Mid-term outcomes of delivery catheter-based and stylet-based right ventricular septal pacing: Follow-up results from a multicenter, prospective, randomized study.

Background: The Mt FUJI study was a multicenter, prospective, randomized, single-blind, controlled trial comparing delivery catheter-based and stylet-based right ventricular (RV) lead placement at the RV septum. This study extended the follow-up duration to 1 year after implantation. Methods: Seventy patients with pacemaker indications for atrioventricular block were randomly assigned to the delivery catheter and stylet groups. We compared the mid-term efficacy and safety between the two groups at 1 year after implantation. The primary outcome was the change in the left ventricular ejection fraction (LVEF), and the secondary outcomes were changes in brain natriuretic peptide (BNP) levels, lead parameters, paced QRS duration, and the incidence of adverse events. Results: At the 1-year follow-up, no significant differences were observed in the changes in the LVEF (+1.0% ± 8.6% vs. +3.1% ± 8.1%, p = .332), BNP levels (+8.0 [-11.1, 26.5] pg/mL vs. -8.7 [-15.3, 13.2] pg/mL, p = .193), or lead performance between the delivery catheter and stylet groups. The QRS duration was significantly shorter in the delivery catheter group than in the stylet group (128 ± 23 ms vs. 146 ± 17 ms, p < .001). All-cause death, hospitalization for heart failure, new development of atrial fibrillation, and pacing-induced cardiomyopathy occurred in seven patients in the delivery catheter group and five in the stylet group. Conclusion: The delivery catheter system was similarly useful and safe compared to the stylet system in the mid-term follow-up from the Mt FUJI trial. Further long-term evaluations are warranted.

Short- and long-term performance of risk calculation tools for mortality in patients with acute coronary syndrome.

Background: The mortality rate of acute coronary syndrome (ACS) remains high. Therefore, patients with ACS should undergo early risk stratification, for which various risk calculation tools are available. However, it remains uncertain whether the predictive performance varies over time between risk calculation tools for different target periods. This study aimed to compare the predictive performance of risk calculation tools in estimating short- and long-term mortality risks in patients with ACS, while considering different observation periods using time-dependent receiver operating characteristic (ROC) analysis. Methods: This study included 404 consecutive patients with ACS who underwent coronary angiography at our hospital from March 2017 to January 2021. The ACTION and GRACE scores for short-term risk stratification purposes and CRUSADE scores for long-term risk stratification purposes were calculated for all participants. The participants were followed up for 36 months to assess mortality. Using time-dependent ROC analysis, we evaluated the area under the curve (AUC) of the ACTION, CRUSADE, and GRACE scores at 1, 6, 12, 24, and 36 months. Results: Sixty-six patients died during the observation periods. The AUCs at 1, 6, 12, 24, and 36 months of the ACTION score were 0.942, 0.925, 0.889, 0.856, and 0.832; those of the CRUSADE score were 0.881, 0.883, 0.862, 0.876, and 0.862; and those of the GRACE score 0.949, 0.928, 0.888, 0.875, and 0.860, respectively. Conclusions: The ACTION and GRACE scores were excellent risk stratification tools for mortality in the short term. The prognostic performance of each risk score was almost similar in the long term, but the CRUSADE score might be a superior risk stratification tool in the longer term than 3 years.

Delivery catheter system carries more physiological right ventricular septal pacing than stylet system.

INTRODUCTION: The Mt. FUJI multicenter trial demonstrated that a delivery catheter system had a higher rate of successful right ventricular (RV) lead deployment on the RV septum (RVS) than a conventional stylet system. In this subanalysis of the Mt. FUJI trial, we assessed the differences in electrocardiogram (ECG) parameters during RV pacing between a delivery catheter system and a stylet system and their associations with the lead tip positions. METHODS: Among 70 patients enrolled in the Mt FUJI trial, ECG parameters, RV lead tip positions, and lead depth inside the septum assessed by computed tomography were compared between the catheter group (n = 36) and stylet group (n = 34). RESULTS: The paced QRS duration (QRS-d), corrected paced QT (QTc), and JT interval (JTc) were significantly shorter in the catheter group than in the stylet group (QRS-d: 130 ± 19 vs. 142 ± 15 ms, p = .004; QTc: 476 ± 25 vs. 514 ± 20 ms, p < .001; JTc: 347 ± 24 vs. 372 ± 17 ms, p < .001). This superiority of the catheter group was maintained in a subgroup analysis of patients with an RV lead tip position at the septum. The lead depth inside the septum was greater in the catheter group than in the stylet group, and there was a significant negative correlation between the paced QRS-d and the lead depth. CONCLUSION: Using a delivery catheter system carries more physiological depolarization and repolarization during RVS pacing and deeper screw penetration in the septum in comparison to conventional stylet system. The lead depth could have a more impact on the ECG parameters rather than the type of pacing lead.

Usefulness of delivery catheter on accurate right ventricular septal pacing: Mt FUJI trial.

AIMS: Although the delivery catheter system for pacemaker-lead implantation is a new alternative to the stylet system, no randomized controlled trial has addressed the difference in right ventricular (RV) lead placement accuracy to the septum between the stylet and the delivery catheter systems. This multicentre prospective randomized controlled trial aimed to prove the efficacy of the delivery catheter system for accurate delivery of RV lead to the septum. METHODS AND RESULTS: In this trial, 70 patients (mean age 78 ± 11 years; 30 men) with pacemaker indications of atrioventricular block were randomized to the delivery catheter or the stylet groups. Right ventricular lead tip positions were assessed using cardiac computed tomography within 4 weeks of pacemaker implantation. Lead tip positions were classified into RV septum, anterior/posterior edge of the RV septal wall, and RV free wall. The primary endpoint was the success rate of RV lead tip placement to the RV septum. RESULTS: Right ventricular leads were implanted as per allocation in all patients. The delivery catheter group had higher success rate of RV lead deployment to the septum (78 vs. 50%; P = 0.024) and narrower paced QRS width (130 ± 19 vs. 142 ± 15 ms P = 0.004) than those in the stylet group. However, there was no significant difference in procedure time [91 (IQR 68-119) vs. 85 (59-118) min; P = 0.488] or the incidence of RV lead dislodgment (0 vs. 3%; P = 0.486). CONCLUSION: The delivery catheter system can achieve a higher success rate of RV lead placement to the RV septum and narrower paced QRS width than the stylet system. TRIAL REGISTRATION NUMBER: jRCTs042200014 (https://jrct.niph.go.jp/en-latest-detail/jRCTs042200014).

Case of catheter ablation of atrial fibrillation in a very young patient without structural heart disease.

The patient was an 18-year-old man who suffered frequent supraventricular premature complexes (SVPCs) and atrial fibrillation. Catheter ablation was performed, and the left pulmonary vein had been isolated, although firing from within the left inferior pulmonary vein remained. After that, the patient did not exhibit SVPCs and atrial fibrillation.

Sequential Abolition of Antegrade and Retrograde Conduction in Wolff-Parkinson-White Syndrome: A Case Series.

BACKGROUND Radiofrequency ablation in cases of Wolff-Parkinson-White (WPW) syndrome is a relatively safe procedure that yields good results. However, the electrical characteristics of WPW syndrome have not yet been fully elucidated. Herein, we report 2 cases of WPW syndrome, wherein antegrade conduction was abolished first, followed by retrograde conduction. CASE REPORT Case 1: A 15-year-old boy who recently reported experiencing frequent palpitations was diagnosed with type A WPW syndrome by electrocardiography (ECG). Radiofrequency energy was delivered to the earliest activation site using an ablation catheter. This procedure abolished antegrade accessory pathway conduction in 6 seconds, and then the ablation was continued for 60 seconds; however, retrograde accessory pathway conduction remained intact. Hence, radiofrequency ablation was performed to further deliver radiofrequency energy to abolish the retrograde accessory pathway conduction. Case 2: A 19-year-old woman with palpitations since elementary school was diagnosed with type A WPW syndrome by ECG. Radiofrequency energy was delivered to the earliest activation site through an ablation catheter to abolish antegrade accessory pathway conduction in approximately 1 second, and then the ablation was continued for 60 seconds. Retrograde accessory pathway conduction was preserved, and further radiofrequency ablation performed multiple times in the same vicinity abolished retrograde accessory pathway conduction. CONCLUSIONS We managed 2 cases of WPW syndrome wherein antegrade and retrograde accessory pathway conduction were individually abolished. This phenomenon may have been caused by an incomplete lesion that resulted in a functional block.

Defibrillation threshold of internal cardioversion prior to ablation predicts atrial fibrillation recurrence.

BACKGROUND: Many studies have reported the predictors of atrial fibrillation (AF) recurrence after persistent AF (peAF) ablation. However, the correlation between the atrial defibrillation threshold (DFT) for internal cardioversion (IC) and AF recurrence rate is unknown. Here we investigated the relationship between the DFT prior to catheter ablation for peAF and AF recurrence. HYPOTHESIS: DFT prior to ablation was the predictive factor for AF recurrence after peAF ablation. METHODS: From June 2016 to May 2019, we enrolled 82 consecutive patients (mean age, 65.0 ± 12.4 years), including 45 with peAF and 37 with long-standing peAF, at Hamamatsu Medical Center. To assess the DFT, we performed IC with gradually increasing energy prior to radiofrequency application. RESULTS: Forty-nine and 33 patients showed DFT values less than or equal to 10 J (group A) and greater than 10 J or unsuccessful defibrillation (group B). During the mean follow-up duration of 20.5 ± 13.1 months, patients in group B showed significantly higher AF recurrence rates than those in group A after the ablation procedure (p = .017). Multivariate analysis revealed that DFT was the only predictive factor for AF recurrence (odds ratio, 1.07; 95% CI, 1.00-1.13, p = .047). CONCLUSIONS: The DFT for IC was among the strongest prognostic factors in the peAF ablation procedure.

Aberrant serum polyunsaturated fatty acids profile is relevant with acute coronary syndrome.

Although a robust relationship between aberrant serum polyunsaturated fatty acids (PUFAs) profile and coronary artery disease (CAD) has been reported, the details concerning the association between aberrant PUFAs profile and clinical feature of CAD are not fully discovered. Therefore, we investigated the relationship between serum PUFAs and clinical profiles in CAD patients. We classified 595 consecutive CAD patients, who underwent coronary angiography into 3 groups according to the clinical profiles of CAD (group A: early phase ACS, n = 96; group B: stable CAD with previous history of ACS, n = 259; group C: stable CAD without previous history of ACS, n = 240) and measured serum n-3 [eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA)] and n-6 [arachidonic acid (AA)] PUFAs. Serum EPA, DHA, and EPA/AA ratio were significantly low in the order of group A < B < C [EPA; 48.1 (34.1-60.3) µg/ml, 61.7 (41.2-94.5) µg/ml, and 74.4 (52.7-104.9) µg/ml, DHA; 113.1 (92.8-135.1) µg/ml, 125.8 (100.4-167.2) µg/ml, and 140.1 (114.7-177.0) µg/ml, EPA/AA ratio; 0.31 (0.22-0.45), 0.39 (0.26-0.62), and 0.44 (0.31-0.69), medians with interquartile range, p < 0.01]. Multiple regression analysis revealed that EPA (p = 0.009) and EPA/AA ratio (p = 0.023), but not DHA and DHA/AA ratio, were negatively associated with clinical profiles of ACS in CAD patients. Significant correlation was not observed between PUFAs profile and severity of coronary stenosis. Low serum EPA and EPA/AA ratio correlates with clinical profiles of ACS in patients with CAD, regardless of the extent and severity of coronary artery stenosis.

A case of ventricular septal rupture associated with major septal branch occlusion after percutaneous coronary intervention.

A 67-year-old man underwent elective percutaneous coronary intervention (PCI) of the left anterior descending artery. The major septal branch became occluded during coronary stenting. The patient developed dyspnea 19 days later. Chest radiography revealed lung congestion and a pleural effusion. Transthoracic echocardiography revealed a basal ventricular septal rupture. Emergency coronary angiography did not reveal any in-stent restenosis, and the major septal branch remained occluded. Therefore, the patient underwent closure of the ventricular septal rupture. The postoperative period was uneventful, and he was discharged 29 days after the operation. Septal branch occlusion due to coronary stenting occasionally occurs during routine PCI for which recanalization is sometimes not attempted. However, this case demonstrates that occluded septal branches, although rare, may cause serious complications. .

Peripartum cardiomyopathy with biventricular thrombus which led to massive cerebral embolism.

A 37-year-old female who delivered her second child via a cesarean section 4 months previously presented to our hospital with gradual worsening of dyspnea on effort. Chest radiographic appearance showed cardiomegaly (cardiothoracic ratio 61%) and slight bilateral pulmonary congestion. Echocardiogram revealed diffuse hypokinesis of both left and right ventricles (left ventricular ejection fraction 29%) and large biventricular thrombus [left ventricular apex (28 mm × 21 mm, 22 mm × 14 mm) and right ventricular apex (16 mm × 11 mm)]. She was diagnosed as having peripartum cardiomyopathy (PPCM) and anticoagulation therapy was started. Surgical thrombectomy was not selected because of risk of complications. Massive cerebral infarction occurred 10 days after diagnosis. She was discharged with aphasia and right incomplete hemiplegia 65 days after admission. Biventricular thrombus is a rare complication of PPCM. If high risk of massive embolism is considered, surgical thrombectomy may be warranted even in cases with low cardiac function. .