Intracardiac echocardiography guided simultaneous atrial fibrillation ablation and Micra implantation 14 days after Watchman FLX implantation.

Key Clinical Message: Atrial fibrillation ablation, including pulmonary vein isolation immediately after left atrial appendage closure (LAAC), is a rare and challenging issue. Intracardiac echocardiography guidance can help identify the LAAC device position for safe atrial fibrillation ablation without LAAC device-related adverse events even immediately after LAAC device implantation. Abstract: Early phase atrial fibrillation (AF) ablation after left atrial appendage closure (LAAC) is a rare and challenging issue. Here, we present a case illustrating the feasibility of AF ablation under intracardiac echocardiography guidance immediately after LAAC device implantation without LAAC device-related adverse events.

A Mobile Thrombus Adhering to an Intra-Annular Self-Expanding Transcatheter Aortic Valve.

An 81-year-old woman who had undergone transcatheter aortic valve implantation 3 months earlier underwent routine follow-up transthoracic echocardiography, which revealed a mobile thrombus adhering to the bioprosthetic valve. This thrombus differed in morphology from transcatheter aortic valve implantation valve thrombi commonly seen in daily practice.

Feasibility of contrast-free left atrial appendage closure with WATCHMAN FLX device for patients with chronic kidney disease.

Contrast media are generally necessary for transcatheter left atrial appendage closure (LAAC), however, it should be avoided in patients with chronic kidney disease (CKD). The objective of this study was to evaluate the safety and feasibility of contrast-free LAAC with WATCHMAN FLX device for patients with CKD. Among 141 patients undergoing LAAC using the WATCHMAN FLX between May 2021 and March 2023, we performed LAAC without contrast media in 10 patients. Procedural and follow-up results were evaluated. The device size was selected based on the transesophageal echocardiographic (TEE) measurements. The device shape was assessed by fluoroscopy, and the device position was adjusted by TEE images. The mean age was 78 ± 4.9 years, CHADS2 score was 3.2 ± 1.1, and the estimated glomerular filtration rate (eGFR) was 28 ± 12 mL/min/1.73m2. The procedure was completed without contrast media in ten patients. Partial recapture of the device was required in four patients, but the initially selected device was finally implanted in all patients. Mean procedure time was significantly shorter in the contrast-free LAAC than in the contrast-use LAAC (41.6 ± 14.1 min vs 30.3 ± 7.6 min, p = 0.01). Postprocedural eGFR did not change from baseline, and there were no adverse events during the hospital stay. Follow-up TEE or cardiac computed tomography performed within 3 months after the procedure revealed no device-related thrombus or peri-device leak > 3 mm, and oral antithrombotic therapy was discontinued in all patients. Our experience shows that contrast-free LAAC using the WATCHMAN FLX device was safe and feasible. Non-contrast LAAC is one of the therapeutic options for patients with severe CKD.

Validation study of new left atrial appendage closure device measurement by two-dimensional and three-dimensional transesophageal echocardiography.

BACKGROUND: In left atrial appendage closure using WATCHMAN FLX, accurate device measurement by transesophageal echocardiography (TEE) is important. We aimed to experimentally validate appropriate methods of device measurement with two-dimensional (2D) and three-dimensional (3D) TEE compared with actual size. METHODS: We prepared a full range of device sizes (20, 24, 27, 31, 35 mm), each with five different compression rates. Each device was measured by 2D and 3D TEE at depths of 2, 4, and 6 cm in vitro using inner, outer, and middle line methods. We compared the difference between the actual size by caliper and measurements at each compression rate and depth by the three methods in 2D and 3D TEE. RESULTS: A total of 450 patterns of measurements were analyzed. The differences using the middle line method were much less than those using the inner and outer line methods in 2D and 3D TEE (2D TEE: 0.45 ± 0.36 vs. 2.55 ± 0.99 vs. 2.59 ± 0.72 mm, p < 0.01; 3D TEE: 0.34 ± 0.27 vs. 2.38 ± 0.69 vs. 1.86 ± 0.77 mm, p < 0.01). Moreover, the differences in measurements by 3D TEE were more accurate than those of 2D TEE in the inner (2.47 ± 1.86 vs. 1.86 ± 0.77 mm, p < 0.01) and middle (0.58 ± 0.37 vs. 0.34 ± 0.27 mm, p < 0.01) line methods. CONCLUSIONS: Middle line method by 3D TEE is the most reliable approach for device measurement at left atrial appendage closure using WATCHMAN FLX device.

Simultaneous procedure transcatheter mitral valve repair and leadless pacemaker implantation under transesophageal echocardiography.

When we implant leadless pacemaker in patients with contrast agent allergy or poor renal function, the use of sufficient contrast agent is hesitant. Aided by imaging assessment (e.g., intracardiac echocardiography), the procedure may be feasible with a small amount of contrast medium or no contrast medium. In this case, leadless pacemaker implantation was performed at the same time as the transcatheter mitral valve repair, and leadless pacemaker implantation was successful with the use of a very small amount of contrast medium under transesophageal echocardiography guidance.

Long-Term Clinical Outcome After Alcohol Septal Ablation and Its Periprocedural Predictive Factors in Japan　- A Retrospective Observational Study.

BACKGROUND: Evidence is limited regarding long-term clinical outcomes after alcohol septal ablation (ASA) for patients with hypertrophic obstructive cardiomyopathy and its periprocedural predictive factors in Japan.Methods and Results: This retrospective observational study included 44 patients who underwent ASA between 1998 and 2022 in a single center. We evaluated the periprocedural change in variables and long-term clinical outcomes after the procedure. The primary outcome was a composite of cardiovascular death or hospitalization for heart failure. The secondary outcome was all-cause death. Using multivariable Poisson regression with robust error variance, we predicted underlying periprocedural factors related to primary outcome development. ASA decreased the median pressure gradient at the left ventricular outflow tract from 88 to 33 mmHg and reduced moderate or severe mitral regurgitation (MR), present in 53% of patients before ASA, to 16%. Over a median 6-year follow-up, the cumulative incidence of the primary outcome at 5 and 10 years was 16.5% and 25.6%, respectively. After multivariable analysis, moderate or severe MR after ASA was significantly associated with the primary outcome (relative risk 8.78; 95% confidence interval 1.34-57.3; P=0.024). All-cause mortality after ASA was 15.1% and 28.9% at 5 and 10 years, respectively. CONCLUSIONS: This study presents long-term clinical outcomes after ASA in Japan. Moderate or severe MR after ASA was significantly associated with the composite of cardiovascular death or hospitalization for heart failure.

Bailout clipping of a leaflet perforation during mitral transcatheter edge-to-edge repair using a larger clip size: a case report.

Background: Leaflet tear and perforation are serious complications of transcatheter edge-to-edge repair (TEER) using the MitraClip system for severe mitral regurgitation (MR). However, no optimal bailout strategy has been established. Case summary: An 80-year-old woman developed heart failure due to acute ischaemic severe MR after primary percutaneous coronary intervention. Given the requirement for inotropic drugs and an intra-aortic balloon pump to stabilize her heart failure, we decided to perform TEER using the MitraClip G4 system. The NTW clip was selected considering the limited posterior leaflet, wide central MR, and delivery to the central A2/P2. The leaflet was successfully grasped, and the MR jet dramatically decreased while the clip was closed. However, the MR jet suddenly appeared after completely closing the clip arm. A new eccentric jet was detected coming from the mid-portion of the posterior leaflet, indicating leaflet perforation. We decided to manage the leaflet perforation by covering the perforated portion with a longer type of clip. An XTW clip was then carefully delivered to the previously grasped portion, after which we confirmed that the tip of the clip arm was positioned more posteriorly to the leaflet perforation. After slowly closing the clip, MR decreased to mild, with transoesophageal echocardiography showing no eccentric MR. After her haemodynamics stabilized, she was discharged 28 days after the procedure. Discussion: This case details a successful bailout clipping of a leaflet perforation using an XTW clip. Leaflet anatomy evaluation is important to ensure that the injured portion is covered by the longer clip arm.

Long-term outcomes of balloon-expandable transcatheter aortic valve replacement in Japanese patients.

BACKGROUND: Data on long-term outcomes of transcatheter aortic valve replacement (TAVR) in Japanese patients beyond 5 years are limited. METHODS: Between June 2010 and December 2014, 55 consecutive inoperable or high surgical risk patients underwent TAVR with SAPIEN XT valves (Edwards Lifesciences, Irvine, CA, USA) for severe aortic stenosis at our institution. Among them, 2 patients were excluded from the analysis because one was converted to open surgery during the TAVR procedure and the other could not undergo TAVR due to device delivery failure. We retrospectively analyzed long-term clinical outcomes of these 53 patients (mean age: 84.1 years; mean STS score: 8.4) who had at least a 7-year follow-up after TAVR. RESULTS: The rates of freedom from all-cause and cardiovascular deaths at 7 years were 35.8 % and 79.3 %, respectively. The moderate or severe structural valve deterioration (SVD) rate at 5 and 7 years was 7.2 % and 11.4 %, respectively. The rate of bioprosthetic valve failure (BVF) at 7 years was 6.2 %. CONCLUSIONS: The 7-year mortality rate of inoperable or high surgical risk patients treated with SAPIEN XT was high, while the cardiovascular mortality rate was acceptable. Although the poor survival rate limited the long-term assessment of SAPIEN XT valve durability, the incidence of SVD and BVF was not rare.

Concomitant Mitral Regurgitation in Severe Aortic Stenosis　- A Report From the CURRENT AS Registry.

BACKGROUND: The clinical significance of concomitant mitral regurgitation (MR) has not been well addressed in patients with severe aortic stenosis (AS).Methods and Results:We analyzed 3,815 patients from a retrospective multicenter registry of severe AS in Japan (CURRENT AS registry). We compared the clinical outcomes between patients with moderate/severe MR and with none/mild MR according to the initial treatment strategy (initial aortic valve replacement [AVR] or conservative strategy). The primary outcome measure was a composite of aortic valve-related death or heart failure hospitalization. At baseline, moderate/severe MR was present in 227/1,197 (19%) patients with initial AVR strategy and in 536/2,618 (20%) patients with a conservative strategy. The crude cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with moderate/severe MR than in those with none/mild MR, regardless of the initial treatment strategy (25.2% vs. 14.4%, P<0.001 in the initial AVR strategy, and 63.3% vs. 40.7%, P<0.001 in the conservative strategy). After adjusting confounders, moderate/severe MR was not independently associated with higher risk for the primary outcome measure in the initial AVR strategy (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.67-1.83, P=0.69), and in the conservative strategy (HR 1.13, 95% CI 0.93-1.37, P=0.22). CONCLUSIONS: Concomitant moderate/severe MR was not independently associated with higher risk for the primary outcome measure regardless of the initial treatment strategy.

Renal cortex thickness and changes in renal function after transcatheter aortic valve implantation.

BACKGROUND: The association between renal morphological findings and changes in renal function in patients undergoing transcatheter aortic valve implantation (TAVI) is unexplored. AIMS: We aimed to investigate the association between renal morphological findings and changes in renal function in patients undergoing TAVI. METHODS: Among 283 consecutive patients undergoing TAVI between 2018 and 2021, the study sample included 224 patients. Renal morphological measurements were performed by preoperative multidetector computed tomography. Estimated glomerular filtration rate (eGFR) improvement and deterioration were defined as positive or negative changes in an eGFR of ≥10% one month after TAVI. The renal cortex thickness index was defined as the ratio of total renal cortex thickness to body surface area. RESULTS: The incidences of eGFR improvement and deterioration were 33.9% and 24.1%, respectively. The renal cortex thickness index had a significant correlation with changes in eGFR (r=0.34, p<0.01). The index of the area under the curve of renal cortex thickness for eGFR improvement and deterioration were 0.73 and 0.68, respectively. The cut-off values were 5.82 mm/m2 for eGFR improvement (odds ratio [OR]: 0.10; 95% confidence interval: 0.05-0.20; p<0.01) and 4.89 mm/m2 for eGFR deterioration (OR: 9.07; 95% confidence interval: 4.55-18.6; p<0.01). CONCLUSIONS: The renal cortex thickness index was associated with changes in renal function in patients who underwent TAVI. Its measurements might be useful for predicting the renal function change in patients undergoing TAVI.

Impact of high-dose statin on cardiovascular outcomes in real-world patients with ST-elevation acute myocardial infarction.

Little is known about the impact of a high-dose statin on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) in real-world Japanese patients. Between July 2011 and June 2017, 1110 consecutive STEMI patients underwent primary percutaneous coronary intervention at our hospital and were discharged. A high-dose statin was administered in 117 patients (10.5%) and non-high-dose statin was administered in 947 patients (85.3%). The low-density lipoprotein cholesterol level was significantly higher in the high-dose statin group at admission (129.8 ± 44.9 vs. 110.4 ± 32.7, p < 0.0001), but the levels were not significantly different at follow-up (86.7 ± 25.7 vs. 85.0 ± 25.0, p = 0.52). The cumulative 2-year incidence of a composite of cardiac death, myocardial infarction, ischemic stroke, and any unplanned coronary revascularization was significantly lower in the high-dose statin group (6.2% vs. 16.9%, log-rank p = 0.004). Propensity score matched analysis indicated similar results. Among the types of coronary revascularization, a high-dose statin was significantly correlated with a lower rate of de novo lesion revascularization (hazard ratio 0.31; 95% confidence interval 0.08-0.83; p = 0.02). The results of our analyses indicate that administration of a high-dose statin may result in better cardiovascular outcomes after STEMI mainly by reducing the rate of revascularization for de novo lesions regardless of the achieved low-density lipoprotein cholesterol level in real-world patients.

Left atrial appendage size in patients with atrial fibrillation in Japan and the United States.

Left atrial appendage (LAA) evaluation is important to select the optimal LAA closure device for patients with atrial fibrillation (AF). The LAA characteristics of Japanese patients remain uninvestigated. We compared the LAA size and morphology between 212 Japanese AF patients before catheter ablation and 119 AF patients undergoing LAA closure in the United States (US). We measured the LAA ostial dimension and depth by transesophageal echocardiography in all patients and determined the LAA morphology types of Japanese patients by multidetector cardiac computed tomography and those of US patients by LAA angiography. The maximum LAA ostial dimension was significantly larger in Japanese patients than in US patients (22.6 ± 4.1 mm vs. 21.5 ± 3.5 mm, P = 0.02). Also, Japanese patients had larger maximum dimension and depth corrected by body surface area than US patients in both paroxysmal and nonparoxysmal AF groups. The angle showing the maximum dimension was 0° or 135° in approximately 75% of patients in both groups. The common LAA morphology types were "cauliflower" and "chicken wing" in Japanese patients and "cactus" and "windsock" in US patients. In this study, Japanese patients had a larger LAA size than US patients. Because the maximum LAA dimension was obtained at the same angles, the LAA measurement method for US patients can be applicable to Japanese patients.

Dynamic severe mitral regurgitation on hospital arrival as prognostic predictor in patients hospitalized for acute decompensated heart failure.

BACKGROUND: Severe mitral regurgitation (MR) on hospital arrival at the onset of acute decompensated heart failure (ADHF) can improve after ADHF treatment because MR is dynamic in nature. This study investigated the clinical significance of the dynamic severe MR on hospital arrival in ADHF patients. METHODS: Transthoracic echocardiography was performed on 784 patients hospitalized for ADHF both on arrival and after ADHF treatment, of whom 563 with at least mild MR after ADHF treatment were enrolled and divided into 3 groups based on the MR severity: severe at both times (persistent MR, n = 106); severe on arrival and improved to mild/moderate after ADHF treatment (dynamic MR, n = 149); and mild/moderate at both times (non-significant MR, n = 308). The primary outcome measure was defined as a composite of cardiac death, rehospitalization for heart failure, and mitral valve intervention within 1-year. RESULTS: The incidence of the primary outcome measure in the dynamic MR group (44.8%) was significantly higher than that in the non-significant MR group (22.1%, adjusted hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.34-0.73, P < 0.001), and similar to that in the persistent MR group (44.4%, adjusted HR: 1.08, 95% CI: 0.69-1.67, P = 0.75). The risk of dynamic MR was consistent in the subgroups of patients with reduced (<45%) and preserved left ventricular ejection fraction (Pinteraction = 0.56). CONCLUSIONS: In patients hospitalized for ADHF, dynamic severe MR on hospital arrival was associated with poorer outcomes than non-significant MR and had similar risk to persistent severe MR. Acute dynamic MR is a potential therapeutic target in ADHF patients.

Relationship between n-3 Polyunsaturated Fatty Acids and Extent of Vessel Disease in Patients with ST Elevation Myocardial Infarction.

A relationship between serum polyunsaturated fatty acids (PUFAs) and cardiovascular disease has been reported; however, the existence of a relationship between serum PUFAs and extent of vessel disease (VD) in patients with ST elevation myocardial infarction (STEMI) remains unclear.Between July 2011 and June 2015, 866 consecutive STEMI patients underwent emergent percutaneous coronary intervention, 507 of whom were enrolled and classified into three groups according to the initial angiograms: 1VD, 294 patients; 2VD, 110 patients; and 3VD/left main trunk disease (LMTD), 103 patients. Serum levels of PUFAs, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid, and other laboratory data during hospitalization were evaluated.The serum EPA level in the 3VD/LMTD group was significantly lower than that in the 1VD group (55.5 ± 22.1 versus 66.2 ± 28.7, P = 0.002) and was slightly lower than that in the 2VD group (55.5 ± 22.1 versus 65.2 ± 28.9, P = 0.0167). Multivariate adjustment analysis revealed that age ≥ 70 years (odds ratio, 1.72; 95% confidence interval, 1.03-2.89; P = 0.038) and a low serum EPA level (odds ratio, 0.98; 95% confidence interval, 0.99-1.00; P = 0.023) were independent risk factors for 3VD/LMTD, while a low serum DHA level was not.A low serum EPA level may be more strongly related than a low serum DHA level to the extent of VD in STEMI patients. Age ≥ 70 years and a low serum EPA level may be independent risk factors for 3VD/LMTD.