRT system.A total of 35 patients indicated for CRT who had "failed" conventional CRT underwent implantation of an LV endocardial pacing electrode and a subcutaneous pulse generator. System performance, clinical efficacy, and safety events were assessed out to 6 months post-implant.The procedure was successful in 97.1% (n = 34) of attempted implants. The most common indications for endocardial LV pacing were difficult CS anatomy (n =12), failure to respond to conventional CRT (n = 10), and a high CS pacing threshold or phrenic nerve capture (n = 5). The primary performance endpoint, biventricular pacing on the 12-lead electrocardiogram at 1 month, was achieved in 33 of 34 patients. A total of 28 patients (84.8%) had improvement in the clinical composite score at 6 months, and 21 (66%) demonstrated a positive echocardiographic CRT response (≥5% absolute increase in LV ejection fraction). There were no pericardial effusions, but serious procedure/device-related events occurred in 3 patients (8.6%) within 24 h, and 8 patients (22.9%) between 24 h and 1 month.The SELECT-LV study demonstrates the clinical feasibility for the WiSE-CRT system, and provided clinical benefits to a majority of patients within an otherwise "failed" CRT population. (Safety and Performance of Electrodes Implanted in the Left Ventricle [SELECT-LV]; NCT01905670).

Just because something doesn’t do what you planned it to do doesn’t mean it’s useless .–Thomas Edison [(1)][1] Cardiac catheter ablation of scar-related ventricular tachycardia (VT) is safe and effective for reducing recurrent VT episodes and implantable cardioverter-defibrillator (ICD)

Background The initial experience with left atrial esophageal fistula (LAEF) secondary to atrial fibrillation (AF) ablation procedures revealed a near-universal mortality. A comprehensive description of the principles of LAEF repair in the modern era and its resulting impact on morbidity and mortality are lacking in the literature. Objective To describe the presentation, surgical management, and outcomes of patients with LAEF. Methods A retrospective cohort analysis of 29 patients was performed, including previously unpublished cases of surgically repaired LAEF from 4 institutions (n = 6), and all published cases of surgically repaired (n = 16) or stented (n = 7) LAEF. Results The mean age was 55 ± 13 years, and 75% were men who were undergoing radiofrequency energy catheter ablation (n = 26), cryoablation (n = 1), high-intensity focused ultrasound ablation (n = 1), and surgical mini-MAZE procedure (n = 1) and presented 30 ± 12 days postablation procedure. Overall, 55% of the patients receiving an intervention for LAEF died (41% surgical repair; 100% stent). Patients who did not receive primary esophageal repair were more likely to experience postoperative complications, including mediastinitis, need for percutaneous endoscopic gastrostomy (PEG) feeds, esophageal stent, or death (P = .05). In addition, interposing tissue between the repaired esophagus and the left atrium resulted in fewer postoperative complications (P = .02). Conclusions While improved relative to initial reports, mortality associated with LAEF remains high after corrective intervention. Primary esophageal repair with the placement of tissue between the repaired esophagus and the left atrium may result in lower morbidity and mortality.

health-care processes and overall patient outcomes. 1 However, these critical evaluations have been lacking in the field of interventional cardiac electrophysiology and in the assessment of catheter ablation for atrial fibrillation (CAAF) in particular. The clinical success of CAAF, the most common ablation procedure performed worldwide, is currently reported in terms of atrial fibrillation (AF) recurrence rates, an assessment strategy with considerable limitations. Since recognition of AF recurrence is largely based on the presence of symptoms and as recurrences are frequently asymptomatic, 2 this strategy can substantially underestimate the true incidence of postablation AF. Even when noninvasive monitoring is routinely used after ablation, the sensitivity for the detection of asymptomatic AF recurrences depends on the protocol used, with more aggressive arrhythmia surveillance certain to identify higher rates of recurrence. 3 Furthermore, the definition of AF burden (symptomatic and asymptomatic) used to define recurrence varies and there are discrepancies as to whether a requirement for antiarrhythmic drugs is considered separately from maintenance of sinus rhythm without adjuvant pharmacotherapy. 4 As a result, there are wide variations in reported recurrence rates after CAAF among centers and the factors accounting for these differences have not been systematically delineated. In addition, and perhaps most importantly, reported success rates do not account for procedural safety, precluding meaningful comparisons between different techniques. The appraisal of CAAF requires a more objective evaluation that combines data on the quality of lesion delivery, complication rates, and clinical outcomes. To develop a more comprehensive, less biased criterion to assess the quality of CAAF and standardize comparisons between ablation strategies, we devised a novel quantitative scoring system based on more objective measures of the ablation procedure and a weighted assessment of procedurerelated complications, which we have termed the AF ablation (AFA) score.

Predicting Steam Pops with Microwave Radiometry Background The disparity between catheter and tissue temperatures during irrigated RF ablation frustrates one's ability to predict steam pops. Microwave radiometry allows for “volumetric” temperature assessment—i.e., within a circumscribed volume around the catheter tip-permitting, direct assessment of temperature during ablation. The aim of this study was to examine (i) the ability of microwave radiometry to predict steam pops, and (ii) compare this to traditional parameters such as power, catheter temperature, and impedance. Methods and Results Irrigated RF ablation was performed in 8 sheep using the Tempasure ablation catheter in all chambers. Power, impedance, catheter tip, and volumetric temperature were continually monitored. Ablation was terminated after a pop or at 60 seconds. A pop was defined as an audible or visualized pop (intracardiac echocardiography). Predictors of pops were determined by univariate and multivariate GEE logistic regression modeling. A total of 48 pops occurred during 143 lesions applied at 20–50 W. There was no association between the chamber of the heart and the occurrence of pops. The rate of rise of volumetric temperature (greater than 1.5 °C/s) was the single best predictor of pops (OR: 88.8 [95% CI: 12–604], P < 0.0007). Pops only occurred above a maximum volumetric temperature threshold of 89 °C. Conclusions During irrigated RF ablation, steam pop occurrence can be predicted by both, the rate of rise and the maximum volumetric temperature measured by microwave radiometry.

Objectives The purpose of this study was to assess the safety and efficacy of left atrial appendage (LAA) closure in nonvalvular atrial fibrillation (AF) patients ineligible for warfarin therapy. Background The PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial demonstrated that LAA closure with the Watchman device (Boston Scientific, Natick, Massachusetts) was noninferior to warfarin therapy. However, the PROTECT AF trial only included patients who were candidates for warfarin, and even patients randomly assigned to the LAA closure arm received concomitant warfarin for 6 weeks after Watchman implantation. Methods A multicenter, prospective, nonrandomized study was conducted of LAA closure with the Watchman device in 150 patients with nonvalvular AF and CHADS 2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ≥1, who were considered ineligible for warfarin. The primary efficacy endpoint was the combined events of ischemic stroke, hemorrhagic stroke, systemic embolism, and cardiovascular/unexplained death. Results The mean CHADS 2 score and CHA 2 DS 2 -VASc (CHADS 2 score plus 2 points for age ≥75 years and 1 point for vascular disease, age 65 to 74 years, or female sex) score were 2.8 ± 1.2 and 4.4 ± 1.7, respectively. History of hemorrhagic/bleeding tendencies (93%) was the most common reason for warfarin ineligibility. Mean duration of follow-up was 14.4 ± 8.6 months. Serious procedure- or device-related safety events occurred in 8.7% of patients (13 of 150 patients). All-cause stroke or systemic embolism occurred in 4 patients (2.3% per year): ischemic stroke in 3 patients (1.7% per year) and hemorrhagic stroke in 1 patient (0.6% per year). This ischemic stroke rate was less than that expected (7.3% per year) based on the CHADS 2 scores of the patient cohort. Conclusions LAA closure with the Watchman device can be safely performed without a warfarin transition, and is a reasonable alternative to consider for patients at high risk for stroke but with contraindications to systemic oral anticoagulation. (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology [ASAP]; NCT00851578)

Adjunctive Renal Sympathetic Denervation to Modify Hypertension Background Hypertension is the most important risk factor directly attributable to the high prevalence of atrial fibrillation (AF), and is one of the few modifiable risk factors for AF. Activation and overactivity of the sympathetic nervous system (SNS) have been implicated in the pathogenesis of both essential hypertension and AF. Catheter-based renal sympathetic denervation (RSDN) appears to be an effective adjunctive treatment for refractory hypertension, and may be beneficial in other conditions characterized by SNS overactivity, such as left ventricular hypertrophy and atrial arrhythmias. Objective The H-FIB study is a multicenter prospective, double-blind, randomized (1:1) controlled trial. The primary efficacy endpoint is antiarrhythmic drug-free freedom from AF recurrence through 12 months. Methods Patients with a history of significant hypertension who are receiving treatment with at least one antihypertensive agent who are planned for a first time ablation for symptomatic paroxysmal or persistent AF will be randomized to either AF ablation alone (control group) or AF ablation + RSDN (study group). Conclusions H-FIB is a multicenter, randomized trial that will test the hypothesis that adjunctive renal sympathetic denervation, at the time of AF ablation, will increase the freedom from recurrent AF.

Objectives This study sought to determine the extent of lateral esophageal displacement required during mechanical esophageal deviation (MED) and to eliminate luminal esophageal temperature elevation (LET Elev ) during pulmonary vein (PV) isolation. Background MED is a conceptually attractive strategy of minimizing esophageal injury while allowing uninterrupted energy delivery along the posterior left atrium during PV isolation. Methods MED was performed using a malleable metal stylet within a plastic tube placed within the esophagus. Barium was instilled to characterize the trailing esophageal edge. For each MED attempt, the MED Effective , defined as the distance from the trailing esophageal edge-to-ablation line, was correlated to occurrences of LET Elev . Results In 114 consecutive patients/221 PV pairs undergoing MED (age 62.1 ± 11 years, 75% men, 62%/38% paroxysmal/persistent AF), esophageal stretching invariably occurred such that the esophageal edge trailed behind the plastic tube. MED Effective distances of 0 mm to 10 mm, 10 mm to 15 mm, 15 mm to 20 mm or >20 mm were achieved in 60 (27.1%), 64 (29%), 48 (21.7%), and 49 (22.2%) attempts, respectively. Overall, LET elevation >38°C occurred in 81 of 221 (36.7%) PV pairs. The incidence of LET Elev among the 4 groups was 73.3%, 35.9%, 25%, and 4.1%, respectively. MED Effective distances were 9.1 ± 6.5 mm and 18 ± 7.6 mm in patients with and without LET Elev , respectively (p Conclusions Mechanical esophageal deviation >20 mm from the PV ablation line prevents significant esophageal heating during PV isolation, but this level of displacement was difficult to safely achieve with this off-the-shelf mechanical stylet approach.

Background— Leadless cardiac pacemakers have emerged as a safe and effective alternative to conventional transvenous single-chamber ventricular pacemakers. Herein, we report a multicenter experience on the feasibility and safety of acute retrieval (6 weeks) of the leadless cardiac pacemaker in humans. Methods and Results— This study included patients enrolled in 3 multicenter trials, who received a leadless cardiac pacemaker implant and who subsequently underwent a device removal attempt. The overall leadless pacemaker retrieval success rate was 94%: for patients whose leadless cardiac pacemaker had been implanted for 6 months before the retrieval attempt. There were no procedure-related adverse events at 30 days post retrieval procedure. Conclusions— This multicenter experience demonstrated the feasibility and safety of retrieving a chronically implanted single-chamber (right ventricle) active fixation leadless pacemaker. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifiers: NCT02051972, NCT02030418, and NCT01700244.

Aims Although complex fractionated atrial electrograms (CFAEs) are purported to represent critical sites for atrial fibrillation (AF) perpetuation, the mechanism and the significance of CFAE in the genesis of AF remain poorly understood. This study evaluated the relationship between CFAE and areas of abnormal atrial tissue defined by low-voltage electrograms (LVE) and signal average of the P-wave (SAPW). Methods and results Complex fractionated atrial electrogram maps were obtained after pulmonary vein isolation in 15 patients with persistent AF. Patients were then cardioverted and voltage/activation maps were acquired in normal sinus rhythm (NSR). Total left atrium (LA), CFAE and LVE areas were measured as % of total LA area (mean ± SD). Conduction velocities of normal, LVE and CFAE areas were also measured during NSR. Patients underwent signal averaged ECG of the P-wave in NSR within 24 h of the procedure. Complex fractionated atrial electrograms areas accounted for 33 ± 24% of total LA. In NSR, only 12 ± 10% of LA area had LVE. There was no anatomic correlation between CFAE sites and LVE; the area of overlap between CFAE and LVE was only 1.6 ± 1.5%. Conduction velocity was faster in CFAE areas (2.3 ± 1.4 m/s) than in normal voltage areas (1.3 ± 0.3 m/s), and LVE areas (1.1 ± 0.7 m/s, P = 0.06). A positive correlation was only found between LVE areas and SAPW duration ( r = 0.7, P = 0.04). Conclusion Areas of CFAEs correspond to areas of normal atrial voltage and normal conduction velocity during NSR. Complex fractionated atrial electrogram probably represents the response of normal healthy atrial tissue to rapid pulmonary vein activation.

Aims Temporary, ablation-mediated effects such as oedema may cause reversible pulmonary vein (PV) isolation. To investigate this, point-by-point circumferential ablation was performed to achieve acute electrical PV isolation with an incomplete circumferential ablation line. Then, the impact of this intentional ‘visual gap’ (ViG) on the conduction properties of the ablation lesion set was assessed with adenosine and pacing manoeuvres. Methods and results Twenty-eight patients undergoing ablation for paroxysmal ( n = 20) or persistent atrial fibrillation ( n = 8) were included. Pulmonary vein (PV) ablation was performed around ipsilateral vein pairs. Once acute isolation was achieved, ablation was halted and the presence and size of the ViG were calculated. The ViG electrophysiological properties were tested with pace capture along the ViG at 10 mA/2 ms, and assessment for dormant PV conduction with adenosine. Despite electrical isolation, a ViG was present in 75% ( n = 42/56) of vein pairs (21 of 28 left PVs and 21 of 28 right PVs). There was no difference in the ViG size between the left and right PVs (22.1 ± 14.2 and 17.3 ± 11.3 mm, P > 0.05). Dormant PV connections were revealed by adenosine in more than a quarter ( n = 12/42) of acutely isolated PV pairs, of which the majority were dependent on conduction through the ViG. Conclusions Electrical PV isolation can usually be achieved without complete circumferential ablation. However, more than a quarter of these ‘isolated’ PVs exhibit dormant conduction—predominantly via the un-ablated ‘ViGs’ in the ablation lesion set. These findings support the hypothesis that reversible tissue injury contributes to PV isolation that may be acute but not necessarily durable.

Esophageal Deviation in AF Ablation. Objective: To determine the feasibility and safety of esophageal displacement during atrial fibrillation (AF) ablation, to prevent thermal injury. Background: Patients undergoing AF ablation are at risk of esophageal thermal injury, which ranges from superficial ulceration, to gastroparesis, to the rare but catastrophic atrioesophageal fistula. A common approach to avoid damage is luminal esophageal temperature (LET) monitoring; however, (1) temperature rises mandate interruptions in energy delivery that interrupt workflow and potentially decrease procedural efficacy, and (2) esophageal fistulas have been reported even with LET monitoring. Methods: A cohort of 20 consecutive patients undergoing radiofrequency (RF) (16 patients) or laser balloon (4 patients) ablation of AF under general anesthesia. After barium instillation, the esophagus was deviated using an endotracheal stylet placed within a thoracic chest tube. LET monitoring was used during catheter ablation. Upper GI endoscopy was performed prior to discharge. Results: At the pulmonary vein level, leftward deviation measured 2.8 ± 1.6 cm (range: 0.4–5.7) and rightward deviation 2.8 ± 1.8 cm (range: 0.5–4.9). The temperature rose to >38.5 °C in 3/20 (15%) patients. In these 3 patients, there was an average of 2 applications/patient that recorded temperatures >38.5 °C. No patient had a temperature rise > 40 °C. Endoscopy revealed no esophageal ulceration from thermal injury in 18/19 (95%) patients; the sole patient with a thermally mediated ulceration had an unusual esophageal diverticulum fully across the posterior left atrium. Twelve patients (63%) exhibited trauma related to instrumentation with no clinical sequelae. Conclusions: Mechanical esophageal deviation is feasible and allows for uninterrupted energy delivery along the posterior wall during catheter ablation of AF. J Cardiovasc Electrophysiol, Vol. 23, pp. 147-154, February 2012)

Coastal and marine tourism has the potential to radically transform natural and social systems. Responsibilities for the condition of complex natural and social systems are properly addressed in the context of sustainable development. Tourism governance—regarded as more than management—concerns structures and processes that can be described and improved in accordance with societal values. Papers from the 6th International Coastal and Marine Tourism Congress illustrate how the African ubuntu dynamic gives meaning to tourism and facilitates positive touristic outcomes. Maturation of the field will be stimulated with studies of such issues as globalization and environmental change, cultural and biological diversity, social and ecological health, governance, and social and environmental justice.

The pharmacological activity of a series of novel amide derivatives was characterized on several nicotinic acetylcholine receptors (AChRs). Ca(2+) influx results indicate that these compounds are not agonists of the human (h) α4β2, α3β4, α7, and α1β1γδ AChRs; compounds 2-4 are specific positive allosteric modulators (PAMs) of hα7 AChRs, whereas compounds 1-4, 7, and 12 are noncompetitive antagonists of the other AChRs. Radioligand binding results indicate that PAMs do not inhibit binding of [(3)H]methyllycaconitine but enhance binding of [(3)H]epibatidine to hα7 AChRs, indicating that these compounds do not directly, but allosterically, interact with the hα7 agonist sites. Additional competition binding results indicate that the antagonistic action mediated by these compounds is produced by direct interaction with neither the phencyclidine site in the Torpedo AChR ion channel nor the imipramine and the agonist sites in the hα4β2 and hα3β4 AChRs. Molecular dynamics and docking results suggest that the binding site for compounds 2-4 is mainly located in the inner β-sheet of the hα7-α7 interface, ∼12 Å from the agonist locus. Hydrogen bond interactions between the amide group of the PAMs and the hα7 AChR binding site are found to be critical for their activity. The dual PAM and antagonistic activities elicited by compounds 2-4 might be therapeutically important.

Objectives: We seek to identify predictors of 30-day mortality after balloon aortic valvuloplasty (BAV). Background: To date, there is no validated method of predicting patient outcomes after percutaneous aortic valve interventions. Methods: Data for consecutive patients with severe aortic stenosis who underwent BAV at the Mount Sinai Medical Center from January 2001 to July 2007 were retrospectively reviewed. Cox-proportional hazards regression was used to identify significant predictors of 30-day mortality, and the resultant model was compared to the EuroSCORE using Akaike's Information Criterion and area under the receiver-operating curve (AUC). Results: The analysis included 281 patients (age 83 ± 9 years, 61% women, aortic valve area: 0.64 ± 0.2 cm2) and 36 (12.8%) of whom died within 30 days of BAV. With identified risk factors for 30-day mortality, critical status, renal dysfunction, right atrial pressure, and cardiac output, we constructed the CRRAC the AV risk score. Thirty-day survival was 72% in the highest tertile versus 94% in the lower two tertiles of the score. Compared to the additive and logistic EuroSCORE, the risk score demonstrated superior discrimination (AUC = 0.75 vs. 0.60 and 0.63, respectively). Conclusions: We derived a risk score, the CRRAC the AV score that identifies patients at high-risk of 30-day mortality after BAV. Validation of the developed risk prediction score, the CRRAC the AV score, is needed in other cohorts of post-BAV patients and potentially in patients undergoing other catheter-based valve interventions. © 2010 Wiley-Liss, Inc.

Compared with warfarin, left atrial appendage closure (LAAC) reduced hemorrhagic stroke and cardiovascular mortality in a patient-level meta-analysis of the PROTECT-AF and PREVAIL trials. However, the strength of the data on mortality outcomes (LAAC vs warfarin) was limited by the patient drop-out

Evolving imaging modalities in hypertrophic cardiomyopathy (HCM), such as tissue Doppler, speckle tracking, measures of myocardial blood flow, and cardiac magnetic resonance with gadolinium enhancement, have advanced our understanding of the pathogenesis of myocardial dysfunction in hypertrophic cardiomyopathy. These modalities have the potential to differentiate HCM from other causes of left ventricular hypertrophy when there is uncertainty about the diagnosis and to identify affected individuals in the pre-clinical phase of the disease process. Furthermore, preliminary data suggests that functional imaging techniques may add incremental value to conventional risk stratification tools to identify individuals at high risk for sudden death or progression to congestive heart failure.

Federal Sentencing Reporter, Vol. 21, No. 4, pp. 227–234, ISSN 1053-9867 electronic ISSN 1533-8363 ©2009 Vera Institute of Justice. All rights reserved. Please direct requests for permission to photocopy or reproduce article content through the University of California Press’s Rights and Permissions website, http://www.ucpressjournals.com/reprintInfo.asp. DOI: 10.1525/fsr.2009.21.4.227. Shaping Modern Sentencing: Three Giants

Marine protected areas (MPAs), ideally, manage human uses that threaten ecosystems, or components of ecosystems. During several recent MPA designation processes, concerns have arisen over the scientific justification for no-take MPAs, particularly those that restrict recreational fishing for pelagic species. An important question is: under what conditions might recreational pelagic fishing be compatible with the conservation goals of an MPA that is primarily focused on benthic communities? In 2005, an expert workshop of fisheries biologists, marine ecologists, MPA managers, and recreational fishermen was convened by NOAA's National MPA Center to evaluate the limited empirical data on benthic-pelagic coupling and to help provide practical advice on this topic. The participants (i) proposed a preliminary conceptual framework for addressing vertical zoning, (ii) developed preliminary guidelines to consider when evaluating whether to allow or restrict pelagic fishing in an MPA, and (iii) identified f...

Retired National Football League (NFL) linemen have higher cardiovascular mortality compared with nonlinemen. We examined echocardiographic characteristics of retired NFL linemen compared with nonlinemen to determine if position-dependent cardiac remodeling resulted in increased left ventricular (LV) mass and left atrial (LA) size. We performed echocardiography in 487 retired NFL football players. Demographic, medical, and professional career information was collected. Interventricular septal and posterior wall thickness, LV end diastolic diameter, and LA area were measured. Body mass index (BMI) and LV mass were calculated. Retired linemen had significantly higher LV mass (234.8 +/- 65.8 g) than nonlinemen (199.8 +/- 55.4 g, p0.0001). LA area was higher in linemen versus nonlinemen (22.5 vs 20.1 cm(2), p0.0001). Independent predictors of increased LV mass were BMI (p0.003), linemen position (p0.024), and systolic blood pressure (p0.005). In former players with BMI35 kg/m(2) there was a difference between linemen and nonlinemen in LV mass (219.9 +/- 44.3 vs 182.6 +/- 44.3 g, p = 0.004) and LV mass/height (114.3 +/- 23.5 vs 98.8 +/- 25.2 g/m, p = 0.005). In former players with BMI35 kg/m(2), there was no difference. There was no difference in LA area between linemen and nonlinemen in both BMI groups. In conclusion, LV mass and LA area size were highest in retired linemen. Player BMI, position, and systolic blood pressure were significant predictors of LV mass. In retired linemen compared with retired nonlinemen, the persistence of these cardiac adaptations may contribute to the higher cardiovascular mortality seen in retired linemen.

The author, in his reply to Kenneth Lewes's discussion of his paper, “Straight, Gay, or Both: The Case of Michael,” takes up several theoretical and technical issues raised by Lewes about how best to understand and work with patients who are confused and conflicted about their sexual orientation. A therapist's theoretical orientation (i.e., Freudian vs. Relational/Intersubjective) can result in differing conceptual emphases (for example, sexual drives seen as primary vs. sexuality seen as reflecting self-esteem and affiliational needs) and differing therapeutic styles of intervention (“probing” and “challenging” vs. what Lewes characterizes as “undue concern for tact”). However each approach inevitably has an impact on the patient's transferential experience, often in unforeseen ways. The author also discusses some of the implications of the discordance in sexual orientation between therapist and patient, which may complicate the therapy process, and the question of whether sexual orientation is ...

This article presents a summary of the ongoing treatment of a man in his fifties who has lived the life of a “happily married man with children” for more than 20 years but who has intermittently sought out clandestine sexual encounters with other men. His wife's discovery of his homosexual activities precipitated a psychological crisis that has forced him to grapple with his confusion and conflicts about his sexual orientation and his identity as a “man.” The article explores some of the ways in which the patient's personal history has complicated the issues of sexual orientation and gender identity for him.

*School of Marine Affairs, University of Washington, Seattle, WA, USA †Office of the Deputy Vice-Chancellor, Massey University, Auckland, New Zealand ‡Oregon Agricultural Experiment Station, Oregon State University, Corvallis, OR, USA §School of Hospitality and Tourism, Auckland University of Technology, Auckland, New Zealand ¶New Zealand Tourism Research Institute, Auckland University of Technology, Auckland, New Zealand

This article comments briefly on the origins of surfing and its growth through the 20th century, discusses the growth of participation in surfing, and then uses a range of social science techniques including observed market expenditure and nonmarket valuation to describe the socioeconomic value of surfing at various locations. The findings demonstrate the significant economic, social, and cultural importance of surfing amenity, the need to clearly articulate and measure changes in recreational amenity, and the need to consider any negative impacts on surf breaks and the natural environment that may occur as a result of development, coastal planning, and protection works. © 2009 Cognizant Comm. Corp.

Hypertrophic cardiomyopathy (HCM) is the most common hereditary cardiac condition and the leading cause of sudden cardiac death (SCD) in young adults. Given that SCD can be the first and most devastating clinical expression of HCM, identifying individuals at high risk is paramount. Determining an individual's risk for HCM-related SCD requires a thorough understanding of the recognized risk factors, of which there are seven established or 'major' and five 'possible'. Major risk factors can be identified by thoroughly reviewing a patient's personal medical history and noninvasive cardiovascular testing. The presence of major risk factors identify patients who are at high enough risk of SCD to warrant consideration of an implantable cardioverter-defibrillator; whereas the absence of any major risk factors provides considerable reassurance to both patient and physician. The risk of HCM-related SCD in patients with no major risk factors is, however, not zero. Possible risk factors gain importance in the presence of an isolated major risk factor. Here, we provide a contemporary review of established and possible risk factors for HCM-related SCD. We also examine microvolt T-wave alternans and cardiovascular MRI as emerging risk stratification tools that could further hone our ability to accurately identify the high-risk patient.

This in vivo ovine study describes the feasibility and safety of retrieving implanted leadless pacemakers (LPs).Although LPs have been shown to be removable soon after implantation, there are no data on the feasibility of removing chronically implanted LPs.This study was performed in 2 phases. In the mid-term cohort, 10 chronically (5.3 months) implanted animals underwent retrieval, followed by: 1) immediate necropsy in 5; and 2) in the remaining 5, reimplantation of a new LP followed by necropsy at 6 weeks. In the long-term cohort, 8 additional sheep underwent retrieval at 2.3 ± 0.1 years followed by necropsy. Retrieval was performed using either a single or triple loop snare. All 18 LPs (100%) were successfully retrieved. The time from retrieval catheter insertion to retrieval was 2:35 ± 01:11 and 3:04 ± 01:13 minutes in the mid-term and long-term study groups, respectively.There were no significant differences in retrieval times using either snare. Intracardiac echocardiography was used pre- and post-retrieval to confirm the absence of pericardial effusion in all 8 sheep. On necropsy, there was no evidence of pericardial bleeding or perforation. Only minor tissue disruption and hemorrhage was noted at the implant site after retrieval. Histology demonstrated fibrous connective tissue at the contact sites of endocardium and LP can and at the helix. There was no evidence of pulmonary thromboembolism.We demonstrate the feasibility and safety of percutaneous, catheter-based retrieval in chronic LP implants of a maximum duration of approximately 2.5 years.

Despite significant advances in battery longevity, lead performance, and programming features since the first implanted permanent pacemaker was developed, the basic design of cardiac pacemakers has remained relatively unchanged over the past 50 years. Because of inherent limitations in their design, conventional (transvenous) pacemakers are prone to multiple potential short- and long-term complications. Accordingly, there has been intense interest in a system able to provide the symptomatic and potentially lifesaving therapies of cardiac pacemakers while mitigating many of the risks associated with their weakest link-the transvenous lead. Leadless cardiac pacing represents the future of cardiac pacing systems, similar to the transition that occurred from the use of epicardial pacing systems to the familiar transvenous systems of today. This review summarizes the current evidence and potential benefits of leadless pacing systems, which are either commercially available (in Europe) or under clinical investigation.

Marine environmental education is a powerful mechanism for shaping human conduct and for enhancing quality of life. Regulation notwithstanding, sustainable tourism depends on sustainable education. Over the last several decades, whale-watching tourism has emerged as a nature-based business and leisure activity of significant proportions. Typically, whale watching brings together vessel operators and their crew, professional onboard naturalists or interpreters, and diverse categories of whale-watching clients or tourists. This compound interest in whales as (eco)touristic objects has led to campaigns for living marine resource management regimes that protect whales while optimizing the whale-watching experience. Preliminary survey research of whale-watching tourists in the San Juan Islands, Washington (USA) reveals that whale-watchers' expectations concern seeing whales and other wildlife, along with learning about the whales and the marine environment. Whale-watchers' evaluations of their experience confirm that onboard interpreters play two important and intertwined roles, helping to avoid disappointment if/when trip expectations are not met. As interpreters are successful as educators, educational and ecological objectives are achieved. As they are successful as social directors, social and business objectives are achieved. Implications of theses findings will be of interest to those in the whale-watching business and other forms of onboard tourism worldwide; those who aspire to be onboard interpreters; those who are whale watchers; and indirectly, to the whales.

A leadless cardiac pacemaker (LCP) system was recently introduced to overcome lead-related complications of conventional pacing systems. To date, long-term results of an LCP system are unknown.The aim of this study was to assess the complication incidence, electrical performance, and rate response characteristics within the first year of follow-up of patients implanted with an LCP.We retrospectively assessed intermediate-term follow-up data for 31 of 33 patients from the LEADLESS trial cohort who had an indication for single-chamber pacing and received an LCP between December 2012 and April 2013.The mean age of the cohort was 76 ± 8 years, and 65% were male. Between 3 and 12 months of follow-up, there were no pacemaker-related adverse events reported. The pacing performance results at 6- and 12-month follow-up were, respectively, as follows: mean pacing threshold (at a 0.4-ms pulse width), 0.40 ± 0.26 V and 0.43 ± 0.30 V; R-wave amplitude 10.6 ± 2.6 mV and 10.3 ± 2.2 mV; and impedance 625 ± 205 Ω and 627 ± 209 Ω. At the 12-month follow-up in 61% of the patients (n = 19 of 31), the rate response sensor was activated, and an adequate rate response was observed in all patients.The LCP demonstrates very stable performance and reassuring safety results during intermediate-term follow-up. These results support the use of the LCP as a promising alternative to conventional pacemaker systems. Continued evaluation is warranted to further characterize this system. (Evaluation of a New Cardiac Pacemaker; NCT01700244).

This article identifies a serious legal gap in current United States Department of Agriculture (USDA) policy concerning decisions about the review and release of biological pest control agents. Currently, most of the critical documents and the quantitative evidence underlying USDA decisions and policy related to the petition, review, and release of biological pest control agents (biocontrols) for weeds are inaccessible. Current practices do not provide sufficient information for biologists or an informed public to understand or evaluate policy decisions and environmental outcomes. The USDA needs to comply with federal law by making all relevant documents and data available on the internet. Federal law and policy requires that the USDA release all relevant information, and make it readily accessible to all interested parties. Public disclosure of all relevant documents, along with the scientific evidence related to the review and release of biocontrols, is required by the Administrative Procedure Act, the Freedom of Information Act, the Federal Advisory Committee Act, the National Environmental Policy Act of 1970, and the Plant Protection Act of 2000. Disclosure of this information will impose at most a trivial financial and administrative burden on the USDA Animal and Plant Health Inspection Service, or the Division of Plant Protection and Quarantine. The importance of full information and open debate in the pursuit of both scientific knowledge and sound environmental management far outweighs any administrative burden.

The coastal economy of the municipality of Mabini located on the Calumpan Peninsula of Luzon has roots on one coast in the harvest of fish and on the opposite coast in the attraction of dive tourists and other recreationalists from metropolitan Manila. Marine protected areas at the base of the municipality promoted by foreign and local conservationists provide de facto illustrations of integrated coastal management. Social survey results show that MPA management and enforcement policies have both benefited and disappointed fishery and tourism constituencies. To a degree, the inherent economic advantages enjoyed by the tourism sector have marginalized the fishery sector in terms of access and control of the MPAs both sectors helped to establish in the municipality. The viability of MPAs in Mabini will depend on the abilities of leaders and managers to reconcile top-level policies of conservation and economic development with local community aspirations.

In concert with an ambitious national agenda that emphasizes free trade and globalization, lncheon Metropolitan City is taking the first steps toward reinventing itself to become a twenty-first century “Pentaport” with integrated Seaport, Airport, Technoport, Business Port, and Leisure Port components. The lncheon Pentaport transformation-projected to be complete by 2020-will entail significant industrial, sociological, and institutional modification. Leisure Port objectives can be achieved through responsible planning attuned to the ideal of sustainable development and by empirical studies of lncheon tourism and leisure dynamics. International benchmarks of leisure port success are found in Sydney, Australia; Vancouver, Canada; and San Diego, USA, among seven other cosmopolitan cities. Growth estimations for coastal ferry passengers; beach use; recreational vessels and yachts in the lncheon region are encouraging. lncheon Leisure Port development of ten amenity destinations will require equal and multidisciplinary attention to questions of tourism design and tourism impacts. Important issues will concern environmental quality, clean shipping practices, the proper balance of modem and traditional amenities and attractions, trade-offs of cultural homogeneity and cultural diversity, and creative destination branding and marketing, among others.

Natural resource policies in the United States are implemented with a social technology of objectivity. Accordingly, resource managers rely on scientific and quantitative analyses to satisfy constituencies distrustful of regulatory authorities. Cultural consensus analysis is a powerful method for determining whether knowledge domains are structured in ways that support a conclusion that cultural members recognize certain cultural truths not known before-hand to the investigator. The authors compare hand-line fishermen and fishery scientists in Hawaii regarding their knowledge about stock structure, fish movements, resource abundance, stock condition, and fishery interactions. Yellow fin tuna fishery results show that fishermen and scientists exhibit an overall consensus about ecological knowledge, although they disagree in some areas. Some practical advantages of consensus analysis are discussed along with the possibilities for growth in the fishery social science sector, cross-cultural applied research, and the practice of environmental anthropology.

In patients with structural heart disease, scar-related ventricular tachycardia (VT) is often associated with hemodynamic instability that precludes detailed entrainment and activation mapping. Furthermore, repetitive inductions of short periods of unstable VT, or even prolonged episodes of otherwise well-tolerated VT, can have a detrimental cumulative effect and expose patients to progressive hemodynamic compromise and end-organ dysfunction. As a result, ablation strategies in patients with scar-VT and significant structural heart disease are often limited to substrate mapping and ablation performed in sinus rhythm.1 Although this approach seems to be effective for a significant number of postmyocardial infarction patients, it is less applicable to other patient populations, such as those with nonischemic cardiomyopathy, which comprise more than one third of all patients presenting with scar-VT and comprises increasing proportion of scar-VT substrates. A substrate-based ablation strategy (late potentials and pace-mapping) is significantly less effective in patients with nonischemic cardiomyopathy as compared with ischemic cardiomyopathy, because of the relative paucity of putative channels in sinus rhythm.2 Furthermore, pure substrate-based ablation is considered nonspecific, and VT can recur in up to half of patients despite extensive substrate modification.1 Finally, patients with VT circuits adjacent to critical structures, such as the coronary artery or phrenic nerve, would also be less than optimal candidates for substrate-based ablation. Despite these limitations, substrate-based ablation is familiar to most operators and avoids the potential negative outcomes associated with prolonged episodes of VT. Article see p 244 However, entrainment/activation mapping is proof that a targeted isthmus is clinically relevant, may be the only option for certain substrates, and theoretically may require less ablation. Although intravenous vasopressors/inotropes are often used to stabilize blood pressure and cardiac output to allow detailed mapping, they are usually insufficient for mapping fast VT or multiple VTs.3 Intra-aortic balloon pumps, which are …

Standard unipolar radiofrequency ablation (RFA) is typically successful in eliminating premature ventricular contractions (PVCs) originating from the ventricular outflow tract region. In a minority of cases, this approach may be ineffective. We report 4 cases where bipolar RFA was attempted after failed unipolar RFA.From a total of 73 consecutive PVC ablations, 4 patients underwent bipolar RFA after failed unipolar ablation. Three-dimensional electroanatomic activation mapping of the right and left ventricular outflow (RVOT and LVOT), coronary sinus, and aortic root was performed.Mean age was 53 ± 22 years, 3 male. The mean 24-hour PVC burden in these patients was 33,107 ± 8,712. In 3 of 4 patients, the RVOT activation was earlier than the left side. The earliest activation on the left was in the right coronary cusp in 2 patients and left coronary cusp in 2. Unipolar RFA delivered sequentially at the site of earliest RVOT and then earliest aortic cusp sites failed to eradicate the PVCs in all 4 patients. Subsequently, bipolar RFA was applied between irrigated catheters placed at the earliest RVOT and aortic root sites. This approach eliminated PVCs in 3 of 4 (75%) cases. At a median follow-up of 4 months, those with successful bipolar RFA had no recurrence of clinical PVCs.This report demonstrates the potential utility of bipolar RFA in patients with outflow tract PVCs that fail unipolar RFA.

Background— Conventional cardiac pacemakers are associated with several potential short- and long-term complications related to either the transvenous lead or subcutaneous pulse generator. We tested the safety and clinical performance of a novel, completely self-contained leadless cardiac pacemaker. Methods and Results— The primary safety end point was freedom from complications at 90 days. Secondary performance end points included implant success rate, implant time, and measures of device performance (pacing/sensing thresholds and rate-responsive performance). The mean age of the patient cohort (n=33) was 77±8 years, and 67% of the patients were male (n=22/33). The most common indication for cardiac pacing was permanent atrial fibrillation with atrioventricular block (n=22, 67%). The implant success rate was 97% (n=32). Five patients (15%) required the use of >1 leadless cardiac pacemaker during the procedure. One patient developed right ventricular perforation and cardiac tamponade during the implant procedure, and eventually died as the result of a stroke. The overall complication-free rate was 94% (31/33). After 3 months of follow-up, the measures of pacing performance (sensing, impedance, and pacing threshold) either improved or were stable within the accepted range. Conclusions— In a prospective nonrandomized study, a completely self-contained, single-chamber leadless cardiac pacemaker has shown to be safe and feasible. The absence of a transvenous lead and subcutaneous pulse generator could represent a paradigm shift in cardiac pacing. Clinical Trial Registration— URL: http://clinicaltrials.gov . Unique identifier: NCT01700244.

OBJECTIVE AND IMPORTANCE: Tophaceous gout uncommonly affects the axial skeleton. The clinical presentations of gout of the spine range from back pain to quadriplegia. Gout that presents as back pain and fever may be difficult to distinguish from spinal infection. We present a case of a patient with tophaceous gout of the lumbar spine who was initially diagnosed with and treated for an epidural infection. The clinical and diagnostic features of tophaceous gout of the spine are reviewed. CLINICAL PRESENTATION: A 70-year-old man presented with a 2-day history of fever and back pain. A physical examination revealed that he had flank tenderness and evidence of polyarthritis affecting the elbows, knees, and right first metatarsophalangeal joint. A magnetic resonance imaging scan of the patient's lumbar spine showed an extensive area of abnormal gadolinium enhancement of the paramedian posterior soft tissues from L3 to S1 with an area of focal enhancement extending into the right L4-L5 facet joint. INTERVENTION: A laminectomy was performed at L4-L5, and a chalky white material in the facet joint was found eroding into the adjacent pars intra-articularis. Light and polarizing microscopy confirmed the presence of gouty tophus. No evidence of infection was found. CONCLUSION: Gouty arthritis of the spine is rare. Thirty-seven previous cases have been reported. When the clinical presentation includes acute back pain and fever, differentiation of spinal gout from spinal infection may be difficult. The clinical suspicion of spinal gout may lead to the correct diagnosis by a less invasive approach than exploration and laminectomy.

This paper considers the constitutionality and wisdom of systematic presidential pardons. A systematic pardon is a pardon applied to a group of offenders selected based on described and consistent criteria and processes, and for reasons that may reflect concerns of justice, equality, and wise policy, rather than mercy. Though the question of the validity of systematic pardons has been ignored by academics, it is far from merely academic. Systematic pardons have been used by presidents through U.S. history, including modern pardons for draft resisters after World War II and the Vietnam War, and pardons for offenders who received excessive mandatory sentences under the Narcotics Act of 1956. Sometimes these pardons have been issued for all members of an identified class; in other instances special presidential boards have been set up to evaluate a group in terms of articulated criteria and to then make pardon recommendations. Shortly after the last presidential election, President Elect Bush and President Clinton both observed that the penalty differentials for possession of crack cocaine and powder cocaine are unjustified. Scholars and the U.S. Sentencing Commission have noted the highly disparate racial impact of the current 100:1 crack/cocaine "quantity" ratio under federal sentencing laws. We examine whether President Clinton then or President Bush now might use the pardon power to reduce incarceration for a class of people serving sentences for possession of crack cocaine to the level of those incarcerated for possession of powder cocaine, or to some other level fully articulated and justified as principled policy. The basic constitutional objection to systematic use of the pardon power by a president to further a policy goal is that it may violate the separation of powers to allow the president to undo what Congress and the courts have approved. We consider the tension between the president's obligation to "take Care that the Laws be faithfully executed," Art. II, sec. 3, and the distinct constitutional power stating that the President "shall have Power to grant Reprieves and Pardons for Offences against the United States, except in Cases of Impeachment." Art II, sec. 2, cl. 1. We examine evidence of original intent, constitutional interpretation of the pardon power, and the overlooked historical practice regarding systematic pardons. We conclude that systematic pardons are both constitutional and, in appropriate circumstances, wise policy.