Adult colorectal intussusception caused by giant lipoma-A case report.

Key Clinical Message: Adult intussusception commonly has a leading point. In the colon, malignancy is a prevalent etiology for the leading point; however, benign tumors should also be considered. We present a case of colorectal intussusception caused by a giant lipoma. Abstract: Intussusception in adults is comparatively infrequent in contrast to children, and in adult colonic intussusception, malignancy is the predominant cause of the leading point. Lipoma, an uncommon tumor in the gastrointestinal tract, rarely induces colonic intussusception in adults. We present the case of a 55-year-old Cambodian man experiencing cramping abdominal pain. He presented with mild abdominal distension with tenderness in the lower abdomen. On the rectal examination a large palpable mass was detected three to four centimeters from the anal verge. Abdominal computerized tomography revealed a collapsed sigmoid colon with mesenteric fat invaginated into the lumen of the upper rectum. Emergency laparotomy was performed and during the surgery the sigmoid intussusception spontaneously reduced. A mass was identified in the mid-sigmoid colon, leading to the decision for segmental resection of the sigmoid colon with the mass and subsequent end-to-end anastomosis. Histological examination results confirmed the mass as a lipoma. Colorectal intussusception in adults due to a lipoma is a relatively rare, with only a few reported cases in the literature.

Identification of concealed cardiomyopathy using next-generation sequencing-based genetic testing in Korean patients initially diagnosed with idiopathic ventricular fibrillation.

AIMS: Idiopathic ventricular fibrillation (IVF) is a disease in which the cause of ventricular fibrillation cannot be identified despite comprehensive clinical evaluation. This study aimed to investigate the clinical yield and implications of genetic testing for IVF. METHODS AND RESULTS: This study was based on the multi-centre inherited arrhythmia syndrome registry in South Korea from 2014 to 2017. Next-generation sequencing-based genetic testing was performed that included 174 genes previously linked to cardiovascular disease. A total of 96 patients were clinically diagnosed with IVF. The mean age of the onset was 41.2 ± 12.7 years, and 79 patients were males (82.3%). Of these, 74 underwent genetic testing and four (5.4%) of the IVF probands had pathogenic or likely pathogenic variants (each having one of MYBPC3, MYH7, DSP, and TNNI3). All pathogenic or likely pathogenic variants were located in genes with definite evidence of a cardiomyopathy phenotype, either hypertrophic cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy. CONCLUSION: Next-generation sequencing-based genetic testing identified pathogenic or likely pathogenic variants in 5.4% of patients initially diagnosed with IVF, suggesting that genetic testing with definite evidence genes of cardiomyopathy may enable molecular diagnosis in a minority of patients with IVF. Further clinical evaluation and follow-up of patients with IVF with positive genotypes are needed to unveil concealed phenotypes, such as the pre-clinical phase of cardiomyopathy.

Clinical and Genetic Features of Korean Inherited Arrhythmia Probands.

BACKGROUND AND OBJECTIVES: Inherited arrhythmia (IA) is a more common cause of sudden cardiac death in Asian population, but little is known about the genetic background of Asian IA probands. We aimed to investigate the clinical characteristics and analyze the genetic underpinnings of IA in a Korean cohort. METHODS: This study was conducted in a multicenter cohort of the Korean IA Registry from 2014 to 2017. Genetic testing was performed using a next-generation sequencing panel including 174 causative genes of cardiovascular disease. RESULTS: Among the 265 IA probands, idiopathic ventricular fibrillation (IVF) and Brugada Syndrome (BrS) was the most prevalent diseases (96 and 95 cases respectively), followed by long QT syndrome (LQTS, n=54). Two-hundred-sixteen probands underwent genetic testing, and 69 probands (31.9%) were detected with genetic variant, with yield of pathogenic or likely pathogenic variant as 6.4%. Left ventricular ejection fraction was significantly lower in genotype positive probands (54.7±11.3 vs. 59.3±9.2%, p=0.005). IVF probands showed highest yield of positive genotype (54.0%), followed by LQTS (23.8%), and BrS (19.5%). CONCLUSIONS: There were significant differences in clinical characteristics and genetic yields among BrS, LQTS, and IVF. Genetic testing did not provide better yield for BrS and LQTS. On the other hand, in IVF, genetic testing using multiple gene panel might enable the molecular diagnosis of concealed genotype, which may alter future clinical diagnosis and management strategies.

Impact of carotid atherosclerosis in CHA2DS2-VASc-based risk score on predicting ischemic stroke in patients with atrial fibrillation.

BACKGROUND/AIMS: Vascular disease is an established risk factor for stroke in patients with atrial fibrillation (AF), which is included in CHA2DS2-VASc score. However, the role of carotid atherosclerosis remains to be determined. METHODS: Three hundred-ten patients with AF who underwent carotid sonography were enrolled. RESULTS: During a median follow-up of 31 months, 18 events (5.8%) of stroke were identified. Patients with stroke had higher carotid intima-media thickness (CIMT) (1.16 ± 0.33 mm vs. 0.98 ± 0.25 mm, p = 0.017). CIMT was significantly increased according to the CHA2DS2-VASc score (p < 0.001) and it was correlated with left ventricular mass index and early diastolic mitral annular velocity (e'), a ratio of early transmitral flow velocity to e' (E/e') and pulmonary artery systolic pressure (all p < 0.05). Cox regression using multivariate models showed that carotid plaque was associated with the risk of stroke (hazard ratio, 3.748; 95% confidence interval [CI], 1.107 to 12.688; p = 0.034). C-statistics increased from 0.648 (95% CI, 0.538 to 0.757) to 0.716 (95% CI, 0.628 to 0.804) in the CHA2DS2-VASc score model after the addition of CIMT and carotid plaque as a vascular component (p = 0.013). CONCLUSION: Increased CIMT and presence of carotid plaque are associated with a high risk of ischemic stroke, and CIMT is related to myocardial remodeling and diastolic dysfunction, suggesting that carotid atherosclerosis can improve risk prediction of stroke in patients with AF, when included under vascular disease in the CHA2DS2-VASc scoring system.

Inherited arrhythmia syndrome predisposing to sudden cardiac death.

Inherited arrhythmia (IA) is one of the main causes of sudden cardiac death (SCD) in young people, and is reported to be a more prevalent cause of SCD in Asia than in Western countries. IAs are a group of genetic disorders caused by mutations in genes encoding cardiac ion channels, leading to electrophysiological characteristics that often occur in the absence of structural abnormalities. Channelopathies, such as long QT syndrome and Brugada syndrome, carry a potential risk of life-threatening ventricular tachyarrhythmias that predispose to SCD, although early prediction and prevention of the risk remain challenging. Recent advances in genetic testing have facilitated risk stratification as well as a precise diagnosis for IA, despite ongoing debates about the implications. Herein, we provide epidemiological data, a pathophysiological overview, and the current clinical approach to IAs related to SCD. In addition, we review the general issues arising from genetic testing for IAs.

The negative impact of long working hours on mental health in young Korean workers.

Long working hours are known to have a negative effect on health. However, there is no clear evidence for a direct link between mental health and long working hours in the young adult populations. Therefore, we aimed to determine whether long working hours are associated with mental health in young adult workers. Data were collected from a 2012 follow-up survey of the Youth Panel 2007. A total of 3,332 young adult employees (aged 20 to 35) were enrolled in the study. We analyzed stress, depression, and suicidal thoughts by multivariate logistic regression analysis based on working hours (41 to 50, 51 to 60 and over 60 hours, compared to 31 to 40 hours per week), which was adjusted for sex, age, marriage status, region, and educational level. From the 3,332 young adult employees, about 60% of the workers worked more than 40 hours and 17% of the workers worked more than 50 hours per week. In a Chi-square test, stress level, depression, and suicidal thoughts increased with increasing working hours (p-value <0.001, 0.007, and 0.018, respectively). The multivariate logistic regression model showed that, compared to the 31 to 40 hours per week group, the adjusted odds ratios of the 41 to 50, 51 to 60, and over 60 hours per week groups for stress were 1.46(1.23-1.74), 2.25(1.79-2.83) and 2.55(1.72-3.77), respectively. A similar trend was shown in depression [odds ratios: 2.08(1.23-3.53), 2.79(1.44-5.39) and 4.09(1.59-10.55), respectively] and suicidal ideation [odds ratios: 1.98(0.95-4.10), 3.48(1.48-8.19) and 5.30(1.61-17.42), respectively]. We concluded that long working hours were associated with stress, depression, and suicidal ideation in young employees, aged 20 to 35.

Effectiveness and Safety of Off-label Dosing of Non-vitamin K Antagonist Anticoagulant for Atrial Fibrillation in Asian Patients.

Non-vitamin K antagonist anticoagulants (NOACs) have been used to prevent thromboembolism in patients with atrial fibrillation (AF) and shown favorable clinical outcomes compared with warfarin. However, off-label use of NOACs is frequent in practice, and its clinical results are inconsistent. Furthermore, the quality of anticoagulation available with warfarin is often suboptimal and even inaccurate in real-world data. We have therefore compared the effectiveness and safety of off-label use of NOACs with those of warfarin whose anticoagulant intensity was accurately estimated. We retrospectively analyzed data from 2,659 and 3,733 AF patients at a tertiary referral center who were prescribed warfarin and NOACs, respectively, between 2013 and 2018. NOACs were used at off-label doses in 27% of the NOAC patients. After adjusting for significant covariates, underdosed NOAC (off-label use of the reduced dose) was associated with a 2.5-times increased risk of thromboembolism compared with warfarin, and overdosed NOAC (off-label use of the standard dose) showed no significant difference in either thromboembolism or major bleeding compared with warfarin. Well-controlled warfarin (TTR ≥ 60%) reduced both thromboembolism and bleeding events. In conclusion, the effectiveness of NOACs was decreased by off-label use of the reduced dose.

The impact of body weight and diabetes on new-onset atrial fibrillation: a nationwide population based study.

BACKGROUND: Being obese or underweight, and having diabetes are important risk factors for new-onset atrial fibrillation (AF). However, it is unclear whether there is any interaction between body weight and diabetes in regard to development of new-onset AF. We aimed to evaluate the role of body weight status and various stage of diabetes on new-onset AF. METHODS: This was a nationwide population based study using National Health Insurance Service (NHIS) data. A total of 9,797,418 patients who underwent national health check-ups were analyzed. Patients were classified as underweight [body mass index (BMI) < 18.5], normal reference group (18.5 ≤ BMI < 23.0), upper normal (23.0 ≤ BMI < 25.0), overweight (25.0 ≤ BMI < 30.0), or obese (BMI ≥ 30.0) based on BMI. Diabetes were categorized as non-diabetic, impaired fasting glucose (IFG), new-onset diabetes, diabetes < 5 years, and diabetes ≥ 5 years. Primary outcome end point was new-onset AF. New-onset AF was defined as one inpatient or two outpatient records of International Classification of Disease, Tenth Revision (ICD-10) codes in patients without prior AF diagnosis. RESULTS: During 80,130,161 patient*years follow-up, a total of 196,136 new-onset AF occurred. Obese [hazard ration (HR) = 1.327], overweight (HR = 1.123), upper normal (HR = 1.040), and underweight (HR = 1.055) patients showed significantly increased risk of new-onset AF compared to the normal reference group. Gradual escalation in the risk of new-onset AF was observed along with advancing diabetic stage. Body weight status and diabetes were independently associated with new-onset AF and at the same time, had synergistic effects on the risk of new-onset AF with obese diabetic patients having the highest risk (HR = 1.823). CONCLUSIONS: Patients with obesity, overweight, underweight, and diabetes had significantly increased risk of new-onset AF. Body weight status and diabetes had synergistic effects on the risk of new-onset AF. The risk of new-onset AF increased gradually with advancing diabetic stage. This study suggests that maintaining optimal body weight and glucose homeostasis might prevent new-onset AF.

Impact of the Duration and Degree of Hypertension and Body Weight on New-Onset Atrial Fibrillation: A Nationwide Population-Based Study.

Hypertension and obesity are known risk factors for atrial fibrillation (AF). However, it is unclear whether uncontrolled, long-standing hypertension has a particularly profound effect on AF. Because they have a similar underlying pathophysiology, hypertension and obesity could act synergistically in the context of AF. We evaluated how various stages of hypertension and body weight status affect new-onset AF. We analyzed a total of 9 797 418 participants who underwent a national health checkup. Hypertension was classified into 5 stages: nonhypertension, prehypertension, hypertension without medication, hypertension with medication <5 years, and hypertension with medication ≥5 years. The participants were also stratified based on body mass index and waist circumference. During the 80 130 161 person×years follow-up, a total of 196 136 new-onset AF cases occurred. The incidence of new-onset AF gradually increased among the 5 stages of hypertension: the adjusted hazard ratio for each group was 1 (reference), 1.145, 1.390, 1.853, and 2.344 for each stage of hypertension. A graded escalation in the risk of new-onset AF was also observed in response to increased systolic and diastolic blood pressure. The incidence of new-onset AF correlated with body mass index and waist circumference, with obese people having a higher risk than others. Hypertension and obesity acted synergistically: obese people with hypertension on medication ≥5 years had the highest risk of AF. In conclusion, the degree and duration of hypertension, as well as the presence of hypertension, were important factors for new-onset AF. Body weight status was significantly associated with new-onset AF and acted synergistically with hypertension.

Risk Factors for Ischemic Stroke in Atrial Fibrillation Patients Undergoing Radiofrequency Catheter Ablation.

Ischemic stroke after radiofrequency catheter ablation (RFCA) in atrial fibrillation (AF) patients is a great challenge for electrophysiologists. We performed this retrospective study to evaluate clinical and echocardiographic characteristics associated with increased risk of ischemic stroke following RFCA. A total of 2,352 consecutive patients with AF who underwent first-time RFCA were analyzed. Among 10,023 patient*year follow up, ischemic stroke occurred in 49 patients (0.49% per year). Late recurrence after last RFCA was significantly associated with ischemic stroke (3.8% vs. 12.9%, p < 0.001). Old age (≥60 years old) (3.2% vs. 15.4%, p = 0.001), non-paroxysmal AF (hazard ratio = 1.91, p = 0.024), left atrium (LA) size ≥45.0 mm (6.6% vs. 11.7%, p < 0.001), E over E' ≥10 (4.3% vs. 20.1%, p < 0.001), dense spontaneous echo contrast (SEC) (5.2% vs. 19.0%, p = 0.006), and decreased left atrial appendage (LAA) flow velocity (≤40 cm/sec) (4.1% vs. 10.8%, p < 0.001) were also associated with increased risk of ischemic stroke. The REVEEAL score derived from the risk factors identified in this study was superior to CHA2DS2-VASc score (p < 0.001) for the prediction of ischemic stroke. In conclusion, the risk factors for ischemic stroke in post-RFCA AF patients are not identical to RFCA naive AF patients and different approach to stratify the risk of ischemic stroke is needed.

Clinical and Echocardiographic Risk Factors Predict Late Recurrence after Radiofrequency Catheter Ablation of Atrial Fibrillation.

The benefits of radiofrequency catheter ablation (RFCA) for patients with atrial fibrillation (AF) significantly decrease with late recurrence (LR). We aimed to develop a scoring system to identify patients at high and low risk for LR following RFCA, based on a comprehensive evaluation of multiple risk factors for AF recurrence, including echocardiographic parameters. We studied 2,352 patients with AF undergoing first-time RFCA in a single institution. The LR-free survival rate up to 5 years was measured using a Kaplan-Meier analysis. The influence of clinical and echocardiographic parameters on LR was calculated with a Cox-regression analysis. Duration of AF ≥4 years (hazard ratio [HR] = 1.75; p < 0.001), non-paroxysmal AF (HR = 3.18; p < 0.001), and diabetes (HR = 1.34; p = 0.015) were associated with increased risk of LR. Left atrial (LA) diameter ≥45 mm (HR = 2.42; p < 0.001), E/e' ≥ 10 (HR = 1.44; p < 0.001), dense SEC (HR = 3.30; p < 0.001), and decreased LA appendage flow velocity (≤40 cm/sec) (HR = 2.35; p < 0.001) were echocardiographic parameters associated with increased risk of LR following RFCA. The LR score based on the aforementioned risk factors could be used to predict LR (area under curve = 0.717) and to stratify the risk of LR (HR = 1.45 per 1 point increase in the score; p < 0.001). In conclusion, LR after RFCA is affected by multiple clinical and echocardiographic parameters. This study suggests that combining these multiple risk factors enables the identification of patients with AF at high or low risk for having arrhythmia recurrence.

Long Working Hours and Poor Self-Rated Health in the Young Working Population in Korea.

: This cross-sectional study investigated the association between long working hours and prevalence of poor self-rated health (SRH) in Korean young workers using data from the 6th Korea Youth Panel Survey 2007. A total of 3317 young wage workers were included. Weekly working hours were divided into four groups (36 to 40 hours, 41 to 52 hours, 53 to 60 hours, and more than 60 hours per week). Multiple logistic regression was performed to investigate the association between long working hours and SRH, adjusting for demographic and work-related factors. Long working hours were associated with increased risk of poor SRH, in both the men and women. Legal restriction on working hours should be suitably applied to help improve the health status of Korean young workers.

Different influence of cardiac hemodynamics on thromboembolic events in patients with paroxysmal and non-paroxysmal atrial fibrillation.

Blood stasis in left atrium (LA) or LA appendage (LAA) is thought to be the main cause of thrombus formation and systemic embolism in atrial fibrillation (AF) patients. Paroxysmal and non-paroxysmal AF differ significantly in various aspects. Impact of cardiac hemodynamics on systemic embolism might also differ between the 2 distinct AF entities. This study was performed to evaluate the influence of cardiac hemodynamics on systemic embolism in both paroxysmal and non-paroxysmal AF. Consecutive AF patients undergoing radiofrequency catheter ablation (RFCA) in Korea University Medical Center Anam Hospital between June 1998 and February 2018 were analyzed. Among 2,801 patients who underwent first-time RFCA, a total of 231 patients had either previous ischemic stroke, transient ischemic attack, or arterial embolism. In paroxysmal AF, LA diameter, LA volume (measured with magnetic resonance imaging), left ventricular (LV) ejection fraction, E/e', LAA flow velocity, and prevalence of spontaneous echocontrast (SEC) and dense SEC were significantly different between patients with and without thromboembolic events. However, only E/e' was different between patients with and without thromboembolic events in non-paroxysmal AF. The influence of LA diameter, LA volume, LV EF, LAA flow velocity, and dense SEC on thromboembolic events was significantly moderated by the type of AF. In conclusion, paroxysmal and non-paroxysmal AF might have a different mechanism responsible for thrombus formation and consequent embolic events. Relative contribution of hemodynamic parameters and other factors such as atrial myopathy to thromboembolic events in paroxysmal versus non-paroxysmal AF needs further evaluation.

Comparison between linear and focal ablation of complex fractionated atrial electrograms in patients with non-paroxysmal atrial fibrillation: a prospective randomized trial.

AIMS: Findings regarding efficacy of substrate modification for non-paroxysmal atrial fibrillation (AF) are inconsistent. We prospectively compared clinical outcomes of complex fractionated atrial electrogram (CFAE)-guided focal ablation (CFA) and CFAE-guided linear ablation (CLA) in patients with non-paroxysmal AF. METHODS AND RESULTS: We randomized 150 patients with non-paroxysmal AF into CFA and CLA groups in a 1:1 ratio. Complex fractionated atrial electrogram distribution was evaluated using an automated algorithm of a three-dimensional mapping system. After pulmonary vein isolation (PVI), CFAE-guided ablation was performed in the left atrium and then in the right atrium (RA). When compared with conventional CFA, CLA was performed based on conventional lines, with additional lines. Atrial fibrillation was not induced after PVI alone or with cavotricuspid isthmus ablation in 20.7% of patients. To achieve the endpoint, additional CFAE-guided RA ablation was required in 42.7% and 36.0% of patients undergoing CFA and CLA, respectively (P = 0.403). Atrial fibrillation was terminated during CFAE-guided ablation in 72.9% and 75.0% of patients undergoing CFA and CLA, respectively (P = 0.792). Termination of atrial tachycardia (AT) or non-inducibility of AF/AT was achieved in 61.3% and 68.0% of patients undergoing CFA and CLA, respectively (P = 0.393). The CLA group showed decreased 1-year freedom from AF/AT recurrence (60.0%, CFA vs. 47.3%, CLA; log rank P = 0.085), but no significant difference throughout the follow-up (22.2 ± 21.0 months) (67.1%, CFA vs. 68.9%, CLA; log rank P = 0.298). CONCLUSION: Long-term efficacy of CFAE-guided ablation was unaffected by the ablation technique in patients with non-paroxysmal AF.

Electrical isolation of the left atrial appendage increases the risk of ischemic stroke and transient ischemic attack regardless of postisolation flow velocity.

BACKGROUND: Electrical isolation of the left atrial appendage (LAA) is associated with a lower rate of atrial fibrillation (AF) recurrence in patients undergoing radiofrequency catheter ablation. However, LAA isolation can significantly impair LAA contractility. OBJECTIVE: This study was performed to evaluate whether electrical isolation of the LAA is associated with an increased risk of ischemic stroke or transient ischemic attack (TIA). METHODS: Consecutive patients with AF undergoing radiofrequency catheter ablation at Korea University Medical Center Anam Hospital were analyzed. RESULTS: Of 2352 patients, 39 (1.7%) had LAA isolation. Patients with LAA isolation had a significantly higher rate of ischemic stroke or TIA than did those without LAA isolation (log-rank, P < .001; hazard ratio 23.6; P < .001). There were significant differences in the baseline characteristics of the 2 groups, including type of AF (34 [87.2%] and 911 [39.4%] patients with and without LAA isolation had nonparoxysmal AF, respectively). After multivariate adjustment, LAA isolation was found to be a significant risk factor for ischemic stroke or TIA (adjusted hazard ratio 11.3; P < .001). Propensity score-matched analysis also revealed an increased risk of ischemic stroke or TIA in patients with LAA isolation compared with those without LAA isolation (log-rank, P = .001). The LAA flow velocity of post-LAA isolation status was not significantly different between patients who did and did not experience ischemic stroke or TIA (30.3 ± 17.7 cm/s vs 33.9 ± 17.9 cm/s; P = .608). CONCLUSION: A significantly increased risk of ischemic stroke or TIA was observed in patients with electrical isolation of the LAA. In addition, postisolation LAA flow velocity is not a reliable marker to predict future ischemic events.

Electrophysiological features and radiofrequency catheter ablation of supraventricular tachycardia in patients with persistent left superior vena cava.

BACKGROUND: The electrophysiological features and roles of persistent left superior vena cava (PLSVC) in supraventricular tachycardia (SVT) are not known. OBJECTIVE: The purpose of this study was to elucidate the electrophysiological features and roles of PLSVC in patients with SVT. METHODS: We included 37 patients with PLSVC (mean age 43.5 ± 17.1 years; 35.1% men) and 510 patients without PLSVC (mean age 43.9 ± 18.8 years; 48.2% men) who underwent an electrophysiology study for SVT. The number of induced tachycardias, location of the slow pathway (SP) or accessory pathway (AP), and radiofrequency catheter ablation (RFCA) outcomes were compared between patients with and without PLSVC. During RFCA of the left AP, a coronary sinus (CS) catheter was placed into the left superior vena cava (left superior vena cava group) or the great cardiac vein (great cardiac vein group). The RFCA outcomes were compared between the groups. RESULTS: In patients with PLSVC, 40 tachycardias were induced: atrioventricular nodal reentrant tachycardia (AVNRT) (n = 19), atrioventricular reentrant tachycardia (n = 17), and focal atrial tachycardia (n = 4). Among patients with AVNRT, an SP in the CS was significantly more frequent in patients with PLSVC than in those without PLSVC (47.4% vs 3.8%; P < .001). In patients with the left AP, the number of RFCA attempts and recurrence were lower in the great cardiac vein group than in the left superior vena cava group. CONCLUSION: An SP in the CS is prevalent in patients with AVNRT and PLSVC. It is useful to place a CS catheter into the great cardiac vein in patients with a left AP and PLSVC.

Different Responses of Left Atrium and Left Atrial Appendage to Radiofrequency Catheter Ablation of Atrial Fibrillation: a Follow Up MRI study.

Atrial fibrillation (AF) is known to cause adverse remodeling of left atrium (LA). Radiofrequency catheter ablation (RFCA) of AF is associated with decrease in LA volume. However, the impact of RFCA on left atrial appendage (LAA) volume and hemodynamic function is not fully understood. We analyzed 123 patients who underwent cardiac magnetic resonance imaging (MRI) evaluation before and after RFCA in Korea University Anam Hospital. LA and LAA volume were measured before and after RFCA based on cardiac MRI. Baseline LA volume was 99.5 ± 38.4 cm3 and decreased to 74.6 ± 28.5 cm3 after RFCA (p < 0.001). LA diameter measured with transthoracic echocardiography was also decreased after RFCA (43.3 ± 6.2 mm at baseline and 39.9 ± 5.9 mm at follow up; p < 0.001). However, LAA volume was significantly increased after RFCA (19.4 ± 8.5 cm3 at baseline and 23.7 ± 13.3 cm3 at follow up; p < 0.001). Total ablation time and additional substrate modification was associated with change in LA volume. After RFCA, average LAA velocity measured by transesophageal echocardiography was increased to 51.0 cm/sec from 41.1 cm/sec (p < 0.001). In conclusion, LAA volume was increased after RFCA in contrast to LA volume. Our data raise a concern about worsening hemodynamics of LA and LAA following RFCA and long term clinical significance of enlarged LAA after RFCA needs further evaluation.

Non-vitamin K antagonist oral anticoagulants versus warfarin for the prevention of spontaneous echo-contrast and thrombus in patients with atrial fibrillation or flutter undergoing cardioversion: A trans-esophageal echocardiography study.

Spontaneous echo-contrast (SEC) and thrombus observed in trans-esophageal echocardiography (TEE) is known as a strong surrogate marker for future risk of ischemic stroke in patients with atrial fibrillation (AF) or atrial flutter (AFL). The efficacy of non-vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin to prevent SEC or thrombus in patients with AF or AFL is currently unknown. AF or AFL patients who underwent direct current cardioversion (DCCV) and pre-DCCV TEE evaluation from January 2014 to October 2016 in a single center were analyzed. The prevalence of SEC and thrombus were compared between patients who received NOAC and those who took warfarin. NOAC included direct thrombin inhibitor and factor Xa inhibitors. Among 1,050 patients who were considered for DCCV, 424 patients anticoagulated with warfarin or NOAC underwent TEE prior to DCCV. Eighty patients who were anticoagulated for less than 21 days were excluded. Finally, 344 patients were included for the analysis (180 warfarin users vs. 164 NOAC users). No significant difference in the prevalence of SEC (44.4% vs. 43.9%; p = 0.919), dense SEC (13.9% vs. 15.2%; p = 0.722), or thrombus (2.2% vs. 4.3%; p = 0.281) was observed between the warfarin group and the NOAC group. In multivariate analysis, there was no association between NOAC and risk of SEC (odds ratio [OR]: 1.4, 95% CI: 0.796-2.297, p = 0.265) or thrombus (OR: 3.4, 95% CI: 0.726-16.039, p = 0.120). In conclusion, effectiveness of NOAC is comparable to warfarin in preventing SEC and thrombus in patients with AF or AFL undergoing DCCV. However, numerical increase in the prevalence of thrombus in NOAC group warrants further evaluation.

Spontaneous partial regression of coronary artery fistula following optimal medical therapy in a patient who had combined significant coronary artery spasm.

Coronary artery fistulas (CAFs) are one of the most rare cardiac anomalies. Some patients with CAF may suffer from ischemic chest pain that originates from combined significant coronary artery spasm (CAS). Spontaneous regression of CAF has been reported in a few cases, almost all of which were infants. We report an adult patient who presented with ischemic chest pain due to multiple coronary arteries to pulmonary artery fistulas and combined significant CAS induced by intracoronary acetylcholine provocation test. Spontaneous regression of one of the fistulas was observed at 2-year angiography follow-up.

Three-dimensional angiography-guided percutaneous transluminal angioplasty for distal aorta and bi-iliac chronic total occlusion.

Percutaneous recanalization of chronic total occlusions (CTOs) in peripheral arteries, especially TASC D classification including the distal aorta and both iliac arteries is still technically challenging. The conventional technique using standard guidewires and catheters guided by computed tomography and angiography can achieve a limited initial success, depending on lesion characteristics and operator's experience. A special imaging technique using 3-dimensional rotational angiography and spatio-temporal reconstruction with endoview for a better examination of the proximal stump, exact obstruction location, and distal stump direction in a stumpless lesion can be indispensable for successful intervention. We report a successful revascularization case of stumpless distal aorta and bi-iliac CTO guided by this specialized imaging technique.