Impact of Sleep Apnea on Nocturnal Parasympathetic Activity in Atrial Fibrillation Patients After Catheter Ablation　- Implications for Heart Rate Variability Analysis.

BACKGROUND: The impact of sleep apnea (SA) on heart rate variability (HRV) in atrial fibrillation (AF) patients has not been investigated. METHODS AND RESULTS: Of 94 patients who underwent AF ablation between January 2021 and September 2022, 76 patients who had a nocturnal Holter electrocardiography and polysomnography conducted simultaneously were included in the analysis. A 15-min duration of HRV, as determined by an electrocardiogram during apnea and non-apnea time, were compared between patients with and without AF recurrence at 12 months' postoperatively. Patients had a mean age of 63.4±11.6 years, 14 were female, and 20 had AF recurrence at 12 months' follow-up. The root mean square of the difference between consecutive normal-to-normal intervals (RMSSD, ms) an indicator of a parasympathetic nervous system, was more highly increased in patients with AF recurrence than those without, during both apnea and non-apnea time (apnea time: 16.7±4.5 vs. 13.5±3.3, P=0.03; non-apnea time: 20.9±9.5 vs. 15.5±5.9, P<0.01). However, RMSSD during an apneic state was decreased more than that in a non-apneic state in both groups of patients with and without AF recurrence (AF recurrence group: 16.7±4.5 vs. 20.9±9.5, P<0.01; non-AF recurrence group; 13.5±3.3 vs. 15.5±5.9, P=0.03). Consequently, the effect of AF recurrence on parasympathetic activity was offset by SA. Similar trends were observed for other parasympathetic activity indices; high frequency (HF), logarithm of HF (lnHF) and the percentage of normal-to-normal intervals >50 ms (pNN50). CONCLUSIONS: Without considering the influence of SA, the results of nocturnal HRV analysis might be misinterpreted. Caution should be taken when using nocturnal HRV as a predictor of AF recurrence.

Tako-Tsubo Syndrome Following Pulmonary Vein Isolation for Atrial Fibrillation in a Patient with Primary Aldosteronism.

Tako-tsubo syndrome (TTS) can be triggered by emotional or physical stress and is characterized by transient left ventricular dysfunction with apical ballooning. Some neurologic disorders and pheochromocytoma serve as triggers for TTS, however, its association with primary aldosteronism (PA) is not well known. Pulmonary vein isolation (PVI) with catheter ablation for atrial fibrillation (AF) has been performed worldwide, and TTS following PVI has been reported as a rare complication. Sympathetic stimulation can play an important role in TTS development, however, its mechanism and risk factors are not yet understood.We describe a 72-year-old woman with PA who developed TTS after PVI with radiofrequency catheter ablation (RFCA) for symptomatic paroxysmal AF. Complete isolation of the pulmonary vein was carried out without any complications, however, she complained of epigastric discomfort 7 hours after the procedure. An electrocardiogram showed recurrent AF with a new negative-T wave and prolonged QT interval. Transthoracic echocardiography revealed apical ballooning and basal hypercontraction, characteristic of TTS, and coronary angiography showed no significant stenosis. She was diagnosed with TTS following RFCA for AF and managed well with conservative therapy.The present case suggests that TTS should be recognized as a complication associated with AF ablation. Moreover, PA may be involved in TTS development by increasing sympathetic activity. Further studies on the mechanism and characteristics of TTS are required.

SEAT CHOICE AND DISTANCE JUDGMENT IN PUBLIC SPACES (1).

This research assessed whether public space users will adopt a least-effort approach and choose a less suitable seat nearby or seek the most suitable seat, even if it is farther away from them when the decision is made. How distance assessment affects seat choice was investigated through an observational survey, which allowed the identification of behavioral patterns. Those behavioral patterns were then tested in a paired comparison experiment with 40 participants. The results showed that the effect of distance on seat choice is related to the difference in distance between the options and that a sufficient difference can cause trade-offs between distance and seat properties. The necessary difference in distance is conditioned by the activity and the seat properties.

Pitfalls and tips for lumenless lead extraction inserted deep within the ventricular septum.

Key Clinical Message: This case highlights the pitfalls and provides tips for the extraction of deeply implanted lumenless leads, and encourages careful lead selection in the current era of widespread left bundle branch area pacing. Abstract: The extraction of cardiovascular implantable electronic device leads is sometimes complicated. We describe a case with difficult but successful extraction of SelectSecure, a lumenless permanent pacemaker lead, implanted deep in the ventricular septum, highlighting its pitfalls and tips in the current era of left bundle branch area pacing.

Prediction model for the new onset of atrial fibrillation combining features of 24-hour Holter electrocardiogram with 12-lead electrocardiogram.

Background: Several factors that predict new-onset atrial fibrillation (AF) have been investigated using the 24-hour Holter electrocardiogram (ECG) and 12-lead ECG; however, these have been based on each test independently. The aim of this study was to combine findings from the two tests to create a comprehensive, easy-to-use score and to examine its validity. Methods and Results: A total of 502 patients underwent 24-hour Holter ECG and 12-lead ECG were followed up for 6.2 ± 3.5 years, and 66 patients developed new-onset AF. Multivariate Cox regression analyses revealed that total number of supraventricular extrasystoles (SVEs) ≥ 100 beats/day and SVE's longest run ≥ 3 beats on 24-hour Holter ECG and PR interval ≥ 185 ms, amplitude ratio of P wave (aVR/V1) < 1.0 and amplitude of RV5 + SV1 ≥ 2.2 mV on 12-lead ECG were significant independent predictors for developing AF (all p < 0.01). Using these cut-off points, the PAAFS (acronym for risk factors) score was constructed by adding one point for each parameter if the patient met each of the criteria. The area under the curve (AUC) of the PAAFS score was 0.80, compared to the AUCs of 24-hour Holter ECG-only factors (0.73) and 12-lead ECG-only factors (0.72), indicating an improvement in score. The annual incidence of AF for each PAAFS score were 0.0%, 0.2%, 0.7%, 1.9%, 5.6%, and 11.1%/year for scores 0 to 5, respectively. Conclusion: The PAAFS score, which combines findings from 24-hour Holter ECG and 12-lead ECG, was superior to 24-hour Holter ECG and 12-lead ECG alone in predictive accuracy for new-onset AF.