Successful Catheter Ablation for Paroxysmal Supraventricular Tachycardia with Two Alternating Cycle Lengths.

A 62-year-old male was transferred to our hospital complaining of palpitations. His heart rate was 185/min. Electrocardiogram showed a narrow QRS regular tachycardia and the tachycardia changed spontaneously to another narrow QRS tachycardia with two alternating cycle lengths. The arrhythmia was stopped by the administration of adenosine triphosphate. Findings from electrophysiological study suggested that there was an accessory pathway (AP) and dual atrioventricular (AV) nodal pathways. After AP ablation, any other tachyarrythmias were not induced. We supposed that the tachycardia was paroxysmal supraventricular tachycardia involving AP and anterograde conduction alternating between slow and fast AV nodal pathways.

Successful left ventricular lead placement by way of an azygos vein for a patient performing cardiac resynchronization therapy implantation with an occluded left subclavian vein: A case report.

Central venous obstruction following pacemaker implantation is not uncommon and can prove challenging in the case of a system upgrade to a cardiac resynchronization therapy pacemaker (CRT-P). We describe the case of a patient who underwent a successful upgrading procedure of a pacemaker to a CRT-P in the presence of an occluded left subclavian vein and superior vena cava, using collateral veins that drained into right atrium.

Successful implantation of left ventricular lead for a cardiac resynchronization therapy defibrillator through a persistent left superior vena cava using the anchor balloon technique.

A 69-year-old woman was referred for upgrading implantable cardioverter defibrillator (ICD) to cardiac resynchronization therapy defibrillator (CRT-D) because of symptomatic heart failure due to dilated cardiomyopathy. Her electrocardiogram showed left bundle branch block and echocardiography showed severe left ventricular dysfunction. Venography confirmed the presence of persistent left superior vena cava (PLSVC), and occlusion of innominate vein and the coronary sinus (CS) ostium. We tried to insert the left ventricular (LV) lead through the PLSVC. Because the PLSVC was narrow, there was concern that insertion of the guiding catheter through the PLSVC might cause vascular damage. Therefore, we planned to implant the LV lead without a guiding catheter. Although the LV lead did not advance to the CS due to the acute angle, using a second wire (buddy wire system), the tip of the first wire was trapped by an inflated balloon delivered by a second wire (anchor balloon technique). This technique allowed us to reinforce the support of the other wire. The LV lead was easily advanced along with the fixed first wire and was delivered to the lateral vein of the CS. Thus, we successfully performed minimally invasive implantation of an LV lead through a PLSVC approach. .

Characteristics and Prognosis of Patients with Vasospastic Angina Diagnosed by a Provocation Test with Secondary Prevention Implantable Cardioverter Defibrillator.

This study aimed to evaluate the characteristics and prognosis of patients with vasospastic angina (VSA) diagnosed by a provocation test with a secondary prevention implantable cardioverter defibrillator (ICD), compared with patients with organic coronary stenosis. We retrospectively evaluated 309 consecutive patients who received an ICD implantation between January 2010 and March 2018 in our institutions. Of these patients, 206 were implanted with an ICD for secondary prevention. In these 206 patients, 40 with VSA and 72 with organic coronary stenosis were evaluated. Patients with VSA were characterized by younger age (56.1 ± 13.1 versus 69.2 ± 9.5 years, respectively), and a lower prevalence of diabetes (15.0% versus 40.3%, respectively) and heart failure (2.5% versus 26.4%, respectively) than patients with organic coronary stenosis (P < 0.001). Using the Kaplan-Meier analysis, with the VSA group as the reference, the incidence of appropriate ICD shock was similar between the two groups (hazard ratio, 0.85; 95% confidence interval, 0.341-2.109; P = 0.722). The incidence of ventricular fibrillation was significantly higher in the VSA group (hazard ratio, 0.22; 95% confidence interval, 0.057-0.814; P = 0.024), whereas the incidence of major adverse cardiac events, including cardiac death, nonfatal myocardial infarction, hospitalization for unstable angina pectoris, and heart failure, was significantly higher in the organic coronary stenosis group (hazard ratio, 13.1; 95% confidence interval, 1.756-98.17; P = 0.012). In conclusion, patients with VSA with an ICD implanted for secondary prevention have a higher risk of ventricular fibrillation and lower risk of major adverse cardiac events than patients with organic coronary stenosis.

A case report of pulmonary vein isolation with radiofrequency catheter using superior vena cava approach in patient with paroxysmal atrial fibrillation and inferior vena cava filter.

BACKGROUND: Transseptal puncture and pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) are generally performed via the inferior vena cava (IVC). However, in cases where the IVC is inaccessible, a specific strategy may be needed. CASE SUMMARY: An 86-year-old woman with paroxysmal AF and an IVC filter in situ was referred to our hospital for ablation therapy. An IVC filter for pulmonary embolism and deep venous thrombosis had been implanted 15 years prior, therefore we selected a transoesophageal echocardiography (TOE)-guided transseptal puncture using a superior vena cava (SVC) approach. After the single transseptal puncture, we performed fast anatomical mapping, voltage mapping by multipolar mapping catheter, and then PVI by contact force-guided radiofrequency catheter using a steerable sheath. Following the ablation, bidirectional conduction block between the four pulmonary veins and the left atrium was confirmed by both radiofrequency and mapping catheter. No complications occurred and no recurrence of AF was documented in the 12 months after the procedure. DISCUSSION: When performing a transseptal puncture during AF ablation, an SVC approach, via access through the right internal jugular vein, enables the sheath to directly approach the left atrium without angulation and improves operability of the ablation catheter. Combining the use of general anaesthesia, TOE, a steerable sheath, and contact force-guided ablation may contribute to achieving minimally invasive PVI with a single transseptal puncture via an SVC approach.

Significance of Ventricular Arrhythmia Based on Stored Electrogram Analysis in a Pacemaker Population.

The incidence of ventricular arrhythmia in patients with an implanted pacemaker is not yet known. The aim of this study was to analyze non-sustained ventricular tachycardia (NSVT) episodes based on stored electrograms (EGM) and determine the occurrence rate and risk factors for NSVT in a pacemaker population.This study included 302 consecutive patients with a dual-chamber pacemaker. A total of 1024 EGMs stored in pacemakers as ventricular high-rate episodes were analyzed. The definition of NSVT was ≥ 5 consecutive ventricular beats at ≥ 150 bpm lasting < 30 seconds.In baseline, most patients (94.8%) had ≥ 60% left ventricular ejection fraction. Of 1024 EGMs, 420 (41.0%) showed appropriate NSVT episodes, as well as premature atrial contractions, atrial tachyarrhythmia, or atrial fibrillation with a rapid ventricular response, whereas other EGMs did not show an actual ventricular arrhythmia. On EGM analysis, during a mean follow-up period of 46.1 months, NSVT occurred one or more times in 82 patients (33.1%). On multivariate analysis, ≥ 50% right ventricular pacing was an independent risk factor for NSVT (odds ratios, 4.519; P < 0.001), but NSVT was not associated with increased all-cause mortality.Moreover, in the pacemaker population, ≥ 50% right ventricular pacing is an independent risk factor for NSVT; however, NSVT was not associated with increased all-cause mortality because of the preserved left ventricular function.

Randomized controlled trial of landiolol, a short-acting beta-1 adrenergic receptor blocker, illustrating changes in high-molecular weight adiponectin levels after elective percutaneous coronary intervention.

Adiponectin (APN) has cardioprotective properties and bisoprolol has been reported to increase myocardial APN expression and reduce myocardial damage. Administration of landiolol, which has a higher cardio-selectivity and shorter half-life than bisoprolol, during the percutaneous coronary intervention (PCI) may increase serum APN and high-molecular weight (HMW)-APN, an active form of APN, in patients with stable angina pectoris (SAP). We recruited 70 patients with SAP and randomized them to intravenous landiolol during PCI (N = 35) or control group (N = 35). The primary endpoint was serum APN and HMW-APN level 3 days after PCI. There was no difference in the primary endpoint between the landiolol and control groups (8.93 ± 5.24 vs. 10.18 ± 5.81 µg/mL, p = 0.35 and 3.36 ± 2.75 vs. 4.28 ± 3.13 µg/mL, p = 0.20) for APN and HMW-APN levels, respectively. APN and HMW-APN level were significantly decreased 1 day after PCI [-0.55 ± 0.92 µg/mL (9.87-9.32 µg/mL), p < 0.001 and -0.20 ± 0.45 µg/mL (3.89-3.69 µg/mL), p < 0.001, respectively]. Additionally, the absolute change in HMW-APN was significantly smaller in the landiolol group compared to the control group (-0.08 ± 0.27 vs. -0.31 ± 0.55 µg/mL, p = 0.031). Multiple linear regression analysis showed that use of landiolol was an independent predictor of change in HMW-APN (ß = 0.276, p = 0.014). Serum APN and HMW-APN level 3 days after PCI were similar between patients treated with and without landiolol. APN and HMW-APN decreased 1 day after PCI in the SAP and landiolol mitigated decrease in HMW-APN.

The AB Portable Driver Generates Higher Drive-Line Pressures Possibly Leading to Accelerated Hemolysis.

The AB5000 Circulatory Support System is paracorporeal pulsatile ventricular assist device. The AB Portable Driver is a portable console for this system. We experienced two cases with accelerated hemolysis while receiving support by the AB Portable Driver. The purpose of this study was to clarify the mechanical differences associated with the hemolysis between the AB5000 console and the AB Portable Driver. The mock circulatory system modeled by an AB5000 ventricle and a blood sampling bag of vinyl chloride was run with an AB5000 console or AB Portable Driver. The peak drive-line pressure, the mean arterial cannula pressure and the pumping rate of the VAD were recorded. The AB5000 console generated a peak drive-line pressure of 280-300 mm Hg in LVAD mode and 210-220 mm Hg in RVAD mode, approximately 100 mm Hg lower than officially documented. In contrast, the AB Portable Driver generated pressures of 310-330 mm Hg in LVAD mode and 230-250 mm Hg in RVAD mode, 65-95 mm Hg higher than officially documented. The AB Portable Driver console generates higher drive-line pressures than the AB5000 console, possibly explaining the accelerated hemolysis.

Relationship between sleep-disordered breathing and renal dysfunction in acute coronary syndrome.

BACKGROUND: Sleep-disordered breathing (SDB) is associated with cardiovascular complications. However, the effect of SDB on renal function in patients with acute coronary syndrome (ACS) treated by percutaneous coronary intervention (PCI) remains unclear. METHODS: We enrolled 154 consecutive ACS patients without heart failure. A sleep study was performed immediately after PCI. RESULTS: The mean apnea-hypopnea index (AHI) was 16.4±13.1, and 33 patients (21%) had severe SDB, defined as AHI≥25. Estimated glomerular filtration rate (eGFR) values on admission (60±12mL/min/1.73m2 vs. 67±17mL/min/1.73m2, p=0.046) and at discharge (54±15mL/min/1.73m2 vs. 63±15mL/min/1.73m2, p=0.002) were lower in patients with severe SDB than in those patients without severe SDB. Multiple linear regression analysis showed that AHIs were significantly correlated with absolute changes in eGFR values from admission to discharge (ß=0.201, p=0.004). Median 24-h urinary noradrenaline excretion measured on the same day of the sleep study was higher [297 (interquartile range {IQR}: 232-472) vs. 174 (IQR: 107-318)µg/day, p=0.021] in patients with severe SDB. On multivariate logistic regression analysis, the presence of severe SDB was a significant predictor (adjusted odds ratio 3.76, 95% confidence interval 1.06-13.9, p=0.047) for eGFR of less than 45mL/min/1.73m2 at discharge. This association was independent of age, eGFR on admission, and a presentation of ST-segment elevation myocardial infarction. CONCLUSION: In patients with ACS who undergo PCI, severe SDB is associated with impaired renal function on admission and its deterioration during hospitalization. Further studies will be needed to conclude that SDB would be a therapeutic target in ACS.

Combined impact of chronic kidney disease and contrast-induced nephropathy on long-term outcomes in patients with ST-segment elevation acute myocardial infarction who undergo primary percutaneous coronary intervention.

Contrast-induced nephropathy (CIN) and chronic kidney disease (CKD) are associated with poor outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI); however, its combined prognostic significance remains unclear. We enrolled 577 patients with AMI undergoing primary PCI within 12 h after symptom onset and measured serum creatinine on admission and the next 3 days. CKD was defined as admission estimated glomerular filtration rate <60 ml/min/1.73 m2, and CIN was defined as creatinine increase ≥0.5 mg/dl or ≥25 % from baseline within the first 72 h. Patients were stratified according to the presence or absence of CKD and CIN. In patients with no CKD and no CIN (n = 244), no CKD but CIN (n = 152), CKD but no CIN (n = 127), and both CKD and CIN (n = 54), the 3-year major adverse cardiovascular events (MACE: a combination of all-cause mortality, nonfatal reinfarction, or heart failure requiring rehospitalization) were 8, 9, 13, and 35 %, respectively (p < 0.001). Multivariate analysis showed that as compared with no CKD and no CIN, hazard ratios (95 % CI) for MACE associated with no CKD but CIN, CKD but no CIN, and both CKD and CIN were 0.91 (0.44-1.84; p = 0.79), 1.11 (0.5-2.23; p = 0.77), and 2.98 (1.48-6.04; p = 0.002), respectively. In patients with AMI undergoing primary PCI, the combination of CKD and CIN is significantly associated with adverse long-term outcomes.

Beneficial effect of early infusion of landiolol, a very short-acting beta-1 adrenergic receptor blocker, on reperfusion status in acute myocardial infarction.

BACKGROUND: An early IV beta blocker during primary percutaneous coronary intervention (PCI) has been shown to reduce infarct size in ST-segment elevation acute myocardial infarction (STEMI), although the underlying mechanism is unknown. The aim of this study was to investigate the efficacy of early infusion of landiolol, the short-acting beta-1 adrenergic receptor blocker, on the reperfusion status in a STEMI. METHODS: We conducted a prospective, single-group trial of landiolol during the primary PCI for a STEMI. Landiolol was started intravenously just before reperfusion. The reperfusion status and outcomes in 55 treated patients were compared with those in 60 historical controls treated without landiolol. The optimal reperfusion was assessed by an ST-segment resolution (STR), coronary flow, and myocardial brush grade (MBG) after reperfusion. RESULTS: Patients in the landiolol group achieved a higher rate of an STR (64% vs. 42%, p=0.023) and MBG 2/3 (64% vs. 45%, p=0.045), whereas coronary flow was comparable between the two groups. A multivariate analysis showed that landiolol use was an independent predictor of an STR (odds ratio 2.99, 95% confidence interval 1.25-7.16, p=0.014). The incidence of non-sustained ventricular tachycardia (27% vs. 50%, p=0.014), hypotension (15% vs. 32%, p=0.046), and progression to Killip class grade III or IV (0% vs. 10%, p=0.028) were lower in the landiolol group. CONCLUSION: Early infusion of landiolol during the primary PCI was associated with optimal reperfusion and a lower incidence of adverse events in comparison with the control group.

Association between gait speed as a measure of frailty and risk of cardiovascular events after myocardial infarction.

OBJECTIVES: This study sought to determine the additional clinical value of gait speed to Framingham risk score (FRS), cardiac function, and comorbid conditions in predicting cardiovascular events in patients with ST-segment elevation myocardial infarction. BACKGROUND: There is growing evidence that gait speed is inversely associated with all-cause mortality, particularly cardiovascular mortality, among the elderly. METHODS: We undertook a single-center prospective observational study of gait speed in 472 patients with ST-segment elevation myocardial infarction in Japan, between 2001 and 2008. Gait speeds were measured using a 200-m course before discharge in all patients, and we followed up cardiovascular events, which consist of cardiovascular deaths, nonfatal myocardial infarctions, and nonfatal ischemic strokes. RESULTS: During the 2,596 person-years of follow-up, 83 patients (17.6%) experienced cardiovascular events. Cardiovascular events increased across decreasing tertiles of gait speed (fastest tertile: n = 5, 3.2%; middle tertile: n = 20, 12.6%; slowest tertile, n = 58, 36.7%). By multiple adjusted Cox proportional hazards analysis, gait speed was a significant and independent predictor of cardiovascular events (hazard ratio for increasing 0.1 m/s of gait speed: 0.71, 95% confidence interval [CI]: 0.63 to 0.81, p < 0.001). The addition of gait speed to the model incorporating FRS, B-type natriuretic peptide levels, and comorbidity index improved reclassification (net reclassification index: 32.8%, 95% CI: 17.4 to 48.3, p < 0.001) and the C-statistics with a reasonable global fit and calibration (C-statistics: from 0.703 [95% CI: 0.636 to 0.763] to 0.786 [95% CI: 0.738 to 0.829]). CONCLUSIONS: Among patients with ST-segment elevation myocardial infarction, slow gait speed was significantly associated with an increased risk of cardiovascular events. (Gait Speed for Predicting Cardiovascular Events After Myocardial Infarction; NCT01484158).

Early, accurate, non-invasive predictors of left main or 3-vessel disease in patients with non-ST-segment elevation acute coronary syndrome.

BACKGROUND: In patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), identification of left main and/or 3-vessel disease (LM/3VD) is crucial for deciding whether to initiate early treatment with clopidogrel, which can increase the risk of surgical bleeding. METHODS AND RESULTS: On admission, the clinical factors of 501 patients with NSTE-ACS, who underwent coronary angiography, were evaluated. ST-segment shifts and the widest QRS duration were measured on an admission 12-lead electrocardiogram. Ninety-six patients had LM/3VD. Univariate analysis indicated that many factors were related to LM/3VD. On multivariate analysis, QRS duration (odds ratio (OR) 9.04, P<0.01), the degree of ST-segment elevation in lead aVR (OR 7.10, P<0.01), and positive-troponin T (OR 1.52, P<0.05) were independent predictors of LM/3VD. A QRS duration of >90 ms and a ST-segment elevation in lead aVR of >or=0.5 mm best identified LM/3VD. A QRS duration of >90 ms, a ST-segment elevation in lead aVR of >or=0.5 mm, and a positive-troponin T identified LM/3VD with sensitivities of 88%, 76%, and 54% (P<0.01), and specificities of 88%, 86%, and 71% (P<0.01), respectively. CONCLUSIONS: A prolonged QRS duration, ST-segment elevation in lead aVR, and a positive-troponin T on admission are useful predictors of LM/3VD in patients with NSTE-ACS. In particular, a maximal QRS duration of >90 ms was the most sensitive predictor of LM/3VD.

Effects of pretreatment with statins on infarct size in patients with acute myocardial infarction who receive fibrinolytic therapy.

BACKGROUND: Experimental studies suggest that statins promote vascular fibrinolysis, so statin treatment before the onset of acute myocardial infarction (AMI) may result in a smaller infarct size. METHODS AND RESULTS: The study group comprised 310 patients with AMI who received fibrinolysis within 12 h after symptom onset: 39 had received statin pretreatment (statin group) and 271 had not (non-statin group). Initial Thrombolysis In Myocardial Infarction (TIMI) flow grade did not differ between groups. Among 120 patients with initial TIMI flow grade 0/1, achievement of TIMI flow grade > or =2 after passing the guidewire through the culprit lesion was more frequent in the statin group (70% vs 35%, P=0.03). The final rate of TIMI flow grade 3 was higher in the statin group (95% vs 86%, P=0.11). Area under the curve (AUC) for creatine kinase (CK) was lower in the statin group (55,972+/-45,934 vs 84,195+/-84,276 IU . L(-1) . h(-1), P=0.04). Multivariate analysis revealed statin pretreatment as an independent negative predictor of larger infarct size as defined by the upper tertile of AUC for CK (odds ratio 0.25, 95% confidence interval 0.07-0.91, P=0.035). CONCLUSION: Statin pretreatment may enhance fibrinolysis and reduce infarct size in patients with AMI.

ST-segment elevation resolution in lead aVR: a strong predictor of adverse outcomes in patients with non-ST-segment elevation acute coronary syndrome.

BACKGROUND: The impact of ST-segment elevation resolution in lead aVR on outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) is unclear. METHODS AND RESULTS: Electrocardigrams (ECGs) were recorded on admission and 6 h later in 367 patients with NSTE-ACS. ST-segment deviation >or=0.5 mm was considered significant: 92 patients had ST-segment elevation in lead aVR on admission ECG (ST upward arrowaVR), and 275 did not. Among patients with ST upward arrowaVR, 50 had ST resolution, defined as a reduction >50% in the degree of ST-segment elevation in lead aVR from admission to 6 h later, and 42 did not. ST upward arrowaVR without ST resolution was associated with older age, greater ST-segment depression in other leads on admission and 6 h later, higher rates of positive troponin T, left main and/or 3-vessel coronary disease, and adverse events such as death, (re)infarction, or urgent revascularization within 30 days after admission. Multivariate analysis showed that ST upward arrowaVR without ST resolution was the strongest independent predictor of death or (re)infarction within 30 days after admission (hazard ratio 5.62, p=0.018). CONCLUSIONS: ST upward arrowaVR without ST resolution is a strong predictor of 30-day adverse outcomes and correlates with the extent and severity of coronary artery disease in patients with NSTE-ACS.