RESUMEN
BACKGROUND: Coexisting sick sinus syndrome (SSS) is associated with both electrical and structural atrial remodelling in patients with atrial fibrillation (AF). Limited data are available concerning catheter ablation (CA) for AF in this condition. This study investigated the efficacy of CA as a curative therapy for AF and SSS in a large-scale prospective multicentre registry. METHODS: The Kansai Plus Atrial Fibrillation (KPAF) registry enrolled 5,010 consecutive patients who underwent CA for AF; this included 3,133 patients with paroxysmal AF (mean age, 66 years; male, 69.3%; mean CHA2DS2-VASc score, 2.05±1.50; SSS, n=315 [tachy-brady syndrome, n=285]). The endpoints included the recurrence of AF with a blanking period of 90 days after CA, and de novo pacemaker implantation during the follow-up period (median duration, 2.93 years). RESULTS: The AF-free survival did not significantly differ between patients with and those without SSS (n=2,818) after the initial (log-rank p=0.864) and final sessions (log-rank p=0.268). Pacemakers were implanted in 48 patients with SSS, and implantation in this group was significantly associated with AF recurrence, including early recurrence (adjusted odds ratio, 3.57; 95% confidence interval, 1.67-7.64; p=0.002). The remaining 85.3% of patients with SSS did not require pacemaker implantation at 3 years after CA. CONCLUSIONS: Coexisting SSS did not adversely affect recurrence-free survival after CA for paroxysmal AF. Pacemaker implantation was not required in most patients with SSS, with AF recurrence serving as a strong predictor for this.
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Fibrilación Atrial , Ablación por Catéter , Humanos , Masculino , Anciano , Fibrilación Atrial/complicaciones , Fibrilación Atrial/cirugía , Síndrome del Seno Enfermo , Estudios Prospectivos , Sistema de Registros , Resultado del TratamientoRESUMEN
BACKGROUND: The relationship between nutritional status and the incidence or prognosis of atrial fibrillation (AF) has been reported, but no studies have described the relationship between the outcomes of AF catheter ablation (CA) and nutritional status as assessed by various scoring tools. We aimed to verify the hypothesis that preoperative nutritional status is associated with arrhythmia recurrence after CA for AF.MethodsâandâResults:We evaluated 913 patients (age, 67±10 years; men, 72%; paroxysmal AF, 56%) who underwent CA for AF between November 2011 and November 2017. Patients were systematically followed with an endpoint of atrial tachyarrhythmia recurrence, the predictive value of which was compared among 3 scoring tools (Controlling Nutritional Status [CONUT] score / Geriatric Nutritional Risk Index [GNRI] / Prognostic Nutritional Index [PNI]). Patients were divided into normal nutrition (CONUT <2 [n=637] / GNRI >98 [n=836] / PNI >38 [n=910]) and undernutrition (CONUT ≥2 [n=276] / GNRI ≤98 [n=77] / PNI ≤3 [n=3]) groups. AF recurred in 274 patients (mean follow-up, 2.3±0.8 years). The AF recurrence rate was higher in patients with undernutrition than in those with normal nutrition (CONUT/GNRI) status. Multivariate Cox regression analysis identified undernutrition status (GNRI ≤98) as an independent predictor of atrial tachyarrhythmia recurrence. CONCLUSIONS: The AF recurrence rate after CA was higher in patients with undernutrition than in those with normal nutrition as stratified by the nutrition scoring tools.
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Fibrilación Atrial , Ablación por Catéter , Desnutrición , Anciano , Humanos , Masculino , Desnutrición/complicaciones , Persona de Mediana Edad , Estado Nutricional , Pronóstico , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Focal activation is believed to be an atrial fibrillation (AF) driver; however, little is known about whether all focal activations are necessary for AF persistence. The purpose of this study was to assess the electrical nature of focal activation and identify high-priority focal activations using a novel mapping system (CARTOFINDER). Thirty-five patients with persistent AF who underwent catheter ablation were assessed. Cycle length (CL) and CL standard deviation (CLSD) on unipolar recordings and voltage amplitude and electrogram morphologies on bipolar recordings were evaluated at all points of interest. The most frequent CL at each mapping site was defined as the dominant CL. We identified dominant focal activations (DFAs) that had a shorter dominant CL on the integrated CARTOFINDER map. The effect of elimination of DFAs on AF maintenance was assessed by the composite endpoint (termination to sinus rhythm, organization of the rhythm to atrial tachycardia, and AF CL slowing). In all, 450 focal activations were identified among 10,868 points, and 50.4% of focal activations were DFAs. Focal activations showed relatively long CL and regularity with short CLSD. Most focal activations showed an isoelectric baseline and were located outside of the fractionated electrogram area. Both DFAs and non-DFAs were typically observed in the normal voltage range. Elimination of DFAs was achieved in 19 (54.3%) patients, with a remarkable impact on AF maintenance (68.4% vs. 25.0%, p = 0.018). In conclusion, DFAs may play an important role in AF maintenance and could be an attractive therapeutic target for AF.
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Fibrilación Atrial , Ablación por Catéter , Taquicardia Supraventricular , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Técnicas Electrofisiológicas Cardíacas , Humanos , Taquicardia Supraventricular/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: The current study aimed to evaluate changes in electrical depolarization and repolarization parameters after His-bundle pacing (HBP) compared with right ventricular pacing (RVP) and its association with ventricular arrhythmia (VA). METHODS: Forty-one patients (13 with HBP, 14 with RVP, and 14 controls [AAI mode]) were evaluated. After continuous pacing algorithm, QRS duration, QT interval, QTc, JT interval, T-peak to T-end (Tpe), and Tpe/QT ratio were measured on electrocardiography at baseline and 1 week, 1 month, and 6 months postoperatively. We investigated VA occurrence and adverse events after implantation. RESULTS: At 6 months, QRS duration was significantly shorter in the HBP (121.6 ± 15.6 ms) than in the RVP (150.1 ± 14.9 ms) group. The QT intervals were lower in the HBP (424.0 ± 40.9 ms) and control (405.9 ± 23.0 ms) groups than in the RVP (453.0 ± 40.2 ms) group. The Tpe and Tpe/QT ratios at 6 months differed significantly between the HBP and RVP groups (Tpe, 69.8 ± 19.7 ms vs 87.4 ± 11.9 ms and Tpe/QT, 0.16 ± 0.03 vs 0.19 ± 0.02, respectively). The Tpe and Tpe/QT ratios were similarly shortened in the HBP and control groups. VA occurred less frequently in the HBP (15%) and control (7.1%) groups than in the RVP (50%) group (p = 0.020). The non-RVP group showed significantly lower rates of VA and major adverse events than the RVP group. Patients with VA demonstrated significantly longer QRS duration, QT interval, Tpe, and Tpe/QT at 6 months than those without VA. CONCLUSION: HBP showed better depolarization and repolarization stability than RVP.
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Fascículo Atrioventricular , Estimulación Cardíaca Artificial , Arritmias Cardíacas , Electrocardiografía , Frecuencia Cardíaca , Ventrículos Cardíacos , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND: The atrial defibrillation threshold (ADFT) for internal cardioversion is theoretically related to the critical mass for sustaining atrial fibrillation (AF). OBJECTIVE: This study aimed to investigate the association of ADFT for internal cardioversion with the outcome of catheter ablation for non-paroxysmal AF (non-PAF). METHODS: We included 368 consecutive patients who underwent first-time catheter ablation for non-PAF. Based on the degree of ADFT recorded by the internal cardioversion before pulmonary vein isolation, we divided the patients into low ADFT (<20 J) and high ADFT (≥20 J) groups and analysed the association between ADFT and atrial tachyarrhythmia recurrence. RESULTS: There were 234 and 134 patients in the low and high ADFT groups, respectively. Of these, 39 patients (16.7%) and 41 (30.6%) patients, respectively, had atrial tachyarrhythmia recurrence during the 2.6±1.0 year follow-up. The high ADFT group showed a significantly higher atrial tachyarrhythmia recurrence than the low ADFT group (p=0.002). This finding was also noted in patients with long-standing persistent AF (p=0.032) but not in patients with persistent AF (p=0.159). The significant predictors of arrhythmia recurrence on multivariate analysis were high ADFT (p=0.004) and long-standing persistent AF (p=0.011). In multivariate analysis within the long-standing persistent AF group, only ADFT remained a significant risk factor for AF recurrence (p=0.035). CONCLUSIONS: The high ADFT of internal cardioversion was found to be a risk factor for post-catheter ablation recurrence in patients with long-standing persistent AF but not in those with persistent AF.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Cardioversión Eléctrica , Atrios Cardíacos , Humanos , Recurrencia , Resultado del TratamientoRESUMEN
BACKGROUND: The effect of prasugrel over clopidogrel on myocardial salvage in ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) is not fully elucidated. METHODS: Among 854 consecutive STEMI patients who underwent p-PCI, 446 patients were evaluated by two-phase (7 days and 3 months) single-photo emission computed tomography (SPECT). Patients were divided into two groups based on the loading P2Y12 inhibitor. The clopidogrel group was further divided based on the result of platelet function testing. Thus, the prasugrel group included 227 patients; the clopidogrel without high-residual platelet reactivity (HRPR) group, 109 patients; and the clopidogrel with HRPR group, 107 patients. The primary endpoint was the Myocardial Salvage Index (MSI), determined by SPECT. RESULTS: The incidence of final TIMI 0/1 and TIMI myocardial perfusion grade 0/1 was higher in the clopidogrel with HRPR group (0.9%, 1.8%, and 7.5%, P = .002; 19.8%, 29.4%, and 41.1%, P = .0002, in the prasugrel, clopidogrel without HRPR, and clopidogrel with HRPR groups, respectively). The MSI was significantly lower in the clopidogrel with HRPR group (48% [27-66], 44% [30-72], and 36% [15-55], P = .006, respectively). CONCLUSIONS: Prasugrel in STEMI patients was associated with an increased MSI compared with clopidogrel in the presence of HRPR.
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Clopidogrel/uso terapéutico , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/uso terapéutico , Clorhidrato de Prasugrel/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Activación Plaquetaria , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/patología , Infarto del Miocardio con Elevación del ST/terapia , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
AIMS: We aimed to examine the benefits of catheter ablation in patients with non-paroxysmal atrial fibrillation (AF) accompanied by heart failure (HF) with preserved ejection fraction (HFpEF), in comparison with the benefits in patients with AF accompanied by HF with reduced ejection fraction (HFrEF) or patients with no HF. METHODS AND RESULTS: From 1173 consecutive patients undergoing catheter ablation, 502 with non-paroxysmal AF were divided into three groups: no history of HF [plasma B-type natriuretic peptide (BNP) <100 pg/mL and no HF hospitalization; n = 125], HFpEF [left ventricular (LV) EF ≥50%; n = 293], and HF with midrange EF (HFmrEF) + HFrEF (LVEF <50%; n = 84) groups. The endpoints were AF recurrence at 1 year, changes in symptomatic and image-based functional status, and changes in BNP levels from baseline to 1 year. In the HFpEF group, AF recurred in 48 patients (16.4%) and 278 patients (94.8%) had sinus rhythm at 1 year; these values were comparable with those in the other groups. Significant improvement was observed in the left atrial diameter, LVEF, and New York Heart Association functional class in the HFpEF and HFmrEF + HFrEF groups. The BNP level significantly decreased irrespective of the index rate control status, and freedom from AF recurrence was an independent predictor of HF remission, defined as BNP <100 pg/mL at 1 year, in the HFpEF group. CONCLUSION: Catheter ablation is highly feasible for restoring sinus rhythm in non-paroxysmal AF with coexisting HFpEF, thereby improving cardiac function and BNP levels. Catheter ablation for AF may be an optional management strategy.
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Fibrilación Atrial , Ablación por Catéter , Insuficiencia Cardíaca , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Estudios de Factibilidad , Insuficiencia Cardíaca/diagnóstico , Humanos , Péptido Natriurético Encefálico , Pronóstico , Volumen SistólicoRESUMEN
BACKGROUND: Catheter ablation (CA) is effective for recurrent episodes of ventricular fibrillation (VF) in Brugada syndrome (BrS). VF development in BrS is associated with several electrocardiogram (ECG) abnormalities. This study investigated changes in ECG parameters in high-risk BrS patients who underwent epicardial CA.MethodsâandâResults:In all, 27 BrS patients were implanted with an implantable cardioverter-defibrillator (ICD). Patients were divided into 2 groups: (1) an ablation group (n=11) that underwent epicardial CA because of VF recurrence; and (2) a primary prevention (PP) group (n=16) with ICD implantation only. ECG parameters were evaluated before and 12 months after CA and compared with ECG parameters in the PP group. The T wave peak-to-end interval was significantly longer and the number of abnormal spikes in leads V1-V3 at the second, third, and fourth intercostal spaces was greater in the ablation than PP group. After ablation, ST levels and the sum of abnormal spikes in leads V1-V3 were significantly decreased. The mean (±SD) number of ICD shocks decreased markedly during a mean follow-up period of 42.0 months (from 3.8±3.7 to 0.2±0.4/year). Four patients had an ICD shock following the ablation procedure. Greater reductions in ST-segment elevation and abnormal spikes were observed in the group without than with VF recurrence. CONCLUSIONS: Improvements in surface ECG parameters appear to be associated with successful ablation in high-risk BrS patients.
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Síndrome de Brugada , Ablación por Catéter , Síndrome de Brugada/cirugía , Desfibriladores Implantables , Electrocardiografía , Humanos , Fibrilación Ventricular/cirugíaRESUMEN
Cardiac resynchronization therapy (CRT) improves functional mitral regurgitation (MR); however, the mechanism and differences in acute and late improvement in MR are unclear. We aimed to evaluate the factors associated with the acute and late MR improvements and the prognosis of MR improvement after CRT. This retrospective study included 121 patients who underwent CRT implantation with full echocardiography assessment at baseline, 1 week, and 6 months after implantation. MR severity was classified into five grades (0: none to 4: severe). Two-dimensional speckle-tracking echocardiography with radial strain was used to assess dyssynchrony, and the time difference between the lateral and inferior segments at papillary muscle levels (TDlate-inf) was calculated. The MR improved 1 week and 6 months after CRT in 40 (33%) and 45 (37%) patients, respectively. On multivariate analyses, TDlate-inf (baseline-1 week) and SPWMD were independently associated with acute MR improvement. The %reduction in left ventricular end-systolic volume (LVESV) (baseline-6 months) and TDlate-inf (baseline-1 week) were independently correlated with late MR improvement. The patients with pre-MR grades 2-4 and improved MR after CRT showed significantly better prognosis in heart failure hospitalization. Cutoff values of ≥ 19.5 ms of the reduction of TDlate-inf and ≥ 30.8% of the %reduction of LVESV were significantly associated with the decrease in heart failure hospitalization. The improved interpapillary muscle activation time delay and volume reduction after CRT were associated with acute and late MR improvements. There may be different time course of recovery and distinct causes for late MR improvement.
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Terapia de Resincronización Cardíaca/métodos , Ventrículos Cardíacos/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/terapia , Marcapaso Artificial , Músculos Papilares/fisiopatología , Remodelación Ventricular/fisiología , Enfermedad Aguda , Anciano , Progresión de la Enfermedad , Ecocardiografía , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/fisiopatología , Músculos Papilares/diagnóstico por imagen , Pronóstico , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
There have been no reports evaluating the impact of long-acting loop diuretics (LLD) on the outcome of heart failure (HF) and arrhythmia treatment in HF with reduced ejection fraction (HFrEF) patients implanted with a cardiac resynchronization therapy (CRT) device.This was a prospective, single-blind, randomized crossover study. We allocated 21 consecutive CRT implanted patients into 2 groups. The furosemide group received furosemide as a first treatment and azosemide as a second treatment. The azosemide group received this treatment in the reverse order. The first treatment was given to each group for 6 months and the second treatment continued for an additional 6 months. We combined the data of each medication regimen in each group and analyzed it at baseline, 6 months, and 1 year. The primary endpoints were the variation of fluid index and thoracic impedance measured by CRT at 6 months.The baseline characteristics were similar for both groups. The difference in the primary endpoints was not statistically significant between the 2 medication arms (fluid index: -29.6 ± 64.4 versus 16.2 ± 48.2; P = 0.22, thoracic impedance: -0.49 ± 17.8 versus 2.45 ± 12.5; P = 0.56). Likewise, the clinical outcome of HF and the CRT derived parameters in both arms were comparable.HFrEF patients taking LLD after CRT implantation might be comparable to those taking short-acting loop diuretics in the treatment of HF and HF-associated arrhythmias.
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Arritmias Cardíacas/inducido químicamente , Terapia de Resincronización Cardíaca , Insuficiencia Cardíaca/tratamiento farmacológico , Inhibidores del Simportador de Cloruro Sódico y Cloruro Potásico/efectos adversos , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Estudios Cruzados , Femenino , Insuficiencia Cardíaca/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Volumen SistólicoRESUMEN
Previous studies reporting that statin increases coronary artery calcium (CAC) were conducted exclusively on patients with statin as a prevention, regardless of the presence or absence of dyslipidemia. The impact of sex on CAC has not been fully evaluated. We aimed to determine the association of dyslipidemia and sex with CAC using 320-row multi-detector computed tomography (MDCT).Of the 356 consecutive patients who underwent coronary MDCT, 251 patients were enrolled, after excluding those with prior stenting and/or coronary bypass grafting or images showing motion artifacts. The primary outcome measures were the percent calcium volume (PCV) and percent atheroma volume (PAV) per coronary vessel.Multivariable analyses indicated that PCV was significantly higher in dyslipidemia patients without statins than in the subjects without dyslipidemia [partial regression coefficient (PRC): 2.59, 95% confidence interval (CI): 0.83 to 4.34, P = 0.004]. In contrast, PCV was similar in dyslipidemia patients taking statins and those without dyslipidemia (PRC: -1.09, 95% CI: -2.82 to 0.65, P = 0.22). There was no significant difference in PCV between men and women, although women exhibited a significantly lower PAV (PRC: -2.87, 95% CI: -4.54 to -1.20, P = 0.001).In low-risk patients, these results could be translated into hypotheses, which should be tested in future prospective studies. Furthermore, there was no significant difference in CAC between men and women, but women had lower PAV than men.
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Calcio/metabolismo , Angiografía por Tomografía Computarizada/métodos , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/etiología , Vasos Coronarios/metabolismo , Dislipidemias/metabolismo , Calcificación Vascular/metabolismo , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/epidemiología , Vasos Coronarios/diagnóstico por imagen , Dislipidemias/complicaciones , Dislipidemias/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Japón/epidemiología , Masculino , Persona de Mediana Edad , Tomografía Computarizada Multidetector/métodos , Estudios Prospectivos , Medición de Riesgo/métodos , Distribución por Sexo , Factores Sexuales , Factores de Tiempo , Calcificación Vascular/complicaciones , Calcificación Vascular/diagnósticoRESUMEN
BACKGROUND: Real-time phase mapping (ExTRa™) is useful in determining the strategy of catheter ablation for non-paroxysmal atrial fibrillation (AF). This study aimed to investigate the features of drivers of AF associated with its termination during ablation. METHODS: Thirty-six patients who underwent catheter ablation for non-paroxysmal AF using online real-time phase mapping (ExTRa™) were enrolled. A significant AF driver was defined as an area with a non-passively activated ratio of ≥ 50% on mapping analysis in the left atrium (LA). All drivers were simultaneously evaluated using a low-voltage area, complex fractionated atrial electrogram (CFAE), and rotational activity by unipolar electrogram analysis. The electrical characteristics of drivers were compared between patients with and without AF termination during the procedure. RESULTS: Twelve patients achieved AF termination during the procedure. The total number of drivers detected on the mapping was significantly lower (4.4 ± 1.6 vs. 7.4 ± 3.8, p = 0.007), and the drivers were more concentrated in limited LA regions (2.8 ± 0.9 vs. 3.9 ± 1.4, p = 0.009) in the termination group than in the non-termination group. The presence of drivers 2-6 with limited (≤ 3) LA regions showed a tenfold increase in the likelihood of AF termination, with 83% specificity and 67% sensitivity. Among 231 AF drivers, the drivers related to termination exhibited a greater overlap of CFAE (56.8 ± 34.1% vs. 39.5 ± 30.4%, p = 0.004) than the non-related drivers. The termination group showed a trend toward a lower recurrence rate after ablation (p = 0.163). CONCLUSIONS: Rotors responsible for AF maintenance may be characterized in cases with concentrated regions and fewer drivers on mapping.
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Fibrilación Atrial , Ablación por Catéter , Humanos , Fibrilación Atrial/cirugía , Atrios Cardíacos/cirugía , Ablación por Catéter/métodos , Técnicas Electrofisiológicas Cardíacas/métodos , Resultado del TratamientoRESUMEN
Functional mitral regurgitation (FMR) often coexists with atrial fibrillation (AF) and may have a causal relation with AF persistence and exacerbation of heart failure (HF). The purpose of this study was to investigate the impact of FMR on AF catheter ablation (AFCA) outcomes and improvement in FMR after AFCA in patients with HF with preserved ejection fraction (HFpEF) and nonparoxysmal AF. Excluding patients with primary valve disease or post-mitral valve repair, 280 patients with HFpEF who underwent CA for nonparoxysmal AF were retrospectively included. All patients completed 1-year follow-up and were assessed for FMR, AF recurrence and HF parameters, including echocardiography. At baseline, FMR was present in 153 (54.6%) patients (mild, n = 112; moderate, n = 40; severe, n = 1), and these were decreased to 70 (25%) significantly 1 year after AFCA (mild, n = 64; moderate, n = 6), 119 patients (78%) had improvement in MR (a decrease of ≥1 level in the severity from baseline to 1 year on echocardiography). Overall, 274 patients (97.9%) had sinus rhythm at the 1-year examination, and recurrent AF-free survival did not differ in patients with and without MR improvement (83.2% vs 82.4%, p = 0.908). However, the MR improvement group had a significantly lower cardiothoracic ratio, left atrial diameter, E/e', and B-type natriuretic peptide levels after 1 year than those in the MR nonimprovement group. In conclusion, the majority of the HFpEF patients with nonparoxysmal AF had improvement of FMR after AFCA with the high maintenance of sinus rhythm, leading to a virtuous cycle of cardiac function.
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Fibrilación Atrial , Ablación por Catéter , Insuficiencia Cardíaca , Insuficiencia de la Válvula Mitral , Humanos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/cirugía , Fibrilación Atrial/diagnóstico , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico , Resultado del Tratamiento , Volumen Sistólico , Estudios Retrospectivos , Ablación por Catéter/efectos adversosRESUMEN
BACKGROUND: Catheter ablation for ventricular tachycardia (VT) is associated with perioperative thromboembolic risk. However, the strategy for postprocedural management remains unknown. OBJECTIVES: The aim of this study was to evaluate the prothrombotic response after VT ablation in various coagulation biomarkers in patients with and without the administration of oral anticoagulation (OAC). METHODS: Data from 112 patients (58 with uninterrupted OAC and 54 without) with structural heart disease who underwent endocardial VT ablation were retrospectively analyzed. We also included 41 patients who underwent ablation for premature ventricular contraction from the right ventricle and 13 patients who underwent electrophysiology study (the control group). Blood samples of coagulation markers were collected before and 3 days after the procedure in all patients. RESULTS: The percentage of D-dimer levels ≤1.0 µg/mL at baseline was lower in the VT ablation groups (76% and 50% in the OAC and non-OAC groups, respectively) than in the other groups (100%). After 3 days, the percentage remained at 67% in the OAC group; however, the non-OAC VT group demonstrated a remarkable decrease of 20%. Similarly, fibrin monomer complex, thrombin antithrombin, and prothrombin fragment 1+2 levels were well suppressed in the control, premature ventricular contraction, and OAC groups. However, the non-OAC group demonstrated increased coagulation markers both before and after 3 days. Multivariate analysis demonstrated that OAC administration and normal coagulation markers at baseline were independent predictors of stable coagulation status after ablation. CONCLUSIONS: The coagulation cascade was significantly activated in patients undergoing VT ablation. Uninterrupted OAC administration suppressed the coagulation response, which might be associated with a reduction in perioperative prothrombotic risk.
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Ablación por Catéter , Taquicardia Ventricular , Complejos Prematuros Ventriculares , Anticoagulantes/efectos adversos , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Humanos , Estudios Retrospectivos , Taquicardia Ventricular/cirugía , Complejos Prematuros Ventriculares/cirugíaRESUMEN
The risk for developing left atrial (LA) thrombi after initial catheter ablation for atrial fibrillation (AF) and requirements for imaging evaluation for thrombi screening at repeat ablation is unclear. This study aimed to assess the occurrence of thrombus development and frequency of any imaging study evaluating thrombus formation during repeat ablation for AF. Of 2,066 patients undergoing initial catheter ablation for AF with uninterrupted oral anticoagulation, 615 patients underwent repeat ablation after 258.0 (105.0-882.0) days. We investigated the factors associated with safety outcomes and requirements for thrombus screening. All patients underwent at least one imaging examination to screen for thrombi in the initial session; however, the examination rate decreased to 476 patients (77%) before the repeat session. The frequency of imaging evaluations was 5.0%, 11%, 21%, 84%, and 91% for transesophageal echocardiography and 18%, 33%, 49%, 98%, and 99% for any imaging modality at repeat ablation performed ≤60 days, ≤90 days, ≤180 days, >180 days, and >1 year after the initial session, respectively. Three patients (0.5%) developed LA thrombi at repeat ablation due to identifiable causes, and no patients experienced thromboembolic events when no imaging evaluation was performed. Multivariate analysis revealed that repeat ablation performed after >180 days, non-paroxysmal atrial arrhythmias, and lower left ventricular ejection fraction were predictors of thrombus development and severe spontaneous echocardiography contrast. In conclusion, the risk for thrombus development at repeat ablation for AF was low. There needs to be a risk stratification of the imaging screening for thrombi at repeat ablation.
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Fibrilación Atrial/complicaciones , Ablación por Catéter , Ecocardiografía Transesofágica/métodos , Vigilancia de la Población/métodos , Trombosis/epidemiología , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Femenino , Estudios de Seguimiento , Atrios Cardíacos , Cardiopatías/diagnóstico , Cardiopatías/epidemiología , Cardiopatías/etiología , Humanos , Incidencia , Japón/epidemiología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Trombosis/diagnóstico , Trombosis/etiologíaRESUMEN
A key to the success of catheter ablation in complex congenital heart disease is an accurate delineation of the anatomy. Here we describe the efficiency of intracardiac echocardiogram in guiding the catheter ablation of persistent atrial fibrillation in a 55-year-old Japanese male with cor triatriatum sinister. Echo imaging provided a detailed three-dimensional anatomy of the whole left atrium and identified an ideal trans-septal puncture site that allowed catheter access to both the accessory and main chambers of the left atrium. We review similar cases from the literature.
RESUMEN
Data on the efficacy of excimer laser coronary atherectomy (ELCA) for patients with ST-elevation myocardial infarction (STEMI) are limited. Therefore, we sought to evaluate the impact of ELCA on myocardial salvage using nuclear scintigraphy in patients with STEMI. Between September 2014 and April 2017, we retrospectively enrolled 316 consecutive patients undergoing primary PCI (p-PCI) after their first STEMI in our institute. Of those, 72 patients with STEMI, an initial thrombolysis in myocardial infarction (TIMI) flow-0/1, and an onset to balloon time (OBT) < 6 h were included (ELCA, n = 32; non-ELCA, n = 40). The endpoint was the myocardial salvage index (MSI) based on a 17-segment model with a 5-point scoring system. MSI was calculated as: MSI = (∑123I-BMIPP defect score at 3-7 days after p-PCI - ∑99mTc-tetrofosmin defect score at 3-6 months after p-PCI)/∑123I-BMIPP defect score × 100 (%) at 3-7 days after p-PCI. The groups were compatible except in age (ELCA: 62.9 ± 12.4 years vs. non-ELCA: 69.8 ± 11.0 years) and loading antiplatelet drug (prasugrel: 100% vs. 40.0%). Direct implantation of shorter stents more frequently occurred in the ELCA group than in the non-ELCA group. MSI seemed to be better in the ELCA group compared with the non-ELCA group (57.6% vs. 45.6%, p = 0.09). This trend was emphasized when the final TIMI-3 flow was achieved (67.1% vs. 45.7%, p = 0.01). The nuclear scintigraphy results showed that ELCA can potentially improve myocardial salvage in patients with STEMI with OBT < 6 h and initial TIMI flow-0/1.
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Aterectomía Coronaria/instrumentación , Láseres de Excímeros/uso terapéutico , Imagen de Perfusión Miocárdica/métodos , Miocardio/patología , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Tomografía Computarizada de Emisión de Fotón Único , Anciano , Toma de Decisiones Clínicas , Ácidos Grasos/administración & dosificación , Estudios de Factibilidad , Femenino , Humanos , Yodobencenos/administración & dosificación , Masculino , Persona de Mediana Edad , Compuestos Organofosforados/administración & dosificación , Compuestos de Organotecnecio/administración & dosificación , Selección de Paciente , Intervención Coronaria Percutánea/instrumentación , Valor Predictivo de las Pruebas , Radiofármacos/administración & dosificación , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/patología , Stents , Factores de Tiempo , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
BACKGROUND: Preprocedural clinical predictors of the successful maintenance of sinus rhythm may contribute to optimal treatment strategies for atrial fibrillation (AF). The CAAP-AF score, a novel simple tool scored as 0-13 points (including six independent variables) has been proposed to predict long-term freedom from AF after catheter ablation. To clarify its reproducibility, we examined the CAAP-AF score's predictive performance and then created subgroups to best predict AF recurrence by using a machine learning algorithm. METHODS: We studied 583 consecutive patients who underwent initial AF catheter ablation at our institute (median CAAP-AF score, 5; age, 66 ± 10 years old; female, 28.3%; coronary artery disease, 10.8%; left atrial diameter, 39.9 ± 6.6 mm; number of antiarrhythmic drugs failed, 0.4 ± 0.6; nonparoxysmal AF, 45.3%). All were systematically followed up with an endpoint of atrial tachyarrhythmia recurrence after the last ablation procedure. RESULTS: During the 1.8 ± 1.2-year follow-up, 157 patients had atrial tachyarrhythmia recurrence. Repeated procedures were performed (n = 115). Arrhythmia recurrence after the last session occurred in 69 patients. We created Kaplan-Meier curves for freedom from AF after final AF ablation for ranges of CAAP-AF scores; these confirmed the original study results. The machine learning using Classification and Regression Trees divided the patients into three categories by the risk score: low (score ≤5), intermediate (score 6-8), and high (score ≥9). CONCLUSIONS: The CAAP-AF score was useful to stratify the atrial tachyarrhythmia recurrence risk in AF patients undergoing catheter ablation into three categories. The score should be considered when deciding whether to perform AF ablation in clinical practice.
RESUMEN
Exercise-induced vasospastic angina (VSA) is an uncommon entity of coronary artery disease. Here, we report a case of exercise-induced VSA, which was detected by exercise stress myocardial perfusion imaging.
Asunto(s)
Angina de Pecho/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Vasoespasmo Coronario/diagnóstico por imagen , Imagen de Perfusión Miocárdica , Angina de Pecho/tratamiento farmacológico , Angina de Pecho/fisiopatología , Circulación Coronaria , Vasoespasmo Coronario/tratamiento farmacológico , Vasoespasmo Coronario/fisiopatología , Dihidropiridinas/uso terapéutico , Prueba de Esfuerzo , Humanos , Masculino , Persona de Mediana Edad , Esfuerzo Físico , Valor Predictivo de las Pruebas , Vasoconstricción , Vasodilatadores/uso terapéuticoRESUMEN
Coronary vasospasm is an emerging potentially lethal complication of catheter ablation for atrial fibrillation (AF), however, its mechanism in this setting has not been well elucidated. A 55-year-old man with symptomatic paroxysmal AF underwent pulmonary vein isolation under sedation with propofol. The procedure was completed without any complications. Fifteen months later, a repeated session was performed because of AF recurrence. Initially, a high-dose infusion of dexmedetomidine instead of propofol was administered to introduce sedation. Then, an ST-segment elevation developed in the inferior leads and the diagnosis of coronary vasospasm was made by urgent coronary angiography. A comparison of the procedural details between the first and second sessions identified dexmedetomidine, an α-2 adrenergic agonist with a short distribution half-life, as a potential cause of coronary vasospasm seen only in the second session in the same individual. Since it has been shown that α-2 adrenoreceptor-mediated vasoconstriction can involve the coronary circulation, it is thus possible that a stimulation of α-2 adrenergic receptors induced by dexmedetomidine caused a coronary vasospasm. The present case provides new insights into dexmedetomidine-induced vasospasm. Physicians should be aware of this potentially lethal side effect of dexmedetomidine which is increasingly used in the current AF ablation practice.