Incidence and clinical impact of early recurrence of atrial tachyarrhythmia after surgical ablation for atrial fibrillation.

BACKGROUND: Atrial tachyarrhythmias (ATAs) are common within the 3-month blanking period after catheter ablation of atrial fibrillation (AF). However, little evidence is available regarding the current guidelines on the blanking period after surgical AF ablation. We investigate the incidence and significance of early recurrence of atrial tachyarrhythmia (ERAT) and evaluate the optimal blanking period after surgical AF ablation. METHODS: Data from 259 patients who underwent surgical AF ablation from 2009 to 2016 were collected. ERAT was defined as documented ATA episodes lasting for 30 s. A multivariate Cox proportional hazard model was constructed to evaluate the role of ERAT as a predictor of late recurrences (LR) for AF. RESULTS: In total, 127 patients (49.0%) experienced their last episodes of ERAT during the first (n = 65), second (n = 14), or third (n = 48) month of the 3-month blanking period (p < .001). One year freedom from ATAs was 97.8% in patients without ERAT compared with 95.4%, 64.3%, and 8.3% in patients with ERAT in the first, second, and third months after the index procedure, respectively (p < .001). Hazard ratios of LR according to the timing of the last episode of ERAT first, second, and third months after the procedure were 2.84, 16.70, and 119.75, respectively. CONCLUSIONS: The ERAT occurred in 49.0% of patients within the first 3 months after surgical ablation. The occurrence of ERAT within 3 months after surgical AF ablation was a significant independent predictor of LR. Hence, the currently accepted 3-month blanking period may be considered for redefining in patients with AF surgical ablation.

Value of Coronary Angiography in the Cardiac Myxoma.

Preoperative coronary angiography for cardiac myxoma not only excludes coronary artery disease but also detects the artery feeding the cardiac myxoma, which has several clinical implications. In this study, we examined cardiac myxoma cases in two tertiary hospitals using coronary angiography to identify the artery feeding the myxoma. We retrospectively reviewed 42 patients with cardiac myxoma who had undergone surgical removal between July 2008 and December 2015 in two tertiary hospitals, and recorded their baseline characteristics, echocardiographic findings, and coronary angiography. Among those 42 patients, 23 (55%) had coronary angiography before surgery and in no case was significant luminal narrowing observed. In 21 of the coronary angiograms, the artery feeding the cardiac myxoma had a vascular branch (100%), clusters of tortuous vessels with contrast medium pooling (67%), an arteriocavity fistula (33%), and a mobile feeding artery (67%). No significant relationship was found between coronary artery dominance type and the origin of the artery feeding the cardiac myxoma (P = 0.362). Identification of the artery feeding the cardiac myxoma, with a distinctive vascular appearance in coronary angiography, is important for several clinical applications such as helping to diagnose cardiac myxoma and to plan the surgical approach. Clin. Anat. 33:833-838, 2020. © 2019 Wiley Periodicals, Inc.

Radiation reduction during percutaneous coronary intervention: A new protocol with a low frame rate and selective fluoroscopic image storage.

The percutaneous coronary intervention (PCI) procedure is associated with potentially high levels of radiation exposure and therefore increased risk of adverse radiation-induced outcomes, ranging from cataract to malignancy. Frame rate reduction and selective fluoroscopy storage may help reduce radiation exposure. In this study, we evaluated the efficacy of a radiation reduction protocol that uses a lower frame rate and selective storage of fluoroscopic images in terms of its effect on reducing the radiation dose during PCI.The new protocol incorporated a lower frame rate as compared with the conventional protocol, and used selective storage of fluoroscopic images. We reviewed the medical records of patients who underwent PCI under the conventional protocol from January 2013 to December 2013, and compared them with those who underwent PCI with the new protocol from January 2015 to December 2015. The primary endpoint was radiation dose reduction expressed as cumulative air kerma and dose-area product (DAP). The image quality was assessed by 3 independent well-trained cardiologists.One hundred fifty-five patients were enrolled in the conventional protocol group, and 152 were enrolled in the radiation reduction protocol group (total, n = 307). There was no statistical significance in terms of the baseline characteristics, including body mass index. Overall, the radiation reduction protocol group showed a significant reduction in both cumulative air kerma (1634.39 ±â€Š717.95 vs 2074.75 ±â€Š1003.72 mGy, P < .001) and DAP (12344.86 ±â€Š5371.75 vs 15312.19 ±â€Š7136.58 µGy m, P < .001). Image quality was acceptable in both groups.The radiation reduction protocol, which uses a lower frame rate and selective storage of fluoroscopic images, may be an alternative approach to reducing PCI radiation dose.

ECG features and proarrhythmic potentials of therapeutic hypothermia.

OBJECTIVE: Hypothermia can induce ECG J waves. Recent studies suggest that J waves may be associated with ventricular fibrillation (VF) in patients with structurally normal hearts. However, little is known about the ECG features, clinical significance or arrhythmogenic potentials of therapeutic hypothermia (TH)-induced J waves. METHODS: We analysed ECGs from 240 patients who underwent TH at six major university hospitals in Korea between August 2010 and December 2013. The prevalence, amplitudes and distributions of the J waves and the development of malignant arrhythmia were analysed. RESULTS: The average patient body temperature was 33.5±1.0°C during TH. J waves were observed in 98 patients (40.8%). They were newly developed in 91 cases, and pre-existing J waves were augmented in seven patients. J waves during TH were primarily observed in leads II, III, aVF and V4-6. The average amplitude of the J waves was 0.239±0.152 mV. There were four VF events during TH. These events occurred in three patients who were finally diagnosed with Brugada syndrome, idiopathic VF or early repolarisation syndrome, respectively, and in one patient with non-cardiac aetiology (asphyxia). CONCLUSIONS: J waves were recorded in about 40% of the patients who received TH. They were most frequently observed in the inferior limb leads or lateral precordial leads. Life-threatening VF occurred only rarely (1.7%) during TH and were mainly observed in patients with primary arrhythmic disorder. Although a causal relationship between TH-induced J waves and VF remains unknown, administering TH to this potentially susceptible, high-risk population may require careful attention.

Rapidly Growing Right Ventricular Outflow Tract Mass in Patient with Sarcomatoid Renal Cell Carcinoma.

Cardiac metastasis from renal cell carcinoma (RCC) without inferior vena cava (IVC) involvements is extremely rare with few reported cases. Sarcomatoid RCC with rhabdoid feature is a rare pathologic type of RCC having aggressive behavior due to great metastatic potential. Here, we report a case of rapidly growing cardiac metastasis of RCC which brought on right ventricular outflow tract (RVOT) obstruction without IVC and right atrial involvement in a 61-year-old woman. Cardiac arrest occurred during radical nephrectomy and echocardiography revealed mass nearly obstructing the RVOT which was not recognized by preoperative echocardiography 1 month ago. Postoperative immunohistochemical evaluation of renal mass revealed sarcomatoid RCC with rhabdoid feature.

Antiplatelet effect of ticagrelor compared to tirofiban in non-ST-segment elevation ACS patients undergoing PCI. The result of the TE-CLOT trial.

Addition of a potent P2Y12 inhibitor to aspirin is the standard therapy for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients undergoing percutaneous coronary intervention (PCI). Glycoprotein IIb/IIIa inhibitor, together with antiplatelet therapy, may be considered as part of initial therapy in NSTE-ACS patients with high-risk features. This study investigated the antiplatelet effect of ticagrelor loading dose (LD) versus tirofiban bolus injection with a post-bolus infusion on top of aspirin among NSTE-ACS patients planned to PCI. NSTE-ACS patients were randomised to receive either ticagrelor (n = 47) or tirofiban (n = 48). Platelet reactivity was assessed by light transmittance aggregometry at 0, 2, 8, and 24 hours (h) after treatment initiation. Primary endpoint was inhibition of platelet aggregation (IPA, 20 µM ADP, final extent) at 2 h after LD therapy, with a non-inferiority margin of 10%. The prevalence of high on-treatment platelet reactivity (HPR) was also compared at 0, 2, 8, and 24 h. The mean difference in IPA between ticagrelor and tirofiban was -9.9% (95% confidence interval: -25.7% to 5.9%) at 2 h, -1.6% (-8.0% to 4.8%) at 8 h, and -3.3% (-18.4% to 12.0%) at 24 h. The prevalence of HPR did not differ between the two groups at any time point (all p values ≥ 0.059), which was almost abolished by 8 h post-LD (< 5%). In conclusion, the antiplatelet effect during the early phase (~2 h) after ticagrelor LD appeared to be relatively strong, but it did not reach that of tirofiban in NSTE-ACS patients.

Radiation Exposure in Coronary Angiography: A Comparison of Cineangiography and Fluorography.

BACKGROUND AND OBJECTIVES: Coronary angiography (CAG) is the gold standard for diagnosing coronary artery disease. However, exposure to ionizing radiation delivered during CAG has various negative biological effects on humans. In this study, there was an evaluation of whether fluorography resulted in decreased radiation exposure, as compared with cineangiography. SUBJECTS AND METHODS: Fifty-five patients were prospectively enrolled and divided into two CAG groups, in accordance with the operator's professional discretion: a conventional cineangiography group versus a fluorography group. Fluorography refers to the photography of fluoroscopic images that are retrospectively stored, e.g., using the "Store fluoro" function of the Siemens cardiac angiography system. The primary outcomes included the air kinetic energy released per unit mass {air kerma (AK) mGy} and the dose (kerma)-area product (DAP; µGy · m(2)), both measured using built-in software in the Siemens system. The secondary outcomes included the total procedure time and amount of contrast agent used with each CAG method. RESULTS: The total AK and DAP were significantly lower in the fluorography group (159.3±64.9 mGy and 1337.9±629.6 µGy · m(2), respectively) than in the cineangiography group (326.9±107.5 mGy and 2341.1±849.9 µGy · m(2), respectively; p=0.000 for both). The total procedure time (cineangiography vs. fluorography, 12.8±4.7 vs. 12.5±2.9 min; p=0.779) and contrast agent amount (136.1±28.3 vs. 126.3±25.7, p=0.214) were comparable between the two groups. CONCLUSION: Fluorography is a useful method to decrease the radiation exposure in selected patients requiring CAG.

Second coupling interval of nonsustained ventricular tachycardia to distinguish malignant from benign outflow tract ventricular tachycardias.

BACKGROUND: Idiopathic ventricular tachycardia (VT) originating from the outflow tract (OT) usually is considered a benign condition. In rare cases, patients with OT-VT suffer from syncope or even sudden cardiac death. OT-VT is frequently preceded by nonsustained VT (NSVT). OBJECTIVE: The purpose of this study was to clarify if the ECG parameters of NSVTs could differentiate malignant from benign OT-VT. METHODS: We retrospectively evaluated patients without structural heart disease who had documented OT-NSVT on ECG. ECG parameters were compared between patients with syncope, aborted sudden cardiac death, or ventricular fibrillation (malignant group, n = 36) and patients without syncope (benign group, n = 40). RESULTS: There were no differences with regard to age and gender between the malignant and benign groups. On analysis of NSVT, the first coupling interval (CI) of NSVT was comparable between the 2 groups (458 ± 87 ms vs 485 ± 95 ms, P = .212). However, the second CI of NSVT beats was significantly shorter in the malignant group (313 ± 58 ms vs 385 ± 83 ms, P < .0001). During 48-month follow-up, the benign group had a significantly lower recurrence of clinical VT than the malignant group (P = .046). The malignant group frequently had more than 1 focus of VT, whereas the benign group showed only a single focus (1.82 vs 1.09, P = .023). CONCLUSION: The second CI of NSVT in the malignant group was significantly shorter than that of the benign OT-VT group. Careful measurement of the second CI of NSVT may help identify the malignant form of OT-VT, enabling early treatment to prevent future cardiac events.

Influence of diabetes mellitus on long-term (five-year) outcomes of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization.

Diabetes mellitus is a major risk factor for coronary artery disease (CAD) and for diffuse and progressive atherosclerosis. We evaluated the outcomes of drug-eluting stent (DES) placement and coronary artery bypass grafting (CABG) in 891 diabetic patients (489 for DES implantation and 402 for CABG) and 2,151 nondiabetic patients (1,058 for DES implantation and 1,093 for CABG) with multivessel CAD treated from January 2003 through December 2005 and followed up for a median 5.6 years. Outcomes of interest included death; the composite outcome of death, myocardial infarction (MI), or stroke; and repeat revascularization. In diabetic patients, after adjusting for baseline covariates, 5-year risk of death (hazard ratio 1.01, 95% confidence interval 0.77 to 1.33, p = 0.96) and the composite of death, MI, or stroke (hazard ratio 1.03, 95% confidence interval 0.80 to 1.31, p = 0.91) were similar in patients undergoing DES or CABG. However, rate of repeat revascularization was significantly higher in the DES group (hazard ratio 3.69, 95% confidence interval 2.64 to 5.17, p <0.001). These trends were consistent in nondiabetic patients (hazard ratio 0.80, 95% confidence interval 0.55 to 1.16, p = 0.23 for death; hazard ratio 0.77, 95% confidence interval 0.56 to 1.05, p = 0.10 for composite of death, MI, or stroke; hazard ratio 2.77, 95% CI 1.95 to 3.91, p <0.001 for repeat revascularization). There was no significant interaction between diabetic status and treatment strategy on clinical outcomes (p for interaction = 0.36 for death; 0.20 for the composite of death, MI, or stroke; and 0.40 for repeat revascularization). In conclusion, there was no significant prognostic influence of diabetes on long-term treatment with DES or CABG in patients with multivessel CAD.