Prediction of atrial fibrillation using a home blood pressure monitor with a high-resolution system.

OBJECTIVE: The usefulness of screening for atrial fibrillation (AF) using several home blood pressure (BP) monitors has been reported. We evaluated the accuracy of a high-resolution system (HiRS) for AF prediction and its usefulness when installed in home BP monitors. METHODS: In patients with paroxysmal, persistent or permanent AF, ECG recording and BP measurements were performed simultaneously. The relationship between ECG rhythm diagnosis and pulse irregularity recognition, using a home BP monitor with HiRS, was investigated. The severity of a pulse disturbance during BP measurement was displayed as an irregular pulse rhythm symbol (IPRS) in three instances. The IPRS was not displayed if the pulse was regular, turned on if there was a weak variation in the pulse, and blinked if there was a strong variation in the pulse. RESULTS: One hundred and seven patients (44 paroxysmal AF, 63 persistent or permanent AF) were enrolled, and a total of 333 recordings were analysed. The rhythms recorded by each ECG were 73 sinus regular rhythms, 35 extrasystoles, 222 AFs and 3 atrial flutters. Sensitivity and specificity for the prediction of any arrhythmia by the IPRS display of the BP monitor were 95.8% (95% CI 92.6% to 97.6%) and 96.8% (95% CI 92.6% to 100%), respectively. In addition, sensitivity and specificity for the prediction of AF were 100% (95% CI 97.5% to 100%) and 74.8% (95% CI 65.6% to 82.5%), respectively. Sensitivity and specificity for the prediction of AF by the IPRS blinking display were 88.3% (95% CI 83.3% to 92.2%) and 94.6% (95% CI 88.6% to 98.0%%), respectively. IPRS exhibited lighting or blinking during AF occurrence; however, during sinus rhythm, IPRS was not displayed in 72 out of 73 recordings. CONCLUSION: The IPRS device predicted AF with precision and may be particularly useful for predicting an arrhythmia attack in patients with paroxysmal AF.

Cardiac Tamponade During Tocilizumab Therapy in a Patient with Rheumatoid Arthritis and Anti-DNA Antibody Positivity.

Drug-induced lupus (DIL) is a drug-mediated immune reaction with the same symptoms as that of lupus erythematosus. We herein report the first case of tocilizumab-induced lupus syndrome presenting with cardiac tamponade. A 65-year-old man presented with cough, exertional dyspnea, and chest pain after 2 months of tocilizumab therapy for rheumatoid arthritis. Echocardiography revealed marked pericardial effusion. Antinuclear antibodies and anti-double-stranded deoxyribonucleic acid antibodies were positive. The diagnosis of cardiac tamponade due to tocilizumab-induced lupus syndrome was made. He had no recurrence of pericardial effusion after tocilizumab discontinuation. Clinicians should be alert for lupus syndrome in patients receiving tocilizumab.

The coronary artery calcium score correlates with left atrial low-voltage area: Sex differences.

INTRODUCTION: In patients with coronary artery disease, a high coronary artery calcium score (CACS) correlates with atrial fibrillation (AF); however, the association between left atrial (LA) remodeling progression and coronary arteriosclerosis is unclear. This study aimed to evaluate the relationship between LA remodeling progression and the CACS. METHODS: This retrospective study enrolled 148 patients with AF (paroxysmal AF, n = 94) who underwent catheter ablation. Voltage mapping for the left atrium and coronary computed tomography for CACS calculations were performed. The ratio of the LA low-voltage area (LA-LVA), defined by values less than 0.5 mV divided by the total LA surface without pulmonary veins, was calculated. Patients with LA-LVA (<0.5 mV) >5% and ≤5% were classified as the LVA (n = 30) and non-LVA (n = 118) groups, respectively. Patient characteristics and CACS values were compared between the two groups. RESULTS: LA volume, age, CHA2 DS2 VASc score, and percentage of female patients were significantly higher, and the estimated glomerular filtration rate was lower in the LVA group than in the non-LVA group. The CACS was significantly higher in the LVA group (248.4 vs. 13.2; p = .001). Multivariate analysis identified the LA volume index and CACS as independent predictors of LA-LVA (<0.5 mV) greater than 5%. The areas under the receiver operating characteristic curves for predicting LA-LVA (<0.5 mV) greater than 5% with CACS were 0.695 in the entire population, 0.782 in men, and 0.587 in women. CONCLUSION: Progression of LA remodeling and coronary artery calcification may occur in parallel. A high CACS may indicate advanced LA remodeling, especially in men.

Quality of life improvements by durable pulmonary vein isolation in patients with atrial fibrillation.

INTRODUCTION: Successful pulmonary vein isolation (PVI) can improve the quality of life (QOL) of patients with atrial fibrillation (AF). However, the role of durable PVI for such QOL improvement is not known. The aim of this study was to clarify the effectiveness of durable PVI in improving the QOL of patients with AF. METHODS AND RESULTS: We assessed 119 patients who underwent PVI (age 66.4 ± 9.6 years, 104 paroxysmal AF). A scheduled electrophysiological study was performed 6 months after the first PVI session-regardless of recurrence of AF-to assess the durability of PVI and to identify and re-isolate reconnected pulmonary veins. QOL scores were evaluated by an AF-specific QOL questionnaire and checked at baseline, 6 months, and 1 year after the first session. In patients without AF recurrence (nonrecurrence group, n = 93), the scores at 6 months improved compared with those at baseline; conversely, the scores did not improve in patients with AF recurrence (n = 26). Nevertheless, the scores at 1 year improved compared with those at 6 months in both groups. Within the nonrecurrence group, the score difference between 6 months and baseline was higher in the durable PVI group (n = 58) than that in the nondurable PVI group (n = 35). CONCLUSIONS: The QOL of AF patients improved by the resumption of sinus rhythm following PVI. Patients with durable PVI had increased QOL scores compared with those with nondurable PVI. The durability of PVI may achieve further improvements in the QOL of patients with AF.

Comparison of touch-up ablation rate and pulmonary vein isolation durability between hot balloon and cryoballoon.

INTRODUCTION: This study aimed to compare touch-up ablation (TUA) rates and pulmonary vein isolation (PVI) durability of hot balloon ablation (HBA) and cryoballoon ablation (CBA) in paroxysmal atrial fibrillation (PAF) patients. METHODS: In total, 137 PAF patients were enrolled in the study. Among them, 59 underwent two HBA procedures at 6-month intervals and 78 patients underwent two CBA sessions, both regardless of atrial fibrillation recurrence. Propensity score matching was performed to estimate similar patient characteristics between the HBA and CBA groups. RESULTS: Each group comprised of 46 matched patients for comparison. The TUA rate at the first session was higher for HBA (49 of 184 PVs) than for CBA (20 PVs) (P = .01), with the highest incidence at the left superior pulmonary vein (LSPV). The rates of PVI durability at the second session performed 7 months later were similar between HBA (168 of 184 PVs) and CBA (162 PVs) groups. The PVI durability rate at the TUA sites of the first session was higher for HBA than for CBA (41 of 49 PVs vs 10 PVs, respectively; P = .01). Fifty percent of the patients underwent HBA at 73°C for the LSPV. HBA performed at 73°C yielded a lower TUA rate than that at 70°C (16 of 23 PVs vs 7 of 23 PVs; P = .008). CONCLUSIONS: While PVI durability was similar between HBA and CBA, the TUA rate was higher for HBA than for CBA, especially on the LSPV. For LSPV, HBA at a balloon temperature of 73°C may reduce the TUA rate.

Recurrent ischemic stroke in patients with atrial fibrillation ablation and prior stroke: A study based on etiological classification.

BACKGROUND: Different subtypes of ischemic stroke may have different risk factors, clinical features, and prognoses. This study investigated the incidence and mode of stroke recurrence in patients with a history of stroke who underwent atrial fibrillation (AF) ablation. METHODS: Of 825 patients who underwent AF ablation from 2006 to 2016, 77 patients (9.3%, median age 69 years) with a prior ischemic stroke were identified. Patients were classified as those with prior cardioembolic (CE) stroke (n = 55) and those with prior non-CE stroke (n = 22). The incidence and pattern of stroke recurrence were investigated. RESULTS: The incidence of asymptomatic AF (54.5% vs 22.7%; P = .011) and left atrial volume (135.8 mL vs 109.3 mL; P = .024) was greater in the CE group than in the non-CE group. Anticoagulation treatment was discontinued at an average of 28.1 months following the initial ablation in 34 (44.2%) patients. None of the patients developed CE stroke during a median 4.1-year follow-up. In the non-CE group, 2 patients experienced recurrent non-CE stroke (lacunar infarction in 1 and atherosclerotic stroke in 1); however, AF was not observed at the onset of recurrent ischemic stroke. CONCLUSIONS: In patients with a history of stroke who underwent catheter ablation for AF, the incidence of recurrent stroke was 0.54/100 patient-years. The previous stroke in these patients may not have been due to AF in some cases; therefore, a large-scale prospective study is warranted to identify the appro priate antithrombotic therapy for the prevention of potentially recurrent stroke.

Catheter ablation for monomorphic ventricular tachycardia in Brugada syndrome patients: detailed characteristics and long-term follow-up.

PURPOSE: Brugada syndrome (BrS) is a risk of sudden cardiac death due to polymorphic ventricular tachycardia and ventricular fibrillation with unusual monomorphic ventricular tachycardia (MVT). Detailed characteristics of MVT and long-term outcome of catheter ablation are still unknown. This study is aimed to identify the detailed characteristics and long-term follow-up of catheter ablation in BrS patients. METHODS: We evaluated 188 patients who were diagnosed with BrS from March 1999 to March 2018. Of those, patients who developed MVT and underwent catheter ablation were included. We identified eight MVTs in seven BrS patients. RESULTS: Three of them already had implantable cardioverter-defibrillator, and MVTs were terminated by cardioversion or anti-tachycardia pacing. Four patients presented with MVT originating from the right ventricular outflow tract, one patient had MVT arising from the LV septum, one patient had MVT arising from the tricuspid annulus, and one patient had bundle branch reentry ventricular tachycardia. All MVTs were successfully treated by catheter ablation in the acute phase, and seven of eight (87.5%) were free from ventricular tachyarrhythmia during the long-term follow-up (median, 7.2 years). CONCLUSIONS: All MVT cases were successfully treated by catheter ablation. We observed high ventricular arrhythmia free rate following catheter ablation during the long-term follow-up period. BrS patients who developed MVT should consider catheter ablation.

Characteristics of Marshall bundle-related atrial tachycardias using an ultrahigh-resolution mapping system.

PURPOSE: Marshall bundle (MB)-related atrial tachycardias (ATs) have already been described; however, their characteristics using an ultrahigh-resolution mapping system are not yet well known. The purpose of this study was to clarify the characteristics of MB-related ATs with ultrahigh-resolution mapping. METHODS: In 28 patients who underwent an electrophysiological study for ATs using an ultrahigh-resolution mapping system, precise circuits of 37 ATs were detected. Among those ATs, five were diagnosed as MB-related ATs that had epicardial connections among the reentrant circuits (mean age 76.6 ± 3.7 years, one male patient). We analyzed the characteristics of those MB-related ATs with ultrahigh-resolution mapping. RESULTS: The mean cycle length was 260 ± 60 ms, and the total acquired electrograms were 12,962 ± 2616 points. Two ATs were perimitral ATs, two rotated around the left pulmonary vein (PV), and one rotated around the left inferior PV. All ATs had a centrifugal activation pattern: 5 o'clock on the mitral annulus in four ATs and the upper ridge in one. Tiny potentials, which indicated epicardial potentials covering the cycle length, were detected in four of five ATs. The local activation times covered over 95% of the tachycardia cycle length on the endocardial side only in all ATs. All ATs were terminated during a radiofrequency ablation from the endocardial side of the Marshall bundle. CONCLUSIONS: The ultrahigh-resolution mapping system demonstrated an activation map of MB-related ATs with a centrifugal pattern. Macroreentrant tachycardias with a centrifugal activation pattern should be considered as possible MB-related ATs.

Characteristics of ventricular intracardiac electrograms of ventricular tachycardias originating from the epicardia in patients with an implantable cardioverter defibrillator.

INTRODUCTION: While characteristic waveforms of 12-lead electrocardiograms have been reported to predict the epicardial origin of ventricular tachycardia (VT), it has not been fully examined whether ventricular intracardiac electrograms (VEGMs) recorded from the implantable cardioverter defibrillator (ICD) via telemetry can determine the origin of VT or not. The aim of this study was to investigate the VEGM characteristics of VT originating from the epicardia. METHOD AND RESULTS: Intracardiac VEGMs of the induced VTs, with detected sites of origin during the VT study, were recorded in 15 (23 VTs) of the 46 patients. The characteristics of the 23 VTs were evaluated using far-field and near-field VEGMs recorded via telemetry. Five of 23 VTs were found to be focused on the epicardial site (epi group) and 18 VTs were focused on the endocardium (endo group). VTs of the epi group had longer VEGM duration in far-field EGM than those of the endo group (epi group: 240 ± 49 ms vs endo group: 153 ± 45 ms; P = 0.002) and the duration from the onset to the peak of VEGM was also longer than that of the endo group (epi group: 153 ± 53 ms vs endo group: 63 ± 28 ms; P < 0.001). There was no difference in the V wave duration in tip-ring EGM between both groups (epi group: 122 ± 52 ms vs endo group: 98 ± 6 ms; P = 0.377). CONCLUSION: Evaluation of intracardiac VEGM before VT ablation may be helpful to predict the epicardial origin of VT in patients with an ICD.

The relationship between obstructive sleep apnea and recurrence of atrial fibrillation after pulmonary vein isolation using a contact force-sensing catheter.

PURPOSE: Our aim was to elucidate the relationship between obstructive sleep apnea (OSA) and atrial fibrillation (AF) recurrence after repeated pulmonary vein isolation (PVI). METHODS: We conducted a non-randomized observational study, with the data prospectively collected. One hundred patients (paroxysmal AF, n = 89) underwent PVI using a contact force-sensing catheter. All patients underwent an electrophysiological study and additional ablation for left atrium-pulmonary vein (PV) reconnection and non-PV foci, 6 months after the first treatment session, regardless of AF recurrence. Those with an apnea-hypopnea index ≥ 15 were diagnosed with OSA. Continuous positive air pressure (CPAP) therapy was initiated after the second treatment session, based on results of a sleep study. For analysis, patients were classified into the non-OSA (n = 66), treated OSA (OSA patients undergoing CPAP; n = 11), and untreated OSA (n = 23) groups, and between-group differences evaluated. RESULTS: After the first session, AF recurrence was observed in 18.2% (12/66) and 14.7% (5/34) of patients without and with OSA, respectively (P = 0.678). After the second procedure, the rate of AF recurrence was 12.1% (8/66) in the non-OSA group, 9.1% (1/11) in the treated OSA group, and 8.7% (2/23) in the untreated OSA group (log-rank P = 0.944). CONCLUSIONS: The rate of AF recurrence might not be greater in patients with untreated OSA than in those without OSA and those with treated OSA after repeated PVI, using a contact force-sensing catheter, for patients with paroxysmal or short-term persistent AF.

Ventricular Fibrillation Induced by Coronary Vasospasm in a Patient with Early Repolarization and Hyperthyroidism.

Vasospastic angina (VSA) has been recognized as a cause of ventricular fibrillation (VF) degenerating into sudden cardiac death. We experienced a case of VSA with hyperthyroidism in which VF was provoked with an augmented J-wave amplitude in the inferior leads. The patient underwent insertion of an implantable cardioverter-defibrillator for the secondary prevention of VF in addition to taking Ca-channel antagonists. He has shown no recurrence of fatal arrhythmia or anginal attack for a follow-up period of one year.

Ventricular tachycardia storm originating from interventricular septum successfully treated with surgical cryoablation with electroanatomic and electrophysiological mapping before dual valve replacement.

A 58-year-old man with dilated cardiomyopathy was admitted with heart failure. He had a history of two catheter ablation procedures for ventricular tachycardia (VT) originating from the intraventricular septum (IVS). Before dual valve replacement (DVR), he suffered a VT storm. An electrophysiological study revealed an extended low-voltage area at the IVS with the exit of the induced VT at the anterior side. Radiofrequency application was performed at the VT exit as a landmark for surgical cryoablation (SA). During the DVR, SA was performed at the IVS using this landmark. After SA, the patient had no ventricular tachyarrhythmia.

Successful catheter ablation of ventricular premature complexes from the right atrial side of the atrioventricular septum with good contact force.

The acquisition of good contact force for radiofrequency catheter ablation of ventricular premature complexes (VPCs) originating from the basal septum of the left ventricle (LV) is often difficult. We describe a case of VPCs originating from the basal septum of the LV, which were successfully eliminated by applying radiofrequency at the right atrium (RA) side of the atrioventricular septum (AVS) without causing any significant impairment of atrioventricular conduction because the ablation catheter could obtain better contact force through the RA approach. Moreover, intracardiac echocardiography (ICE) and RA angiography effectively demonstrated the AVS.

Usefulness of epicardial impedance evaluation for epicardial mapping and determination of epicardial ablation site for ventricular tachycardia: A pilot study.

BACKGROUND: During epicardial mapping, determination of appropriate ablation sites in low voltage areas (LVA) is challenging because of large epicardial areas covered by adipose tissue. OBJECTIVE: To evaluate the impedance difference between epicardial fat and the epicardial LVA using multiple detector computed tomography (MDCT). METHODS: We enrolled patients who underwent ventricular tachycardia (VT) ablation via the epicardial approach after endocardial ablation failure. After the procedure, MDCT-derived images of epicardial fat were loaded to the mapping system. Then, all points acquired during sinus rhythm were retrospectively superimposed and analyzed. RESULTS: This study included data from 7 patients (62.5 ± 3.9 years old) who underwent eight epicardial VT ablation procedures. After the procedure, MDCT-derived images of epicardial fat were registered in eight procedures. Retrospective analysis of 1,595 mapping and 236 ablation points was performed. Of the 1,595 mapping points on the merged electroanatomical and epicardial fat maps, normal voltage area (NVA) and low voltage area (LVA) without fat had lower impedance than those with fat (NVA without fat 182 ± 46 Ω vs. NVA with fat 321 ± 164.0 Ω, P  =  0.001, LVA without fat 164 ± 69 Ω vs. LVA with fat 248 ± 89 Ω, P  =  0.002). Of the 236 ablation points, initial impedance before ablation was higher on epicardial fat than on epicardial LVA without fat (134 ± 16 Ω vs. 156 ± 28 Ω, P  =  0.01). CONCLUSIONS: Real time epicardial impedance evaluation may be useful to determine effective epicardial ablation sites and avoid adipose tissue. However, the number of patients in the present study is limited. Further investigation with a large number of patients is needed to confirm our result.

Genotype-Phenotype Correlation of SCN5A Mutation for the Clinical and Electrocardiographic Characteristics of Probands With Brugada Syndrome: A Japanese Multicenter Registry.

BACKGROUND: The genotype-phenotype correlation of SCN5A mutations as a predictor of cardiac events in Brugada syndrome remains controversial. We aimed to establish a registry limited to probands, with a long follow-up period, so that the genotype-phenotype correlation of SCN5A mutations in Brugada syndrome can be examined without patient selection bias. METHODS: This multicenter registry enrolled 415 probands (n=403; men, 97%; age, 46±14 years) diagnosed with Brugada syndrome whose SCN5A gene was analyzed for mutations. RESULTS: During a mean follow-up period of 72 months, the overall cardiac event rate was 2.5%/y. In comparison with probands without mutations (SCN5A (-), n=355), probands with SCN5A mutations (SCN5A (+), n=60) experienced their first cardiac event at a younger age (34 versus 42 years, P=0.013), had a higher positive rate of late potentials (89% versus 73%, P=0.016), exhibited longer P-wave, PQ, and QRS durations, and had a higher rate of cardiac events (P=0.017 by log-rank). Multivariate analysis indicated that only SCN5A mutation and history of aborted cardiac arrest were significant predictors of cardiac events (SCN5A (+) versus SCN5A (-): hazard ratio, 2.0 and P=0.045; history of aborted cardiac arrest versus no such history: hazard ratio, 6.5 and P<0.001). CONCLUSIONS: Brugada syndrome patients with SCN5A mutations exhibit more conduction abnormalities on ECG and have higher risk for cardiac events.

Life-Threatening Ventricular Arrhythmia and Brugada-Type ST-Segment Elevation Associated With Acute Ischemia of the Right Ventricular Outflow Tract.

BACKGROUND: Brugada-type ECG (Br-ECG) is occasionally observed during acute myocardial ischemia of the right ventricular outflow tract (RVOT). No studies have explored, however, the association of ventricular tachyarrhythmia and development of Br-ECG due to acute ischemia of the RVOT.Methods and Results:The study included 13 consecutive patients with acute ischemia of the RVOT during coronary catheterization. Patients were divided into 2 groups: those with Br-ECG (group B) and those without (group N). The proportion of male patients was higher in group B than in group N (100% vs. 25%, P<0.01), and VT/VF developed in only patients with Br-ECG (group B). In group B, VT/VF was observed in patients without pre-existing organic change in the conus/right ventricular (RV) branch of the right coronary artery and no VT/VF was seen in patients with organic coronary stenosis despite Br-ECG. CONCLUSIONS: Acute myocardial ischemia of the RVOT caused Br-ECG predominantly in male patients and subsequent development of VT/VF in some patients. VT/VF was seen in patients without any obstructive lesion but arrhythmic events were not observed in RVOT ischemia in the case of pre-existing coronary occlusion or stenosis of the conus or RV branch, suggesting the effects of precondition.