Association of left pulmonary vein trunk and subclinical atrial fibrillation in patients with cardiac implantable electronic device.

The relationship between subclinical atrial fibrillation (SCAF) and left pulmonary vein anatomy is unknown. This study sought to investigate whether left pulmonary vein trunk predict the development of SCAF in patients with cardiac implantable electronic device (CIED). We also examined the relationship between the duration of SCAF and left pulmonary vein trunk. We retrospectively enrolled 162 patients who underwent implantation of dual-chamber CIEDs and follow-up by remote monitoring system. Computed tomography was used to measure the length of the left pulmonary vein. During median follow up of 2.7 years, the episodes of > 6 min and > 24 h SCAF were observed in 61 (37.7%) and 24 (14.8%) patients, respectively. The diagnosis of sinus node disease (HR: 3.66 [2.06-6.52], P < 0.01 and HR: 2.68 [1.09-6.62], P = 0.04) and left atrial diameter (HR: 1.04 [1.00-1.07], P = 0.04 and HR: 1.05 [1.00-1.10], P = 0.04) were independent predictors for > 6 min and > 24 h SCAF, respectively. Length of the left pulmonary vein trunk was an independent predictor for > 6 min SCAF (HR: 1.06 [1.02-1.10], P < 0.01), but not for > 24 h SCAF (P = 0.06). Sinus node disease, size of the left atrium and length of the left pulmonary vein trunk were related to SCAF. The left pulmonary vein trunk might especially contribute as a trigger rather than as a driver of development of atrial fibrillation.

Transvenous permanent pacemaker implantation after debranching thoracic endovascular aortic repair; A case series.

Debranching thoracic endovascular aortic repair may disturb the implantation of a cardiac implantable electronic device in the anterior thoracic region. In case 1, the bypass graft between the right axillary artery, left axillary artery, and left common carotid artery disturbed pacemaker implantation from the left anterior thoracic region. Therefore, right-sided implantation was selected. By contrast, in case 2, the bypass graft between axillary arteries in the anterior thoracic region was visible on fluoroscopy, and we performed conventional left-sided pacemaker implantation with extra-thoracic puncture. The pacemaker implantations were successful in both cases. The implantation strategies were affected by the number of debranched arteries and visibility of the bypass graft.

Relationship between postoperative atrial fibrillation and its recurrence after lung resection.

PURPOSE: Atrial fibrillation (AF) frequently occurs after pulmonary resection and is commonly referred to as postoperative atrial fibrillation (POAF). This study explored whether or not POAF is related to the recurrence of AF in the chronic phase. METHODS: A total of 1311 consecutive patients without a history of AF who underwent lung resection based on a diagnosis of lung tumor were retrospectively analyzed. RESULTS: POAF occurred in 46 patients (3.5%), and a logistic regression analysis revealed that the age (p < 0.05), history of hyperthyroidism (p < 0.05), and major lung resection (p < 0.05) were independent predictors of POAF. AF events in the chronic phase were observed in 15 (32.6%) and 45 (3.6%) patients with and without POAF, respectively. A Cox regression analysis revealed that POAF was the only independent predictor of AF development in the chronic phase (p < 0.01). The Kaplan-Meier curve and log-rank test revealed that the cumulative incidence of AF in the chronic phase was significantly higher in patients with POAF than in those without POAF (p < 0.01). CONCLUSION: POAF was an independent predictor for AF in the chronic phase after lung resection. Further investigations including cases of catheter ablation and optimal medical therapy for patients with POAF after lung resection are needed.

Characteristics of Discharged Elderly Patients with Acute Heart Failure Followed by Board-Certified-Cardiologists in a Rural Area of Japan.

The worldwide incidence rates of heart failure (HF) are approaching pandemic status due to aging societies. Board-certified cardiologists (BCCs) of the Japanese Circulation Society (JCS) are cardiologists who have completed the respective fellowship program and passed the examination. However, in rural areas, patients have limited access to medical care for social or geographical reasons. The clinical features of the specialist's follow-up for HF patients in rural areas are unclear.This study consists of 205 consecutive discharged elderly patients who were admitted to our hospital due to acute HF (AHF). All patients were recommended for follow-up with BCCs-JCS by the multidisciplinary HF team at the discharge-care planning meeting. The aim of this study was to investigate the clinical features and impact of BCC follow-up for discharged elderly patients with AHF in rural areas.A total of 156 patients chose follow-up with BCCs-JCS (BCC group), and 49 patients chose follow-up with non-BCCs-JCS (non-BCC group). Patients in the BCC group were younger (83 [76-86] versus 89 [75-93] years old, P < 0.001) and had more frequent use of ß-blockers (67% versus 39%, P < 0.001). The degree of frailty assessed by the clinical frailty scale was more severe in the non-BCC group than in the BCC group (4 [3-5] versus 6 [4-7], P < 0.001). The non-BCC group lived in nursing homes more frequently than the BCC group (16% versus 5%, P = 0.011).The HF patients followed by BCCS-JCS in rural areas were younger and had less frailty.

Impact of pulmonary vein anatomy and left atrial size on postoperative atrial fibrillation after esophagectomy for esophageal cancer.

BACKGROUND: This study aimed to investigate the relationship between postoperative atrial fibrillation (POAF) after esophagectomy and pre-existing cardiac substrate. METHODS: We retrospectively analyzed 212 consecutive patients from between July 2010 and December 2022 who were scheduled to undergo esophagectomy for esophageal cancer without previous history of atrial fibrillation. All the patients underwent both echocardiography and contrast-enhanced multi-detector computed tomography (MDCT). RESULTS: POAF occurred in 49 patients (23.1%). Multivariable logistic analysis demonstrated that independent predictors for POAF were age [OR; 1.06 (1.01-1.10), P < 0.01), three-field lymph node dissection [OR; 2.55 (1.25-5.23), P < 0.01), left atrial dilatation (> 35 mm) assessment by echocardiography [OR; 3.05 (1.49-6.25), P < 0.01) and common left pulmonary vein [OR; 3.03 (1.44-6.39), P < 0.01). The correlation coefficient was high for left atrial dimensions assessed by echocardiography and MDCT (r = 0.91, P < 0.01). Combination of left atrial dilatation by echocardiography and common left pulmonary vein had high odds ratio [OR; 8.10 (2.62-25.96), P < 0.01). Instead of echocardiographic assessment, combination of left atrial enlargement (> 35 mm) assessed by MDCT and common left pulmonary vein also showed high odds ratio for POAF [OR; 11.23 [2.19-57.63], P < 0.01). CONCLUSION: Incidence of POAF after esophagectomy was related to both left atrial enlargement and common left pulmonary vein assessed by preoperative MDCT. Additional analysis of atrial size and pulmonary vein variation would facilitate preoperative assessment of the risk of POAF, but future studies must ascertain therapeutic strategy.

Vascular Response After Everolimus-Eluting Stent in Acute Myocardial Infarction Caused by Calcified Nodule.

BACKGROUND: Patients with acute myocardial infarction (AMI) caused by calcified nodules (CN) have worse clinical outcomes following primary percutaneous coronary intervention (PCI). This study investigated the late vascular response after everolimus-eluting stent (EES) implantation assessed by optical coherence tomography (OCT) in patients with AMI caused by CN, by comparing with plaque rupture (PR) and plaque erosion (PE).Methods and Results: Based on the OCT findings in AMI culprit lesions before PCI, a total of 141 patients were categorized into 3 groups (PR, PE, or CN), and the OCT findings immediately and 10 months after PCI were compared. The frequency of PR, PE, and CN was 85 (60%), 45 (32%), and 11 patients (8%), respectively. In the 10-month follow-up OCT, the frequency of lesions with uncovered struts and lesions with malapposed struts were highest in the CN group, followed by the PR and PE groups (82% vs. 52% vs. 40%, P=0.042 and 73% vs. 26% vs. 16%, P<0.001, respectively). The incidence of intra-stent thrombus, re-appearance of CN within the stent, and target lesion revascularization were higher in the CN group compared with the PR and PE groups (36% vs. 9% vs. 7%, P=0.028; 27% vs. 0% vs. 0%, P<0.001; and 18% vs. 2% vs. 2%, P=0.024, respectively). CONCLUSIONS: Late arterial healing response at 10 months after EES implantation in the CN was worse compared with PR and PE in patients with AMI.

Real-time venography-guided extrathoracic puncture technique for cardiovascular implantable electronic device implantation.

Central venous access is an essential technique for cardiovascular implantable electronic device (CIED) implantation, and the use of axillary vein approach has recently been increasing. This study sought to examine whether real-time venography-guided extrathoracic puncture facilitates the procedure. We retrospectively analyzed 179 consecutive patients who underwent CIED implantation using the axillary vein puncture method. Patients were divided into two groups: the conventional method group (CG, n = 107) and the real-time venography-guided group (RG, n = 82). The application of real-time venography was at the discretion of individual operators. Operators with experience of less than 50 CIED implantations were defined as inexperienced operators in this study. Puncture duration and number of attempts were significantly less in the RG group than in the CG group (283 ± 198 vs. 421 ± 361 s, p < 0.01, and 3.19 ± 2.00 vs. 4.18 ± 2.85, p < 0.01). These benefits of real-time venography were observed in inexperienced operators, but not in experienced operators. In addition, the success rate without extra attempts at puncture was higher in the RG group (54% vs. 32%, p < 0.01). Although the total amount of contrast medium was higher in the RG group (16.3 ± 4.1 mL vs. 11.9 ± 6.6 mL, p < 0.01), serum levels of creatinine pre- and post-operation were not different in the two groups (p = NS). We concluded that real-time venography is a safe and effective method for axillary vein puncture, especially in inexperienced operators.

Impact of left ventricular ejection fraction and preoperative hemoglobin level on perioperative adverse cardiovascular events in noncardiac surgery.

The prediction of a perioperative adverse cardiovascular event (PACE) is an important clinical issue in the medical management of patients undergoing noncardiac surgery. Although several predictors have been reported, simpler and more practical predictors of PACE have been needed. The aim of this study was to investigate the predictors of PACE in noncardiac surgery. We retrospectively analyzed 723 patients who were scheduled for elective noncardiac surgery and underwent preoperative examinations including 12-lead electrocardiography, transthoracic echocardiography, and blood test. PACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, congestive heart failure, arrhythmia attack that needs emergency treatment (rapid atrial fibrillation, ventricular tachycardia, and bradycardia), acute pulmonary embolism, asystole, pulseless electrical activity, or stroke during 30 days after surgery. PACE occurred in 54 (7.5%) of 723 patients. High-risk operation (11% vs. 3%, p = 0.003) was more often seen, left ventricular ejection fraction (LVEF) (55 ± 8% vs. 60 ± 7%, p = 0.001) and preoperative hemoglobin level (11.8 ± 2.2 g/dl vs. 12.7 ± 2.0 g/dl, p = 0.001) were lower in patients with PACE compared to those without PACE. By multivariate logistic regression analysis, high-risk operation (odds ratio (OR): 7.05, 95% confidence interval (CI) 2.16-23.00, p = 0.001), LVEF (OR 1.06, every 1% decrement, 95% CI 1.03-1.09, p = 0.001), and preoperative hemoglobin level (OR 1.22, every 1 g/dl decrement, 95% CI 1.07-1.39, p = 0.003) were identified as independent predictors of PACE. Receiver operating characteristic analysis demonstrated that LVEF of 58% (sensitivity = 80%, specificity = 61%, area under the curve (AUC) = 0.723) and preoperative hemoglobin level of 12.2 g/dl (sensitivity = 63%, specificity = 64%, AUC = 0.644) were optimal cut-off values for predicting PACE. High-risk operation, reduced LVEF, and reduced preoperative hemoglobin level were independently associated with PACE in patients undergoing noncardiac surgery.

Global longitudinal strain evaluated by speckle-tracking echocardiography as a surrogate marker for predicting replacement fibrosis detected by magnetic resonance-late gadolinium enhancement in patients with nonischemic cardiomyopathy.

PURPOSE: This study aimed to investigate whether left ventricular (LV) global longitudinal strain (GLS) evaluated by speckle-tracking echocardiography (STE) can be used as a surrogate marker for the detection of replacement fibrosis by late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) in patients with nonischemic cardiomyopathy (NICM). METHODS: This study analyzed 41 NICM patients who successfully underwent both STE and CMR, and were divided into those with (Group A, n = 18) and those without CMR-LGE (Group B, n = 23). Echocardiographic indexes, including GLS, were compared between the two groups. RESULTS: No significant differences were observed in LV end-diastolic and end-systolic volume indexes, LV ejection fraction, mitral E/A, deceleration time, E/e', left atrial volume index, and the systolic trans-tricuspid pressure gradient between Groups A and B. STE-GLS was significantly worse in Group A than in Group B (-7.6% ± 3.0% vs -9.9% ± 3.2%, P = .01). Receiver operating characteristic curve analysis showed that STE-GLS of -7.9% was the best cut-off value for detection of CMR-LGE (sensitivity, 78%; specificity, 74%; and area under the curve, 0.74). CONCLUSIONS: STE-GLS may be a potential surrogate marker for the detection of CMR-LGE-derived replacement fibrosis in patients with NICM.

Expression of Cyclophilin A in Coronary Artery Plaque with Intraplaque Hemorrhage Is More Frequent in Deceased Patients Who Had Impaired Kidney Function.

Patients with impaired kidney function have a high frequency of intraplaque hemorrhage (IPH) in their coronary arteries. Levels of cyclophilin A (CyPA), an indirect matrix metalloproteinase inducer, are increased in deceased patients who had impaired kidney function. In this study, we have examined the relationship between IPH and CyPA.We examined 47 samples of coronary plaque from 27 cadavers with coronary stenosis. These sections, all with > 50% coronary stenosis, were stained with an antibody against CyPA and the expression of CyPA was semi-quantified. Cadavers and plaques were classified into one of two groups depending on the presence or absence of IPH. IPH was defined as the presence of red blood cells stained with hematoxylin and eosin (HE) indicative of overt acute hemorrhage.In an individual analysis, estimation of glomerular filtration rate (eGFR) in the IPH group was significantly lower than that in the non-IPH group (P = 0.002). In a histological analysis, the percentage of stained area of CyPA in the IPH group was significantly higher than that in the non-IPH group (P < 0.0001).IPH was associated with a significantly higher expression of CyPA in this study. In addition, patients with IPH in their coronary arteries had significantly impaired kidney function.

Prognostic Value of Human Peripheral Monocyte Subsets for Future Coronary Events in Patients Without Significant Coronary Artery Stenosis.

BACKGROUND: Monocytes in human peripheral blood are heterogeneous and can be divided into 2 groups, inflammatory and pro-inflammatory, according to the differential expression of CD14 and CD16. Pro-inflammatory monocytes (CD14+CD16+) seem to contribute to the development of coronary artery disease. This study aimed to investigate the involvement of specific human peripheral monocyte subsets in the development of future coronary events.Methods and Results:We enrolled 271 patients who were suspected to have either stable angina pectoris or silent myocardial ischemia and underwent coronary angiography (CAG). Two monocyte subsets (CD14+CD16-and CD14+CD16+) were measured by flow cytometry. Patients who did not undergo coronary artery revascularization at initial CAG were followed as the medical therapy group, which included 136 patients among whom 15 had future coronary events. The frequency of CD14+CD16+monocytes was significantly higher in patients who had future coronary events than in those who did not (P<0.01). Furthermore, the frequencies of CD14+CD16+monocyte were not significantly different between patients who had future coronary events and those who underwent coronary revascularization at initial CAG (P<0.33). Multivariate analysis revealed that the frequency of CD14+CD16+monocytes was an independent predictor for future coronary events (P<0.01). CONCLUSIONS: An increase in the abundance of human peripheral pro-inflammatory monocytes is related to the development of future coronary events.

Value of tissue-tracking tricuspid annular plane by speckle-tracking echocardiography for the assessment of right ventricular systolic dysfunction.

BACKGROUND: Assessment of right ventricular (RV) function remains challenging because of its complex geometry. Application of speckle-tracking echocardiography (STE) to the tricuspid annulus provides rapid and automated assessment of the midpoint of the tricuspid annular plane displacement (TAD). The aim of this study was to investigate the value of tissue-tracking TAD for the assessment of RV systolic dysfunction. METHODS: We retrospectively studied 61 patients in whom RV ejection fraction (EF) measured by 3-dimensional echocardiography was performed. STE-derived displacement of the midpoint between the septal and lateral tricuspid annulus and its percentage of RV length at end-diastole (MTAD) were automatically assessed. We performed comparative analyses between the RVEF ≥45% group and the RVEF <45% group in each parameter for the assessment of RV systolic function. RESULTS: MTAD was successfully assessed in 56 (91.2%). According to receiver operating characteristics analysis, RVEF <45% was best detected by MTAD <14.7% with area under curve (AUC) 0.97, sensitivity 93%, specificity 95%, followed by RV free wall longitudinal strain (AUC 0.86), RV fractional area change (AUC 0.84), tricuspid annular plane systolic excursion (AUC 0.79), and systolic peak velocity of tricuspid annulus (AUC 0.70), although there was no significant difference between MTAD and RV free wall strain (P = 0.14). CONCLUSION: The present study showed that MTAD was simple index and useful for the assessment of RV systolic dysfunction.

Assessment of decreased left ventricular longitudinal deformation in asymptomatic patients with organic mitral regurgitation and preserved ejection fraction using tissue-tracking mitral annular displacement by speckle-tracking echocardiography.

BACKGROUND: Application of speckle-tracking echocardiography (STE) provides rapid assessment of tissue-tracking mitral annular displacement (TMAD). We investigated the value of TMAD for the assessment of decreased LV longitudinal deformation in asymptomatic patients with severe or moderate-to-severe mitral regurgitation (MR) and preserved LV ejection fraction (LVEF). METHODS: We retrospectively studied 50 patients with severe or moderate-to-severe organic MR and preserved LVEF (>60%) in whom global longitudinal strain (GLS) was successfully measured by STE. TMAD was quickly assessed in the apical four-chamber view using STE. We calculated the percentage of TMAD to LV length from the midpoint of mitral annulus to the apex at end-diastolic (%TMAD). The study population was divided into two groups: decreased GLS patients (>-20%; Group A) and preserved GLS patients (≤-20%; Group B). We examined whether %TMAD could be used as a diagnostic factor of decreased GLS. RESULTS: %TMAD was significantly lower in Group A than Group B (12.5 ± 0.5 vs 16.8 ± 2.2, P < 0.0001). By univariate logistic regression analysis, %TMAD was a diagnostic factor of decreased GLS. By multiple regression analysis, %TMAD remained an independent diagnostic factor of decreased GLS (Odds ratio [OR] = 4.21, 95% confidence interval [CI] = 1.34-28.94, P < 0.0001). A cutoff value of %TMAD <14.6 had a sensitivity of 94% and specificity of 94% for the presence of decreased GLS. CONCLUSIONS: Tissue-tracking mitral annular displacement is useful in the assessment of decreased LV longitudinal deformation in asymptomatic patients with severe or moderate-to-severe MR and preserved LVEF.

Association of Toll-Like Receptor 4 on Human Monocyte Subsets and Vulnerability Characteristics of Coronary Plaque as Assessed by 64-Slice Multidetector Computed Tomography.

BACKGROUND: Although Toll-like receptor 4 (TLR-4) is involved in monocyte activation in patients with accelerated forms of atherosclerosis, the relationship between the expression of TLR-4 on circulating monocytes and coronary plaque vulnerability has not previously been evaluated. We investigated this relationship using 64-slice multidetector computed tomography (MDCT) in patients with stable angina pectoris (SAP).Methods and Results:We enrolled 65 patients with SAP who underwent MDCT. Three monocyte subsets (CD14++CD16-, CD14++CD16+, and CD14+CD16+) and expression of TLR-4 were measured by flow cytometry. Intracoronary plaques were assessed by 64-slice MDCT. We defined vulnerability of intracoronary plaques according to the presence of positive remodeling (remodeling index >1.05) and/or low CT attenuation (<35 HU). The circulating CD14++CD16+monocytes more frequently expressed TLR-4 than CD14++CD16-and CD14+CD16+monocytes (P<0.001). The relative proportion of the expression of TLR-4 on CD14++CD16+monocytes was significantly greater in patients with vulnerable plaque compared with those without (10.4 [4.1-14.5] % vs. 4.5 [2.8-7.8] %, P=0.012). In addition, the relative proportion of TLR-4 expression on CD14++CD16+monocytes positively correlated with the remodeling index (r=0.28, P=0.025) and negatively correlated with CT attenuation value (r=-0.31, P=0.013). CONCLUSIONS: Upregulation of TLR-4 on CD14++CD16+monocytes might be associated with coronary plaque vulnerability in patients with SAP.

Prospective Evaluation of Electromyography-Guided Phrenic Nerve Monitoring During Superior Vena Cava Isolation to Anticipate Phrenic Nerve Injury.

BACKGROUND: Right phrenic nerve injury (PNI) is a major concern during superior vena cava (SVC) isolation due to the anatomical close proximity. The functional and histological severity of PNI parallels the degree of the reduction in the compound motor action potential (CMAP) amplitude. This study aimed to evaluate the feasibility of monitoring CMAPs during SVC isolation to anticipate PNI during atrial fibrillation (AF) ablation. METHODS: Thirty-nine paroxysmal AF patients were prospectively enrolled. Radiofrequency energy was delivered point-by-point for 30 seconds with 20 W until eliminating all SVC potentials after the pulmonary vein isolation. Right diaphragmatic CMAPs were obtained from modified surface electrodes by pacing from the right subclavian vein. Radiofrequency applications were applied without fluoroscopy under CMAP monitoring at sites with phrenic nerve capture by high output pacing. RESULTS: Electrical SVC isolation was successfully achieved with a mean of 9.4 ± 3.3 applications in all patients. In 3 (7.5%) patients, the SVC was isolated without radiofrequency delivery at phrenic nerve capture sites. Among a total of 346 applications in the remaining 36 patients, 71 (20.5%) were delivered while monitoring CMAPs. In 1 (1.4%) application, the RF application was interrupted due to a decrease in the CMAP amplitude. However, no PNI was detected on fluoroscopy, and the decreased amplitude recovered spontaneously. The remaining 70 (98.6%) applications exhibited no significant changes in the CMAP amplitude throughout the applications (from 1.01 ± 0.47 to 0.98 ± 0.45 mV, P = 0.383). CONCLUSIONS: Stable right diaphragmatic CMAPs could be obtained, and monitoring CMAPs might be useful for anticipating right PNI during SVC isolation.

Impact of Catheter Contact Force on Superior Vena Cava Mapping and Localization of the Right Phrenic Nerve by High Output Pacing.

BACKGROUND: Right phrenic nerve injury (PNI) is a major concern during superior vena cava (SVC) isolation. Phrenic nerve (PN) localization by high-output pacing is a standard technique for anticipating PNI. This study evaluated the impact of catheter contact force (CF) on SVC mapping and PN localization. METHODS: Twenty-one atrial fibrillation patients undergoing cardiac enhanced computed tomography (CT) were prospectively enrolled. SVC geometries were created at the SVC-right atrium junction level with low (<10 × g) and high (>10 × g) CFs. The PN was localized by high-output pacing (10 V, 2 milliseconds) at the SVC and anterior right superior pulmonary vein (RSPV) with different CFs. RESULTS: The SVC cross-sectional area was significantly greater when created with high (22.1 ± 4.9 × g) compared with low CFs (4.2 ± 1.3 × g) (5.3 ± 1.4 cm2 vs. 2.3 ± 0.7 cm2 , P < 0.0001). High CFs distorted the SVC and anterior RSPV by a mean of 4.8 ± 2.5 and 4.4 ± 1.7 mm, with minimal distortion at the anteroseptal SVC. The PN was more frequently captured with a high compared with low CF at the SVC (95.2% vs. 71.4%, P = 0.038) and RSPV (66.7% vs. 14.3%, P = 0.0005). The PN capture area was also wider with a high compared with low CF at the SVC (9.0 ± 4.1 mm vs. 4.5 ± 2.8 mm, P = 0.001). The PN location was at the anterolateral, lateral, and posterolateral SVC in 3 (14.3%), 13 (61.9%), and 5 (23.8%) patients, respectively, which was identical to that identified on CT. No PNs located >1.98 mm from the RSPV were captured by RSPV pacing. CONCLUSIONS: CF impacted the SVC mapping and PN localization. Cardiac CT identified the PN location, and the distance from the pacing site influenced PN capture.

Early Recurrence After Pulmonary Vein Isolation of Paroxysmal Atrial Fibrillation With Different Ablation Technologies - Prospective Comparison of Radiofrequency vs. Second-Generation Cryoballoon Ablation.

BACKGROUND: Inflammation plays a prominent role in the etiology of the early recurrence of atrial fibrillation (ERAF). We prospectively compared the proportion of ERAF and time-course patterns of biomarkers between radiofrequency (RF) and cryoballoon (CB) ablation. METHODS AND RESULTS: We enrolled 82 consecutive paroxysmal AF patients undergoing pulmonary vein (PV) isolation, performed with either a 28-mm 2nd-generation CB and 3-min freeze technique or point-by-point RF ablation. Each group had 41 patients. In the RF group, all PVs were successfully isolated with 28.9 ± 6.5 min of RF delivery. In the CB group, a mean of 5.3 ± 1.4 applications/patient was delivered. The proportion of ERAF was similar between the groups. The time-course patterns significantly differed between the groups for high-sensitivity C-reactive protein (hs-CRP) value (P=0.006) and myocardial injury markers (P<0.0001). Greater myocardial injury was observed in the CB than in the RF group (P<0.0001), whereas the peak hs-CRP value was comparable between the groups. The 2-day post-procedure hs-CRP value was the sole factor correlating with ERAF as identified by the multivariable analysis (hazard ratio 1.697; 95% confidence interval, 1.005-2.865; P=0.048) in the RF, but not the CB group. CONCLUSIONS: The proportion of ERAF was comparable after RF and 2nd-generation CB ablation. Despite CB ablation exhibiting greater myocardial injury than RF ablation, the inflammatory responses were comparable between the groups. The inflammatory response extent predicted ERAF post-RF ablation but not post-CB ablation.

Impact of Pulmonary Vein Isolation on Superior Vena Cava Potentials With a Second-Generation Cryoballoon.

BACKGROUND: Radiofrequency ablation of the right superior pulmonary vein (RSPV) can lead to inadvertent superior vena cava (SVC) isolation due to the close anatomical proximity. This study aimed to evaluate the impact of PV isolation on SVC potentials with a second-generation cryoballoon. METHODS: Thirty-one consecutive paroxysmal atrial fibrillation patients who underwent PV isolation exclusively with a 28 mm second-generation cryoballoon and single 3-minute freeze technique were prospectively enrolled. The produced SVC potential conduction delay during the RSPV isolation was prospectively evaluated using circular mapping catheters placed in the SVC throughout the cryoballoon procedure. RESULTS: Stable SVC potentials were recorded in 28 (90.3%) patients. The produced SVC potential conduction delay during the RSPV isolation was a median of 6.0 (0.5-7.6) milliseconds, and >5.0 milliseconds in 16 (57.1%) patients. Among them, the delay had shortened by >5.0 milliseconds in 7 (43.8%) patients within 5 minutes after the RSPV application. The distance between the RSPV ostium and SVC was the sole parameter correlated with the produced delay (R = 0.77, P < 0.0001). For the association between the distance and a produced delay of >5 milliseconds, the area under the curve was 0.896 (95% confidential interval = 0.775-1.000). The optimal cutoff point for the distance predicting the occurrence of the conduction delay (>5 milliseconds) was 2.5 mm (sensitivity 83.3%, specificity 81.2%). CONCLUSIONS: RSPV isolation with a second-generation cryoballoon could produce an SVC potential conduction delay. The anatomical distance between the RSPV and SVC significantly correlated with the impact.

Evaluation of diaphragmatic electromyograms in radiofrequency ablation of atrial fibrillation: prospective study comparing different monitoring techniques.

BACKGROUND: The utility of compound motor action potential (CMAP) monitoring for anticipating phrenic nerve injury (PNI) during cryoballoon ablation has been reported. We sought to compare two different CMAP recording techniques and evaluated the feasibility during pulmonary vein antrum isolation (PVAI) and superior vena cava isolation (SVCI) using radiofrequency energy. METHODS AND RESULTS: Forty-two patients undergoing paroxysmal atrial fibrillation ablation were prospectively enrolled. SVCI was performed following PVAI if SVC potentials were observed. CMAPs were recorded 3 times (before and after PVAI, and after SVCI) simultaneously from surface electrodes (CMAPsuf) and a decapolar catheter in the subdiaphragmatic hepatic vein (CMAPabd). The baseline CMAPsuf and CMAPabd were 0.92 ± 0.36 and 0.65 ± 0.43 mV except in one case with catheter inaccessibility. The CMAPsuf did not correlate with the body mass index, or CMAPabd. In 2 and 9 patients, the CMAPsuf and CMAPabd amplitudes were < 0.5 and < 0.3 mV, respectively. The diaphragm to catheter distance was significantly longer in cases with a CMAPabd < 0.3 mV than one > 0.3 mV (39.2 ± 10.8 vs. 21.5 ± 6.6 mm, P < 0.0001). Two cases with a CMAPsuf < 0.5 mV had larger amplitudes on the CMAPabd. In 1 patient, apparent PNI occurred during the SVCI, and the CMAP disappeared after the SVCI in both techniques. The CMAPs did not significantly decrease after the PVAI and SVCI; however, a >30% decrease was observed in 2 patients in both techniques. In both, no PNI was apparent on fluoroscopy or chest X-ray. CONCLUSIONS: Stable evaluable CMAPs were obtained with the CMAPsuf in most patients. Monitoring with the CMAPabd could be an alternative and complementary method.

Adenosine Triphosphate Test After Cryothermal Pulmonary Vein Isolation: Creating Contiguous Lesions Is Essential for Eliminating Dormant Conduction.

BACKGROUND: Adenosine triphosphate (ATP) testing reveals dormant pulmonary vein (PV) conduction after electrical PV isolation (PVI). This study aimed to evaluate the incidence of latent PV conduction after cryothermal PVI. METHODS: Fifty-four consecutive paroxysmal atrial fibrillation patients undergoing cryothermal PVI were prospectively enrolled. PVI was performed with one 28-mm second-generation balloon using a 3-minute freeze technique, and touch-up lesions were created by focal cryothermal applications. ATP testing was performed following PVI with a 20-mm circular mapping catheter placed in each PV. RESULTS: Of 217 PVs, 205 (94.5%) were isolated using a cryoballoon, and 12 required additional focal ablation. ATP testing was performed in 46 patients for 173 and 8 PVs, which were isolated by cryoballoons and focal ablation, respectively. No dormant PV conduction was provoked in any PVs, which were isolated by cryoballoons, whereas 4 (50.0%) out of 8 PVs requiring focal ablation had transient ATP-provoked reconnections (0 vs. 50.0%, P < 0.0001) with a median duration of 11.3 (10.7-17.1) seconds. The latent PV conduction site was identical to the residual conduction gap site after cryoballoon ablation in all. All latent conduction was successfully eliminated by 2 (2.0-9.5) additional focal applications. At a mean follow-up of 7.7 ± 1.6 months, 81.5% of the patients were arrhythmia free after a single procedure. CONCLUSIONS: No dormant PV conduction was provoked in PVs, which were isolated by 28-mm second-generation cryoballoons, but was provoked in 50% of PVs, which were isolated by focal cryoablation. These findings suggest that creating contiguous lesions is essential for eliminating dormant conduction in cryothermal ablation.