Successful left ventricular lead placement by way of an azygos vein for a patient performing cardiac resynchronization therapy implantation with an occluded left subclavian vein: A case report.

Central venous obstruction following pacemaker implantation is not uncommon and can prove challenging in the case of a system upgrade to a cardiac resynchronization therapy pacemaker (CRT-P). We describe the case of a patient who underwent a successful upgrading procedure of a pacemaker to a CRT-P in the presence of an occluded left subclavian vein and superior vena cava, using collateral veins that drained into right atrium.

Contrast defect of left atrial appendage on computed tomography is associated with higher risk of recurrence after catheter ablation in patients with paroxysmal atrial fibrillation.

The previous study has shown that the contrast defect of the left atrial appendage (LAA) on contrast-enhanced cardiac computed tomography (CT) is associated with a higher rate of stroke in patients with atrial fibrillation (AF). This study aimed to investigate the association between LAA CT contrast defect and the risk of arrhythmia recurrence after catheter ablation (CA) in patients with paroxysmal AF. A total of 283 paroxysmal AF patients [age: 67 ± 10 years, 185 (65%) males] who underwent cardiac CT before CA were retrospectively analyzed. The presence or absence of LAA CT contrast defect was visually assessed using early phase CT images. Recurrence was an episode of atrial arrhythmia beyond the first 90 days post-ablation. LAA flow velocity was measured using transesophageal echocardiography in 246 paroxysmal AF patients. Sixty-eight (24%) patients had an LAA CT contrast defect. LAA flow velocity was significantly reduced in patients with LAA CT defect compared to those without (56.8 ± 28.7 cm/s vs. 41.1 ± 19.1 cm/s, p < 0.001). During a median follow-up period of 858 days, arrhythmia recurrence was identified in 85 (30%) patients. On a Kaplan Meier curve, patients with LAA CT contrast defect had significantly higher recurrence rates than those without (p = 0.043). On a multivariable Cox regression analysis, LAA CT contrast defect was a significant and independent predictor after adjustment of age, sex and left atrial volume index (hazard ratio: 1.79, 95% confidence interval: 1.03-3.07, p = 0.036). LAA CT contrast defect was associated with decreased LAA flow velocity and a higher rate of arrhythmia recurrence after CA, suggesting its usefulness as a non-invasive predictor for high-risk AF patients resistant to CA therapy.

Combination of extracellular volume fraction by cardiac magnetic resonance imaging and QRS duration for the risk stratification for patients with non-ischemic dilated cardiomyopathy.

The extracellular volume fraction (ECV) by T1 mapping can quantify diffuse myocardial fibrosis, and useful as a non-invasive marker for risk stratification for patients with non-ischemic dilated cardiomyopathy (NIDCM). Prolonged QRS interval on electrocardiogram is related to worse clinical outcome for heart failure patients. The purpose of this study was to evaluate the prognostic value of the combination of ECV and QRS duration for NIDCM patients. A total of 60 NIDCM patients (mean age 61 ± 12 years, mean left ventricular ejection fraction 37 ± 10%, mean QRS duration 110 ± 19 ms) were enrolled. Using a 1.5-T MR scanner and 32-channel cardiac coils, the mean ECV value of six myocardial segments at the mid-ventricular level was measured by the modified look-locker inversion recovery method. Adverse events were defined as follows: cardiac death; recurrent hospitalization due to heart failure. Patients were allocated into three groups based on ECV value and QRS duration (group 1: ECV â‰¦ 0.30 and QRS â‰¦ 120 ms; group 2: ECV > 0.30 or QRS > 120 ms; group 3: ECV > 0.30 and QRS > 120 ms). During a median follow-up duration of 370 days, 7 of 60 (12%) NIDCM patients experienced adverse events. NIDCM patients with events had longer QRS duration (134 ± 31 ms vs. 106 ± 14 ms, p = 0.01) and higher ECV (0.34 ± 0.07 vs 0.29 ± 0.05, p = 0.026) compared with those without events. On Kaplan-Meier curve analysis, significant difference was found between group 1 and group 3 (p < 0.001, log-rank test). No significant difference was found between group 1 and group 2 (p = 0.053), group 2 and group 3 (p = 0.115). The area under the receiver operating characteristic curve (AUC) for predicting adverse events was 0.778 (95% confidence interval CI 0.612-0.939) for ECV, 0.792 (95% CI 0.539-0.924) for QRS duration, 0.822 (95% CI 0.688-0.966) for combination of ECV and QRS duration. NIDCM patients with high ECV and prolonged QRS duration had significantly worse prognosis compared to those with normal ECV and normal QRS duration. The combination of ECV and QRS duration could be useful as a non-invasive method for better risk stratification for patients with NIDCM.

Atherosclerosis of the carotid bulb is associated with the severity of orthostatic hypotension in non-diabetic adult patients: a cross-sectional study.

BACKGROUND: The carotid bulb has a high density of baroreceptors that play an important role in maintaining blood pressure. We hypothesized that atherosclerosis of the carotid bulb would reflect the severity of orthostatic hypotension more accurately than would atherosclerosis of other carotid artery segments. METHODS: This cross-sectional study included 198 non-diabetic adults. We measured the cardio-vascular ankle index as an index of arterial stiffness, intima-media thickness in each carotid artery segment (internal carotid artery, carotid bulb, distal and proximal portions, respectively, of the common carotid artery) as a measure of atherosclerosis, and heart rate variability as a measure of cardiac autonomic function. The sit-to-stand test was used to assess severity of orthostatic hypotension. RESULTS: Intima-media thickness of the carotid bulb was correlated with orthostatic systolic blood pressure change (r = -0.218, p = 0.002), cardio-ankle vascular index (r = 0.365, p < 0.001) and heart rate variability parameters. Multivariate regression analysis revealed that among all of the segments, only intima-media thickness of the carotid bulb was an independent predictor of orthostatic systolic blood pressure change (p = 0.022). CONCLUSION: Atherosclerosis of the carotid bulb was associated with severity of orthostatic hypotension, arterial stiffening and cardiac autonomic dysfunction than that of other carotid artery segments.

Effects of tolvaptan in patients with chronic kidney disease and chronic heart failure.

BACKGROUND: Tolvaptan, a vasopressin V2 receptor blocker, has a diuretic effect for patients with heart failure. However, there were a few data concerning the effects of tolvaptan in patients with chronic kidney disease (CKD). METHODS: We retrospectively analyzed 21 patients with chronic heart failure and CKD. Tolvaptan was co-administered with other diuretics in-use, every day. We compared clinical parameters before and after the treatments with tolvaptan. Furthermore, we examined the correlations between baseline data and the change of body weight. RESULTS: Tolvaptan decreased the body weight and increased the urine volume (p = 0.001). The urine osmolality significantly decreased throughout the study period. Urinary Na/Cr ratio and FENa changed significantly after 4 h, and more remarkable after 8 h (p = 0.003, both). Serum creatinine increased slightly after 1 week of treatment (p = 0.012). The alteration of body weight within the study period correlated negatively with the baseline urine osmolality (r = -0.479, p = 0.038), the baseline urine volume (r = -0.48, p = 0.028), and the baseline inferior vena cava diameter (IVCD) (r = -0.622, p = 0.017). Hyponatremia was improved to the normal value, and the augmentations of the sodium concentration were negatively associated with the basal sodium levels (p = 0.01, r = -0.546). CONCLUSIONS: Tolvaptan is effective in increasing diuresis and improved hyponatremia, even in patients with CKD. The baseline urine osmolality, urine volume, and IVCD may be useful predictors for diuretic effects of tolvaptan.

Optimal Anticoagulant Strategy for Periprocedural Management of Atrial Fibrillation Ablation: A Systematic Review and Network Meta-Analysis.

This network meta-analysis was performed to rank the safety and efficacy of periprocedural anticoagulant strategies in patients undergoing atrial fibrillation ablation. MEDLINE, EMBASE, CENTRAL, and Web of Science were searched to identify randomized controlled trials comparing anticoagulant regimens in patients undergoing atrial fibrillation ablation up to July 1, 2021. The primary efficacy and safety outcomes were thromboembolic and major bleeding events, respectively, and the net clinical benefit was investigated as the primary-outcome composite. Seventeen studies were included (n = 6950). The mean age ranged from 59 to 70 years; 74% of patients were men and 55% had paroxysmal atrial fibrillation. Compared with the uninterrupted vitamin-K antagonist strategy, the odds ratios for the composite of primary safety and efficacy outcomes were 0.61 (95%CI: 0.31-1.17) with uninterrupted direct oral anticoagulants, 0.63 (95%CI: 0.26-1.54) with interrupted direct oral anticoagulants, and 8.02 (95%CI: 2.35-27.45) with interrupted vitamin-K antagonists. Uninterrupted dabigatran significantly reduced the risk of the composite of primary safety and efficacy outcomes (odds ratio, 0.21; 95%CI, 0.08-0.55). Uninterrupted direct oral anticoagulants are preferred alternatives to uninterrupted vitamin-K antagonists. Interrupted direct oral anticoagulants may be feasible as alternatives. Our results support the use of uninterrupted direct oral anticoagulants as the optimal periprocedural anticoagulant strategy for patients undergoing atrial fibrillation ablation.

Extracellular volume fraction by T1 mapping predicts improvement of left ventricular ejection fraction after catheter ablation in patients with non-ischemic dilated cardiomyopathy and atrial fibrillation.

Absence of myocardial fibrosis on late gadolinium enhanced (LGE) magnetic resonance imaging (MRI) is associated with improvement of left ventricular systolic function after catheter ablation (CA) for atrial fibrillation (AF) with non-ischemic dilated cardiomyopathy (NIDCM). Extracellular volume fraction (ECV) by T1 mapping has emerges as a non-invasive mean to quantify severity of myocardial fibrosis. The aim of this study was to assess the incremental value of ECV over LGE-MRI for the improvement of LVEF(∆EF) after CA in NIDCM patients. A total of thirty-two patients with NIDCM and AF (mean age 67.4 ± 9.3 years; 29 (91%) male) were retrospectively studied. Using a 1.5 T MR scanner and 32 channel cardiac coils, LGE-MRI, pre- and post-T1 mapping images of LV wall at mid-ventricular level (modified look-locker inversion recovery sequence) were acquired. All patients successfully underwent CA for AF, and the improvement of LVEF after CA were evaluated by echocardiography. All patients restored sinus rhythm after CA at the time of echocardiography. The mean LVEF was 35.1 ± 9.7% before CA and 52.2 ± 10.2% after CA (p < 0.001), resulting an increase of 17.4 ± 12.6%. Significant correlation was found between ∆LVEF and % LGE (r = - 0.49, p = 0.004), ∆LVEF and extracellular volume fraction (ECV) (r = - 0.47, p = 0.010). Area under the receiver operating characteristics curve (AUC) of combination of %LGE and ECV for predicting improvement of LVEF > 10% was substantially higher than that of %LGE alone (AUC: 0.830 vs 0.602). In NIDCM patients with AF, ECV had incremental value over %LGE for predicting improvement of EF by CA, suggesting that the assessment of diffuse interstitial fibrosis may be important to forecast the response of CA.

Relationship between the cardiac magnetic resonance derived extracellular volume fraction and feature tracking myocardial strain in patients with non-ischemic dilated cardiomyopathy.

BACKGROUND: Feature tracking (FT) has emerged as a promising method to quantify myocardial strain using conventional cine magnetic resonance imaging (MRI). Extracellular volume fraction (ECV) by T1 mapping enables quantification of myocardial fibrosis. To date, the correlation between FT-derived left ventricular strain and ECV has not been elucidated yet. The aim of this study was to evaluate the relationship between myocardial strain by FT and ECV by T1 mapping in patients with non-ischemic dilated cardiomyopathy (NIDCM). METHODS: A total of 57 patients with NIDCM (61 ± 12 years; 46 (81%) male)) and 15 controls (62 ± 11 years; 11 (73%) male)) were studied. Using a 1.5 T magnetic resonance scanner, pre- and post- T1 mapping images of the LV wall at the mid-ventricular level were acquired to calculate the ECV by a modified Look-Locker inversion recovery (MOLLI) sequence. The radial strain (RS), circumferential strain (CS), and longitudinal strain (LS) were assessed by the FT technique. The ECV and myocardial strain were compared using a 6-segment model at the mid-ventricular level. RESULTS: The ECV and myocardial strain were evaluable in all 432 segments in 72 subjects. On a patient-based analysis, NIDCM patients had a significantly higher ECV (0.30 ± 0.07 vs. 0.28 ± 0.06, p = .007) and impaired myocardial strain than the control subjects (RS, 22.7 ± 10.3 vs. 30.3 ± 18.2, p < .01; CS, -6.47 ± 1.89 vs. -9.52 ± 5.15, p < .001; LS -10.2 ± 3.78 vs. -19.8 ± 4.30, p < .001, respectively). A significant linear correlation was found between the RS and ECV (r = -0.38, p < .001) and CS and ECV, (r = 0.38, p < .001). LS and ECV also correlated (r = 0.31, p < 0.001). On a segment-based analysis, there was a significant correlation between the ECV and RS and ECV and CS (all p values < .05). The intraclass correlation coefficient was good for the strain measurement (>0.80). CONCLUSIONS: In patients with NIDCM, significant correlation was found between myocardial strain and ECV, suggesting the FT-derived myocardial strain might be useful as a non-invasive imaging marker for the detection of myocardial fibrosis without any contrast media.

Reduced secretion of parathyroid hormone and hypocalcemia in systemic heterozygous ATP2B1-null hypertensive mice.

The ATP2B1 gene is associated with hypertension. We previously reported that systemic heterozygous ATP2B1-null (ATP2B1+/-) mice exhibited hypertension due to impaired endothelial nitric oxide synthase (eNOS) activity and decreased nitric oxide (NO) production. The ATP2B1 gene encodes plasma membrane calcium ATPase 1 (PMCA1), which has been thought to regulate only intracellular Ca2+ concentration. However, recently, it has been suggested that ATP2B1 works not only at cellular levels, but also throughout the entire body, including in the calcium metabolism, using small intestine-specific ATP2B1 knockout mice. To clarify the roles of ATP2B1 in the entire body and the effects of ATP2B1 on blood pressure, we examined the alterations of calcium related factors in ATP2B1+/- mice. ATP2B1+/- mice exhibited hypocalcemia. The expression of ATP2B1 in the kidney and small intestine decreased, and hypercalciuria was confirmed in ATP2B1+/- mice. The intact-PTH levels were lower, and bone mineral density was increased in these mice. These results suggest that hypocalcemia is mainly a result of inhibited bone resorption without compensation by PTH secretion in the case of ATP2B1 knockout. Moreover, NO production may be affected by reduced PTH secretion, which may cause the increase in vascular contractility in these mice. The ATP2B1 gene is important for not only intra-cellular calcium regulation but also for calcium homeostasis and blood pressure control.

The effects of anti-hypertensive drugs and the mechanism of hypertension in vascular smooth muscle cell-specific ATP2B1 knockout mice.

ATP2B1 is a gene associated with hypertension. We reported previously that mice lacking ATP2B1 in vascular smooth muscle cells (VSMC ATP2B1 KO mice) exhibited high blood pressure and increased intracellular calcium concentration. The present study was designed to investigate whether lack of the ATP2B1 gene causes a higher response to calcium channel blockers (CCBs) than to other types of anti-hypertensive drugs. Both VSMC ATP2B1 KO and control mice were administered anti-hypertensive drugs while monitoring blood pressure shifts. We also examined the association of nitric oxide synthase (NOS) activity in those mice to investigate whether another mechanism of hypertension existed. VSMC ATP2B1 KO mice exhibited significantly greater anti-hypertensive effects with a single injection of nicardipine, but the effects of an angiotensin II receptor blocker (ARB), an α-blocker and amlodipine on blood pressure were all similar to control mice. However, long-term treatment with amlodipine, but not an ARB, significantly decreased the blood pressure of KO mice compared with control mice. Both mRNA and protein expression levels of the L-type calcium channel were significantly upregulated in KO VSMCs. There were no alterations in neural NOS protein expression of VSMCs or in urinary NO production between the two groups. VSMC ATP2B1 KO mice had a higher response to CCBs for blood pressure-lowering effects than other anti-hypertensive drugs. These results mean that increased intracellular calcium concentration in VSMCs due to lack of ATP2B1 and subsequent activation of L-type calcium channels mainly affects blood pressure and suggests increased susceptibility to CCBs in this type of hypertension.

Relationship between Arterial Stiffness and Blood Pressure Drop During the Sit-to-stand Test in Patients with Diabetes Mellitus.

AIM: Patients with orthostatic hypotension (OH) have high arterial stiffness. Patients with diabetes mellitus (DM) often have cardiac autonomic neuropathy that leads to OH; however, whether OH is an indicator of arterial stiffness progression is unclear. We aimed to investigate whether the cardio-ankle vascular index (CAVI) varies between DM patients with and without OH using the sit-to-stand test (STST). METHODS: One hundred and fifty-nine patients with DM underwent CAVI assessment and blood pressure (BP) and heart rate change evaluation during the STST. OH was defined as a decline in systolic BP (SBP) and/or diastolic BP of at least 20 mmHg or 10 mmHg, respectively, in the initial and late upright positions compared with that in the sitting position. RESULTS: OH was diagnosed in 42 patients (26.4%). DM patients with OH had significantly higher CAVI (9.36±1.15 versus 8.89±1.18, p=0.026) than those without OH. CAVI was significantly inversely correlated with systolic and diastolic BP changes (R=－0.347, p＜0.001 and R=－0.314, p＜0.001, respectively) in the initial upright position. Multivariate regression analysis revealed that age, SBP changes, and low frequency component in the initial upright position were independent determinants of CAVI. CONCLUSION: Patients with DM having large BP drops occurring when moving from sitting to standing have high arterial stiffness. A significant BP drop during the STST necessitates careful evaluation of advanced arterial stiffness in patient with DM.