Association Between the Combined Effects of Physical Activity Intensity and Particulate Matter and All-Cause Mortality in Older Adults.

OBJECTIVE: To investigate the association between the combined effects of physical activity (PA) intensity and particulate matter ≤10 µm in diameter (PM10) and mortality in older adults. METHODS: This nationwide cohort study included older adults without chronic heart or lung disease who engaged in regular PA. Physical activity was assessed by a standardized, self-reported questionnaire that asked the usual frequency of PA sessions with low (LPA), moderate (MPA), or vigorous intensity (VPA). Each participant's annual average cumulative PM10 was categorized as low to moderate and high PM10 on the basis of a cutoff value of 90th percentile. RESULTS: A total of 81,326 participants (median follow-up, 45 months) were included. For participants engaged in MPA or VPA sessions, every 10% increase in the proportion of VPA to total PA sessions resulted in a 4.9% (95% CI, 1.0% to 9.0%; P=.014) increased and 2.8% (95% CI, -5.0% to -0.5%; P=.018) decreased risk of mortality for those exposed to high and low to moderate PM10, respectively (Pinteraction, <.001). For participants engaged only in LPA or MPA sessions, every 10% increase in the proportion of MPA to total PA sessions resulted in a 4.8% (95% CI, -8.9% to -0.4%; P=.031) and 2.3% (95% CI, -4.2% to -0.3%; P=.023) decreased risk of mortality for those exposed to high and low to moderate PM10, respectively (Pinteraction, .096). CONCLUSION: We found that for the same level of total PA, MPA was associated with delayed mortality whereas VPA was associated with hastened mortality of older adults in high levels of PM10.

Effect of direct stenting on microvascular dysfunction during percutaneous coronary intervention in acute myocardial infarction: a randomized pilot study.

OBJECTIVE: Whether direct stenting (DS) without predilatation during primary percutaneous coronary intervention (PPCI) reduces microvascular dysfunction in patients with ST-elevation myocardial infarction is unclear. We performed a randomized study to assess the effect of DS on microvascular reperfusion. METHODS: Seventy-two patients undergoing PPCI were randomly assigned to the DS or conventional stenting (CS) with predilatation groups. The primary endpoint was the post-PPCI index of microcirculatory resistance (IMR). We compared thrombolysis in myocardial infarction myocardial perfusion (TMP) grades, ST-segment resolution, and long-term clinical outcomes between the groups. RESULTS: Microvascular reperfusion parameters immediately after PPCI (e.g., the IMR, TMP grade, and ST-segment resolution) were not different between the groups. However, significantly fewer patients in the DS group had the IMR measured because of no-reflow or cardiogenic shock during PPCI than those in the CS group. No differences were found in left ventricular functional recovery or clinical outcomes between the groups. CONCLUSIONS: This trial showed no effect of DS on the IMR. However, our finding should be interpreted with caution because the number of patients who could not have the IMR measured was higher in the CS group than in the DS group. A larger randomized trial is required (Research Registry number: 8079).

Association between exercise habit changes and mortality following a cardiovascular event.

OBJECTIVE: To investigate the associations between exercise habit changes following an incident cardiovascular event and mortality in older adults. METHODS: We analysed the relationship between exercise habit change and all-cause, cardiovascular and non-cardiovascular deaths in adults aged ≥60 years between 2003 and 2012 who underwent two consecutive health examinations within 2 years before and after diagnosis of cardiovascular disease (CVD). They were categorised into four groups according to exercise habit changes: persistent non-exercisers, exercise dropouts, new exercisers and exercise maintainers. Differences in baseline characteristics were adjusted using inverse probability of treatment weighting. RESULTS: Of 6076 participants, the median age was 72 (IQR 69-76) years and men accounted for 50.6%. Compared with persistent non-exercisers (incidence rate (IR) 4.8 per 100 person-years), new exercisers (IR 3.5, HR 0.73, 95% CI 0.58 to 0.91) and exercise maintainers (IR 2.9, HR 0.53, 95% CI 0.38 to 0.73) were associated with reduced risk of all-cause death. The rate of non-cardiovascular death was significantly lower in new exercisers (IR 2.3, HR 0.73, 95% CI 0.56 to 0.95) and exercise maintainers (IR 2.3, HR 0.61, 95% CI 0.42 to 0.90) than in persistent non-exercisers (IR 3.2). Also, trends towards reduced cardiovascular death in new exercisers and exercise maintainers were observed (p value for trend <0.001). CONCLUSIONS: More virtuous exercise trajectories in older adults with CVD are associated with lower mortality rates. Our results support public health recommendations for older adults with CVD to perform physical activity.

Association of Physical Activity With Primary Cardiac Arrest Risk in the General Population: A Nationwide Cohort Study of the Dose-Response Relationship.

OBJECTIVE: To quantify the dose-response relationship between moderate to vigorous physical activity and primary cardiac arrest (PCA). PATIENTS AND METHODS: There were 504,840 participants older than 18 years who underwent the Korean National Health Screening Program, including a self-administered questionnaire for physical activity from January 1, 2009, through December 31, 2014. Physical activity levels were converted into metabolic equivalent tasks (METs) per week and categorized to correspond with multiples of public health recommendations. We evaluated the quantitative and categorical dose-response relationship between physical activity and PCA. RESULTS: A curvilinear dose-response relationship between physical activity and PCA was observed; the benefits started at two-thirds (5 MET-hour/week) of the United States and World Health Organization guidelines-recommended minimum (7.5 MET-hour/week) and continued to 5 times (40 MET-hour/week) the recommended minimum (P nonlinearity <.001). The largest benefit was noted at a level of 2 to 3 times the recommended minimum (hazard ratio, 0.6; 95% CI, 0.4 to 0.8). In addition, there was no evidence of an increased PCA risk at a level more than 5 times the recommended minimum (hazard ratio, 0.7; 95% CI, 0.5 to 1.1). These associations were consistent regardless of age, sex, body mass index, comorbid conditions, and estimated 10-year risk for cardiovascular disease. CONCLUSION: The beneficial effect of physical activity on PCA started at two-thirds of the recommended minimum and continued to 5 times the recommended minimum. No excess risk for PCA was present among individuals with activity levels more than 5 times the recommended minimum regardless of cardiovascular disease or lifestyle risk factor presence.

Impact of Statin Treatment Intensity after Endovascular Revascularization on Lower Extremity Peripheral Artery Disease.

PURPOSE: Only a few Asian studies have discussed the impact of statin intensity on clinical outcomes in patients with peripheral artery disease (PAD). We aimed to investigate the clinical impact of statin intensity in patients with PAD after endovascular revascularization. MATERIALS AND METHODS: From April 2009 to June 2019, 376 patients with lower extremity PAD treated with endovascular revascularization were enrolled. They were classified into three groups according to statin intensity: no-statin, low-to-moderate intensity (LMI), and high-intensity (HI). The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE). RESULTS: During the 40-month follow-up, MACE occurred less frequently in the HI and LMI groups than the no-statin group (11.4% vs. 16.0% vs. 39%, p<0.001). In adjusted Cox models, the HI group had the fewest MACE [hazard ratio (HR): 0.447; 95% confidence interval (CI): 0.244-0.834; p=0.018] and MALE (HR: 0.360; 95% CI: 0.129-1.006; p=0.051) events, while the LMI group had fewer MACE (HR: 0.571; 95% CI: 0.326-1.0; p=0.050) events than the no-statin group. HI statin therapy was associated with better outcomes in terms of MALE (HR: 0.432; 95% CI: 0.223-0.837; p=0.003) than LMI statin therapy after inverse probability treatment weighting analysis. CONCLUSION: HI and LMI statin use is associated with a significant reduction in MACE events than no-statin use. HI statin use was associated with better MALE outcomes than no-statin or LMI statin use.

Takotsubo syndrome presenting with high-degree atrioventricular block with ventricular asystole.

Takotsubo syndrome (TS) is a reversible form of cardiomyopathy characterized by transient systolic dysfunction with regional wall motion abnormalities and absence of coronary artery obstruction, which can be precipitated by severe emotional or physical stress. Its clinical presentation is similar to that of acute coronary syndrome. However, TS presenting with atrioventricular (AV) block with ventricular asystole is rarely reported. In this article, we describe the case of a postmenopausal woman who experienced near cardiac arrest due to high-degree AV block. Although transthoracic echocardiography revealed left ventricular dysfunction with severe global hypokinesia, coronary angiography and cardiac magnetic resonance imaging showed normal coronary arteries without myocardial scarring. The patient's condition improved after permanent pacemaker implantation and medical treatment for heart failure. Echocardiography and pacemaker analysis at two-month follow-up revealed normalization of heart function and cardiac rhythm, and the patient was finally diagnosed with TS. .

Elevated C-Reactive Protein/Albumin Ratio Is Associated With Lesion Complexity, Multilevel Involvement, and Adverse Outcomes in Patients With Peripheral Artery Disease.

Inflammation plays an important role in the progression of peripheral artery disease (PAD). We investigated the predictive value of the C-reactive protein-to-albumin ratio (CAR) on the severity of PAD and outcomes after endovascular therapy (EVT). Patients (n = 307) with PAD who underwent EVT were retrospectively reviewed and categorized according to CAR tertiles. The groups were compared for the prevalence of complex lesions and multilevel involvement as well as the incidence of major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). The rates of complex lesions and multilevel involvement increased with increasing CAR tertiles (all P < .001). These associations remained significant even after adjustment for other confounders (complex lesion odds ratio, 1.22 [1.03-1.50]; P = .036; multilevel disease odds ratio, 1.20 [1.01-1.44]; P = .041). The third CAR tertile showed a significantly higher incidence of MACEs and MALEs than the second and first tertiles within a year (log-rank P < .001). A higher CAR as a continuous variable was also independently associated with the 4-year rate of MACE (hazard ratio, 1.20 [1.04-1.38]; P = .015). Elevated CAR was a powerful surrogate marker of severe PAD and worse outcomes. Thus, CAR might become a predictor of poor prognosis in patients with PAD.

Impact of Physical Activity on All-Cause Mortality According to Specific Cardiovascular Disease.

BACKGROUND: Patients with cardiovascular disease (CVD) tend to have higher mortality rates and reduced physical activity (PA). We aimed to evaluate the effect of PA on mortality in older adults with specific CVD. METHODS: We enrolled 68,223 participants (n = 23,871 with CVD, n = 44,352 without CVD) aged ≥65 years with available physical activity data between 2005 and 2012 from the Korean National Health Insurance Service of Korea-Senior database. CVD was defined as a history of ischemic stroke, transient ischemic attack, heart failure, myocardial infarction, and peripheral artery disease. RESULTS: Patients with CVD were older than those without CVD. Compared with the sedentary group, the physically active groups with and without CVD had a lower incidence and risk of all-cause death during a median follow up period of 42 (interquartile range 30-51) months. A 500 metabolic equivalent task-min/week increase in PA resulted in an 11% and 16% reduction in the risk of mortality in the non-CVD and CVD groups, respectively. With regard to specific CVDs, the risk of mortality progressively reduced with increasing PA in patients with heart failure or myocardial infarction. However, the reduction reached a plateau in patients with stroke or peripheral artery disease, but was significantly greater in patients with stroke (20% vs. without stoke, 11%, Pint = 0.006) or heart failure (13% vs. without heart failure, 11%; Pint = 0.045). CONCLUSIONS: PA was associated with a reduced risk of all-cause mortality in older adults with and without CVD. The benefits of PA in patients with CVD, especially patients with stroke or heart failure, were greater than those without.

Association of Physical Activity Level With Risk of Dementia in a Nationwide Cohort in Korea.

Importance: Current guidelines recommend 500 to 999 metabolic equivalent (MET)-minutes per week (MET-min/wk) of regular physical activity. However, evidence regarding the association between light-intensity physical activity (LPA) and dementia in older adults is inconsistent. Objective: To assess the association between physical activity and new-onset dementia, focusing on the dose-response association between physical activity and dementia and the association of LPA with the incidence of dementia. Design, Setting, and Participants: For this nationwide retrospective cohort study, we analyzed 62 286 participants aged 65 years or older without preexisting dementia who had available health checkup data from the Korean National Health Insurance Service database from January 2009 to December 2012. Participants were followed up until December 31, 2013, and data analysis was performed from July 2020 to January 2021. Exposures: Physical activity level was assessed using a standardized, self-reported questionnaire at baseline. Physical activity-related energy expenditure (in MET-min/wk) was calculated by summing the product of frequency, intensity, and duration. Main Outcomes and Measures: Incidence of dementia. Incidence rates were calculated by dividing the number of events by the person-time at risk (presented as the incidence per 1000 person-years). Hazard ratios (HRs) and 95% CIs for dementia were analyzed according to physical activity level. Competing risk regression was performed by using the Fine-Gray subdistribution hazard model, with mortality as the competing risk for dementia events. Multivariable regression models were constructed with adjustment for various patient characteristics. Incident dementia occurring 2 years after enrollment was assessed, and separate analyses included all follow-up periods. Restricted cubic spline curves were used to examine the association of continuous values of physical activity with dementia. Results: Among 62 286 participants, 60.4% were women, and the mean (SD) age was 73.2 (5.3) years. During a median follow-up of 42 months, 3757 participants (6.0%) developed dementia, and the overall incidence was 21.6 per 1000 person-years. Compared with inactive individuals (0 MET-min/wk), insufficiently active (1-499 MET-min/wk; mean, 284 MET-min/wk), active (500-999 MET-min/wk; mean, 675 MET-min/wk), and highly active participants (≥1000 MET-min/wk; mean, 1627 MET-min/wk) showed 10% (adjusted hazard ratio [HR], 0.90; 95% CI, 0.81-0.99), 20% (adjusted HR, 0.80; 95% CI, 0.71-0.92), and 28% (adjusted HR, 0.72; 95% CI, 0.60-0.83) reduced dementia risk, respectively. Thus, a progressive decrease in the adjusted HR of dementia was associated with increasing physical activity level, and a restricted cubic spline curve showed that this association started with a low amount of total physical activity. This association was consistent regardless of age, sex, and other comorbidities or after censoring for stroke. Compared with total sedentary behavior, even a low amount of LPA (1-299 MET-min/wk; mean, 189 MET-min/wk) was associated with reduced dementia risk (adjusted HR, 0.86; 95% CI, 0.74-0.99). Conclusions and Relevance: In older adults, an increased physical activity level, including a low amount of LPA, was associated with a reduced risk of dementia. Promotion of LPA might reduce the risk of dementia in older adults.

Usefulness of cardiac magnetic resonance images for prediction of sudden cardiac arrest in patients with mitral valve prolapse: a multicenter retrospective cohort study.

BACKGROUND: An association has been identified between mitral valve prolapse (MVP) and sudden cardiac arrest (SCA), and ventricular arrhythmias (VA). This study aimed to elucidate predictive factors for SCA or VA in MVP patients. METHODS: MVP patients who underwent cardiac magnetic resonance (CMR) were retrospectively included. Patients with other structural heart disease or causes of aborted SCA were excluded. Clinical characteristics (sex, age, body mass index, histories of diabetes, hypertension, and dyslipidemia) and electrocardiographic (PR interval, QRS duration, corrected QT interval, inverted T wave in the inferior leads, bundle branch block, and atrial fibrillation), echocardiographic [mitral regurgitation grade, prolapsing mitral leaflet, and right ventricular systolic pressure (RVSP)], and CMR [left atrial volume index, both ventricular ejection fractions, both ventricular end-diastolic and systolic volume indexes, prolapse distance, mitral annular disjunction, systolic curling motion, presence of late gadolinium enhancement (LGE), LGE volume and proportion] parameters were analyzed. RESULTS: Of the 85 patients [age, 54.0 (41.0-65.0) years; 46 men], seven experienced SCA or VA. Younger age and wide QRS complex were observed more often in the SCA/VA group than in the no-SCA/VA group. The SCA/VA group exhibited lower RVSP, more systolic curling motion and LGE, greater LGE volume, and higher LGE proportion. The presence of LGE [hazard ratio (HR), 19.8; 95% confidence interval (CI) 2.65-148.15; P = 0.004], LGE volume (HR 1.08; 95% CI 1.02-1.14; P = 0.006) and LGE proportion (HR 1.32; 95% CI 1.08-1.60; P = 0.006) were independently associated with higher risk of SCA or VA in MVP patients together with systolic curling motion in each model. CONCLUSIONS: The presence of systolic curling motion, high LGE volume and proportion, and the presence of LGE on CMR were independent predictive factors for SCA or VA in MVP patients.

Subclinical cardiac perforation by cardiac implantable electronic device leads detected by cardiac computed tomography.

BACKGROUND: The relationship between the characteristics of cardiac implantable electronic device (CIED) leads and subclinical cardiac perforations remains unclear. This study aimed to evaluate the incidence of subclinical cardiac perforation among various CIED leads using cardiac computed tomography (CT). METHODS: A total of 271 consecutive patients with 463 CIED leads, who underwent cardiac CT after CIED implantation, were included in this retrospective observational study. Cardiac CT images were reviewed by one radiologist and two cardiologists. Subclinical perforation was defined as traversal of the lead tip past the outer myocardial layer without symptoms and signs related to cardiac perforation. We compared the subclinical cardiac perforation rates of the available lead types. RESULTS: A total of 219, 49, and 3 patients had pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy, respectively. The total subclinical cardiac perforation rate was 5.6%. Subclinical cardiac perforation by screw-in ventricular leads was significantly more frequent than that caused by tined ventricular leads (13.3% vs 3.3%, respectively, p = 0.002). There were no significant differences in the incidence of cardiac perforation between atrial and ventricular leads, screw-in and tined atrial leads, pacing and defibrillator ventricular leads, nor between magnetic resonance (MR)-conditional and MR-unsafe screw-in ventricular leads. Screw-in ventricular leads were significantly associated with subclinical cardiac perforation [odds ratio, 4.554; 95% confidence interval, 1.587-13.065, p = 0.005]. There was no case subclinical cardiac perforation by septal ventricular leads. CONCLUSIONS: Subclinical cardiac perforation by screw-in ventricular leads is not rare. Septal pacing may be helpful in avoiding cardiac perforation.

Long-term prognosis of short QT interval in Korean patients: a multicenter retrospective cohort study.

BACKGROUND: Short QT syndrome is a rare, inherited channelopathy associated with sudden cardiac arrest (SCA) but the characteristics and prognosis of short QT interval (SQTI) in Korean patients remain unclear. This study aimed to determine the clinical characteristics and outcomes of SQTI in a Korean population. METHODS: Consecutive patients with SQTI from January 1999 to March 2019 in three university hospitals in South Korea were recruited. SQTI was defined as a Bazett's formula-corrected QT interval (QTc) ≤ 340 ms in serial electrocardiograms. Age- and sex-matched patients with a normal QTc and without overt cardiovascular disease were included in a 1:4 ratio. Clinical and ECG features and outcomes were compared between patients with and without SQTI. RESULTS: 34 patients with SQTI [age, 23.5 (21-30.5) years; 31 male] were followed up for 4.8 (2.0-7.8) years. Early repolarization, tall T wave, and U wave were significantly more frequent in patients with SQTI than in those without SQTI. QT dispersion [44.0 (28.0-73.0) vs. 20.0 (12.0-35.0) ms, P < 0.001] was significantly wider and heart rate [52.0 (47.0-58.0) vs. 70.0 (62.3-84.0)/min, P < 0.001] was significantly slower in patients with SQTI than in those without. Atrial fibrillation (AF, 11.8% vs. 2.2%, P = 0.030) and ventricular arrhythmia (VA)/SCA (8.7% vs. 0%, P = 0.007) were significantly more frequent in patients with SQTI than in those without. SQTI was significantly associated with AF [odds ratio, 5.911; 95% confidence interval, 1.257-27.808; P = 0.025] and VA/SCA. CONCLUSIONS: In this subset of Korean population, SQTI was associated with AF and VA/SCA.

Nonspecific intraventricular conduction delay is associated with future occurrence of atrial fibrillation in patients with structurally normal heart.

BACKGROUND: We aimed to elucidate the long-term prognosis of nonspecific intraventricular conduction delay (NIVCD) in patients with structurally normal heart. METHODS: We included 107,838 patients (age, 52.1 ±â€¯15.5 years; men, 46.8%) who underwent electrocardiography in outpatient clinics or medical checkup (unmatched cohort). NIVCD was defined as QRS duration ≥110 ms without meeting the criteria for bundle branch block. Patients with structurally normal heart and sinus rhythm were assigned to the NIVCD and normal QRS groups according to propensity score with matching variables of age, sex, hypertension, and diabetes (matched cohort 1), and additional PR interval (matched cohort 2). Baseline characteristics, electrocardiographic parameters, and clinical outcomes were compared in the unmatched cohort and the matched cohort. RESULTS: In the unmatched cohort, the frequencies of male sex and preexisting atrial fibrillation were significantly higher in the NIVCD group than in the normal QRS group. In matched cohort 1 (n = 690), the NIVCD group exhibited significant slower sinus rate and longer PR interval than the normal QRS group. In matched cohort 2 (n = 598), the cumulative incidence of atrial fibrillation was significantly higher in the NIVCD group than in the normal QRS group during a follow-up period of 8.8 ±â€¯2.9 years. NIVCD significantly increased the risk for AF (hazard ratio, 2.571; 95% confidence interval, 1.074-6.156; p = 0.034). CONCLUSIONS: It is suggested that NIVCD may be associated with future occurrence of atrial fibrillation in patients with structurally normal heart and sinus rhythm.

Long-Term Outcome of Additional Superior Vena Cava to Septal Linear Ablation in Catheter Ablation of Atrial Fibrillation.

Background We previously reported the benefit of linear ablation from the superior vena cava to the right atrial septum (SVC-L) within a year after circumferential pulmonary vein isolation (CPVI) in patients with paroxysmal atrial fibrillation (AF). We explored the long-term effects of SVC-L and its potential related mechanisms. Methods and Results Among 2140 consecutive patients with AF ablation, we included 614 patients (73.3% male, aged 57.8±10.7 years, 13.7% with persistent AF) who did not undergo an extra-pulmonary vein left atrial ablation after propensity score matching; of those, 307 had additional SVC-L and 307 had CPVI alone. We evaluated the heart rate variability and computational modeling study to explore mechanisms. Although the procedure time was longer in the SVC-L group than the CPVI group (P<0.001), the complication rates did not differ (P=0.560). During 40.5±24.4 months of follow-up, the rhythm outcome was significantly better in the SVC-L group than the CPVI group (log rank, P<0.001). At 2-year follow-up of heart rate variability, a significantly higher mean heart rate (P=0.018) and a lower ratio of low/high-frequency components (P=0.011) were found with SVC-L than CPVI alone. In realistic in silico biatrial modeling, which reflected the electroanatomies of 10 patients, SVC-L significantly reduced biatrial dominant frequency compared with CPVI alone (P<0.001) and increased AF termination and defragmentation rates (P=0.033). Conclusions SVC-L ablation in addition to CPVI significantly improved the long-term rhythm outcome over 2 years after AF catheter ablation by mechanisms involving autonomic modulation and AF organization.

Physical Activity and Risk of Atrial Fibrillation: A Nationwide Cohort Study in General Population.

Although exercise prevents cardiovascular disease and mortality, vigorous exercise and endurance athletics can cause atrial fibrillation (AF). However, no large cohort study has assessed the relationship between physical activity and AF in the general population. We assessed the effect of physical activity at different energy expenditures on the incidence of AF. We studied 501,690 individuals without pre-existing AF (mean age, 47.6 ± 14.3 years; 250,664 women [50.0%]) included in the Korean National Health Insurance Service database. The physical activity level was assessed using a standardized self-reported questionnaire at baseline. During a median follow-up of 4 years, 3,443 participants (1,432 women [41.6%]) developed AF. The overall incidence of AF at follow-up was 1.79 per 1,000 person-years. The subjects who met the recommended physical activity level (500-1,000 metabolic equivalent task [MET] minutes/week) had a 12% decreased AF risk (adjusted hazard ratio [HR]: 0.88, 95% confidence interval [CI]: 0.80-0.97), but not the insufficiently (1-500 MET-minutes/week; HR: 0.94, 95% CI: 0.86-1.03) and highly active subjects (≥1,000 MET-minutes/week; HR: 0.93, 95% CI: 0.85-1.03). The recommended minimum key target range of physical activity level was associated with the maximum benefit for reduced AF risk in the general population. The dose-response relationship between physical activity level and AF risk showed a U-shaped pattern. Although exceeding the key target range attenuated this benefit, it did not increase the AF risk beyond that during inactivity.

Radiofrequency catheter ablation of accessory pathways at the site of prior valve surgery.

BACKGROUND: Radiofrequency catheter ablation (RFCA) for accessory pathways (APs) at the site of prior valve surgery (VS) remains challenging. We aimed to clarify the factors associated with successful RFCA for such APs. METHODS: Upon reviewing a RFCA registry and previous case reports, we included nine patients who underwent RFCA of APs at the site of prior VS (total-VS group; age, 34.0 [24.5-45.0] years; men, 4/9) and 196 patients who underwent RFCA of APs with no history of VS (no-VS group; age, 40.5 [23.0-54.0] years; men, 114/196). Electrophysiological features, procedural details, and outcomes were examined. RESULTS: Accessory pathway exhibited decremental conduction in four of nine patients in the total-VS group. The number of RFCA attempts was significantly higher in the total-VS group than in the no-VS group (10.0 [4.5-14.5] vs 2.0 [1.0-3.0]; P < 0.001). In four patients who underwent mitral VS, successful RFCA was achieved using the transaortic approach, coronary sinus (CS) approach, or bipolar ablation. In three patients who underwent tricuspid VS, successful RFCA was achieved using the above-prosthetics or trans-prosthetics approach. In two patients, RFCA failed. The trans-prosthetics approach and bipolar ablation technique were effective. The transaortic and CS approaches were occasionally effective. The transseptal approach was ineffective. CONCLUSIONS: Successful RFCA of APs at the site of prior VS can be achieved by detailed mapping of the areas both above and below the prosthetic valve, as well as by ensuring effective radiofrequency energy delivery using various catheter approaches and RFCA techniques.

Atrial Fibrillation Catheter Ablation Improves 1-Year Follow-Up Cognitive Function, Especially in Patients With Impaired Cognitive Function.

BACKGROUND: Although atrial fibrillation (AF) has a risk of cognitive dysfunction, it is not clear whether AF catheter ablation improves or worsens cognitive function. This prospective case-control study sought to assess the 1-year serial changes in the cognitive function with or without AF catheter ablation. METHODS: We evaluated the Montreal Cognitive Assessment score in 308 patients (71.4% male, 60.6±9.1 years of age, 34.1% persistent AF) who underwent AF ablation (ablation group) and 50 AF patients on medical therapy who met the same indication for AF ablation (control group), at baseline and 3 and 12 months after enrollment. Cognitive impairment was defined as a published cutoff score of <23 points. To exclude any learning effects, we used the practice-adjusted reliable change index for assessing the cognitive changes. RESULTS: Preablation cognitive impairment was detected in 18.5% (57/308). The Montreal Cognitive Assessment score significantly improved 1 year after radiofrequency catheter ablation in both overall ablation group (24.9±2.9-26.4±2.5; P<0.001) and the propensity-matched ablation group (25.4±2.4-26.5±2.3; P<0.001), but not in the control group (25.4±2.5-24.8±2.5; P=0.012). Preablation cognitive impairment (odds ratio, 13.70; 95% CI, 4.83-38.87; P<0.001) was independently associated with an improvement in the 1-year post-ablation cognitive function. In the reliable change index analyses, 94.7% of propensity-matched ablation group showed an improved/stable cognitive function at the 1-year follow-up. CONCLUSIONS: Catheter ablation of AF, at least, does not deteriorate the cognitive function, but rather improves the performance on 1-year follow-up neurocognitive tests, especially in patients with a preablation cognitive impairment.

Left Ventricular End-Systolic Volume Can Predict 1-Year Hierarchical Clinical Composite End Point in Patients with Cardiac Resynchronization Therapy.

PURPOSE: This study aimed to elucidate which echocardiographic criteria at three time points, for cardiac resynchronization therapy (CRT) response, are accurate in discriminating the hierarchical clinical composite end point (HCCEP). MATERIALS AND METHODS: We included 120 patients (age, 66.1±12.6 years; men, 54.2%) who underwent CRT implantation for heart failure (HF). Echocardiography was performed before and at 3, 6, and 12 months after CRT implantation. The 1-year HCCEP included all-cause mortality, hospitalization for HF, and New York Heart Association functional class for 12 months. CRT response criteria were decrease in left ventricular (LV) end-systolic volume (LVESV) >15%, decrease in LV end-diastolic volume >15%, absolute increase in LV ejection fraction (LVEF) ≥5%, relative increase in LVEF ≥15%, and decrease in mitral regurgitation ≥1 grade. Temporal changes in CRT response rates, accuracy of CRT response criteria at each time and cutoff value for the discrimination of improvement in HCCEP, and agreements with improvement in HCCEP were analyzed. RESULTS: HCCEP improvement rates were 65.8% in total group. In nonischemic group, CRT response rates according to all echocardiographic criteria significantly increased with time. In ischemic group, CRT response rate did not significantly change with time. In total group, ΔLVESV at 6 months (ΔLVESV6) had the most significant accuracy for the discrimination of HCCEP (area under the curve=0.781). The optimal cutoff value of ΔLVESV6 was 13.5% (sensitivity=0.719, specificity=0.719). ΔLVESV6 had fair agreement with HCCEP (κ=0.391, p<0.001). CONCLUSION: ΔLVESV6 is the most useful echocardiographic CRT response criterion for the prediction of 1-year HCCEP.