Clinical Outcomes of Next-Generation Microwave Thermosphere Ablation for Hepatocellular Carcinoma with Primarily Hepatitis-Related Etiology.

BACKGROUND AND AIM: We investigated the clinical outcomes of patients with hepatocellular carcinoma (HCC) who underwent next-generation microwave thermosphere ablation (MTA). METHODS: A total of 429 patients with 607 HCCs (maximum tumor diameter ≤40 mm) were included. We defined the following areas of the liver as those where MTA therapy is difficult to perform: caudate lobe and areas near the primary and secondary branches of the intrahepatic portal vein, inferior vena cava, gallbladder, heart, duodenum, abdominal esophagus, collateral veins around the liver, and spleen. Factors which predisposed patients to local tumor recurrence in the context of tumor location and complications were examined. RESULTS: The primary etiologies of HCC were hepatitis-related: 259 (60.4%) cases of HCV, 31 (7.3%) cases of HBV, and two instances of both. Median maximum tumor diameter was 15.0 (interquartile range, 10.0-21.0) mm. There were 86 tumors in areas of the liver where MTA is difficult. The most common area was near the primary and secondary branches of the intrahepatic portal vein (26 nodules). The cumulative local tumor recurrence rates at 1, 2, and 3 years were 4.4%, 8.0%, and 8.5%, respectively. The cumulative local tumor recurrence rate differed significantly by tumor size group: 6.6%, 13.8%, and 29.4% at three years in the ≤20 mm group (n = 483), 20-30 mm group (n = 107), and ≥30 mm group (n = 17), respectively (p < 0.001). The cumulative local tumor recurrence rate was similar despite difficult-to-treat status (p = 0.169). In the multivariable analysis, tumor size (>15 mm) (hazard ratio [HR], 2.15; 95% confidence interval [CI], 1.11-4.16; p = 0.023) and ablative margin (<3 mm) (HR, 2.94; 95% CI, 1.52-5.71; p = 0.001) were significantly associated with local tumor recurrence. Only tumor size (>15 mm) (odds ratio, 3.41 95% CI, 1.53-7.84; p = 0.026) was significantly associated with complications. CONCLUSIONS: MTA is a safe and effective local ablation therapy for HCC, even for tumors located in areas of the liver where local ablation therapy is difficult.

Differences in the structural characteristics and distribution of epicardial adipose tissue between left and right atrial fibrillation.

Aims: Right atrial (RA) fibrillation (RAF) was previously characterized by initiation from RA ectopies, presence of a right-to-left dominant frequency gradient during atrial fibrillation (AF), and augmentation of the gradient by adenosine triphosphate infusion. We investigated structural characteristics of the bi-atria and epicardial adipose tissue (EAT) volume in patients with RAF. Methods and results: By using multidetector computed tomography, RA, left atrial (LA), right and LA appendage (RAA and LAA, respectively) volumes, pulmonary vein (PV) sizes, and EAT volumes were compared between the RAF group (n = 8) and LA fibrillation (LAF) group (n = 32). Compared with the LAF group, the LA volume was smaller (median 81.3 [95% CI, 74.2-88.5] vs. 64.5 [54.8-74.2] mL/m2; P = 0.04), the LAA volume was smaller (10.1 [9.0-11.3] vs. 6.5 [4.5-8.5] mL/m2; P = 0.008), and the RAA volume was larger (10.8 [9.1-12.4] vs. 14.1 [11.6-16.6] mL/m2; P = 0.044) in the RAF group. The RA volume was not significantly different between the groups (73.6 [66.8-80.3] vs. 68.1 [57.1-79.1] mL/m2; P = 0.47). The RAF group had smaller PVs (1.44 [1.33-1.55] vs. 1.12 [0.94-1.30] cm2/m2 for the left inferior PV; P = 0.01). Both the LA-EAT and RA-EAT volumes were smaller in the RAF group than the LAF group (4.2 [2.8-5.6] vs. 9.1 [7.8-10.4] mL/m2; P < 0.001 and 5.3 [4.3-6.3] vs. 9.5 [8.4-10.6] mL/m2; P < 0.001, respectively). Conclusion: RAF was structurally characterized by predominant RAA enlargement, small left atrium, and less EAT surrounding the atria. Electrical properties that determine the features of AF (RAF vs. LAF) may be genetically linked to structural properties.

Trade-off between elimination of premature ventricular complexes and loss of synchronized left ventricular pacing improved cardiac function in a patient with heart failure.

Synchronized left ventricular pacing (sLVP) via adaptive cardiac resynchronization therapy (aCRT) algorithm might enhance the efficacy of CRT. A 71-year-old female was admitted with the diagnosis of heart failure. Electrocardiograms revealed left bundle branch block with QRS width of 144 ms, and frequent premature ventricular complexes (PVCs). A CRT device was implanted, and sLVP via a CRT algorithm was provided. Frequent PVCs arising from the His-bundle suppressed effective sLVP percentage. Radiofrequency application at the His-bundle successfully eliminated the PVCs, but induced complete atrioventricular (AV) block, leading to loss of sLVP. These procedures remarkably improved the patient's cardiac function, suggesting the advantage of PVC elimination overweighed the disadvantage of loss of sLVP.

Right-to-left frequency gradient during atrial fibrillation initiated by right atrial ectopies and its augmentation by adenosine triphosphate: Implications of right atrial fibrillation.

BACKGROUND: A left-to-right dominant frequency (DF) gradient commonly exists in paroxysmal atrial fibrillation (AF). AF initiated by right atrial (RA) ectopy (AF-RAE) is rare. OBJECTIVE: This study aimed to investigate characteristics of AF-RAE using pharmacological maneuvers and spectral analysis. METHODS: Seventy-nine consecutive patients referred for catheter ablation of paroxysmal AF were enrolled. Infusions of isoproterenol and adenosine triphosphate (ATP) were used to induce AF. Patients with AF-RAE and patients with AF initiated only by pulmonary vein (PV) ectopies were classified into the RA-ectopy group (n = 7[9%]) and PV-ectopy group (n = 32[41%]), respectively. ATP was also injected during ongoing AF to unmask the driver of AF. High RA, coronary sinus, and PV-left atrial junction electrograms and electrocardiogram lead V1 underwent spectral analyses. RESULTS: Patients in the RA-ectopy group were younger (51 ± 13 years vs 63 ± 7 years; P = .01) and more commonly had a family history of AF (71% vs 9%; P < .001) than patients in the PV-ectopy group. There was a baseline right-to-left DF gradient in the RA-ectopy group (PV-left atrial junction: 6.0 ± 0.4 Hz; coronary sinus: 5.7 ± 0.6 Hz; RA: 7.3 ± 0.8 Hz; P < .05) in contrast to a left-to-right DF gradient in the PV-ectopy group (5.9 ± 0.8, 5.3 ± 0.7, 5.2 ± 0.8 Hz; P < .01). ATP injection predominantly increased the DF of the high RA in the RA-ectopy group and augmented a right-to-left DF gradient (7.9 ± 1.8, 7.6 ± 1.0, 10.7 ± 0.7 Hz; P < .001), whereas it augmented a left-to-right DF gradient in the PV-ectopy group (7.9 ± 1.0, 6.4 ± 0.5, 6.6 ± 1.2 Hz; P < .05). CONCLUSION: A rare type of paroxysmal AF initiated by RA ectopy may be maintained by a reentrant driver localized in the RA (so-called RA fibrillation).