Successful Left Atrial Posterior Wall Isolation Including Roof Line Ablation Using a Cryoballoon for Persistent Atrial Fibrillation with Dextrocardia and Situs Inversus.

Cryoballoon ablation has been established as an effective method for pulmonary vein isolation and has recently been investigated for its efficacy of substrate modification on the left atrial roof area in patients with persistent atrial fibrillation. We herein report the first successful case of left atrial posterior wall isolation including roof line ablation using cryoballoons in a patient with persistent atrial fibrillation, dextrocardia, and situs inversus. Cryoballoon ablation proved to be a safe and straightforward approach to create lasting lesions along the left atrial roof line and left atrial posterior wall, even under challenging anatomical conditions.

Electrophysiological evidence of right atrial epicardial connections in a case with recurrent common atrial flutter.

The majority of the cavotricuspid isthmus (CTI) region consists of discretely arranged muscle bundles separated by connective tissue. Heterogeneity in the anatomic arrangement of the muscle bundles results in differences in the endocardial and epicardial activation patterns. We present a case of recurrent atrial flutter (AFL) despite the presence of a complete endocardial CTI block. We found epicardial-endocardial breakthrough (EEB) sites on the right atrial high septum. In addition, the epicardial excitation confirmed by endocardial activation mapping was detected as far-field potentials. Radiofrequency ablation was performed at the EEB site. No AFL has recurred for 12 months after the present procedure.

A Case Report of Superficial Solitary Fibrous Tumor in the Right Parotideomasseteric Region.

Solitary fibrous tumors (SFTs) are rare mesenchymal tumors that occur in various soft tissues and organs throughout the body. Superficial SFTs in the head and neck region are uncommon and reports of such cases are limited. An elderly Japanese woman in her 80s presented to our clinic with a smooth mass in the right parotideomasseteric region. Ultrasonography and magnetic resonance imaging revealed a well-defined subcutaneous mass measuring 20 mm. For a definitive diagnosis and treatment, surgical resection was performed under local anesthesia. Intraoperatively, a brown-colored tumor was identified beneath the skin, without surrounding tissue adhesion, and was completely excised. Immunohistochemistry, revealing the expression of STAT6, confirmed the diagnosis of SFT. Based on the SFT risk classification, this case was classified into the low-risk group, and no recurrence occurred during the 4 year postoperative period. According to the 2020 World Health Organization Classification of Soft Tissue Tumors, SFTs belong to the intermediate category with recurrence potential. In previous studies, cases of positive margins and recurrence have been reported in superficial SFTs, and SFTs may show benign features on clinical presentation but require precise surgical manipulation. Therefore, it is crucial for otolaryngologists to gain a comprehensive understanding of this tumor for appropriate treatment.

Impact of Atrial Fibrillation Triggers on Long-Term Outcomes of a Second Catheter Ablation of Nonparoxysmal Atrial Fibrillation.

Background: Catheter ablation (CA) of atrial fibrillation (AF) triggers, including non-pulmonary vein (PV) foci, contributes to improved procedural outcomes. However, the clinical significance of an AF trigger ablation during second CA procedures for nonparoxysmal AF is unknown. Methods and Results: We enrolled 94 patients with nonparoxysmal AF undergoing a second CA. Intracardiac cardioversion during AF using high-dose isoproterenol was performed to determine the presence or absence of AF triggers. PV re-isolations were performed if PV potentials recurred, and if AF triggers appeared from any non-PV sites, additional ablation was added to those sites. We investigated the incidence of atrial arrhythmia recurrence (AAR) >3 months post-CA. Of the 94 enrolled patients, AF triggers were identified in 65 (69.1%), and of those with AF triggers, successful elimination of the triggers was achieved in 47 patients (72.3%). Multivariate analysis revealed that no observed AF triggers were a significant predictor of AAR (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.21-3.46, P=0.019). In a subanalysis of the patients with AF triggers, multivariate analysis showed that unsuccessful trigger ablation was significantly associated with AAR (HR 5.84, 95% CI 2.79-12.22, P<0.01). Conclusions: Having no observed AF triggers during a second CA session significantly increased the risk of AAR, as did unsuccessful CA of AF triggers.

Case with translating to multiple myeloma at 8 years after radiation therapy for extramedullary plasmacytoma of the larynx.

We report a case of extramedullary plasmacytoma of the larynx that was eradicated by radiotherapy; however, 8 years later, the disease had progressed to multiple myeloma. A mid -60s Japanese woman presented with a right-sided arytenoid mass in the larynx who underwent biopsy at another hospital. Based on the biopsy results, the patient was diagnosed with extramedullary plasma cell tumour and was referred to the Department of Otorhinolaryngology at our hospital. She received radiotherapy (50.4 Gy) and the laryngeal tumour was eradicated. Positron emission tomography/CT (PET-CT) revealed no abnormal accumulation in the larynx or whole body. After radiotherapy, the department of otorhinolaryngology, in consultation with Ddepartment of haematology performed follow-ups using laryngoscope, blood examination and PET-CT. Five years after the end of radiotherapy, the patient had no local recurrence or transition to multiple myeloma. However, 8 years later, blood examination and PET-CT revealed multiple myeloma. Laryngoscopy did not reveal any recurrent laryngeal tumour. Therefore, chemotherapy for multiple myeloma was administered at the department of haematology. Three months after the initiation of chemotherapy, the accumulation had disappeared in PET-CT. Three years have passed since chemotherapy initiation. At present, no recurrence or metastasis was observed in the larynx or whole body.

A Case of Floating Aortic Arch Thrombosis in a Patient without Thrombophilia.

Floating aortic arch thrombi-blood clots forming in an aorta without aneurysms or atherosclerosis-in a normal aorta are exceedingly rare. The etiology is unknown, and there are no guidelines for appropriate treatment strategies. We report a case of floating aortic arch thrombosis in a patient without coagulopathy that was treated surgically. As the mass could not be identified preoperatively as a tumor or thrombus, synthetic graft replacement was performed, allowing resection of the lesion site. Histopathological examination revealed erosion and fissures in the tunica intima of the aorta, which suggested vessel damage to the tunica intima as the cause.

Gasdermin D represses inflammation-induced colon cancer development by regulating apoptosis.

Chronic inflammation is widely recognized as a major risk factor for cancer formation, but the underlying mechanisms are poorly understood. Recently, it was shown that Gasdermin D (GSDMD) protein drives pyroptotic cell death in macrophages on cleavage by inflammatory caspases. Even though the Gsdmd gene is specifically expressed in the intestinal epithelium, the role of Gsdmd in the intestinal tissues remains poorly characterized. In this study, we examined the biological role of Gsdmd in colorectal cancer (CRC) development, employing an azoxymethane/dextran sulfate sodium carcinogenesis model. Results show that GSDMD deficiency enhances CRC development, probably due to decreased apoptosis caused by downregulation of interferon-gamma (IFNγ)-signal transducer and activator 1 (STAT1) signaling. Furthermore, we show that GSDMD protein is diminished in human colorectal cancer, indicating involvement of GSDMD in repression of CRC development in humans. Our findings provide a new insight into functions of Gsdmd/GSDMD in colonic inflammation and human CRC development.

Significance of mitral L-waves in predicting late recurrences of atrial fibrillation after radiofrequency catheter ablation.

BACKGROUND: The mitral L-wave, a prominent mid-diastolic filling wave in echocardiographic examinations, is associated with severe left ventricular diastolic dysfunction. The relationship between the mitral L-wave and outcome of catheter ablation (CA) in patients with atrial fibrillation (AF) has not been established. This study aimed to evaluate the predictive value of mitral L-waves on AF recurrence after CA. METHODS: This was a retrospective and observational study in a single center. One hundred forty-six patients (mean age; 63.9 [56.0-72.0] years, 71.9% male) including 66 non-paroxysmal AF patients (45.2%) who received a first CA were enrolled. The mitral L-waves were defined as a distinct mid-diastolic flow velocity with a peak velocity ≥20 cm/s following the E wave in the echocardiographic examinations before CA. The patients enrolled were divided into groups with (n = 31, 21.2%) and without (n = 115, 78.8%) mitral L-waves. Univariate and multivariate analyses were carried out to determine the predictive factors of late recurrences of AF (LRAFs), which meant AF recurrence later than 3 months after the CA. RESULTS: During a follow-up of 28.8 (15.0-35.8) months, the ratio of LRAFs in patients with mitral L-waves was significantly higher than that in those without mitral L-waves (15 [46.9%] vs. 16 [14.0%], p < .001). A multivariate analysis using a Cox proportional hazard model revealed that the mitral L-waves were a significant predictive factor of LRAFs (hazard ratio: 3.09, 95% confidence interval: 1.53-6.24, p = .002). CONCLUSION: The appearance of mitral L-waves could predict LRAFs after CA.

Fatal Cardiac Tamponade Due to a Pericardial Inflammatory Myofibroblastic Tumor.

The patient was a 34-year-old woman who suddenly collapsed. On arrival, she was in cardiac arrest. Cardiac ultrasound revealed cardiac tamponade; thus, urgent thoracotomy with pericardiotomy was performed. Spontaneous circulation was temporarily obtained; however, her circulation was not stabilized, and she ultimately died. An autopsy revealed a pericardial inflammatory myofibroblastic tumor (IMT) causing bloody cardiac tamponade. There were no signs of cardiac rupture, myocardial infarction or aortic dissection. We reported the first case of fatal bloody cardiac tamponade due to pericardial IMT in an adult. An autopsy is important for clarifying the etiology in cases of fatal cardiac tamponade of unknown cause.

The inducibility and focus of atrial fibrillation after ablation in patients with tachycardia-induced heart failure.

BACKGROUND: The inducibility of atrial fibrillation (AF) and incidence of nonpulmonary vein (nonPV) triggers in patients with heart failure (HF) have not been elucidated. Furthermore, the relationship between AF triggers and the change in the left ventricular (LV) function after catheter ablation (CA) remains unclear. METHODS: A total of 101 consecutive patients with a history of HF due to tachycardia who underwent CA of AF were prospectively enrolled (64.8 ± 10.7 years, male 72.3%, and paroxysmal AF 15.8%). According to the AF inducibility by isoproterenol (ISP), the patients were divided into two groups: inducible AF (66.3%) and noninducible AF (33.7%). Furthermore, inducible AF was categorized into a PV type (61.2%) and nonPV type (38.8%). This study investigated the AF recurrence and change in the LV ejection fraction (LVEF) after CA. RESULTS: AF recurred in 35 patients (34.7%) during the follow-up period (41.6 ± 26.8 months). Kaplan-Meier curves showed that patients with noninducible AF had just as bad an AF recurrence rate as those with the nonPV type. Cox proportional hazards models also revealed that noninducible AF (Hazard-ratio, 5.74; 95% CI, 1.81-18.13) was associated with a higher risk of recurrence. The LVEF significantly improved after the CA (from 49.1 ± 16.3% to 67.0 ± 7.9%). However, the nonPV type was associated with a lower improvement in the LVEF (Odds-ratio, 0.18; 95% CI, 0.05-0.70). CONCLUSION: The AF inducibility was associated with AF recurrence. Furthermore, the nonPV triggers were associated with a lesser improvement in the LVEF. Confirming the AF inducibility and triggers was important to predict the outcome after CA.

Myocarditis Following a COVID-19 Messenger RNA Vaccination: A Japanese Case Series.

COVID-19 vaccine-related myocarditis has been reported worldwide. We herein report two Japanese cases with suspected vaccine-related myocarditis. A 27-year-old man was admitted with chest pain 4 days after the second vaccination. An electrocardiogram (ECG) did not reveal any significant abnormalities. The second patient, a 37-year-old man, was admitted with chest pain 9 days after the first vaccination. His ECG exhibited ST-elevation in multiple leads. In both cases, cardiac magnetic resonance imaging findings were consistent with myocarditis. They recovered with symptomatic relief within a few days. These cases suggest that the benefit of COVID-19 vaccination exceeds the risk of vaccine-related myocarditis.

Predictive value of the cardio-ankle vascular index for recurrence of atrial fibrillation after catheter ablation.

BACKGROUND: The predictive value of the cardio-ankle vascular index (CAVI) for estimating the efficacy outcome of catheter ablation (CA) in atrial fibrillation (AF) patients is unclear. We aimed to examine the predictive performance of the CAVI for recurrences of atrial arrhythmias after CA. METHODS: We enrolled a total of 193 patients with AF (paroxysmal 126 and non-paroxysmal 67) who underwent initial CA procedures at our institute, and CAVI measurements were conducted between January 2016 and March 2017. We evaluated recurrences of atrial arrhythmias after the first CA procedure as a clinical outcome. The CAVI value was assessed and the enrolled patients were divided according to the optimal CAVI value cut-off point (9.5) in the atrial arrhythmia recurrence group. RESULTS: During a mean follow-up of 31.3 (17.5-43.0) months, 74 (32.5%; PaAF 41 and 49.3%; non-PaAF 33) patients had recurrences of atrial arrhythmias. The recurrence ratio of atrial arrhythmias was significantly higher in patients with a high CAVI (≥9.5) than those with a low CAVI (<9.5) (log rank test; p = 0.018). A univariate analysis showed the association between higher CAVI values and recurrences of atrial arrhythmias (p = 0.072). Multivariate analyses using a Cox proportional hazard model after adjusting for other clinical factors revealed that the CAVI value was determined to be a significant predictive factor of a recurrence of atrial arrhythmias after CA (Hazard ratio: 1.44, 95% confidence interval: 1.17-1.78, p < 0.01). CONCLUSIONS: The CAVI was significantly associated with a recurrence of atrial arrhythmias after CA in AF patients.

Immunotactoid Glomerulopathy with Nontuberculous Mycobacterial Infection: A Novel Association.

A 70-year-old woman underwent a renal biopsy due to nephrotic syndrome. She had suffered from nontuberculous mycobacterial infection (NTM) for 14 years. The patient was diagnosed as having membranoproliferative glomerulonephritis (MPGN) type 3 and immunoglobulin (Ig)-associated MPGN based upon LM/erythromycin and IF findings, respectively. In high-magnification imaging, electron-dense deposits showed immunotactoid glomerulopathy (ITG). There was no evidence of hematological cancer, and the patient improved after receiving treatments for NTM. To the best of our knowledge, this patient is the first to show an association between ITG and NTM. Although ITG is generally considered as related to lymphoproliferative disease, it is suggested that ITG is driven by bacterial infection and is a potential outcome of Ig-associated MPGN.

Relationship between the degree of renal dysfunction and the safety and efficacy outcomes in patients with atrial fibrillation receiving direct oral anticoagulants.

BACKGROUND: The clinical evaluation of a direct oral anticoagulant (DOAC) treatment for atrial fibrillation (AF) patients with renal dysfunction has not been sufficiently studied. This study aimed to evaluate the safety and efficacy of DOACs for patients with a severely impaired renal function. METHODS: This was a retrospective and observational study in a single center. We enrolled 894 consecutive AF patients who were prescribed DOACs, and divided them into three groups based on their creatinine clearance (CrCl) value: CrCl ≥ 50 mL/min group (n = 634), CrCl 30-49 mL/min group (n = 207), and CrCl 15-29 mL/min group (n = 53). We evaluated the occurrence of major bleeding (MB) as the safety outcome and thromboembolic events (TEs) as the efficacy outcome during the follow-up. RESULTS: The incidence of MB in the CrCl 15-29 mL/min group was significantly higher than in the other groups (CrCl ≥ 50 mL/min group, 0.8/100 person-years; CrCl 30-49 mL/min group, 1.2/100 person-years; CrCl 15-29 mL/min group, 9.0/100 person-years, log rank test, P < .001). On the other hand, there was no significant difference in the incidence of TEs among the three groups. A multivariate analysis using a Cox proportional hazard model adjusted for the age revealed that the CrCl 15-29 mL/min group was significantly associated with increased MB compared to the CrCl ≥ 50 mL/min group (hazard ratio: 9.76, 95% confidence interval: 2.69-35.5, P < .001). Similar results were observed when adjusting for other multiple clinical factors. CONCLUSION: This study demonstrated that the degree of renal dysfunction was a significant prognostic factor for MB in AF patients receiving DOACs.

Role of Intracardiac Defibrillation During the Ablation Procedure as a Predictor of Atrial Fibrillation Recurrence After Catheter Ablation.

Intracardiac defibrillation (IDF) is performed to restore sinus rhythm (SR) during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). This study aimed to investigate the change in the IDF threshold before and after RFCA during the ablation procedure and determine whether the IDF threshold after RFCA was associated with the AF substrate and AF recurrence. A total of 141 consecutive patients with drug-refractory persistent AF (age 62.5 ± 10.3 years, 84.4% male) were enrolled in this study. Before RFCA, we initially performed IDF with an output of 1 J. When IDF failed to restore SR, the output was gradually increased to 30 J. After RFCA, we attempted pacing-induced AF to provoke other focuses of AF. When AF was induced, we performed IDF again to terminate AF with outputs of 1 to 30 J. The change in the IDF threshold to restore SR before and after RFCA was evaluated. After RFCA, the IDF threshold for restoring SR significantly decreased (from 11.5 ± 8.6 J to 4.0 ± 3.8 J, P < 0.001). During the follow-up (24.3 ± 12.2 months), SR was maintained in 107 patients (75.9%). The multivariate analysis using a Cox proportional-hazards model revealed that an IDF threshold of > 5 J after RFCA was significantly associated with the AF recurrence (HR, 3.99; 95% confidence interval 1.93-8.22; P = 0.0001). RFCA decreased the IDF threshold for restoring SR in patients with persistent AF. The IDF output of > 5 J after RFCA could be a predictor of AF recurrence independent of the AF substrate.

A Case of Nasopharyngeal Tuberculosis with Cervical Lymph Node Tuberculosis Suspected of Cervical Malignant Disease at the First Examination.

A case of nasopharyngeal tuberculosis with cervical lymph node tuberculosis is reported. The patient was a 20-year-old female immigrant from Vietnam and cook apprentice. Her chief complaint was left neck swelling with pain for three months. She was diagnosed with left neck lymphadenitis at a previous hospital, which suspected malignant lymphoma and referred her to our hospital. At the time of the first visit, she had left lymph swelling with tenderness and granuloma-like masses in the nasopharynx. PET-CT showed accumulations in both the swollen left neck lymph and nasopharynx. The diagnosis of this case would appear to be nasopharyngeal cancer with left and neck lymph node metastasis or nasopharyngeal tuberculosis with cervical lymph node tuberculosis in addition to malignant lymphoma. Based on some examinations (biopsy, bacteria culture, and imaging), it was diagnosed as nasopharyngeal tuberculosis with cervical lymph node tuberculosis. Therefore, she was treated with anti-tuberculosis agent in respiratory medicine.