The differences between conventional lead, thin lead, and leadless pacemakers regarding effects on tricuspid regurgitation in the early phase.

PURPOSE: Trans-venous pacemaker leads are associated with worsening of tricuspid regurgitation (TR) after pacemaker implantation (PMI) in some cases. Recently, leadless pacemakers and thin ventricular pacemaker leads without a stylet lumen have become popular. However, the differences in the effects of these leads on TR are unclear. We investigated differences in the changes in TR in the early phase after PMI in patients with conventional leads, thin leads, and leadless pacemakers. METHODS: We enrolled 65 patients who underwent PMI (32 males, 79 ± 8 years), including 48 with trans-venous PMI (29 with conventional 6.0-Fr leads and 19 with 4.1-Fr thin leads) and 17 with leadless pacemakers. Transthoracic echocardiography was performed before and 1 month after PMI for assessment of conventional echocardiographic parameters and severity of TR by quantitative assessment. RESULTS: Atrial fibrillation was the most frequent indication for PMI in patients with leadless pacemakers (p = 0.015). In the before and 1 month after PMI comparison, left ventricular ejection fraction decreased after PMI only in the conventional lead group (p = 0.022). The TR effective regurgitant orifice area (EROA) decreased post PMI in the leadless (p = 0.002) and thin lead groups (p = 0.001), but not in the conventional lead group (p = 0.596). The change in TR EROA was greater in the leadless and thin lead groups as compared with the conventional lead group (p < 0.05). CONCLUSION: The decrease in TR EROA in the early phase after PMI differed according to the type of pacemaker lead. The thin lead might be beneficial for reduction of TR after PMI.

Efficacy of Sodium-Glucose Cotransporter 2 Inhibitors on Outcomes After Catheter Ablation for Atrial Fibrillation.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have recently been a significant focus of attention because of their multiple pleiotropic effects. However, the impact of SGLT2i on atrial fibrillation (AF) remains unclear. OBJECTIVES: The goal of this study was to examine the effects of SGLT2i on AF after catheter ablation (CA). METHODS: This prospective, randomized controlled study compared the suppressive effect of SGLT2i vs dipeptidyl peptidase-4 inhibitors on AF recurrence after CA. Eighty AF patients with type 2 diabetes mellitus were randomized (by a computer-generated random sequence) to the tofogliflozin group (20 mg/d) or the anagliptin group (200 mg/d) stratified according to left atrial diameter and AF type (paroxysmal AF [PAF] or non-paroxysmal atrial fibrillation [PAF]) at screening. The primary outcome was AF recurrence at 12 months after CA. RESULTS: Seventy patients were analyzed (mean age 70.3 ± 8.1 years; 48 male; 30 with paroxysmal AF; 38 tofogliflozin treated). Recurrent AF was detected in 24 (34.3%) of 70 patients, and the AF recurrence ratio was higher in the anagliptin group than in the tofogliflozin group (15 of 32 patients [47%] vs 9 of 38 patients [24%]; P = 0.0417). Moreover, univariate analysis revealed that compared with the nonrecurrence group (n = 46), the recurrence group (n = 24) had a higher prevalence rate of non-PAF, elevated brain natriuretic peptide, higher urinary albumin-creatinine ratio, lower rate of SGLT2i use, larger left atrial diameter, elevated E wave, lower left ventricular ejection fraction, and lower rate of cryoballoon pulmonary vein isolation. CONCLUSIONS: Compared with anagliptin, tofogliflozin achieved greater suppression of AF recurrence after CA in patients with type 2 diabetes mellitus.

Increase in heart rate-dependent left atrial pressure is associated with symptoms in patients with paroxysmal atrial fibrillation.

BACKGROUND: It remains unclear why some patients with the same heart rate during an atrial fibrillation (AF) have subjective symptoms, whereas others do not. We assessed the hypothesis that different responses of arterial and left atrial blood pressures to rapid stimulation may be associated with the symptoms of AF. METHODS: A total of 110 patients who underwent catheter ablation for paroxysmal AF were retrospectively studied. Asymptomatic AF was defined as a European Heart Rhythm Association score of Ⅰ for AF-related symptoms. The left atrial pressure (LAP) was measured during sinus rhythm (SR), in 10 pacing per minute (ppm) increments from 100 ppm to the Wenckebach block rate in high right atrial pacing. RESULTS: Asymptomatic AF was observed in 19/110 patients (17%). Patients with symptomatic AF showed higher E/e' ratio and gradual LAP increase that was dependent on the pacing rate. Patients with asymptomatic AF had decreased LAP at 100 ppm compared that at SR, and thereafter, LAP gradually increased depending on the pacing rate. The rate of LAP change compared to that at SR was significantly lower in patients with asymptomatic AF than that in patients with symptomatic AF. The rate of LAP change was independently associated with AF symptoms. CONCLUSION: Patients with asymptomatic AF showed lower E/e' ratio and decreased LAP at 100 ppm to rapid stimulation, followed by a steady increase in LAP afterwards. Factors other than left ventricular diastolic dysfunction may be involved in AF symptoms.

Left ventricular stiffness assessed by diastolic Wall strain predicts asymptomatic atrial high-rate episodes in patients with pacemaker implantation.

BACKGROUND: Cardiac implantable electronic device-detected atrial high-rate episodes (AHREs) have been reported to be associated with thromboembolic risks. The present study aimed to investigate the association of echocardiographic and clinical parameters with the occurrence of AHREs in patients with a dual-chamber pacemaker (PMI). METHODS: One hundred forty-seven patients (76 males, 75.2 ± 8.9 years) who did not show atrial tachyarrhythmia before the implantation of the PMI were studied. Diastolic wall strain (DWS) and other measurements were assessed during sinus rhythm using transthoracic echocardiography before the PMI. DWS was calculated from the M-mode echocardiographic measurement of the left ventricular (LV) posterior wall thickness at end-systole (PWs) and end-diastole (PWd), and DWS was defined as (PWs-PWd) / PWs. RESULTS: AHREs (defined as AHREs duration >6 min and atrial rate >180 bpm) were detected in 50 / 147 patients during follow up (38.3 ± 13.8 months). Patients in the AHREs group had reduced DWS (0.29 ± 0.07 vs. 0.39 ± 0.06, p < 0.0001), larger left atrial volume index, thicker LV posterior diameter, higher rate of patients taking ß-blocker / diuretics, and higher prevalence of sinus node dysfunction. On multivariable analysis, only DWS was independently associated with AHREs. Patients with reduced DWS (<0.33) had a higher risk of incidences of AHREs. CONCLUSION: LV stiffness assessed by DWS was associated with AHREs in patients with a PMI.

Predictors for reduced flow velocity in left atrial appendage during sinus rhythm in patients with atrial fibrillation.

Discontinuation of anticoagulation therapy after catheter ablation (CA) for atrial fibrillation (AF) remains controversial. While decreased left atrial appendage flow velocity (LAAFV) during AF leads to left atrial appendage thrombus and embolic events, some AF patients show decreased LAAFV even during sinus rhythm (SR). We studied 392 patients (256 males, 68 ± 10 years) who exhibited SR during transesophageal echocardiography (TEE) before CA for AF. Clinical factors, transthoracic echocardiography, and blood samples were obtained before TEE. Reduced LAAFV was defined as < 35 cm/s of LAAFV. Reduced LAAFV was observed in 72/392 patients (18%). Reduced LAAFV was significantly associated with high prevalence of non-paroxysmal AF, elevated brain natriuretic peptide (BNP), prior heart failure, high CHADS2 score, high CHA2DS2-VASc score, no beta blocker administration, increased left atrial volume index (LAVI), elevated E/e' ratio, reduced left ventricular ejection fraction and high prevalence of left ventricular hypertrophy. On multivariate analysis, BNP (P = 0.0005, OR 1.045 for each 10 pg/ml increase in BNP, 95% CI 1.018-1.073) and LAVI (P = 0.0045, OR 1.044 for each 1 increase in LAVI, 95% CI 1.013-1.077) were associated with decreased LAAFV. The elevated BNP levels and large LAVI predict decreased LAAFV during SR in patients with AF.

Plasma brain natriuretic peptide level on admission predicts long-term outcome in patients with non-traumatic subarachnoid hemorrhage.

INTRODUCTION: Non-traumatic subarachnoid hemorrhage (SAH) is a type of stroke that still has a high mortality rate. Some patients with SAH have electrocardiography (ECG) abnormalities or asymptomatic left ventricular apical ballooning, and requires intervention by cardiologists. However, the impact of cardiac abnormalities after SAH onset remains unclear. We investigated whether ECG abnormalities, myocardial damage, sympathetic nervous activity or echocardiographic left ventricular wall motion abnormalities (WMA) could provide additional risk stratification in patients with SAH. METHODS: We studied 118 SAH patients (78 women, age 63 ± 15) without a history of heart disease. Neurological grade (Hunt and Kosnik Grade) and clinical factors were evaluated. A standard 12-lead ECG, echocardiography and blood samples were obtained within 48 h after SAH onset. ECG abnormalities were defined as abnormal Q wave, ST elevation, giant T-wave inversion or QT prolongation. RESULTS: Twenty of 118 patients (17%) died during the follow-up (35 ± 31 months). Death was significantly associated with higher age (p < 0.0001), neurological grade (p < 0.0001), elevated BNP level (p < 0.0001), increased plasma norepinephrine levels (p < 0.0001) and WMA (p = 0.0070), while ECG abnormalities were not significantly associated. Neurological grade (p < 0.0001), age (p = 0.0047) and BNP (p = 0.0014, hazard ratio 1.0255 for each 1 pg/mL increase in BNP, 95%CI 1.0088 to 1.0499) were independently associated with death. Patients with BNP ≥ 96.6 had a higher risk of death (log- rank p < 0.0001). CONCLUSION: Plasma BNP might provide an additional risk stratification in patients with non-traumatic SAH that requires intervention by cardiologists for both its prevention management after onset.

Is the abnormal conduction zone of the left atrium a precursor to a low voltage area in patients with atrial fibrillation?

BACKGROUND: The abnormal conduction zone (ACZ) in the left atrium (LA) has attracted attention as an arrhythmia source in atrial fibrillation (AF). We investigated the hypothesis that the ACZ is related to the low voltage area (LVA) or the LA anatomical contact areas (CoAs) with other organs. METHODS AND RESULTS: We studied 100 patients (49 non-paroxysmal AF, 66 males, and 67.9 ± 9.9 years) who received catheter ablation for AF. High-density LA mapping during high right atrial pacing was constructed. Isochronal activation maps were created at 5-ms interval setting, and the ACZ was identified on the activation map by locating a site with isochronal crowding of ≥3 isochrones, which are calculated as ≤27 cm/s. The LVA was defined as the following; mild ( < 1.3 mV), moderate (<1.0 mV), and severe LVA (<0.5 mV). The CoAs (ascending aorta-anterior LA, descending aorta-posterior LA, and vertebrae-posterior LA) were assessed using computed tomography. The ACZ was linearly distributed, and observed in 95 patients (95%). The ACZ was most frequently observed in the anterior wall region (77%). A longer ACZ was significantly associated with a larger LA size and a prevalence of non-PAF. The 51.2 ± 36.2% of ACZ overlapped with mild LVA, 32.9 ± 32.8% of ACZ with moderate LVA, and 14.6 ± 22.0% of ACZ with severe LVA. In contrast, only 25.6 ± 28.0% of ACZ matched with the CoAs. CONCLUSION: The ACZ reflects LA electrical remodeling and may be a precursor finding of the low voltage zone and not the LA CoAs in patients with atrial fibrillation.

Predictors of movable type left atrial appendage thrombi in patients with atrial fibrillation.

Left atrial appendage thrombi (LAAT) are the main cause of thromboembolic events. Especially, movable type LAAT is high-risk for thromboembolic events. We aimed to investigate the predictors of the movable type LAAT in patients with atrial fibrillation (AF). We retrospectively studied 827 consecutive patients who underwent transthoracic echocardiography (TEE) prior to cardioversion or catheter ablation for AF. Sixty-nine patients who underwent cardiac surgery or significant valvular disease were excluded. The remaining 758 patients (age 67.6 ± 9.3, 535 males) were included in this study. Clinical data were evaluated at the time of TEE. The LAAT were classified into movable and fixed type LAAT by three independent observers who did not know clinical data. LAAT were detected in 57 (11 with movable and 46 with fixed type) of 758 patients (7.5%). Patients with movable type LAAT had an elevated E/e' ratio, lower left ventricular ejection fraction (LVEF), larger left atrial volume index, elevated C-reactive protein, higher prevalence of non-paroxysmal AF, patients taking warfarin (73% vs. 21%, P < 0.0001), and structural heart disease than control group (fixed type LAAT and without LAAT). On multivariate analysis, E/e' ratio, LVEF, and taking warfarin were significantly associated with movable type LAAT. The rate of movable type LAAT was the highest (7 of 49 patients, 14.3%) in patients with elevated E/e' ratio (> 12.7) and decrease LVEF (< 44%). E/e' ratio and LVEF could predict movable type LAAT in patients with AF. High-risk patients might need powerful antithrombotic therapy or taking early TEE.

Aortic dissection during transoesophageal echocardiography: a case report.

BACKGROUND: Transoesophageal echocardiography (TOE) is a safe and useful tool. In our case, we are presenting a rare case of a patient with aortic dissection during TOE procedure. CASE SUMMARY: A 79-year-old woman was referred to our hospital for recurrent paroxysmal atrial fibrillation (AF) with palpitation. Pre-procedural cardiac computed tomography (CT) showed slight dilated ascending aorta (maximum diameter: 40 mm). We decided to perform catheter ablation (CA) for AF, and recommended TOE before the CA because she had a CHADS2 score of 4. On the day before the CA, TOE was performed. Her physical examinations at the time of TOE procedure were unremarkable. At 3 min after probe insertion, there was no abnormal finding of the ascending aorta. At 5 min after the insertion, TOE showed ascending aortic dissection without pericardial effusion. After waking, she had severe back pain and underwent a contrast-enhanced CT. Computed tomography demonstrated Stanford type A aortic dissection extending from the aortic root to the bifurcation of common iliac arteries, and tight stenosis in the right coronary artery (maximum diameter; 49 mm). The patient underwent a replacement of the ascending aorta, and a coronary artery bypass graft surgery for the right coronary artery. DISCUSSION: Transoesophageal echocardiography would have to be performed under sufficient sedation with continuous blood pressure monitoring in patients who have risk factors of aortic dissection. The risk-benefit of TOE must be considered before a decision is made. Depending on the situation, another modality instead of TOE might be required.

Left Ventricular Inflow Velocity Pattern in Patients With Symptomatic Premature Ventricular Contraction.

BACKGROUND: Because premature ventricular contractions (PVCs) are one of the most common arrhythmias, but with unclear causative mechanisms, we studied the hemodynamic features that can cause symptomatic PVCs.Methods and Results:We studied 109 patients (48 males, age 60±19 years) with frequent monomorphic PVCs and no structural heart disease. The left ventricular inflow diastolic filling velocity was recorded by transthoracic echocardiography (TTE) at the time of PVCs in all patients. We assessed the PVC E wave flow (E wave velocity×duration at PVC). A total of 38 patients (35%) had PVC-related symptoms (19 palpitations, 12 pulse deficit, 6 shortness of breath, 6 malaise, 1 syncope). These patients showed reduced PVC E wave flow (9.3±6.0 vs. 14.6±6.5 cm, P<0.0001), and reduced PVC stroke volume (20.5±10.8 vs. 29.9±17.2 mL, P=0.0030). In the multivariate analysis, only reduced PVC E wave flow was independently associated with PVC-related symptoms (P=0.00349, odds ratio: 1.134029, each 1.0 cm increase in PVC E wave flow, 95% confidence interval: 1.040726-1.247544). CONCLUSIONS: Decreased E wave flow at the time of PVC was independently related with PVC-related symptoms in patients with PVCs. The LV contraction at the time of inadequate filling might be a cause of PVC-related symptoms.

The association between left atrial stiffness and low-voltage areas of left atrium in patients with atrial fibrillation.

The low-voltage areas of left atrium (LA-LVA) have recently been of significant focus. However, very few studies have focused on the association between LA function and LA-LVA, and the mechanism of appearance of LA-LVA remains unclear. We investigated the marker for the existence of LA-LVA using automated 3-D mapping system. We studied 92 patients (75 males, 68 ± 9 years, 47 non-paroxysmal AF) who received CA for AF and 40 control patients without AF. Echocardiography was performed before the CA, and high-density voltage mapping during sinus rhythm after pulmonary isolation was performed in AF patients. LA-LVA was defined as < 0.5 mV, and LA stiffness index (LASI) was defined as the ratio of E/e' to LA peak strain. LA-LVA (LVA burden > 10%) was detected in 19/92 AF patients (21%). Patients with LA-LVA were associated with higher LASI (1.64 ± 1.70 vs. 0.61 ± 0.46, p < 0.0001), larger LA volume, non-paroxysmal AF, higher brain natriuretic peptide, structural heart disease, and older age. On multivariate analysis, LASI, LA volume, and age were independently associated with the existence of LA-LVA. Of these markers, the highest area under curve was obtained with LASI. The rate of high LASI (≥ 0.552) was highest in AF patients with LA-LVA. Moreover, the existence of LVA in anterior LA wall was associated with higher LASI. High LA stiffness index was associated with the presence of LA-LVA. The LA-LVA might be attributed to LA functional remodeling rather than LA anatomical remodeling.

Predictors of Left Atrial Thrombi and Spontaneous Echocardiographic Contrast in the Acute Phase After Cardioembolic Stroke in Patients With Atrial Fibrillation.

INTRODUCTION: The underlying mechanism of the residual left atrial thrombus (LAT)/spontaneous echo contrast (SEC) after the onset of cardioembolic stroke (CES) is unknown. This study aims to investigate the utility of CHADS2 and CHA2DS2-VASc scores for predicting LAT/SEC, and to investigate the risk factors of residual LAT/SEC after CES onset. METHODS: This retrospective study included 124 patients who were admitted with the acute phase of CES at our center. The clinical, echocardiographic variables, the CHADS2/CHA2DS2-VASc scores, and National Institutes of Health Stroke Scale score were retrospectively assessed on admission. RESULTS: Of 124 patients, LAT or SEC was detected in 39 patients (31.5%, 17 LAT and 38 SEC). Univariate analysis showed that the LAT/SEC group had a higher prevalence of nonparoxysmal atrial fibrillation (AF), left ventricular (LV) hypertrophy, hypertension, the rate of anticoagulation before admission, higher National Institutes of Health Stroke Scale score, larger left atrial diameter, and elevated E wave. In contrast, the CHADS2 and CHA2DS2-VASc scores were not associated with LAT/SEC. LAT/SEC was associated with nonparoxysmal AF and LV hypertrophy on multivariate analysis. Moreover, all patients were divided into 4 groups based on the combination between non-paroxysmal AF and LV hypertrophy. The rate of LAT/SEC was the highest (87.5%) in patients with nonparoxysmal AF and LV hypertrophy. CONCLUSIONS: Nonparoxysmal atrial fibrillation and left ventricular hypertrophy were associated with residual left atrial thrombus/spontaneous echo contrast in the acute phase after cardioembolic stroke that was independent of the CHADS2 and CHA2DS2-VASc scores.

Predictors of left atrial appendage stunning after electrical cardioversion in patients with atrial fibrillation.

The transient left atrial appendage (LAA) dysfunction after electrical cardioversion (CV), which is called as LAA-stunning, was found to be an important etiology of thrombus formation. The aim of the present study was to investigate the risk factors of LAA-stunning. This study included 134 patients who underwent catheter ablation for non-paroxysmal, non-valvular, and symptomatic atrial fibrillation (AF). Internal-CV was performed, and LAA emptying fraction (LAA-EF) was assessed using LAA-angiogram before and just after CV. LAA-stunning (defined as 10% reduction of LAA-EF after CV) was observed in 45/134 patients (34%). Patients in LAA-stunning group had longer duration of AF prior to CV, higher brain natriuretic peptide (BNP), higher prevalence of patients taking calcium blocker, larger left atrial (LA) diameter, elevated E wave, and larger LA volume than those in non LAA-stunning group. Multivariate analysis showed that longer duration of AF prior to CV (p = 0.015, OR 1.033 for 1 month extend, 95% CI 1.006-1.073) and elevated BNP (p = 0.038, OR 1.041 for each 10 pg/mL increase, 95% CI 1.001-1.009) were associated with LAA-stunning. In addition, all patients were divided into four groups based on the combination between duration of AF prior to CV and BNP; group 1 (low BNP/short-lasting AF), group 2 (high BNP/short-lasting AF), group 3 (low BNP/long-lasting AF), and group 4 (high BNP/long-lasting AF). The rate of LAA-stunning was the highest in the group 4 (55.6%). Elevated BNP and long duration of AF were associated with LAA stunning after electrical cardioversion.

A novel protocol for initial heparin administration during catheter ablation for atrial fibrillation in patients taking direct oral anticoagulants.

Thromboembolism and bleeding complications remain a major limitation of the catheter ablation (CA) for atrial fibrillation (AF). This study aimed to evaluate the association between achieving target activated clotting time (ACT) and clinical factors, and to develop an appropriate protocol for early achievement of target ACT in patients with direct oral anticoagulants (DOACs). At the initiation cohort, 190 patients (127 males, age 68 ± 9) taking DOACs who underwent CA for AF were studied. All patients underwent transthoracic echocardiography/transesophageal echocardiography/blood sampling before the CA. The ACTs were measured before heparin administration (pre-ACT) and in 30 min (30-min ACT) after initial heparin administration (100 U/kg +3000 U). At the validation cohort, the indicator obtained from the first study was reassessed in the subsequent 138 patients (94 males, age 68 ± 10). At the initiation cohort, 30-min ACT reached the target ACT in 79/190 patients (42%). Univariate analysis showed that longer pre-ACT, elevated aPTT, higher PT-INR, antiplatelet medication, and dabigatran were associated with achieving the target 30-min ACT. On multivariate analysis, only longer pre-ACT was independently associated with achieving the target 30-min ACT (P = 0.0396, the optimal cutoff value; 130 s). As a novel protocol, we added 2000 U of initial heparin dose (total 100 U/kg +5000 U) in patients with low pre-ACT (< 130); then, the achievement rate to target 30-min ACT improved from 41.6 to 80.5% without increasing bleeding complications. Our novel protocol of initial heparin administration based on pre-ACT is useful for an appropriate systemic anticoagulation in patients taking DOACs during the CA for AF.

Left atrial pressure pattern without a-wave in sinus rhythm after cardioversion affects the outcomes after catheter ablation for atrial fibrillation.

The a-wave in left atrial pressure (LAP) is often not observed after cardioversion (CV). We hypothesized that repeated atrial fibrillation (AF) occurs in patients who do not show a-wave pattern after CV. We investigated the impact of "LAP pattern without a-wave" on the outcome after catheter ablation (CA) for AF. We studied 100 patients (64 males, age 66 ± 8 years, 42 with non-paroxysmal AF) who underwent CA for AF. Sustained- or induced-AF were terminated with internal CV, and LAP was measured during sinus rhythm (SR) after CV. LAP pattern without a-wave was defined as absence of a-wave (the "a-wave" was defined as a protruding part by 0.2 mmHg or more from the baseline) in LAP wave form. AF was terminated with CV in all patients. Recurrent AF was detected in 35/100 (35%) during the follow-up period (13.1 ± 7.8 month). Univariate analysis revealed higher prevalence of LAP pattern without a-wave (71 vs. 17%, P < 0.0001), larger left atrial volume, elevated E wave, and decreased deceleration time as significant variables. On multivariate analysis, LAP pattern without a-wave was only independently associated with recurrent AF (P = 0.0014, OR 9.865, 95% CI 2.327-54.861). Moreover, patients with LAP pattern without a-wave had a higher risk of recurrent AF than patients with a-wave (25/36 patients, 69 vs. 10/64 patients, 16%, log-rank P < 0.0001). Left atrial pressure pattern without a-wave in sinus rhythm after cardioversion could predict recurrence after catheter ablation for AF.

Interatrial septal motion as a novel index to predict left atrial pressure.

We investigated whether the interatrial septal (IAS) motion of each heartbeat which is observed by transesophageal echocardiography reflects left atrial pressure (LAP) in patients with atrial fibrillation (AF). We studied 100 patients (70 males, age 67 ± 9 years) who underwent catheter ablation for AF. The amplitude of IAS motion was measured using M-mode and averaged for five cardiac cycles. Left and right atrial pressures, the left to right atrial pressure gradient were directly measured during the catheter ablation. In patients with sinus rhythm during measurement, elevated mean LAP, larger maximum left to right atrial pressure gradient, and greater left atrial emptying fraction were associated with IAS motion. The optimal cut-off value of the IAS motion for predicting high LAP (mean LAP > 15 mmHg) was 8.5 mm (sensitivity 100%, specificity 70.1%) in patients with sinus rhythm during pressure measurement. In addition, all patients were divided into 6 groups based on rhythm during measurement and cutoff value of IAS motion. In patients with sinus rhythm during measurement, low IAS motion group had a highest prevalence of elevated LAP compared with high IAS motion group (64 vs. 0%, P < 0.0001). The amplitude of interatrial septal motion during sinus rhythm reflects left atrial pressure in patients with atrial fibrillation. Interatrial septal motion could be a new index to predict elevated left atrial pressure.

Left atrial ejection force predicts the outcome after catheter ablation for paroxysmal atrial fibrillation.

INTRODUCTION: Left atrium (LA) systolic dysfunction is observed in the early stages of atrial fibrillation (AF) prior to LA anatomical change. We investigated whether LA systolic dysfunction predicts recurrent AF after catheter ablation (CA) in patients with paroxysmal AF. METHODS AND RESULTS: We studied 106 patients who underwent CA for paroxysmal AF. LA systolic function was assessed with the LA emptying volume = Maximum LA volume (LAVmax ) - Minimum LA volume (LAVmin ), LA emptying fraction = [(LAVmax - LAVmin )/LAVmax ] × 100, and LA ejection force calculated with Manning's method [LA ejection force = (0.5 × ρ × mitral valve area × A2 )], where ρ is the blood density and A is the late-diastolic mitral inflow velocity. Recurrent AF was detected in 35/106 (33%) during 14.6 ± 9.1 months. Univariate analysis revealed reduced LA ejection force, decreased LA emptying fraction, larger LA diameter, and elevated brain natriuretic peptide as significant variables. On multivariate analysis, reduced LA ejection force and larger LA diameter were independently associated with recurrent AF. Moreover, patients with reduced LA ejection force and larger LA diameter had a higher risk of recurrent AF than preserved LA ejection force (log-rank P = 0.0004). CONCLUSIONS: Reduced LA ejection force and larger LA diameter were associated with poor outcome after CA for paroxysmal AF, and could be a new index to predict recurrent AF.

The Impact of Transforming Growth Factor-ß1 Level on Outcome After Catheter Ablation in Patients With Atrial Fibrillation.

INTRODUCTION: Transforming growth factor-ß1 (TGF-ß1 ) is an important factor that induces atrial fibrosis and atrial fibrillation (AF). The purpose of this study was to evaluate the association between TGF-ß1 level and clinical factors before catheter ablation (CA), and to investigate the impact of TGF-ß1 level on the outcome after CA for AF. METHODS AND RESULTS: This prospective study included 151 patients (persistent AF group: n = 59, paroxysmal AF [PAF] group: n = 54, and control group: n = 38). All patients who underwent CA for AF were followed up for 12 months. The PAF group had the highest TGF-ß1 levels in all patients. An early recurrence of AF (ERAF: defined as episodes of atrial tachyarrhythmia within a 3-month blanking period) was detected in 60 patients (53%). Recurrent AF after the blanking period was detected in 36 patients (32%). On multivariate analysis, low TGF-ß1 level was the only independent factor associated with recurrent AF. Moreover, the AF recurrence ratio was higher in the low TGF-ß1 group (< 12.56 ng/mL) than in the high TGF-ß1 group (16 of 29 patients, 55% vs. 20 of 84 patients, 24%, P = 0.002 by log-rank test). CONCLUSIONS: PAF was associated with a higher TGF-ß1 level. Moreover, lower TGF-ß1 level in AF patients could be a cause of recurrent AF after CA.