Improved outcomes of cardiac resynchronization therapy with a defibrillator in systolic heart failure: Analysis of the Japan cardiac device treatment registry database.

Background: Temporal change in outcomes of heart failure patients receiving cardiac resynchronization therapy with a defibrillator (CRT-D) is unknown. Methods: We assess outcomes and underlying heart diseases of patients receiving CRT-D with analyzing database of the Japan cardiac device treatment registry (JCDTR) at the implantation year 2011-2015 and New JCDTR at the implantation year 2018-2021. Results: Proportion of nonischemic heart diseases was about 70% in both the groups (JCDTR: 69%; New JCDTR: 72%). Cardiac sarcoidosis increased with the rate of 5% in the JCDTR to 9% in the New JCDTR group. During an average follow-up of 21 months, death from any cause occurred in 167 of 906 patients in the JCDTR group (18%) and 79 of 611 patients in the New JCDTR group (13%) (adjusted hazard ratio [aHR] in the New JCDTR group, 0.72; 95% confidence interval [CI]: 0.55-0.94; p = .017). The superiority was mainly driven by reduction in the risk of noncardiac death. With regard to appropriate and inappropriate implantable cardioverter-defibrillator (ICD) therapy, there was a significant reduction in the New JCDTR group versus the JCDTR group (aHR in the New JCDTR group, 0.76; 95% CI: 0.59-0.98; p = .032 for appropriate ICD therapy; aHR in the New JCDTR group, 0.24; 95% CI: 0.12-0.50; p < .0001 for inappropriate ICD therapy). Conclusions: All-cause mortality was reduced in CRT-D patients implanted during 2018-2021 compared to those during 2011-2015, with a significant reduction in noncardiac death.

Impact of a Cancer History on Cardiovascular Events Among Patients With Myocardial Infarction Who Received Revascularization.

BACKGROUND: It remains controversial whether a cancer history increases the risk of cardiovascular (CV) events among patients with myocardial infarction (MI) who undergo revascularization.Methods and Results: Patients who were confirmed as type 1 acute MI (AMI) by coronary angiography were retrospectively analyzed. Patients who died in hospital or those not undergoing revascularization were excluded. Patients with a cancer history were compared with those without it. A cancer history was examined in the in-hospital cancer registry. The primary outcome was a composite of cardiac death, recurrent type 1 MI, post-discharge coronary revascularization, heart failure hospitalization, and stroke. Among 551 AMI patients, 55 had a cancer history (cancer group) and 496 did not (non-cancer group). Cox proportional hazards model revealed that the risk of composite endpoint was significantly higher in the cancer group than in the non-cancer group (adjusted hazard ratio [HR]: 1.78; 95% confidence interval [CI]: 1.13-2.82). Among the cancer group, patients who were diagnosed as AMI within 6 months after the cancer diagnosis had a higher risk of the composite endpoint than those who were diagnosed as AMI 6 months or later after the cancer diagnosis (adjusted HR: 5.43; 95% CI: 1.55-19.07). CONCLUSIONS: A cancer history increased the risk of CV events after discharge among AMI patients after revascularization.

Unusual atrial pacing induced by type II far-field p-wave sensing in a patient with complete atrioventricular block.

An 88-year-old Japanese woman underwent DDD pacemaker (MicroPort KORA 250 DR, V lead: VEGA R52) implantation for complete atrioventricular block. A 12-lead electrocardiogram for a routine examination showed atrial pacing within the intrinsic P wave, followed by inhibition of ventricular pacing. Pacemaker interrogation revealed no abnormalities in the basic parameters; however, ventricular pacing was inhibited by far-field sensing of intrinsic atrial waves before atrial events; type II far-field P-wave sensing. As a result, unusual atrial pacing occurred due to the pause suppression algorithm, which is the one of the functions that prevent atrial fibrillation development.

The observation of below-the-knee artery by optical frequency domain image and angioscopy: a case series.

Background: Endovascular treatment (EVT) is a well-established treatment for patients with chronic limb-threatening ischaemia, and below-the-knee (BTK) artery is its main target, although the re-intervention rate is still high. Understanding of the characteristics of BTK artery atherosclerosis would be required to overcome this issue. In this case series, we elucidated the characteristics of non-stenotic BTK artery atherosclerosis in the patients who received EVT of the superficial femoral artery (SFA) using optical frequency domain imaging (OFDI) and angioscopy. Case summary: We presented five patients who underwent EVT of SFA and subsequent observation of ipsilateral BTK artery using OFDI and angioscopy. Patients one and two had advanced atherosclerosis; however, patients three, four, and five had only mild atherosclerosis. Discussion: All patients had multiple risk factors for atherosclerosis and stenosis/occlusion of the SFA and ipsilateral BTK arteries. Furthermore, some patients had several other atherosclerotic vascular diseases suggesting the presence of advanced systemic atherosclerosis. On the other hand, some patients with multiple BTK artery stenosis/occlusion did not have advanced atherosclerosis in the examined BTK artery. The absence of significant atherosclerosis in a BTK artery in patients with multiple stenoses or occlusion in other ipsilateral BTK arteries may suggest some mechanism of vessel occlusion other than atherosclerosis. Further investigations are needed to clarify the mechanism.

Cardiac resynchronization therapy with a defibrillator in non-ischemic and ischemic patients for primary and secondary prevention of sudden cardiac death: Analysis of the Japan cardiac device treatment registry database.

Background: Panoramic studies in patients with cardiac resynchronization therapy with a defibrillator (CRT-D) focusing on the etiology and indication are scarce. Besides, a controversy exists regarding requirement of a defibrillator in non-ischemic patients for primary prevention with CRT. Methods: Annual trends of de novo CRT-D implantations from 2011 to 2020 and outcomes of those between January 2011 and August 2015 were analyzed from the Japan cardiac device treatment registry (JCDTR) and New JCDTR database. Results: From 2011 to 2020, 8062 CRT-D recipients were registered, whose dominant indication was primary prevention of sudden cardiac death with a steady rate of about 70%. There was no significant temporal change of the proportion of non-ischemic patients being about 70% and 65% for primary and secondary prevention, respectively. Non-ischemic patients for primary prevention were associated with increased odds of appropriate ICD therapy [adjusted hazard ratio (aHR): 1.66; 95% confidence interval (CI): 1.01-2.75; p = .047] and reduced odds of any death (aHR: 0.66; 95% CI: 0.44-0.99; p = .046) as compared to ischemic patients. Conclusions: Proportion of non-ischemic etiology was much higher than that of ischemic one in the CRT-D cohort. Based on the higher odds of appropriate ICD therapy, non-ischemic patients for primary prevention appear to be prudently selected in Japan.

Initial heart rate score predicts new-onset atrial tachyarrhythmias in pacemaker patients.

AIMS: Heart rate score (HRSc), the per cent of atrial paced and sensed event in the largest 10 b.p.m. rate histogram bin of a pacemaker, predicts survival in patients with cardiac devices. No correlation between HRSc and development of atrial fibrillation (AF) has been reported. In this study, we evaluated the relationship between pacemaker post-implantation HRSc and the incidence of newly developed atrial tachyarrhythmias (ATAs). METHODS AND RESULTS: Patients with dual-chamber pacemakers, implanted 2013-17, with the LATITUDE remote monitoring data with ≥600 000 beats of histogram data collected at baseline were included (N = 34 543). Heart rate score was determined from the initial 3-month post-implantation histogram data. Patients were excluded if they had ATAs, defined as atrial high-rate episodes >5 min or >1% of right atrial beats >170 b.p.m. during the initial 3 months post-implantation. New ATAs, after the baseline period, were defined by each of the following: >1, >10, or >25% of atrial beats >170 b.p.m. or atrial tachycardia response (ATR) events >24 h. Patients were followed a median of 2.8 (1.0-4.0) years. The incidence of ATAs increased in proportion to HRSc (log-rank P-value <0.001), and the initial HRSc ≥70% was associated with increased ATAs by all definitions. Patients with initial HRSc ≥70% were older, had a higher percentage of right atrium pacing (%RA pacing), had a lower percentage of right ventricular pacing (%RV pacing), and were more likely programmed with rate-response vs. subjects with HRSc <70%. Initial HRSc (hazard ratio: 1.07, 95% confidence interval: 1.05-1.09; P < 0.0001) independently predicted ATAs after adjusting for age, gender, %RV pacing, and rate-response programming. The %RA pacing and initial HRSc were correlated. CONCLUSION: Heart rate score independently predicts any subsequent duration of ATAs in pacemaker patients.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic.

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Belt-type electrocardiograph for diagnosing palpitation occurring only during high-intensity exercise in athletes.

Belt-type ambulatory electrocardiograph (EV-201) is an arrhythmia diagnostic device that can record an electrocardiogram (ECG) for a maximum of 2 weeks. Here, we report the novel utility of EV-201 in detecting arrhythmias in two professional athletes. Treadmill exercise test and Holter ECG failed to detect arrhythmia because of insufficient exercise, electrocardiogram noise. However, by wearing EV-201 only during a marathon run, supraventricular tachycardia onset and termination were successfully detected. Throughout, both athletes were diagnosed with fast-slow atrioventricular nodal re-entrant tachycardia. Therefore, EV-201 enables long-term belt-type recording, thereby being useful in detecting tachyarrhythmias that occur infrequently and during strenuous exercises. Learning objective: Diagnosis of arrhythmias during high-intensity exercise in athletes by conventional electrocardiography is sometimes difficult due to inducibility and frequency of arrythmias or motion artifacts. The primary finding of this report is that EV-201 is useful in diagnosing such arrhythmias. The secondary finding is that fast-slow atrioventricular nodal re-entrant tachycardia is a common occurrence in arrhythmias among athletes.

2023 HRS/EHRA/APHRS/LAHRS expert consensus statement on practical management of the remote device clinic.

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic.

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Prognostic Impact of Echocardiographic Congestion Grade in HFpEF With and Without Atrial Fibrillation.

Background: Atrial fibrillation (AF) is common in heart failure with preserved ejection fraction (HFpEF). Objectives: This study aimed to investigate the prognostic value of echocardiographic markers of congestion that can be applied to both AF and patients without AF with HFpEF. Methods: We conducted a multicenter study of 505 patients with HFpEF admitted to hospitals for acute decompensated heart failure. The ratio of early diastolic transmitral flow velocity to mitral annulus velocity (E/e'), the tricuspid regurgitation peak velocity, and the collapsibility of the inferior vena cava were obtained at discharge. Congestion was determined by echocardiography if any one of E/e' ≥14 (E/e' ≥11 for AF), tricuspid regurgitation peak velocity ≥2.8 m/s, or inferior vena cava collapsibility <50% was positive. We classified patients into grade A, grade B, and grade C according to the number of positive congestion indices. The primary endpoint was the composite of cardiovascular death and heart failure hospitalization. Results: During the follow-up period (median: 373 days), 162 (32%) patients experienced the primary endpoint. Grade C patients had a higher risk for the primary endpoint than grade A (HR: 2.98; 95% CI: 1.97-4.52) and grade B patients (HR: 1.92; 95% CI: 1.29-2.86) (log-rank P < 0.0001). Echocardiographic congestion grade improved the predictive value when added to the age, sex, New York Heart Association functional class, and N-terminal pro-B-type natriuretic peptide, not only in sinus rhythm (Uno C-statistic: 0.670 vs 0.655) but in AF (Uno C-statistic: 0.667 vs 0.639). Conclusions: Echocardiographic congestion grade has prognostic value in patients with HFpEF with and without AF.

Qualitative study of barriers and facilitators encountered by individuals with physical diseases in returning and continuing to work.

BACKGROUND: The number of employees with physical diseases is increasing, and there is a need for support to help them return and continue to work. To provide effective support, it is important to identify barriers and facilitators for individuals in returning and continuing to work. Previous studies have reported barriers and facilitators for specific diseases. However, few reports have dealt with these issues across various diseases. To identify a range of barriers and facilitators that may apply to different physical diseases, we conducted a qualitative analysis by interviewing patients with diverse characteristics being treated for diseases. METHODS: We conducted semi-structured interviews based on the criteria for qualitative research. We investigated three disease groups to obtain details of barriers and facilitators: impairments that were visible to other people (mainly stroke); impairments invisible to others (mainly heart disease); and impairments that changed over time (mainly cancer). Interview transcripts were analyzed and the results reported using systematic text condensation. RESULTS: We extracted 769 meaning units from 28 patient interviews. We categorized barriers and facilitators that were generalizable to various diseases into three themes (personal factors, workplace factors, and inter-sectoral collaboration and social resources) and 10 sub-themes (work ability, psychological impacts, health literacy, social status, family background, workplace structure, workplace system, workplace support, inter-sectoral collaboration, and social resources). CONCLUSIONS: This study identified 10 sub-themes that can be applied for workers with physical diseases; those sub-themes may be used as a basis for communicating with those individuals about returning and continuing to work. Our results suggest that various barriers and facilitators for workers with physical diseases should be understood and addressed at medical institutions, workplaces, and support sites.

Prediction of PR interval prolongation after catheter ablation of incisional atrial tachycardia.

A three-dimensional (3D) mapping system is safe and effective for catheter ablation of incisional atrial tachycardia (IAT). Prolongation of the PR interval is occasionally observed after this procedure. Although a first-degree atrioventricular block is typically benign, an excessively prolonged PR interval can indicate a worse prognosis. Currently, a method to predict the PR interval after ablation therapy for IAT is lacking. We report the case of a 70-year-old woman with paroxysmal atrial tachycardia, in which our maneuver using a 3D mapping system and the electrophysiological findings enabled us to preoperatively predict the post-ablation PR interval. We believe that this method is useful for determining treatment strategies for IAT. Learning objective: Three-dimensional (3D) mapping systems can clearly visualize macro-reentrant circuits and enable the creation of precise ablation lines. When creating ablation lines for incisional atrial tachycardia, attention should be paid to the prolongation of the PR interval, because an excessively prolonged PR interval may indicate a worse prognosis. Herein, we have presented a method for predicting the post-ablation PR interval using a 3D mapping system and electrophysiological findings.

Fulminant myocarditis after the first dose of mRNA-1273 vaccination in a patient with previous COVID-19: a case report.

Background: COVID-19 vaccines have shown success in protecting people worldwide, although serious adverse effects have been reported in very rare cases. Case summary: A 32-year-old male with a prior medical history of mild COVID-19 infection developed fulminant myocarditis five days after mRNA-1273 vaccination (first dose), which was confirmed using endomyocardial biopsy. He acutely developed respiratory failure and cardiogenic shock with ventricular tachycardia, but recovered completely with short-term high-dose steroid therapy and mechanical cardiac support, which is the recommended treatment for fulminant lymphocytic myocarditis. Discussion: COVID-19 vaccine-induced myocarditis varies from mild to severe. In the present case, the patient was treated as for fulminant lymphocytic myocarditis and recovered relatively quickly. The mechanism of COVID-19 vaccine-associated myocarditis needs to be urgently investigated.

Relationship between Effective Refractory Period and Inducibility of Atrial Fibrillation from the Superior Vena Cava after Pulmonary Vein Isolation.

In terms of the pulmonary vein (PV), atrial fibrillation (AF) patients have a shorter effective refractory period (ERP) than those without AF and a large dispersion of the ERP. Although the frequency of AF from the superior vena cava (SVC) was the highest among non-PV foci, the characteristics of the ERP in the SVC (SVC-ERP) were unclear. The purpose of this study was to elucidate the relationship between SVC-ERP and the inducibility of AF after PV isolation (PVI).Consecutive 28 patients who underwent PVI were included. After successful PVI, the SVC-ERP was measured at three positions in SVC. Rapid electrical stimuli were delivered at the shortest SVC-ERP to induce AF. Patients in whom AF was induced were assigned to the SVC-induced group (SIG), and the remaining patients were the non-SVC-induced group (non-SIG). The size of the SVC sleeve was evaluated via three-dimensional electroanatomic mapping.The SIG had a significantly shorter average SVC-ERP (236.0 ± 25.2 versus 294.8 ± 36.8 ms, P < 0.001), whereas SVC-ERP dispersion was not significantly different (30.0 ± 25.4 versus 33.3 ± 20.1 ms, P = 0.56). Although the longer SVC diameter was significantly longer in the SIG (27.4 ± 4.3 versus 22.9 ± 4.6 mm, P = 0.03), the SVC-ERP was significantly associated with pacing inducibility of AF after adjustment for the longer SVC diameter (odds ratio: 0.96 [1 ms increments], P = 0.01).The SIG had a shorter SVC-ERP, whereas the dispersion was not significantly different between the two groups. The SVC-ERP can be one of the mechanisms of arrhythmogenicity for AF originating from the SVC.

Influence of the right ventricular septum/free-wall boundary (hinge) on differentiation of the ventricular lead implantation site.

BACKGROUND: The prognosis associated with right ventricular (RV) free-wall pacing is worse than that of septal pacing. Identification of the pacing site using a 12­lead electrocardiogram (ECG) is controversial and may be influenced by ECG changes within the same septal or free-wall area. The relationship between the diagnostic capabilities of ECG and pacing sites has previously been qualitatively evaluated. However, in this study, this relationship was analyzed quantitatively, and accurate evaluation of the pacing site was determined using computed tomography (CT). METHODS: Of 779 consecutive outpatients, 65 who underwent pacemaker implantation and thoracic CT were prospectively included and classified into the following groups according to the lead tip position: free-wall, septal, or septum/free-wall boundary (hinge) group. The hinge was used as an anatomical marker, and the distance from the hinge to the lead tip was measured. Under RV pacing, a 12­lead ECG was obtained. ECG findings were evaluated using three criteria (including lead I, II, and aVL and precordial leads V5 and V6) previously reported to be useful in differentiating pacing sites. RESULTS: The lead tips were anchored at the free-wall in 10 patients, the septal wall in 19 patients, and the hinge in 32 patients. Paced QRS duration correlated with the distance from the hinge to the lead tip for the free-wall and septum (r = 0.47 and - 0.68, respectively). Estimation of the lead tip implantation site using the ECG algorithm was useful; however, the algorithm's accuracy decreased around the hinge. CONCLUSIONS: ECG is useful in differentiating pacing sites but is less accurate around the hinge, which may be the reason that the identification of the RV pacing site using ECG remains controversial.