Clinical outcomes of catheter ablation for atrial fibrillation, atrial flutter, and atrial tachycardia in wild-type transthyretin amyloid cardiomyopathy: a proposed treatment strategy for catheter ablation in each arrhythmia.

AIMS: Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) is often accompanied by atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT), which are difficult to control because beta-blockers and antiarrhythmic drugs can worsen heart failure (HF). This study aimed to investigate the outcomes of catheter ablation (CA) for AF/AFL/AT in patients with ATTRwt-CM and propose a treatment strategy for CA. METHODS AND RESULTS: A cohort study was conducted on 233 patients diagnosed with ATTRwt-CM, including 54 who underwent CA for AF/AFL/AT. The background of each arrhythmia and the details of the CA and its outcomes were investigated. The recurrence-free rate of AF/AFL/AT overall in ATTRwt-CM patients with multiple CA was 70.1% at 1-year, 57.6% at 2-year, and 44.0% at 5-year follow-up, but CA significantly reduced all-cause mortality [hazard ratio (HR): 0.342, 95% confidence interval (CI): 0.133-0.876, P = 0.025], cardiovascular mortality (HR: 0.378, 95% CI: 0.146-0.981, P = 0.045), and HF hospitalization (HR: 0.488, 95% CI: 0.269-0.889, P = 0.019) compared with those without CA. There was no recurrence of the cavotricuspid isthmus (CTI)-dependent AFL, non-CTI-dependent simple AFL terminated by one linear ablation, and focal AT originating from the atrioventricular (AV) annulus or crista terminalis eventually. Twelve of 13 patients with paroxysmal AF and 27 of 29 patients with persistent AF did not have recurrence as AF. However, all three patients with non-CTI-dependent complex AFL not terminated by a single linear ablation and 10 of 13 cases with focal AT or multiple focal ATs originating beyond the AV annulus or crista terminalis recurred even after multiple CA. CONCLUSION: The outcomes of CA for ATTRwt-CM were acceptable, except for multiple focal AT and complex AFL. Catheter ablation may be aggressively considered as a treatment strategy with the expectation of improving mortality and hospitalization for HF.

Clinical, electrocardiographic, and echocardiographic parameters associated with the development of pacing and implantable cardioverter-defibrillator indication in patients with transthyretin amyloid cardiomyopathy.

AIMS: This study aimed to identify factors for attention leading to future pacing device implantation (PDI) and reveal the necessity of prophylactic PDI or implantable cardioverter-defibrillator (ICD) implantation in transthyretin amyloid cardiomyopathy (ATTR-CM) patients. METHODS AND RESULTS: This retrospective single-center observational study included consecutive 114 wild-type ATTR-CM (ATTRwt-CM) and 50 hereditary ATTR-CM (ATTRv-CM) patients, neither implanted with a pacing device nor fulfilling indications for PDI at diagnosis. As a study outcome, patient backgrounds were compared with and without future PDI, and the incidence of PDI in each conduction disturbance was examined. Furthermore, appropriate ICD therapies were investigated in all 19 patients with ICD implantation. PR-interval ≥220 msec, interventricular septum (IVS) thickness ≥16.9 mm, and bifascicular block were significantly associated with future PDI in ATTRwt-CM patients, and brain natriuretic peptide ≥35.7 pg/mL, IVS thickness ≥11.3 mm, and bifascicular block in ATTRv-CM patients. The incidence of subsequent PDI in patients with bifascicular block at diagnosis was significantly higher than that of normal atrioventricular (AV) conduction in both ATTRwt-CM [hazard ratio (HR): 13.70, P = 0.019] and ATTRv-CM (HR: 12.94, P = 0.002), whereas that of patients with first-degree AV block was neither (ATTRwt-CM: HR: 2.14, P = 0.511, ATTRv-CM: HR: 1.57, P = 0.701). Regarding ICD, only 2 of 16 ATTRwt-CM and 1 of 3 ATTRv-CM patients received appropriate anti-tachycardia pacing or shock therapy, under the number of intervals to detect for ventricular tachycardia of 16-32. CONCLUSIONS: According to our retrospective single-center observational study, prophylactic PDI did not require first-degree AV block in both ATTRwt-CM and ATTRv-CM patients, and prophylactic ICD implantation was also controversial in both ATTR-CM. Larger prospective, multi-center studies are necessary to confirm these results.

Effect of contact vector direction on achieving cavotricuspid isthmus block.

Cavotricuspid isthmus (CTI) ablation is an important treatment strategy for CTI-dependent atrial flutter (AFL). The location of the catheter contact area is confirmed by the contact vector direction (CVD) through three-dimensional mapping during the procedure. However, the relationship between CVD during radiofrequency ablation and its efficacy in achieving CTI block has not been clarified. This study aimed to investigate the relationship between CVD and efficacy in achieving CTI block. CVDs during radiofrequency ablation were divided into proximal vectors against the distal tip (P-vector) and other vectors (normal-vector). In 39 patients who underwent CTI linear ablation, the CTIs were divided into two segments: the tricuspid valve area (anterior) and inferior vena cava area (posterior). The frequency of the residual conduction gap was compared between segments in which the P- and normal-vectors were observed. P-vectors were observed in 13 of the 78 segments. The median ablation index was not significantly different between segments in which the P-vector and normal-vector were observed (398.2 [384.2-402.2] vs. 393.3 [378.3-400.1], p = 0.15). However, residual conduction gaps were significantly more frequently observed in the segment in which the P-vector was observed than those in which only the normal-vector was observed (6/13, 46.2% vs. 3/65, 4.6%; p < 0.01). During a 6-month follow-up, two patients required a second session of ablation due to AFL recurrence. A residual conduction gap was observed in one patient at the site where the P-vector was observed in the first session. Avoiding the P-vector might be an important factor in improving CTI block and reducing AFL recurrence.

Placement of catheters without magnetic sensors in the coronary sinus without fluoroscopic guidance: Feasibility and safety evaluation.

Background: A three-dimensional (3D) mapping system is essential to reduce radiation exposure during catheter ablation. When using the CARTO 3D mapping system, only the catheter with magnetic sensor can visualize its location. However, once target chamber matrix is created using the catheter, even the catheters without magnetic sensors (CWMS) can enable visualization. We aimed to investigate the feasibility and safety of placing a CWMS in the coronary sinus (CS) without fluoroscopic guidance. Methods: The study group comprised 88 consecutive patients who underwent catheter ablation. CWMS placement was performed without fluoroscopic guidance in 47 patients and with fluoroscopic guidance in 41 patients. Placement without fluoroscopic guidance was performed after creating a visualization matrix of the CS, right atrium, and superior vena cava using a catheter with a magnetic sensor. Feasibility and safety were compared between the two groups. Results: Successful catheter placement was achieved in all patients without fluoroscopic guidance, with no inter-group difference in the median procedure time: with guidance, 120.0 [96.0-135.0] min, and without guidance, 110.0 [97.5-125.0] min; p = .22. However, radiation exposure was significantly shorter, and the effective dose was lower without fluoroscopic guidance (0 [0-17.5] s and 0 [0-0.004] mSv, respectively) than with fluoroscopic guidance (420.0 [270.0-644.0] s and 0.73 mSv [0.36-1.26], respectively); both p < .001. Conclusions: CWMS placement without fluoroscopic guidance is feasible, safe to perform, and does not involve complications. Our technique provides an option to decrease radiation exposure during catheter ablation and electrophysiological testing.

Unified expression for the rate constant of the bridged electron transfer derived by renormalization.

Electron transfer (ET) from a donor to an acceptor through an energetically close intermediary state on a midway molecule is a process found often in natural and artificial solar-energy capturing systems such as photosynthesis. This process has often been thought of in terms of opposing "superexchange" and "sequential or hopping" mechanisms, and the recent theory of Sumi and Kakitani (SK) [J. Phys. Chem. B 105, 9603 (2001)] has shown an interpolation between these mechanisms. In their theory, however, dynamics governing the most interesting intermediary region between them has artificially been introduced by phenomenologies. The dynamics is played by decoherence among electronic states, their decay, and thermalization of phonons in the medium. The present work clarifies the dynamics on a microscopic basis by means of renormalization in electronic coupling among the states, and gives a complete unified expression of the rate constant of the ET. It merges to that given by the SK theory in the semiclassical approximation for phonons interacting with an electron transferred.

Sequential or superexchange mechanism in bridged electron transfer distinguished by dynamics at a bridging molecule.

Two kinds of mechanisms are well known for electron transfer (ET) in the system DMA where a donor D and an acceptor A are fixed in a close distance by a bridging molecule M. When the free energy DeltaG(m) of the intermediate state |m of DM(-)A is much higher than the thermal energy k(B)T above the initial state of D(-)MA, the ET occurs unistep from D to A by the superexchange (SX) mechanism, passing |m as a quantum-mechanical virtual state. However, when DeltaG(m) becomes not much higher than k(B)T, the ordinary sequential (OS) ET may manifest itself, where the second ET from |m to the final state of DMA(-) takes place after thermalization of phonons in |m. Recently, much interest has been aroused in how the SX mechanism switches to the OS one as DeltaG(m) is lowered. This subject has often been described conventionally by summation of the rate constant for the SX mechanism and that for the OS one. However, such convention cannot be justified, since these mechanisms are realized in mutually opposite limits concerned with dynamics in mediation of ET by a bridging molecule, hence they cannot both be realized simultaneously in a single system. An observation of such a bridged ET by Paulson, Miller, Gan and Closs (J. Am. Chem. Soc. 2005, 127, 4860) provides a good example of this feature. Describing their observation in a unified framework for the ET, it is shown that the switch occurs at DeltaG(m) congruent with-0.5 eV, which is much lower than 0.3 eV reported by them, where the hot-sequential ET reveals itself, taking place during thermalization of phonons in |m.

Efficient excitation energy transfer in long meso-meso linked Zn(II) porphyrin arrays bearing a 5,15-bisphenylethynylated Zn(II) porphyrin acceptor.

Electronically coupled porphyrin arrays are suitable for artificial light harvesting antenna in light of a large absorption cross-section and fast excitation energy transfer (EET). Along this line, an artificial energy transfer model system has been synthesized, comprising of an energy donating meso-meso linked Zn(II) porphyrin array and an energy accepting 5,15-bisphenylethynylated Zn(II) porphyrin linked via a 1,4-phenylene spacer. This includes an increasing number of porphyrins in the meso-meso linked Zn(II) porphyrin array, 1, 2, 3, 6, 12, and 24 (Z1A, Z2A, Z3A, Z6A, Z12A, and Z24A). The intramolecular singlet-singlet EET processes have been examined by means of the steady-state and time-resolved spectroscopic techniques. The steady-state fluorescence comes only from the acceptor moiety in Z1A-Z12A, indicating nearly the quantitative EET. In Z24A that has a molecular length of ca. 217 A, the fluorescence comes largely from the acceptor moiety but partly from the long donor array, indicating that the intramolecular EET is not quantitative. The transient absorption spectroscopy has provided the EET rates in real time scale: (2.5 ps)(-1) for Z1A, (3.3 ps)(-1) for Z2A, (5.5 ps)(-1) for Z3A, (21 ps)(-1) for Z6A, (63 ps)(-1) for Z12A, and (108 ps)(-1) for Z24A. These results have been well explained by a revised Förster equation (Sumi formula), which takes into account an exciton extending coherently over several porphyrin pigments in the donor array, whose length is not much shorter than the average donor-acceptor distance. Advantages of such strongly coupled porphyrin arrays in light harvesting and transmission are emphasized in terms of fast EET and a large absorption cross-section for incident light.