Implications of QRS Prolongation in Patients With Atrial Fibrillation (from a Multicenter Outpatient Registry).

Patients with atrial fibrillation (AF) at the highest risk of progression to heart failure (HF) need to be identified. We investigated whether QRS duration can stratify patients with AF at risk for poor clinical outcomes, including health-related quality of life (HR-QoL). We analyzed data from a multicenter registry-based cohort study of patients with AF. Patients were grouped according to the QRS duration (narrow: <120 ms; wide: ≥120 ms) at registration (baseline). The primary outcome was a composite of all-cause death and HF hospitalizations during a 2-year follow-up. In addition, the AF effect on the quality-of-life overall summary score was compared between the groups. In 3,269 patients, 302 (9.2%) had a wide QRS; these patients were more likely to be older, male, and have higher CHA2DS2-VASc scores than those with a narrow QRS. The incidence of the composite outcome was higher in patients with a wide QRS than those with a narrow QRS (13.1% vs 4.9%, p <0.001). After adjustment, a wide QRS was an independent predictor of the primary outcome (adjusted hazard ratio 1.58, 95% confidence interval 1.09 to 2.29, p = 0.016), and the results persisted after the exclusion of patients with bundle branch block or cardiac implantable electronic devices. Regarding HR-QoL outcomes, patients with a wide QRS were less likely to improve AF effect on quality-of-life overall summary scores at 1 year than those with a narrow QRS (adjusted difference -2.31, 95% confidence interval -4.06 to -0.57, p = 0.009). QRS prolongation, even for a nonspecific conduction disturbance, was an independent predictor of adverse outcomes and worse HR-QoL in patients with AF.

Very delayed sinus arrest during complete remission of diffuse large B-cell lymphoma invading right atrium.

Diffuse large B-cell lymphoma (DLBCL)-associated arrhythmias may be due to cardiac involvement or may be chemotherapy-induced. There have been no reports of significant arrhythmias with normal cardiac function occurring during the complete remission of DLBCL. A 57-year-old female, who had had no history of abnormal electrocardiograms (ECGs) in annual medical checkups, was admitted to our hospital because of low-grade fever, night sweats, and weight loss. On admission, ECG revealed a variable rhythm consisting of sinus beats and occasional escape beats. Computed tomography and 18F-fluorodeoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) revealed two masses in the right atrium (RA) and the uterus. Total hysterectomy was performed, and pathological findings were consistent with diffuse large B-cell lymphoma (DLBCL). Chemotherapy (R-CHOP) was initiated. After two chemotherapy cycles, RA tumors disappeared, and bradyarrhythmia simultaneously converted to sinus rhythm without antiarrhythmic drug therapy. Six months after completion of chemotherapy, FDG-PET/CT revealed negative uptake in the RA and the uterus. The patient attained complete remission of DLBCL, but ECG showed bradycardia because of sinus arrest. Our case suggests that DLBCL-induced arrhythmia can occur even after its remission and should be monitored.

Prognosis of Japanese Patients With Coronary Artery Disease Who Underwent Implantable Cardioverter Defibrillator Implantation　- The JID-CAD Study.

Background: There has been no large multicenter clinical trial on the prognosis of implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy with a defibrillator (CRT-D) in Japanese patients with coronary artery disease (CAD). The aim of the present study was to compare differences in the prognoses of Japanese patients with CAD between primary and secondary prevention, and to identify potential predictors of prognosis. Methods and Results: We investigated 392 CAD patients (median age 69 years, 90% male) treated with ICD/CRT-D enrolled in the Japan Implantable Devices in CAD (JID-CAD) Registry. The primary endpoint was all-cause death, and the secondary endpoint was appropriate ICD therapies. Endpoints were assessed by dividing patients into primary prevention (n=165) and secondary prevention (n=227) groups. The mean (±SD) follow-up period was 2.1±0.9 years. The primary endpoint was similar in the 2 groups (P=0.350). Conclusions: The mortality rate in Japanese patients with CAD who underwent ICD/CRT-D implantation as primary prevention was not lower than that of patients who underwent ICD/CRT-D implantation as secondary prevention, despite the lower cardiac function in the patients undergoing ICD/CRT-D implantation as primary prevention.

Factors associated with heart failure hospitalization in patients with high sodium excretion: subanalysis of the ESPRIT, evaluation of sodium intake for the prediction of cardiovascular events in Japanese high-risk patients, cohort study.

We have reported that high sodium excretion ≥ 4.0 g/day, assessed by repeated measurements of spot urine, is associated with composite cardiovascular (CV) events of heart failure (HF) hospitalization, acute coronary syndrome, cerebrovascular events, and documented CV deaths in Japanese high-risk patients with either stable and compensated congestive HF, high brain natriuretic peptide, coronary artery disease, cerebrovascular disease, chronic kidney disease, or atrial fibrillation. A total of 520 patients were enrolled. During the median follow-up period of 5.2 years, 105 (20%) experienced composite CV events, which were predominantly driven by 60 (12%) HF hospitalizations. The aim of the present study was to elucidate which subgroups of patients with high sodium excretion were associated with HF hospitalization. We divided the enrolled patients into three groups according to the amount of sodium excretion (< 3.0 g/day, 3.0-3.99 g/day (reference), and ≥ 4.0 g/day) based on a median of 14 measurements during follow-up. We assessed the hazard ratio for HF hospitalization according to age, bodyweight, and gender, using the Cox hazard model. In the total population, high sodium excretion ≥ 4.0 g/day was associated with HF hospitalization [hazard ratio (HR) 1.75, confidence interval (CI) 1.05-2.83] after adjustment for gender, age, and bodyweight, but was not associated with other CV events. In older patients (≥ 75 years old), high sodium excretion ≥ 4.0 g/day was associated with HF hospitalization after adjustment for gender and bodyweight (HR 3.25, CI 1.55-6.55), which was not observed in younger (< 75 years old) patients. In patients with lower bodyweight (< 60 kg), high sodium excretion ≥ 4.0 g/day was associated with HF hospitalization after adjustment for age and gender (HR 3.05, CI 1.34-6.61), which was not observed in heavier (≥ 60 kg) patients. High sodium excretion is associated with HF hospitalization in patients with older age and lower bodyweight in Japanese high-risk patients.

Unusual Permanent Form of Junctional Reciprocating Tachycardia Associated With an Accessory Pathway With Bidirectional Conduction.

We describe an unusual case of permanent form of junctional reciprocating tachycardia in a patient with manifest Wolff-Parkinson-White syndrome. The electrophysiological study revealed an accessory pathway responsible for the tachycardia, revealing fast and nondecremental anterograde conduction and slow and decremental retrograde conduction that was successfully ablated from the middle cardiac vein. (Level of Difficulty: Advanced.).

Cohort profile: patient characteristics and quality-of-life measurements for newly-referred patients with atrial fibrillation-Keio interhospital Cardiovascular Studies-atrial fibrillation (KiCS-AF).

PURPOSE: Besides the high rates of morbidity and mortality, atrial fibrillation (AF) is also associated with impairment of quality-of-life (QOL). However, reports covering non-selected AF population within Asian countries remain scarce. The objective of the Keio interhospital Cardiovascular Studies-atrial fibrillation (KiCS-AF) registry is to clarify the baseline and QOL profiles of the AF patients at the time of initial referral to identify areas for improvement and country-specific gaps. PARTICIPANTS: The KiCS-AF registry is a multicentre, prospective cohort study designed to specifically recruit AF patients newly referred to the 11 network hospitals within the Kanto area of Japan. The registry completed its enrolment in June 2018. All patients were requested to answer the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire both at baseline and 1 year, with planned clinical follow-up for 5 years. The registry also assessed individual treatment strategies including rate and rhythm control, stroke prophylaxis, and their impacts on patient-reported QOL. FINDINGS TO DATE: As of December 2016, 2464 AF patients were registered; their mean age was 67.1 years (SD, 11.7), majority (69.7%; n=1717) were men and 49.2% presented with paroxysmal AF. The mean CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age ≥75 years, diabetes, stroke including vascular disease, age 65-74 years, and sex category [female]) score was 2.3 (SD, 1.6) and oral anticoagulant therapy was used for 88.6% of patients with CHA2DS2-VASc scores ≥2. The median AFEQT-overall summary score was 79.1 (IQR, 66.6-89.1). Roughly 50% had significantly impaired QOL (ie, AFEQT <80) at baseline. Currently, 2307 eligible patients (93.6%) have completed the 1-year follow-up, of which 2072 patients (89.8%) answered the second AFEQT questionnaire. FUTURE PLANS: The KiCS-AF allowed for extensive investigation of AF-related QOL in a non-selected population with long-term follow-up using a rigorously validated QOL assessment tool. Almost half of patients had impaired QOL at baseline. Further investigations aimed at providing care and improving patient-reported QOL are required.

Multiple papillary fibroelastomas attached to left ventricular side and aortic side of the aortic valve: A report of new case and literature review.

The aortic valve (AV) is the most commonly affected site in multiple papillary fibroelastomas, but the frequency of embolism caused by the attachment side of the AV has not been elucidated. According to the review of the previous literature, 16 cases have been found attached to the AV. Of these, 6 of these have been found to be attached on the aortic side and 4 on the left ventricular side, 1 was bilateral, and 5 cases were unknown. Of the cases found on the aortic side, embolism occurred in 3 of them, and of the left ventricular side cases, embolism occurred in 2 of them. The frequency of embolism is equivalent even if papillary fibroelastoma attached to either side of the AV.

Assessment of Sex Differences in the Initial Symptom Burden, Applied Treatment Strategy, and Quality of Life in Japanese Patients With Atrial Fibrillation.

Importance: The clinical characteristics and outcomes of women and men with atrial fibrillation (AF) are reported to be different. However, whether sex-related differences extend to patients' symptom burden and perceived quality of life (QOL) or the management pattern of AF has been rarely studied, particularly in Asian countries. Objective: To assess the differences in symptoms, treatment, and QOL between Japanese female and male patients with AF. Design, Setting, and Participants: Retrospective cohort study using data from the multicenter outpatient registry Keio Interhospital Cardiovascular Studies-Atrial Fibrillation (KiCS-AF), which collects information regarding health status and the treatment of patients with newly diagnosed or referred AF. One-year follow-up data were available for 1534 patients at 11 referral centers in the Tokyo, Japan, area who were enrolled between September 2012 and December 2015. All data available up to the 1-year follow-up examination through July 31, 2017, were included. Main Outcomes and Measures: Sex, symptoms, AF treatment, and QOL as determined by Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaires at their initial visit and 1 year later. Results: Of 1534 patients, 1076 (70.1%) were men. Compared with men, women were more likely to be older (median age, 73 years [interquartile range {IQR}, 65-78 years] vs 65 years [IQR, 57-73 years], P < .001) and have higher median brain-type natriuretic peptide levels (102.8 pg/mL [IQR, 47.3-235.5 pg/mL] vs 74.1 pg/mL [IQR, 28.5-150.5 pg/mL], P < .001). Women also had lower median AFEQT overall summary scores than men (75 [IQR, 61-85] vs 80 [IQR, 69-90]; P < .001) but similar treatment satisfaction at baseline. During follow-up, women were less likely to be treated with a rhythm control strategy (48.1% [n = 214] vs 58.0% [n = 621], P < .001), including catheter ablation of AF (adjusted hazard ratio, 0.77 [95% CI, 0.62-0.95]; P = .02). At 1-year follow-up, women and men had improved QOL scores, regardless of their baseline characteristics (eg, age or brain-type natriuretic peptide levels) or treatment strategies, yet the sex gap persisted and grew (adjusted change in AFEQT overall summary score during 12 months, 5.89 [95% CI, 2.24-9.54] in women vs 8.94 [95% CI, 5.59-12.30] in men; P = .02). Conclusions and Relevance: In contemporary Japanese clinical practice among unselected patients with AF, women were initially seen with greater QOL impairment, and the sex gap grew 1 year after presentation. The present study underscores the need for focused efforts to better understand and close this observed sex gap over the initial year of treatment for patients with AF.

Delayed hemopericardium due to non-penetrating chest trauma: a report of new case and literature review.

To our knowledge, only 15 cases of delayed traumatic hemopericardium resulting from non-penetrating chest trauma have been reported. We present the case of a 63-year-old man with delayed hemopericardium, 2 months after striking the anterior chest on a mailbox when he fell down three steps during a postal delivery. Our case and review of the previously reported cases suggest that some cases might show quite slow progression of blood accumulation. Therefore, careful observation of patients who have experienced blunt trauma of the anterior chest is necessary.

Cancer therapeutics-related cardiac dysfunction in a patient treated with abiraterone for castration-resistant prostate cancer.

Abiraterone is an agent effective for castration-resistant prostate cancer, but there have been no reports of cardiotoxic effects inducing cardiomyopathy, to our knowledge. We present a case of an 86-year-old man with castration-resistant prostate cancer treated with abiraterone. He had received an androgen receptor antagonist (bicalutamide) and a gonadotropin-releasing hormone antagonist (degarelix) for 3 years. These agents were changed to enzalutamide due to elevation of plasma prostate-specific antigen level of 129 ng/mL. One year later, the oral androgen receptor inhibitor (enzalutamide) caused drug-induced lung injury and was changed to abiraterone. Transthoracic echocardiography (TTE) revealed normal left ventricular systolic function, and left ventricular ejection fraction (LVEF) was 67%. Four weeks after administration of abiraterone, he complained of dyspnea on effort and bilateral leg edema, and he was diagnosed with heart failure. TTE showed hypokinesis of the diffuse LV, and LVEF decreased to 45%. The various causes of heart failure were excluded. Since a cardiotoxic effect of abiraterone was suspected, administration of abiraterone was discontinued. Two weeks after cessation of abiraterone, LVEF ameliorated to 57%, and then 5 months after cessation of abiraterone, LVEF further improved to 65%. To our knowledge, this is the first report of definite cancer therapeutics-related cardiac dysfunction due to a hormonal agent such as abiraterone diagnosed according to the American Society of Echocardiography and European Association of Cardiovascular Imaging criteria.

Evaluation of sodium intake for the prediction of cardiovascular events in Japanese high-risk patients: the ESPRIT Study.

The optimal level of sodium intake remains controversial, and the effects on a broad range of cardiovascular (CV) conditions remain unknown. The Evaluation of sodium intake for the prediction of cardiovascular events in Japanese high-risk patients (ESPRIT) is a prospective observational study designed to investigate whether sodium intake assessed by spot urine testing is associated with adverse CV events. A total of 520 patients who visited our cardiology clinic with various cardiovascular risk profiles were included. Sodium intake was estimated by spot urine testing at the time of entry, and the measurement was repeated at least every 6 months during follow-up. The primary endpoint was composed of (1) hospitalization due to heart failure, (2) acute coronary syndrome, (3) cerebrovascular events, and (4) documented CV deaths. The secondary endpoint was all-cause mortality. During the median follow-up period of 5.2 years, there were 105 composite CV events (3.9%/year), including 60 hospitalizations due to heart failure, 9 acute coronary syndromes, 21 cerebrovascular events, 15 CV deaths, and 26 cases of all-cause mortality. The average sodium excretion (from a median of 14 measurements) during the follow-up period was 3.52 ± 0.67 g/day. After adjustment for age, sex, and body weight, higher sodium excretion ( ≥ 4.0 g/day) was associated with composite CV events (hazard ratio 1.79, confidence interval 1.01-3.15 compared with the reference value of 3.0-3.49 g/day) but not all-cause mortality. The ESPRIT study showed that high sodium excretion (≥ 4.0 g/day) was associated with the predefined composite CV events (UMIN ID: UMIN000005419).

Significant impact of electrical storm on mortality in patients with structural heart disease and an implantable cardiac defibrillator.

BACKGROUND: Electrical storm (E-Storm), defined as multiple episodes of ventricular arrhythmias within a short period of time, is an important clinical problem in patients with an implantable cardiac defibrillator (ICD) including cardiac resynchronization therapy devices capable of defibrillation. The detailed clinical aspects of E-Storm in large populations especially for non-ischemic dilated cardiomyopathy (DCM), however, remain unclear. OBJECTIVE: This study was performed to elucidate the detailed clinical aspects of E-Storm, such as its predictors and prevalence among patients with structural heart disease including DCM. METHODS: We analyzed the data of the Nippon Storm Study, which was a prospective observational study involving 1570 patients enrolled from 48 ICD centers. For the purpose of this study, we evaluated 1274 patients with structural heart disease, including 482 (38%) patients with ischemic heart disease (IHD) and 342 (27%) patients with DCM. RESULTS: During a median follow-up of 28months (interquartile range: 23 to 33months), E-Storm occurred in 84 (6.6%) patients. The incidence of E-Storm was not significantly different between patients with IHD and patients with DCM (log-rank p=0.52). Proportional hazard regression analyses showed that ICD implantation for secondary prevention of sudden cardiac death (p=0.0001) and QRS width (p=0.015) were the independent risk factors for E-storm. In a comparison between patients with and without E-Storm, survival curves after adjustment for clinical characteristics showed a significant difference in mortality. CONCLUSION: E-Storm was associated with subsequent mortality in patients with structural heart disease including DCM.

Report of periprocedural oral anticoagulants in catheter ablation for atrial fibrillation: The Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF).

BACKGROUND: To obtain a perspective of the current status of catheter ablation for the cure of atrial fibrillation, the Japanese Heart Rhythm Society conducted a nationwide survey: the Japanese Catheter Ablation Registry of Atrial Fibrillation. In this report, we aimed to evaluate the periprocedural use of direct oral anticoagulants with respect to thromboembolic or bleeding complications. METHODS: Using an online questionnaire, the Japanese Heart Rhythm Society requested electrophysiology centers in Japan to register the relevant data of patients who underwent atrial fibrillation ablation over selected five-months from 2011 to 2014. We compared the clinical profiles and the ablation data, including the incidence of pericardial effusion, major bleeding, and ischemic stroke among patients with periprocedural use of warfarin or a direct oral anticoagulant. RESULTS: A total of 204 institutions reported data on 6200 atrial fibrillation ablation sessions. We analyzed data obtained from 4698 subjects (Age 63.2±10.6 yr; 73.9% male, 26.1% female) who were administered warfarin or a direct oral anticoagulant, at least up to the day before atrial fibrillation ablation. Warfarin was administered to 54.7% of patients. Dabigatran, rivaroxaban, and apixaban were used in 21.9%, 12.9%, and 10.6% of patients, respectively. Clinical profiles of apixaban-treated patients were similar to those of warfarin-treated patients; they were different from the clinical profiles of patients treated with dabigatran or rivaroxaban. There were 104 complications in 103 subjects (2.2%). Complications were more frequent in older patients (65.3±8.6 yr vs. 63.1±10.7 yr; P=0.012), patients on chronic hemodialysis (4.9% vs. 1.1%; P=0.001), or those treated with warfarin (66.0% vs. 54.4%; P=0.019). Multiple logistic regression analysis revealed that age (OR, 1.02; 95% CI: 1.00-1.04; P=0.035), chronic hemodialysis (OR, 4.40; CI: 1.68-11.50; P=0.003), and assistance by 3-D mapping system (OR, 0.30; CI: 0.16-0.57; P<0.001) were significantly related to the incidence of complications, while periprocedural direct oral anticoagulant was not a predictive factor for complication. CONCLUSIONS: Compared with uninterrupted warfarin, the choice of a direct oral anticoagulant as a periprocedural oral anticoagulant did not significantly change the incidence of serious complications.

Impact of postconditioning with lactate-enriched blood on in-hospital outcomes of patients with ST-segment elevation myocardial infarction.

BACKGROUND: Reperfusion injury offsets the beneficial effects of reperfusion therapy for ST-segment elevation myocardial infarction (STEMI). In our previous reports, postconditioning with lactate-enriched blood (PCLeB) induced excellent microcirculation recovery and less inflammation in STEMI patients. This study aimed to determine the in-hospital outcomes of STEMI patients treated using PCLeB. METHODS: Fifty-five consecutive STEMI patients were treated using PCLeB (Age 66.6±13.8years, 76.4% men) within 12h of symptom onset. In our modified postconditioning protocol, the duration of each brief reperfusion was prolonged from 10s to 60s in a stepwise manner. Lactated Ringer's solution (20-30mL) was injected directly into the culprit coronary artery at the end of each brief reperfusion and the balloon was quickly inflated at the lesion site, whereby lactate could be trapped inside the ischemic myocardium. Each brief ischemic period lasted 60s. After 7cycles of balloon inflation and deflation, full reperfusion was performed. Thereafter, stenting was performed and percutaneous coronary intervention (PCI) was completed. RESULTS: The mean corrected thrombolysis in myocardial infarction frame count was 20.1±10.1 after PCI completion. The mean peak serum creatine kinase and creatine kinase-MB levels were 2751±2227IU/L and 276±181IU/L respectively. None of the study patients died during their hospital stay or required continuation of oral diuretic or inotropic therapy for heart failure on discharge. CONCLUSIONS: PCLeB led to zero in-hospital mortality and no overt heart failure on discharge in 55 consecutive STEMI patients undergoing reperfusion therapy.

Diagnostic Accuracy of Commercially Available Automated External Defibrillators.

BACKGROUND: Although automated external defibrillators (AEDs) have contributed to a better survival of out-of-hospital cardiac arrests, there have been reports of their malfunctioning. We investigated the diagnostic accuracy of commercially available AEDs using surface ECGs of ventricular fibrillation (VF), ventricular tachycardia (VT), and supraventricular tachycardia (SVT). METHODS AND RESULTS: ECGs(VF 31, VT 48, SVT 97) were stored during electrophysiological studies and transmitted to 4 AEDs, the LifePak CR Plus (CR Plus), HeartStart FR3 (FR3), and CardioLife AED-2150 (CL2150) and -9231 (CL9231), through the pad electrode cables. For VF, the CL2150 and CL9231 advised shocks in all cases, and the CR Plus and FR3 advised shocks in all but one VF case. For VTs faster than 180 bpm, the ratios for advising shocks were 79%, 36%, 89%, and 96% for the CR Plus, FR3, CL2150, and CL9231, respectively. The FR3 and CR Plus did not advise shocks for narrow QRS SVTs, whereas the CL9231 tended to treat high-rate tachycardias faster than 180 bpm even with narrow QRS complexes. The characteristics of the shock advice for the FR3 differed from that for the CL9231 (kappa coefficient [κ]=0.479, P<0.001), and the CR Plus and CL2150 had characteristics somewhere between the 2 former AEDs (κ=0.818, P<0.001). CONCLUSIONS: Commercially available AEDs diagnosed VF almost always correctly. For VT and SVT diagnoses, a discrepancy was evident among the 4 investigated AEDs. The differences in the arrhythmia diagnosis algorithms for differentiating SVT from VT were thought to account for these differences.