Frequent Premature Atrial Contractions Lead to Adverse Atrial Remodeling and Atrial Fibrillation in a Swine Model.

BACKGROUND: Frequent premature atrial complexes (PACs) are associated with future incident atrial fibrillation (AF), but whether PACs contribute to development of AF through adverse atrial remodeling has not been studied. This study aimed to explore the effect of frequent PACs from different sites on atrial remodeling in a swine model. METHODS: Forty swine underwent baseline electrophysiologic studies and echocardiography followed by pacemaker implantations and paced PACs (50% burden) at 250-ms coupling intervals for 16 weeks in 4 groups: (1) lateral left atrium (LA) PACs by the coronary sinus (Lat-PAC; n=10), (2) interatrial septal PACs (Sep-PAC; n=10), (3) regular LA pacing at 130 beats/min (Reg-130; n=10), and (4) controls without PACs (n=10). At the final study, repeat studies were performed, followed by tissue histology and molecular analyses focusing on fibrotic pathways. RESULTS: Lat-PACs were associated with a longer P-wave duration (93.0±9.0 versus 74.2±8.2 and 58.8±7.6 ms; P<0.001) and greater echocardiographic mechanical dyssynchrony (57.5±11.6 versus 35.7±13.0 and 24.4±11.1 ms; P<0.001) compared with Sep-PACs and controls, respectively. After 16 weeks, Lat-PACs led to slower LA conduction velocity (1.1±0.2 versus 1.3±0.2 [Sep-PAC] versus 1.3±0.1 [Reg-130] versus 1.5±0.2 [controls] m/s; P<0.001) without significant change in atrial ERP. The Lat-PAC group had a significantly increased percentage of LA fibrosis and upregulated levels of extracellular matrix proteins (lysyl oxidase and collagen 1 and 8), as well as TGF-ß1 (transforming growth factor-ß1) signaling proteins (latent and monomer TGF-ß1 and phosphorylation/total ratio of SMAD2/3; P<0.05). The Lat-PAC group had the longest inducible AF duration (terminal to baseline: 131 [interquartile range 30, 192] seconds versus 16 [6, 26] seconds [Sep-PAC] versus 22 [11, 64] seconds [Reg-130] versus -1 [-16, 7] seconds [controls]; P<0.001). CONCLUSIONS: In this swine model, frequent PACs resulted in adverse atrial structural remodeling with a heightened propensity to AF. PACs originating from the lateral LA produced greater atrial remodeling and longer induced AF duration than the septal-origin PACs. These data provide evidence that frequent PACs can cause adverse atrial remodeling as well as AF, and that the location of ectopic PACs may be clinically meaningful.

Tumor suppressive role of the epigenetic master regulator BRD3 in colorectal cancer.

Bromodomain and extraterminal domain (BET) family proteins are epigenetic master regulators of gene expression via recognition of acetylated histones and recruitment of transcription factors and co-activators to chromatin. Hence, BET family proteins have emerged as promising therapeutic targets in cancer. In this study, we examined the functional role of bromodomain containing 3 (BRD3), a BET family protein, in colorectal cancer (CRC). In vitro and vivo analyses using BRD3-knockdown or BRD3-overexpressing CRC cells showed that BRD3 suppressed tumor growth and cell cycle G1/S transition and induced p21 expression. Clinical analysis of CRC datasets from our hospital or The Cancer Genome Atlas revealed that BET family genes, including BRD3, were overexpressed in tumor tissues. In immunohistochemical analyses, BRD3 was observed mainly in the nucleus of CRC cells. According to single-cell RNA sequencing in untreated CRC tissues, BRD3 was highly expressed in malignant epithelial cells, and cell cycle checkpoint-related pathways were enriched in the epithelial cells with high BRD3 expression. Spatial transcriptomic and single-cell RNA sequencing analyses of CRC tissues showed that BRD3 expression was positively associated with high p21 expression. Furthermore, overexpression of BRD3 combined with knockdown of, a driver gene in the BRD family, showed strong inhibition of CRC cells in vitro. In conclusion, we demonstrated a novel tumor suppressive role of BRD3 that inhibits tumor growth by cell cycle inhibition in part via induction of p21 expression. BRD3 activation might be a novel therapeutic approach for CRC.

Rapid three-dimensional quantification of high-intensity plaques from coronary atherosclerosis T1-weighted characterization to predict periprocedural myocardial injury.

BACKGROUND: High-intensity plaque (HIP) on magnetic resonance imaging (MRI) has been documented as a powerful predictor of periprocedural myocardial injury (PMI) following percutaneous coronary intervention (PCI). Despite the recent proposal of three-dimensional HIP quantification to enhance the predictive capability, the conventional pulse sequence, which necessitates the separate acquisition of anatomical reference images, hinders accurate three-dimensional segmentation along the coronary vasculature. Coronary atherosclerosis T1-weighted characterization (CATCH) enables the simultaneous acquisition of inherently coregistered dark-blood plaque and bright-blood coronary artery images. We aimed to develop a novel HIP quantification approach using CATCH and to ascertain its superior predictive performance compared to the conventional two-dimensional assessment based on plaque-to-myocardium signal intensity ratio (PMR). METHODS: In this prospective study, CATCH MRI was conducted before elective stent implantation in 137 lesions from 125 patients. On CATCH images, dedicated software automatically generated tubular three-dimensional volumes of interest on the dark-blood plaque images along the coronary vasculature, based on the precisely matched bright-blood coronary artery images, and subsequently computed PMR and HIP volume (HIPvol). Specifically, HIPvol was calculated as the volume of voxels with signal intensity exceeding that of the myocardium, weighted by their respective signal intensities. PMI was defined as post-PCI cardiac troponin-T > 5 × the upper reference limit. RESULTS: The entire analysis process was completed within 3 min per lesion. PMI occurred in 44 lesions. Based on the receiver operating characteristic curve analysis, HIPvol outperformed PMR for predicting PMI (C-statistics, 0.870 [95% CI, 0.805-0.936] vs. 0.787 [95% CI, 0.706-0.868]; p = 0.001). This result was primarily driven by the higher sensitivity HIPvol offered: 0.886 (95% CI, 0.754-0.962) vs. 0.750 for PMR (95% CI, 0.597-0.868; p = 0.034). Multivariable analysis identified HIPvol as an independent predictor of PMI (odds ratio, 1.15 per 10-µL increase; 95% CI, 1.01-1.30, p = 0.035). CONCLUSIONS: Our semi-automated method of analyzing coronary plaque using CATCH MRI provided rapid HIP quantification. Three-dimensional assessment using this approach had a better ability to predict PMI than conventional two-dimensional assessment.

Motion robust coronary MR angiography using zigzag centric ky-kz trajectory and high-resolution deep learning reconstruction.

PURPOSE: To develop a new MR coronary angiography (MRCA) technique by employing a zigzag fan-shaped centric ky-kz k-space trajectory combined with high-resolution deep learning reconstruction (HR-DLR). METHODS: All imaging data were acquired from 12 healthy subjects and 2 patients using two clinical 3-T MR imagers, with institutional review board approval. Ten healthy subjects underwent both standard 3D fast gradient echo (sFGE) and centric ky-kz k-space trajectory FGE (cFGE) acquisitions to compare the scan time and image quality. Quantitative measures were also performed for signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) as well as sharpness of the vessel. Furthermore, the feasibility of the proposed cFGE sequence was assessed in two patients. For assessing the feasibility of the centric ky-kz trajectory, the navigator-echo window of a 30-mm threshold was applied in cFGE, whereas sFGE was applied using a standard 5-mm threshold. Image quality of MRCA using cFGE with HR-DLR and sFGE without HR-DLR was scored in a 5-point scale (non-diagnostic = 1, fair = 2, moderate = 3, good = 4, and excellent = 5). Image evaluation of cFGE, applying HR-DLR, was compared with sFGE without HR-DLR. Friedman test, Wilcoxon signed-rank test, or paired t tests were performed for the comparison of related variables. RESULTS: The actual MRCA scan time of cFGE with a 30-mm threshold was acquired in less than 5 min, achieving nearly 100% efficiency, showcasing its expeditious and robustness. In contrast, sFGE was acquired with a 5-mm threshold and had an average scan time of approximately 15 min. Overall image quality for MRCA was scored 3.3 for sFGE and 2.7 for cFGE without HR-DLR but increased to 3.6 for cFGE with HR-DLR and (p < 0.05). The clinical result of patients obtained within 5 min showed good quality images in both patients, even with a stent, without artifacts. Quantitative measures of SNR, CNR, and sharpness of vessel presented higher in cFGE with HR-DLR. CONCLUSION: Our findings demonstrate a robust, time-efficient solution for high-quality MRCA, enhancing patient comfort and increasing clinical throughput.

Prognostic significance of cardiorenal dysfunction within 1 year after atrial fibrillation ablation in patients with systolic dysfunction.

Atrial fibrillation (AF) ablation can improve left ventricular ejection fraction (LVEF) and renal function and can even reduce mortality in patients with impaired LVEF. However, the effect of post-ablation cardiorenal dysfunction on the prognosis of patients with impaired LVEF who underwent AF ablation remains unclear. Of the 1243 consecutive patients undergoing AF ablation, the prognosis of 163 non-dialysis patients who underwent AF ablation with < 50% LVEF was evaluated. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, and a need for modification of the treatment for heart failure. During the median follow-up of 4.2 years after the first AF ablation procedure, the primary outcome occurred in 30 of 163 patients (18%). The receiver operating characteristic curve analysis demonstrated that the post-LVEF (LVEF within 1 year after the procedure, and before the occurrence of primary outcome) had larger areas under the curve (0.70) than the pre-LVEF (LVEF before the procedure), and the most optimal cutoff value was LVEF ≤ 42%. Multivariate analysis demonstrated that patients with post-LVEF ≤ 42% and worsening renal function (WRF; an absolute increase in serum creatinine [SCr] ≥ 0.3 mg/dL compared with the SCr at baseline within 1 year after the procedure and before the occurrence of primary outcome) had a 3.4- to 4.3-fold and 3.4- to 3.7-fold higher risk of the primary outcome compared with those without these predictors, respectively. Patients were categorized using post-LVEF ≤ 42% and WRF as follows: group 1 (post-LVEF > 42% without WRF), group 2 (post-LVEF ≤ 42% without WRF), group 3 (post-LVEF > 42% with WRF), and group 4 (post-LVEF ≤ 42% with WRF). Group 4 had a 15.8-fold (P = 0.0001) higher risk of the primary outcome compared with group 1 after adjusting for pre-procedural factors. In patients with impaired LVEF undergoing AF ablation, post-LVEF ≤ 42% and WRF were independent predictors of poor prognosis. The combination of post-LVEF ≤ 42% and WRF is strongly associated with a poor prognosis in patients with AF undergoing ablation, who with these post-ablation cardiorenal dysfunction may have to be treated more intensively after AF ablation.

Generative adversarial network-based post-processed image super-resolution technology for accelerating brain MRI: comparison with compressed sensing.

BACKGROUND: It is unclear whether deep-learning-based super-resolution technology (SR) or compressed sensing technology (CS) can accelerate magnetic resonance imaging (MRI) . PURPOSE: To compare SR accelerated images with CS images regarding the image similarity to reference 2D- and 3D gradient-echo sequence (GRE) brain MRI. MATERIAL AND METHODS: We prospectively acquired 1.3× and 2.0× faster 2D and 3D GRE images of 20 volunteers from the reference time by reducing the matrix size or increasing the CS factor. For SR, we trained the generative adversarial network (GAN), upscaling the low-resolution images to the reference images with twofold cross-validation. We compared the structural similarity (SSIM) index of accelerated images to the reference image. The rate of incorrect answers of a radiologist discriminating faster and reference image was used as a subjective image similarity (ISM) index. RESULTS: The SR demonstrated significantly higher SSIM than the CS (SSIM=0.9993-0.999 vs. 0.9947-0.9986; P < 0.001). In 2D GRE, it was challenging to discriminate the SR image from the reference image, compared to the CS (ISM index 40% vs. 17.5% in 1.3×; P = 0.039 and 17.5% vs. 2.5% in 2.0×; P = 0.034). In 3D GRE, the CS revealed a significantly higher ISM index than the SR (22.5% vs. 2.5%; P = 0.011) in 2.0 × faster images. However, the ISM index was identical for the 2.0× CS and 1.3× SR (22.5% vs. 27.5%; P = 0.62) with comparable time costs. CONCLUSION: The GAN-based SR outperformed CS in image similarity with 2D GRE for MRI acceleration. In addition, CS was more advantageous in 3D GRE than SR.

A case series of very slow atrioventricular nodal reentrant tachycardia resembling junctional tachycardia.

INTRODUCTION: The surface electrocardiography of typical atrioventricular nodal reentrant tachycardia (AVNRT) shows simultaneous ventricular-atrial (RP) activation with pseudo R' in V1 and typical heart rates ranging from 150 to 220/min. Slower rates are suspicious for junctional tachycardia (JT). However, occasionally we encounter typical AVNRT with slow ventricular rates. We describe a series of typical AVNRT cases with heart rates under 110/min. METHODS: A total of 1972 patients with AVNRT who underwent slow pathway ablation were analyzed. Typical AVNRT was diagnosed when; (1) evidence of dual atrioventricular nodal conduction, (2) tachycardia initiation by atrial drive train with atrial-His-atrial response, (3) short septal ventriculoatrial time, and (4) ventricular-atrial-ventricular (V-A-V) response to ventricular overdrive (VOD) pacing with corrected post pacing interval-tachycardia cycle length (cPPI-TCL) > 110 ms. JT was excluded by either termination or advancement of tachycardia by atrial extrastimuli (AES) or atrial overdrive (AOD) pacing. RESULTS: We found 11 patients (age 20-78 years old, six female) who met the above-mentioned criteria. The TCL ranged from 560 to 782 ms. Except for one patient showing tachycardia termination, all patients demonstrated a V-A-V response and cPPI-TCL over 110 ms with VOD. AES or AOD pacing successfully excluded JT by either advancing the tachycardia in 10 patients or by tachycardia termination in one patient. Slow pathway was successfully ablated, and tachycardia was not inducible in all patients. CONCLUSIONS: This case series describes patients with typical AVNRT with slow ventricular rate (less than 110/min) who may mimic JT. We emphasize the importance of using pacing maneuvers to exclude JT.

Balloon Pulmonary Angioplasty in the Management of Chronic Thromboembolic Pulmonary Hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH), which is classified as group 4 pulmonary hypertension (PH) in the 2015 European Society of Cardiology/European Respiratory Society guidelines for the diagnosis and treatment of PH, is regarded as a complication of pulmonary embolism and is caused by the transformation of incompletely resolved thrombi into fibrous tissue that occludes the pulmonary arteries. The current established reference standard curative therapy for CTEPH is pulmonary endarterectomy (PEA), which provides good long-term outcomes with a low mortality rate. For patients with inoperable disease with inaccessible lesions and risk factors for surgery or patients who are diagnosed with residual or recurrent PH after PEA, medical therapy with riociguat is recommended. Balloon pulmonary angioplasty (BPA) is an emerging alternative treatment option for patients with inoperable disease or those with residual or recurrent PH after PEA. BPA has been reported to improve hemodynamics, cardiac function, exercise capacity, and symptoms, as well as PEA. A detailed assessment of thromboembolic lesions in pulmonary arteries by using multiple imaging techniques and treatment strategies with multiple staged procedures based on the patient's condition is important for safe and effective BPA. However, this new technique may still induce life-threatening complications, such as reperfusion pulmonary edema, wire perforation, vessel dissection, and vessel rupture. Meticulous attention to technique is mandatory to minimize serious complications owing to the nature of the anatomic territory involved. The authors summarize the current roles, goals, and complications of BPA in patients with CTEPH and demonstrate ways to formulate an effective and safe treatment strategy. The future perspective of BPA is also discussed. Online supplemental material is available for this article. ©RSNA, 2022.

Clinical impact of perioperative atrial fibrillation on long-term recurrence of malignancy.

Perioperative complications have been reported to be associated with a lower incidence of cancer-free survival. Perioperative atrial fibrillation (POAF) is one of occasionally observed complications in patients with malignancies who undergo noncardiac surgeries. However, the long-term clinical impact of POAF on those with malignancies have remained unknown. This was a prospective, single-center, observational study. Patients who underwent noncardiac surgeries for definitive malignancies between 2014 and 2017 were included. The primary and secondary endpoints were 3-year recurrence of malignancies and cancer death, respectively. The present study included consecutive 752 patients (mean age, 68 ± 11 years; males, 62%), and POAF was observed in 77 patients. The follow-up duration was 1037 (interquartile range, 699-1408) days. The 3-year recurrence of malignancies was observed in 239 (32%) patients (POAF, 32 [42%]; non-POAF, 207 [31%]) and 3-year mortality was 130 patients (17%). Cardiac, noncardiac, and cancer deaths were observed in 4 (0.5%), 126 (17%), and 111 (15%) patients, respectively. Multivariate Cox regression analysis demonstrated that POAF was associated with 3-year recurrence of malignancies (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.15-2.52). Landmark analysis demonstrated that POAF tended to be correlated with the incidence of 3-year cancer death (HR, 1.79; 95% CI, 0.96-3.31). In conclusion, POAF is associated with the subsequent recurrence of malignancies. The association of arrhythmia with cancer death may be revealed under longer follow-up durations.Clinical Trial Registration: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000018270 . UMIN ID: UMIN000016146.

Predictors of long-term success after catheter ablation of premature ventricular complexes.

INTRODUCTION: Some patients have late recurrence after acutely successful radiofrequency catheter ablation (RFCA) of premature ventricular complexes (PVCs). The aim of this study was to evaluate predictors of long-term success following acutely successful PVC RFCA. METHODS: We identified consecutive patients at our institution with frequent PVCs undergoing RFCA and reviewed procedural data and medical records. Acute success was defined as elimination of targeted PVCs for at least 30-min after RFCA. Long-term success was defined as absence of targeted PVCs during all follow-up visits and PVC-burden <5% on follow-up monitoring. RESULTS: Among 241 patients (mean age 57 ± 15 years, 58% male), 161 (66.8%) had long-term success with median follow-up of 17.7 (IQR, 12.2-29.8) months. Unadjusted predictors of late PVC recurrence were increasing age, diabetes mellitus and alcohol use, while female-sex, shorter ablation-time, right ventricular PVC-origin, single PVC morphology, and earliest bipolar activation ≥24 ms pre-QRS were predictors of long-term success. In multivariate-analysis, female-sex, single-PVC morphology and earliest-onset of PVC ≥ 24 ms pre-QRS were independent predictors for long-term success. The positive-predictive value of earliest-bipolar onset of PVC ≥ 24 ms pre-QRS for long-term success was 0.77 (p < .001). Negative-predictive value of PVC < 15 ms pre-QRS for long-term success was 0.86 (p = .003), suggesting that RFCA when the bipolar electrogram preceded QRS by <15 ms was unlikely to result in long-term success. CONCLUSIONS: Female-sex, single-PVC morphology, and earliest-onset of bipolar electrogram ≥24 ms pre-QRS were multivariable predictors of long-term success in patients with PVCs undergoing RFCA. RFCA at sites with local onset <15 ms pre-QRS are unlikely to be successful.

Comparison of high-power and conventional-power radiofrequency energy deliveries in pulmonary vein isolation using unipolar signal modification as a local endpoint.

INTRODUCTION: Negative component abolition of the unipolar signal (unipolar signal modification [USM]) reflects the lesion transmurality. The purpose of this study was to compare the procedural safety and outcome between high-power and conventional-power atrial radiofrequency applications during a pulmonary vein isolation (PVI) using USM as a local endpoint. METHODS AND RESULTS: High-power (50 W) and conventional-power (25-40 W) applications were compared among 120 consecutive patients with paroxysmal atrial fibrillation who underwent a USM-guided PVI. The first 60 patients were treated with conventional-power (CP) group and last 60 with high-power (HP) group. The atrial radiofrequency applications lasted for 5 to 10 seconds (CP group) or 3 to 5 seconds (HP group) after the USM. All procedures were performed using 3D mapping systems with image integration and esophageal temperature monitoring. The baseline characteristics were similar between the two groups. The HP group had fewer acute PV reconnections (62% vs 78%; P = .046) and a reduced procedure time (119.3 ± 28.1 vs 140.1 ± 51.2 minutes; P = .04). Freedom from recurrence after a single ablation procedure without any antiarrhythmic drugs was higher in the HP group than CP group (88.3% vs 73.3% at 12-months after the procedure, log-rank; P = .0423). There were no major complications that required any intervention. CONCLUSIONS: The high-power PVI guided by USM decreased the procedural time and may improve the procedural outcomes without compromising the safety.

Right atrial conduction time for predicting coexistent typical atrial flutter in patients with paroxysmal atrial fibrillation.

INTRODUCTION: Screening of coexistent typical atrial flutter (AFL) in patients with atrial fibrillation (AF) is sometimes challenging. This study investigated whether a prolonged right atrial conduction time (RACT) estimated by tissue Doppler imaging (TDI) predicts patients with concomitant AFL and AF. METHODS AND RESULTS: We retrospectively analyzed 398 patients (mean age: 61.6 years, 73.4% men) undergoing catheter ablation of paroxysmal AF. The patients were classified into two groups according to whether they had evidence of AFL (N = 122, 30.7%) determined by a clinical observation (N = 68), induction during procedures (N = 33), or AFL recurrence after procedures (N = 21) or not (N = 276, 69.3%). The preoperative RACT, defined as a longer duration between the onset of the P-wave and peak A'-wave on the right atrial lateral wall or septal wall, and total atrial conduction time (TACT), defined as the same time duration on the left atrial lateral wall, were evaluated in all patients. Patients with evidence of AFL had a significantly longer RACT than those without AFL (p < .001). A multiple logistic regression and receiver operator characteristics curve analysis revealed the ratio of the RACT and TACT (RACT/TACT) was the independent and most superior accurate cofounder for predicting evidence of AFL (area under the curve: 0.867). When adding a discriminator of an RACT/TACT ≧ 93% into the conventional screening, 98.4% of the patients with evidence of AFL were estimated to be treated during the initial procedures. CONCLUSION: The estimated RACT/TACT using the TDI may be useful for predicting patients with concomitant AFL in patients with AF.

Feasibility and safety of noncontrast percutaneous coronary intervention in patients with complicated acute coronary syndrome.

OBJECTIVES: This study aimed to examine the feasibility and safety of noncontrast percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) occurs in 10-20% of ACS patients undergoing PCI, resulting in poor short- and long-term prognoses. Reducing the amount of contrast medium can prevent CI-AKI. METHODS: This was a prospective single-center study. In successful noncontrast PCI, contrast medium was not injected from guiding catheter engagement to wire removal in ad-hoc PCI. Coronary angiography after PCI was permitted once. CI-AKI was defined as an increase in the serum creatinine level of ≥0.5 mg/dl or ≥1.25 times the baseline within 72 hr post PCI. Worsening renal function (WRF) was defined as an increase in the serum creatinine level of ≥0.3 mg/dl from baseline after PCI. RESULTS: This study included 106 lesions from 81 patients. Forty-eight (45%) lesions were Type C lesions. Successful noncontrast PCI was performed in 95 (90%) lesions. CI-AKI, coronary perforation, no/slow flow, and periprocedural death were observed in 4 (5%), 0, 9 (11%), and 0 patients, respectively. The follow-up period was 348 (190-492) days. Six-month WRF was observed in 18 individuals (22%). While successful noncontrast PCI was not associated with the incidence of CI-AKI, successful noncontrast PCI was inversely associated with WRF (hazard ratio, 0.28; 95% confidence interval, 0.09-0.90) after adjustment for renal function. CONCLUSIONS: The present study suggests that noncontrast PCI is feasible and can be safely performed in ACS patients with complex lesions.

Clinical Differences of Recent Myocardial Infarction Compared With Acute Myocardial Infarction　- Insights From the Tokyo CCU Network Multicenter Registry.

BACKGROUND: Characteristics and treatment outcomes of acute myocardial infarction (AMI) patients have been studied; however, those of recent myocardial infarction (RMI) patients remain unclear. This study aimed to clarify characteristics, treatment strategy, and in-hospital outcomes of RMI patients in the Tokyo CCU network database.Methods and Results:In total, 1,853 RMI and 12,494 AMI patients from the Tokyo CCU network database during 2013-2016 were compared. Both RMI and AMI were redefined by onset times of 2-28 days and ≤24 h, respectively. The RMI group had a higher average age (70.4±12.9 vs. 68.0±13.4 years, P<0.001), more women (27.6% vs. 23.6%, P<0.001), lower proportion of patients with chest pain as the chief complaint (75.2% vs. 83.6%, P<0.001), higher prevalence of diabetes mellitus (35.9% vs. 31.0%, P<0.001), and higher mechanical complication incidence (3.0% vs. 1.5%, P<0.001) than did the AMI group. Thirty-day mortality was comparable (5.3% vs. 5.8%, P=0.360); major causes of death were cardiogenic shock and mechanical complications in the AMI and RMI groups, respectively. Death from mechanical complications (not onset time) in the AMI group plateaued almost 1 week after hospitalization, whereas it continued to increase in the RMI group. CONCLUSIONS: Both RMI and AMI patients have distinctive clinical features, sequelae, and causes of death. Although treatment of RMI patients adhered to guidelines, it was insufficient, and death from mechanical complications continues to increase.

Safety and efficacy of transvenous lead extractions for noninfectious superfluous leads in a Japanese population: A single-center experience.

BACKGROUND: A challenging decision exists as whether to abandon or remove noninfectious superfluous leads during lead revisions or cardiac implantable electronic device (CIED) upgrades. There is insufficient data in the Asian population to guide decision making. METHODS: This study investigated the safety and efficacy of transvenous lead extractions (TLEs) in a high-volume Japanese center. Among a total of 341 patients who underwent lead revisions or CIED upgrades between 2008 and 2018, 53 patients (16%) who underwent TLEs to remove the superfluous leads were analyzed. RESULTS: Indications for TLE were vascular issues (60%), recalled leads (21%), growth of the body size (6%), abandoned leads in young patients (6%), switch to a subcutaneous implanted cardiac defibrillator (4%), need for an MRI conditional CIED (2%), and risks of vascular injury (2%). The population included 29 patients (55%) with nonfunctional leads and 24 (45%) with functional abandoned leads. A total of 74 target leads (mean 1.4 leads/person, median lead age 6.7 years) were extracted with a complete removal achieved in 98%. All coexisting leads, intended for continued use, were not damaged. All new leads (mean 1.4 leads/person) that had been simultaneously implanted during the TLE procedures were successfully implanted. There was one minor complication (2%) involving a pericardial effusion but it did not affect the hemodynamics. CONCLUSIONS: In this Japanese single center experience, the removal of noninfectious superfluous leads with TLEs seemed to be a safe and effective therapeutic option.

Impact of a prolonged interatrial conduction time for predicting the recurrence of atrial fibrillation after circumferential pulmonary vein isolation of persistent atrial fibrillation.

There are some cases that are difficult to cure with only circumferential pulmonary vein isolation (CPVI) of persistent atrial fibrillation (PerAF). Recently, prolonged interatrial conduction times (IACTs), which seem to be associated with progressive remodeled atria, have been reported as a predictor of new-onset AF. This study aimed to investigate the prognostic value of a prolonged IACT for predicting AF recurrences after CPVI of PerAF. One hundred thirteen patients who underwent CPVI without an empirical substrate modification of PerAF were retrospectively analyzed. The IACT was defined as the interval from the earliest P-wave onset on the ECG to the latest activation in the coronary sinus and was measured after achieving the CPVI and conversion to sinus rhythm. During a mean 22.7-month follow-up after the initial procedure, 56 patients (50%) had AF recurrences. Patients with AF recurrence had a longer IACT than those without AF recurrence (p < 0.001). The best discriminative cut-off value for the IACT was 123 ms (sensitivity 53%, specificity 85%). In a Cox multivariate analysis, a prolonged IACT of ≥ 123 ms was the only independent predictor (hazard ratio: 2.38; 95% confidence interval: 1.36-4.16, p = 0.002) of being associated with the incidence of an AF recurrence. Even after multiple CPVI procedures, patients with an IACT ≥ 123 ms had a higher AF recurrence rate than those with an IACT < 123 ms (p = 0.002). In conclusion, a prolonged IACT of ≥ 123 ms may be a useful marker for predicting AF recurrences after both initial and multiple CPVI procedures for PerAF.

Higher non-cardiac mortality and lesser impact of early revascularization in patients with type 2 compared to type 1 acute myocardial infarction: results from the Tokyo CCU Network registry.

As the definition of type 2 acute myocardial infarction (AMI) is obscure, the characteristics of this disease vary among studies. The clinical significance of type 2 AMI is unclear. We surveyed the Tokyo Cardiovascular Care Unit (CCU) Network registry between 2010 and 2014. The difference in clinical characteristics and the impact of revascularization in patients with type 1 and type 2 AMI were evaluated. The cohort study included 12514 patients admitted to CCU (type 1 AMI, 12023; type 2 AMI, 491; mean age, 68 ± 15 years; 75% male). Coronary angiography was performed in 11402 patients (95%) with type 1 AMI and 427 (87%) with type 2 AMI (p < 0.001). Type 2 AMI was associated with higher in-hospital mortality (type 1 AMI, 769 (6.4%); type 2 AMI, 54 (11.0%); adjusted odds ratio (OR) 1.64; 95% confidence interval (CI) 1.12-2.41; p = 0.011) and higher non-cardiac mortality (adjusted OR 2.19; 95% CI 1.33-3.62; p = 0.002), but similar cardiac mortality rate compared to type 1 AMI (adjusted OR 1.17; 95% CI 0.71-1.91; p = 0.539). Percutaneous coronary intervention (PCI) within 24 h after the onset was associated with lower in-hospital mortality in those with type 1 AMI (OR 0.47; 95% CI 0.40-0.55; p < 0.001), but not in those with type 2 AMI (OR 1.09; 95% CI 0.62-1.94; p = 0.763). The results persisted after adjustment for multivariate logistic regression analysis and inverted probability weighting. In conclusion, patients with type 2 AMI had higher in-hospital mortality owing to higher non-cardiac death. More refined definitions focusing on the treatment of comorbidities may be required, as the treatment strategy for type 2 AMI can be different from that for type 1 AMI.

Long-term clinical course after catheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy.

Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients is highly associated with deterioration of their clinical condition, such as worsening heart failure symptoms, and an increased thromboembolic stroke risk and cardiac mortality rate. This study aimed to investigate the long-term clinical course after catheter ablation (CA) in HCM patients with AF. Among 566 primary HCM patients at our institution, 94 who underwent rhythm control therapy to manage AF from 2002 to 2016 were retrospectively analyzed. The eligible patients were divided into two groups: those who managed AF with CA (n = 34) and those without CA (n = 60). The endpoints were the incidence of initial clinical events, including HCM-related death or an unplanned heart failure hospitalization, or new-onset thromboembolic strokes. During a mean follow-up of 5.8 years, 6% in the CA group and 28% in the non-CA group had a progression of the AF type into permanent AF (Log-rank: p = 0.012). In the Kaplan-Meyer curve analyses, the incidence of clinical events was significantly lower in the CA group than non-CA group (p = 0.025). The annual rates for the incidence of clinical events were 1.2% in the CA group and 6.7% in the non-CA group. In a Cox multivariate analysis, CA therapy (adjusted hazard ratio 0.22; 95% confidence interval: 0.05-0.97; p = 0.046) was the only independent predictor of the incidence of clinical events. In conclusion, CA may be associated with a favorable long-term clinical course in HCM patients with AF.

Left Ventricular T1 Mapping during Chemotherapy-Radiation Therapy: Serial Assessment of Participants with Esophageal Cancer.

Purpose To assess changes in left ventricular function and tissue composition by using MRI after chemotherapy-radiation therapy in participants with esophageal cancer. Materials and Methods Between January 2013 and April 2015, this prospective study enrolled 24 participants (42% women; mean age, 63 years; range, 49-73 years) scheduled for chemotherapy-radiation therapy. 3.0-T MRI examinations were performed before, at 0.5 year, and at 1.5 years after chemotherapy-radiation therapy. Myocardial native T1, postcontrast T1, and extracellular volume were measured in basal septum (as irradiated areas) and apical lateral wall (as nonirradiated areas). Left ventricular function, prevalence of late gadolinium enhancement, and T1 and extracellular volume values were compared over the follow-up period by using Friedman or Cochran Q tests, followed by Dunn test. Results In 14 participants who were followed up for 1.5 years, native T1 and extracellular volume in the septum were elevated at 0.5 year compared with baseline (1183 msec ± 46 [standard deviation] vs 1257 msec ± 35; 26% ± 3 vs 32% ± 3; adjusted P < .01 for both), but not in the lateral wall. Left ventricular stroke volume index and late gadolinium enhancement changed at 1.5 years compared with baseline (41 mL/m2 ± 11 vs 36 mL/m2 ± 9; P = .046; 7% [one of 14] vs 78% [11 of 14]; P < .01). Other measures of left ventricular function did not change during the follow-up period (P > .10 for all). Conclusion Native T1 and extracellular volume could detect early changes in myocardium at 0.5 year after chemotherapy-radiation therapy, whereas left ventricular stroke volume index and late gadolinium enhancement showed abnormality at 1.5 years. © RSNA, 2018 Online supplemental material is available for this article.