Epicardial adipose tissue density predicts the presence of atrial fibrillation and its recurrence after catheter ablation: three-dimensional reconstructed image analysis.

Epicardial adipose tissue (EAT) induces inflammation in the atria and is associated with atrial fibrillation (AF). Several studies have examined the relationship between EAT volume (EAT-V) and density (EAT-D) and the presence of AF after catheter ablation. However, conclusions have been inconsistent. This study included 43 consecutive patients who underwent catheter ablation for AF and 30 control patients. EAT-V and EAT-D around the entire heart, entire atrium, left atrium (LA), and right atrium (RA) were measured in detail using reconstructed three-dimensional (3D) EAT images from dual-source computed tomography (CT). None of the measurements of EAT-V differed significantly between patients with AF and controls or between patients with recurrent AF and those without. On the other hand, all measurements of EAT-D were higher in patients with AF than in controls (entire atrium, p < 0.001; RA, p < 0.001; LA, p = 0.002). All EAT-D measurements were associated with the presence of AF. Among patients with AF who underwent ablation, all EAT-D measurements were higher in patients with recurrent AF than in those without. The difference was significant for EATRA-D (p = 0.032). All atrial EAT-D values predicted recurrent AF (EATRA-D: hazard ratio [HR], 1.208; 95% confidence interval [95% CI], 1.053-1.387; p = 0.007; EATLA-D: HR, 1.108; 95% CI 1.001-1.225; p = 0.047; EATatrial-D: HR, 1.174; 95% CI 1.040-1.325; p = 0.010). The most sensitive cutoffs for predicting recurrent AF were highly accurate for EATRA-D (area under the curve [AUC], 0.76; p < 0.01) and EATatrial-D (AUC = 0.75, p < 0.05), while the cutoff for EATLA-D had low accuracy (AUC, 0.65; p = 0.209). For predicting the presence of AF and recurrent AF after catheter ablation, 3D analysis of atrial EAT-D, rather than EAT-V, is useful.

Treatment with catheter ablation for patients with arrhythmia-induced cardiomyopathy caused by atrial fibrillation promises a good prognosis.

Clinical outcomes after catheter ablation in patients with reduced left ventricular (LV) ejection fraction (EF) and atrial fibrillation (AF) remain unclear. This study aimed to explore the clinical outcomes of patients with arrhythmia-induced cardiomyopathy (AIC) and the influence of pharmacological treatment on clinical outcomes in patients with AIC after the procedure. Ninety-six patients with AF with a reduced LVEF (LVEF < 50%, 66.7 ± 10.9 years; 72 males) underwent AF ablation. AIC was defined as patients whose LVEF recovered ≥ 50% after catheter ablation (n = 67) and patients whose LVEF remained reduced were defined as non-AIC (n = 29). During a median follow-up of 25 (13-40) months, Kaplan-Meier analysis demonstrated that patients with AIC were associated with less frequent cardiovascular death (p = 0.025) and hospitalization for worsening heart failure (p < 0.001) than those without AIC. Freedom from AF recurrence was similar between the two groups (p = 0.47). In multivariate analysis, the LV end-diastolic diameter (p = 0.0002) and the CHA2DS2-VASc scores (p = 0.0062) were independent predictors of AIC. Among the 67 patients with AIC, no significant differences in baseline characteristics, except for LV chamber size and cryoballoon use, were observed between patients with AIC with (n = 31) and without renin-angiotensin system (RAS) inhibitors (n = 36). In the Kaplan-Meier analysis, cardiovascular death, hospitalization for worsening heart failure, and AF recurrence after catheter ablation did not differ between patients treated with and without RAS inhibitors (all p > 0.05). Catheter ablation in patients with AIC due to AF is associated with a good post-procedural prognosis.IRB information The study was approved by the Research Ethics Committee of the University of Fukui (No. 20220151) and clinical trial registration (UMIN000050391).

Contrast-enhanced computed tomography in the venous rather than the arterial phase is essential for the evaluation of the right phrenic nerve.

BACKGROUND: Preprocedural detection of the running course of the right pericardiophrenic bundles (PBs) is considered to be useful in preventing phrenic nerve (PN) injury during catheter ablation for atrial fibrillation (AF). However, previous studies using the arterial phase of contrast-enhanced computed tomography (CT) reported a relatively low right PBs detection rate. METHODS: This study included 63 patients with AF who underwent catheter ablation and preoperative contrast-enhanced CT imaging of the venous and arterial phases (66.7 ± 10.2 years; 44 male). The venous phase of contrast-enhanced CT significantly improved the detection rate of PBs compared to the arterial phase (96.8% vs. 60.3%, p < .001), and PBs were detected in the venous phase only in 23 (36.7%) patients. No significant differences were observed between the right PBs detection rate using non-contrast CT versus the arterial phase of contrast-enhanced CT (p = .37). Patients without visualization of the right PBs during the arterial phase had a higher frequency of chronic heart failure (p = .0083), lower left ventricular ejection fraction (p = .021), and a higher CHADS2 score (p = .048) than those with visualization. In five patients whose right PBs could only be detected during the venous phase of contrast-enhanced CT, the reconstructed running course of the right PBs corresponded with the PN generated by electrical high-output pacing. CONCLUSION: Contrast-enhanced CT images of the venous phase, rather than the arterial phase, are useful in detecting the right PBs, especially in patients with heart failure or reduced left ventricular ejection fraction.

Effects of door-to-tolvaptan time on short-term clinical outcome in patients with acute heart failure.

AIMS: We investigated the effects of door-to-tolvaptan (D2T) time on short-term urine volume and in-hospital clinical outcomes in patients with acute heart failure (AHF). METHODS AND RESULTS: Patients with AHF, treated with tolvaptan at two hospitals, were enrolled in this retrospective observational study. The D2T time was defined as the time elapsed from the arrival of a patient at a participating hospital to the first administration of tolvaptan. The group with the D2T time within 6 h was defined as the 'early group'. The primary outcome was 48-h urine volume. The secondary outcomes were in-hospital death, length of hospital stay, and worsening renal function (WRF) incidence. A restricted cubic spline model was used to evaluate the presence of a nonlinear association between the D2T time and 48-h urine volume and the odds ratio of WRF incidence. Our study included a total of 138 patients with AHF who were started on tolvaptan after hospitalization. The median D2T time was 5.3 h (interquartile range: 3.0-31.9 h). Seventy-four patients (53.6%) were classified to be in the early group. Baseline characteristics were similar in the two groups: mean age (85.4 ± 9.6 years vs. 84.5 ± 9.5 years; P = 0.59) and male sex (n = 22 [33.3%] vs. n = 29 [46%]; P = 0.16), except that patients in the early group had higher systolic blood pressure than those in the delayed group (138.2 ± 22.9 vs. 125.7 ± 21.7; P = 0.001). The initial tolvaptan dose in the delayed group was much lower than that in the early group (7.5 [7.5, 7.5] vs. 7.5 [5.6, 7.5] mg; P = 0.01). Total urine volume in 48 h did not differ in the early and delayed groups (4113 ± 1758 mL vs. 4201 ± 1893 mL; P = 0.80). The relationship between D2T time and total urine volume within 48 h increased slightly, with a peak at a D2T time of 15 h, and gradually decreased, thereafter. In-hospital death and the length of hospital stay did not differ significantly between the two groups (n = 1, 1.3% vs. n = 4, 6.3%; P = 0.18, and 5.0 [12.0, 30.0] vs. 22.0 [14.5, 30.0] days; P = 0.17, respectively). Notably, the restricted cubic spline model for the odds ratio of WRF incidence increased as the D2T time was delayed (P for effect<0.01). CONCLUSIONS: The shorter D2T time did not affect the short-term urine volume and in-hospital outcomes but reduced the risk of WRF incidence in patients with AHF.

Atrial fibrillation activation patterns predict freedom from arrhythmias after catheter ablation: utility of ExTRa mapping™.

Background: Mechanisms underlying atrial fibrillation (AF) are widely complex and vary tremendously among individuals. Objectives: This retrospective study aimed to investigate the association between AF activation patterns and clinical outcomes post-ablation. Methods: Fifty-five AF patients (64.0 ± 12.9 years; 41 men; 17 paroxysmal) underwent bi-atrial endocardial driver mapping during AF pre-ablation with a real-time phase mapping system (ExTRa Mapping). The nonpassively activated ratio (%NP) of meandering rotors and multiple wavelets relative to the recording time was evaluated in 26 atrial segments [15 in the left atrium (LA) and 11 in the right atrium]. Irrespective of the mapping results, all patients underwent standard AF ablation via cryoballoons and/or radiofrequency catheters. Results: In a median follow-up interval of 27(14-30) months, 69.1% of patients were free from recurrent arrhythmias and antiarrhythmic drugs at one year post-procedure. Patients with recurrent AF were more likely to have non-paroxysmal AF, a significantly larger LA size, and higher LA maximal %NP(LAmax%NP) and LA anterior wall %NP(LAAW%NP) than those without recurrent AF. A multivariate Cox regression analysis showed that both an LAmax%NP (hazard ratio [HR] = 1.075; 95% confidence interval [CI] = 1.02-1.14, p = 0.012) and LAAW%NP (HR = 1.061; 95% CI = 1.01-1.11, p = 0.013) were independent predictors of atrial arrhythmia recurrence. The optimal cutoff points for the LAmax%NP and LAAW%NP for predicting AF recurrence were 64.5% and 60.0%, respectively. A Kaplan-Meier analysis demonstrated that both an LAmax%NP > 64.5% (p = 0.0062) and LAAW%NP > 60.0% (p = 0.014) were associated with more frequent AF recurrences. Conclusion: Baseline AF activation pattern mapping may aid in predicting freedom from arrhythmias after standard AF ablation procedures.

Low troponin I levels predict the presence of arrhythmia-induced cardiomyopathy in patients with atrial fibrillation and left ventricular systolic dysfunction.

Successful atrial fibrillation (AF) ablation can improve reduced left ventricular ejection fraction (LVEF) with AF, which is defined as arrhythmia-induced cardiomyopathy (AIC). However, it is difficult to pre-procedurally predict the presence of AIC. We aimed to explore the pre-procedural predictors of AIC in patients with AF and reduced LVEF. This study included 60 patients with a reduced LVEF (LVEF < 50%; 69.1 ± 8.8 years; 45 men) who underwent successful AF ablation. Responders were defined as patients whose LVEF post-procedurally improved to the normal range (≥ 50%). Multivariate analysis revealed that the log-transformed pre-procedural troponin I (TnI) levels (odds ratio [OR] = 0.059; 95% confidence interval [CI] = 0.0052-0.42, p = 0.003) and age (OR = 0.91; 95% CI = 0.82-1.00, p = 0.044) were independent predictors of post-procedural LVEF recovery; further, low TnI levels (< 11.1 pg/ml) predicted LVEF recovery (sensitivity, 79.1%; specificity, 76.5%; positive predictive value, 89.5%; and negative predictive value, 59.1%). There were no significant differences in TnI levels between the baseline and 1 month after the procedure. However, four patients with high baseline TnI levels showed a > 50% reduction in the TnI levels post-procedurally, with three of these patients showing LVEF recovery. Low pre-procedural TnI levels can predict LVEF recovery after successful AF ablation in patients with reduced LVEF.

Prognostic value of 1,5-anhydro-D-glucitol incorporating syntax score in acute coronary syndrome.

The utility of adding information on 1,5-anhydro-D-glucitol (1,5-AG), a marker for postprandial hyperglycemia, to a pre-existing scoring system in acute coronary syndrome (ACS) patients is unknown. This retrospective cohort study included 266 ACS patients. The end point was major adverse cardiac and cerebral events (MACCE) through 5 years of follow-up. To evaluate incremental benefits of combining 1,5-AG with the syntax score, we applied time-dependent receiver operating curve (ROC) analysis, net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA). Temporal changes to the area under time-dependent ROC curves showed that addition of 1,5-AG parameters to syntax score did not provide any incremental value (area under the curve for syntax alone, 0.673 (95% confidence interval (CI), 0.599-0.747) vs. with 1,5-AG combined, 0.671 (95%CI 0.596-0.746; Delong p = 0.65). Incorporating 1,5-AG into syntax score yielded a significant NRI of 0.291 (95%CI 0.015-0.567) and IDI of 0.055 (95%CI 0.018-0.093), while DCA analysis showed the limited net benefit in combination with 1,5-AG and syntax score. 1,5-AG values exhibited significant discriminatory utility for detecting MACCE within the ACS population. However, 1,5-AG levels contributed limited utility beyond syntax score based on time-dependent ROC and DCA analyses.Trial registration: UMIN000023837.

Subclinical sinus node dysfunction in patients with atrial fibrillation-Insight from ultrahigh-resolution mapping of human sinoatrial exits.

BACKGROUND: Even a short duration of paroxysmal episodes of atrial fibrillation (AF) is associated with sinus node (SN) remodeling and a reduced SN reserve or dysfunction. The number of earliest atrial activation sites (EASs) during sinus rhythm decreases according to the decrease in the SN reserve. OBJECTIVE: We sought to evaluate the EASs during sinus rhythm using an ultrahigh-density mapping system. METHODS: This study included 35 patients (supraventricular tachycardia [SVT]/paroxysmal atrial fibrillation [PAF]/persistent atrial fibrillation [PsAF] = 5/21/9) who underwent ultrahigh-resolution endocardial mapping of the SN area at rest and during ß-stimulation. The number of EASs was determined by the Lumipoint™ algorithm. RESULTS: The number of EASs was greatest in SVT patients both at rest (SVT/PAF/PsAF = 1.4 ± 0.8/1.0 ± 0/1.0 ± 0, p = .04) and during ß-stimulation (SVT/PAF/PsAF = 2.6 ± 1.0/1.3 ± 0.6/1.0 ± 0, p < .01). The number significantly increased with ß-stimulation as compared to baseline in the PAF patients (p = .02), but not in the PsAF patients. The brain natriuretic peptide (BNP) level was significantly higher in AF than SVT patients (SVT/PAF/PsAF = 12.3 [10.1-14.5]/25.7 [14.8-36.0]/73.4 [57.6-140] pg/ml, p < .01). In the PAF patients, the BNP level was significantly higher in those with unicentric EASs than multicentric EASs during ß-stimulation (28.1 [19.1-46.5] vs. 13.1 [9.4-26.9] pg/ml, p = .03), and the optimal cutoff point for the BNP level predicting unicentric EASs was 21.8 pg/ml (sensitivity 82.6%; specificity 85.7%). CONCLUSIONS: AF patients have a smaller number of EASs and poorer response to ß-stimulation than non-AF patients. An elevated BNP level might predict subclinical SN dysfunction in patients with PAF.

Focal post-Maze atrial tachycardia mimicking macroreentrant tachycardia around the Maze lesion diagnosed using ultra-high-resolution mapping.

Focal post-Maze atrial tachycardia mimicked macroreentrant tachycardia around the Maze lesion.

Pseudo superior vena cava entrance block during sinus rhythm uncovered by continuous atrial pacing.

Usually, superior vena cava (SVC) entrance block is confirmed when SVC potentials disappear during sinus rhythm. We present a case of pseudo SVC entrance block during sinus rhythm, which was uncovered by continuous atrial pacing.

Declines in serum uric acid level after catheter ablation of atrial fibrillation.

BACKGROUND: Few studies have examined whether catheter ablation for AF patients improves biomarkers other than serum levels of brain natriuretic peptide (BNP) and renal function. This study was to explore whether catheter ablation for atrial fibrillation (AF) patients affects uric acid (UA), glucose and lipid metabolism. METHODS AND RESULTS: A total of 206 patients (66.6 ± 10.4 years; 132 men) who underwent initial AF ablation without changes to oral medications were included. Baseline BNP and UA levels significantly decreased at 1 year after ablation (p < 0.05 each). Changes in UA level correlated significantly with pre-procedural UA level (r = 0.57). In multivariable logistic regression modeling, pre-procedural UA level, persistent AF, and hemoglobin A1c (p < 0.05 each) were independent predictors of post-procedural UA level decline. Significant improvements in both persistent and paroxysmal AF patients were identified, and the magnitude of post-procedural serum UA level decline after ablation (ΔUA) was significantly greater in patients with persistent AF (0.8 ± 1.0 mg/dl) than in those with paroxysmal AF (0.2 ± 0.8 mg/dl, p < 0.001). Of the 48 patients with high UA level before procedure, 28 patients showed improvement in UA level to normal range. CONCLUSIONS: Catheter ablation for AF patients significantly improved serum UA levels without obvious influences of heart failure, renal function, or inflammation, suggesting that AF ablation may be effective for AF patients with hyperuricemia. Trial registration The study was approved by the Research Ethics Committee of University of Fukui (no. 20210132) and clinical trial registration (UMIN000044669).

Evaluation of cryoballoon pulmonary vein isolation lesions during the acute and chronic phases using a high-resolution mapping system.

BACKGROUND: An acute cryothermal ablation lesion contains both reversible and irreversible elements. However, differences in lesions created with cryoballoon pulmonary vein isolation (PVI) between the acute and chronic phases have not been fully elucidated. METHODS: We retrospectively analyzed 23 consecutive patients with atrial fibrillation who underwent cryoballoon PVI during the initial procedure followed by a second ablation procedure. In all patients, cryoballoon PVI lesions were evaluated with high-resolution voltage mapping just after PVI (acute phase) and during the second session (chronic phase). We compared the area and width of the non-isolated left atrial posterior wall (NI-LAPW) with voltage ≥ 0.5 mV during both sessions. RESULTS: PVI was successfully achieved in all patients. Cryoballoon PVI lesions were re-evaluated at 11 [2-17] months post-procedure. During the chronic phase, NI-LAPW width became significantly larger at the level of the roof (change, 5.8 ± 5.5 mm; p < 0.001) and at the level of the carina (change, 3.3 ± 7.0 mm; p < 0.05), and NI-LAPW area became significantly larger (change, 1.5 ± 1.9 cm2; p < 0.001) compared with the acute phase. Eight patients without any PV reconnections also had larger NI-LAPW areas (change, 1.3 ± 1.2 cm2; p < 0.05) during the chronic phase. Conduction resumption confined to the right carina was observed in 1 (4.3%) patient who presented with circumferential PVI that included the carina during the first session. CONCLUSION: Acute cryoballoon PVI lesions significantly regressed during the chronic phase. PV reconnections and the isolation area should be carefully re-evaluated during the second procedure.

Relationship of body mass index to clinical outcomes after percutaneous coronary intervention.

BACKGROUND: Elevated body mass index (BMI) demonstrates lower all-cause and cardiovascular mortalities compared with normal-weight or lean patients in chronic diseases. This study investigated relationships between BMI and clinical outcomes following percutaneous coronary intervention (PCI) in coronary artery disease (CAD) patients, together with the sex-specific impacts of BMI on mortality. METHODS: We reviewed 1104 CAD patients who underwent PCI between 2006 and 2015. Patients were divided by BMI into three groups: lean, <18.5 kg/m2 ; normal, 18.5-24.9 kg/m2 ; and overweight/obese, ≥25 kg/m2 . The primary endpoint was all-cause mortality, and the secondary endpoint was 3-point major adverse cardiovascular events (MACE). RESULTS: Kaplan-Meier survival analysis demonstrated risks of all-cause death, and 3-point MACE were higher in lean patients compared with normal-weight and overweight/obese subjects (log-rank p < .001). Cox proportional hazard modelling showed overweight/obese was significantly associated with all-cause death (hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.48-0.95; p = .03), and lean was significantly associated with 3-point MACE (HR 2.02, 95% CI 1.15-3.53; p = .01). Cox proportional hazard analysis with restricted cubic spline showed non-linear associations between BMI and both all-cause mortality and 3-point MACE (p for effect = .002 and = .003, respectively). No significant interaction was evident between sex and BMI for all-cause mortality (p for interaction = .104) or 3-point MACE (p for interaction =0.122). CONCLUSIONS: Lean category was associated with adverse outcomes among CAD patients. An obesity paradox regarding the independent association of elevated BMI with reduced mortality after PCI is evident in both males and females.

Oral Adrenergic Agents Produced Ventricular Fibrillation and QT Prolongation in an Elderly Patient Carrying an RYR2 Variant.

Mutant cardiac ryanodine receptor channels (RyR2) are "leaky," and spontaneous Ca2+ release through these channels causes delayed afterdepolarizations that can deteriorate into ventricular fibrillation. Some patients carrying RYR2 mutations in type 1 catecholaminergic polymorphic ventricular tachycardia exhibit QT prolongation and are initially diagnosed with long QT syndrome. However, none have been reported to cause drug-induced ventricular fibrillation in patients with RYR2 variants. We describe the first case of an elderly woman with drug-induced QT prolongation and ventricular fibrillation who carried a novel RYR2 variant but no other mutations related to long QT syndrome. Oral adrenergic agents might induce QT prolongation and subsequent ventricular fibrillation in patients carrying an RYR2 variant. Screening for RYR2 could be valuable in patients with suspected drug-induced long QT syndrome.

Evaluation of interatrial conduction pattern after pulmonary vein isolation using an ultrahigh-resolution electroanatomical mapping system.

Interatrial conduction consists of various muscular bundles, including the Bachmann bundle. In this study, we investigated interatrial activation patterns using ultrahigh-resolution left atrial endocardial mapping. This study investigated 58 patients who underwent catheter ablation of atrial arrhythmia via an ultrahigh-resolution mapping system (Rhythmia) at our hospital from May 2020 to January 2021. Left atrial voltage maps and activation maps were acquired after the ablation procedure during right atrial appendage (RAA) pacing. We defined left atrial breakout sites (LABSs) as centrifugal activation patterns shown by the LUMIPOINT Activation Search Tool. The distance between each LABS in the left atrial anterior wall and the superior border of the interatrial septum (DLABS-IAS) was measured on the shell of the electroanatomical map, and anterior LABSs were divided equally into roof- and septal-side groups. Fifty-three (91%) patients underwent cryoballoon pulmonary vein isolation. Ultrahigh-resolution left atrial mapping was successfully performed in all patients (6831 ± 2158 points). A total of 82 LABSs were identified in left atrial anterior wall; 34 patients had single LABS and 24 patients had dual LABSs. The mean DLABS-IAS was 10.3 ± 9.6 mm. Seven patients also exhibited posterior LABS near the interatrial raphe below the right inferior pulmonary vein. Patients with a single roof-side LABS had significantly shorter left atrial activation times than those with a single septal-side LABS (81.6 ± 13.2 ms vs. 93.5 ± 13.7 ms, p < 0.05). Interatrial conduction patterns during RAA pacing varied between patients and affected the left atrial activation time.

Mapping and ablation of left atrial roof-dependent tachycardias using an ultra-high resolution mapping system.

BACKGROUND: Left atrial roof-dependent tachycardias (LARTs) are common macroreentrant atrial tachycardias (ATs). We sought to characterize clinical LARTs using an ultra-high resolution mapping system. METHODS: This study included 22 consecutive LARTs in 21 patients who underwent AT mapping/ablation using Rhythmia systems. RESULTS: Three, 13, 4, and 2 LART patients were cardiac intervention naïve (Group-A), post-roof line ablation (Group-B), post-atrial fibrillation ablation without linear ablation (Group-C), and post-cardiac surgery (Group-D), respectively. The mean AT cycle length was 244 ± 43 ms. Coronary sinus activation was proximal-to-distal or distal-to-proximal in 16 (72.7%) ATs. The activation map revealed 13 (59.1%) clockwise and 9 (40.9%) counter-clockwise LARTs. A 12-lead synchronous isoelectric interval was observed in 10/19 (52.6%) LARTs. The slow conduction area was identified on the LA roof, anterior/septal wall, and posterior wall in 18, 6, and 2 ATs, respectively. Twenty concomitant ATs among 13 procedures were also eliminated, and peri-mitral AT coexisted in 7 of 9 non-group-B patients. In group-B, the conduction gap was predominantly located on the mid-roof. Sustained LARTs were terminated by a single application and linear ablation in 6 (27.3%) and 9 (40.9%), while converting to other ATs in 7 (31.8%) LARTs. Complete linear block was created without any complications in all, however, ablation at the mid-posterior wall was required to achieve block in 4 (18.2%) procedures. During 14.0 (6.5-28.5) months of follow-up, 17 (81.0%) and 19 (90.5%) patients were free from any atrial tachyarrhythmias after single and last procedures. CONCLUSIONS: The LART mechanisms were distinct in individual patients, and elimination of all concomitant ATs was required for the management.

Abdominal Fat Pad Fine-Needle Aspiration for Diagnosis of Cardiac Amyloidosis in Patients with Non-Ischemic Cardiomyopathy.

The diagnosis of cardiac amyloidosis is frequently delayed because histological confirmation is often challenging. Few studies have attempted to clarify the utility and safety of abdominal fat pad fine-needle aspiration (FPFNA) for an initial screening test in patients with suspected cardiac amyloidosis.This study included 77 consecutive patients with suspected non-ischemic cardiomyopathy who had left ventricular dysfunction and/or hypertrophy. All patients underwent abdominal FPFNA and an endomyocardial biopsy. In all patients, the abdominal FPFNA could be performed within less than 5 minutes with no complications; however, in 1 patient (1.3%), the obtained specimen was too small to evaluate. Among the remaining 76 patients, 5 (6.6%) were positive for amyloid (FPFNA[+]) and 7 (9.2%), including the 5 FPFNA[+], were diagnosed with cardiac amyloidosis (AL = 1, ATTR = 6) by endomyocardial biopsy. Positive abdominal FPFNAs indicated cardiac amyloidosis with high accuracy (sensitivity, 71.4%; specificity, 100%).Positive abdominal FPFNAs are directly linked to diagnoses of cardiac amyloidosis. Abdominal FPFNA is simple and useful for the initial screening test for cardiac amyloidosis in patients with non-ischemic cardiomyopathy.

Conduction delay across the cavotricuspid isthmus block line caused by the gap near the inferior vena cava: the role of conduction block in the lower lateral right atrium.

The electrophysiological properties of the gap associated with the cavotricuspid isthmus (CTI) block line near the inferior vena cava (IVC) are not fully elucidated. Of 143 patients who underwent CTI block line ablation between September 2020 and April 2021, high-resolution CTI gap mapping was performed for 15 patients. Four patients were identified as having a gap near the IVC (IVC-side gap) despite wide double potentials (DPs) with > 90 ms intervals at the block line. Detailed gap mapping during coronary sinus ostial pacing was performed before and after touch-up ablation. CTI conduction delays caused by an IVC-side gap were classified into 3 patterns: (1) conduction delay at the IVC-side gap without detouring gap conduction, (2) detouring gap conduction due to intrinsic lower lateral right atrium (LLRA)-IVC functional block, and (3) detouring gap conduction due to LLRA-IVC conduction block created by lateral deviation of the CTI ablation line. In Pattern 2, IVC-side gap conduction traveled backward toward the crista terminalis below the LLRA-IVC junction and came back forward again above the border. One patient presented with a head-to-bottom activation pattern of the lateral right atrium (pseudo-CTI block). Pattern 3 was caused by lateral deviation of initial RF deliveries and presented with the same course as intrinsic LLRA-IVC functional block. All patients had wide DP intervals near the tricuspid annulus (mean, 112 ms) and just above the gap site (mean, 109 ms). An IVC-side gap associated with the CTI block line can present with various conduction delay patterns.

Relationships between sodium levels, haemodynamics and metalloproteinases in heart failure patients.

To estimate the associations between dysnatraemia and inflammatory marker [including interleukin-6 (IL-6)], and tissue remodelling marker [matrix metalloproteinase (MMP)-9 and tissue inhibitor of MMP (TIMP)-1], the pulmonary capillary wedge pressure (PCWP), mean pulmonary artery pressure (PAP), and left ventricular end-diastolic pressure (EDP), and the prognostic relevance in patients with heart failure. The serum sodium level and circulating levels of IL-6, MMP-9, and TIMP-1 were measured in 173 heart failure patients. Dual heart catheterisation was performed to measure PCWP, mean PAP, and EDP. All-cause mortality was assessed during the follow-up period (mean 88 ± 49 months). Restricted cubic spline (RCS) regression showed a U-shaped association of serum sodium level with TIMP-1, with the lowest values in the 138-140 mmol/L range (P for effect = 0.042, P for non-linearity = 0.017). IL-6 and MMP-9 levels showed non-significant associations with serum sodium level. U-shaped associations of serum sodium level with PCWP (P for effect = 0.004, P for non-linearity = 0.001) and mean PAP (P for effect = 0.042, P for non-linearity = 0.017) were found with the RCS regression model. The random forest model revealed that TIMP-1, MMP-9, and IL-6 were important predictors for serum sodium levels. Restricted cubic spline Cox regressions demonstrated that TIMP-1 levels indicated a U-shaped, concaved, non-linear association with all-cause mortality (P for effect = 0.011, P for non-linearity = 0.022). Dysnatraemia is an index of TIMP-1 aggravation and elevated PCWP, mean PAP; hence, it is associated with worsening all-cause mortality.Clinical Trial Registration: UMIN000023840.