Selective complex fractionated atrial electrogram ablation based on the number-of-fractionation for persistent atrial fibrillation refractory to pulmonary vein isolation.

INTRODUCTION: Previous studies have suggested that the prolonged or highly fractionated electrograms during atrial fibrillation (AF) are closely related to the reentrant driver regions. We hypothesized that exploration and ablation of these critical complex atrial fractionated electrograms (CFAE) may improve the outcome of persistent AF (PeAF) refractory to conventional PVI. METHODS: A total of 73 PeAF patients with residual inducibility or failed cardioversions of AF after PVI were enrolled and underwent number-of-fractionation mapping (NFM) by counting the number of fractionations in 2.5 s at each of the points using the CARTO3 (ICL mode) and EnSite (fractionation map) systems. After NFM, selective CFAE ablation (NFM-CA) targeting the sites of the upper 40% of the counted fraction number (NF40) was performed as an additional procedure for refractory PeAF. We investigated the prognosis of these patients within 24 months after the index ablation procedure and the relationship between changes in activation patterns during the ablation procedure and their prognosis. We also performed a propensity score-matched analysis comparing these patients with historical controls (HC) to identify the optimal indications for NFM-CA. RESULTS: The AF/AT free survival rate was 79.1% at 12 months and 56.7% at 24 months. Patients with AF termination or AF cycle length prolongation > 21 ms during the procedure had significantly better AF/AT-free survival rates than those without notable activation changes (87.7% vs. 69.0%, logrank p = 0.028). After propensity-matched analysis, AF/AT-free survival showed comparable results between the two groups (1 year; NFM 72.1% vs. HC 77.1%, logrank p = 0.649). CONCLUSIONS: NFM-CA is a versatile and less invasive adjunctive procedure for patients with PVI-refractory PeAF who showed a comparable prognosis to patients with PVI-compliant PeAF. In particular, remarkable activation changes during the procedure (AFCL prolongation > 21 ms or acute termination) suggest a favorable prognosis.

Clinical effects of combined anteversion and offset on postoperative dislocation in total hip arthroplasty.

BACKGROUND: Implant impingement and soft tissue tension are factors involved in dislocation after total hip arthroplasty (THA). Combined anteversion (CA) has been used as an indicator for implant placement. However, optimal implant placement remains a challenge. Moreover, the effect of changes in offset on dislocation is still unclear. In this study, we aimed to clarify the effects of postoperative CA and pre- and postoperative changes in offset on dislocation. METHODS: Included were patients who underwent primary cementless THA between 2013 and 2020. The mean values of CA and offset in the dislocation and non-dislocation groups were compared. The CA values within ± 10% of the recommended values were defined as good CA, and those outside the range were rated as poor CA. The dislocation rates were compared between the good and poor CA groups and between the groups with and without increased offset. RESULTS: A total of 283 hips were included. The mean values of CA in the dislocation and non-dislocation groups were significantly different (P < 0.05). The dislocation rate was significantly lower in the good CA group (P < 0.05). The dislocation rates in the groups with and without increased total offset were 0.5% and 4.3%, respectively (P = 0.004). There were no dislocations in patients with good CA and increased offset. CONCLUSIONS: The dislocation rate was significantly lower when implants were placed within ± 10% of the recommended CA value. Our results suggest that dislocation can be avoided by placing the implant in the good CA range and considering the increase in total offset on the operative side.

Impact of post-procedural peripheral fractional flow reserve after drug-coated balloon angioplasty in femoropopliteal lesions.

PURPOSE: The aim of this study was to determine if postprocedural peripheral fractional flow reserve (pFFR) is associated with patency one year after drug-coated balloon (DCB) angioplasty for femoropopliteal (FP) lesions. MATERIALS AND METHODS: Forty-five consecutive patients having 49 de novo FP lesions were enrolled in this prospective, observational study conducted from April 2022 to Aug 2023. The pFFR was measured under hyperemic conditions after the administration of 30 mg of papaverine. The relationship between pFFR and restenosis 12 months after the procedure was determined using receiver operating characteristic (ROC) curve analysis. RESULTS: The one-year follow-up was completed for 47 lesions (95.9 %). Restenosis was detected in 7 lesions (14.9 %). Postprocedural pFFR was significantly higher in the nonrestenosis group compared with the pFFR in the stenosis group (0.95 ± 0.054 vs. 0.88 ± 0.090, p = 0.010). The optimal pFFR cutoff value for predicting restenosis was 0.92 (sensitivity, 0.824; specificity, 0.600). The area under the curve for pFFR was numerically higher than the area under the curve for minimum lumen area (0.73 vs. 0.64, p = 0.22). Rates of freedom from restenosis at one year were significantly higher in the pFFR >0.92 group compared with the pFFR ≤0.92 group (p = 0.0042). CONCLUSION: Postprocedural pFFR was associated with patency at one year after DCB angioplasty for FP lesions.

Utility and optimal dose of nicorandil for physiological assessment of the femoropopliteal artery.

BACKGROUND: Nicorandil is widely used as a vasodilator for the physiological assessment of coronary arteries because of its usefulness and safety; however, there are no data on its use in peripheral arteries. AIMS: To identify the utility of nicorandil and its appropriate dose for the physiological assessment on the femoropopliteal artery. METHODS: We retrospectively enrolled patients from three institutes in which physiological assessment was carried out with various doses of nicorandil before treatment. Twenty-four femoropopliteal artery stenotic lesions from 22 patients were included. The nicorandil doses used were 2, 4, and 6 mg. Twenty-two lesions were also assessed using 30 mg of papaverine. The pressure gradient (PG) and peripheral fractional flow reserve (pFFR) were calculated based on the mean and systolic pressure levels. We examined the correlation of each parameter with the peak systolic velocity ratio (PSVR) based on the duplex ultrasound images using Spearman's rank correlation coefficient. Systemic blood pressure was assessed for safety. RESULTS: The correlations were higher for mean pressure-based parameters than for systolic pressure-based parameters. As the nicorandil dose increased, the correlations among PG, pFFR, and PSVR also increased (mean pressure-based PG: 2 mg, r = 0.360; 4 mg, r = 0.498; 6 mg, r = 0.694, mean pressure-based pFFR: 2 mg, r = -0.479; 4 mg, r = -0.469; 6 mg, r = -0.641). The blood pressure after the administration of 6 mg of nicorandil was low, and the median systemic mean pressure was 65 mmHg. CONCLUSION: A 4 mg dose of nicorandil is effective and safe for the mean pressure-based physiological assessment of lesions in the femoropopliteal artery.

Comprehensive clinical outcomes of drug-coated balloon treatment for coronary artery disease. Insights from a single-center experience.

BACKGROUND: Some clinical trials have verified the efficacy and safety of paclitaxel drug-coated balloon (DCB) for small vessel coronary artery disease. However, nonsmall vessel and calcified lesions received less attention. AIMS: This study aimed to investigate the efficacy of DCB treatment for various types of coronary artery lesions, including not only small vessel disease but also nonsmall vessel disease and calcified lesions. In this real-world clinical practice study, in-stent restenosis was excluded. METHODS: This study consecutively included 934 patients with 1751 nonstented lesions who received DCB at a cardiovascular center in Kyoto Katsura Hospital in Japan between 2009 and 2012 and 2014 to 2019. This study enrolled and retrospectively analyzed all of the patients. Eligible patients routinely underwent follow-up angiography at 6-8 months after percutaneous coronary intervention. The primary endpoint includes target lesion revascularization (TLR) during follow-up. Further, this study calculated the predictor of TLR using multivariate analysis. RESULTS: This study included the lesions involving 46.4% of type B2/C, 26.9% with severe calcification, and 6.0% with DCB restenosis. Mean DCB diameter and length were 2.75 ± 0.51 mm and 24.2 ± 9.6 mm, respectively. The median follow-up duration was 18 months. Follow-up angiography revealed a TLR rate of 9% and a restenosis rate of 9%. This study identified hemodialysis and current smoking as independent TLR predictors. CONCLUSION: In routine clinical practice, the effectiveness of DCB was observed consistently across various types of coronary artery disease.