Hybrid epicardial and endocardial ablation of a persistent atrial tachycardia arising from the marshall bundle: the importance of a detailed analysis of the local potentials.

Radiofrequency catheter ablation of an atrial tachycardia (AT) and atrial fibrillation (AF) was performed in a patient with a history of pulmonary vein isolation for paroxysmal AF. The AT exhibited a centrifugal pattern with the posterolateral LA as the earliest activation site. The AT was not terminated by ablation at the endocardial earliest site, but its cycle length was prolonged by ablation at an opposite site within the Vein of Marshall. Finally, the AT was terminated by an energy application at a site 7 mm posteroinferior to the initial earliest activation site. We analyzed the local potentials of each energy delivery site in detail.

Relationship between the long-term preventive effect of combined treatment with antiarrhythmic drugs plus angiotensin-converting enzyme inhibitors and circadian variation in the onset of paroxysmal atrial fibrillation.

We examined the relationship between the efficacy of combined treatment with antiarrhythmic drugs (AAD) plus enalapril for maintaining sinus rhythm and circadian variation in the onset of paroxysmal AF.Three hundred and forty-four patients with paroxysmal AF (239 men, mean age, 69 ± 11 years) who could be followed up ≥ 12 months were divided into 3 groups on the basis of circadian variation in the onset of AF: a diurnal group (7:00 AM-5:00 PM, n = 57), a nocturnal group (5:00 PM-7:00 AM, n = 108), and a mixed group (onset during both periods, n = 169). The maintenance rate of sinus rhythm during the follow-up period was compared between combined therapy (AAD plus enalapril) and AAD alone.In the diurnal group, the maintenance rates of sinus rhythm at 12, 36, 60, and 90 months were 100%, 100%, 100%, and 100%, respectively, for patients treated with AAD plus enalapril (n = 22) versus 97%, 91%, 89%, and 80% for patients treated with AAD alone (n = 35, P < 0.05). In the nocturnal group, the maintenance rates of sinus rhythm at 12, 36, 60, and 90 months were 96%, 96%, 96%, and 92%, respectively, in patients treated with AAD plus enalapril (n = 24) versus 100%, 100%, 100%, and 100% in patients treated with AAD alone (n = 84, P = NS). In the mixed group, maintenance rates of sinus rhythm at 12, 36, 60, and 90 months were 90%, 71%, 61%, and 57%, respectively, in patients treated with AAD plus enalapril (n = 49) versus 88%, 78%, 68%, and 61% in patients treated with AAD alone (n = 120, P = NS). Our findings suggest that the preventive efficacy of combined therapy with AAD plus enalapril is dependent on the timing of onset of paroxysmal AF, and this regimen seems to be most beneficial for the diurnal type of paroxysmal AF.

A unique case of primary effusion lymphoma-like lymphoma showing disappearance and recurrence of the body cavity effusion.

Primary effusion lymphoma-like lymphoma (PEL-LL) is a rare B-cell lymphoma that the etiology remains unclear. We describe a case of PEL-LL with a pleuropericardial effusion. Diagnosis required long period of time as it followed a unique progress of disappearance and recurrence of the body cavity effusion. We finally had a diagnosis of B-cell lymphoma by the immunocytochemistry of effusion using the cell block procedure. Authors consider that it is valuable to actively try the cell block procedure at the time of the first drainage for early diagnosis, if the body cavity effusion due to the malignancy is suspected.

Efficacy of antiarrhythmic drug therapy in preventing recurrence of atrial fibrillation and long-term cardiovascular prognosis in patients with asymptomatic paroxysmal atrial fibrillation.

We evaluated the efficacy of antiarrhythmic drug therapy (AAD) and long-term cardiovascular prognosis in patients with asymptomatic paroxysmal atrial fibrillation (AF). This retrospective study included 334 patients (229 men and 105 women, mean age, 69 +/- 11 years, mean follow-up, 60 +/- 11 months) who were divided into two groups; patients with symptomatic AF (group I) and those with asymptomatic AF (group II) on the basis of subjective symptoms. (1) Actuarial rates of patients without AF recurrence, those with AF recurrence and with electrical/pharmacological cardioversion to restore sinus rhythm, and those with conversion to permanent AF despite AAD were 40%, 41%, and 19%, respectively, in group I, and 22%, 24%, and 54%, respectively, in group II at the end of the follow-up period. At 60 months, the percentage of patients with conversion to the permanent form of AF was significantly greater in group II than in group I (P < 0.05, group I versus group II). (2) Survival rates free from symptomatic thromboembolism at 36, 60, and 120 months were 96%, 93%, and 88%, in group I, and 82%, 76%, and 71%, respectively, in group II (P < 0.05, group I versus group II). In patients not undergoing anticoagulant therapy, the annual rate of symptomatic thromboembolism was significantly greater in group II (5.3%) than in group I (2.3%) (P < 0.05), while in patients undergoing anticoagulant therapy there was no significant difference in the annual rate of symptomatic thromboembolism between group I (0.9%) and group II (1.8%). The clinical course of asymptomatic paroxysmal AF is refractory to AAD when compared to symptomatic AF, meaning that anticoagulant therapy is required to prevent symptomatic thromboembolism in this group.

Relationship between CHADS2 score and ischemic stroke during rhythm control therapy for paroxysmal atrial fibrillation.

The CHADS2 score has been proposed for stratifying patients with nonvalvular atrial fibrillation (NVAF) according to the risk of thromboembolism in the AHA/ACC/ESC guidelines. However, there is little information about its usefulness for predicting the long-term risk of ischemic stroke in Japanese patients with paroxysmal AF. We retrospectively evaluated the incidence of ischemic stroke and the efficacy of anticoagulant therapy in paroxysmal AF patients on rhythm control therapy who were stratified by their CHADS2 score. The subjects were 334 NVAF atients (229 men and 105 women, mean age, 68 +/- 12 years, mean follow-up period, 60 +/- 35 months) who were categorized into low risk (score 0), moderate risk (1 or 2), and high risk (3 or more) groups for thromboembolism. The low, moderate, and high risk groups accounted for 34%, 50%, and 16% of the patients, respectively. Among 257 patients without warfarin therapy, the annual rate of symptomatic ischemic stroke was 0.6% in the score 0 group, 0.5% in the score 1 group, 3.1% in the score 2 group, and 9.6% in the score 3 or more group. Among 77 patients treated with warfarin (target PT-INR: 1.6-3.0), the stroke rate was 0% in the score 0 group, 0% in the score 1 group, 1.4% in the score 2 group, and 6.6% in the score 3 or more group. The annual rate of ischemic stroke was 0.88% in patients treated with warfarin versus 2.67% in those without warfarin, or a decrease in risk of 68% with warfarin (P < 0.01). In Japanese patients with paroxysmal AF, the CHADS2 score is useful for predicting the risk of ischemic stroke. Anticoagulant therapy is needed to prevent ischemic stroke in patients with paroxysmal AF, especially those who have a CHADS2 score of 2 or more.

Long-term efficacy of upstream therapy using angiotensin-converting enzyme inhibitors and statins in combination with antiarrhythmic agents for the treatment of paroxysmal atrial fibrillation.

The long-term efficacy of upstream therapy to prevent occurrence of paroxysmal atrial fibrillation (AF) in Japanese patients remains unclear. We retrospectively assessed the long-term efficacy of combination therapy with pravastatin (10 mg/day) and enalapril (5 mg/day) in addition to antiarrhythmic drugs (AAD) for maintaining sinus rhythm in patients with AF. This study included 319 patients (221 men, 98 women, mean age, 68+/-10 years, mean follow-up period, 50+/-34 months) who were divided into 4 groups: group I (n=191) without combination therapy--namely pravastatin(-) and enalapril(-); group II (n=81) with combination therapy--pravastatin (-) and enalapril (+) (n=81); group III (n=29) with combination therapy--pravastatin (+) and enalapril (-); and group IV (n=18) with combination therapy--pravastatin (+) and enalapril (+). The percentages of patients free from conversion to permanent AF at 12, 36, 60, 90, and 120 months were as follows: group I 88, 83, 78, 75, and 73%, respectively; group II 96, 88, 79, 77, and 75%, respectively; group III 100, 97, 91, 91, and 86%, respectively; group IV 100, 100, 100, 94, and 94%, respectively. The actuarial rate free from conversion to permanent AF at 120 months was significantly higher in group IV than in group I (P<0.05). The results suggest that in patients with paroxysmal AF, the addition of both pravastatin and enalapril to AAD was more effective for maintaining sinus rhythm in terms of an upstream therapy.

Combination therapy with amiodarone and enalapril in patients with paroxysmal atrial fibrillation prevents the development of structural atrial remodeling.

The purpose of this study was to examine the relationship between long-term efficacy of amiodarone therapy (100-200 mg/day) combined with angiotensin converting enzyme inhibitor (ACEI; enalapril 5 mg/day) administration, and the development of structural atrial remodeling in patients with paroxysmal atrial fibrillation (AF). Fifty-eight patients (40 men, 18 women, mean age, 68 +/- 8 years, mean follow-up period, 43 +/- 18 months) with AF refractory to >or= two class I antiarrhythmic drugs were divided into two groups; those treated with enalapril on amiodarone (group A, n = 25) and those treated with amiodarone alone (group B, n = 33), to evaluate the efficacy of combination therapy. 1) At 12 and 24 months, the survival rates for patients free from AF recurrence were 80% and 64% in group A, and 45% and 30% in group B, respectively (P < 0.05, group A versus group B). The percentage of patients with conversion to permanent AF despite amiodarone therapy was 20% in group A and 48.5% in group B (P < 0.05, group A versus group B). 2) In group B, left atrial dimension (LAD) was significantly greater after amiodarone therapy (40.2 +/- 6.3 mm) than at baseline (35.2 +/- 6.6 mm) (P < 0.01), whereas there was no significant difference in LAD between baseline and after amiodarone therapy in group A (39.1 +/- 5.0 mm versus 41.0 +/- 5.0 mm, respectively). In patients with paroxysmal AF, ACE-I appears to enhance the efficacy of amiodarone therapy in maintaining sinus rhythm and preventing the development of structural remodeling in atria.