Initial multicenter clinical experience with the first-generation endoscopic guided laser balloon in Japan.

BACKGROUND: Isolation of the pulmonary veins (PVs) is the golden standard for atrial fibrillation (AF) ablation. To achieve a permanent PV isolation, the endoscopic guided HeartLight laser balloon system was invented. We analyzed the safety and efficacy of this laser balloon system. METHODS AND RESULTS: Three hundred four patients from 21 investigational sites inside Japan were enrolled in this study. One thousand sixty-two out of 1175 PVs (90.4%) were isolated using the HeartLight laser balloon. The isolation rate of the left superior, left inferior, right superior, and right inferior PVs was 87.8%, 91.3%, 91.6%, and 92.1%, respectively. The procedure time, defined as the time from the venous access to taking out the balloon, was 155 ± 39 min. The fluoroscopic time was 44 ± 25 min. The mean follow-up period was 309 ± 125 days. The freedom from AF recurrence at 3 months was 89.0% and at 12 months 82.1%. Adverse events occurred in 22 patients (7.2%) including phrenic nerve injury lasting more than 3 months in 1.6% and strokes in 1.0% of the patients. CONCLUSIONS: This initial experience demonstrated that the laser balloon ablation was feasible for PV isolation in Japanese AF patients.

Efficacy of left atrial posterior wall isolation guided by lesion size prediction module for non-paroxysmal atrial fibrillation.

AIMS: The efficacy of left atrial posterior wall isolation (PWI) is controversial. Lesion durability may be a major cause of arrhythmia recurrence. The use of the lesion size prediction module improves lesion durability. This study aimed to compare the clinical outcomes of pulmonary vein isolation (PVI) alone and PWI in addition to PVI (PVI + PWI) in patients with non-paroxysmal atrial fibrillation (AF) using a lesion size prediction module. METHODS AND RESULTS: This study is a sub-analysis of the recently published prospective multicentre observational study called ALCOHOL-AF (association of alcohol consumption with outcome of catheter ablation of AF). In this sub-analysis, patients with non-paroxysmal AF in whom PVI alone or PVI + PWI was performed using the lesion size prediction module were included. Freedom from atrial tachyarrhythmia was compared between PVI alone and PVI + PWI groups using propensity score analyses. Of the 3474 patients registered in the ALCOHOL-AF study, 572 patients (age 65.6 ± 10.1 years, male 77.4%, longstanding persistent AF 25.5%) were included in this sub-analysis. We selected 212 patients treated with PVI alone and 212 treated with PVI + PWI using one-to-one propensity score matching. During the follow-up period, atrial tachyarrhythmia recurrence was documented in 92 (43.4%) and 50 (23.6%) patients in the PVI alone and PVI + PWI groups, respectively. Freedom from atrial tachyarrhythmia recurrence without anti-arrhythmic drugs after a single procedure was significantly higher in PVI + PWI than in PVI alone groups (hazard ratio: 0.452, 95% confidence interval: 0.308-0.664, P < 0.001). CONCLUSION: In this hypothesis-generating study, lesion size prediction module-guided PVI + PWI was associated with better clinical outcomes than PVI alone in patients with persistent or longstanding persistent AF.

Effect of Cardiac Rehabilitation on Glomerular Filtration Rate Using Serum Cystatin C Concentration in Patients With Cardiovascular Disease and Renal Dysfunction.

PURPOSE: Among patients with chronic kidney disease (CKD), little is known about whether the effect of cardiac rehabilitation (CR) on renal function differs across baseline estimated glomerular filtration rate using the serum concentration of cystatin C (eGFRcys). The aim of this study was to evaluate the effect of CR on renal function in patients with CKD. METHODS: We performed a retrospective cohort study of patients with CKD (15 ≤ eGFRcys < 60 mL/min/1.73 m2) who participated in our CR program for cardiovascular disease. First, the patients were divided into three groups according to the baseline severity of the eGFRcys: G3a, G3b, and G4 groups. We compared the eGFRcys before and after the CR in each group. Second, to determine the association of baseline eGFRcys with the effect of CR, we fitted a linear regression model using the percent change in the eGFRcys (%ΔeGFRcys) as an outcome. RESULTS: Of the 203 patients, 122 were in G3a, 60 were in G3b, and 21 were in G4 groups. The mean improvement of eGFRcys in each group was 1.3, 3.1, and 4.8 mL/min/1.73 m2, respectively. The %ΔeGFRcys was larger among patients with lower baseline eGFRcys (0.47% greater improvement of %ΔeGFRcys/one lower baseline eGFRcys; 95% CI, 0.23-0.72%). This association remained significant after adjustment for potential confounders (0.63% greater improvement of %ΔeGFRcys/one lower baseline eGFRcys; 95% CI, 0.35-0.91%). CONCLUSIONS: The effect of CR on renal function was greater in patients with worse renal dysfunction measured by eGFRcys. A CR program could be useful for patients with severe renal dysfunction and it might have a beneficial effect on their renal function.

Effect of ganglionated plexi ablation by high-density mapping on long-term suppression of paroxysmal atrial fibrillation - The first clinical survey on ablation of the dorsal right plexusus.

BACKGROUND: Long-term outcomes of suppressing paroxysmal atrial fibrillation (PAF) with additive ganglionated plexus (GP) ablation (GPA) remains unknown. OBJECTIVES: The aim of the study is to assess potential role of additional GPA for PAF suppression. METHODS: This study consisted of 225 patients; 68 (group A: 58 male, aged 60 ± 11 years) underwent pulmonary vein isolation (PVI) alone and 157 (group B: 137 male, aged 61 ± 11 years) GPA followed by PVI. GPA was performed based on the high-density mapping with high-frequency stimulation (HFS) delivered to left atrial (LA) major GP. The latter 85 group B patients (54%) underwent ablation to a posteromedial area within superior vena cava as a part of dorsal right atrial GP (SVC-Ao GP). RESULTS: In group B, HFS was applied to 126 ± 32 sites, with a median of 47 GP sites (40.0%) being ablated. In patients undergoing an SVC-Ao GPA, HFS and the SVC-Ao GPA were applied at a median of 15 and 4 sites (29.4%), respectively. The PVI with a GPA provided higher PAF suppression than a PVI alone during more than 4 years of follow-up (56.7% vs 38.2%, odds ratio: 0.42, 95% confidence interval: 0.23-0.76, P < .05), but the SVC-Ao GPA did not provide further suppressive effects. Multivariate analyses revealed that tachycardia-bradycardia syndrome and non-PV foci were independent predictors of PAF recurrence after PVI with a GPA (P < .01). CONCLUSION: GPA to LA major GP by high-density mapping provides long-term benefits for PAF suppression over 4 years of follow-up, but the effect of an empiric SVC-Ao GPA could not be appreciated, suggesting little effect on suppressing non-PV foci.

Impact of bedrest on cardiovascular events and complications associated with temporary pacemakers in patients waiting for permanent pacemaker implantation.

BACKGROUND: Patients with a temporary pacemaker (TPM) for bradycardias are required to maintain bedrest until permanent pacemakers (PPMs) are implanted because of the development of Adams-Stokes syndrome, worsening heart failure, or complications associated with TPMs is anticipated. However, bedrest may be detrimental in patients because it leads to disuse syndrome. This study examined whether bedrest could decrease the incidence of cardiovascular events or complications associated with TPMs in patients waiting for PPM implantation. METHODS: We conducted a retrospective cohort study on 88 patients who had emergency hospitalization for the treatment of bradycardias, and a TPM was inserted during the waiting period before PPM implantation. We divided patients into two groups according to whether they underwent bedrest (Bedrest Group) or not (Ambulation Group) during the period that patients were supported with TPM. We evaluated whether bedrest was a predictor of adverse events using a logistic regression analysis. RESULTS: Adverse events occurred in 31 patients (35%). In the univariate analysis, there was no significant difference in the incidence of adverse events between the Bedrest and Ambulation Groups (39% vs. 29%). In the logistic regression analysis, bedrest was not a predictor of adverse events (odds ratio, 1.40; 95% confidence interval, 0.53-3.68, P = .497). CONCLUSIONS: In patients with TPMs for bradyarrhythmias during the waiting period for PPM implantations, bedrest might not prevent adverse events, such as cardiovascular events and complications associated with TPMs.

Alcohol Consumption Reduction and Clinical Outcomes of Catheter Ablation for Atrial Fibrillation.

[Figure: see text].

Effects of cardiac rehabilitation on physical function and exercise capacity in elderly cardiovascular patients with frailty.

BACKGROUND: The effects of cardiac rehabilitation (CR) on long-term prognosis of cardiovascular disease (CVD) are well known. However, the effect of CR on frail CVD patients has not been fully addressed. METHODS: This study consisted of 89 CVD patients with their age ≥65 years old (68 males, 75 ± 6 years), who participated in the outpatient CR program for 3 months. All the patients underwent cardiopulmonary exercise testing and the physical frailty was assessed using the Japanese Version of the Cardiovascular Health Study Standard before and after CR. Based on the assessment of frailty before CR, the patients were divided into the following two groups: frailty group (n = 23) and non-frailty group (n = 66: robust in 10 and pre-frail in 56 patients). RESULTS: In the frailty group, 20 patients (87%) improved from frail status after CR, and usual walking speed, maximal grip strength, and lower extremity strength were significantly improved (1.06±0.20 vs. 1.20±0.18 m/sec, p<0.001; 21.7 ± 5.5 vs. 23.6 ± 6.3 kg, p<0.01; 0.37±0.09 vs. 0.43±0.11 kgf/kg, p = 0.001, respectively), but peak VO2 did not change after CR (15.9 ± 3.1 vs. 16.2 ± 3.8 ml/min/kg, NS). In the non-frailty group, all these parameters were significantly improved after CR (1.24±0.19 vs. 1.29±0.23 m/sec, p<0.05, 28.7 ± 7.0 vs. 30.2 ± 7.3 kg, p<0.001, 0.50±0.18 vs. 0.54±0.13 kgf/kg, p<0.05, 17.7 ± 4.7 vs 18.5 ± 4.2 ml/min/kg, p<0.01, respectively). CONCLUSION: Short-term CR could obtain the improvement of the physical function, providing the prerequisite step for possibly following improvement of exercise capacity in elderly CVD patients with frailty. It may be inferred that longer duration of CR would be needed to obtain the improvement of exercise capacity in these patients, being the future consideration to be determined.

Current Trends in Implantable Cardioverter-Defibrillator Therapy in Children　- Results From the JCDTR Database.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) are being used with increasing frequency in children. Our aim was to examine the current trend of pediatric ICD implantation in Japan. Methods and Results: Data was extracted from the Japanese Cardiac Device Treatment Registry (JCDTR), a nation-wide registry started in 2006. All patients aged less than 18 years who had an ICD implantation registered between 2006 and 2016 were included in the analysis. A total of 201 patients were included, with a median age of 16 years (range 1-18). The underlying cardiac diagnosis was primary electrical disease (67%), cardiomyopathy (26%) and congenital heart disease (4%), with idiopathic ventricular fibrillation (29%) and long QT syndrome (21%) being the 2 most common diagnoses. Implantation indication was primary prevention in only 30 patients (15%). There were 27 patients (13%) aged ≤12 years, with a larger proportion of patients with cardiomyopathy (33%). The indication in younger children was secondary prevention in all cases. Younger children may be under-represented in our study given the nature of the database as it is a predominantly adult cardiology database. CONCLUSIONS: In the past decade, ICD implantation has been performed in approximately 20 children per year in Japan, mostly for secondary prevention. There was no increase in the trend nor a change in age distribution.

Influence of substrate modification in catheter ablation of atrial fibrillation on the incidence of acute complications: Analysis of 10 795 procedures in J-CARAF Study 2011-2016.

BACKGROUND AND PURPOSE: In expectation of better outcome of catheter ablation of atrial fibrillation (AF), several strategies of extra-PV (pulmonary vein) substrate modification have been utilized. We assessed whether substrate modification or ablation of extra-PV source is a predictor of complications. METHODS: Japanese Heart Rhythm Society requested electrophysiology centers to register the data of patients who underwent AF ablation. RESULTS: The data of 10 795 AF ablation cases (age; 63.8 ± 10.6 years) treated during 2011-2016 were registered. Pericardial effusion (n = 105), massive bleeding (n = 108), stroke (n = 6), atrial-esophageal fistula (n = 2), and other 114 complications occurred in 323 patients (3.0%). Univariate analysis revealed that age â‰§ 65 years, female gender, heart failure, CHA2DS2-VASc≧3, hemodialysis, deep sedation, and complex fractionated atrial electrogram (CFAE)-guided ablation ([+] vs [-] = 4.3% vs 2.8%, P = .005) were related with the higher incidence of complications. Redo session, 3-D imaging system ([+] vs [-]: 4.4% vs 2.9%, P = .017), and periprocedural dabigatran were related with the lower incidence of complications. None of the linear ablation of the left atrium, ganglionated plexi ablation, and superior vena cava ablation affected the incidence of complications. Multiple logistic regression analysis showed that in addition to 3-D imaging system, age â‰§ 65 years, redo session, and deep sedation, CFAE ablation was an independent predictor of the risk of complications (OR 1.78, P = .001). Specifically, implantation of a permanent pacemaker due to emerging sinus node dysfunction was frequent after CFAE ablation (CFAE [+] vs [-] = 4/1047 vs 2/9748, P < .001). CONCLUSIONS: Among extra-PV ablation strategies, CFAE-guided ablation is a predictor of ablation-related complications.

Effect of cardiac rehabilitation on the renal function in chronic kidney disease - Analysis using serum cystatin-C based glomerular filtration rate.

BACKGROUND: Whether an individually determined appropriate level of cardiac rehabilitation (CR) has a favorable effect on the renal function still remains unclarified. The aim of this study was to confirm the effect of CR on the estimated glomerular filtration rate (eGFR) using cystatin C, which is known to be unaffected by physical exercise. METHODS: The study population was comprised of 86 patients (61 males; average age 74 y/o) with a lower-moderate level of chronic kidney disease (CKD) who was admitted to our hospital for treatment of cardiovascular disease (CVD) and who participated in our 3-month CR program. The exercise capacity was assessed by cardiopulmonary exercise testing (CPX) and the eGFR was measured by a formula based on the serum cystatin C concentration (eGFRcys) in each patient both at the beginning and end of the CR. RESULTS: In the CVD patients with CKD, both the peak oxygen uptake (VO2) and peak work rate (WR) improved significantly after CR (15.0 ±â€¯3 to 15.8 ±â€¯3 ml/min/kg, p = 0.002. 65.5 ±â€¯21 to 70.2 ±â€¯25 W, p = 0.001). Regarding the renal function, the eGFRcys improved (45.2 ±â€¯11 to 47.3 ±â€¯13 ml/min/1.73 m2, p = 0.023), however, the eGFR assessed by the serum creatinine (eGFRcr) did not improve after CR (45.1 ±â€¯12 to 44.9 ±â€¯13 ml/min/1.73 m2, p = 0.834). CONCLUSIONS: In CVD patients, a novel CR program significantly improved the exercise capacity. Further, CR was shown to have a favorable effect on the renal function when it was estimated by the eGFRcys.

Prognostic significance of nonsustained ventricular tachycardia in patients receiving cardiac resynchronization therapy for primary prevention: Analysis of the Japan cardiac device treatment registry database.

Background: Whether nonsustained ventricular tachycardia (NSVT) is a marker of increased risk of sustained ventricular tachyarrhythmias (VTAs) remains to be established in patients receiving cardiac resynchronization therapy with a defibrillator (CRT-D) for primary prevention. Methods: Among the follow-up data of the Japan cardiac device treatment registry (JCDTR) with an implantation date between January 2011 and August 2015, information regarding a history of NSVT before the CRT-D implantation for primary prevention had been registered in 269 patients. Outcomes were compared between two groups with and without NSVT: NSVT group (n = 179) and No NSVT group (n = 90). Results: There was no significant difference with regard to age, gender, and NYHA class between the two groups. Left ventricular ejection fraction (LVEF) was 25.6% in the NSVT group and 28.0% in the No NSVT group (P = .046). The rate of appropriate therapy at 24 months was 26.0% and 18.4% in the NSVT and No NSVT groups (P = .22), respectively. Survival free from heart failure death was reduced in the NSVT group, as compared with the No NSVT group, with the rate of 90.2% vs 97.2% at 24 months (P = .030). A multivariate analysis identified a history of NSVT, anemia, and no use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) as predictors of heart failure death. Conclusions: NSVT appears to be a surrogate marker of severe heart failure rather than a substrate for subsequent sustained VTAs in patients with CRT-D for primary prevention.

Incidence and predictors of pericardial effusion as an early complication of catheter ablation for atrial fibrillation: The Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF).

BACKGROUND: Pericardial effusion (PE) is one of the most frequent complications from catheter ablation of atrial fibrillation (AF). We assessed the prevalence and predictive factors of PE that require invasive treatment as an early complication of AF ablation. METHODS: The Japanese Heart Rhythm Society requested electrophysiology centers to register the relevant data of patients who underwent AF ablation during 6 months from 2011 to 2015. We compared the clinical profiles and the procedures of AF ablation between patients who had ablation-related PE and those who did not. RESULTS: Two-hundred-and-eight institutions reported the data of 8319 AF ablation sessions (age 63.4±10.7 years). A total of 414 complications occurred in 401 patients (4.8%). The incidence of invasively treated critical PE was 1.0% (n=85) of total procedures, while conservatively treated noncritical PE appeared in 95 subjects. When clinical and procedural variables were compared between patients who suffered critical PE and 8140 PE-free patients, deep sedation (p=0.030), impaired left ventricular function (p=0.031), and periprocedural warfarin (p=0.023) significantly increased the incidence of critical PE in univariate analysis. Use of 3-D imaging system (p<0.001) and a periprocedural direct oral anticoagulant (DOAC, p=0.002) were related with lower incidence of critical PE. Among these factors, multivariate logistic regression analysis showed that 3-D imaging system (odds ratio 0.23 [95% CI: 0.14-0.39], p<0.001) and a periprocedural DOAC (odds ratio 0.49 [95% CI: 0.27-0.90], p=0.020) are independent predictors of the lower incidence of PE. CONCLUSIONS: Critical PE occurred in 1% of AF ablation procedures in Japan. Our results suggest that 3-D imaging system use independently reduces the frequency of PE. DOACs in the setting of catheter ablation of AF seemed to be non-inferior to warfarin in terms of safety and effectiveness.

Survival and Heart Failure Hospitalization in Patients With Cardiac Resynchronization Therapy With or Without a Defibrillator for Primary Prevention in Japan　- Analysis of the Japan Cardiac Device Treatment Registry Database.

BACKGROUND: Randomized control trials comparing the effectiveness of cardiac resynchronization therapy devices, with (CRT-D) or without (CRT-P) a defibrillator, are scarce in heart failure patients with no prior sustained ventricular tachyarrhythmias.Methods and Results:The Japan Cardiac Device Treatment Registry (JCDTR) has data for 2714 CRT-D and 555 CRT-P recipients for primary prevention with an implantation date between January 2011 and August 2015. Of these patients, follow-up data were available for 717. Over the mean follow-up period of 21 months, Kaplan-Meier curves of survival free of combined events for all-cause death or heart failure hospitalization (whichever came first) diverged between the CRT-D (n=620) and CRT-P (n=97) groups with a rate of 22% vs. 42%, respectively, at 24 months (P=0.0011). However, this apparent benefit of CRT-D over CRT-P was no longer significant after adjustment for covariates. With regard to mortality, including heart failure death or sudden cardiac death, there was no significant difference between the 2 groups. CONCLUSIONS: In patients without sustained ventricular tachyarrhythmias enrolled in the JCDTR, there was no significant difference in mortality between the CRT-D and CRT-P groups, despite a lower trend in CRT-D recipients. This study was limited by large clinical and demographic differences between the 2 groups.

Report of periprocedural oral anticoagulants in catheter ablation for atrial fibrillation: The Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF).

BACKGROUND: To obtain a perspective of the current status of catheter ablation for the cure of atrial fibrillation, the Japanese Heart Rhythm Society conducted a nationwide survey: the Japanese Catheter Ablation Registry of Atrial Fibrillation. In this report, we aimed to evaluate the periprocedural use of direct oral anticoagulants with respect to thromboembolic or bleeding complications. METHODS: Using an online questionnaire, the Japanese Heart Rhythm Society requested electrophysiology centers in Japan to register the relevant data of patients who underwent atrial fibrillation ablation over selected five-months from 2011 to 2014. We compared the clinical profiles and the ablation data, including the incidence of pericardial effusion, major bleeding, and ischemic stroke among patients with periprocedural use of warfarin or a direct oral anticoagulant. RESULTS: A total of 204 institutions reported data on 6200 atrial fibrillation ablation sessions. We analyzed data obtained from 4698 subjects (Age 63.2±10.6 yr; 73.9% male, 26.1% female) who were administered warfarin or a direct oral anticoagulant, at least up to the day before atrial fibrillation ablation. Warfarin was administered to 54.7% of patients. Dabigatran, rivaroxaban, and apixaban were used in 21.9%, 12.9%, and 10.6% of patients, respectively. Clinical profiles of apixaban-treated patients were similar to those of warfarin-treated patients; they were different from the clinical profiles of patients treated with dabigatran or rivaroxaban. There were 104 complications in 103 subjects (2.2%). Complications were more frequent in older patients (65.3±8.6 yr vs. 63.1±10.7 yr; P=0.012), patients on chronic hemodialysis (4.9% vs. 1.1%; P=0.001), or those treated with warfarin (66.0% vs. 54.4%; P=0.019). Multiple logistic regression analysis revealed that age (OR, 1.02; 95% CI: 1.00-1.04; P=0.035), chronic hemodialysis (OR, 4.40; CI: 1.68-11.50; P=0.003), and assistance by 3-D mapping system (OR, 0.30; CI: 0.16-0.57; P<0.001) were significantly related to the incidence of complications, while periprocedural direct oral anticoagulant was not a predictive factor for complication. CONCLUSIONS: Compared with uninterrupted warfarin, the choice of a direct oral anticoagulant as a periprocedural oral anticoagulant did not significantly change the incidence of serious complications.

Hypodysfibrinogenemia with a Heterozygous Mutation of γCys326Ser by the Novel Transversion of TGT to TCT in a Patient with Pulmonary Thromboembolism and Right Ventricular Thrombus.

We encountered a 45-year-old Japanese man who suffered from pulmonary thromboembolism and huge right ventricular thrombus after inferior vena cava (IVC) filter implantation without apparent thrombus in either the deep veins or inside the IVC filter. The biochemical data showed a discrepancy in the level of fibrinogen between the immunological and thrombin time methods, suggesting hypodysfibrinogenemia. The sequencing of the fibrinogen γ-chain gene (FGG) revealed a novel heterozygous missense mutation in exon 8 - a TGT to TCT transversion in codon 326 - resulting in an amino acid substitution of serine for cysteine (γCys326Ser). The characterization of the protein did not show known mechanisms for thrombosis in dysfibrinogenemia, such as dimer or albumin-binding complex formation. In summary, the current case with a life-threatening thrombotic event was found to have a novel heterozygous missense mutation resulting in γCys326Ser, which was suggested as a predisposing factor of the thrombosis. Known mechanisms responsible for thrombosis in the current case were not demonstrated, suggesting other mechanisms including superimposing inherited and/or acquired risk factors. When a patient presents with unusual thrombosis such as breakthrough pulmonary embolism and huge thrombus in the right ventricle, as in the current case, the laboratory process for heritable thrombophilia should be considered.

Trends and determinant factors in the use of cardiac resynchronization therapy devices in Japan: Analysis of the Japan cardiac device treatment registry database.

BACKGROUND: The choice of cardiac resynchronization therapy device, with (CRT-D) or without (CRT-P) a defibrillator, in patients with heart failure largely depends on the physician׳s discretion, because it has not been established which subjects benefit most from a defibrillator. METHODS: We examined the annual trend of CRT device implantations between 2006 and 2014, and evaluated the factors related to the device selection (CRT-D or CRT-P) for primary prevention of sudden cardiac death in patients with heart failure by analyzing the Japan Cardiac Device Treatment Registry (JCDTR) database from January 2011 and August 2015 (CRT-D, n=2714; CRT-P, n=555). RESULTS: The proportion of CRT-D implantations for primary prevention among all the CRT-D recipients was more than 70% during the study period. The number of CRT-D implantations for primary prevention reached a maximum in 2011 and decreased gradually between 2011 and 2014, whereas CRT-P implantations increased year by year until 2011 and remained unchanged in recent years. Multivariate analysis identified age (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.90-0.95, P<0.0001), male sex (OR 1.99, 95% CI 1.28-3.11, P<0.005), reduced left ventricular ejection fraction (LVEF) (OR 0.96, 95% CI 0.94-0.98, P<0.0001), and non-sustained ventricular tachycardia (NSVT) (OR 2.85, 95% CI 1.87-4.35, P<0.0001) as independent factors favoring the choice of CRT-D. CONCLUSIONS: Younger age, male sex, reduced LVEF, and a history of NSVT were independently associated with the choice of CRT-D for primary prevention of sudden cardiac death in patients with heart failure in Japan.

Current status of catheter ablation of atrial fibrillation in Japan: Summary of the 4th survey of the Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF).

BACKGROUND AND METHODS: The Japanese Heart Rhythm Society performs an annual survey, J-CARAF, to collect data on the atrial fibrillation (AF) ablation procedure, and requests its members to register data for AF ablation performed in specified months. We compared data from the latest survey (September 2013, n=1049) with that of the previous survey (September 2012, n=1246) to investigate trends related to the AF ablation procedure. RESULTS: Patients in the latest survey were older (September 2012 vs. September 2013, 62.1±10.7 years vs. 63.3±10.8 years, p=0.012), and fewer used antiarrhythmic drugs (73.3% vs. 67.4%, p<0.0001). The fluoroscopic time decreased significantly (65.2±47.2min vs. 57.4±38.8min, p<0.0001), although the frequency of left atrial linear ablation increased (21.5% vs. 28.2%, p=0.0002). The use of factor Xa inhibitors (FXaI) during and post-procedure considerably increased (during, 3.0% vs. 15.8%; post, 3.7% vs. 32.8%, p<0.0001), whereas warfarin and direct thrombin inhibitor (DTI) were used less as oral anticoagulants during or after the procedure (warfarin: during, 47.8% vs. 33.7%; after, 55.2% vs. 37.5%; DTI: during, 21.2% vs. 16.0%; after 38.4% vs. 28.3%; p<0.0001). CONCLUSIONS: On comparison of the data from the surveys, the AF ablation procedure was observed to be performed in older patients and as a first-line therapy in Japan. In addition, more intensive ablation with less fluoroscopy was an observed trend. The use of FXaI during and after the procedure increased considerably, while the use of warfarin and DTI decreased.

Electrophysiological and anatomical background of the fusion configuration of diastolic and presystolic Purkinje potentials in patients with verapamil-sensitive idiopathic left ventricular tachycardia.

BACKGROUND: It is unclear whether false tendons (FTs) are a substantial part of the reentry circuit of verapamil-sensitive idiopathic left ventricular tachycardia (ILVT). This study aimed to prove the association between FTs and the slow conduction zone by evaluating the electro-anatomical relationship between the so-called diastolic Purkinje (Pd) potentials and FTs using an electro-anatomical mapping (EAM) system (CARTO). METHODS: The 1st protocol evaluated the spatial distribution of Pd and presystolic Purkinje (Pp) potentials in 6 IVLT patients using a conventional CARTO system. In the remaining 2 patients (2nd protocol), the electro-anatomical relationship between the Pd-Pp fusion potential and the septal connection of the FT was evaluated using an EAM system incorporating an intra-cardiac echo (CARTO-Sound). RESULTS: Pd potentials were observed in the posterior-posteroseptal region of the LV and had a slow conduction property, whereas Pp potentials were widely distributed in the interventricular (IV) septum. At the intersection of the 2 regions, which was located in the mid-posteroseptal area, both Pd and Pp potentials were closely spaced and often had a fused configuration. In the latter 2 patients (2nd protocol), it was confirmed that the intra-cardiac points at which the Pd-Pp fusion potential was recorded were located in the vicinity of the attachment site of the FT to the IV septum. In all patients, ILVTs were successfully eliminated by the application of radiofrequency at those points. CONCLUSION: FTs may at least partly contribute to the formation of the Pd potential, and thus form a critical part of the reentry circuit of ILVT.