Unipolar-voltage-based evaluation of left atrial tissue properties and ablation outcome in patients with atrial fibrillation.

AIMS: The relationship between local unipolar voltage (UV) in the pulmonary vein (PV)-ostia and left atrial wall thickness (LAWT) and the utility of these parameters as indices of outcome after atrial fibrillation (AF) ablation remain unclear. METHODS AND RESULTS: Two-hundred seventy-two AF patients who underwent AF ablation were enrolled. Unipolar voltage of PV-ostia was measured using a CARTO system, and LAWT was measured using computed tomography. The primary endpoint was atrial tachyarrhythmia (ATA) recurrence including AF. The ATA recurrence was documented in 74 patients (ATA-Rec group). The UV and LAWT of the bilateral superior PV roof to posterior and around the right-inferior PV in the ATA-Rec group were significantly greater than in patients without ATA recurrence (ATA-Free group) (P < 0.001). The UV had a strong positive correlation with LAWT (R2 = 0.446, P < 0.001). The UV 2.7 mV and the corresponding LAWT 1.6 mm were determined as the cut-off values for ATA recurrence (P < 0.001, respectively). Multisite LA high UV (HUV, ≥4 areas of >2.7 mV) or multisite LA wall thickening (≥5 areas of >1.6 mm), defined as LA hypertrophy (LAH), was related to higher ATA recurrence. Among 92 LAH patients, 66 had HUV (LAH-HUV) and the remaining 26 had low UV (LAH-LUV), characterized by history of non-paroxysmal AF and heart failure, reduced LV ejection fraction, or enlarged LA. In addition, LAH-LUV showed the worst ablation outcome, followed by LAH-HUV and No LAH (log-rank P < 0.001). CONCLUSION: Combining UV and LAWT enables us to stratify recurrence risk and suggest a tailored ablation strategy according to LA tissue properties.

Utility of a novel wearable electrode embedded in an undershirt for electrocardiogram monitoring and detection of arrhythmias.

BACKGROUND: A 12-lead electrocardiogram (ECG) and Holter ECG have been established as gold standards for detection of arrhythmias. Recently, wearable ECG monitoring devices have been available. Our purpose of the present study was to investigate whether a novel wearable electrode embedded in an undershirt is useful for ECG monitoring and detection of arrhythmias. METHODS: We studied 31 consecutive hospitalized patients who underwent catheter ablation of tachyarrhythmias. Patients equipped a wearable electrode and a lead CM5 of Holter ECG simultaneously, and total heart beats, maximum heart rate (HR), mean HR, minimum HR, detections of arrhythmias, such as atrial fibrillation, non-sustained ventricular tachycardia, and premature ventricular contractions (Lown's grade >II), were compared between the two methods using a Holter ECG analysis software. RESULTS: Median recording time of ECG by wearable electrodes was 12.6 hours. Strong correlations between the two methods were observed in total heart beats (R = 0.999, P <0.001), maximum HR (R = 0.997, P <0.001), mean HR (R = 0.999, P <0.001), minimum HR (R = 0.989, P <0.001) and QRS duration (R = 0.900, P <0.001). Bland-Altman analysis showed excellent concordance between each parameter measured by two methods. In addition, the detection of atrial fibrillation (nine events), non-sustained ventricular tachycardia (two events), and premature ventricular contractions of Lown's grade >II (five events) were concordant in two methods. In addition, there were no significant difference in parameters of time-domain and frequency-domain analyses of heart rate variability between the two methods. CONCLUSIONS: The usefulness of a novel electrode embedded in an undershirt is equivalent to that of a Holter ECG in monitoring the ECG and detection of arrythmias.

DNA Damage Induced by Radiation Exposure from Cardiac Catheterization.

Almost 40% of medical radiation exposure is related to cardiac imaging or intervention. However, the biological effects of low-dose radiation from medical imaging remain largely unknown. This study aimed to evaluate the effects of ionized radiation from cardiac catheterization on genomic DNA integrity and inflammatory cytokines in patients and operators.Peripheral mononuclear cells (MNCs) were isolated from patients (n = 51) and operators (n = 35) before and after coronary angiography and/or percutaneous coronary intervention. The expression of γH2AX, a marker for DNA double-strand breaks, was measured by immunofluorescence. Dicentric chromosomes (DICs), a form of chromosome aberrations, were assayed using a fluorescent in situ hybridization technique.In the patient MNCs, the numbers of γH2AX foci and DICs increased after cardiac catheterization by 4.5 ± 9.4-fold and 71 ± 122%, respectively (P < 0.05 for both). The mRNA expressions of interleukin (IL)-1α, IL-1ß, leukemia inhibitory factor, and caspase-1 were significantly increased by radiation exposure from cardiac catheterization. The increase in IL-1ß was significantly correlated with that of γH2AX, but not with the dose area product. In the operators, neither γH2AX foci nor the DIC level was changed, but IL-1ß mRNA was significantly increased. The protein expression of IκBα was significantly decreased in both groups.DNA damage was increased in the MNCs of patients, but not of operators, who underwent cardiac catheterization. Inflammatory cytokines were increased in both the patients and operators, presumably through NF-κB activation. Further efforts to reduce radiation exposure from cardiac catheterization are necessary for both patients and operators.

Procedural characteristics of pulmonary vein isolation with high-power short-duration setting compared to conventional setting.

PURPOSE: The purpose of this study was to investigate the safety and efficacy of high-power short-duration (HP-SD) ablation compared to conventional ablation in patients with atrial fibrillation (AF). METHODS: We enrolled consecutive 158 drug-refractory symptomatic AF patients (119 males, mean age 63 ± 10 years) who had undergone first radiofrequency pulmonary vein isolation (PVI). PVI was performed using the conventional setting (20-35 W) in 73 patients (Conventional group) and using the HP-SD setting (45-50 W) in 85 patients (HP-SD group). The rate of first pass isolation, remaining gaps after circumferential ablation, dormant conduction, and the radiofrequency application time in each pulmonary vein (PV) were compared between the groups. RESULTS: The first pass isolation ratio was significantly higher in the HP-SD group than in the Conventional group (81% vs. 65%, P = 0.027) in the right PV, but did not differ in the left PV. The remaining gaps were fewer in the right superior PV (4% vs. 21%, P = 0.001) and left inferior PV (1% vs. 8%, P = 0.032) areas, and the radiofrequency application time in each PV was shorter (right PV, 12.0 ± 8.9 min vs. 34.0 ± 31.7 min, P < 0.001; left PV, 10.6 ± 3.6 min vs. 25.7 ± 22.3 min, P < 0.001) in the HP-SD group than in the Conventional group. CONCLUSION: The use of the HP-SD setting might contribute to improve the first pass isolation rate and to shorten the radiofrequency application time in each PV.

Influence of power setting on superior vena cava potential during right pulmonary vein isolation.

PURPOSE: High-power short-duration (HP-SD) ablation could reduce collateral tissue damage by shortening the conductive heating phase. However, it is difficult to evaluate the transmural effect of ablation lesions during pulmonary vein isolation (PVI) procedures. The present study aimed to evaluate the change in superior vena cava (SVC) potential delay as a surrogate marker of collateral tissue damage during right PVI, which is adjacent to SVC. METHODS: Out of 250 consecutive patients who underwent PVI, 86 patients in whom SVC potential during sinus rhythm was recorded both before and after right PVI were analyzed. In 46 of the patients, an HP-SD setting of 45-50 W was used (HP-SD group). In the remaining 40 patients, a conventional power setting of 20-30 W was used (conventional group). We compared the change in SVC potential delay after right PVI, radiofrequency energy, and mean contact force in the anterior-superior right PVI line, which was close to the posterior aspect of SVC, between the two groups. RESULTS: Although the total delivered radiofrequency energy (2,924 J vs. 2,604 J) and the mean contact force (18.5 g vs. 16.0 g) in the SVC overlapping area did not differ, the change in SVC potential delay after right PVI was significantly longer in the conventional group compared to the HP-SD group (5.0 ms vs. 0.0 ms, p < 0.001). CONCLUSIONS: The changes in SVC potential delay after right PVI might be a surrogate marker of collateral tissue damage according to the used energy settings.

Predictive impacts of chronic kidney disease and cardiac sympathetic nervous activity on lethal arrhythmic events in chronic heart failure.

BACKGROUND: The clinical implications of chronic kidney disease (CKD) and cardiac sympathetic nervous activity (CSNA) regarding lethal arrhythmic events have not yet been fully elucidated in patients with chronic heart failure (CHF). We hypothesized that the combination of CKD and abnormal CSNA, assessed by 123 I-metaiodobenzylguanidine (123 I-MIBG) scintigraphy, may provide useful prognostic information for lethal arrhythmic events. METHODS: We studied 165 consecutive hospitalized CHF patients without dialysis. Cardiac 123 I-MIBG scintigraphy was performed in a clinically stable condition, and abnormal CSNA was defined as a late heart-to-mediastinum ratio of <1.6. CKD was defined as an estimated glomerular filtration rate of <60 ml/min/1.73 m2 . We then investigated the incidence of lethal arrhythmic events (sustained ventricular tachyarrhythmia, appropriate implantable cardioverter-defibrillator therapy, or sudden cardiac death). RESULTS: During a median follow-up of 5.3 years, lethal arrhythmic events were observed in 40 patients (24.2%). The patients were divided into four groups according to the presence of CKD and CSNA abnormality: non-CKD/normal CSNA (n = 52), CKD/normal CSNA (n = 39), non-CKD/abnormal CSNA (n = 33), and CKD/abnormal CSNA (n = 41). Kaplan-Meier analysis showed that CKD/abnormal CSNA had the highest event rate (log-rank p = .004). Additionally, the Cox proportional hazard analysis revealed that CKD/abnormal CSNA was a predictor for lethal arrhythmic events compared with non-CKD/normal CSNA (hazard ratio, 5.368, p = .001). However, the other two groups did not show significant differences compared with the non-CKD/normal CSNA group. CONCLUSIONS: The combination of CKD and abnormal CSNA, assessed by 123 I-MIBG scintigraphy, had a high predictive value for lethal arrhythmic events in patients with CHF.

Autonomic cardiogastric neural interaction after pulmonary vein isolation in patients with atrial fibrillation.

PURPOSE: Clinical significance of reduced vagal activity following pulmonary vein isolation (PVI) for atrial fibrillation (AF) remains unclear. Periesophageal vagal nerve injury following PVI may be a powerful contributing factor of decreased vagal tone. METHODS: Drug-refractory 51 AF patients (31 males, 64 ± 11 years), who underwent successful PVI, were enrolled. We performed esophagogastroduodenoscopy 2 days after PVI and assessed delayed gastric emptying (DGE). Additionally, the coefficient of variance of R-R interval (CVRR) as a surrogate for vagal tone was measured before PVI, as well as at 1 day and 3 months after PVI. The patients were divided into two groups, patients with DGE and patients without DGE, and changes in CVRR were compared. RESULTS: After PVI, 12 out of 51 patients (23.5%) had DGE. The baseline CVRR did not differ between the patients with (n = 12) and those without (n = 39) DGE (median 3.13%, interquartile range 1.69-5.13 vs. median 3.76%, interquartile range 2.96-5.90, P = 0.297). However, CVRR at 1 day after PVI was significantly lower in the patients with DGE than in those without (median 1.49%, interquartile range 0.90-2.19 vs. median 2.59%, interquartile range 1.58-3.86, P = 0.035), and then CVRR at 3 months became similar between the two groups, suggesting that the two groups had different changes in vagal tone after PVI. The recurrence of AF was similar at 3-6 months after PVI between the two groups. CONCLUSIONS: A significantly decreased CVRR immediately after PVI is a sign of DGE incidence, implying collateral damage to the esophagus.

Electrophysiological properties and involvement of anatomical factors for the prediction of intramural origin in patients with ventricular tachyarrhythmia arising from the left ventricular outflow tract.

PURPOSE: To elucidate the electrophysiological predictors of the intramural origins of left ventricular outflow tract-ventricular tachyarrhythmias (LVOT-VAs), and to clarify the involvement of anatomical factors. METHODS: Twenty-nine successfully ablated LVOT-VAs patients with origins in the aortomitral continuity (AMC) (n = 8), aortic sinus of valsalva (ASV) (n = 9), great cardiac vein (GCV) (n = 5), and intramural myocardium (n = 7) were enrolled. Intramural origins were defined as when effective ablation from AMC and epicardium (ASV and/or GCV) was needed. The local activation time difference (LATD) was calculated as follows: (earliest AMC activation) - (earliest epicardial activation), and was presented as an absolute value. Electrophysiological parameters and anatomical factors predisposing the intramural origins were investigated. RESULTS: LATD of intramural origins was significantly shorter than that of AMC and GCV (4.5 ± 2.6 vs. 12.1 ± 7.4 vs. 17.4 ± 4.7, P < 0.05), respectively. In multivariate logistic regression analysis, LATD was associated with intramural origins (odds ratio: 0.711, confidence interval: 0.514-0.985, P = 0.040). ROC analysis revealed LATD of 7 ms as cut-off value. In computed tomography analysis, some patients who had thick fat tissue below the GCV, and an unusual GCV running pattern might be misdiagnosed as intramural origins. CONCLUSION: LATD ≤ 7 ms was associated with intramural origins, but with some anatomical limitations.

A sudden rise in pacing threshold of left ventricular lead associated with myocardial ischemia.

We report for the first time a sudden rise in the pacing threshold of the left ventricular lead due to myocardial ischemia after cardiac resynchronization therapy with defibrillator implantation, and its recovery to the baseline after the revascularization.

Visit-to-Visit Blood Pressure Variability Predicts Atrial Fibrillation Recurrence After Pulmonary Vein Isolation in Patients With Hypertension and Atrial Fibrillation.

Background: The impact of preprocedural visit-to-visit blood pressure variability (BPV) on pulmonary vein isolation (PVI) outcome in patients with hypertension (HTN) and atrial fibrillation (AF) remains unclear. Methods and Results: This study enrolled 138 AF patients with HTN who underwent successful PVI. Patients were classified into 2 groups, those with AF recurrence (AF-Rec; n=42) and those without AF recurrence (No-AF-Rec; n=96). Blood pressure (BP) was measured at least 3 times during sinus rhythm, and systolic and diastolic BPV (Sys-BPV and Dia-BPV, respectively) were defined as the standard deviation of BP. Clinical characteristics were compared between the 2 groups, and the relationship between BPV and AF recurrence was investigated. Sys-BPV and Dia-BPV were significantly higher in the AF-Rec than No-AF-Rec group (Sys-BPV: 10.6±3.7 vs. 6.9±3.5; Dia-BPV: 7.3±3.1 vs. 4.8±3.0; P<0.05 for both). Receiver operating characteristic analysis revealed Sys-BPV 9.1 and Dia-BPV 5.7 as cut-off values for AF recurrence. Kaplan-Meyer analysis demonstrated higher AF recurrence in patients with Sys-BPV >9.1 and Dia-BPV >5.7 (P<0.05 for both). Cox multivariate regression analysis revealed that Sys-BPV >9.1 and Dia-BPV >5.7 were independent predictors of AF recurrence (hazard ratios 3.736 and 2.958, respectively; P<0.05 for both). Conclusions: Sys-BPV and Dia-BPV were associated with AF recurrence in AF patients with HTN.

Symptomatic Long QT Syndrome Coexisting with Asymptomatic Acetylcholine-induced Vasospasm.

We herein report a rare case of long QT syndrome (LQTS) coexisting with acetylcholine (Ach)-induced vasospasm. A 31-year-old woman experienced cardiopulmonary arrest during running. LQTS was diagnosed by an electrocardiogram, and the coexistence of Ach-induced vasospam was determined by an Ach provocation test on coronary angiography. Although an implantable cardioverter defibrillator was placed, a beta-blocker was not prescribed for two reasons: first, the patient showed Ach-induced vasospasm alone with no symptoms and no ST change by Ach injection, and second, the use of beta-blockers alone in such patients carries a risk of vasospasm-induced ventricular fibrillation.

Associations of the Prognostic Nutritional Index with the Cardiac Function and Survival after Cardiac Resynchronization Therapy.

Objective The relationship between changes in the nutritional status after cardiac resynchronization therapy (CRT) and the prognosis has not been fully elucidated. We aimed to evaluate the changes in the nutritional status as assessed by the prognostic nutritional index (PNI) and their associations with the improvement in the cardiac function and subsequent clinical outcomes. Methods The study population consisted of 119 patients with a CRT-device. They were divided into 2 groups, based on whether their PNI had increased at 6 months after CRT-device implantation (positive ΔPNI group, n=73) or not (negative ΔPNI group, n=46). The left ventricular (LV) end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and LV ejection fraction (LVEF) were measured before and six months after CRT-device implantation. We compared the changes in the cardiac function and prevalence of adverse events (re-hospitalization due to worsening heart failure or all cause death) between the two groups. Results In the positive ΔPNI group, the LVEDV (186±93 mL vs. 149±71 mL, p<0.05) and LVESV (134±75 mL vs. 98±62 mL, p<0.05) were significantly decreased 6 months after CRT-device implantation. In addition, the LVEF (31±11% vs. 37±12%, p<0.05) was significantly increased after CRT-device implantation. In the negative ΔPNI group, no significant changes were observed in any echocardiographic parameters. During a median follow-up period of 914 days, there were 67 (56.3%) adverse events. In the Kaplan-Meier analysis, the positive ΔPNI group was associated with a lower risk of adverse events than the negative ΔPNI group (50.6% vs. 65.2%, log-rank p=0.042). Conclusion Our results suggest that improvement in the cardiac function after CRT-device implantation is associated with increases in the PNI, resulting in favorable outcomes.

Clinical impact of long PR-interval and presence of late gadolinium enhancement on hospitalized patients with non-ischemic heart failure.

BACKGROUND: The combination of electrical and structural remodeling may have a strong effect on the prognosis of non-ischemic heart failure (HF). We aimed to clarify whether prolonged PR-interval and the presence of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) influence the outcomes of patients with non-ischemic HF. METHODS: We studied 262 consecutive hospitalized patients with non-ischemic HF. In a clinically stable condition, a 12-lead electrocardiogram and CMR were performed, and the clinical characteristics and outcomes were investigated. RESULTS: During the follow-up of 967.7 ± 851.8 days, there were 68 (25.9%) cardiac events (HF or sudden death, re-hospitalization due to HF, or ventricular tachyarrhythmias). In a multivariable analysis, a median rate-adjusted PR (PRa)-interval of ≥173.5 ms and the presence of LGE were associated with cardiac events with a hazard ratio of 1.690 and 2.045 (p = .044 and p = .006, respectively). Study subjects were then divided into four groups based on long (≥173.5 ms) or short (<173.5 ms) PRa-interval and LGE status: short PRa/non-LGE (n = 80), long PRa/non-LGE (n = 72), short PRa/LGE (n = 51), and long PRa/LGE (n = 59). Cardiac events were 16.2% in short PRa/non-LGE, 25.0% in long PRa/non-LGE, 27.4% in short PRa/LGE, and 38.9% in long PRa/LGE (p = .026), respectively. The multivariable Cox proportional hazard analysis showed that long PRa/LGE was an independent predictor for cardiac events compared to short PRa/non-LGE (hazard ratio, 3.378, p = .001). CONCLUSIONS: The combination of a long PRa-interval and the presence of LGE provide a better predictive value of cardiac events in non-ischemic HF.

The relationship between red cell distribution width and cardiac autonomic function in heart failure.

BACKGROUND: Both increases in red cell distribution width (RDW) levels and autonomic dysfunction are considered to be correlated with worsening heart failure. However, the relation of RDW levels to autonomic function remains uncertain. We aimed to investigate the association of RDW levels in heart failure with autonomic function, evaluated by heart rate variability (HRV) and heart rate turbulence (HRT), and prognosis. METHODS: We studied 222 hospitalized patients with stable heart failure before discharge, and Holter recordings (HRV and HRT) were performed. Additionally, RDW levels were measured, and high RDW was defined as over 14.5%. We then divided the patients into two groups based on RDW levels: high RDW group (>14.5%, n = 92) and low RDW group (≤14.5%, n = 130). The relation of RDW to autonomic function and prognosis was assessed. RESULTS: In the high RDW group, severely impaired HRV and HRT were found compared to the low RDW group. In the linear regression analysis after the adjustment of multiple confounders, RDW levels were correlated with a low-frequency (LF) to high-frequency (HF) ratio and very low-frequency (VLF) power (LF to HF ratio, ß = -0.146, P = .027, and VLF power, ß = -0.137, P = .041, respectively). During the observation period (median 1400 days), cardiac events (re-hospitalization of heart failure, cardiac death or sudden death) were found in 73 (32.8%) patients. The Kaplan-Meier analysis demonstrated that the high RDW group had a higher rate of cardiac events compared to the low RDW group (45.6% vs 23.8%, log-rank P < .001). CONCLUSION: High RDW levels were correlated with autonomic dysfunction, resulting in poor clinical outcomes.

Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting.

BACKGROUND: The mechanism of esophageal thermal injury (ETI; esophageal mucosal injury and periesophageal nerve injury leading to gastric hypomotility) remains unknown when using a high-power short-duration (HP-SD) setting. This study sought to evaluate the characteristics of esophageal injuries in atrial fibrillation ablation using a HP-SD setting. METHODS: After exclusion of 5 patients with their esophagus at the right portion of left atrium and 21 patients with additional ablations such as box isolation and low voltage area ablation in left atrium posterior wall, 271 consecutive patients (62±10 years, 56 women) who underwent pulmonary vein isolation by radiofrequency catheter ablation were analyzed. In the 101 patients, a HP-SD setting at 45 to 50 W with an Ablation Index module was used (HP-SD group). In the remaining 170 patients before introduction of the HP-SD setting, a conventional power setting of 20 to 30 W with contact force monitoring was used (conventional group). We performed esophagogastroduodenoscopy after pulmonary vein isolation in all patients and investigated the incidence and characteristics of ETI. RESULTS: Although the incidence of ETI was significantly higher in the HP-SD group compared with the conventional group (37% versus 22%, P=0.011), the prevalence of esophageal lesions did not differ between the groups (7% versus 8%). Multivariate logistic regression analysis revealed that the use of the HP-SD setting (odds ratio, 6.09, P<0.001), and the parameters that suggest anatomic proximity surrounding the esophagus, were independent predictors of ETI. However, the majority of ETI in the HP-SD group was gastric hypomotility, and the thermal injury was limited to the shallow layer of the periesophageal wall using the HP-SD setting. CONCLUSIONS: Although the use of the HP-SD setting was a strong predictor of ETI, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.

Autonomic dysfunction in cardiac amyloidosis assessed by heart rate variability and heart rate turbulence.

BACKGROUND: Cardiac amyloidosis (CA) is characterized by left ventricular hypertrophy (LVH) and autonomic nervous imbalance due to amyloid infiltration. However, autonomic dysfunction is often seen in heart failure (HF) with LVH from other etiologies. We aimed to characterize autonomic dysfunction in CA from other etiologies of LVH. METHODS: Fifty-five HF patients with LVH (35 males, mean age 65 ± 16 years) were enrolled. LVH was defined as left ventricular mass index measured by echocardiography >95 g/m2 in women and 115 g/m2 in men. The etiology was as follows: amyloid light chain (AL)-CA, n = 14; hypertrophic cardiomyopathy, n = 21; and aortic stenosis (AS), n = 20. With the patient in a clinically stable condition, heart rate variability (HRV) and heart rate turbulence (HRT), which reflect autonomic dysfunction, were measured using Holter monitoring and compared among the three groups. RESULTS: Brain natriuretic peptide levels, LVH severity, left ventricular ejection fraction, and tissue Doppler index E/e' did not differ among the three groups. However, severe abnormalities of HRV and HRT were obtained in AL-CA. In the ROC analysis to identify AL-CA in HF with LVH, the best cutoff value for standard deviation of all R-R intervals, standard deviation of the 5-min mean R-R intervals, turbulence onset, and turbulence slope were 68.5 ms (AUC: 0.865), 58.5 ms (AUC: 0.834), 0.25% (AUC: 0.813), and 1.00 ms/RR (AUC 0.736), respectively. CONCLUSION: Autonomic dysfunction is a hallmark of AL-CA, and its noninvasive assessment by Holter monitoring may be a useful tool for differential diagnosis of HF with LVH.

Temperature drop in thawing phase reflects sufficient ice formation and better outcome of pulmonary vein isolation using second-generation cryoballoon.

BACKGROUND: Few reports exist regarding the details of ice formation on second-generation cryoballoon (CB) surface during pulmonary vein isolation (PVI). We propose a new parameter "temperature drop" in thawing phase for predicting sufficient ice formation and CB-PVI outcome. METHODS: Consecutive 106 patients who underwent successful CB-PVI for atrial fibrillation (AF) were analyzed. We defined "temperature drop" as a temperature drop of more than 3 °C just after CB catheter bending. We compared the previously known parameters predicting durable PVI between PVs with or without temperature drop. Then, we compared the PVI outcome among three groups: group 1 with temperature drop in all PVs, group 2 with temperature drop in 1-3 PVs, and group 3 without temperature drop in any PV. RESULTS: Temperature drop was present in 206 out of 424 isolated PVs. In those, PV occlusion score was significantly higher (3.7 ± 0.5 vs. 3.5 ± 0.6, P <0.001), and thawing time was significantly longer (55 ± 20 vs. 46 ± 21 s, P < 0.001) in PVs with temperature drop than those without. With a mean follow up period of 376 ± 217 days, Kaplan-Meier survival analysis revealed that no patients in group 1 experienced AF recurrence, 14 out of 86 patients (16%) experienced AF recurrence in group 2, and 5 out of 10 (50%) patients experienced AF recurrence in group 3 (Log-Rank P = 0.003). CONCLUSION: The temperature drop in thawing phase might reflect the state of ice formation and can be used to predict clinical outcome after CB-PVI.

The efficacy of combination of transcatheter atrial septal defects closure and radiofrequency catheter ablation for the prevention of atrial fibrillation recurrence through bi-atrial reverse remodeling.

PURPOSE: Atrial fibrillation (AF) often coexists with atrial septal defects (ASD). Each of the transcatheter closure for ASD and radiofrequency catheter ablation (RFCA) for AF have been established as the first-line therapy. However, there are limited data about therapeutic effect RFCA plus transcatheter ASD closure on AF recurrence in AF patients with ASD. The aim of the current study was to investigate the clinical impact of ASD closure following RFCA on AF recurrence. METHODS: Forty-two ASD patients (17 males and 54 ± 20 years old) were enrolled and classified into three groups: ASD occlusion-sinus rhythm (ASO-SR) (n = 26), no AF history prior to ASD closure; ASO-AF-RFCA (n = 11), RFCA was performed due to AF history before ASD closure; and ASO-AF-anti-arrhythmic drug (ASO-AF-AAD) (n = 5), AF was treated with AAD before and after ASD closure. AF occurrence among the 3 groups was evaluated. RESULTS: Kaplan-Meier analysis showed that ASO-SR and ASO-AF-RFCA groups showed a lower AF occurrence ratio than ASO-AF-AAD group during the 14- ± 9-month follow-up periods (P = 0.013). AF occurrence in ASO-SR and ASO-AF-RFCA groups was comparable (P = 0.480). Bi-atrial reverse remodeling, such as decrease in left atrial volume index (P = 0.049) and right atrial area (P = 0.046), and significant decrease in high-sensitivity C-reactive protein levels (P = 0.049) were identified in ASO-AF-RFCA group, but not in ASO-AF-AAD group. CONCLUSION: A combination of two percutaneous therapies was proven to be effective and induced bi-atrial reverse remodeling in association with inflammatory reaction.

Case reports of a c.475G>T, p.E159* lamin A/C mutation with a family history of conduction disorder, dilated cardiomyopathy and sudden cardiac death.

BACKGROUND: Patients with some mutations in the lamin A/C (LMNA) gene are characterized by the presence of dilated cardiomyopathy (DCM), conduction abnormalities, ventricular tachyarrhythmias (VT), and sudden cardiac death (SCD). Various clinical features have been observed among patients who have the same LMNA mutation. Here, we show a family with cardiac laminopathy with a c.475G > T, p.E159* LMNA mutation, and a family history of conduction disorder, DCM, VT, and SCD. CASE PRESENTATION: A proband (female) with atrial fibrillation and bradycardia was implanted with a pacemaker in her fifties. Twenty years later, she experienced a loss of consciousness due to polymorphic VT. She had a serious family history; her mother and elder sister died suddenly in their fifties and sixties, respectively, and her nephew and son were diagnosed as having DCM. Genetic screening of the proband, her son, and nephew identified a nonsense mutation (c.475G > T, p.E159*) in the LMNA gene. Although the proband's left ventricular ejection fraction remained relatively preserved, her son and nephew's left ventricular ejection fraction were reduced, resulting in cardiac resynchronization therapy by implantation of a defibrillator. CONCLUSIONS: In this family with cardiac laminopathy with a c.475G > T, p.E159* LMNA mutation, DCM, SCD, and malignant VT occurred. Clinical manifestation of various atrial and ventricular arrhythmias and heart failure with reduced ejection fraction occurred in an age-dependent manner in all family members who had the nonsense mutation. It appears highly likely that the E159* LMNA mutation is related to various cardiac problems in the family of the current report.