Late life-threatening arrhythmia in patients with Brugada syndrome: Results from long-term follow-up in a large Japanese cohort.

INTRODUCTION: Most patients with Brugada syndrome (BrS) are first diagnosed in their 40s, with sudden cardiac death (SCD) often occurring in their 50s. Ventricular fibrillation (VF) may occur in some patients with BrS despite having been asymptomatic for a long period. This study aimed to assess the incidence and risk factors for late life-threatening arrhythmias in patients with BrS. METHODS: Patients with BrS (n = 523; mean age, 51 ± 13 years; male, n = 497) were enrolled. The risk of late life-threatening arrhythmia was investigated in 225 patients who had experienced no cardiac events (CEs: SCD or ventricular tachyarrhythmia) for at least 10 years after study enrollment. The incidence of CEs during the follow-up period was examined. RESULTS: During the follow-up of the 523 patients, 59 (11%) experienced CEs. The annual incidences of CEs were 2.87%, 0.77%, and 0.09% from study enrollment to 3, 3-10, and after 10 years, respectively. Among 225 patients who had experienced no CEs for at least 10 years after enrollment, four patients (1.8%) subsequently experienced CEs. Kaplan-Meier analysis revealed significant differences in the incidence of late CEs between patients with and without a history of symptoms (p = .032). The positive and negative predictive values of late CEs for the programmed electrical stimulation (PES) test were 2.9% and 100%, respectively. CONCLUSION: Our results suggest that patients with BrS who are asymptomatic and have no ventricular tachycardia/VF inducibility by PES are at extremely low risk of experiencing late life-threatening arrhythmias.

Risk stratification in asymptomatic patients with Brugada syndrome: Utility of multiple risk factor combination rather than programmed electrical stimulation.

BACKGROUND: The prognostic value of programmed electrical stimulation (PES) in Brugada syndrome (BrS) remains controversial. Asymptomatic BrS patients generally have a better prognosis than those with symptoms. The purpose of this study was to evaluate the value of nonaggressive PES with up to two extra stimuli and predict clinical factors for risk stratification in asymptomatic BrS patients. METHODS: The study enrolled 193 consecutive asymptomatic BrS patients with type 1 ECG (mean age: 50 ± 13 years, 180 males) who underwent PES using a nonaggressive uniform protocol. Cardiac events (CEs: sudden cardiac death or ventricular tachyarrhythmia) during the follow-up period were examined. RESULTS: During a mean follow-up of 101 ± 48 months, seven asymptomatic patients (3.6%) had a CE. The incidence of CEs was not different between patients with and without inducible ventricular tachyarrhythmia by PES (p = .51). The clinical significance of risk factor combinations, including spontaneous type 1 ECG, family history of sudden cardiac death, QRS duration in lead V2 , and presence of J wave, was evaluated. Using the Kaplan-Meier method according to the number of risk factors, the prevalence of CE in patients with three or four risk factors was determined to be significantly higher than in those with one risk factor (p = .02 and p = .004, respectively). CONCLUSIONS: The present study suggests that inducibility of ventricular tachyarrhythmia does not predict future CEs in asymptomatic BrS patients. Combination analysis of the other four clinical risk parameters may be effective for risk assessment.

Long-term prognosis in patients with non-type 1 Brugada electrocardiogram: Results from a large Japanese cohort of idiopathic ventricular fibrillation.

BACKGROUND: Brugada syndrome (BrS) is diagnosed in patients with ST-segment elevation with spontaneous, drug-induced, or fever-induced type 1 morphology. Prognosis in type 2 or 3 Brugada electrocardiogram (Br-ECG) patients remains unknown. The purpose of this study is to evaluate long-term prognosis in non-type 1 Br-ECG patients in a large Japanese cohort of idiopathic ventricular fibrillation (The Japan Idiopathic Ventricular Fibrillation Study [J-IVFS]). METHODS: From 567 patients with Br-ECG in J-IVFS, a total of 28 consecutive non-type 1 patients who underwent programmed electrical stimulation (PES) (median age: 58 years, all male, previous sustained ventricular tachyarrhythmias [VTs] 1, syncope 11, asymptomatic 16) were enrolled. Cardiac events (CEs: sudden cardiac death or sustained VT/ventricular fibrillation) during the follow-up period were examined. RESULTS: During a median follow-up of 136 months, four patients (14%) had CEs. None of patients with PES- have experienced CEs. There was no statistically significant clinical risk factor for the development of CEs. Using the Kaplan-Meier method, the event-free rate significantly decreased in a group with all 3 risk factors (symptom, wide QRS complex in lead V2 , and positive PES) (p = .01). CONCLUSIONS: Our study revealed long-term prognosis in patients with non-type 1 Br-ECG. The combination analysis of these risk factors may be useful for the risk stratification of CEs in non-type 1 Br-ECG patients. The present study suggests that the patients with all these parameters showed high risk for CEs and need to be carefully followed.

The prognostic impact of single extra-stimulus on programmed ventricular stimulation in Brugada patients without previous cardiac arrest: multi-centre study in Japan.

Aims: The prognostic value of programmed electrical stimulation (PES) in Brugada syndrome (BrS) remains controversial. One of the reasons for discrepant results may be due to the selection of stimulation protocol. We evaluated the prognostic value of a positive PES result (PES+) according to the inducible pacing sites and the number of extra-stimuli in BrS patients without previous cardiac arrest (CA). Methods and results: We enrolled 224 consecutive BrS patients without previous CA (mean age 51 ± 14 years, 209 males), who underwent PES with the identical protocol. Clinical outcomes of development of CA were explored in the patients with and without PES+ according to sites and number of extra-stimuli. During a mean follow-up period of 76 months, 12 cardiac events (CE: sudden cardiac death or documented VF) occurred (8 with and 4 without PES+). The incidence of CE was not different in patients with and without PES+, those with PES+ from RVA (n = 72) or RVOT (n = 60), and those with and without PES+ by up to 2 extra-stimuli (n = 58). However, in patients that were PES+ by a single extra-stimulus (n = 8) the incidence of CE was significantly higher than in those without PES+ (8.8 vs. 0.6%/year, P < 0.0001). On univariate analysis, syncope, spontaneous type 1 ECG, and PES+ by a single extra-stimulus were associated with CE. Conclusion: Details of the stimulation protocol may be important for risk assessment in BrS patients without previous CA. A single extra-stimulus may be useful in stratifying risk in patients with spontaneous type 1 ECG and syncope.

Persistent tachycardia within isolated pulmonary veins during atrial fibrillation ablation.

During circumferential pulmonary vein (PV) isolation for ongoing atrial fibrillation (AF), distinguishing passive conduction to the pulmonary vein (PV) from rapid PV arrhythmia in the isolated PV is difficult. Hence, the purpose of this study is to investigate both the feasibility of distinguishing the PV tachycardia after circumferential PV isolation and the electrophysiological characteristics of these tachycardia. Among 178 consecutive patients who underwent circumferential PV isolation during ongoing AF, fibrillatory PV converted to a regular cycle length PV tachycardia independent of the atrial rhythm (=independent PV tachycardia) in 13 PVs among 12 (7%) patients. We classified independent PV tachycardia according to 3 different atrial rhythms: sinus rhythm (type 1, n = 2), atrial tachycardia (type 2, n = 4), and AF (type 3, n = 6). independent PV tachycardia was observed in 3 right PV and 10 left PV (P = 0.0864). There were 10 mappable independent PV tachycardia, in which 8 were focal and 2 were macroreentrant tachycardia. i-PVT can be diagnosed in a small number of patients who underwent circumferential PV isolation during AF. The main mechanism or independent PV tachycardia was focal tachycardia mainly in the left PV.

Validation of Novel Risk Prediction Models in Patients with Brugada Syndrome: A Multicenter Study in Japan.

BACKGROUND: Risk stratification in patients with Brugada syndrome (BrS) is challenging, especially in those at intermediate risk. The Predicting Arrhythmic evenT (PAT) score has recently been demonstrated to be excellent for predicting future arrhythmic events in patients without prior ventricular fibrillation (VF). However, validation studies are lacking. OBJECTIVE: This study aimed to assess the performance of a novel risk stratification model in predicting future VF events in patients with BrS in a Japanese multicenter cohort. METHODS: The PAT score was calculated for 413 patients with BrS (mean age, 50.9±13.6 years; 395 men) from 59 hospitals in Japan, including 314 patients without prior VF. The incidence of developing VF during the follow-up period was investigated. RESULTS: During the 106.8-month follow-up period, 54 patients (13.1%) experienced VF events. Of the 314 patients without prior VF at enrollment, 14 (4.5%) experienced VF events. The incidence of VF events during the follow-up period was significantly higher in patients with PAT scores ≥10 than in those with scores <10 (41/173 [23.7%] vs. 13/240 [5.4%], p<0.0001) in the total cohort. No difference was observed in the incidence of VF events between patients with PAT scores ≥10 and <10 among the 314 patients without prior VF (6/86 [7.0%] vs. 8/228 [3.5%], p=0.22). PAT scores ≥10 predicted future VF events with a sensitivity and specificity of 42.9% and 73.3%, respectively. CONCLUSION: This Japanese multicenter registry demonstrated that the novel risk stratification model could not accurately predict future VF events in patients with BrS, but without prior VF.

New clinical and electrocardiographic classification in patients with idiopathic ventricular fibrillation.

INTRODUCTION: The presence of early repolarization (ER) recently has been considered as a prognostic marker for sudden cardiac death in patients with idiopathic ventricular fibrillation (IVF), but there are certain numbers of IVF patients lacking ER. We aimed to clarify the clinical and electrocardiographic characteristics of the patients with IVF in the presence and absence of ER. METHODS AND RESULTS: We studied 64 consecutive IVF patients from the Japan Idiopathic Ventricular Fibrillation Study (J-IVFS) registry, which subjected with at least one episode of documented VF in the absence of structural heart diseases and excluding Brugada syndrome. We assessed clinical and electrophysiological characteristics in the IVF patients with and without ER. ER was defined as J-point elevation of >0.1 mV in either inferior or lateral leads. Twelve-lead electrocardiogram (ECG) demonstrated 24 (38%) of 64 patients with ER (ER[+] group) and the remaining 40 (62%) patients without ER (ER[-] group ). ER[+] group had a male predominance (92% for males) and ER[-] group revealed nearly equal distribution in both sexes. While no patients in ER[+] group showed intraventricular conduction disturbance (CD) with abnormal axis deviation and/or bundle branch block in ECG, 9 in ER[-] group had signs of CD (ER[-]/CD[+] subgroup). ER[-]/CD[+] subgroup had prolonged P-R interval and QRS duration compared to other patient groups. CONCLUSION: We found 3 distinct ECG patterns in IVF patients. In addition to the presence and absence of ER, there is a subgroup without ER demonstrating intraventricular CD, which represents a distinct clinical entity of IVF.

Efficacy of additional radiofrequency applications for spontaneous dissociated pulmonary vein activity after pulmonary vein isolation in patients with paroxysmal atrial fibrillation.

BACKGROUND: The aim is to evaluate the efficacy of additional radiofrequency ablation (RFCA) for spontaneous dissociated pulmonary vein activity (DPV-spike) after PV isolation (PVI) in patients with paroxysmal atrial fibrillation (AF). METHODS: One hundred fifty-two consecutive patients with paroxysmal AF referred for RFCA were enrolled. When DPV-spike was documented after PVI, we randomly assigned these patients to receive additional RFCA for DPV-spike or only PVI. We divided them into 4 groups: 87 patients without DPV-spike after PVI (No-spike group), 31 without DPV-spike after additional RFCA (Successful group), 8 with remaining DPV-spike after additional RFCA (Unsuccessful group), and 26 with DPV-spike after only PVI (Spike group). AF recurrence was evaluated among the 4 groups. RESULTS: After PVI, DPV-spike was documented in 87 PVs (14%) from 65 patients. During 16 ± 9 months of follow-up, the incidence of the freedom from AF was significantly higher in the No-spike group than that in the Spike group and Unsuccessful group (P < 0.05), and tended to be higher in the Successful group than that in the Spike group and Unsuccessful group (P = 0.08 and 0.11, respectively). In a multivariate analysis, the remaining PV-spike after ablation was an independent predictor of AF recurrence (HR 2.44; CI 1.10-5.43, P < 0.05). No major complications including PV stenosis were observed during the follow-up. CONCLUSIONS: DPV-spike after PVI may be associated with higher electrical activity within the PVs and may be one of the risk factors for AF recurrence. Additional RFCA for DPV-spike was effective to reduce the AF recurrence after PVI.

Prognosis and risk stratification of young adults with Brugada syndrome.

Prognosis and risk factors for patients age 35years or younger with Brugada syndrome (BrS) were prospectively explored in a sub-analysis of the Japan Idiopathic Ventricular Fibrillation Study (J-IVFS) registry. During the period from February 2002 to January 2011, 69 cases (mean age 30±6years, male=66) of the young (at or less than 35years old) BrS were enrolled in J-IVFS and the clinical course was followed for more than 1year. They were divided into 3 groups: documented ventricular fibrillation (VF) or aborted sudden cardiac death (SCD) (VF group, 12 cases), syncope without documentation of VF (Syncope group, 17 cases) and asymptomatic group (Asympt. group, 40 cases). During a mean follow-up period of 43±27months, cardiac events (VF and/or SCD) developed in 8 cases, with 5 of 12 cases in the VF (41.7%), 2 of 17 cases in the Syncope (11.8%) and 1 of 40 cases in the Asympt. group (2.5%). The VF group had a worse prognosis for cardiac events than the Syncope and Asympt. group. Multivariate analysis revealed symptoms as a risk factor for predicting cardiac events.

Effects of exercise training in patients with chronic heart failure and advanced left ventricular systolic dysfunction receiving ß-blockers.

BACKGROUND: It remains unclear whether patients with chronic heart failure (CHF) and advanced left ventricular (LV) dysfunction on ß-blocker therapy benefit from exercise training (ET). METHODS AND RESULTS: We studied 45 CHF patients with advanced LV dysfunction [ejection fraction (LVEF) < 25%] and impaired exercise tolerance [normalized peak oxygen uptake (PVO2) < 70%] receiving a ß-blocker: 33 patients participated in a cardiac rehabilitation program with ET (ET group) and 12 did not (inactive control group). Exercise capacity, LV dimension and plasma B-type natriuretic peptide (BNP) were assessed before and after a 3-month study period. At baseline, both groups had markedly reduced LVEF (ET group 18 ± 4% vs. Control group 18 ± 5%, NS) and impaired exercise capacity (normalized PVO2 51 ± 10% vs. 55 ± 9%, NS). Although one patient in the ET group withdrew from the program due to worsening CHF, no serious cardiac events occurred during the ET sessions. After 3 months, the ET group (n = 24) had significantly improved PVO2 by 16 ± 15% (1,005 ± 295 to 1,167 ± 397ml/min, P < 0.001), while the PVO2 of the control group was unchanged. LV end-diastolic dimension decreased in both groups to a similar extent, but plasma BNP was significantly decreased only in the ET group (432 to 214 pg/ml, P < 0.05). CONCLUSIONS: The data indicate that in CHF patients with advanced LV dysfunction on ß-blocker therapy, ET successfully improves exercise capacity and BNP without adversely affecting LV remodeling or causing serious cardiac complications.

Efficacy of out-patient cardiac rehabilitation in low prognostic risk patients after acute myocardial infarction in primary intervention era.

BACKGROUND: The efficacy of out-patient cardiac rehabilitation (OPCR) in patients with a low prognostic risk after acute myocardial infarction (AMI) is unclear in the recent primary intervention era. METHODS AND RESULTS: A total of 637 AMI patients who participated in in-hospital cardiac rehabilitation were divided into 2 groups; low prognostic risk group (n=219; age <65 years, successful reperfusion, Killip class I, peak serum creatine kinase <6,000U/L, and left ventricular ejection fraction ≥40%) and non-low prognostic risk group (n=418). The prevalence of coronary risk factors (CRF) was compared between the 2 groups. Then, in the low-risk group, the efficacy of OPCR was compared between active OPCR participants (n=52; ≥20 sessions/3 months) and non-active participants (n=60; <6 sessions/3 months). Compared with the non-low prognostic risk group, the low prognostic risk group had a significantly higher prevalence of current smokers (72% vs. 49%, P<0.05) and patients with multiple CRF (3 or more; 49% vs. 39%, P<0.05). Among the low- risk group, active OPCR participants showed a significantly greater improvement in exercise capacity (peak VO(2), P<0.05) and maintained a better CRF profile (total cholesterol, triglyceride and blood pressure, all P<0.05) than inactive participants at 3 months. CONCLUSIONS: Low prognostic risk AMI patients have a higher prevalence of multiple CRF than non-low risk patients. Even in this low risk group, active participation in OPCR is associated with improved exercise capacity and better CRF profile.

Neurally mediated syncope as a cause of syncope in patients with Brugada electrocardiogram.

INTRODUCTION: Patients with type 1 Brugada electrocardiogram (ECG) and an episode of syncope are diagnosed as symptomatic Brugada syndrome; however, all episodes of syncope may not be due to ventricular tachyarrhythmia. METHODS AND RESULTS: Forty-six patients with type 1 Brugada ECG (all males, 51 +/- 13 years, 29 spontaneous, 17 Ic-drug induced), 20 healthy control subjects (all males, 35 +/- 11 years), and 15 patients with suspected neurally mediated syncope (NMS; 9 males, 54 +/- 22 years) underwent the head-up tilt (HUT) test. During the HUT test, 12-lead ECGs were recorded in all patients, and the heart rate variability was investigated in some patients. Sixteen (35%) of 46 patients with Brugada ECG, 2 (10%) of 20 control subjects, and 10 (67%) of 15 patients with suspected NMS showed positive responses to the HUT test. Although no significant differences were observed in HUT-positive rate among Brugada patients with documented VT (7/14; 50%), syncope (5/19; 26%) and asymptomatic patients (4/13; 31%), the HUT-positive rate was significantly higher in patients with documented VT (50%) and those with VT or no symptoms (11/27, 41%) compared to that in control subjects (10%) (P < 0.05). Augmentation of ST-segment amplitude (> or =0.05 mV) in leads V1-V3 was observed in 11 (69%) of 16 HUT-positive patients with Brugada ECG during vasovagal responses, and was associated with augmentation of parasympathetic tone following sympathetic withdrawal. CONCLUSION: Thirty-five percent of patients with Brugada ECG showed vasovagal responses during the HUT test, suggesting that some Brugada patients have impaired balance of autonomic nervous system, which may relate to their syncopal episodes.

The positional relationship between the coronary sinus musculature and the atrioventricular septal junction.

AIMS: The atrioventricular (AV) septal junction includes the coronary sinus (CS) and the compact part of the AV node and its posterior extensions. It has been recognized as the target site for ablation therapy of the AV nodal reentrant tachycardia and its variant forms. Despite the clinical significance of this region, the arrangement of the musculature in the AV septal junction, including the CS, has not fully been elucidated. We tried to explore the histological muscular diversity within the AV septal junction. METHODS AND RESULTS: Sixteen autopsied human hearts (seven women), mean age 59.8 years, without structural anomalies, were studied. We removed the whole AV septum, including the CS opening after the macroscopic measurements, and prepared serial sections parallel to mitral and tricuspid annuli (short-axis style) to elucidate the positional relationships between the compact AV node and the CS musculature. Out of 16 hearts, the CS musculature extended deeply into the AV septal junction in eight hearts. In the other eight hearts, the CS musculature was located above the AV septal junction. In the former group, we found that the offset of both annuli was wide (mean 3.8 +/- 1.4 vs. 2.4 +/- 1.1 mm), the distance between CS opening and membranous septum was long (mean 14.8 +/- 1.6 vs. 12.3 +/- 2.2 mm), and the CS opening level was lower and closer to the His bundle level (mean 2.8 +/- 1.9 vs. 5.8 +/- 2.9 mm) (P < 0.05). CONCLUSION: The deep extension of CS musculature into the AV septal junction seems to increase the tissue non-uniformity in this area.

Relationship between oral amiodarone and inappropriate therapy from an implantable cardioverter defibrillator.

BACKGROUND: This study evaluated the efficacy of amiodarone for avoiding inappropriate therapies by implantable cardioverter defibrillators (ICDs). METHODS AND RESULTS: A total of 232 patients with structural heart disease (58+/-13 years; 78% males) who underwent an initial ICD implantation were retrospectively investigated to compare baseline characteristics and event rates of inappropriate ICD therapy delivery between patients with oral amiodarone therapy (amiodarone group, n=116) and those without (non-amiodarone group, n=116). During a mean follow-up of 29+/-21 months, inappropriate therapies occurred less frequently in the amiodarone group than in the non-amiodarone group (12% vs 27%, P=0.0068). As a cause of inappropriate ICD therapy, only atrial fibrillation (AF) significantly differed between the groups (3% vs 12%, P=0.01). The results of multivariate logistic regression analysis showed that amiodarone therapy (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.19-0.77, P=0.0073) and no history of spontaneous AF (OR 0.27, 95%CI 0.13-0.57, P=0.0007) were independent predictors of a lower risk of inappropriate ICD therapy. CONCLUSIONS: In the present group of ICD patients with structural heart disease, inappropriate therapy delivery occurred predominantly in those with spontaneous AF and/or without amiodarone.

Predictors of electrical storm in patients with idiopathic dilated cardiomyopathy--how to stratify the risk of electrical storm.

BACKGROUND: Electrical storm (ES) is a serious problem in patients with an implantable cardioverter defibrillator (ICD). However, insufficient reports have indicated the predictors of ES in ICD patients with idiopathic dilated cardiomyopathy (DCM). The purpose of this study was to clarify the predictors of ES for risk stratification in DCM patients with an ICD. METHODS AND RESULTS: Of 446 ICD patients, 53 DCM patients were included in this study. During a mean follow-up of 55+/-36 months, ES (> or =3 times appropriate ICD therapy within 24 h) occurred in 18/53 (34%) patients. According to multivariate Cox proportional hazard regression analysis, a duration of the terminal low amplitude signals of <40 microV (LAS40) (HR 1.4/10 ms increase, 95% confidence interval (CI) 1.1-2.1; P=0.0049) or root mean square voltage of the last 40 ms of the QRS complex (RMS40) (HR 0.88/1 microV, 95%CI 0.77-0.96; P=0.001) on the signal averaged electrocardiogram, and a history of atrial fibrillation (AF) before ICD implantation (HR 2.3, 95%CI 1.2-5.0; P=0.013) were independently associated with an increased risk of ES. CONCLUSIONS: Our data indicated that a longer LAS40, lower RMS40 and history of AF before ICD implantation could strongly predict ES, and the combination of those parameters could effectively stratify the risk of ES in DCM patients.

Clinical effect of implantable cardioverter defibrillator replacements: when should you resume driving after an implantable cardioverter defibrillator replacement?

BACKGROUND: The intervals of the driving restrictions after an implantable cardioverter defibrillator (ICD) replacement vary across the different countries around the world. However, little is known regarding the appropriate duration for driving restrictions after an ICD replacement. The aim of this study was to investigate the clinical effect of ICD replacements and to elucidate when to resume driving an automobile after an ICD replacement. METHODS AND RESULTS: The study reviewed 139 consecutive patients with an ICD replacement in order to evaluate the incidence of ICD therapies before and after ICD replacements, and to assess the time-dependence of the ICD therapies after the ICD replacement. There was no significant difference in the incidence of ICD therapies delivered during durations of 3 months and 6 months before and after the ICD replacement (P=0.28, and 1.0, respectively). ICD therapies after the replacements were observed in 8.6% of the patients who were legally eligible to drive according to the Japanese guidelines at 1 year, and that was associated with a relatively low annual risk of death or injury to others. CONCLUSIONS: Implantable cardioverter defibrillator replacements did not affect the future ICD therapies under similar algorithms. The appropriate interval for driving restrictions after an ICD replacement is recommended to be a week or so, with a system integrity check performed before resumption of driving.

Radiofrequency catheter ablation of parasystole originating from the inferior vena cava.

A 76-year-old man with a history of atrial septal defect repair underwent radiofrequency (RF) ablation of typical atrial flutter. During electrophysiological study, incessant sharp potentials were recorded, originating from the ostium of the inferior vena cava (IVC), and dissociated from atrial activity. During sinus rhythm, these potentials propagated to the atria and caused premature complexes when falling beyond the atrial refractory period. Electro-anatomical mapping revealed the presence of the earliest potential in the postero-lateral ostium of the IVC, propagating to the septal region. After RF isolation of the IVC, the patient has remained arrhythmia-free over a 5-year follow-up.

Mitral isthmus pathology of re-entrant ventricular tachycardia in a patient with idiopathic dilated cardiomyopathy.

A 68-year-old woman with idiopathic dilated cardiomyopathy suffered from drug-resistant monomorphic ventricular tachycardia (VT). Electrophysiological study revealed a re-entrant VT circuit located just beneath the inferior mitral valve annulus. The VT was considered to be related to the mitral valve isthmus and was abolished by radiofrequency ablation. The patient died 2 years after the ablation due to worsening of heart failure and an autopsy was performed. Pathological examination revealed ablation scar tissue on the localized myocardial bundle running parallel to the mitral valve annulus. Therefore, this bundle appeared to comprise the slow conduction area of the re-entrant VT in this case.

Extremely late pacemaker-infective endocarditis due to Stenotrophomonas maltophilia.

This case report describes a patient with an intravascular infection of a pacemaker system with Stenotrophomonas maltophilia, which occurred 17 years after the implantation. The patient was treated with appropriate antibiotics and debridement of the infectious tissue in the pocket, and the entire pacemaker system was removed by open heart surgery. She was discharged from our center after a 6-week course of antibiotics and implantation of a new pacemaker.