Inability to capture with increasing current strength: Is this near-field or far-field?

We present a case of wide-complex tachycardia in which the clinical electrophysiological diagnosis was considered to be bundle branch re-entry ventricular tachycardia. A series of ventricular entrainment attempts were performed from the left and right ventricular septum to confirm the diagnosis. Entrainment pacing with a general current output (10 mA) was performed from the right ventricular septum with manifest fusion and a post-pacing interval similar to tachycardia cycle length. Thereafter, another entrainment attempt with a greater current output (20 mA) was performed from the same site. Paradoxically, concealed fusion was demonstrated by selective RB capture only, though there was no clear "RB" potential seen. In this case, we attempt to explain and illustrate the mechanism of paradoxical near-field inability to capture with increasing current strength.

Transvenous dual-chamber pacemaker implantation in patients with persistent left superior vena cava.

BACKGROUND: Persistent left superior vena cava (PLSVC) is a rare congenital vascular anomaly. Permanent pacemaker implantation (PPI) in patients with PLSVC can be challenging because of the venous anomalies. We reported a case series of patients with PLSVC who underwent PPI with double active fixation leads. METHODS: From January 2012 to July 2016, 9 patients (three male and six females, mean age 68 ± 11 years) with PLSVC who received a dual-chamber pacemaker with double active fixation leads were enrolled retrospectively in this observational study. The indications for pacemaker implantation were symptomatic third-degree atrioventricular block in one and sick sinus syndrome in eight patients. RESULTS: PPI were implanted successfully in all 9 patients. Successful positioning of the ventricular leads at the right ventricular outflow tract (RVOT) septum with a "C" shaped stylet was achieved in 7 patients (77.8%). In the remaining two cases, the ventricular leads were placed in the right ventricular apex and the inferior free wall of the sub-tricuspid annulus. The atrial leads were placed at the lateral wall of the right atrium in all patients. Procedure time and fluoroscopy time were 85.3 ± 11.3 min and 4.5 ± 1.1 min respectively. During a mean follow-up of 4 years, no complications were observed and pacing parameters did not change significantly. CONCLUSION: PPI through PLSVC may be technically feasible, safe, and effective. Double active fixation leads may be standard for patients with PLSVC and most of the ventricular leads could be placed at the RVOT septum.

Unique electrocardiographic pattern "w" wave in lead I of idiopathic ventricular arrhythmias arising from the distal great cardiac vein.

BACKGROUND: The ECG characteristics of the distal coronary venous system ventricular arrhythmias (VAs) share common features with VAs arising from the aortic cusps or the endocardial left ventricular outflow tract (LVOT) beneath the cusps. The purpose of this study was to identify specific electrocardiographic and electrophysiological characteristics of VAs originating from the distal great cardiac vein (GCV). METHODS: Based on the successful ablation site, patients with idiopathic VAs from the distal GCV, left coronary cusp (LCC) or the subvalvular left ventricular outflow tract (LVOT) area were included in the present study. RESULTS: The final population consisted of 39 patients (35 males, mean age 51 ± 23 years). All VAs displayed a right bundle branch block (RBBB) morphology with inferior axis. Among these patients, 15 were successfully ablated at the GCV, 15 at the LCC and 9 at the subvalvular region. A "w" pattern in lead I was present in 12 out of 15 (80%) VAs originating from the distal GCV compared to none of VAs arising from the other two sites (p < 0.01). VAs with a GCV origin exhibited more commonly increased intrinsicoid deflection time, higher maximum deflection index and wider QRS duration compared to LCC and subvalvular sites (p < 0.05). Acceptable pace mapping at the successful ablation site was achieved in 10 patients. After an average of 36 ± 24 months follow up, 14 (93.3%) patients were free from VAs recurrence. CONCLUSION: A "w" pattern in lead I may distinguish distal GCV VAs from VAs arising from the LCC or the subvalvular region.

Association between elevated blood glucose level and non-valvular atrial fibrillation: a report from the Guangzhou heart study.

BACKGROUND: To estimate the prevalence of elevated blood glucose level (EBG, including type 2 diabetes mellitus and impaired fasting glucose), and its association with non-valvular atrial fibrillation (NVAF) in Guangzhou, China. METHODS: The population-based follow-up Guangzhou Heart Study collected baseline data from July 2015 to August 2017 among 12,013 permanent residents aged > 35 from 4 Guangzhou districts. Two streets (Dadong and Baiyun) in the Yuexiu District, and one street (Xiaoguwei) and two towns (Xinzao and Nancun) in the Panyu District were chosen as representative of urban and rural areas, respectively. Each participant completed a comprehensive questionnaire, and underwent physical examination, blood sample collection for laboratory testing, electrocardiography, and other evaluations. Multivariable logistic regression analyses were used to estimate the independent association between hyperglycemia and NVAF prevalence. RESULTS: The prevalence of EBG in overall study population was 29.9%. Compared with residents without EBG, the odds ratio (OR) for AF among residents with EBG was significantly higher (1.94, 95% confidence interval [CI]: 1.40-2.70, P <  0.001), even after multivariate adjustment for metabolic abnormalities (OR = 1.60, 95% CI: 1.14-2.25, P = 0.007), and driven by women (OR = 1.80, 95% CI: 1.12-2.91, P = 0.016). CONCLUSIONS: In Guangzhou, China, prevalence of EBG is high among residents aged > 35 years and associated with a multivariate adjusted increase in prevalence of NVAF overall and in women.

Mid-term outcomes of concomitant left atrial appendage closure and catheter ablation for non-valvular atrial fibrillation: a multicenter registry.

To investigate the safety and midterm outcome of concomitant left atrial appendage (LAA) closure and catheter ablation (CA) as a one-stage hybrid procedure for non-valvular atrial fibrillation (AF) in a multicenter registry. A total of 50 consecutive patients with symptomatic drug-resistant non-valvular AF with CHA2DS2-VASc score ≥ 2 and contraindications for antithrombotic therapy were included in the prospectively established LAA closure registry, and underwent concomitant LAA closure (48 for WATCHMAN and 2 for ACP) and CA procedure (40 for radiofrequency and 10 for cryoballoon CA). Two cardiac tamponades, one peripheral vascular complications and one mild air embolism were observed during perioperative period. After mean follow-up of 20.2 ± 11.5 months, 18 (36%) patients presented with atrial arrhythmia relapse and 45 (91.8%) patients presented with complete sealing; furthermore, there were two transient ischemic attacks and one ischemic stroke under an off-oral anticoagulant situation, respectively. Concomitant CA and LAA closure as a one-stage hybrid procedure might be feasible and potentially decrease costs in patients with symptomatic non-valvular AF with high stroke risk and contraindication to antithrombotic treatment, and as safe as LAA closure procedure only during the perioperative period. However, it was necessary to further validate the mid-term safety.

Characteristics, Mechanism and Long-Term Ablation Outcome of Atrial Tachycardias After Mitral Valvular Surgery and Concomitant Cox-MAZE IV Procedure.

The incidence of atrial tachycardia (AT) after rheumatic mitral valvular (RMV) surgery has been well described. However, there have been few reports on the characteristics, mechanism, and long-term ablation outcome of ATs after RMV surgery and concomitant Cox-MAZE IV procedure.The present study reviewed consecutive patients who underwent AT ablation between May 2008 and July 2013. All patients were refractory to antiarrhythmic drugs (AADs) and had a history of RMV surgery and Cox-MAZE IV procedure. A total of 34 patients underwent AT ablation after RMV surgery and concomitant Cox-MAZE IV procedure, and presented 57 mappable and 2 unmappable ATs. The 57 mappable ATs included 14 focal-ATs and 43 reentry-ATs. Ten of the 14 focal-like ATs were located at the pulmonary vein (PV) antrum and border of a box lesion. Of the 43 reentry-ATs, 16 were marco-reentrant around the mitral annulus (MA) and 16 around the tricuspid annulus. There were 41 atypical ATs (non-cavotricuspid isthmus related) including 16 ATs related to the box lesion and 21 ATs related to other Cox-MAZE IV lesions. The AT were successfully terminated in 33 (97.1%) patients. After mean follow-up of 46.9 ± 15.7 months, 25 (73.5%) patients maintained sinus rhythm without AADs after a single procedure and 28 (82.4%) patients after repeated procedures.The recurrent ATs after RMV surgery and concomitant Cox-MAZE IV were mainly reentry mechanism, and largely related to LA. An incomplete lesion or re-conductive gaps in a prior lesion might be the predominant mechanisms for these ATs. Catheter-based mapping and ablation of these ATs seems to be effective and safe during a long-term follow-up.

Association of Thromboembolic Risk Score with Left Atrial Thrombus and Spontaneous Echocardiographic Contrast in Non-Anticoagulated Nonvalvular Atrial Fibrillation Patients.

OBJECTIVES: The aim of the study was to examine the association of CHADS2/CHA2DS2-VASc scores with left atrial thrombus (LAT) and spontaneous echocardiographic contrast (SEC) in non-anticoagulated nonvalvular atrial fibrillation (NVAF) spontaneous patients, and to develop a new scoring system for LAT/SEC prediction. METHODS: Consecutive non-anticoagulated NVAF patients with or without LAT/SEC by transesophageal echocardiography were identified in the Guangdong General Hospital. RESULTS: Among 2,173 patients, the prevalence of LAT/SEC was 4.9%. Both predictive values of CHADS2 and CHA2DS2-VASc scores for the presence of LAT/SEC were low-to-moderate (receiver operating characteristic [ROC] = 0.591 and 0.608, respectively, p = 0.90). By multivariate analysis, non-paroxysmal AF, decreased left ventricular ejection fraction, and left atrial enlargement were positively associated with LAT/SEC, while CHADS2/CHA2DS2VASc scores were not. A new scoring system based on these 3 factors above significantly improved the discrimination for LAT/SEC (ROC = 0.792). CONCLUSIONS: CHADS2/CHA2DS2-VASc scores had limited value in predicting LAT/SEC; a new scoring system that combines AF type and echocardiographic parameters may better predict LAT/SEC as a surrogate for cardioembolic risk in NVAF patients.

Clinical Prediction Score for Successful Retrograde Procedure in Chronic Total Occlusion Percutaneous Coronary Intervention.

OBJECTIVE: To develop and validate a prediction score for a successful retrograde procedure in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: A total of 228 CTO lesions in 223 patients who underwent PCI by retrograde approach were analyzed. All subjects were randomly grouped to a derivation set and a validation set at a ratio of 2:1. A successful retrograde procedure was set as the end point. Each of the identified predictors for the end point by logistic regression was assigned 1 point and summed. RESULTS: Independent predictors of a successful retrograde procedure were Werner's score [odds ratio (OR) 4.841, 95% confidence interval (CI) 1.952-12.005, p = 0.001], diameter of distal CTO segment (OR 5.263, 95% CI 2.067-13.398, p < 0.001) and tortuous collateral (type b; OR 0.119, 95% CI 0.032-0.444, p = 0.002). The predictive model developed in the derivation set stratified the difficulty of achieving a successful retrograde procedure into 4 grades - very difficult (10.5%), difficult (23.7%), intermediate (50.7%) and easy (15.1%) - and was demonstrated significantly in the validation set: very difficult (15.8%), difficult (18.4%), intermediate (47.4%) and easy (18.4%). The area under the receiver-operating characteristic curve was 0.832 ± 0.042 for the derivation set and 0.912 ± 0.041 for the validation set with an almost equal performance. CONCLUSIONS: According to the experience of our center, this model performed excellently in predicting the difficulty in achieving a successful retrograde procedure.

Combined approach improves the outcomes of catheter ablation of idiopathic ventricular arrhythmias originating from the vicinity of tricuspid annulus.

BACKGROUND: Ablation of idiopathic ventricular arrhythmias (VAs) originating from the vicinity of tricuspid annulus (TA) is often unsuccessful via inferior approach. We report the initial experience with catheter ablation of VAs arising from the vicinity of the TA via superior approach. METHODS: We retrospectively studied 36 patients with VAs arising from the vicinity of TA who underwent ablation via transfemoral vein approach first. If patients had a failed prior ablation or VAs recurred during follow-up, they were referred for repeat ablation via transsubclavian vein approach. RESULTS: Among 36 patients, 11 (30.6%) patients (five failed during the index procedure and six recurred during the follow-up) were assigned to perform repeat ablation via the transsubclavian vein approach. After the final procedure two patients recurred again, and success rate increased from 69.5% (25/36) to 94.4% (34/36). Amplitudes of the atrial electrograms of all successful ablation sites via the transsubclavian vein approach was <0.036 mV. CONCLUSIONS: The transsubclavian vein approach plus transfemoral vein approach improve the outcomes of catheter ablation of idiopathic VAs originating from the vicinity of TA. The transsubclavian vein approach is a feasible alternative for VAs, which has been refractory to ablation via the inferior approach.

Role of ideal cardiovascular health metrics in reducing risk of incident arrhythmias.

AIMS: Cardiovascular health (CVH) has been proven to reduce cardiovascular disease burden and mortality, but data are lacking regarding cardiac arrhythmias. The aim of this study was to assess the association between CVH metrics and atrial fibrillation/flutter (AF), ventricular arrhythmias, and bradyarrhythmias. METHODS AND RESULTS: This study analysed data from the Atherosclerosis Risk in Communities (ARIC) cohort, with participants recruited from four different communities across the United States. Cardiovascular health metrics were scored at baseline (1987-89) following the American Heart Association's recommendations and categorized as poor, intermediate, or ideal. Arrhythmia episodes were diagnosed by International Classification of Diseases (ICD)-9 code. Adjusted associations were estimated using Cox models and event rates and population attributable fractions were calculated by CVH metrics category. The study population consisted of 13 078 participants, with 2548 AF, 1363 ventricular arrhythmias, and 706 bradyarrhythmias occurred. The adjusted hazard ratios (HRs) for ideal (vs. poor) CVH metrics were 0.59 [95% confidence interval (CI): 0.50-0.69] for AF, 0.38 (95% CI: 0.28-0.51) for ventricular arrhythmias, and 0.70 (95% CI: 0.51-0.97) for bradyarrhythmia. The risk of incident arrhythmias decreased steadily as the CVH metrics improved from 0 to 14 scores. The adjusted population attributable fractions were calculated to be 29.9% for AF, 54.4% for ventricular arrhythmias, and 21.9% for bradyarrhythmia, respectively. The association between CVH metrics and incident arrhythmias was also seen in people who remained free of coronary heart disease over the follow-up. CONCLUSION: Achieving ideal CVH metrics recommendations by AHA in midlife was associated with a lower risk of incident arrhythmias later in life.

Intermediate and ideal levels of cardiovascular health (CVH) metrics are associated with a markedly reduced risk of developing incident arrhythmias, including atrial fibrillation/flutter, ventricular arrhythmias, and bradyarrhythmia, independent of coronary heart disease. A majority of incident arrhythmias could be prevented if the risk profile of the entire population was optimized. These findings emphasize the significance of public health policies that improve CVH to reduce the social and economic burden of arrhythmias.

Trans-subclavian approach for radiofrequency ablation of premature ventricular contractions originating from subtricuspid annulus: a case report.

BACKGROUND: Catheter ablation has been established as a curative treatment strategy for ventricular arrhythmias. The standard procedure of most ventricular arrhythmias originating from the right ventricle is performed via the femoral vein. However, a femoral vein access may not achieve a successful ablation in some patients. CASE PRESENTATION: We reported a case of a 29-year old patient with symptomatic premature ventricular contractions was referred for catheter ablation. Radiofrequency energy application at the earliest endocardial ventricular activation site via the right femoral vein could not eliminate the premature ventricular contractions. Epicardial mapping could not obtain an earlier ventricular activation when compared to the endocardial mapping, and at the earliest epicardial site could not provide an identical pace mapping. Finally, we redeployed the ablation catheter via the right subclavian vein by a long sheath. During mapping of the subvalvular area of the right ventricle, a site with a good pace mapping and early ventricular activation was found, and premature ventricular contractions were eliminated successfully. CONCLUSION: Ventricular arrhythmias originating from the subtricuspid annulus may be successfully abolished via a trans-subclavian approach and a long sheath. Although access via the right subclavian vein for mapping and ablation is an effective alternative, it is not a routine approach.

[A new technique for bilateral angiography in a single radial access].

OBJECTIVE: To develop a new technique of bilateral angiography in a single radial access (BASiRalA) which can reduce a puncture site. METHODS: From March 2011 to February 2012, 13 cases of coronary heart disease patients with chronic total occlusion (CTO) were treated (6 CTOs in right coronary artery and 7 in left anterior descending artery). All patients underwent percutaneous coronary intervention (PCI) via the right radial artery access and 6 F guiding catheters were delivered to the diseased artery. Once the wires crossed the CTO lesions and were uncertain if the wires were in true lumen or not, BASiRalA was performed. The Finecross microcatheters were advanced out of the 6 F guiding catheter, then withdraw 6F guiding catheter to the opening of diseased artery, the soft wires were manipulated into the middle portion of opposite coronary artery. After that, the microcatheters were advanced to this segment or the branches relative to the collateral vessels connected with CTOs. After pulling out the wires, microcatheter injections can be performed for contralateral angiography. BASiRalA related complications were observed after the procedure. RESULTS: BASiRalA technique was applied to 13 CTOs and 10 procedures succeeded (76.92%). BASiRalA failed in 3 cases and the wires and microcatheters could not be advanced to the opposite coronary arteries within 20 minutes. Alternatively, contralateral angiography via femoral arteries was performed in these 3 patients. The average time of BASiRalA technique was 7 (5 - 13) minutes and the shortest time of wires crossing to the opposite coronary artery was 5 seconds. There was no procedure induced complication during procedure or post procedure. CONCLUSION: BASiRalA technique is feasible in treating CTO patients by PCI.

Higher Cumulative Blood Pressure in Midlife Predicts an Increased Risk of Atrial Fibrillation: Evidence From the Atherosclerosis Risk in Communities Study.

BACKGROUND: Elevated blood pressure (BP) is reportedly associated with an increased risk of atrial fibrillation (AF). However, the association between cumulative BP exposure in midlife and incident AF in mid-to-late life remains unclear. METHODS AND RESULTS: Participants enrolled in the ARIC (Atherosclerosis Risk in Communities) study with 4 consecutive BP measurements and no prevalent AF at baseline were included. Cumulative BP was calculated as the area under the curve from visit 1 to visit 4. Incident AF was identified by study visit ECGs, hospital discharge codes, or death certificates. A total of 9892 participants were included (44.6% men and mean age 62.9±5.7 years at visit 4) with 1550 (15.7%) individuals who developed new-onset AF during an average follow-up of 15.4 years. The incidence rates of AF per 1000 person-years across the 4 quartiles of cumulative systolic BP were 7.9, 9.2, 12.5, and 16.9, respectively. After multivariable adjustment, the hazard ratios for incident AF among participants in the highest quartile of cumulative systolic BP, pulse pressure, and mean arterial pressure were 1.48 (95% CI, 1.27-1.72), 1.81 (95% CI, 1.53-2.13), and 1.22 (95% CI, 1.05-1.41), respectively, compared with those in the lowest quartile. The addition of cumulative systolic BP or pulse pressure slightly improved the ability to predict new-onset AF. CONCLUSIONS: Higher exposure to cumulative systolic BP, pulse pressure, and mean arterial pressure was significantly associated with increased risk of incident AF.

Prevalence and modifiable risk factors of degenerative valvular heart disease among elderly population in southern China.

OBJECTIVE: To investigate the prevalence and modifiable risk factors of degenerative valvular heart disease (DVHD) among elderly population in southern China. METHODS: A stratified multistage sampling method was used to recruit subjects. The contents of the survey included the questionnaire, laboratory examination, echocardiography, and other auxiliary examinations. The possible risk factors of DVHD were analyzed by logistic regression analysis. RESULTS: A total of 3538 subjects ≥ 65 years of age were enrolled. One thousand three hundred and seven subjects (36.9%) were diagnosed with DVHD. Degenerative was the most common etiology of VHD. Prevalence of DVHD increased with advancing age. The prevalence of DVHD differed by living region (χ 2 = 45.594, P < 0.001), educational level ( χ 2 = 50.557, P < 0.001), and occupation ( χ 2 = 36.961, P < 0.001). Risk factors associated with DVHD included age (two-fold increased risk for each 10-year increase in age), elevated level C-reactive protein (OR = 1.346, 95% CI: 1.100-1.646), elevated level low density lipoprotein (OR = 1.243, 95% CI: 1.064-1.451), coronary artery disease (OR = 1.651, 95% CI: 1.085-2.513), smoking (OR = 1.341, 95% CI: 1.132-1.589), and hypertension (OR = 1.414, 95% CI: 1.221-1.638). Other significant risk factors included reduced or elevated level red blood cell (OR = 1.347, 95% CI: 1.031-1.761; OR = 1.599, 95% CI: 1.097-2.331; respectively), elevated level platelets (OR = 1.891, 95% CI: 1.118-3.198), elevated level uric acid (OR = 1.282, 95% CI: 1.112-1.479), and stroke (OR: 1.738, 95% CI = 1.085-2.513). CONCLUSIONS: The survey characterized the baseline conditions of DVHD cohort of elderly population in Guangzhou city. The established and emerging risk factors for DVHD may represent challenges and opportunities for therapy.

Clinical Characteristics and Long-Term Prognosis of Elderly Valvular Heart Disease Patients with Diabetes Mellitus: Five-Year Experience from a Single-Center Study of Southern China.

BACKGROUND: Diabetes mellitus (DM) is a prognostic marker in elderly patients with cardiovascular diseases, but its predictive value in elderly valvular heart disease (VHD) patients is unclear. This study aimed to investigate the effect of DM on the long-term outcome of elderly VHD patients. METHODS: This single-center, observational study enrolled patients aged 65 and older consecutively with confirmed VHD using echocardiography. Patients, divided into the DM group and non-DM group, were followed up for major adverse cardiac and cerebrovascular events (MACCEs), including all-cause death, ischemic stroke, and heart failure rehospitalization. RESULTS: Our study consisted of 532 patients over a median follow-up of 52.9 months. Compared with the non-DM group (n = 377), the DM group (n = 155) had higher incidences of ischemic stroke (25.2% vs. 13.5%, P=0.001), heart failure rehospitalization (37.4% vs. 20.7%, P < 0.001), and MACCEs (60.0% vs. 35.8%, P < 0.001). After adjustment of confounders by the multivariable cox regression, DM appeared as an independent predictor for MACCEs (adjusted hazard ratio, aHR: 1.88; 95% confidence interval 1.42-2.48; P < 0.001). In the subgroup analysis of VHD etiology and functional style, conversely, DM was a protective factor for MACCEs in the patients with rheumatic VHD compared with those without rheumatic VHD (aHR: 0.43 vs. 2.27, P=0.004). CONCLUSIONS: DM was an independent predictor for ischemic stroke and heart failure rehospitalization in elderly VHD patients undergoing conservative treatment.

[Retrograde percutaneous recanalization of chronic total occlusion of the coronary arteries via epicardial coronary collateral artery in 5 patients].

OBJECTIVE: to explore the feasibility of percutaneous recanalization by retrograde approach via epicardial collaterals. METHODS: retrograde percutaneous coronary intervention (PCI) via epicardial collaterals was performed in 5 patients with previously failed antegrade PCI from April 2009 to November 2009. 7 F guiding catheters were engaged in donor artery. Hydrophilic wires and microcatheters were crossed to the distal ends of chronic total occlusion (CTO) lesions via epicardial collaterals. Four retrograde wires were exchanged into stiffer wires and further crossed the CTO, eventually went into the 6 F antegrade guiding catheters and were jailed by a 2.5 mm balloon. After dilatations of retrograde balloons, the lesions were crossed by antegrade wires, and finalized by conventional PCI method. One case was recanalized with retrograde wire trapping technique and another case was recanalized by reverse CART technique. RESULTS: the epicardial collaterals were reached from left anterior descending branch (LAD) to distal right coronary artery (RCA) via apex in 3 patients, from left circumflex branch via left atrium branch to posterior descending artery and RCA in 1 patient and from obtuse marginal artery to diagonal artery and LAD in 1 patient. CTO was successfully recanalized and stents were implanted in 4 patients and failed in 1 patient despite successful wire positioning to the distal end of CTO. There was no procedure-induced cardiovascular event in all cases. CONCLUSIONS: epicardial collaterals may not be used as a routine route in retrograde approach PCI due to the potential risk of myocardial rupture and pericardial tamponade. In some cases with unavailable or unsuitable septal collaterals, epicardial collaterals may be used as an alternative route for CTO recanalization.

Left atrial enlargement and non-paroxysmal atrial fibrillation as risk factors for left atrial thrombus/spontaneous Echo contrast in patients with atrial fibrillation and low CHA2DS2-VASc score.

OBJECTIVE: To determine the risk factors for thromboembolism in lower risk patients with non-valvular atrial fibrillation (AF) and low CHA2DS2-VASc scores, which remain undefined. METHODS: We retrospectively analyzed the baseline clinical characteristics, routine laboratory parameters, and echocardiographic measurements of 705 patients (71.1% male; mean age: 52.10 ± 9.64 years) with low CHA2DS2-VASc score (0 or 1; 1 point for female sex) out of 1346 consecutive patients with non-valvular AF who underwent transesophageal echocardiography (TEE) at Guangdong Cardiovascular Institute between January 2013 and December 2015. RESULTS: Patients with left atrial thrombus (LAT) or spontaneous echo contrast (SEC) on TEE (24/705, 4%) showed a higher incidence rate of vascular disease (54.2% vs. 32.9%, P = 0.045) and non-paroxysmal AF (79.2% vs. 29.4%, P < 0.001), larger left atrial diameter (43.08 ± 4.59 vs. 36.02 ± 5.53 mm, P < 0.001), and lower left ventricular ejection fraction (58.23 ± 8.82% vs. 64.15 ± 7.14%, P < 0.001) than those without. Multivariate logistic regression analysis identified left atrial diameter [odds ratio (OR) = 1.171, 95% confidence interval (CI): 1.084-1.265, P < 0.001] and non-paroxysmal AF (OR = 3.766, 95% CI: 1.282-11.061, P = 0.016) as independent risk factors for LAT/SEC. In ROC curve analysis, a left atrial dimeter cutoff of 37.5 mm yielded 95.0% sensitivity and 62.7% specificity (AUC: 0.847, P < 0.0001, 95% CI: 0.793-0.914). CONCLUSION: In patients with non-valvular AF with low CHA2DS2-VASc score, the presence of LAT or SEC was associated with left atrial enlargement, which had moderate predictive value, and non-paroxysmal AF.

Clinical, sonographic characteristics and long-term prognosis of valvular heart disease in elderly patients.

BACKGROUND: Valvular heart disease (VHD) is expected to become more prevail as the population ages and disproportionately affects older adults. However, direct comparison of clinical characteristics, sonographic diagnosis, and outcomes in VHD patients aged over 65 years is scarce. The objective of this study was to evaluate the differences in clinical characteristics and prognosis in two age-groups of geriatric patients with VHD. METHODS: We retrospectively enrolled consecutive individuals aged ≥ 65 years from Guangdong Provincial People's Hospital and screened for VHD using transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). Finally, 260 (48.9%) patients were in the 65-74 years group, and 272 (51.1%) were in the ≥ 75-year group. Factors that affected long-term survival was explored. A multivariable Cox hazards regression was performed to identify the predictors of major adverse cardiac events (MACEs) in each group. RESULTS: In our population, the older group were more likely to have chronic obstructive pulmonary disease (COPD), degenerative VHD, but with less rheumatic VHD, aortic stenosis (AS) and mitral stenosis (MS). Compared with those aged 65-74 years, the older group had a higher incidence of all-cause death (10.0% vs. 16.5%, P = 0.027), ischemic stroke (13.5% vs. 20.2%, P = 0.038) and MACEs (37.3% vs. 48.2%, P = 0.011) at long-term follow-up. In multivariable Cox regression analysis, mitral regurgitation, a history of COPD, chronic kidney disease, diabetes, hypertension, atrial fibrillation and New York Heart Association (NYHA) functional class were identified as independent predictors of MACEs in the older group. CONCLUSION: Advanced age profoundly affect prognosis and different predictors were associated with MACEs in geriatric patients with VHD.

Successful treatment of complex coronary chronic total occlusions improves midterm outcomes.

BACKGROUND: Data regarding outcomes of percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) is still limited. Our aim was to evaluate clinical outcomes in patients after successful CTO PCI when compared to patients with failed PCI. METHODS: The cohort study enrolled 145 eligible patients with attempted PCI of CTO. Detailed baseline clinical and procedural data, and in-hospital complications were analyzed. The primary end point was occurrence of major adverse cardiac events (MACE). RESULTS: Median follow-up was 11.49±2.01 months. Successful revascularization was associated with a significantly lower 1-year MACE compared to failed revascularization [hazard ratio (HR): 0.026; 95% confidence interval (CI): 0.004-0.176; P=0.0002]. A J-CTO score of ≥3 was associated with a significantly higher 1-year MACE compared with a J-CTO score of <3 in patients undergoing PCI (HR: 4.819; 95% CI: 1.463-15.870; P=0.0097). Moreover, in patients with a J-CTO score ≥3, success of CTO PCI was associated with significantly lower risk of 1-year MACE than failure of CTO revascularization (HR: 0.114; 95% CI: 0.023-0.569; P=0.0081). Multivariate analysis identified the J-CTO score (HR: 2.10; 95% CI: 1.09-4.04; P=0.026) as a positive predictor, and the success of CTO PCI (HR: 0.17; 95% CI: 0.05-0.59; P=0.005) as a negative significant independent predictor of MACEs. CONCLUSIONS: Among patients with CTOs, high J-CTO score was independently associated with worse clinical outcomes. Furthermore, successful PCI was associated with a lower risk of midterm MACE compared with failed revascularization of CTOs.