Association Between Serum 3-Hydroxyisobutyric Acid and Prognosis in Patients With Chronic Heart Failure　- An Analysis of the KUNIUMI Registry Chronic Cohort.

BACKGROUND: Diabetes increases the risk of heart failure (HF). 3-Hydroxyisobutyric acid (3-HIB) is a muscle-derived metabolite reflecting systemic insulin resistance. In this study, we investigated the prognostic impact of 3-HIB in patients with chronic HF.Methods and Results: The KUNIUMI Registry chronic cohort is a community-based cohort study of chronic HF in Awaji Island, Japan. We analyzed the association between serum 3-HIB concentrations and adverse cardiovascular (CV) events in 784 patients from this cohort. Serum 3-HIB concentrations were significantly higher in patients with than without diabetes (P=0.0229) and were positively correlated with several metabolic parameters. According to Kaplan-Meier analysis, rates of CV death and HF hospitalization at 2 years were significantly higher among HF patients without diabetes in the high 3-HIB group (3-HIB concentrations above the median; i.e., >11.30 µmol/L) than in the low 3-HIB group (log-rank P=0.0151 and P=0.0344, respectively). Multivariable Cox proportional hazard models adjusted for established risk factors for HF revealed high 3-HIB as an independent predictor of CV death (hazard ratio [HR] 1.82; 95% confidence interval [CI] 1.16-2.85; P=0.009) and HF hospitalization (HR 1.72; 95% CI 1.17-2.53, P=0.006) in HF patients without diabetes, whereas no such trend was seen in subjects with diabetes. CONCLUSIONS: In a community cohort, circulating 3-HIB concentrations were associated with prognosis in chronic HF patients without diabetes.

Estimating Incidence of Acute Heart Failure Syndromes in Japan　- An Analysis From the KUNIUMI Registry.

BACKGROUND: Few registries have provided precise information concerning incidence rates for acute heart failure syndrome (AHFS) in Japan.Methods and Results:All hospitals with acute care beds in Awaji Island participated in the Kobe University heart failure registry in Awaji Medical Center (KUNIUMI Registry), a retrospective, population-based AHFS registration study, enabling almost every patient with AHFS in Awaji Island to be registered. From 1 January 2015 to 31 December 2017, 743 patients with de novo AHFS had been registered. Mean age was 82.1±11.5 years. Using the general population of Japan as of 2015 as a standard, age- and sex-adjusted incidence rates for AHFS were 133.8 per 100,000 person-years for male and 120.0 for female. In 2015, there were an estimated 159,702 new-onset patients with AHFS, which was predicted to increase to 252,153 by 2040, and reach a plateau. The proportion of patients aged >85 years accounted for 42.6% in 2015, which was predicted to increase up to 62.5% in 2040. The proportion of patients with heart failure with preserved ejection fraction was estimated at 52.0% in 2015, which was predicted to increase gradually to 57.3% in 2055. CONCLUSIONS: The present analysis suggested that the number of patients with de novo AHFS keeps increasing with progressive aging in Japan. Establishment of countermeasures against the expanding burden of HF is urgently required.

Incidence and Characteristics of Coronary Artery Spasms Related to Atrial Fibrillation Ablation Procedures　- Large-Scale Multicenter Analysis.

BACKGROUND: Coronary artery spasms (CASs), which can cause angina attacks and sudden death, have been recently reported during catheter ablation. The aim of the present study was to report the incidence, characteristics, and prognosis of CASs related to atrial fibrillation (AF) ablation procedures.Methods and Results:The AF ablation records of 22,232 patients treated in 15 Japanese hospitals were reviewed. CASs associated with AF ablation occurred in 42 of 22,232 patients (0.19%). CASs occurred during ablation energy applications in 21 patients (50%). CASs also occurred before ablation in 9 patients (21%) and after ablation in 12 patients (29%). The initial change in the electrocardiogram was ST-segment elevation in the inferior leads in 33 patients (79%). Emergency coronary angiography revealed coronary artery stenosis and occlusions, which were relieved by nitrate administration. No air bubbles were observed. A comparison of the incidence of CASs during pulmonary vein isolation between the different ablation energy sources revealed a significantly higher incidence with cryoballoon ablation (11/3,288; 0.34%) than with radiofrequency catheter, hot balloon, or laser balloon ablation (8/18,596 [0.04%], 0/237 [0%], and 0/111 [0%], respectively; P<0.001). CASs most often occurred during ablation of the left superior pulmonary vein. All patients recovered without sequelae. CONCLUSIONS: CASs related to AF ablation are rare, but should be considered as a dangerous complication that can occur anytime during the periprocedural period.

Circulating intermediate CD14++CD16+monocytes are increased in patients with atrial fibrillation and reflect the functional remodelling of the left atrium.

AIMS: A recent large clinical study demonstrated the association between intermediate CD14++CD16+monocytes and cardiovascular events. However, whether that monocyte subset contributes to the pathogenesis of atrial fibrillation (AF) has not been clarified. We compared the circulating monocyte subsets in AF patients and healthy people, and investigated the possible role of intermediate CD14++CD16+monocytes in the pathophysiology of AF. METHODS AND RESULTS: This case-control study included 44 consecutive AF patients without systemic diseases referred for catheter ablation at our hospital, and 40 healthy controls. Patients with systemic diseases, including structural heart disease, hepatic or renal dysfunction, collagen disease, malignancy, and inflammation were excluded. Monocyte subset analyses were performed (three distinct human monocyte subsets: classical CD14++CD16-, intermediate CD14++CD16+, and non-classical CD14+CD16++monocytes). We compared the monocyte subsets and evaluated the correlation with other clinical findings. A total of 60 participants (30 AF patients and 30 controls as an age-matched group) were included after excluding 14 AF patients due to inflammation. Atrial fibrillation patients had a higher proportion of circulating intermediate CD14++CD16+monocytes than the controls (17.0 ± 9.6 vs. 7.5 ± 4.1%, P < 0.001). A multivariable logistic regression analysis demonstrated that only the proportion of intermediate CD14++CD16+monocytes (odds ratio: 1.316; 95% confidence interval: 1.095-1.582, P = 0.003) was independently associated with the presence of AF. Intermediate CD14++CD16+monocytes were negatively correlated with the left atrial appendage flow during sinus rhythm (r= -0.679, P = 0.003) and positively with the brain natriuretic peptide (r = 0.439, P = 0.015). CONCLUSION: Intermediate CD14++CD16+monocytes might be closely related to the pathogenesis of AF and reflect functional remodelling of the left atrium.

Effects of 6-month eicosapentaenoic acid treatment on postprandial hyperglycemia, hyperlipidemia, insulin secretion ability, and concomitant endothelial dysfunction among newly-diagnosed impaired glucose metabolism patients with coronary artery disease. An open label, single blinded, prospective randomized controlled trial.

BACKGROUND: Recent experimental studies have revealed that n-3 fatty acids, such as eicosapentaenoic acid (EPA) regulate postprandial insulin secretion, and correct postprandial glucose and lipid abnormalities. However, the effects of 6-month EPA treatment on postprandial hyperglycemia and hyperlipidemia, insulin secretion, and concomitant endothelial dysfunction remain unknown in patients with impaired glucose metabolism (IGM) and coronary artery disease (CAD). METHODS AND RESULTS: We randomized 107 newly diagnosed IGM patients with CAD to receive either 1800 mg/day of EPA (EPA group, n = 53) or no EPA (n = 54). Cookie meal testing (carbohydrates: 75 g, fat: 28.5 g) and endothelial function testing using fasting-state flow-mediated dilatation (FMD) were performed before and after 6 months of treatment. The primary outcome of this study was changes in postprandial glycemic and triglyceridemic control and secondary outcomes were improvement of insulin secretion and endothelial dysfunction. After 6 months, the EPA group exhibited significant improvements in EPA/arachidonic acid, fasting triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C). The EPA group also exhibited significant decreases in the incremental TG peak, area under the curve (AUC) for postprandial TG, incremental glucose peak, AUC for postprandial glucose, and improvements in glycometabolism categorization. No significant changes were observed for hemoglobin A1c and fasting plasma glucose levels. The EPA group exhibited a significant increase in AUC-immune reactive insulin/AUC-plasma glucose ratio (which indicates postprandial insulin secretory ability) and significant improvements in FMD. Multiple regression analysis revealed that decreases in the TG/HDL-C ratio and incremental TG peak were independent predictors of FMD improvement in the EPA group. CONCLUSIONS: EPA corrected postprandial hypertriglyceridemia, hyperglycemia and insulin secretion ability. This amelioration of several metabolic abnormalities was accompanied by recovery of concomitant endothelial dysfunction in newly diagnosed IGM patients with CAD. Clinical Trial Registration UMIN Registry number: UMIN000011265 ( https://www.upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000013200&language=E ).

[Tracheal Foreign Body Removal under Rigid Bronchoscope in a Child with Fistula-like Structure in the Trachea after Surgery of Congenital Esophageal Atresia.]

We report a case of 1-year-2-month old boy with tetralogy of Fallot who had a surgical history of Gross C-type of congenital esophagus atresia. Difficult ventila- tion occurred by aberrant placement of tracheal tube during previous general anesthesia. He suffered from a cyanosis four hours after dinner. Tracheal foreign body was suspected. General anesthe- sia was induced for an emergency foreign body re- moval under rigid bronchoscopy. After the insertion of a tracheal tube just below glottis, the stenosis and fistula-like structure were confirmed in the trachea by bronchofiberscopy. The tip of the tube was placed beyond them. A "natto" was found in the orifice of the left main bronchus, and taken out by a rigid bronchoscope. Although tracheal intubation was performed several times during procedure, aberrant placement of the tra- cheal tube could be avoided by using bronchofibers- copy. We have to consider the remaining anatomic abnormalities of the respiratory tract in children after surgery of congenital esophageal atresia.

The Relationship Between Cardiac Vulnerability and Restitution Properties of the Ventricular Activation Recovery Interval.

INTRODUCTION: The restitution of the action potential duration (APD) is an important contributor to ventricular fibrillation (VF) initiation by a single critically timed ectopic beat. We hypothesized that a steep slope of the activation recovery interval restitution curve was related to the upper limit of vulnerability (ULV). METHODS AND RESULTS: Fifty-four consecutive patients with implantable cardioverter defibrillators (ICDs) implanted between April 2012 and July 2013 were included. At the implantation, pacing from the right ventricular (RV) coil to an indifferent electrode inserted in the ICD pocket was performed, and the unipolar electrograms from the RV coil were simultaneously recorded. We assessed the standard restitution by introducing extra-stimuli, while measuring the activation recovery interval (ARI). Our protocol for the vulnerability test consisted of delivering three 15 J shocks on the T-peak and within ±20 milliseconds of it. If VF was not induced by that procedure, a ULV of ≤15 J was defined. The relationship between the ULV and maximum slope of the restitution curve was analyzed. A restitution curve could finally be obtained in a total of 40 patients. The background characteristics were similar between the two groups. The maximum slope of the restitution curve was steeper in the ULV > 15 J group than ULV ≤ 15 J group (1.55 ± 0.45 vs. 0.91 ± 0.64, P < 0.05). A maximum slope exceeding 1.0 was the optimal point for discriminating patients with a ULV > 15 J from a ULV ≤ 15 J (sensitivity 61.5% and specificity 96.3%). CONCLUSION: The maximum slope of the restitution curve was significantly related to the ULV. High defibrillation threshold patients could be detected by the ARI dynamics.

Reduction in coronary microvascular resistance through cardiac resynchronization and its impact on chronic reverse remodelling of left ventricle in patients with non-ischaemic cardiomyopathy.

AIMS: Left bundle branch block (LBBB) induces mechanical dyssynchrony, thereby compromising the coronary circulation in non-ischaemic cardiomyopathy. We sought to examine the effects of cardiac resynchronization therapy (CRT) on coronary flow dynamics and left ventricular (LV) function. METHODS AND RESULTS: Twenty-two patients with non-ischaemic cardiomyopathy (New York Heart Association class, III or IV; LV ejection fraction, ≤35%; QRS duration, ≥130 ms) were enrolled. One week after implantation of the CRT device, coronary flow velocity and pressure in the left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCx) were measured invasively, before and after inducing hyperemia by adenosine triphosphate administration, with two programming modes: sequential atrial and biventricular pacing (BiV) and atrial pacing in patients with LBBB or sequential atrial and right ventricular pacing in patients with complete atrioventricular block (Control). We assessed hyperemic microvascular resistance (HMR, mean distal pressure divided by hyperemic average peak velocity) and the relationship between the change in HMR and mid-term LV reverse remodelling. Hyperemic microvascular resistance was lower during BiV than during Control (LAD: 1.76 ± 0.47 vs. 1.54 ± 0.45, P < 0.001; LCx: 1.92 ± 0.42 vs. 1.73 ± 0.31, P = 0.003). The CRT-induced change in HMR of the LCx correlated with the percentage change in LV ejection fraction (R = -0.598, P = 0.011) and LV end-systolic volume (R = 0.609, P = 0.010) before and 6 months after CRT. CONCLUSION: Cardiac resynchronization therapy improves coronary flow circulation by reducing microvascular resistance, which might be associated with LV reverse remodelling.

Crista Terminalis as the Anterior Pathway of Typical Atrial Flutter: Insights from Entrainment Map with 3D Intracardiac Ultrasound.

BACKGROUND: The precise location of truly active reentry circuits of typical atrial flutter (AFL) has not been well identified. The purpose of this study was to verify our hypothesis that the posterior block line is located along the posteromedial right atrium (PMRA) and the crista terminalis (CT) is the anterior pathway of AFL, with real-time intracardiac echo (ICE). METHODS: The entire right atrium (RA) three-dimensional activation and entrainment mapping were evaluated during AFL in 18 patients using CARTO sound. RESULTS: The CT was clearly visualized by ICE and the local electrograms along the CT were single potentials in all the patients. The CT was recognized as the truly active anterior pathway based on entrainment mapping in all patients. Double potentials were recorded along the PMRA. Entire RA entrainment mapping could be performed in 16 patients. The reentry circuits were separated into three passages. The first was around the tricuspid annulus (TA), the second the anterior superior vena cava (SVC; AFL waves passed between the anterior SVC and RA appendage), and the last the posterior SVC (between the posterior SVC and upper limit of the PMRA). All three of these passages were active in four, around the TA and anterior SVC in eight, around the TA and posterior SVC in three, and around only the anterior SVC in one patient. CONCLUSIONS: The CT functions as the anterior pathway of typical AFL, and the posterior block line was located along the PMRA. Dual or triple circuits were recognized in the majority of AFL patients.

Upper limit of vulnerability during defibrillator implantations predicts the occurrence of appropriate shock therapy for ventricular fibrillation.

BACKGROUND: The utility of the upper limit of vulnerability (ULV) test in patients undergoing defibrillator implantation has been reported, so the purpose of this study was to evaluate the difference in the clinical outcomes between patients with ULV ≤15 J or >15 J. METHODS AND RESULTS: A total of 165 patients receiving an implantable cardioverter-defibrillator underwent a vulnerability test. At the time of the implantation, we delivered a 15-J shock on the T-peak and ±20 ms later to cover the most vulnerable part of the cardiac cycle. The clinical outcomes were prospectively analyzed. A 15-J shock induced ventricular fibrillation (VF) in 30 patients (ULV >15 J) and did not in 135 (ULV ≤15 J). The characteristics of the 2 groups were comparable. After a mean follow-up of 757 days, Kaplan-Meier curve analysis showed that the ULV ≤15 J group experienced less VF than the ULV >15 J group (log-rank P=0.003). The occurrence of ventricular tachycardia was similar between the 2 groups (P=0.140). Furthermore, the effectiveness of ATP was comparable. After adjusting for other known predictors of shock therapy, a ULV >15 J was independently associated with the occurrence of VF (hazard ratio: 6.25; 95% confidence interval: 1.913-20.40; P<0.01). CONCLUSIONS: A high ULV value was associated with a high incidence of VF, which suggests that cardiac vulnerability to electrical shock may be linked to electrical instability.

Visualization of the antegrade fast and slow pathway inputs in patients with slow-fast atrioventricular nodal reentrant tachycardia.

INTRODUCTION: Mapping of the antegrade fast pathway (A-FP) exact sites and antegrade slow pathway (A-SP) input locations has not been well described. METHODS: In 56 patients with slow-fast atrioventricular nodal reentrant tachycardia (SF-AVNRT), pacing during sinus rhythm and entrainment pacing during SF-AVNRT were performed at various sites in the triangle of Koch and coronary sinus (CS) to identify the A-FP and A-SP inputs. User-defined three-dimensional electro-anatomical mapping of the stimulus-His potential (St-H) interval and anatomical location was performed. The A-FP input was defined as the site of the shortest St-H interval, and A-SP input as the site of the shortest St-H interval and with a postpacing-interval equal to the tachycardia cycle length. The locations of the A-FP and A-SP inputs were mapped as a ratio of the distance between the His bundle (HB) and CS orifice (CSO), and the HB-CSO axis was divided into three zones: superior-, mid-, and inferior septum. The distance between the A-SP and A-FP inputs was calculated using the distance from each input to the HB and HB-CSO axis. RESULTS: Only 30 patients were included in this study because the A-SP mapping failed in 26. The A-SP input was distributed to the superior septum in four, mid- or inferior septum in 25, and CS in one. An A-SP input which was located less than 10 mm from the A-FP input was observed in one of four patients with a superior septum A-SP. CONCLUSIONS: An A-SP input at the superior septum seemed to be a potential risk for atrioventricular nodal injury during ablation.

Discrepancy between electrical and mechanical dyssynchrony in patients with heart failure and an electrical disturbance.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves the survival rates of patients with heart failure, but 30-40% of them do not respond to CRT, partially because of the position of the left ventricular (LV) lead. The relationship between the electrical and mechanical activation of the left ventricle is unknown. The aim of this study was to compare the electrical and mechanical dyssynchrony. METHODS: We inserted electrode catheters into the coronary sinus (CS) and venous branches of the CS during CRT implantations and constructed electroanatomical contact maps in 16 patients using the EnSite NavX™ system. Mechanical activation was evaluated by speckle-tracking echocardiography and the latest mechanical and electrical sites were compared. The degrees of the electrical and mechanical delays of the implanted LV lead were also compared. RESULTS: The electroanatomical maps revealed that the latest electrical sites were anterior in one, anterolateral in five, lateral in eight, and posterolateral in two. Echocardiographic imaging revealed that the latest mechanical sites were anteroseptal in two, anterior in four, lateral in five, posterior in two, and inferior in three. The latest electrical and mechanical sites matched in only three patients. The degree of the local mechanical delay for the LV lead was significantly larger in the responders than nonresponders, whereas the local electrical delay did not differ. CONCLUSION: A discrepancy between the electrical and mechanical dyssynchrony might affect an adequate LV lead positioning.

Accuracy of lung ultrasound examinations of residual congestion performed by novice residents in patients with acute heart failure.

AIMS: The popularity of B-line-guided congestion assessment by lung ultrasound (LUS) has been increasing. However, the ability of novice residents to detect residual congestion with B-line-guided assessment by LUS after decongestion treatment is poorly understood. In this study, we investigated whether novice residents (no prior echocardiography experience) can acquire the skills for B-line-guided residual congestion assessment and whether the range of variation in assessment is acceptable in actual clinical use. METHODS AND RESULTS: The study included 30 postgraduate first-year novice residents and an expert. The residents underwent training for LUS. At the end of the training session, a set of 15 LUS videos was provided to the residents, and they were asked to estimate the number of B-lines in each video. When the residents' answers greatly differed from the correct answer, we provided feedback to raise awareness of the discrepancies. After the training session, the residents performed residual congestion assessment by LUS after decongestion treatment in patients hospitalized with acute heart failure. The residents identified residual congestion in 57% of the patients. The sensitivity and specificity to identify residual congestion by the residents were 90% and 100%, respectively. The inter-operator agreement between the residents and the expert was substantial (κ = 0.86). The Spearman rank correlation coefficient for the B-lines between the expert and each resident was very high at 0.916 (P < 0.0001). CONCLUSIONS: After a brief lecture, novice residents can achieve proficiency in quantifying B-lines on LUS and can reliably identify residual congestion on LUS.

Time-dependent effect of cardiac resynchronization therapy on ventricular repolarization and ventricular arrhythmias.

AIMS: Cardiac resynchronization therapy (CRT) improves the clinical status of patients with congestive heart failure, although left ventricular epicardial pacing may increase transmural dispersion of repolarization (TDR). The aim of this study was to investigate the time-dependent effect of CRT on ventricular repolarization and ventricular arrhythmia at mid-term follow-up. METHODS AND RESULTS: The study group consisted of 84 patients treated with CRT. Twelve-lead electrocardiogram was digitally recorded and Tpeak-to-Tend interval (Tp-e) was measured at baseline, 1 week, 1 month, and 3, 6, and 12 months after device implantation. We determined the time-dependent changes in Tp-e, ventricular tachycardia and ventricular fibrillation (VT/VF) during 12 months of follow-up, in both CRT responders and non-responders. Seventeen of 84 patients (20%) had VT/VF during first year. Six of those 17 patients (35%) experienced VT/VF within 1 month of implantation and diminished over time. Tp-e decreased significantly at 6 and 12 months after implantation compared with 1 week [108 ± 14 ms at 1 week vs. 97 ± 21 ms at 6 months (P = 0.03) and 95 ± 19 ms at 12 months (P = 0.01)]. Responders demonstrated a greater time-dependent reduction of Tp-e at 6 and 12 months of CRT and had a lower rate of VT/VF compared with non-responders (log-rank test, P = 0.004). CONCLUSION: Transmural dispersion of repolarization and the number of patients with VT/VF decreased over time after CRT. Patients with reverse remodelling demonstrated a lower rate of VT/VF and a greater time-dependent reduction of TDR.

Optimal strength and number of shocks at upper limit of vulnerability testing required to predict high defibrillation threshold without inducing ventricular fibrillation.

BACKGROUND: The upper limit of vulnerability (ULV) closely correlates with the defibrillation threshold (DFT). The aim of this study was to establish the optimal protocol for using the ULV test to predict high DFT (>20 J) without inducing ventricular fibrillation (VF). METHODS AND RESULTS: The 10-J and 15-J ULV test with 3 coupling intervals (-20, 0, and +20 ms to the peak of T-wave) and the DFT test were performed in 96 patients receiving implantable cardioverter defibrillator. ULV ≤ 10 J was confirmed in 47 (49%). ULV ≤ 15 J was confirmed in 70 (77%) of 91 patients (15-J ULV test could not be done in 5). The sensitivity and negative predictive value of both ULV >10 J and >15 J for predicting high DFT were 100%. The specificity and positive predictive value of ULV >15 J were higher than those for ULV >10 J (85% vs. 55%, 43% vs. 22%, respectively). The rate of VF inducibility for confirming ULV ≤ 15 J was lower than that for ULV ≤ 10 J (23% vs. 51%, P<0.0001). On analysis of single 15-J ULV test only at the peak of T-wave, VF was not induced in 79 of 91 patients, but 4 of these had high DFT. CONCLUSIONS: The 15-J ULV test with 3 coupling intervals could correctly identify high-DFT patients and reduce the necessity for VF induction at defibrillator implantation.

[Anesthetic management for laparoscopic Nissen fundoplication in a 18 trisomy patient with congestive heart disease].

A 21-month-old patient diagnosed as 18 trisomy, having large ventricular septal defect with pulmonary valve stenosis, and gastroesophageal reflux disease, was admitted for laparoscopic Nissen fundoplication and gastrostomy. Anesthesia was induced with midazolam, fentanyl, and rocuronium, and maintained with sevoflurane and remifentanil. After induction of anesthesia, oxygenation became worse, possibly due to diminished pulmonary blood flow, which was partially resolved with vasopressor administration and fluid infusion. After the abdomen was insufflated, oxygenation improved significantly. We supposed that an increase in systemic vascular resistance due to O2 insufflation augmented pulmonary blood flow and improved the oxygenation. She was extubated the next day and recovered uneventfully. However, we should bear in mind that 18 trisomy patients are frequently complicated by congestive heart disease, and require caution for hemodynamic changes during anesthesia.

The spatiotemporal electrogram dispersion ablation targeting rotors is more effective for elderly patients than non-elderly population.

Background: Modulating atrial fibrillation (AF) drivers has been proposed as one of the effective ablation strategies for non-paroxysmal AF (non-PAF). However, the optimal non-PAF ablation strategy is still under debate because the exact mechanisms of AF persistence including focal activity and/or rotational activity, are not well-understood. Recently, spatiotemporal electrogram dispersion (STED) assumed to indicate rotors in the form of rotational activity is proposed as an effective target for non-PAF ablation. We aimed to clarify the effectiveness of STED ablation for modulating AF drivers. Methods: STED ablation plus pulmonary vein isolation was applied in 161 consecutive non-PAF patients not undergoing previous ablation. STED areas within the entire left and right atria were identified and ablated during AF. After the procedures, the STED ablation's acute and long-term outcomes were investigated. Results: (1) Despite a more effective acute outcome of the STED ablation for both AF termination and non-inducibility of atrial tachyarrhythmias (ATAs), Kaplan-Meier curves showed that the 24-month freedom ratio from ATAs was 49%, which resulted from the higher recurrence ratio of atrial tachycardia (AT) rather than AF. (2) A multivariate analysis showed that the determinant of ATA recurrences was only a non-elderly age, not long-standing persistent AF, and an enlarged left atrium, which were conventionally considered as key factors. Conclusions: STED ablation targeting rotors was effective in elderly non-PAF patients. Therefore, the main mechanism of AF persistency and the component of the fibrillatory conduction might vary between elders and non-elders. However, we should be careful about post-ablation ATs following substrate modification.

Recurrent cardiac arrests caused by Kounis syndrome without typical allergic symptoms.

Kounis syndrome is a rare disease in which coronary spasm or acute coronary syndrome is induced by type I allergy. Concurrence of allergic reaction and chest pain are important clues to establish diagnosis. We report a rare case of Kounis syndrome without obvious signs of allergy.A 52-year-old woman experienced abdominal pain followed by ventricular fibrillation (VF) storm. Ten months earlier, the patient underwent subcutaneous implantable cardioverter-defibrillator implantation based on the previous diagnosis of idiopathic VF. In both episodes, the patient was given dental treatment and administered loxoprofen before VF onset. After we performed loxoprofen provocation test, electrocardiogram revealed ST-segment elevation in leads II, III, and aVF. Moreover, the patient developed VF again. An emergency coronary angiography after recovery showed no significant findings. However, myocardial scintigraphy presented a perfusion-metabolism mismatch in the inferior wall. Furthermore, laboratory test results after provocation revealed increased histamine level. Based on these findings, we diagnosed the patient with Kounis syndrome.Kounis syndrome without typical allergic symptoms is challenging to diagnose. Therefore, suspecting the possibility of allergic reactions and detailed history taking are important, particularly when confronted with recurrent coronary spasm, acute coronary syndrome, and inexplicable cardiac arrest. Learning objective: Kounis syndrome is a rare coronary disease with vasospasm or plaque rupture, induced by type I allergy. Since Kounis syndrome without typical allergic symptoms is challenging to diagnose, a high index of suspicion is necessary. Detailed history taking can provide important clues to establish diagnosis, particularly when confronted with recurrent coronary spasm, acute coronary syndrome, and inexplicable cardiac arrest.

Association between B-lines on lung ultrasound, invasive haemodynamics, and prognosis in acute heart failure patients.

AIMS: Increased left atrial pressure leads to pulmonary congestion. Although the B-lines in lung ultrasound (LUS) are useful in detecting pulmonary congestion, data regarding the association between B-lines and invasive haemodynamics are inconsistent. This study aimed to explore the correlation of the B-line count by LUS with pulmonary capillary wedge pressure (PCWP) stratified for preserved and reduced ejection fraction (EF) in acute heart failure patients. METHODS AND RESULTS: We performed a prospective observational study on 116 hospitalized patients with acute heart failure (mean age, 75.2 ± 10.3 years), who underwent right heart catheterization before discharge. LUS was performed in eight zones within 4 h of right heart catheterization and compared with PCWP separately in each EF group. Cardiac events were recorded 1 year after discharge. PCWP revealed a clear pivot point at which the B-lines began to increase in the overall cohort and each EF. Specific thresholds of the increase in B-lines were identified at 19 and 25 mmHg for preserved and reduced EF, respectively. Residual congestion at discharge was defined as the presence of ≥6 B-lines. Patients with residual congestion had a higher risk for cardiac events than those without residual congestion (hazard ratio, 12.6; 95% confidence interval, 4.71-33.7; log-rank, P < 0.0001). CONCLUSION: A clear pivot point was associated with increased B-lines count in PCWP at 19 and 25 mmHg for preserved and reduced EF, respectively. Moreover, the increased B-line count above the defined cut-off used to quantify residual congestion was associated with significantly worse outcomes.

Aetiology of chronic heart failure in patients from a super-aged society: the KUNIUMI registry chronic cohort.

AIMS: With the rapidly increasing ageing population, heart failure is an urgent challenge, particularly in developed countries. The study aimed to investigate the main aetiologies of chronic heart failure in a super-aged society. METHODS AND RESULTS: The KUNIUMI registry chronic cohort is a community-based, prospective, observational study of chronic heart failure in Awaji Island, Japan. Inhabitants of this island aged ≥65 years accounted for 36.3% of the population. In the present study, data from patients with symptomatic heart failure were extracted from the registry. A total of 1646 patients were enrolled from March 2019 to March 2021, accounting for ~1.3% of the inhabitants of Awaji Island. We analysed 852 patients with symptomatic heart failure. The mean age was high (78.7 ± 11.1 years), with 357 patients (41.9%) being female. The proportion of women increased significantly with advancing age and constituted more than half of the patients aged 85 years and older (P < 0.01). The prevalence of atrial fibrillation, and in particular long-standing persistent atrial fibrillation, increased at 70 years of age (P < 0.01). The proportion of patients with heart failure with preserved ejection fraction increased to ~60% when age was over 75 years. Although ischaemic heart disease accounted for 35.0% of chronic heart failure aetiologies, valvular heart disease was the most common cause of chronic heart failure (49.8%). The major types of valvular heart disease were mitral regurgitation and tricuspid regurgitation (27.2% and 21.7%, respectively), both of which increased significantly with age (P < 0.01). The incidence of aortic valve stenosis increased markedly over the age of 85 years (P < 0.01). Atrial functional mitral regurgitation increased with age and was the major cause of mitral regurgitation in patients aged >75 years. Patients with atrial functional mitral regurgitation had a higher prevalence of atrial fibrillation (especially long-standing persistent atrial fibrillation) and a larger left atrial volume index when compared with patients with other types of mitral regurgitation (P < 0.001, respectively). CONCLUSIONS: The KUNIUMI registry chronic cohort showed a change in heart failure aetiology to valvular heart disease in a super-aged society. Effective and comprehensive countermeasures are required to prepare for the rapid rise in heart failure incidence in a super-aged society.