Comparison of the electrophysiological properties of the pulmonary veins between paroxysmal and persistent atrial fibrillation.

Background: The role of the pulmonary veins (PVs) as triggers in atrial fibrillation (AF) is well-known; however, their detailed electrophysiological properties have not been thoroughly examined. Objective: This study aimed to investigate the electrophysiological properties of the PVs between paroxysmal AF (pAF) and persistent AF (perAF). Methods: Prior to catheter ablation in patients with pAF (n = 51) and perAF (n = 41), a voltage map of the left atrium and PVs was created under sinus rhythm, and the area of the myocardial sleeves in the PVs and their electrophysiological characteristics, including the pacing threshold and effective refractory period (ERP), were compared between the two groups. Results: Compared with perAF, the myocardial sleeves of PVs for pAF were significantly larger for all PVs. The ERP for perAF was significantly shorter than that for pAF for all PVs. The pacing threshold for perAF was significantly higher than that for pAF for the right and left superior PVs. Conclusion: In patients with perAF, a decrease in the normal myocardial sleeves and a shortening of the ERP were observed for all PVs. Those changes in the electrophysiological properties of the PVs might be related to the persistence of AF.

Effects of uninterrupted dabigatran on the intensity of anticoagulation during atrial fibrillation ablation.

BACKGROUND: Uninterrupted dabigatran during atrial fibrillation (AF) ablation is now established as the standard therapy. However, there are few reports on the effects of uninterrupted dabigatran on the intensity of anticoagulation during AF ablation. METHODS: We retrospectively analyzed 247 consecutive patients who underwent AF ablation in our hospital from January 2017 to December 2018. Patients who took warfarin or uninterrupted direct oral anticoagulants (DOACs) except for dabigatran were excluded. 89 patients underwent ablation with uninterrupted dabigatran (uninterrupted group, male 71, mean age 59.6 ± 14.0) and 124 with interrupted DOACs (interrupted group, male 105, mean age 56.9 ± 12.9) during AF ablation. The initial ACT level, proportion of ACT levels of more than 300 s, and total amount of heparin were compared. Furthermore, the incidence of procedure complications was also evaluated. RESULTS: The initial ACT levels were significantly higher in the uninterrupted group, and the total number of ACTs of more than 300 s was significantly higher in the uninterrupted group (uninterrupted vs. interrupted; initial ACT level, 315.6 ± 59.8 vs. 264.5 ± 48.6, p < .001; total number of ACTs ≧300, n [%], 304/ 484 [62.8 %] vs. 372/745 [49.9%], p < .001). The total amount of heparin during procedure was significantly lower in the uninterrupted group (uninterrupted group vs. interrupted group; 12966 ± 4773 vs. 16371 ± 5212, p < .001). There was no significant difference in the incidence of complications between the two groups. CONCLUSIONS: In the catheter ablation of AF, uninterrupted dabigatran would be useful to obtain a stable anticoagulation status during the entire procedure.

The target ablation index values for electrical isolation of the superior vena cava.

PURPOSE: The ablation index (AI), developed as a radiofrequency (RF) catheter ablation composite component endpoint, which incorporates contact force (CF), time, and power in a weighted formula, has been reported to be useful for a durable pulmonary vein isolation (PVI) to treat atrial fibrillation (AF). No study has reported the target AI value for the SVC isolation (SVCI). In this study, we aimed to investigate the target AI for the SVCI. METHODS: Thirty-six AF patients who underwent an initial SVCI were enrolled. Ablation was performed at 556 points. The sites where dormant conduction was induced or additional ablation was needed were defined as touch up sites (n = 36). We compared the energy deliver time, power, generator impedance (GI) drop, local bipolar voltage, contact force (CF), force-time integral (FTI), and AI between the touch up sites and the no touch up sites (n = 520). RESULTS: The FTI and AI were significantly lower at the touch up sites (touch up sites vs. no touch up sites; FTI, 126.5 [99.3-208.8] vs. 244 [184-340.8], p < 0.0001; AI, 350.1 ± 43.6 vs. 277.2 ± 21.8, p < 0.0001). The median value of the AI at the no touch up sites was 350, and no reconnections were seen where the minimum AI value was more than 308. Most of the touch up sites were located in the anterior wall and lateral wall (anterior wall, 20/36 sites [55.6%]; lateral wall, 10/36 sites [27.8%]; septal wall, 6/36 sites [16.7%]; posterior wall, 0/36sites [0.0%]). CONCLUSION: The target AI value for the SVCI should be 350, and at least 308 would be needed.

A Case of Coexistence of Severe Coronary and Carotid Artery Stenosis Treated with Carotid Artery Stenting Using Intra-Aortic Balloon Pumping and a Temporary Pacemaker.

The risk factors of carotid stenosis and coronary stenosis are similar, and therefore, certain patients with carotid stenosis may have coronary heart disease. Coronary artery bypass graft (CABG) is the major therapy for ischemic heart disease with three-vessel and left main coronary artery (LMCA) disease. However, CABG can induce cerebral infarctions in cases with carotid stenosis. Carotid endarterectomy (CEA) was used to be the standard therapy for carotid stenosis; however, CEA requires general anesthesia and has a high risk of cardiovascular events in patients with ischemic heart disease. In recent times, carotid artery stenting (CAS), which does not need general anesthesia, is the new strategy for carotid stenosis. However, CAS induces hypotension and bradycardia because of a carotid node reflex, which is dangerous in patients with ischemic heart disease. We reported a case of the coexistence of severe coronary stenosis including the LMCA and three vessels and carotid stenosis. CAS before CABG under local anesthesia was successful with the use of intra-aortic balloon pumping (IABP) and a temporary pacemaker.

Improvement of left ventricular function after successful radiofrequency catheter ablation in persistent atrial fibrillation with preserved left ventricular ejection fraction: a comprehensive echocardiographic assessment using two-dimensional speckle tracking analysis.

BACKGROUND: A limited number of studies have investigated the effects of radiofrequency catheter ablation (RFCA) on left ventricular (LV) function and the left atrial (LA) size in patients with atrial fibrillation (AF). The purpose of this study was to conduct a comprehensive assessment of LV function in patients with AF with preserved left ventricular ejection fraction (LVEF) before and after RFCA. METHOD: A total of 30 consecutive patients with no recurrences after RFCA for persistent AF (age, 57.7 ± 8.4 years) were enrolled. Transthoracic echocardiography was performed at the baseline and 6 months after the final RFCA using speckle tracking derived LV strain analysis. RESULTS: After RFCA, we measured decreases in the LA volume index (33.7 ± 10.4 ml/m2 vs. 24.6 ± 8.6 ml/m2, p < 0.0001), while we observed improvements in systolic indices such as LVEF (56.8 ± 9.8% vs. 65.1 ± 9.1%, p < 0.0001), global longitudinal strain (- 16.8 ± 4.4% vs. - 18.8 ± 3.4%, p = 0.0055) and twist (8.12 ± 3.66° vs. 12.33 ± 6.75°, p = 0.0050), and also in diastolic indices such as strain rate during early diastole (SRE) (0.73 ± 0.10 s-1 vs. 1.32 ± 0.29 s-1, p < 0.0001) and early transmitral inflow velocity (E)/SRE (1.11 ± 0.36 m vs. 0.61 ± 0.19 m, p < 0.0001). Logistic regression analysis showed that ΔE/SRE was a contributing factor for improvement in LVEF (odds ratio 126.9; p = 0.021). CONCLUSION: In persistent AF with preserved LVEF, further improvement in LVEF and reverse remodeling of the LA are achieved after RFCA. LV filling pressure may play significant roles in the mechanisms.

Observational Study of Infective Endocarditis at a Community-based Hospital: Dominance of Elderly Patients with Comorbidity.

Objective The purpose of this study was to present the recent clinical profiles and the real-world management of infective endocarditis (IE). Methods All medical records of patients with IE were reviewed retrospectively for their clinical data, including clinical presentation, laboratory results, blood cultures, echocardiographic findings, treatments and complications. Using the clinical data collected, we calculated the EuroSCORE II, the European risk score for adult cardiac surgery, the Charlson Comorbidity Index as a surrogate of comordibity, and the Katz Index as a surrogate of frailty. Results Thirty-eight patients were identified as having IE (24 men, age: 71.8±13.1 years). Congestive heart failure occurred in 16 patients (42%), stroke in 14 (50%), and systemic embolism in 5 (13%). The EuroSCORE II and Charlson Comorbidity Index were high (7.7±5.8% and 5.5±2.8%, respectively). The Katz Index was fair (5.5±1.4) before the onset but deteriorated to 2.8±2.7 at the time of establishing the diagnosis of IE (p<0.001). Early surgery was performed in 22 cases (61%). In-hospital death occurred in 10 cases (26%). A EuroSCORE II ≥9%, Staphylococcus aureus etiology, and a Charlson Comorbidity Index were suggested as determinants of in-hospital death (hazard ratios: 173.60, 9.31, 1.57, respectively). In contrast, early surgery was suggested as a determinant of the survival (hazard ratio: 0.04). The Charlson Comorbidity Index was also suggested as a determinant for selecting conservative management (odds ratio: 1.40). Conclusion Comorbidity may influence the treatment selection and outcome of elderly patients with IE.

The impact of left ventricular deformation and dyssynchrony on improvement of left ventricular ejection fraction following radiofrequency catheter ablation in Wolff-Parkinson-White syndrome: A comprehensive study by speckle tracking echocardiography.

PURPOSE: The purpose of this study was to evaluate left ventricular (LV) deformation and LV dyssynchrony in patients with Wolff-Parkinson-White (WPW) syndrome and to identify the factors that affect the efficacy of radiofrequency catheter ablation (RFCA). METHODS: Thirty patients (26 men, mean age 40 ± 12 years) with WPW syndrome were prospectively recruited for this study. They underwent 2-dimensional transthoracic echocardiography with speckle tracking analysis before RFCA and again within 48 hours after RFCA. Control group consisted of 15 age and sex-matched healthy volunteers. RESULTS: The patients had significantly lower LV ejection fraction (LVEF), global longitudinal strain (Sl ), and global circumferential strain (Sc ) compared with healthy controls (64% ± 8% vs 68% ± 5%, P = .049; -17.6% ± 3.2% vs -19.9% ± 3.3%, P = .037, -15.2% ± 2.5% vs -19.4% ± 2.5%, P < .0001, respectively). Patients had a significantly higher dyssynchrony index relative to healthy controls (58.4 ± 49.0 ms vs 36.4 ± 31.1 ms, P = .031). After RFCA, there was a significant increase in LVEF and global Sc (68% ± 8% vs 64% ± 8%, P = .005; -17.3% ± 2.0% vs -15.2% ± 2.5%, P < .0001, respectively), along with a significant decrease in the dyssynchrony index (36.9 ± 36.3 ms vs 58.4 ± ms, P < .001) relative to the baseline values. Logistic regression revealed that the baseline dyssynchrony index was a predictor of LVEF improvement after RFCA (odds ratio: 1.060, P = .038). CONCLUSION: In WPW syndrome, impaired LV circumferential deformation can be restored by RFCA with concomitant improvement in LV dyssynchrony and LVEF.

Systolic collapse of aortic composite graft after Bentall operation: A sign of pseudoaneurysm formation.

Although aortic root replacement using a composite graft including the Bentall operation is the treatment of choice for a diseased aortic valve and root dilatation, composite graft endocarditis can occur as a life-threatening complication with a high mortality rate. When aortic pseudoaneurysm occurs due to composite graft endocarditis, it usually indicates that saccular bulging of the surrounding tissue of the composite graft is present. Furthermore, another sign and a clue of the diagnosis of pseudoaneurysm is the collapse of the composite graft due to the outer compression pressure of the leaking blood flow. Additionally, right parasternal view is useful to get the clear images of this phenomenon. Echocardiographic evaluation will contribute to the early recognition of this highly critical pathology.

Primary Mural Endocarditis Without Valvular Involvement.

Primary mural endocarditis is an extremely rare infection in which nonvalvular endocardial involvement is seen without any cardiac structural abnormalities such as ventricular septal defects. The rapid and precise diagnosis of this disease remains challenging. We present 2 cases (67- and 47-year-old male patients) of pathologically confirmed primary mural endocarditis that could have been detected by initial transthoracic echocardiography in the emergency department. Transthoracic echocardiography and transesophageal echocardiography play critical roles in the early recognition and confirmation of primary mural endocarditis.

Visualization of Recanalized Coronary Occlusion with Dissection by Optical Frequency Domain Imaging.

A 43-year-old asymptomatic male patient with a positive stress myocardial perfusion imaging result was admitted to our institution. Although no organic lesion was detected by 64-row coronary computed tomography angiography (CCTA), invasive coronary angiography revealed a unique anatomy with a long lesion in the middle of the left anterior descending artery. Optical frequency domain imaging (OFDI) demonstrated the details of the recanalized occlusion with coronary dissection. OFDI provides in vivo coronary images with high spatial resolution and better three-dimensional reconstructions and supports invasive coronary angiography to elucidate infinitesimal and complicated intraluminal morphology that might be missed by CCTA alone.

Cardiac Asystole Triggered by Temporal Lobe Epilepsy with Amygdala Enlargement.

A 25-year-old previously healthy man was hospitalized for syncope. While standing, he suddenly lost consciousness, followed by a generalized tonic clonic seizure. An electrocardiogram demonstrated asystole. No cardiac abnormalities were detected on the echocardiogram, cardiac magnetic resonance imaging (MRI), positron emission tomography, or a coronary angiogram. An electrophysiological study showed normal sinus node and atrioventricular node function. An electroencephalogram revealed small spike waves in the fronto-temporal region. Brain MRI demonstrated a left-sided amygdala enlargement. To the best of our knowledge, this is the first case of temporal lobe epilepsy with an amygdala enlargement that induced cardiac asystole.

Successful Endovascular Removal of a Perforated Inferior Vena Cava Filter Complicated by a Large Retroperitoneal Hematoma: Pitfall of Catheter-Directed Thrombolysis.

Symptomatic caval perforation is rare complication after inferior vena cava (IVC) filter insertion. A 44-year-old woman developed back pain after the placement of retrieval IVC filter during catheter-directed thrombolysis (CDT). Her computed tomography showed a large right-sided retroperitoneal hematoma. After 2 weeks, endovascular removal of the perforated filter was successfully performed without complication. Because thrombolytic agents can accelerate bleeding caused by endovascular procedures, the bleeding rate of the IVC filter deployment during CDT might be higher than expected.

A novel cardiac ryanodine receptor gene (RyR2) mutation in an athlete with aborted sudden cardiac death: a case of adult-onset catecholaminergic polymorphic ventricular tachycardia.

Sudden cardiac death (SCD) in athletes <35 years of age are mostly due to congenital or acquired cardiac malformations or hypertrophic cardiomyopathy. However, ion channelopathies such as catecholaminergic polymorphic ventricular tachycardia (CPVT) or long-QT syndromes, which are less frequently observed, are also potential pathogenesis of SCD in young athletes. CPVT is an inherited arrhythmia that is induced by physical or emotional stress and may lead to ventricular fibrillation syncope or SCD. Here, we report a case of athlete woman with adult-onset CPVT and aborted SCD who has a novel missense mutation (K4392R) in the cardiac RyR2 gene.

'Honeycomb appearance' on three-dimensional transthoracic echocardiography as the landmark of left ventricular non-compaction: two case reports.

INTRODUCTION: Left ventricular non-compaction is a rare congenital heart disease, and is most commonly diagnosed via two-dimensional echocardiography according to echocardiographic criteria. Recently, transthoracic three-dimensional echocardiography has become available in the clinical setting. CASE PRESENTATION: We present two isolated cases of left ventricular non-compaction from Japan (in an 84-year-old woman and 47-year-old man) that were confirmed by two-dimensional echocardiography, contrast-enhanced two-dimensional echocardiography, three-dimensional echocardiography and cardiac magnetic resonance imaging. In both cases, three-dimensional echocardiography successfully demonstrated the trabecular meshwork of the left ventricle, referred to as a 'honeycomb appearance'. CONCLUSIONS: Three-dimensional echocardiography has the advantage of visualizing an en-face view of the trabecular meshwork, which is not possible with two-dimensional echocardiography. We further emphasize the clinical utility of three-dimensional echocardiography, which is not limited to just the observation of the trabeculations and inter-trabecular recesses, but can also visualize the trabecular meshwork with a 'honeycomb appearance'.

Newly developed mobile mass superimposed on mitral annulus calcification in patient with cerebral infarction: Documentation of a unique embolic source.

Mitral annulus calcification (MAC) has been recognized as a potent risk factor to cause cerebral infarction. There has been suggested possible linkage between mass on MAC and systemic embolic events. We report a case of cerebral infarction with newly developed mobile mass superimposed on MAC.