Large Tissue Debris Causing Cerebral Embolism After Transcatheter Aortic Valve Replacement.

Cerebral vascular embolism is one of the complications of transcatheter aortic valve replacement (TAVR). Thrombolytic therapy is not expected to be effective when embolic material consists of a large tissue fragment. Instead, mechanical aspiration may be more effective therapy for acute cerebral infarction after TAVR. Here, we describe the case of an 87-year-old woman with aortic valve stenosis and heart failure who underwent TAVR using a self-expandable valve. Acute cerebral infarction with left middle cerebral artery occlusion caused by a large tissue fragment developed after the procedure.

Is narrowest QRS the best? A case of cardiac resynchronization therapy in a patient with left anterior fascicular block.

The efficacy of cardiac resynchronization therapy (CRT) in patients with a narrow QRS duration has not been established. We present a patient with a narrow QRS duration and left anterior fascicular block in which CRT was effective. Left ventricular lead implantation at the optimal site and appropriately-timed left ventricular pacing (LVP) resulted in left ventricle reverse remodeling. Left ventricular dyssynchrony did not improve with LVP at a timing that resulted in narrower QRS than an intrinsic QRS duration. The optimization of LVP timing in CRT for patients with a narrow QRS duration is discussed.

Utility of Routine Transthoracic Echocardiographic Parameters to Predict Functional Recovery after Catheter Ablation Therapy in Patients with Atrial Fibrillation and Left Ventricular Systolic Dysfunction.

Arrhythmia-induced cardiomyopathy (AIC) occurring in patients with atrial fibrillation (AF) is a reversible form of cardiomyopathy characterized by LV systolic dysfunction. However, it is difficult to predict the reversibility before rhythm control therapy. We performed this study to develop a parameter for the identification of AIC in routine transthoracic echocardiography (TTE) in patients with presumptive AIC due to AF.We retrospectively studied 72 patients treated with catheter ablation therapy for persistent AF, and LV ejection fraction (LVEF) ≤ 45%. The patients were divided into 2 groups by follow-up TTE performed within 12 ± 6 months postoperatively. Patients with ≥ 15% improvement in LVEF or ≥ 10% improvement and ≥ 50% in LVEF were classified as the AIC group, and the others were classified as the non-AIC group.A total of 57 (79%) patients were classified as the AIC group. In the stepwise multivariate logistic regression model, LV end-diastolic dimension (LVDd) and e' (septal) were independent predictors of AIC. The sensitivities of LVDd ≤ 53 mm and e' (septal) ≥ 6.3 cm/second were 60% and 75%, respectively. Their specificities were 80% and 67%, respectively. The presence of either LVDd ≤ 53 mm or e' (septal) ≥ 6.3 cm/second had a higher sensitivity (90%); their co-occurrence had a higher specificity (93%) in predicting AIC.The functional recovery in patients with AIC can occur in LV systolic dysfunction without remodeling and impairment of relaxation. The combination of LVDd and e' (septal) is useful in predicting AIC due to AF with routine TTE.

Bachmann's bundle-ridge related biatrial tachycardia with a long epicardial circuit.

Biatrial tachycardia (BiAT), involving Bachmann's bundle in the circuit, has sometimes been observed after mitral anterior line ablation. In this article, we present a case of BiAT, involving a long epicardial circuit, composed of Bachmann's bundle and the left atrial ridge (LAR). We discuss the optimal ablation technique for this tachycardia based on our experience in addition to the relationship between Bachmann's bundle and the LAR. Furthermore, the evaluation method for the mitral anterior block line is also discussed.

Achievement rate and learning curve of left bundle branch capture in left bundle branch area pacing procedure performed to demonstrate output-dependent QRS transition.

INTRODUCTION: Recently, output-dependent QRS transition was reported to be required to confirm left bundle branch (LBB) capture in LBB area pacing (LBBAP) procedure. This study aimed to evaluate the achievement rate and the learning curve of LBB capture in LBBAP procedure performed with the goal of demonstrating output-dependent QRS transition, and investigate predictors of LBB capture. METHODS AND RESULTS: The LBBAP procedure was performed in 126 patients with bradyarrhythmia. LBB capture was defined as a demonstration of output-dependent QRS transition. The following pacing definitions were used for evaluation: (1) LBBAP, which met the previously reported LBBAP criteria, (2) LBB pacing (LBBP), LBB capture was confirmed, and (3) available LBBP, LBB threshold was clinically usable (<3 V at 0.4 ms). The learning curve was evaluated by division into three time-periods. The achievement rates of LBBAP, LBBP, and available LBBP were 88.1%, 41.2%, and 35.7%, respectively. The achievement rates of all three pacing definitions significantly increased with experience (p < .01), but the achievement rate of available LBBP was still 50% in the third period. As predictors of LBB capture, the interval between LBB-Purkinje potential and QRS onset ≥22 ms had high specificity of 98.3%, while R wave peak time in V6 < 68 ms had insufficient sensitivity of 79% and specificity of 68%. CONCLUSION: Even if LBB capture was aimed in LBBAP procedure, it was not easy to achieve, and there was a clear learning curve. Much of LBBAP may be left ventricular septal pacing that does not capture LBB.

Characteristics and proposed mechanisms of QRS morphology observed during the left bundle branch pacing procedure.

BACKGROUND: In performing left bundle branch pacing (LBBP), various QRS morphologies are observed as the lead penetrates the ventricular septum (VS). This study aimed to evaluate these characteristics and infer the mechanism underlying each QRS morphology. METHODS: In 19 patients who met the strict criteria for LBB capture, we classified the QRS morphologies observed during the LBBP procedure into seven patterns, the first five of which were determined by the depth of penetration: right ventricular septal pacing (RVSP), intraventricular septal pacing (IVSP1 and IVSP2), endocardial side of left ventricular septal pacing (LVSeP), nonselective LBBP (NS-LBBP), selective LBBP (S-LBBP), and NS-LBBP with anodal capture. The parameters of the QRS morphologies in these seven patterns were evaluated. RESULTS: Among the first five patterns, stimulus-QRSend duration (s-QRSend) was the narrowest in IVSP1 rather than in NS-LBBP, and stimulus-to-peak of R wave in V6 (s-LVAT) was significantly shortened in two steps, from RVSP to IVSP1 (96 ± 11; 82 ± 8 ms, p < .01) and from LVSeP to NS-LBBP (76 ± 7; 60 ± 4 ms, p < .01). The late-R duration in V1 was significantly prolonged in the order of LVSeP, NS-LBBP, and S-LBBP (45 ± 7; 53 ± 10; 71 ± 15 ms, respectively, p < .01). CONCLUSIONS: s-QRSend was the narrowest in IVSP1 rather than in NS-LBBP among the QRS morphologies observed during lead penetration through the VS. The prolonged late-R duration in V1 and abrupt shortening of the s-LVAT in V6 may help determine LBB capture during lead penetration.

The Impact of Aorto-Mitral Angle on New-Onset Atrial Arrhythmia after Mitral Valve Repair in Patients with Mitral Regurgitation.

In this study, we hypothesized that post-operative aorto-mitral angle might be associated to the occurrence of post-operative atrial arrhythmia (AA), including atrial fibrillation and atrial tachycardia, after mitral valve repair in patients with mitral regurgitation (MR). Thus, this present study aims to determine the effects of post-operative aorto-mitral angle on new-onset AA after mitral valve repair with mitral annuloplasty for the treatment of MR.In total, 172 patients without any history of AA underwent mitral valve repair with mitral annuloplasty in our institution between 2008 and 2017. Patient information, including medical records and echocardiographic data, were retrospectively studied.As per our findings, AA occurred in 15 (8.7%) patients during the follow-up period (median, 35.7 months; range, 0.5-132 months). The patients with AA were noted to have a longer cardiopulmonary bypass time and a smaller aorto-mitral angle at post-operative TTE than the others (119 ± 6° versus 125 ± 10°, P = 0.003). No significant difference was noted in the degree of post-operative residual MR or functional MS between the groups. In a multivariate Cox proportional hazards analysis, the longer cardiopulmonary bypass time and the smaller post-operative aorto-mitral angle were independent predictors of the occurrence of AA during the follow-up period (odds ratio per 10 minutes 1.11; 95% CI 1.02-1.22, P = 0.019: odds ratio 0.91; 95% CI 0.85-0.98, P = 0.012).A small aorto-mitral angle at post-operative TTE was determined to be a predictor of new-onset AA after a mitral valve repair for treating MR.

Etiology of Atrial Functional Mitral Regurgitation: Insights from Transthoracic Echocardiography in 159 Consecutive Patients with Atrial Fibrillation and Preserved Left Ventricular Ejection Fraction.

BACKGROUND: Left atrial (LA) dilatation in patients with atrial fibrillation (AF) can induce functional mitral regurgitation (MR) despite a preserved left ventricular ejection fraction (LVEF). The purpose of this study was to investigate the etiology of this functional MR. METHODS: We retrospectively examined clinical and echocardiographic data from 5,202 consecutive cases that underwent transthoracic echocardiography. AF appeared in 544 patients, and we selected 159 with AF and LVEF ≥50% after excluding patients with other underlying heart diseases. RESULTS: Significant (moderate or greater) degrees of functional MR were seen in 13 (8.2%) patients and were more frequently seen in patients with an AF duration of >10 years than in others (27 vs. 4%, p = 0.0057). Multiple regression analysis revealed that both the LA dimension index and the left ventricular (LV) systolic dimension index were independent determinants of the MR grading. Among the mitral morphologic parameters, the mitral annular (MA) dimension index and the hamstringing phenomenon of the posterior mitral leaflet were independent determinants of MR grading. Significant MR was not seen in patients without LA dilatations, but it occurred in 14% of patients with LA dilatation alone and in 55% with both LA and LV dilatations; the MA dimension index increased in this order. CONCLUSIONS: The grading of functional MR occurring in patients with AF and preserved LVEF depends on both the LA dimension and the LV systolic dimension. The MR grading also depends on both the MA dilatation and the hamstringing phenomenon of the posterior mitral leaflet.

Utility of the combination of simple electrocardiographic parameters for identifying mid-septal pacing.

INTRODUCTION: The electrocardiograms (ECG) criteria to anchor the lead to the right ventricular septum have not been established. This study aimed to identify ECG criteria of pacing at the right ventricular mid septum (RVMS) and investigate whether the paced QRS duration (pQRSd) from the RVMS was narrow. METHODS AND RESULTS: In 42 patients, ECG pacing at the basal anterior wall (BA), mid-anterior wall (MA), apex (AP), and mid septum (MS) was recorded. The pacing sites were validated by using right ventriculography and computed tomography. We estimated the ECG parameters and compared them among the four pacing sites. The combination of simple four paced-ECG parameters could reliably confirm the pacing at the RVMS. The area under the receiver-operating characteristics curve for the number of positive findings among the following: (a) positive QRS in lead aVL, (b) QRS notching in lead I, (c) precordial leads transition at less than V5, and (d) presence of isoelectric QRS in the inferior leads was 0.95 (95% confidence interval, 0.91-0.98) and the number of positive findings (≥3) had a sensitivity of 83.3% and a specificity of 93.7% for discriminating MS from the other sites. The pQRSd with three or more positive findings was significantly narrower than that with less than three positive findings (≥3: 137.4 ± 9.2 ms, <3: 151.8 ± 13.1 ms, P ≤ .05). CONCLUSION: The combination of ECG parameters can help identify right ventricular mid-septal pacing. The use of these parameters may enable the implantation of the pacing lead in the RVMS accurately and obtain a narrower QRS duration.

Efficacy of the current of injury in envisaging the dislodgement of leads implanted in the right atrial septum or the right ventricular septum.

BACKGROUND: The implantation of leads in the right atrial septum (RAS) or the right ventricular septum (RVS) is technically challenging, and dislodgement occurs occasionally. This study aims to determine a predictor for the dislodgement of leads implanted in the RAS or RVS. METHODS: This retrospective cohort study enrolled 137 consecutive patients who underwent the cardiac implantable electronic devices implantation, using active fixation leads in the RAS and RVS. We compared the pacing threshold, R- or P-wave amplitude, slew rate, and presence of the current of injury (COI) between dislodged and nondislodged leads. RESULTS: We performed lead fixation for 74 and 125 times in the RAS and RVS, respectively. Atrial lead dislodgement occurred five times (6.8%) intraoperatively and five times (6.8%) postoperatively, whereas ventricular lead dislodgement occurred eight times (6.4%) intraoperatively and three times (2.4%) postoperatively. Although there were no lead parameters that showed a significant difference common to RAS lead and RVS lead, the presence of the COI was significantly different between nondislodged and dislodged leads in both the RAS and RVS (atrial leads: 57.8% vs 0%, P < 0.001; ventricular leads: 67.5% vs 9.1%, P < 0.001). The positive predictive value of COI presence for predicting no lead dislodgement was 100% and 98.7% in the RAS and RVS, respectively. CONCLUSION: Lead dislodgement is more likely when the COI is absent; documentation of COI should be pursued during lead implantation in challenging sites as the RAS and RVS.

The usefulness of right ventriculography to aid anchoring a pacing lead to the right ventricular septum.

Aims: Although right ventricular septal pacing is thought to be more effective in minimizing pacing-induced left ventricular dysfunction, the accurate way to anchor the lead to the right ventricular septum (RVS) has not been established. Our aim was to clarify the usefulness of right ventriculography (RVG) to aid accurate anchoring of the lead to the RVS. Methods and results: Eighty-four patients who underwent pacemaker implantation were enrolled. We anchored the lead to the RVS by using an RVG image obtained at a 30° right anterior oblique view as a reference. We confirmed the actual lead position by performing computed tomography after the procedure and examined the characteristics of the paced QRS complex. Of the 81 patients, except 3 patients whose leads were anchored to the apex due to high pacing thresholds in the RVS, the leads were successfully anchored to the RVS in the 79 (98%) patients, and the number of leads placed in the high-, mid-, and low-RVS was 3 (4%), 58 (73%), and 18 (23%), respectively. The paced QRS duration in these 79 patients was 140 ± 13 ms. The paced QRS duration from mid-RVS was considerably narrower than that from high- or low-RVS (137 ± 12 ms vs. 146 ± 12 ms; P = 0.012). Conclusion: Right ventriculography was very useful in aiding accurate anchoring of the lead to the RVS. Further, pacing from mid-RVS may be more effective in minimizing the QRS duration than pacing from other RVS sites.

Prevalence and Prognostic Significance of Functional Mitral and Tricuspid Regurgitation Despite Preserved Left Ventricular Ejection Fraction in Atrial Fibrillation Patients.

BACKGROUND: We investigated the prevalence and prognostic significance of functional mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with atrial fibrillation (AF) and preserved left ventricular ejection fraction (LVEF).Methods and Results:We retrospectively studied the cases of 11,021 consecutive patients who had undergone transthoracic echocardiography. AF appeared in 1,194 patients, and we selected 298 with AF and LVEF ≥50% but without other underlying heart diseases. Moderate or greater (significant) degree of functional MR and of TR was seen in 24 (8.1%) and in 44 (15%) patients, respectively (P=0.0045). In contrast, significant MR and TR were more frequently seen in patients with AF duration >10 years (28% vs. 25%, respectively). During the follow-up period of 24±17 months, 35 patients (12%) met the composite endpoint defined as cardiac death, admission due to heart failure, or mitral and/or tricuspid valve surgery. On Cox proportional hazard ratio analysis, both MR and TR grading predicted the endpoint, independently of other echocardiographic parameters. On Kaplan-Meyer analysis, presence of both significant functional MR and TR was associated with poor prognosis, with an event-free rate of only 21% at the mean follow-up period of 24 months. CONCLUSIONS: Significant functional MR and TR are seen in a substantial proportion of patients with longstanding AF, despite preserved LVEF. This MR/TR combination predicts poor outcome for AF patients, who may have to be treated more intensively.

Effective ablation of atrial tachycardia with an epicardial circuit-insights from endocardial scars sites: a case study.

A previous study reported primary macroreentrant atrial tachycardia (AT) in the left atrium (LA), including the epicardial circuit on a left atrial anterior wall (LAAW) scar, without any prior cardiac intervention (Miyazawa et al. in J Cardiovasc Electrophysiol 2019; 30: 263-264). However, determining the target for terminating macroreentrant ATs is challenging. The mapping revealed a centrifugal pattern but did not fully elucidate the AT circuit. The reentrant mechanism of these ATs was confirmed using entrainment pacing. The earliest excitation site (EES) was traditionally selected as the ablation site, typically located in healthy tissue. However, our two cases provide new insights into AT termination, including the epicardial bridge across the endocardial LAAW scar, using minimum ablation points, without the need to ablate the healthy EES.

Enhanced expression of neopterin in valve tissue of bicuspid aortic stenosis.

Background: Aortic valve stenosis (AS) occurs in bicuspid aortic valve (BAV) patients at a relatively young age compared to tricuspid aortic valve (TAV) patients. However, the underlying cause of this phenomenon remains unknown. Neopterin, which is a by-product of the guanosine triphosphate (GTP) pathway, enhances the oxidative potential of reactive oxygen species. To clarify the role of neopterin in the aortic valve, we immunohistochemically studied the presence of neopterin in aortic valve specimens from patients with AS harboring either TAV or BAV. Methods: Frozen aortic valve samples were surgically obtained from 68 patients with severe AS with TAV (n=34) and BAV (n=34). Normal aortic valves were obtained from cadavers who died of non-cardiovascular causes as controls (n=9). Samples were immunohistochemically stained with antibodies against smooth muscle cells, macrophages, T lymphocytes, neopterin, and 4-hydroxy-2-nonenal (4-HNE). Results: Quantitative analysis showed that the percentage of macrophages, 4-HNE- and neopterin-positive macrophage score, and the number of T lymphocytes were significantly higher in BAV patients than in TAV patients (macrophages, P=0.013; T lymphocytes, P=0.011; neopterin, P<0.001; 4-HNE, P=0.008). Double immunostaining for neopterin and macrophages demonstrated that most neopterin-positive cells were macrophages in BAV patients. Conclusions: Neopterin accumulation in macrophages may increase oxidative stress and contribute to the early onset of AS in BAV.

Myeloperoxidase and progression of aortic valve stenosis in patients undergoing hemodialysis.

BACKGROUND AND AIM OF THE STUDY: Currently, there is an increased incidence of aortic valve stenosis (AS) in patients undergoing hemodialysis (HD), though the exact mechanisms are not fully understood. Myeloperoxidase (MPO) is a leukocyte-derived enzyme that catalyzes the formation of reactive oxygen species and is an index of oxidative stress. The study aim was to examine, immunohistochemically, the expression of MPO, using surgically resected aortic valve specimens from AS patients undergoing HD. METHODS: The study population consisted of 15 HD patients and 19 non-HD patients with severe AS undergoing aortic valve replacement. Frozen aortic valve samples obtained surgically from AS patients were stained immunohistochemically with antibodies against smooth muscle cells, neutrophils, macrophages, T lymphocytes, CD31, MPO and 4-hydroxy-2-nonenal (4-HNE). RESULTS: Quantitative analyses showed that the macrophage-positive area, and numbers of T lymphocytes, neutrophils, CD31-positive microvessels and MPO-positive cells in HD patients were significantly higher than in non-HD patients (macrophages, p < 0.0001; T lymphocytes, p < 0.0001; neutrophils, p < 0.0001; CD31, p < 0.0001; MPO, p < 0.0001). Moreover, the number of MPO-positive cells was positively correlated with CD31-positive microvessels and the 4-HNE-positive macrophage score (CD31, R = 0.73, p < 0.0001; 4-HNE, R = 0.49; p < 0.005). CONCLUSION: These findings suggest that MPO is highly expressed in the aortic valves of AS patients undergoing HD. Furthermore, MPO is positively associated with neovascularization and oxidative stress, which contribute to a rapid progression of AS in HD patients.

Erythrocyte-rich thrombus aspirated from patients with ST-elevation myocardial infarction: association with oxidative stress and its impact on myocardial reperfusion.

AIMS: Recent studies have demonstrated that erythrocytes are a potential component in atheromatous lesions and thrombus formation in patients with ST-elevation myocardial infarction (STEMI). The purpose of this study was to determine the associations of red blood cell (RBC) component of coronary thrombi with oxidative stress and myocardial reperfusion. METHODS AND RESULTS: Aspirated thrombi from 178 STEMI patients within 12 h of symptom onset were investigated immunohistochemically using antibodies against platelets, RBCs, fibrin, macrophages, and neutrophils [myeloperoxidase (MPO)]. The thrombi were divided into tertiles according to the percentage of glycophorin-A-positive area: low (glycophorin-A-positive area <33%; n = 60), intermediate (<54 to 33%; n = 59), and high group (≥54%; n = 59). We also measured plasma MPO levels on admission. In the thrombi, the number of MPO-positive cells in the high-RBC group was significantly greater than that in the low-RBC group (high, 927 ± 385; intermediate, 765 ± 406; low, 279 ± 220 cells/mm(2); P< 0.0001). Plasma MPO levels were significantly higher in the high-RBC group than that in the low-RBC group [low 43.1 (25.0-71.6); intermediate 71.0 (32.9-111.2); high 74.3 (31.1-126.4)ng/mL; P< 0.005]. Distal embolization occurred more frequently in the high-RBC group (P= 0.0009). Moreover, the signs of impaired myocardial reperfusion, as indicated by incomplete ST-segment resolution (STR) and lower myocardial blush grades (MBG), and progression of left ventricular remodelling at 6 months were frequently observed in the high-RBC group (high vs. low: STR, P= 0.056; MBG, P< 0.01; remodelling, P< 0.01). CONCLUSION: The present study demonstrated that erythrocyte-rich thrombi contain more inflammatory cells and reflect high thrombus burden, leading to impaired myocardial reperfusion in STEMI patients.

Relationship between oxidative stress and aortic valve stenosis in humans: an immunohistochemical study.

BACKGROUND: Oxidative stress contributes to plaque formation and the destabilization of coronary atherosclerotic lesions. It has been reported that disease processes and clinical risk factors of aortic valve stenosis (AS) are similar to those of atherosclerosis. In this study, we immunohistochemically examined the expression of 4-hydroxy-2-nonenal (4-HNE), an oxidative stress-related molecule, by using surgically resected aortic valve specimens from AS patients. METHODS: The study was conducted using aortic valve specimens, surgically obtained from 24 patients with severe AS undergoing aortic valve replacement. We immunohistochemically investigated frozen aortic valve samples with antibodies against smooth muscle cells, macrophages, CD31 and 4-HNE. RESULTS: Morphometric analysis showed that the percentage of the macrophage-positive area and the number of CD31-positive microvessels were significantly higher in AS patients than those in reference cases (macrophages, p < 0.005 and CD31, p < 0.0001). Furthermore, the 4-HNE-positive macrophage score was also significantly higher in AS patients than in reference cases (p < 0.005). CONCLUSIONS: 4-HNE was expressed in the stenotic aortic valves in patients with severe AS, suggesting a close relationship between oxidative stress and the progression of calcific AS.

Acute impact of atrial fibrillation on pacemaker lead-induced tricuspid regurgitation: Case report.

We report a case of worsening lead-induced tricuspid regurgitation (TR) after new-onset atrial fibrillation (AF) evaluated using three-dimensional (3D) transthoracic echocardiography (TTE) from admission through TR improvement. An 84-year-old man experienced worsening lead-induced TR with new-onset AF, acutely resulting in low output syndrome. Less invasive interventions, such as rhythm control therapy and diuretics administration worked effectively. However, 3DTTE revealed consistent restricted motion of the septal leaflet with lead impingement. Right heart dilatation due to AF and worsened TR led to incomplete closure of other leaflets and tricuspid annular dilatation, which caused further deterioration of the TR. According to the course of our case, new-onset AF can cause acute worsening of lead-induced TR and low output syndrome in patients with cardiac implantable electronic devices (CIED). Our findings emphasize the importance of understanding the TR etiology in patients with CIED, which may prevent unnecessary CIED lead extraction. Learning objective: Lead-induced tricuspid regurgitation (TR) can acutely deteriorate after new onset of atrial fibrillation (AF). AF-induced deterioration of TR may not depend on restricted motion of a leaflet with lead impingement but on incomplete closure of other leaflets caused by right heart and tricuspid annular dilatation. Rhythm control therapy and diuretics administration may improve AF-induced deterioration of lead-induced TR, and should be considered before performing invasive lead extractions.