Prognostic Implication of Platelet Reactivity According to Left Ventricular Systolic Dysfunction Status in Patients Treated With Drug-Eluting Stent Implantation: Analysis of the PTRG-DES Consortium.

BACKGROUND: Coronary artery disease patients undergoing percutaneous coronary intervention (PCI) often exhibit reduced left ventricular ejection fraction (LVEF). However, the impact of LV dysfunction status in conjunction with platelet reactivity on clinical outcomes has not been previously investigated. METHODS: From the multicenter PTRG-DES (Platelet function and genoType-Related long-term prognosis in DES-treated patients) consortium, the patients were classified as preserved-EF (PEF: LVEF ≥ 50%) and reduced-EF (REF: LVEF< 5 0%) group by echocardiography. Platelet reactivity was measured using VerifyNow P2Y12 assay and high platelet reactivity (HPR) was defined as PRU ≥ 252. The major adverse cardiac and cerebrovascular events (MACCEs) were a composite of death, myocardial infarction, stent thrombosis and stroke at 5 years after PCI. Major bleeding was defined as Bleeding Academic Research Consortium bleeding types 3-5. RESULTS: A total of 13,160 patients from PTRG-DES, 9,319 (79.6%) patients with the results of both PRU and LVEF were analyzed. The incidence of MACCE and major bleeding was higher in REF group as compared with PEF group (MACCEs: hazard ratio [HR] 2.17, P < 0.001, 95% confidence interval [CI] 1.85-2.55; major bleeding: HR 1.78, P < 0.001, 95% CI 1.39-2.78). The highest rate of MACCEs was found in patients with REF and HPR, and the difference between the groups was statistically significant (HR 3.14 in REF(+)/HPR(+) vs. PEF(+)/HPR(-) group, P < 0.01, 95% CI 2.51-3.91). The frequency of major bleeding was not associated with the HPR in either group. CONCLUSION: LV dysfunction was associated with an increased incidence of MACCEs and major bleeding in patients who underwent PCI. The HPR status further exhibited significant increase of MACCEs in patients with LV dysfunction in a large, real-world registry. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04734028.

Safety and efficacy of intracardiac echocardiography-guided zero-fluoroscopic cryoballoon ablation for atrial fibrillation: a prospective randomized controlled trial.

AIMS: The development of intracardiac echocardiography (ICE) has enabled fluoroless atrial fibrillation (AF) ablation using three-dimensional electroanatomical mapping systems. However, fluoroless cryoballoon ablation (CBA) remains challenging, mainly because of the lack of a visual mapping system. Hence, this study aimed to investigate the safety and efficacy of fluoroless CBA for AF under ICE guidance. METHODS AND RESULTS: Patients (n = 100) who underwent CBA for paroxysmal AF were randomly assigned to zero-fluoroscopic (Zero-X) and conventional groups. Intracardiac echocardiography was used to guide the transseptal puncture and catheter and balloon manipulation in all enrolled patients. The patients were prospectively followed for 12 months after CBA. The mean age was 60.4 years, and the left atrial (LA) size was 39.4 mm. Pulmonary vein isolation (PVI) was achieved in all patients. In the Zero-X group, fluoroscopy was used in only one patient because of unstable phrenic nerve capture during right-sided PVI. The procedure time and LA indwelling time in the Zero-X group were not statistically different compared with that in the conventional group. Fluoroscopic time (9.0 vs. 0.008 min) and radiation exposure (29.4 vs. 0.02 mGy) were significantly shorter in the Zero-X group than in the conventional group (P < 0.001). The complication rate did not differ between the two groups. During a mean follow-up of 663.3 ± 172.3 days, the recurrence rate was similar (16.0 vs. 18.0%; P = 0.841) between the groups. Multivariate analysis revealed that LA size was the only independent predictor of clinical recurrence. CONCLUSION: Intracardiac echocardiography-guided fluoroless CBA for AF was a feasible strategy without compromising acute and long-term success or complication rates.

Bleeding risk in patients with atrial fibrillation treated with combined anti-platelet and non-vitamin K antagonist oral anticoagulant therapy.

BACKGROUND: The use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation (AF) has been increasing. Accordingly, the combined use of antiplatelet agents (APT) and NOAC therapy is commonly encountered in clinical practice. The purpose of this study was to compare the clinical outcomes between combination therapy (NOAC and APT) vs. monotherapy (NOAC only) in patients with AF. METHODS: We retrospectively analyzed patients who were prescribed NOACs between January 2012 and December 2016. The primary outcome was major bleeding and any bleeding events, and the secondary outcomes were stroke/systemic embolic (SE) events and major adverse cardiac events (MACE). RESULTS: Of the 1068 participants, there were 264 (24.7%) patients in the combination therapy group. The prevalence of diabetes (p = 0.017) and history of stroke and transient ischemic attacks (p < 0.001) was higher in the combination group than in the monotherapy group. During the mean 14.6 ± 9.8 months of follow-up, the incidence of any bleeding was significantly higher in the combination therapy group than in the monotherapy group (p < 0.001). The rate of major bleeding, stroke/SE, and MACE between the two groups was similar. The rate of under-dosage NOAC prescriptions was higher in the combination therapy group than in the monotherapy group (p = 0.024). CONCLUSIONS: The combination therapy group had higher incidences of any bleeding events compared to the monotherapy in patients with appropriate dosing. However, there was no difference in stroke/SE, and MACE. The bleeding risk in AF patients taking the combination of NOACs and APT should be carefully evaluated.

Does isolation of the left atrial posterior wall using cryoballoon ablation improve clinical outcomes in patients with persistent atrial fibrillation? A prospective randomized controlled trial.

AIMS: Posterior wall isolation (PWI) of the left atrium (LA) adjunct to pulmonary vein isolation (PVI) by radiofrequency catheter ablation has shown favourable outcomes in patients with persistent atrial fibrillation (PeAF). This study was sought to investigate the efficacy and safety of additional PWI by cryoballoon ablation (CBA) alone in patients with PeAF. METHODS AND RESULTS: Patients who underwent de novo CBA for PeAF (n = 100) were randomly assigned (1 : 1) to the PVI only group and PVI combined with PWI (PVI+PWI) group. Procedural and clinical outcomes were prospectively compared over a 12-month follow-up.Baseline characteristics, including mean AF duration (56.2 ± 43.2 months) and LA size (48.2 ± 7.7 mm), were well-balanced between the groups. Successful PVI was achieved in all patients. In the PVI+PWI group, complete PWI by CBA was achieved in 31 (62%) patients. The LA indwelling and procedure times were significantly longer in the PVI+PWI group. The complication rates were not different between groups. During a mean follow-up of 457.9 ± 61.8 days, the recurrence rate of atrial tachyarrhythmia was significantly lower in the PVI+PWI group than in the PVI only group (24% vs. 46%; P = 0.035). The recurrence-free survival rate was significantly higher in the PVI+PWI group compared with the PVI only group, irrespective of complete PWI (log-rank P = 0.013). Multivariate analysis showed that adjunctive PWI [hazard ratio (HR) 0.255; P = 0.003] and LA size (HR 1.079; P = 0.014) were independent predictors of clinical recurrence. CONCLUSION: Compared with PVI only, adjunctive PWI achieved exclusively by CBA resulted in better clinical outcomes without increasing complications in patients with PeAF.

Prognostic Impact of In-Hospital Use of Mechanical Cardiopulmonary Resuscitation Devices Compared with Manual Cardiopulmonary Resuscitation: A Nationwide Population-Based Observational Study in South Korea.

Background and Objectives: This study analyzed the prognostic impact of mechanical cardiopulmonary resuscitation (CPR) devices in out-of-hospital cardiac arrest (OHCA) patients, in comparison to manual CPR. Materials and Methods: This study was a nationwide population-based observational study in South Korea. Data were retrospectively collected from 142,905 OHCA patients using the South Korean Out-of-Hospital Cardiac Arrest Surveillance database. We included adult OHCA patients who received manual or mechanical CPR in the emergency room. The primary outcome was survival at discharge and the secondary outcome was sustained return of spontaneous circulation (ROSC). Statistical analysis included propensity score matching and multivariate logistic regression. Results: A total of 19,045 manual CPR and 1125 mechanical CPR cases (671 AutoPulseTM vs. 305 ThumperTM vs. 149 LUCASTM) were included. In the matched multivariate analyses, all mechanical CPR devices were associated with a lower ROSC than that of manual CPR. AutoPulseTM was associated with lower survival in the multivariate analysis after matching (aOR with 95% CI: 0.57 (0.33-0.96)), but the other mechanical CPR devices were associated with similar survival to discharge as that of manual CPR. Witnessed arrest was commonly associated with high ROSC, but the use of mechanical CPR devices and cardiac origin arrest were associated with low ROSC. Only target temperature management was the common predictor for high survival. Conclusions: The mechanical CPR devices largely led to similar survival to discharge as that of manual CPR in OHCA patients; however, the in-hospital use of the AutoPulseTM device for mechanical CPR may significantly lower survival compared to manual CPR.

Characteristics and prognosis of patients with cryptogenic stroke and suggestive of patent foramen ovale.

AIMS: The purpose of this study were to identify the usefulness of screening for PFO using agitated saline echocardiography (ASE) and characteristics and prognosis of patients with suggestive of patent foramen ovale (PFO). METHODS: Three hundred three patients (mean age, 53 ± 9 years; 199 [66%] men) admitted with acute stroke or suspicion of stroke were included. Patients were classified into those with and without right-to-left shunt (RLS) according to the ASE results (positive ASE [n = 92] vs. negative ASE [n = 211]). Fifty-one out of ninety-two patients with positive ASE and twenty-one out of two hundred eleven patients with negative ASE underwent TEE with ASE to confirm PFO. RESULTS: Ninety-two were positive for ASE and thirty-six of the fifty-one patients who underwent TEE were confirmed as having PFO. Of the patients with RLS grade 1, 50% were diagnosed with PFO and all patients with RLS grade ≥ 2 were diagnosed with PFO. All patients with negative ASE had no PFO (sensitivity of 100% and specificity of 58%). Patients with positive ASE were younger, had a lower body mass, and a lower prevalence of hypertension. The positive ASE patients had a higher mean S' velocity and better diastolic function. Four of ninety-one patients with positive ASE and thirteen of one hundred seventy-seven showed recurrence of stroke and suspicion of stroke. CONCLUSION: Transthoracic ASE is a good method to screen for PFO. Patients with suggestive of PFO had lower risk factors, less atherosclerosis, and better cardiac performance.

Features of Patients Receiving Extracorporeal Membrane Oxygenation Relative to Cardiogenic Shock Onset: A Single-Centre Experience.

Background and Objectives: Extracorporeal membrane oxygenation (ECMO) can be helpful in patients with cardiogenic shock associated with myocardial infarction, and its early use can improve the patient survival rate. In this study, we report a mortality rate-difference analysis that examined the time and location of shock occurrence. Materials and Methods: We enrolled patients who underwent ECMO due to cardiogenic shock related to myocardial infarction and assigned them to either a pre- or post-admission shock group. The primary outcome was the 1-month mortality rate; a subgroup analysis was conducted to assess the effect of bailout ECMO. Results: Of the 113 patients enrolled, 67 (38 with pre-admission shock, 29 with post-admission shock) were analysed. Asystole was more frequently detected in the pre-admission shock group than in the post-admission group. In both groups, the commonest culprit lesion location was in the left anterior descending artery. Cardiopulmonary resuscitation was performed significantly more frequently and earlier in the pre-admission group. The 1-month mortality rate was significantly lower in the pre-admission group than in the post-admission group. Male sex and ECMO duration (≥6 days) were factors significantly related to the reduced mortality rate in the pre-admission group. In the subgroup analysis, the mortality rate was lower in patients receiving bailout ECMO than in those not receiving it; the difference was not statistically significant. Conclusions: ECMO application resulted in lower short-term mortality rate among patients with out-of-hospital cardiogenic shock onset than with in-hospital shock onset; early cardiopulmonary resuscitation and ECMO might be helpful in select patients.

Efficacy of high-power and short-duration ablation in patients with atrial fibrillation: a prospective randomized controlled trial.

AIMS: The formation of radiofrequency lesions depends on the power and duration of ablation, and the contact force (CF). Although high power (HP) creates continuous and transmural lesions, most centres still use 25-30 W for 30-40 s for safety reasons. We evaluated the clinical efficacy and safety of a HP and short-duration (HPSD) strategy for atrial fibrillation (AF) ablation. METHODS AND RESULTS: One hundred and fifty patients [58.2 ± 10.0 years, 48% with paroxysmal AF (PAF)] scheduled for index AF ablation using a CF-sensing catheter were randomly assigned to three groups [30 W, 40 W, and 50 W at ablation sites of anterior, roof, and inferior segments of pulmonary vein (PV) antra and roof line between each upper PV]. In 25-30 W for ≤20 s was applied at posterior wall ablation site in all subjects. Compared with the 30 W and 40 W groups, procedure (P < 0.001) and ablation times (P < 0.001) were shorter and ablation number for PV isolation (P < 0.001) was smaller in the 50 W group. There were no significant differences in the CF and ablation index (AI) among the three groups. There were no significant differences in the procedure-related complication rates. During the 12-month follow-up, AF recurred in 24 (16%) patients with no significant difference among the groups (P = 0.769). In the multivariate analysis, non-PAF [hazard ratio (HR) 2.836, P = 0.045] and AI (HR 0.983, P = 0.001) were independent risk factors for AF recurrence. CONCLUSION: Radiofrequency ablation with HPSD is a safe and effective strategy with reduced ablation number and shortened procedure time compared to conventional ablation.

Clinical Outcomes of Intracardiac Echocardiography-Guided Contrast Agent-Free Cryoballoon Ablation in Atrial Fibrillation Patients With Renal Insufficiency.

BACKGROUND AND OBJECTIVES: Previous studies have reported an association between impaired renal function and poor outcomes after radiofrequency catheter ablation in patients with atrial fibrillation (AF). However, outcomes of cryoballoon ablation (CBA) in patients with renal insufficiency are not fully elucidated. This study aimed to compare outcomes of CBA in AF patients with chronic kidney disease (CKD) versus those without CKD and to assess changes in renal function over 12 months following CBA. METHODS: A total of 839 patients (65.1% with non-paroxysmal AF [PAF]) who underwent de novo CBA were prospectively enrolled. We divided patients into two groups based on creatinine clearance rate (CCr) and performed intracardiac echocardiography (ICE)-guided contrast agent-free CBA. RESULTS: In comparison with patients without CKD (CCr >50, n=722), those with CKD (CCr ≤50, n=117) were older and predominantly female, had a lower body mass index, and showed a higher prevalence of heart failure and hypertension. Mean CHA2DS2-VAS score was significantly higher in CKD group than in non-CKD group. Procedure-related complications were not significantly different between two groups. During a mean follow-up period of 25.4±11.9 months, clinical recurrence occurred in 182 patients (21.7%) and not significantly different between two groups. In multivariate analysis, non-PAF and left atrial size were independent predictors of AF recurrence. CCr levels significantly improved over 12 months after CBA in CKD group. CONCLUSIONS: ICE-guided contrast-agent-free CBA showed comparable long-term clinical outcomes without increasing procedure-related complications and improvement of renal function over 12 months following CBA in AF patients with CKD.

Safety of a single bolus administration of heparin without the measurement of activated clotting time during cryoballoon ablation: a prospective randomized controlled trial.

BACKGROUND: Single-shot ablation has emerged as an effective technique for index atrial fibrillation (AF) ablation, with an advantage of short procedure time. Although recent guidelines recommend peri-procedural uninterrupted oral anticoagulants (OACs), the intra-procedural anticoagulation strategy remains uncertain under non-vitamin K OACs (NOACs). We investigated procedural safety of a single bolus administration of heparin without activated clotting time (ACT) measurement during cryoballoon ablation (CBA). METHODS: Two hundred patients (64.2 ± 10.0 years, 70% with non-paroxysmal AF) who underwent CBA with uninterrupted NOACs were randomly assigned to No-ACT group and ACT group. A bolus of heparin (100 U/kg) was routinely administered immediately after transseptal puncture. In the ACT group, an additional injection of heparin (30 U/kg) was administered if ACT at 30 min after the initial bolus was < 300 s. RESULTS: There were no differences in baseline characteristics including CHA2DS2-VASc score between the two groups. The left atrium indwelling and procedure times were 60.4 ± 13.1 min and 78.9 ± 13.9 min, respectively, and not significantly different between the two groups. The mean ACT was 335.2 ± 59.9 s in the ACT group. Any bleeding rate was 3.2% in all patients and there was no statistically significant difference in bleeding complications between the two groups. In the ACT group, groin hematoma, laryngopharyngeal bleeding, and hemoptysis occurred in 3, 1, and 1 patient, respectively. Cardiac tamponade occurred in 1 patient in the No-ACT group. No thromboembolic events occurred during the 30-day follow-up after CBA. CONCLUSIONS: Single bolus administration of heparin without ACT measurement is a feasible anticoagulation strategy for CBA in patients with uninterrupted NOAC intake.

Prevalence of stable coronary artery disease and its associated clinical factors among patients with chest pain and elevated cardiac troponin alone.

Cardiac troponin is a useful test for diagnosing cardiogenic causes in patients with chest pain. However, cardiac troponin levels are often elevated in patients with chest pain due to non-cardiac causes other than coronary artery disease. The purpose of this study was to investigate the prevalence of coronary artery disease (CAD) and its associated factors in patients with chest pain and elevated cardiac troponin I (cTnI). 104 patients (mean age, 65 ± 11 years; 60 [58%] men) who underwent coronary angiography (CAG) for chest pain and elevated cTnI levels were enrolled in this study. All patients had a normal CK-MB range and did not show any ischemic changes on electrocardiography or echocardiography. Patients were classified into two groups according to the presence of CAD (Group 1, n = 62) and the absence of CAD (Group 2, n = 42). Patients were classified into subgroups according to the presence (Group 2a, microvascular angina [MVA], n = 18) and absence (Group 2b, non-angina [NA], n = 25) of angina. CAD was diagnosed in 62 (60%) patients and MVA was suspected in 18 (17%) patients without CAD. Patients with CAD showed elevated blood pressure and slightly decreased heart rate. Diabetes mellitus was more prevalent in patients with CAD and patients without CAD (esp. with MVA) were more likely to be common drinkers. Increased relative wall thickness (RWT) and reduced E' velocity were associated with CAD. High-density lipoprotein (HDL) levels were reduced in patients with CAD and MVA but were higher in patients with NA. Lower HDL level was found to be independently associated with the presence of CAD. Elevated cTn1 levels without other evidence of myocardial ischemia are sufficient for performing CAG in patients with stable chest pain.

Enlarged left atrium and decreased left atrial strain are associated with atrial fibrillation in patients with hyperthyroidism irrespective of conventional risk factors.

The purpose of this study was to investigate factors associated with AF in patients with hyperthyroidism beyond heart failure (HF), coronary heart disease (CHD), or valvular diseases. A total of 136 patients (mean age, 52 ± 15 years; 86 [63%] female) who were diagnosed with hyperthyroidism for the first time were enrolled. Patients who had HF, CHD, or significant valvular diseases were excluded. Patients were classified into two groups according to the presence (group 1, n = 40) and absence of AF (group 2, n = 96). AF occurred in 40 (29%) patients and 23 (58%) of these patients showed paroxysmal AF. Among the symptoms of hyperthyroidism, the most common chief complaint was palpitation (30%). Advanced age, presence of prior cerebrovascular events, and presence of palpitations were associated with AF. Larger left atrial volume index (LAVI), increased left ventricular mass index, and decreased left ventricular ejection fraction (LVEF) and S' velocity were associated with AF. Among them, presence of palpitations and increased LAVI were independently associated with the occurrence of AF. In addition, strain analysis, decreased LA expansion index (EI), ejection fraction (EF), peak atrial longitudinal strain, contraction strain, and late diastolic strain rate (A sr) and systolic strain rate (S sr) were associated with the occurrence of AF and LAVI. Presence of palpitations and enlarged left atrium were associated with the occurrence of AF in patients with hyperthyroidism irrespective of conventional risk factors. Additional LA analysis revealed that decreased LA function was associated with AF and enlarged left atrium.

Analysis of the accuracy of automatic electrocardiogram interpretation in ST-segment elevation myocardial infarction.

OBJECTIVE: This study aimed to analyze the association between the culprit artery and the diagnostic accuracy of automatic electrocardiogram (ECG) interpretation in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: This single-centered, retrospective cohort study included adult patients with STEMI who visited the emergency department between January 2017 and December 2020. The primary endpoint was the association between the culprit artery occlusion and the misinterpretation of ECG, evaluated by the chi-square test or Fisher exact test. RESULTS: The rate of misinterpretation of the automated ECG for patients with STEMI was 26.5% (31/117 patients). There was no significant correlation between the ST segment change in the four involved leads (anteroseptal, lateral, inferior, and aVR) and the misinterpretation of ECG (all P > 0.05). Single culprit artery occlusion significantly affected the misinterpretation of ECG compared with multiple culprit artery occlusion (single vs. multiple, 27/86 [31.3%] vs. 4/31 [12.9%], P = 0.045). There was no association between culprit artery and the misinterpretation of ECG (P = 0.132). CONCLUSION: Single culprit artery occlusion might increase misinterpretation of ECG compared with multiple culprit artery occlusions in the automatic interpretation of STEMI.

Diagnostic Accuracy of the Deep Learning Model for the Detection of ST Elevation Myocardial Infarction on Electrocardiogram.

We aimed to measure the diagnostic accuracy of the deep learning model (DLM) for ST-elevation myocardial infarction (STEMI) on a 12-lead electrocardiogram (ECG) according to culprit artery sorts. From January 2017 to December 2019, we recruited patients with STEMI who received more than one stent insertion for culprit artery occlusion. The DLM was trained with STEMI and normal sinus rhythm ECG for external validation. The primary outcome was the diagnostic accuracy of DLM for STEMI according to the three different culprit arteries. The outcomes were measured using the area under the receiver operating characteristic curve (AUROC), sensitivity (SEN), and specificity (SPE) using the Youden index. A total of 60,157 ECGs were obtained. These included 117 STEMI-ECGs and 60,040 normal sinus rhythm ECGs. When using DLM, the AUROC for overall STEMI was 0.998 (0.996-0.999) with SEN 97.4% (95.7-100) and SPE 99.2% (98.1-99.4). There were no significant differences in diagnostic accuracy within the three culprit arteries. The baseline wanders in false positive cases (83.7%, 345/412) significantly interfered with the accurate interpretation of ST elevation on an ECG. DLM showed high diagnostic accuracy for STEMI detection, regardless of the type of culprit artery. The baseline wanders of the ECGs could affect the misinterpretation of DLM.

Analysis of Mortality in Intracerebral Hemorrhage Patients with Hyperacute Ischemic Stroke Treated Using Thrombolytic Therapy: A Nationwide Population-based Cohort Study in South Korea.

This study investigated the impact of intracerebral hemorrhage (ICH) on the cumulative mortality of patients with hyperacute ischemic stroke. This population-based retrospective cohort study used claims data from the National Health Insurance Service customized database of South Korea. The recruitment period was 2005−2018. The study population included patients with hyperacute ischemic stroke who had received intravenous thrombolysis. The primary endpoint was 12-month cumulative mortality, which was analyzed in both the ICH and no-ICH groups. Of the 50,550 patients included, 2567 (5.1%) and 47,983 (94.9%) belonged to the ICH and no-ICH groups, respectively. In the univariable analysis for 12-month mortality, ICH patients were substantially more prevalent among dead patients than among patients who survived (11.6% versus 3.6%; p < 0.001). The overall 12-month cumulative mortality rate was 18.8%. Mortality in the ICH group was higher than that in the no-ICH group (42.8% versus 17.5%; p < 0.001). In the multivariable analysis, the risk of 12-month cumulative mortality was 2.97 times higher in the ICH group than in the no-ICH group (95% confidence interval, 2.79−3.16). The risk of 12-month cumulative mortality in hyperacute ischemic stroke can increase approximately threefold after the occurrence of spontaneous ICH following intravenous thrombolysis.

Complications associated with the Rotarex® wire in a patient with peripheral artery disease.

The Rotarex® device is used for thrombectomy as well as atherectomy in patients with PAD. It is important to carefully consider the wire position of the Rotarex® device during the procedure. As possible as the wire should be located in a lesion-free area.

Does merged three-dimensional mapping improve contact force and long-term procedure outcome in atrial fibrillation ablation? (MICRO-AF study): a prospective randomized controlled study.

Integration of electroanatomical map (EAM) with preacquired three-dimensional (3D) cardiac images provides detailed appreciation of the complex anatomy of the left atrium (LA) and pulmonary vein (PV). High-density (HD) multi-electrode mapping catheters have enabled creating more accurate EAM reflecting real-time volume-rendered LA-PV geometry during atrial fibrillation (AF) ablation. However, no study has compared the outcomes of AF ablation using HD-EAM versus 3D-merged map. We aimed to investigate the procedural and clinical outcomes of AF ablation with HD-EAM (HD-EAM group) versus 3D-merged map (Merge group). One hundred patients (59.5 ± 11.5 years, 53% with paroxysmal AF [PAF]) were randomly assigned (1:1) to HD-EAM or Merged group. HD multi-electrode mapping and contact force (CF)-sensing catheters were used to create virtual LA-PV chamber and to perform wide antral circumferential ablation (WACA), respectively. The two groups showed no significant differences in baseline characteristics and procedural data including ablation time, fluoroscopy time, LA voltage, and CF. PV isolation with a single WACA line was achieved in 21 (42%) and 27 (54%) patients in the Merge and HD-EAM groups, respectively (P = NS). CF was significantly lower in lesions with gap than lesions without gap after a single WACA (7.3 ± 7.3 g vs. 16.0 ± 8.3, respectively, P < 0.001). During the 12-month follow-up, no significant difference in AF recurrence was observed between two groups, irrespective of AF type. In multivariate analysis, non-PAF was an independent risk factor for AF recurrence. Integration of 3D cardiac imaging did not improve procedural and clinical outcomes. HD-EAM provides an accurate real-time LA geometry.

Vasodilator agents improve hemodialysis vascular access patency: A population-based study from Korea.

ABSTRACT: Vascular access (VA) failure is an important problem for patients undergoing hemodialysis, and maintaining VA patency is challenging. In this study, we used a nationwide database to investigate the effects of nitrate, as a vasodilator, on VA failure in hemodialysis patients.We investigated the Korean insurance claims data of hemodialysis patients who underwent angioplasty for VA failure between January 2012 and December 2017. The patients were divided into 2 groups: those not receiving vasodilator therapy (controls) and those receiving any vasodilator administration (vasodilator treatment, VDT). The primary endpoint was VA primary patency, defined as the time between arteriovenous dialysis access creation and the first percutaneous transluminal angioplasty (PTA).During the study period, a total of 6350 patients were recruited, 409 (6.4%) patients assigned to the VDT group and 5941 (93.6%) controls. PTA was performed in 998 patients (15.7%), including 8 in the VDT group and 990 controls. The VA site PTA rate was significantly lower in the VDT group (2.0%) than in the control group (16.7%, P < .001). In the subgroup analysis, the patency rates associated with the different vasodilators were similar (P = .736). All vasodilators, except molsidomine, improved the patency rate by approximately 20%.In this large national database study, vasodilator administration was associated with higher VA primary patency, compared with controls, in hemodialysis patients. VDT may have a beneficial effect on maintaining VA patency in patients undergoing hemodialysis.

Clinical significance of high on-treatment platelet reactivity in patients with prolonged clopidogrel therapy.

BACKGROUND/AIMS: Prolonged dual antiplatelet therapy (DAPT) with aspirin and clopidogrel beyond 1 year has been shown to reduce ischemic events at the expense of increased bleeding. However, limited data are available on the clinical significance of platelet reactivity (PR) at 1 year. METHODS: We retrospectively identified 331 patients who underwent percutaneous coronary intervention (PCI) and assessed the on-clopidogrel PR using VerifyNow P2Y12 assay at 1 year in a single center. Two hundred eleven patients were on DAPT for > 1 year. The relationship between high on-treatment platelet reactivity (HPR) at 1 year and clinical outcomes beyond 1 year, as well as the longitudinal change in PR was analyzed. RESULTS: At 1 year, 135 (64%) patients showed HPR and 76 (36%) did not. There was a significant increase in ischemic endpoint events, including cardiovascular death, non-fatal myocardial infarction, and stroke/transient ischemic attack in patients with compared to without HPR at 1 year (hazard ratio [HR], 2.68; 95% confidence interval [CI], 1.06 to 6.77; p = 0.036). However, the incidence of any Bleeding Academic Research Consortium bleeding was significantly lower in the HPR group (HR, 0.11; 95% CI, 0.02 to 0.65; p = 0.015). In the longitudinal analysis, PR significantly decreased from post-load to 1 year after index PCI in the non-HPR group. Conversely, the HPR group showed high PR from baseline through 1 year. CONCLUSION: HPR at 1 year may be a useful surrogate for predicting ischemic and bleeding events in patients on prolonged DAPT. Patients with and without HPR at 1 year showed different patterns of longitudinal change in PR.

Prognostic value of changes in the cardiac arrest rhythms from the prehospital stage to the emergency department in out-of-hospital cardiac arrest patients without prehospital returns of spontaneous circulation: A nationwide observational study.

BACKGROUND: This study aimed to assess the prognostic value of the changes in cardiac arrest rhythms from the prehospital stage to the ED (emergency department) in out-of-hospital cardiac arrest (OHCA) patients without prehospital returns of spontaneous circulation (ROSC). METHODS: This retrospective analysis was performed using nationwide population-based OHCA data from South Korea between 2012 and 2016. Patients with OHCA with medical causes and without prehospital ROSC were included and divided into four groups according to the nature of their cardiac arrest rhythms (shockable or non-shockable) in the prehospital stage and in the ED: (1) the shockable and shockable (Shock-Shock) group, (2) the shockable and non-shockable (Shock-NShock) group, (3) the non-shockable and shockable (NShock-Shock) group, and (4) the non-shockable and non-shockable (NShock-NShock) group. The presence of a shockable rhythm was confirmed based on the delivery of an electrical shock. Propensity score matching and multivariate logistic regression analyses were used to assess the effect of changes in the cardiac rhythms on patient outcomes. The primary outcome was sustained ROSC in the ED; the secondary outcomes were survival to hospital discharge and good neurological outcomes at hospital discharge. RESULTS: After applying the exclusion criteria, 51,060 eligible patients were included in the study (Shock-Shock, 4223; Shock-NShock, 3060; NShock-Shock, 11,509; NShock-NShock, 32,268). The propensity score-matched data were extracted from the six comparative subgroups. For sustained ROSC in the ED, Shock-Shock showed a higher likelihood than Shock-NShock (P <0.01) and NShock-NShock (P <0.01), Shock-NShock showed a lower likelihood than NShock-Shock (P <0.01) and NShock-NShock (P <0.01), NShock-Shock showed a higher likelihood NShock-NShock (P <0.01). For survival to hospital discharge, Shock-Shock showed a higher likelihood than Shock-NShock (P <0.01), NShock-Shock (P <0.01), and NShock-NShock (P <0.01), Shock-NShock showed a higher likelihood than NShock-Shock (P <0.01) and NShock-NShock (P <0.01), of sustained ROSC in the ED. For good neurological outcomes, Shock-Shock showed higher likelihood than Shock-NShock (P <0.01), NShock-Shock (P <0.01), and NShock-NShock (P <0.01), Shock-NShock showed better likelihood than NShock-NShock (P <0.01), NShock-Shock showed a better likelihood than NShock-NShock (P <0.01). CONCLUSION: Sustained ROSC in the ED may be expected for patients with shockable rhythms in the ED compared with those with non-shockable rhythms in the ED. For the clinical outcomes, survival to hospital discharge and neurological outcomes, patients with Shock-Shock showed the best outcome, whereas patients with NShock-NShock showed the poorest outcome and Shock-NShock showed a higher likelihood of achieving survival to hospital discharge with no significant differences in the neurological outcomes compared with NShock-Shock.