Prevalence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during local impedance-guided extensive pulmonary vein isolation of atrial fibrillation with high-resolution mapping.

INTRODUCTION: Local impedance (LI) drops during radiofrequency ablation can predict lesion formation. Some conduction gaps during pulmonary vein isolation (PVI) can be associated with nonendocardial connections. This study aimed to investigate the incidence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during an LI-guided PVI. METHODS AND RESULTS: We prospectively enrolled 157 consecutive patients undergoing an initial LI-guided extensive PVI of atrial fibrillation (AF). After the first-pass encirclement, the residual conduction gaps and reconnected gaps were mapped using Rhythmia (Boston Scientific) and a mini-basket catheter. Right and left PV (RPV/LPV) gaps were observed in 22.3% and 18.5% of the patients, respectively: 27 endocardial and 49 nonendocardial gaps. The carina regions were common sites for the gaps (51 carina-related vs. 25 noncarina-related). The carina-related gaps consisted of more nonendocardial gaps than endocardial gaps (RPVs: 90.0% vs. 10.0%, p = .001; LPVs: 76.2% vs. 23.8%, p < .001). A univariate analysis revealed that paroxysmal AF and the left atrial (LA) volume index for RPV endocardial gaps (odds ratio [OR]: 8.640 and 0.946; p = .043 and 0.009), minor right inferior PV diameter for RPV nonendocardial gaps (OR: 1.165; p = .028), and major left inferior PV diameter for LPV endocardial gaps (OR: 1.233; p = .028) were significant predictors. CONCLUSIONS: During the LI-guided PVI, approximately two-thirds of the conduction gaps were nonendocardial. The carina regions had more conduction gaps than noncarina regions, which was due to the presence of nonendocardial connections. Paroxysmal AF, a lower LA volume index, and larger inferior PV diameters may increase the risk of conduction gaps.

Incidence and characteristics of silent cerebral embolisms after radiofrequency-based atrial fibrillation ablation: A propensity score-matched analysis between different mapping catheters and indices for guiding ablation.

INTRODUCTION: The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS: Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537). CONCLUSIONS: Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.

Postablation cerebral embolisms in balloon-based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation.

INTRODUCTION: This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon-based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA). METHODS AND RESULTS: We enrolled 123 consecutive AF patients who underwent a balloon-based pulmonary vein isolation (PVI) and brain magnetic resonance (MR) imaging after the ablation procedure (CBA, n = 65; HBA, n = 58). The DOACs were continued in 62 patients throughout the periprocedural period and discontinued in 61 on the procedural day. Intravenous heparin was infused to maintain an activated clotting time of 300 to 400 seconds during the procedure. No symptomatic embolisms occurred in this series. Silent cerebral ischemic lesions (SCILs) were observed on MR imaging in 22 patients (17.9%), and the incidence of SCILs did not significantly differ between the CBA and HBA groups (21.5 vs 13.8%; P = 0.263). According to a multivariate logistic regression analysis, an older age was an independent positive predictor of SCILs (odds ratio, 1.062; 95% CI, 1.001-1.126; P = 0.046), but neither the balloon catheter type nor periprocedural continuation or discontinuation of the DOACs were significant predictors. The incidence of major and minor bleeding complications was comparable between the CBA and HBA groups (1.5 vs 0%, P = 0.528; 7.7 vs 5.2%, P = 0.424). CONCLUSIONS: Both CBA and HBA of AF revealed a similar incidence of postablation cerebral embolisms. Elderly patients may be at a risk of SCILs after a balloon-based PVI with periprocedural DOAC treatment.

Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-centre study on post-ablation thrombo-embolic and haemorrhagic events.

AIMS: This prospective, randomized, single-centre study aimed to directly compare the safety and efficacy of uninterrupted and interrupted periprocedural anticoagulation protocols with direct oral anticoagulants (DOACs) in patients undergoing catheter ablation of non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS: We randomly assigned 846 NVAF patients receiving DOACs prior to ablation to uninterruption (n = 422) or interruption (n = 424) of the DOACs on the day of the procedure. The primary endpoint was a composite of symptomatic thromboembolisms and major bleeding events within 30 days after the ablation. Secondary endpoints included symptomatic and silent thromboembolisms and major and minor bleeding events. The primary endpoint occurred in 0.7% of the uninterrupted DOAC group [1 transient ischaemic attack (TIA) and 2 major bleeding events] and 1.2% of the interrupted DOAC group (1 TIA and 4 major bleeding events) (P = 0.480). The incidence of major and minor bleeding was comparable between the two groups (0.5% vs. 0.9%, P = 0.345; 5.9% vs. 5.4%, P = 0.753). Silent cerebral ischaemic lesions (SCILs) were observed in 138 (20.9%) of the 661 patients undergoing post-ablation magnetic resonance (MR) imaging. The uninterrupted and interrupted DOAC groups revealed a similar incidence of SCILs (19.8% vs. 22.0%, P = 0.484) and percentage of SCILs with disappearance on follow-up MR imaging (77.8% vs. 82.1%, P = 0.428). CONCLUSION: Both the uninterrupted and interrupted DOAC protocols revealed a low risk of symptomatic thromboembolisms and major bleeding events and similar incidence of SCILs and minor bleeding events and may be feasible for periprocedural anticoagulation in NVAF patients undergoing catheter ablation.

The effect of bilateral cardiac sympathetic denervation for refractory ventricular tachycardia in ischemic cardiomyopathy.

Recent studies have shown that cardiac sympathetic denervation (CSD) is effective in the treatment of refractory ventricular tachyarrhythmia in patients with structural heart disease. This case report aimed to highlight the effect of bilateral CSD in suppressing treatment-resistant ventricular tachycardia in patients with ischemic cardiomyopathy.

Impact of the type of electroanatomic mapping system on the incidence of cerebral embolism after radiofrequency catheter ablation of left atrial tachycardias.

BACKGROUND: Left atrial tachycardias (ATs) often occur after left atrial ablation. The incidence of symptomatic and silent cerebral embolism after radiofrequency catheter ablation of left ATs and the impact of the type of 3-dimensional electroanatomic mapping (3D-EAM) system on the incidence of cerebral embolism remain unclear. OBJECTIVES: This study aimed to investigate the incidence of cerebral embolism after a 3D-EAM system-guided left AT ablation procedure and compare that between the different 3D-EAM systems. METHODS: We prospectively enrolled 59 patients who underwent left AT ablation and brain magnetic resonance imaging after the procedure: 30 were guided by the Rhythmia system (Boston Scientific, Marlborough, MA) and 29 by the CARTO system (Biosense Webster, Diamond Bar, CA) (groups R and C, respectively). RESULTS: One transient ischemic attack occurred in group R, and no symptomatic embolism occurred in group C. Silent cerebral ischemic lesions (SCILs) were observed in 35 patients (59.3%), and group R had a significantly higher incidence of SCILs than did group C (86.2% vs 33.3%; P < .001). In multivariate analysis, group R and left atrial linear ablation were independent positive predictors of SCILs (odds ratio 12.822 and 8.668; P = .001 and P = .005). The incidence of bleeding complications was comparable between groups R and C (0% vs 3.3%; P = .508). CONCLUSION: Group R exhibited a higher incidence of postablation cerebral embolism than did group C. The use of the high-resolution 3D-EAM system with a mini-basket catheter to guide radiofrequency ablation of left atrial macroreentrant tachycardias may markedly increase the risk of silent cerebral embolism. The present results require further validation in a randomized study.

Use of the GuideLiner catheter for aspiration thrombectomy in a patient with ST-elevation myocardial infarction with a large intracoronary thrombus.

We report a 67-year-old man with ST-elevation myocardial infarction with a large intracoronary thrombus who was successfully treated with percutaneous thrombectomy using the GuideLiner catheter. This catheter is designed for the "Mother and Child" technique with a rapid exchange system and it has a larger internal diameter than conventional aspiration devices. When aspiration thrombectomy using a conventional aspiration catheter is not feasible or fails, use of the GuideLiner catheter for aspiration of thrombus is a reasonable alternative for primary percutaneous coronary intervention in patients with acute myocardial infarction.

Successful treatment using corticosteroids in early phase of eosinophilic myocarditis with eosinophilic granulomatosis with polyangiitis.

We report the case of a 50-year-old man with eosinophilic myocarditis and bronchial asthma treated successfully with prednisolone. He was initially diagnosed with eosinophilia, and complained of acute chest pain with electrocardiographic changes and elevation of cardiac enzymes. Coronary angiography showed no atherosclerotic changes; therefore, we performed endomyocardial biopsy and started oral prednisolone therapy immediately. His general condition improved with the disappearance of eosinophilia upon treatment. He was finally diagnosed with eosinophilic granulomatosis with polyangiitis complicated by eosinophilic myocarditis. This case report highlights that eosinophilic myocarditis may occur in association with systemic disease, and early steroid therapy is essential. .

Steam-deformed Judkins-left guiding catheter with use of the GuideLiner(®) catheter to deliver stents for anomalous right coronary artery.

OBJECTIVE: Percutaneous coronary intervention for anomalous right coronary artery (RCA) originating from the left coronary cusp is challenging because of our current inability to coaxially engage the guiding catheter. METHODS: We report a case of an 88-year-old woman with non-ST segment elevation myocardial infarction, with an anomalous RCA origin. Using either the Judkins-Left catheter or Amplatz-Left catheter was difficult because of RCA ostium tortuosity. Thus, we used steam to deform the Judkins-Left catheter, but back-up support was insufficient to deliver the stent. RESULTS: We used GuideLiner®, a novel pediatric catheter with rapid exchange/monorail systems, to enhance back-up support. CONCLUSIONS: We were able to successfully stent with both the deformed Judkins-Left guiding catheter and GuideLiner® for an anomalous RCA origin.

A rare case of acute myocardial infarction with multivessel coronary artery ectasia successfully treated with percutaneous coronary intervention and systemic thrombolysis.

Coronary artery ectasia (CAE) is defined as a coronary artery dilatation with a diameter ≥1.5 times greater than that of a normal adjacent artery. All 3 coronary vessels can be affected by CAE, but the incidence of multivessel CAE among patients undergoing coronary angiography is quite low. We herein report an extremely rare case of acute myocardial infarction due to massive thrombi in the giant right coronary artery with multivessel CAE. Thrombus aspiration during percutaneous coronary intervention may be limited in giant coronary artery cases, and systemic thrombolysis may be effective in patients with massive thrombi in the giant coronary artery.

Successful percutaneous coronary intervention of a chronic totally occluded left anterior descending artery via an ipsilateral intraseptal channel using intravascular ultrasound-guided retrograde wire-crossing technique.

We herein report a 59-year-old man with a chronic totally occluded left anterior descending artery treated by percutaneous coronary intervention via an ipsilateral intraseptal channel using an intravascular ultrasound-guided retrograde wire-crossing technique. When an antegrade approach is not feasible or fails, a retrograde approach to a chronic totally occluded lesion is reasonable. However, a retrograde approach from the contralateral coronary artery is not always feasible. We herein report that an ipsilateral intraseptal channel can serve as one route by which to perform a retrograde approach to chronic totally occluded lesions of the left anterior descending artery.

Successful percutaneous thrombectomy in an elderly patient with massive pulmonary embolism with cardiogenic shock.

We report on an 80-year-old woman with cardiogenic shock due to massive pulmonary embolism who was successfully treated with percutaneous thrombectomy using a conventional angiographic guide wire and catheters combined with systemic thrombolysis. We successfully treated the patient without a ventilator or extracorporeal life support. We report that percutaneous thrombectomy can provide rapid improvement of hemodynamic instability and can be used as an effective adjuvant therapy for systemic thrombolysis in patients with massive pulmonary embolism. Percutaneous thrombectomy is a less invasive and reasonable alternative to surgical embolectomy for patients with massive pulmonary embolism with cardiogenic shock.

Successful treatment using corticosteroids in a patient with refractory vasospastic angina and bronchial asthma.

We report a 55-year-old female patient with refractory vasospastic angina and bronchial asthma treated successfully with corticosteroids. She was diagnosed with vasospastic angina by coronary angiography and the acetylcholine provocation test. Even after administration of oral vasodilators (benidipine, diltiazem, nicorandil, isosorbide mononitrate) she had recurrent chest pain with ST elevation. She had a history of bronchial asthma, so we added 30 mg/day of oral prednisolone. Her symptoms disappeared completely upon treatment. This case report suggests that corticosteroids are a therapeutic choice for patients with refractory vasospastic angina, especially for those with bronchial asthma. .

Clinical history and colliquative myocytolysis are keys to the diagnosis of shoshin beriberi.

Cardiovascular beriberi presents as either the fulminant (Shoshin beriberi) or chronic form. Shoshin beriberi is a rare disease that may lead to a fatal outcome if the patient does not receive appropriate treatment. In the present report, we describe the case of a 66-year-old man presenting with leg edema and dyspnea at rest. Clinical presentations were nonalcoholic Shoshin beriberi and lactate accumulation; however, clinical improvement was observed after the administration of thiamine. His pretherapy thiamine level (2.1 µ g/dL) was consistent with a diagnosis of beriberi. Based on the findings of the present case, we believe that a diagnosis can be made in patients with a clinical history that is consistent with that of Shoshin beriberi, combined with low thiamine levels, lactate accumulation, and colliquative myocytolysis. Learning Objective. Shoshin beriberi is often misdiagnosed because of its rarity; a detailed clinical history and characteristic myocardial histopathology changes may be useful for making a definite diagnosis.

Successful percutaneous coil embolization of a large and tortuous coronary artery to pulmonary artery fistula.

We herein report the case of a 73-year-old woman with a large and tortuous coronary artery to pulmonary artery fistula treated with percutaneous coil embolization. The patient was hospitalized due to unstable angina with an elevated serum troponin-T level. Coronary angiography revealed no significant atherosclerotic stenosis, with a large and tortuous coronary artery to pulmonary artery fistula originating from the proximal portion of the left anterior descending artery. We successfully performed percutaneous coil embolization of the fistula. In this case, 320-slice multidetector computed tomography played a pivotal role in the diagnosis and percutaneous intervention.

A rare adult case of left main coronary artery atresia.

We report a 65-year-old woman with congenital left main coronary artery atresia detected by coronary angiography and 320-slice multidetector computed tomography. The patient was hospitalized with congestive heart failure and treated by medical therapy conservatively. Surgical revascularization of the left coronary artery was not performed since stress myocardial perfusion scintigraphy revealed no clear evidence of myocardial ischemia. Recently, there are many patients with congenital coronary artery anomalies detected by multidetector computed tomography. However, the adult case of left main coronary artery atresia is extremely rare. In this case, 320-slice multidetector computed tomography played a pivotal role in the diagnosis of the extremely rare coronary artery anomaly.

Parachute mitral valve incidentally diagnosed in an adult patient with hypertension.

We describe a 52-year-old woman incidentally diagnosed as having parachute mitral valve (PMV). Echocardiography displayed a parachute-like deformity of the mitral valve characterized by a unifocal attachment of mitral valve chordae. PMV is a congenital cardiac malformation that causes stenosis of the mitral valve and is often found in combination with left-heart obstruction in the pediatric population. The incidence of PMV in adults is extremely low. This patient had no related cardiac complications, which accounts for the long asymptomatic period. Thus, rare forms of congenital heart disease in late adulthood need attention in echocardiographic study.