Enlarged right atrium predicts pacemaker implantation after atrial fibrillation ablation in patients with tachycardia-bradycardia syndrome.

Introduction: Although catheter ablation (CA) of tachycardia-bradycardia syndrome (TBS) in patients with atrial fibrillation (AF) is considered to be an effective treatment strategy, pacemaker implantations (PMIs) are often required even after a successful CA. This study aimed to elucidate the clinical predictors of a PMI after CA. Methods: From 2011 to 2020, 103 consecutive patients diagnosed with TBS were retrospectively enrolled in the study. Among the 103 patients, 54 underwent a PMI and 49 CA of AF. During 47.4 ± 35.4 months after 1.4 ± 0.6 CA sessions, 37 (75.5%) of 49 patients were free from atrial arrhythmia recurrences. PMIs were performed in 11 patients (PMI group) and the remaining 38 did not receive a PMI (non-PMI group). Results: When comparing the PMI and non-PMI groups, there were no differences in the basic mean heart rate (P = 0.36), maximum pauses detected by 24-hour Holter-monitoring (P = 0.61), and other clinical parameters between the two groups while the right atrial area index was larger (42.1 ± 24.0 vs. 21.8 ± 8.4 cm2/m2 P = 0.002) in the PMI group than non-PMI group. The ROC curve analysis showed that the optimal cutoff point of the ratio of the right atrial area index to the left atrial area index for predicting a PMI following CA was 0.812 (Sensitivity 72.7%, specificity 71.1%, positive predictive value 42.1%, negative predictive value 90.0%, diagnostic accuracy 71.4%, AUC = 0.81). Conclusion: Right atrial enlargement prior to CA was considered to be one of the risk factors for a PMI after CA of AF.

Improvement in Quality of Life via Catheter Ablation for Atrial Fibrillation in Patients Undergoing Hemodialysis Therapy.

Background: Atrial fibrillation (AF) is the most common arrhythmia in patients undergoing hemodialysis (HD); AF lowers quality of life (QoL) and increases the risk of dialysis-related complications. The present study aimed to evaluate the effectiveness of AF ablation on the QoL in patients undergoing HD. Methods: Nineteen patients undergoing HD (14 men, age 68 ± 8 years; 15 with paroxysmal AF) who underwent catheter ablation (CA) of AF were enrolled in the study. The Kidney Disease Quality of Life Short Form (KDQOL-SF) was assessed to evaluate the QoL of the HD patients at baseline and 6 months after the ablation. Ablation outcomes and procedural complications were evaluated and compared to those of 1053 consecutive non-HD patients who underwent AF ablation. Results: The KDQOL-SF of the HD patients 6 months after the ablation showed an improvement in physical functioning (54 ± 23 to 68 ± 28, P < 0.01), general health perceptions (38 ± 17 to 48 ± 15, P < 0.01), and symptoms/problems (75 ± 21 to 84 ± 13, P = 0.02), compared to baseline. For intradialytic symptoms, dyspnea during HD significantly improved after the CA in the HD patients without AF recurrence (43% to 7%, P = 0.04), whereas the atrial tachyarrhythmias and hypotension during HD remained unchanged. During the follow-up period of 17 ± 13 months after the last procedure, the incidence of being arrhythmia-free was similar (HD patients, 79% vs non-HD patients, 86%, log-rank P = 0.82). No life-threatening complications occurred in any of the patients. Conclusions: CA of AF improves QoL in patients undergoing chronic HD therapy.

Contexte: La fibrillation auriculaire (FA), la forme d'arythmie la plus fréquente chez les patients sous hémodialyse (HD), entraîne une diminution de la qualité de vie (QdV) et une augmentation des risques de complications liées à la dialyse. La présente étude visait à évaluer l'effet de l'ablation de la FA sur la QdV des patients sous HD. Méthodologie: Dix-neuf patients sous HD (âgés de 68 ± 8 ans, dont 14 étaient des hommes et 15 étaient atteints de FA paroxystique) ayant subi une ablation par cathéter de la FA ont été admis dans l'étude. Le questionnaire KDQOL-SF (Kidney Disease Quality of Life Short Form) a été utilisé pour évaluer la QdV des patients sous HD avant l'intervention et six mois après l'ablation. L'issue de l'ablation et les complications liées à l'intervention ont été évaluées et comparées à celles de 1 053 patients consécutifs n'étant pas hémodialysés et ayant subi une ablation de la FA. Résultats: La comparaison des résultats initiaux au KDQOL-SF des patients hémodialysés avec les résultats obtenus six mois après l'ablation a montré des améliorations de la fonction physique (de 54 ± 23 à 68 ± 28, p < 0,01), de la perception de l'état de santé global (de 38 ± 17 à 48 ± 15, p < 0,01), et des symptômes/problèmes de santé (de 75 ± 21 à 84 ± 13, p = 0,02). En ce qui concerne les symptômes survenant lors des séances d'HD, une amélioration significative de la dyspnée a été observée après l'ablation par cathéter chez les patients sous HD sans récurrence de la FA (de 43 % à 7 %, p = 0,04), alors qu'aucun changement n'a été constaté pour les tachyarythmies auriculaires et l'hypotension. Durant la période de suivi de 17 ± 13 mois après la dernière intervention, le nombre de patients sans arythmie était comparable dans les deux groupes (79 % chez les patients hémodialysés et 86 % chez les patients non hémodialysés, test du log-rank = 0,82). Aucun patient n'a subi de complication menaçant le pronostic vital. Conclusions: L'ablation par cathéter de la FA permet d'améliorer la QdV des patients qui subissent un traitement par HD de longue durée.

Associations between health literacy and information-evaluation and decision-making skills in Japanese adults.

BACKGROUND: Health literacy among Japanese is often low, making it difficult for them to evaluate health information and make informed decisions. However, the health literacy scales applied measure the perceived difficulty of health-related tasks; they do not directly assess the specific skills needed to perform the tasks: the skills to judge the reliability of diverse information using evaluation criteria and implement rational decision-making. Therefore, the study objectives were to investigate the following issues using a nationwide survey in Japan. (1) When obtaining information, to what extent do people apply criteria for evaluating information to confirm its reliability; when making decisions, to what extent do they seek out available options and compare pros and cons based on their own values? (2) How strongly are such skills associated with health literacy and demographic characteristics? (3) What opportunities are available to learn these skills? METHODS: We conducted an online questionnaire survey using a Japanese Internet research company; 3,914 valid responses were received. The measures comprised health literacy (European Health Literacy Survey Questionnaire), five items on information evaluation, four items on decision-making, and items on the availability and location of learning opportunities. We calculated Pearson correlations to explore the association of health literacy with information-evaluation and decision-making skills. Multivariate analyses were also conducted using these factors as dependent variables. RESULTS: Fewer than half (30%-50%) of respondents reported always or often evaluating information and engaging in decision-making. Health literacy was significantly and positively correlated with the specific skills of information evaluation and decision-making (r = .26 and .30, respectively) as were multivariate analyses (beta = .15 and .22, respectively). Over 40% of respondents had never learned those skills. The most common resources for learning the skills were the Internet and television; less-used resources were schools and workplaces. CONCLUSIONS: Both information-evaluation and decision-making skills were associated with health literacy. However, these skills are not sufficiently widespread in Japan because there are few opportunities to acquire them. More research is needed to raise awareness of the importance of such skills for improving health literacy and providing learning opportunities.

Possibility of steroid therapy without pacemaker implantation in patients with sarcoidosis presenting atrioventricular block.

Atrioventricular Block (AVB) is one of the common manifestations in cardiac sarcoidosis (CS). Although pacemaker implantation is generally recommended in patients with CS complicated by symptomatic AVB, some case reports have shown that they can be managed by steroid therapy without pacemaker implantation. The aim of this study was to evaluate the feasibility and effectiveness of steroid therapy without pacemaker implantation in patients with CS complicated by symptomatic AVB. We performed medical record review of consecutive ten CS patients who admitted Nippon Medical School Hospital for symptomatic second or third degree AVB between April 2015 and March 2021. Of the studied population, steroid therapy before pacemaker implantation was feasible in three patients with second degree AVB. Two of them showed subsequent recovery of atrioventricular conduction to 1:1, and they were managed by steroid therapy without pacemaker. The remaining one patient showed no improvement of atrioventricular conduction and required pacemaker implantation. Seven patients with third degree AVB required device implantation (pacemaker; n = 7, cardiac resynchronization therapy defibrillator; n = 1) before steroid therapy mainly because of hemodynamic instability. Steroid therapy without pacemaker implantation might be feasible, and possibly be effective in patients with CS presenting second degree AVB. However, the feasibility is limited in patients with third degree AVB.

Localization of Late Gadolinium Enhancement and Its Association with Ventricular Tachycardia in Patients with Cardiac Sarcoidosis.

Sustained ventricular tachycardia (sVT), leading to sudden cardiac death, is one of the common manifestations in cardiac sarcoidosis (CS). Although late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) has been reported to be associated with sVT, the relationships of its localization to sVT have not been fully evaluated.To evaluate the localization of LGE and its relationships to sVT in patients with CS, we reviewed medical record of consecutive 31 patients with CS who underwent CMR. The localization of LGE was divided into four categories: Left ventricular (LV) septum, LV free wall, right ventricular (RV) septum, and RV free wall. We investigated the association of sVT with localization of LGE and other parameters including serum biomarkers LV ejection fraction on echocardiography and Fluorine-18-fluorodeoxyglucose (FDG) accumulation on positron emission tomography (PET) -CT.Of the studied population, 8 patients (25.8%) were known to present with sVT among 31 CS patients. LGE was observed in the RV free wall in 6 patients with sVT, whereas it was in 5 patients without sVT (75.0% versus 21.7%, P = 0.022). Univariate analysis showed that only LGE in the RV free wall was associated with sVT (odds ratio [OR]: 10.80; 95% confidence interval [CI]: 1.64-70.93, P = 0.013).LGE in the RV free wall was associated with sVT in patients with CS.

Feasibility and safety of CT-aided pericardiocentesis from a subxiphoid anterior approach by using fluoroscopy in patients with chronic pericardial effusions.

BACKGROUND: Pericardiocentesis is an essential procedure for the diagnosis and treatment of pericardial effusions. The purpose of this study was to evaluate the feasibility and safety of a subxiphoid anterior approach using fluoroscopy aided by a sagittal axis chest computed tomography (CT) view in comparison with an ultrasound-guided apical approach in patients with chronic pericardial effusion. METHODS: Among 72 consecutive patients (68.8 ± 14.4 years old, 52 males) with hemodynamically stable chronic pericardial effusions, a total of 85 procedures were retrospectively analyzed. We divided them into two groups according to the site of the approach for the pericardiocentesis. RESULTS: A subxiphoid anterior approach (n = 53) was performed guided by fluoroscopy. The sagittal axis view of the chest CT was constructed to determine the puncture angle and direction for the subxiphoid anterior approach. An apical approach (n = 32) was performed by ultrasound guidance. The success rates of the anterior and apical approaches were 98.1% and 93.8%, respectively. There were two cases with cardiac perforations in the apical approach group, while no cases developed perforations in the subxiphoid anterior approach group. CONCLUSION: The subxiphoid anterior approach for pericardiocentesis was feasible and safe for managing chronic pericardial effusions. A reconstruction of the sagittal axis view of the chest CT imaging was helpful to identify the direction and depth to access the pericardial space from the subxiphoid puncture site before the pericardiocentesis using the lateral fluoroscopic view.

COVID-19 Preventive Behaviors and Health Literacy, Information Evaluation, and Decision-making Skills in Japanese Adults: Cross-sectional Survey Study.

BACKGROUND: Health literacy is important for the prevention of COVID-19 transmission. Research in Japan shows that health literacy is related to skills in evaluating information and decision-making (skills that are not necessarily limited to information about health). Such basic skills are important, particularly when individuals encounter new health issues for which there is insufficient evidence. OBJECTIVE: We aimed to determine the extent to which COVID-19 preventive behaviors were associated with health literacy and skills in evaluating information and making decisions. METHODS: A web-based questionnaire survey was conducted using a Japanese internet research company. The measures comprised 8 items on COVID-19 preventive behaviors, health literacy items (European Health Literacy Survey Questionnaire), 5 items on information evaluation, and 4 items on decision-making process. Pearson correlations between these variables were calculated. Multivariable analyses were also conducted using the COVID-19 preventive behavior score as a dependent variable. RESULTS: A total of 3914 valid responses were received.COVID-19 preventive behaviors were significantly correlated with health literacy (r=0.23), information evaluation (r=0.24), and decision-making process (r=0.30). Standardized regression coefficients (health literacy: ß=.11; information evaluation: ß=.13; decision-making: ß=.18) showed that decision-making process contributed the most. CONCLUSIONS: Although comprehensive health literacy is necessary for COVID-19 preventive behaviors, the skills to evaluate a wide range of information and to make appropriate decisions are no less important. Opportunities for people to acquire these skills should be available at all times.

Characteristics of patients with atrial flutter and spontaneous 1:1 atrioventricular conduction with and without anti-arrhythmic drug treatment.

Atrial flutter (AFL) is a large reentrant circuit located in the right atrium. Anti-arrhythmic drugs (AADs) can provoke AFL with 1:1 atrioventricular conduction (AVC) to cause hemodynamic collapse. We elucidated the characteristics of patients with AFL exhibiting spontaneous 1:1 AVC. Fifteen patients (1:1 AFL group; 11 males, 52.4 ± 13.7 years old) who documented AFL with 1:1 AVC were enrolled and compared to 153 patients without 1:1 AVC (Control group; 137 males, 68.9 ± 11.2 years old). AFL cycle length during maximum AVC was significantly longer in the 1:1 AFL group than in the control group (274.7 ± 37.0 vs. 216.2 ± 25.6 ms, p < 0.001). Among 1:1 AVC group, 9 patients had AADs, and AFL cycle length was significantly longer during 1:1 AVC as compared with 2:1 AVC documented the other day (284.4 ± 41.3 vs. 233.3 ± 26.0 ms, p < 0.001), suggesting enhancement effect of the AADs during 1:1 AVC. Remaining 6 patients who did not take AADs, 2 patients showed enlargement of the tricuspid annulus and 3 patients developed 1:1 AVC during exercise. Multivariate analysis revealed that younger age and the use of AADs was independent risk factors for the development of 1:1 AFL group. Prolonged AFL cycle length associated with the class Ia/Ic AAD use, slower heart rate during sinus rhythm and younger age were important risk factors for the development of 1:1 AVC during AFL.

Metal interference alert guided septal approach with 3 catheter positions on intracardiac echocardiography for a near-zero fluoroscopy catheter ablation of atrial fibrillation.

BACKGROUND: Attempting to minimize radiation exposure during catheter ablation of atrial fibrillation (AF) for patients, operators and medical staffs should be performed. This study aimed to investigate the feasibility and safety of a metal interference alert guided septal approach using 3 intracardiac echocardiography viewing positions for near-zero fluoroscopy AF ablation procedures. METHODS/RESULTS: A total of 668 procedures among 608 consecutive patients with AF (67.2 ± 7.3 years, 408 males) who underwent catheter ablation were retrospectively evaluated and divided into 2 groups, near-zero group (n = 42) and conventional group (n = 595). In the near-zero group, a metal interference alert guided septal approach with 3 different catheter intracardiac echocardiography positions to minimize the fluoroscopy time was applied, and a left atrial access with 2 long sheaths from a single septal puncture without fluoroscopy was successfully achieved in 41 out of 42 cases. The total fluoroscopy time was significantly shorter in the near-zero group than that in the conventional group (0.5 ± 2.0 vs. 21.4 ± 12.9 min p < 0.0001). The total procedure time and time to the septal puncture were both significantly longer in the near-zero group than those in the conventional group (131.4 ± 40.2 vs. 116.6 ± 46.4p = 0.0453, 31.6 ± 9.2 vs. 19.9 ± 10.2 min, p < 0.0001), The ablation time did not differ between the 2 groups (Near-zero: 99.8 ± 41.0 vs. Conventional: 96.8 ± 44.3 min, p = 0.6663). There were no significant differences in the complication rate between the 2 groups (Near-zero: 0 vs. Conventional 14 case, p = 0.6151). CONCLUSION: A metal interference alert guided septal approach using 3 intracardiac echocardiography viewing positions was feasible and safe for a near-zero fluoroscopy catheter ablation of AF.

Esophageal pressure monitoring for airway management during catheter ablation of atrial fibrillation.

BACKGROUND: Respiratory management during catheter ablation of atrial fibrillation (AF) is important for the efficacy and safety of the procedure. Obstructive apnea due to an upper airway obstruction might cause serious complications including air embolisms and cardiac tamponade. However, real time monitoring of upper airway obstructions during catheter ablation has not been established. The purpose of the present study was to evaluate esophageal pressure monitoring for respiratory management during catheter ablation of AF. METHODS AND RESULTS: Twenty-four consecutive patients (20 men and 4 women; mean age, 61 ± 13 years) with AF who underwent esophageal pressure monitoring during catheter ablation of AF were retrospectively analyzed. The patients were divided into 2 groups. One was the obstructive apnea (OA) group (n = 17), which required airway management tools including nasal airways and/or non-invasive positive airway pressure (NPPV) and the other was the control group (n = 7), which did not require airway management. Esophageal pressure measurements were obtained in all patients, and the OA group exhibited a substantial negative esophageal pressure as compared to the control group (-41.48 ± 19.58 vs. -12.42 ± 5.77 mmHg, p < 0.001). Airway management in the OA group immediately improved the negative esophageal pressure and returned to a normal range (-41.48 ± 19.58 vs. -16 ± 8.1 mmHg, 0 < 0.001) along with a recovery from desaturation. CONCLUSIONS: Esophageal pressure monitoring was a simple and effective method for the evaluation and management of obstructive apnea during AF catheter ablation.

Prognostic impact of newly detected atrial fibrillation in patients with hypertrophic cardiomyopathy following cardiac implantable electronic device implantation.

Atrial fibrillation (AF) is the most common arrhythmia in patients with hypertrophic cardiomyopathy (HCM). The present study aimed to investigate the incidence and prognostic impact of newly detected AF after cardiac implantable electronic device (CIED) implantation with HCM patients. Fifty-six patients (33 men, age 57 ± 17 years) with HCM who underwent CIED implantations with no previous history of AF at the time of implantation (ICD n = 46, Pacemaker n = 10) were retrospectively enrolled. During 5.7 ± 3.6 years of follow-up, AF was newly detected in 20 (36%) of 56 patients after the CIED implantation (AF group) and the rest of the patients had no newly detected AF (non-AF group). The presence of mitral regurgitation (HR 8.49; 95% CI 2.29-30.6 P < 0.01) and concomitant NYHA II-IV (HR 3.37; 95% CI 1.30-8.86 P = 0.01) were the independent predictors of newly detected AF. During the follow-up, all patients in the AF group started anticoagulation mean 21 days after detection of AF, and none had a stroke during the follow-up period. The rate of appropriate ICD therapy (log-rank P = 0.95), inappropriate ICD therapy (log-rank P = 0.78), and all-cause death (log-rank P = 0.23) were similar between the two groups. However, the incidence of hospitalizations due to heart failure was higher in the AF group (55% vs. 6% log-rank P < 0.01). In conclusion, the incidence of newly detected AF after CIED implantations in HCM patients was high. The newly detected AF was associated with worsening heart failure and careful follow-up is recommended.

Differential Effectiveness of Landiolol Between Atrial Fibrillation and Atrial Flutter/Atrial Tachycardia Patients With Left Ventricular Dysfunction.

BACKGROUND: Landiolol, an ultra-short acting ß1-selective blocker, is more effective for controlling the heart rate (HR) than digoxin in patients with atrial tachyarrhythmias and left ventricular (LV) dysfunction. The impact of the type of atrial tachyarrhythmias on the effectiveness of landiolol is uncertain. We evaluated the efficacy and safety of landiolol on tachycardiac atrial fibrillation (AF) and tachycardiac atrial flutter/atrial tachycardia (AFl/AT) in patients with reduced LV function. Methods and Results: Seventy-seven patients treated with landiolol were retrospectively analyzed. There were no significant differences in the baseline characteristics between the AF group (n=65) and AFl/AT group (n=12). Despite a higher dosage, the %change in HR from baseline to 12 and 24 h was only -10.2±12.7% and -16.1±19.4% in the AFl/AT group, while it was -28.3±13.2% and -31.3±11.3% in the AF group (P<0.02), respectively. The prevalence of the responders to landiolol treatment was much greater in the AF group than in the AFl/AT group (P<0.001). Alternative treatments such as i.v. amiodarone and electrical cardioversion were required in 83% of the AFl/AT patients. CONCLUSIONS: Landiolol was ineffective in the majority of AFl/AT patients. An alternative management to prevent any worsening of heart failure might be considered in those patients.

Prevalence and Significance of an Early Repolarization Electrocardiographic Pattern and Its Mechanistic Insight Based on Cardiac Magnetic Resonance Imaging in Patients With Acute Myocarditis.

BACKGROUND: An early repolarization electrocardiographic (ER-ECG) pattern is caused by various pathophysiological conditions and is reported to be a predictor of life-threatening ventricular tachyarrhythmias. However, little evidence has been reported on the prevalence and significance of the ER-ECG pattern in acute myocarditis. This study aimed to investigate the prevalence and significance of the ER-ECG pattern and its mechanistic insight based on the cardiac magnetic resonance findings in patients with acute myocarditis. METHODS: Thirty patients (23 men; 39.2±19.1 years) with a diagnosis of acute myocarditis by a clinical presentation between March 2011 and April 2018 were retrospectively evaluated. The patients were divided into 2 groups depending on the presence of an ER-ECG pattern on admission. RESULTS: Nine cases had an ER-ECG pattern, which was defined as terminal QRS notching or slurring with an amplitude of >0.1 mV in at least 2 inferior or lateral leads (early repolarization [ER] group), whereas the remaining 21 cases had broad ST-segment elevation or pathological Q waves (non-ER group). The cardiac troponin T level was significantly higher in the non-ER group than ER group (3.2±4.3 versus 0.9±1.2 ng/mL; P=0.036). The ECG changes returned to baseline along with the normalization of the cardiac biomarkers. Nine of the 21 non-ER group patients, but none of the 9 ER group patients, developed a fulminant course and lethal ventricular tachyarrhythmias. T2-weighted cardiac magnetic resonance showed high-intensity signals over the entire transmural left ventricle in the non-ER group, whereas they were localized to the left ventricular epicardium in the ER group. CONCLUSIONS: The ER-ECG pattern in acute myocarditis was transient and reversible and was not associated with a worse prognosis. Inflammation/swelling localized to the left ventricular epicardium because of acute myocarditis might provide a mechanistic insight into the ER-ECG pattern.

Electrocardiographic characteristics in the patients with a persistent left superior vena cava.

A persistent left superior vena cava (PLSVC) is a congenital venous abnormality and is usually asymptomatic and does not cause hemodynamic disturbances. Therefore, it is difficult to identify it by routine examinations in clinical practice. This study aimed to elucidate the electrocardiographic characteristics for the prediction of a PLSVC. Twelve patients (9 males, 56.2 ± 18.3 years) who were diagnosed with a PLSVC were enrolled. The electrocardiographic parameters, including the P-wave duration, axis, and morphology of the P waves, were automatically measured and compared to 150 controls (77 males, 57.3 ± 14.6 years). There were no significant differences in the P-wave duration. Negative or positive/negative P waves in lead III predicted a PLSVC with a sensitivity of 100% and specificity of 81%. The P-wave axis in PLSVC exhibited a significant leftward deviation as compared to the controls (14.8 ± 21.1 vs. 54.0 ± 17.4°, p < 0.001). A receiver operating characteristic curve analysis of the P-wave axis for predicting a PLSVC exhibited an area under curve of 0.93 [CI 95% (0.87-0.98), p < 0.001), and identified a P-wave axis of less than 37.5° to have a 92% sensitivity and 83% specificity in predicting a PLSVC. A negative or positive/negative P-wave morphology in lead III was a useful finding for suggesting the presence of a PLSVC.

Blanking Period Phenomenon After a Second Atrial Fibrillation Ablation Session: The Application and Factors Related to It.

INTRODUCTION: The concept of a 3-month blanking period is widely accepted after the first radiofrequency catheter ablation (RFCA) session for atrial fibrillation (AF). We sought to investigate whether this phenomenon was also observed after a 2nd session, and which factors were related to it. METHODS AND RESULTS: We conducted a prospective observational study including all AF patients who underwent RFCA since 2010. The patients who underwent a second RFCA were followed without any antiarrhythmic drugs. Their clinical background, laboratory data, echocardiographic parameters, ablation procedures, and arrhythmia recurrences were analyzed. Recurrences were classified into early period recurrences (EPRs) and late period recurrences (LPRs) recorded within and after the first 3 months postablation, respectively. Among 925 patients who underwent an initial AF ablation, 2nd sessions were performed in 250 patients, and EPRs and LPRs occurred in 53 (21.2%) and 54 (21.6%) patients, respectively. Although EPRs were an independent predictor of LPRs (hazard ratio [HR], 8.01; 95% confidence interval [CI] 4.03-15.93, P < 0.001), 20 of the patients with EPRs (37.7%) did not experience LPRs, supporting the concept of a blanking period. Among 53 patients with EPRs, the E/E' ratio on echocardiography (HR, 1.156; 95% CI 1.00-1.33, P = 0.04) was an independent predictor of LPRs, while other parameters including the maximum serum C-reactive protein level after the session and the ablation procedure details were not. CONCLUSION: A 3-month blanking period was also applicable after the 2nd AF ablation session. This phenomenon was related to a lower left atrial pressure demonstrated by the E/E' ratio.

Urgent Catheter Ablation in Octogenarians with Serious Tachyarrhythmias.

BACKGROUND: Urgent catheter ablation is often required for various tachyarrhythmias; however, its efficacy and safety in elderly patients have not been fully elucidated. METHODS: This study included consecutive octogenarians who underwent urgent radiofrequency catheter ablation (RFCA) for various serious tachyarrhythmias (urgent group, n=28) that were life-threatening, hemodynamically deleterious, or provoking ischemia, and consecutive octogenarians who underwent elective RFCA (control group, n=36). The rate of a successful RFCA, complications, later arrhythmia recurrences, and mortality were compared between the groups. RESULTS: There was no significant difference in the breakdown of the targeted arrhythmias between the groups, and common-type atrial flutter was most often targeted in both the urgent group (57%) and the elective group (56%). Compared with the control group patients, the patients of the urgent group were older (84±3 vs. 82±2 years P=0.001), with a higher frequency of baseline heart disease (68% vs. 17%, P<0.001) and lower left ventricular ejection fraction (45%±15% vs. 68%±10%, P<0.001). The rates of acute success (100% vs. 100%, P=1.00) and later arrhythmia recurrences (4% vs. 14%, P=0.22) were comparable between the groups. Two patients in the urgent group and 2 in the elective group had procedure-related nonlethal complications (7% vs. 6%, P=1.00): groin hematoma in 2, pressure ulcer in 1, and CO2 narcosis in 1. There were no in-hospital deaths, and mortality during follow-up did not differ between the urgent and elective groups (6.0% vs. 3.9% per year, log-rank P=0.38). CONCLUSION: Even in octogenarian patients, urgent catheter ablation for serious tachyarrhythmias can be safely performed with a high success rate and acceptable prognosis.

Mechanisms of postoperative atrial tachycardia following biatrial surgical ablation of atrial fibrillation in relation to the surgical lesion sets.

BACKGROUND: Atrial tachycardia (AT) may develop after biatrial surgical ablation of atrial fibrillation. However, the mechanism has not been determined in detail. OBJECTIVE: We aimed to determine the mechanism and treatment of postoperative AT following biatrial surgical ablation in relation to the design and durability of the surgical lesion sets. METHODS: An electrophysiologic study and radiofrequency ablation were performed in 34 consecutive patients (23 male, mean age of 63 ± 9.4 years) who were referred for AT that developed late after biatrial surgical ablation. RESULTS: The mechanism of a total of 53 ATs was macroreentry in 30, a focal mechanism in 20, and localized reentry in 1, and could not be determined in 2. The cause of the macroreentrant AT was residual conduction across a surgical lesion, most of which was located at the annular end of the mitral (n = 18) or tricuspid isthmus incision (n = 7), where cryoablation was applied during the surgery. We did not find any gaps across the cut-and-sew lesions. Radiofrequency (RF) applications to the gap, or an alternative site to transect the circuit, or the earliest activation site of the focus was effective for 48 ATs (91%). After a total of 1.3 ± 0.6 RF sessions, 27 patients (79%) were free of AT (n = 2) or AF (n = 5) during a follow-up period of 50 ± 49 months. CONCLUSIONS: Macroreentry due to a gap in a surgical lesion and focal AT were the major mechanisms of AT in patients after biatrial surgical ablation. Radiofrequency ablation of those ATs is feasible.