Acute procedural safety of the latest radiofrequency ablation catheters in atrial fibrillation ablation: Data from a large prospective ablation registry.

BACKGROUND: Safety data of the latest radiofrequency (RF) technologies during atrial fibrillation (AF) ablation in real-world clinical practice are limited. OBJECTIVES: We sought to evaluate the acute procedural safety of the four latest ablation catheters commonly used for AF ablation. METHODS: A total of 3957 AF ablation procedures performed between January 2022 and December 2023 at 20 centers with either the THERMOCOOL SMARTTOUCH SF (STSF), TactiCath (TC), QDOT Micro (QDM), or TactiFlex (TF) were retrospectively analyzed. RESULTS: In total, QDM, STSF, TF, and TC were used in 343 (8.7%), 1793 (45.3%), 1121 (28.4%), and 700(17.7%) procedures. Among 2406 index procedures, electrical pulmonary vein isolations were successfully achieved in 99.5%. Despite similar total procedure times in the four groups, the total fluoroscopic time was significantly shorter for QDM/STSF with CARTO than TF/TC with EnSite (18.7 ± 14 vs. 27.6 ± 20.6 min, p < .001) and longest in the TF group. The incidence of cardiac tamponade was 0.7% (0.5% and 0.9% during index and redo procedures, 0.8% and 0.3% for paroxysmal and non-paroxysmal AF) and was significantly lower for QDM/STSF than TF/TC (0.2% vs. 1.1%, p = .008) and highest in the TF group. The incidence of cardiac tamponade was higher for TF than TC and STSF than QDM. In the multivariate analysis, TF/TC with EnSite was a significant independent predictor of cardiac tamponade during both the index (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.5, p = .02) and all procedures (OR = 3.0, 95% CI = 1.3-7.2, p = .01). CONCLUSIONS: The incidence of cardiac tamponade and the fluoroscopic time during AF ablation significantly differed among the latest RF catheters and mapping systems in real-world clinical practice.

Predictors of pulmonary vein non-reconnection in the second procedure after ablation index-guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome.

INTRODUCTION: Although first-pass isolation (FPI) of the pulmonary vein (PV) has been suggested as a marker for PV isolation (PVI) durability, it has not been confirmed. Non-PV atrial fibrillation (AF) triggers were the main target in patients without PV reconnection in the second ablation procedure, but the outcome was unclear. We aimed to validate FPI as a marker of PVI durability and evaluate the outcome after the second procedure in patients without PV reconnection by comparing it to those with reconnection. METHODS: Among the 2087 patients undergoing the first ablation index-guided radiofrequency AF ablation, 309 with atrial tachyarrhythmias (ATs) recurrence and undergoing the second procedure were studied. Clinical characteristics and outcomes were compared between the patients without PV reconnection (PV non-reconnection group, n = 142) and with reconnection (PV reconnection group, n = 167). RESULTS: FPI in both PV sides in the first ablation procedure was significantly more frequent in the PV non-reconnection group (77.5%) than in the PV reconnection group (45.5%) (p < .001). Multivariate logistic regression analysis revealed that FPI (odds ratio, 3.71 [95% confidence interval, 2.23-6.19], p < .001) was the only predictor of PV non-reconnection. Radiofrequency applications for non-PV AF triggers were more frequently performed in the PV non-reconnection group (40.8% vs. 24.6%, respectively, p < .001). Kaplan-Meier analysis revealed that AT recurrence-free rate was significantly lower in the PV non-reconnection group (1-year recurrence-free rate, 62.7% vs. 75.4%, respectively; p = .01 by log-rank test). CONCLUSION: FPI was the only independent predictor of PV non-reconnection. Despite aggressive ablation for non-PV triggers, AT recurrence was more frequent in patients with PV non-reconnection.

Peri-procedural anticoagulation in patients with end-stage kidney disease undergoing atrial fibrillation ablation: results from the multicentre end-stage kidney disease-atrial fibrillation ablation registry.

AIMS: The optimal anticoagulation regimen in patients with end-stage kidney disease (ESKD) undergoing atrial fibrillation (AF) catheter ablation is unknown. We sought to describe the real-world practice of peri-procedural anticoagulation management in patients with ESKD undergoing AF ablation. METHODS AND RESULTS: Patients with ESKD on haemodialysis undergoing catheter ablation for AF in 12 referral centres in Japan were included. The international normalized ratio (INR) before and 1 and 3 months after ablation was collected. Peri-procedural major haemorrhagic events as defined by the International Society on Thrombosis and Haemostasis, as well as thromboembolic events, were adjudicated. A total of 347 procedures in 307 patients (67 ±9 years, 40% female) were included. Overall, INR values were grossly subtherapeutic [1.58 (interquartile range: 1.20-2.00) before ablation, 1.54 (1.22-2.02) at 1 month, and 1.22 (1.01-1.71) at 3 months]. Thirty-five patients (10%) suffered major complications, the majority of which was major bleeding (19 patients; 5.4%), including 11 cardiac tamponade (3.2%). There were two peri-procedural deaths (0.6%), both related to bleeding events. A pre-procedural INR value of 2.0 or higher was the only independent predictor of major bleeding [odds ratio, 3.3 (1.2-8.7), P = 0.018]. No cerebral or systemic thromboembolism occurred. CONCLUSION: Despite most patients with ESKD undergoing AF ablation showing undertreatment with warfarin, major bleeding events are common while thromboembolic events are rare.

The relationship between scapular position and glenohumeral rotational range of motion in high school baseball players.

BACKGROUND: Past research indicated that scapular malposition is related to the glenohumeral internal rotation deficit (GIRD). However, there is no research examining the effect of throwing-related pain on this relationship. This study investigated the relationship between scapular position and range of motion (ROM) and compared the difference in this relationship between with and without throwing-related pain. METHODS: Forty male baseball players in high school were recruited for this study. The existence and degree of throwing-related pain were obtained from a questionnaire. Participants were divided into 2 groups according to the presence or absence of the pain. Glenohumeral internal and external rotation ROM (abduction internal rotation angle and abduction external rotation angle [ABER], respectively) were measured using a digital inclinometer. The pectoralis minor muscle length was measured using a vernier caliper and scapula index, which indicated the scapular position, measured using a measuring tape. All these measurements were taken on both dominant and nondominant sides. The GIRD and total motion arc (TMA) deficit were calculated from the ROM measurements. Groups were compared using a mixed-model analysis of variance. RESULTS: There was a significant interaction between group and ABER dominance. Other variables were not seen as the interaction effect. There was a significant positive correlation between the scapula index and TMA (r = 0.47, P = .02) and a negative correlation between the scapula index and GIRD (r = -0.65, P < .01) in the dominant side of the pain group. In addition, in the nondominant side of the pain group, the scapula index and ABER were significantly correlated (r = 0.43, P = .04). CONCLUSIONS: The results of this study indicate that the scapular position is associated with the glenohumeral ROM in high school baseball players. In addition, this study demonstrated that the scapular internally rotated position was correlated with the GIRD and TMA deficit in high school baseball players who had throwing-related pain. On the other hand, the scapular externally rotated position was correlated with increased ABER, mainly in the pain-free baseball players or on the nondominant side. These results indicated that the scapular position might affect the glenohumeral rotational ROM in high school baseball players.

Multivariate analysis of the surface water in tropical river-estuary-sea continuums with changing land use.

The monitoring and assessment of surface water properties has been mainly conducted for freshwater rivers using multivariate analyses. The present study aimed to evaluate the effectiveness of introducing the absorption spectrum of water in order to develop a better monitoring and assessment technique for the surface waters of a river-estuary-sea continuum. Fourteen variables were measured at 17 different sites along three rivers, including estuaries and coastal sea, in Brunei Darussalam, Borneo, from August 2017 to December 2020. Among the 17 sites, freshwater streams surrounded by primary forests and coastal seawaters had the lowest ranges of the absorption coefficient at 350 nm, suspended solids, and nutrients, but had the highest range of dissolved oxygen concentration. The other sites were more or less affected by natural leaching of chromophoric dissolved organic matter (CDOM) from forests, soil runoff from agricultural lands, and wastewater discharge from urban and industrial activities. The principal component analysis (PCA) showed that four principal components were significant and explained 91% of the total variance in the data set. Four most explanatory factors were also extracted using the factor analysis (FA). In addition to the absorption spectrum, only seven basic water variables (salinity, pH, dissolved oxygen, total suspended solid, particulate organic matter, particulate inorganic matter, phosphate) were found to be necessary to assess the spatial variations in water properties at the present river-estuary-sea continuum. We conclude that it is important to include absorption spectrum data in water monitoring programs for more efficient and comprehensive assessment at land-sea interfaces.

High-power application is associated with shorter procedure time and higher rate of first-pass pulmonary vein isolation in ablation index-guided atrial fibrillation ablation.

BACKGROUNDS: Ablation index (AI) is useful to complete circumferential pulmonary vein isolation (CPVI) for atrial fibrillation (AF), but the role of radiofrequency power in AI-guided CPVI remains to be elucidated. METHODS: We investigated 60 patients with AF undergoing AI-guided CPVI (mean age, 66 ± 9 years; nonparoxysmal AF in 16). The first 40 patients were randomly assigned to low-power (LP; n = 20) and medium-power (MP; n = 20) groups and the following 20 patients to high-power (HP). In LP, radiofrequency (RF) application was done at 30 W at the anterior and 20 W at the posterior left atrial (LA) wall, while in MP, it was at 40 W at the anterior and 30 W at the posterior LA wall. In HP, 50 W was applied at the anterior, 40 W at posterior LA wall and 30 W on the esophagus. At each ablation point, target AI was 400 at the anterior, 360 at the posterior LA wall, and 260 on the esophagus. RESULTS: The time to complete both-side CPVI was shortest in HP (median, 40 minutes, interquartile range [IQR], 28-63) followed by MP (58 [49-83] minutes, P = .008 vs HP) and LP (84 [72-93] minutes, P = .002 vs MP). Higher RF power application significantly increased first-pass isolation rate (55% in LP, 80% in MP and 85% in HP, P = .002) and decreased LA-PV reconnection rate (10% in LP, 8% in MP, and 0% in HP, P = .03). CONCLUSION: In AI-guided PVI, the HP RF application can shorten the time to complete PVI with a high rate of first-pass isolation and a low rate of LA-PV reconnection.

Temporally stable frequency mapping using continuous wavelet transform analysis in patients with persistent atrial fibrillation.

INTRODUCTION: Dominant frequency (DF) derived from fast Fourier transform (FFT) analysis has failed to guide atrial fibrillation (AF) ablation since it cannot guarantee temporal stability. Continuous wavelet transform (CWT) analysis is another frequency analysis that can show the temporal stability of a frequency. METHODS AND RESULTS: Forty-four consecutive patients with persistent AF (PeAF) underwent pulmonary vein (PV) isolation (PVI) as the first-time catheter ablation. The PVs and left atrium were mapped and electrograms (EGMs) were recorded for 30 seconds at each site. Pseudo-frequency (PF) and coefficient of variation (CV) were calculated by CWT analysis. A PF with CV ≤ 10 was defined as a temporally stable PF (sPF). DF was also calculated by traditional FFT analysis from the first 5 seconds of the recorded EGMs. The highest sPF was shown inside the PVs in 20 patients (PV group), and at the non-PV sites in 24 patients (non-PV group). During the follow-up period of 15.3 ± 4.4 months, the ablation success rate in the PV group was significantly higher than that in the non-PV group (90% vs. 62%, P = 0.023). The location of the highest DF did not have a significant effect on ablation success rate between inside the PVs and at the non-PV sites. CONCLUSION: PVI results for PeAF were significantly worse for patients with highest sPF at the non-PV sites compared to patients with highest sPF sites inside the PVs. CWT analysis during AF could be used to verify whether PVI alone is sufficient for the first-time catheter ablation in patients with PeAF.

Simple and novel technique to confirm complete mitral isthmus block.

BACKGROUND: Differential pacing technique to confirm mitral isthmus (MI) block is sometimes challenging due to destroyed tissues after extensive ablation. The purpose of this study is to set an endpoint of MI ablation using conduction time around the mitral annulus (MA). METHODS: Forty-five consecutive patients with persistent atrial fibrillation who received MI linear ablation were included. The geometry and activation times of the left atrium around the MA were collected using a multipolar catheter before ablation. During coronary sinus (CS) pacing, the time between the stimulus and the wave-front collision at the opposite side of the MA (defined as T/2) was calculated, and the doubled value was defined as the estimated perimitral conduction time (E-PMCT). The endpoint for complete MI block was when the stimulus (at distal CS) minus the maximal delayed potential (St-MDP) on the MI interval reached the E-PMCT. RESULTS: St-MDP reached E-PMCT during MI ablation in 44/45 patients. Among these 44 patients, differential pacing revealed bidirectional block in 39/44 (88.6%), whereas in 5/44 (11.4%), the differential pacing was not possible because of the loss of capture of local potentials due to extensive applications around the linear line. In one patient, the St-MDP did not reach E-PMCT (E-PMCT: 148 ms, St-MDP :130 ms) and differential pacing revealed no MI block. E-PMCT values (median 176 ms) correlated strongly with St-MDP (median 185 ms, P < 0.0001, R = 0.98). CONCLUSIONS: Although E-PMCT differs between individuals, the value is significantly correlated with the St-MDP. This technique may be useful in providing an individual endpoint of MI ablation as an alternative to differential pacing.

Novel Ablation Strategy for Isolating the Superior Vena Cava Using Ultra High-Resolution Mapping.

BACKGROUND: The aim of this study was to categorize the conduction patterns between the right atrium (RA) and the superior vena cava (SVC), and to determine the ideal procedure for SVC isolation using a novel high-resolution mapping system.Methods and Results:RA-SVC conduction was evaluated using the RHYTHMIA system in 113 patients (age 62.8±11.5 years, paroxysmal: 67) with atrial fibrillation (AF) after pulmonary vein (PV) isolation. In 56 patients, a line of conduction block was found to run obliquely just above the sinus node (Block group). The remaining 57 patients did not have block (Non-block group). Non-PV foci were spontaneous or provoked with isoproterenol after electrical cardioversion of pacing-induced AF. In 43 patients with SVC foci (Block group: 22, Non-Block group: 21), SVC was isolated by radiofrequency applications delivered along the line connecting the open ends of the block line (Block group) or by conventional methods (Non-block group). The Block group required fewer radiofrequency deliveries for SVC isolation than the Non-Block group (4.2±0.9 vs. 10.2±2.8 times; P<0.0001). The isolated SVC area was larger in the Block group (15.7±3.7 vs. 10.5±3.1 cm2; P<0.0001). CONCLUSIONS: We found that approximately half of patients with AF had a diagonal line of block at the RA-SVC junction that could be utilized to isolate the SVC with fewer radiofrequency deliveries.

Safety and Efficacy of Subcutaneous Cardioverter Defibrillator in Patients at High Risk of Sudden Cardiac Death　- Primary Japanese Experience.

BACKGROUND: The entirely subcutaneous implantable cardioverter defibrillator (S-ICD) was introduced as a new alternative to conventional transvenous ICD (TV-ICD) in Japan in February 2016, but its safety and efficacy are unclear.Methods and Results:A total of 60 patients (48 men, median age, 60 years; IQR, 44-67 years; primary prevention, n=24) underwent S-ICD implantation between February 2016 and August 2017. The device pocket was formed in the intermuscular space between the serratus anterior muscle and the latissimus dorsi muscle, and the parasternal S-ICD lead was placed according to pre-implant screening. Defibrillation test was performed in 56 patients (93%). Ventricular fibrillation (VF) was induced in 55 patients and terminated by a single 65-J shock in all patients. The median time to shock therapy was 13.4 s (IQR, 12.1-14.9 s) and the median post-shock impedance of the S-ICD lead was 64 Ω (IQR, 58-77 Ω). There were no operation-related complications or subsequent infectious complications. During follow-up (median, 275 days; IQR, 107-421 days), 1 patient (1.7%) had appropriate shock for VF with successful termination, whereas 5 patients (8.3%) had inappropriate shock due to oversensing of myopotential (n=3) or T-wave (n=1), and detection of supraventricular tachycardia (n=1). CONCLUSIONS: S-ICD is a safe and effective alternative to conventional TV-ICD. The long-term safety and efficacy of the S-ICD need further investigation.

The proportion of asymptomatic recurrence after catheter ablation of atrial fibrillation in patients with a pacemaker for sick sinus syndrome.

BACKGROUND: Catheter ablation (CA) of paroxysmal atrial fibrillation (PAF) is an effective treatment. However, the frequency of asymptomatic AF recurrence after CA in patients with PAF and sick sinus syndrome (SSS) is not clear. The aim of this study was to elucidate the real AF recurrence after CA in patients with PAF and a pacemaker for SSS. METHODS AND RESULTS: Fifty-one consecutive patients (mean age 66.6 ± 7.0 years, male 34) with PAF and SSS and pacemakers underwent CA. All patients were followed at 1, 3, 6, 9, and 12 months after the CA using a 12-lead ECG, Holter-ECG, and 1-month event recorder as a conventional follow-up. In addition, the pacemakers were interrogated every 12 months. During a 5-year follow-up after the final CA procedure, AF recurrences were observed in 7 patients (13.7%) with a conventional follow-up, including 1 (2.0%) asymptomatic patient. Pacemaker-interrogation revealed another 10 patients (19.6%) with asymptomatic AF recurrences. Ultimately, the conventional follow-up plus pacemaker-interrogation provided a higher incidence of AF recurrences (P = 0.009). Multiple CA procedures contributed to a significant increase in the AF-free survival rate at 5 years: 58.6% after a single CA and 86.0% after multiple CA procedures with a conventional follow-up, but which decreased to 40.6% and 60.9% with a conventional follow-up plus a pacemaker interrogation, respectively. CONCLUSIONS: One-third of PAF patients with SSS and pacemakers recurred after multiple CA sessions. However, 65% of them were asymptomatic and difficult to be identified with conventional follow-up. Pacemaker interrogation significantly increased the detection rate of AF-recurrence.

Apixaban versus Warfarin for the Prevention of Periprocedural Cerebral Thromboembolism in Atrial Fibrillation Ablation: Multicenter Prospective Randomized Study.

INTRODUCTION: Stroke can be a life-threatening complication of atrial fibrillation (AF) catheter ablation. Uninterrupted warfarin treatment contributes to minimizing the risk of stroke complications. METHODS AND RESULTS: This was a prospective, open-label, randomized, multicenter study assessing the safety and efficacy of apixaban for the prevention of cerebral thromboembolism complicating AF catheter ablation. Two hundred patients with drug-resistant AF were equally assigned to take either apixaban (5 mg or 2.5 mg twice daily) or warfarin (target international normalized ratio, 2-3) for at least 1 month before AF ablation. Neither drug regimen was interrupted throughout the operative period. Diffusion-weighted magnetic resonance imaging was performed for all patients to detect silent cerebral infarction (SCI) after the ablation. Primary outcomes were defined as the occurrence of stroke, transient ischemic attack, SCI, or major bleeding that required intervention. The secondary outcome was minor bleeding. The groups did not statistically differ in patients' backgrounds or procedural parameters. During AF ablation, the apixaban group required administration of more heparin to maintain an activated clotting time > 300 seconds than the warfarin group (apixaban, 14,000 ± 4,000 units; warfarin, 9,000 ± 3,000 units). Three primary outcome events occurred in each group (apixaban, 2 SCI and 1 major bleed; warfarin, 3 SCI, P = 1.00), and 3 and 4 secondary outcome events occurred in the apixaban and warfarin groups (P = 0.70), respectively. CONCLUSION: Apixaban has similar safety and effectiveness to warfarin for the prevention of cerebral thromboembolism during the periprocedural period of AF ablation.

The Relationship between the Profiles of SVC and Sustainability of SVC Fibrillation Induced by Provocative Electrical Stimulation.

BACKGROUND: Superior vena cava (SVC) can be a focus of atrial fibrillation (AF). However, distinctive features that identify SVC arrhythmogenicity remain unclear. Sustainability of fibrillation within the SVC might help with identifying SVC arrhythmogenicity. The purpose of this study was to investigate the relationship between the anatomical and electrical profiles of SVC and sustainability of SVC fibrillation induced by proactive electrical stimulation. METHODS: Consecutive 36 patients with paroxysmal or persistent AF who underwent repetitive pulmonary vein isolation (PVI) session were included in the study. After successful PVI, periodic rapid electrical stimuli were delivered to the SVC to induce SVC fibrillation. SVC fibrillation was defined as follows: (1) the local fibrillatory electrical activity persisted longer than 3 seconds, (2) the local fibrillatory activity penetrated through the atrium and maintained AF, and (3) the frequency of local activity was higher than that of any other atrial components such as coronary sinus and right atrial appendage. RESULTS: SVC fibrillation was induced in seven patients. The group with SVC fibrillation had significantly longer SVC sleeve and longer left atrial diameter compared with the group without SVC fibrillation. All patients with SVC fibrillation were free from AF recurrence after SVC isolation. CONCLUSIONS: The SVC sleeve longer than 30 mm had sustainability of SVC fibrillation induced by electrical stimulation. This finding advocates that arrhythmogenic substrate may exist in the SVC with long myocardial sleeve.

Electrocardiographic characteristics differentiating epicardial outflow tract-ventricular arrhythmias originating from the anterior interventricular vein and distal great cardiac vein.

BACKGROUND: The aim of this study was to identify the ECG features that might differentiate between anterior interventricular vein (AIV) and distal great cardiac vein (d-GCV) outflow tract-ventricular arrhythmias (OT-VAs). METHODS AND RESULTS: Radiofrequency catheter ablation was performed in 13 of 375 patients (3.5%) for AIV or d-GCV OT-VAs. We grouped the 13 patients by the origin, d-GCV (n=9) or AIV (n=4), and compared their ECGs and electrophysiological data. The OT-VA ECGs had S waves in lead I in all 13 patients. The voltage in the inferior lead III and peak deflection index showed no significant between-group differences (2.3±0.7 vs. 2.5±0.3 mV and 0.65±0.04 vs. 0.68±0.04 mV, respectively) for the d-GCV and AIV groups. There were also no significant between-group differences in the QaVL/QaVR, where Q denotes the amplitude of the Q wave in the suffix lead. However, the R/S ratio in V1 (1.7±1.0 [n=5] vs. 0.2±0.05, P=0.04), and QRS duration (149±16.6 vs. 123±3.8 ms, P=0.012) were greater in the d-GCG group than in the AIV group. There were no significant between-group differences in the activation time or pace mapping score at the optimal ablation sites. CONCLUSIONS: A low R/S ratio in V1 and shorter QRS duration may help identify AIV sites of epicardial OT-VA origin.

Catecholaminergic Polymorphic Ventricular Tachycardia with QT Prolongation.

The QT interval in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT) is typically normal. However, CPVT patients are sometimes misdiagnosed as concealed long QT syndrome (LQTS), because patients with LQTS also manifest with syncope or sudden death following periods of exertion or extreme emotion. We report a CPVT patient with a pathogenic RyR2 mutation associated with a marked QT prolongation, which normalized after flecainide therapy.

Tyrosinase inhibition prevents non-coplanar polychlorinated biphenyls and polybrominated diphenyl ethers-induced hyperactivity in developing zebrafish: Interaction between pigmentation and neurobehavior.

Non-coplanar polychlorinated biphenyl (PCB) mixture Aroclor 1254 and polybrominated diphenyl ether (PBDE) BDE-47 are known to impede neurogenesis and neuronal development. We previously reported that exposure to PCB and PBDE leads to increased embryonic movement in zebrafish by decreasing dopamine levels. In this study, we studied the connection between the melanin and dopamine synthesis pathways in this context. Both genetic and chemical inhibition of tyrosinase, the rate-limiting enzyme in melanin synthesis, not only led to reduced pigmentation but also inhibit PCB/PBDE-induced embryonic hyperactivity. Furthermore, PCB and PBDE rarely affected tyrosinase expression in the potential pigment cells, suggesting that these compounds reduce dopamine through enzymatic regulation, including a competitive interaction for the substrate tyrosine. Our results provide new insights into the interactions between melanogenesis and dopaminergic neuronal activity, which may contribute to understanding the mechanisms underlying PCB/PBDE toxicity in developing organisms.

Posterior wall thickness of the confluent inferior pulmonary veins measured by left atrial intracardiac echocardiography: implications for catheter ablation.

BACKGROUND: Confluent inferior pulmonary veins (CIPV) is a rare anatomical variant. There is few evidence in the literature regarding anatomic landmarks consideration to guide radiofrequency application in avoiding complications in the esophagus in CIPV cases. METHODS: Of 986 consecutive patients undergoing atrial fibrillation (AF) ablation from July 2020 to June 2022, seven (0.7%) had CIPV with a common trunk connecting to the LA diagnosed by 3-dimensional contrast-enhanced computed tomography. Using intracardiac echocardiography (ICE) performed from the left atrium (LA), we measured the posterior wall thickness (PWT) of the CIPV adjacent to the esophagus and compared the measurement with the LA posterior wall thickness (LAPWT) at the left inferior PV level of 25 controls without CIPV. For ablation in CIPV patients, each superior PV was individually isolated, and box isolation of CIPV without ablating the CIPV posterior wall was added (tri-circle ablation technique). RESULTS: The CIPV PWT was 0.7 ± 0.1 mm, while non-CIPV LAPWT was 2.0 ± 0.4 mm (P < 0.001). In the CIPV group, upper and lower portions of the CIPV were both apart from the esophagus (mean distances, 6.7 ± 3.4 mm and 7.9 ± 2.7 mm, respectively). Individual superior PV isolation and box CIPV isolation resulted in complete isolation of all PVs, with no complications. All CIPV patients except one remained AF recurrence-free for 376 ± 52 days. CONCLUSIONS: Although CIPV frequency is low, CIPV PWT is very thin and special care is needed during ablation. A "tri-circle" ablation strategy avoids ablating in the thinnest portion of the posterior wall. Further studies are warranted to assess the safety.

Differential Pacing Maneuver From the Vein of Marshall.

BACKGROUND: Bidirectional mitral isthmus (MI) block is conventionally verified by differential pacing from the coronary sinus (CS) and its sequence change. This study aimed to evaluate the ability of differential pacing from the vein of Marshall (VOM) to detect epicardial MI connections. METHODS: Radiofrequency and VOM ethanol MI ablation were performed with a VOM electrode catheter inserted to the septal side of the ablation line. MI block was verified using conventional CS pacing. To perform differential VOM pacing analysis, initial pacing was delivered from a distal VOM bipole closer to the block line, and then from a proximal VOM bipole. The intervals from pacing stimulus during different VOM pacing sites to the electrogram recorded through the CS catheter on the opposite side of the line were compared. When the interval during distal VOM pacing was longer than that during proximal VOM pacing, it indicated a VOM connection block; however, if the former interval was shorter, the connection through the VOM was considered persistent. RESULTS: Overall, 50 patients were evaluated. According to CS pacing, MI ablation was incomplete in 9 patients, in whom the analysis indicated persistent VOM connection. Among 41 patients with complete MI block, confirmed by CS finding, in 30 (73%) patients, the interval during distal VOM pacing was longer than that during proximal VOM pacing by 11±5 ms. However, in 11 patients (27%) the former interval was revealed to be shorter than the latter by 16±8 ms, indicating residual VOM connection. Conduction time across the line was significantly shorter in 11 patients than in the other 30 (166±21 versus 197±36 ms; P<0.01). Ten successful reevaluated analyses after VOM ethanol and further radiofrequency ablation of the connection indicated VOM block achievement. CONCLUSIONS: Differential VOM pacing maneuver reflects the VOM conduction status. This maneuver can uncover residual epicardial connections that are missing with CS pacing.

Amiodarone-induced thyrotoxicosis late after amiodarone withdrawal.

BACKGROUND: Amiodarone-induced thyrotoxicosis (AIT) may develop long after amiodarone withdrawal. This study sought to determine the incidence and clinical characteristics of AIT after amiodarone withdrawal. METHODS AND RESULTS: The incidence and clinical characteristics of AIT were examined retrospectively in 71 patients (51 males, mean age 65±13 years) whose amiodarone therapy had been discontinued after at least 1 month of administration. Five (7%) patients developed AIT late after amiodarone withdrawal (11±3 months): 2 patients exhibited exacerbation of heart failure by atrial fibrillation, 2 developed dyspnea on exertion, and 1 patient was asymptomatic. The patients who developed AIT had a high incidence of amiodarone-induced hypothyroidism during amiodarone therapy (100 vs. 24%, P=0.002), had received amiodarone therapy for longer (76±86 months vs. 16±22 months, P<0.001), with a larger cumulative dose (271.1±268.5 g vs. 63.4±86.5 g, P<0.001) compared with those who did not. In all 5 patients, AIT resolved spontaneously within 5 months without the use of steroids. CONCLUSIONS: Occurrence of amiodarone-induced hypothyroidism during amiodarone therapy and long duration of therapy may be cautionary markers of late AIT.

Distribution of the origin of adenosine triphosphatesensitive atrial tachycardias with the earliest activation recorded in the His bundle catheter: are they limited to the immediate vicinity of the His bundle?

BACKGROUND: The aim of this study was to assess the spatial distribution of the origins of adenosine triphosphate (ATP) sensitive focal atrial tachycardias (AT) that have their earliest activation recorded in the His bundle (HB) catheter. METHODS AND RESULTS: Catheters were placed according to the standard fashion for an electrophysiologic study of supraventricular arrhythmia, namely, high right atrium, HB, coronary sinus, and right ventricle. The ATs with their earliest activation recorded in the HB catheter and that were terminated by rapid injection of ATP (4.3 ± 2.5mg), formed the study group (n=12). After catheter ablation of these ATs, the distances between the successful ablation site and the HB area were measured. Only one successful site was near the HB and the other sites were at the noncoronary sinus of Valsalva (n=6), tricuspid annulus (n=3), right atrial septum (n=1), and left atrial septum (n=1). The average distance between the HB catheter and successful site was 10.4 ± 8.8mm. In 5 of the 12 cases (the 3 tricuspid and 2 septal foci), the distances were greater than 10mm. CONCLUSIONS: When ablating ATP-sensitive AT with the earliest activation recorded in the HB catheter, it is important to perform detailed mapping not only around the HB.