The effect of an initial catheter ablation with an adjunctive ethanol infusion into the vein of Marshall on persistent atrial fibrillation.

INTRODUCTION: Some previous studies have reported that a first-step ethanol infusion into the vein of Marshall (EIVOM) with touch-up radiofrequency (RF) ablation can facilitate mitral isthmus (MI) block and improves the ablation outcomes in persistent atrial fibrillation (PeAF) patients. However, the effect of an initial RF ablation with an adjunctive EIVOM has not been fully investigated. METHODS: This study enrolled 233 PeAF patients undergoing pulmonary vein isolation and linear ablation including an MI, roof line, and cavotricuspid isthmus ablation. An EIVOM was performed when endocardial ablation with or without coronary sinus ablation failed to create MI block. RESULTS: Bidirectional MI block was achieved in 224 patients (96.1%). Among them, MI block was obtained by only RF ablation in 174/224 patients (77.7%) (RF group) and an adjunctive EIVOM was needed in 50/224 (22.3%) (EIVOM group). During the follow-up, 113 (64.9%) RF group patients were free from AF/atrial tachycardia compared to 41 (82.0%) EIVOM group patients (log-rank p = .045). In a multivariate Cox regression analysis, an adjunctive EIVOM was associated with a lower recurrence rate (hazard ratio = 0.39, 95% confidence interval = 0.17-0.78, p = .006). CONCLUSION: An initial RF ablation with an adjunctive EIVOM strategy improved MI ablation's acute success rate and was associated with better clinical outcomes.

Symptomatic periesophageal vagal nerve injury by different energy sources during atrial fibrillation ablation.

Background: Symptomatic gastric hypomotility (SGH) is a rare but major complication of atrial fibrillation (AF) ablation, but data on this are scarce. Objective: We compared the clinical course of SGH occurring with different energy sources. Methods: This multicenter study retrospectively collected the characteristics and clinical outcomes of patients with SGH after AF ablation. Results: The data of 93 patients (67.0 ± 11.2 years, 68 men, 52 paroxysmal AF) with SGH after AF ablation were collected from 23 cardiovascular centers. Left atrial (LA) ablation sets included pulmonary vein isolation (PVI) alone, a PVI plus a roof-line, and an LA posterior wall isolation in 42 (45.2%), 11 (11.8%), and 40 (43.0%) patients, respectively. LA ablation was performed by radiofrequency ablation, cryoballoon ablation, or both in 38 (40.8%), 38 (40.8%), and 17 (18.3%) patients, respectively. SGH diagnoses were confirmed at 2 (1-4) days post-procedure, and 28 (30.1%) patients required re-hospitalizations. Fasting was required in 81 (92.0%) patients for 4 (2.5-5) days; the total hospitalization duration was 11 [7-19.8] days. After conservative treatment, symptoms disappeared in 22.3% of patients at 1 month, 48.9% at 2 months, 57.6% at 3 months, 84.6% at 6 months, and 89.7% at 12 months, however, one patient required surgery after radiofrequency ablation. Symptoms persisted for >1-year post-procedure in 7 patients. The outcomes were similar regardless of the energy source and LA lesion set. Conclusions: The clinical course of SGH was similar regardless of the energy source. The diagnosis was often delayed, and most recovered within 6 months, yet could persist for over 1 year in 10%.

Intraplaque wiring enables drug-coated balloons to be utilized for percutaneous recanalization of chronically occluded coronary arteries.

OBJECTIVES: This study aimed to determine whether drug-coated balloon (DCB) angioplasty following intraplaque wiring and the use of modified balloons is safe and effective in the percutaneous treatment of coronary chronic total occlusions (CTOs). BACKGROUND: DCB is an alternative therapeutic option without the limitations of permanent vascular implants. However, its efficacy in CTOs has yet to be confirmed. The combination of modified balloons and DCB can be effectively applied when the intraplaque passage of the guidewire is achieved in CTOs. METHODS: Data from 124 consecutive CTO lesions (105 patients) treated at our hospital between February 2016 and December 2020 were screened for inclusion and retrospectively analyzed. Among the 118 lesions successfully recanalized, intraplaque wiring was achieved in 108, and 85 were treated by the DCB-only approach following cutting/scoring balloon dilatation. RESULTS: Follow-up data were available for 82 lesions (71 patients). The median occlusion length was 18.5 mm, and the J-CTO score was 1.7 ± 0.9. No in-hospital major adverse cardiac events occurred, including abrupt vessel closure. During the median 29-month follow-up period, target lesion revascularization was performed for 10 lesions. Follow-up coronary angiography (8.7 ± 3.9 months after the index procedure) was performed for 64 lesions, demonstrating late lumen loss of -0.15 mm (interquartile range -0.4 to 0.23 mm), binary restenosis (diameter stenosis ≥50%) in 12 lesions (18.8%), and late lumen enlargement in 37 (57.8%). CONCLUSION: The DCB-only approach following the use of modified balloons is a promising strategy for coronary CTOs when intraplaque wiring is achieved.

Incidence and Characteristics of Coronary Artery Spasms Related to Atrial Fibrillation Ablation Procedures　- Large-Scale Multicenter Analysis.

BACKGROUND: Coronary artery spasms (CASs), which can cause angina attacks and sudden death, have been recently reported during catheter ablation. The aim of the present study was to report the incidence, characteristics, and prognosis of CASs related to atrial fibrillation (AF) ablation procedures.Methods and Results:The AF ablation records of 22,232 patients treated in 15 Japanese hospitals were reviewed. CASs associated with AF ablation occurred in 42 of 22,232 patients (0.19%). CASs occurred during ablation energy applications in 21 patients (50%). CASs also occurred before ablation in 9 patients (21%) and after ablation in 12 patients (29%). The initial change in the electrocardiogram was ST-segment elevation in the inferior leads in 33 patients (79%). Emergency coronary angiography revealed coronary artery stenosis and occlusions, which were relieved by nitrate administration. No air bubbles were observed. A comparison of the incidence of CASs during pulmonary vein isolation between the different ablation energy sources revealed a significantly higher incidence with cryoballoon ablation (11/3,288; 0.34%) than with radiofrequency catheter, hot balloon, or laser balloon ablation (8/18,596 [0.04%], 0/237 [0%], and 0/111 [0%], respectively; P<0.001). CASs most often occurred during ablation of the left superior pulmonary vein. All patients recovered without sequelae. CONCLUSIONS: CASs related to AF ablation are rare, but should be considered as a dangerous complication that can occur anytime during the periprocedural period.

Intracardiac conduction time as a predictor of cardiac resynchronization therapy response: Results of the BIO|SELECT pilot study.

BACKGROUND: Quadripolar left ventricular (LV) leads are capable of sensing and pacing the left ventricle from 4 different electrodes, which may potentially improve patient response to cardiac resynchronization therapy (CRT). OBJECTIVE: We measured 3 different time intervals: right ventricular (RV)-sensed to LV-sensed during intrinsic rhythm (RVs-LVs), RV-paced to LV-sensed (RVp-LVs), and LV-paced to LV-sensed (LVp-LVs, between distal [LV1] and proximal pole on a quadripolar LV lead), and assessed their association with CRT response in terms of LV end-systolic volume (LVESV) and a composite benefit index (CBI) comprising LVESV, LV ejection fraction (LVEF), brain natriuretic peptide level, and NYHA class. METHODS: A CRT-defibrillator system with quadripolar LV lead was implanted in 196 patients (mean age 69 years, mean LVEF 30%, left bundle-branch block [LBBB] 58%). Conduction intervals were measured before hospital discharge. At baseline and 7-month follow-up, echocardiographic and other components of CBI were determined. RESULTS: The mean RVs-LV1s, RVp-LV1s, and LVp-LVs delays were 68 ± 38 ms, 132 ± 34 ms, and 99 ± 31 ms, respectively. From baseline to 7 months, LVESV decreased by 17.3% ± 28.6%. The RVs-LV1s interval correlated stronger with CBI (R2 = 0.12, P < .00001) than with LVESV change (R2 = 0.05, P = .006). In contrast, RVp-LV1s did not correlate and LVp-LVs correlated only weakly with CRT response. The subgroup of patients (44%) with LBBB and RVs-LV1s above the lower quartile (≥34 ms) showed the greatest response to CRT. CONCLUSION: The RVs-LVs interval during intrinsic rhythm is relevant for CRT success, whereas RVp-LVs and LVp-LVs intervals did not predict CRT response.

The deeper the pouch is, the longer the radiofrequency duration and higher the radiofrequency energy needed-Cavotricuspid isthmus ablation using intracardiac echocardiography.

BACKGROUND: The aim of this study was to explore whether the pouch depth influenced the radiofrequency (RF) duration and total delivered RF energy for cavotricuspid isthmus (CTI) ablation and define the cutoff value for a deep pouch-specified ablation strategy. METHODS: This study included 94 atrial fibrillation (AF) patients (56 males, age 68 ± 8.0 years). With intracardiac echocardiography, the isthmus length and pouch depth were precisely measured. After a standard AF ablation, all patients underwent the CTI ablation along the lateral isthmus. If bidirectional block could not be achieved, the ablation catheter was deflected more than 90 degrees to ablate inside the pouch (knuckle-curve ablation). RESULTS: Seventy-two patients (76.6%) had a sub-Eustachian pouch. Bidirectional block could be achieved in all patients. By a univariate logistic regression analysis, only the pouch depth was significantly correlated with the RF duration (P = .005) and RF energy (P = .006). A multivariate logistic regression analysis also revealed the pouch depth was the sole factor that influenced the RF duration (P = .001) and RF energy (P = .001). Among the 72 patients, 21 patients needed a knuckle-curve ablation. Using a receiver operating characteristic curve, the optimal cutoff value of the pouch depth for a knuckle-curve ablation was 3.7 mm with a sensitivity of 90% and specificity of 69%. CONCLUSIONS: The sub-Eustachian pouch depth was the sole factor that influenced the RF duration and energy in the CTI ablation. If the pouch was deeper than 3.7 mm, a deep pouch-specified ablation strategy would be needed.

Ventricular Tachycardia Rotating a Scar of a Total Right Ventricular Exclusion.

We describe a 15-year-old postoperative girl who underwent surgical 3-dimensional mapping and ablation of hemodynamically unstable ventricular tachycardia (VT) with an on-pump beating heart surgical technique. She had previously received a tricuspid valve closure, entire right ventricular free wall resection, and finally Fontan operation with an extracardiac conduit to treat a severe Ebstein's anomaly. Activation mapping revealed a VT rotating around a large right ventricular free wall incisional scar with a narrow conduction channel between the scar and a tricuspid annulus (TA). A linear radiofrequency ablation connecting the scar and the TA terminated the VT.

Impact of aortic plaque morphology on survival rate and incidence of a subsequent embolic event ­ long-term follow-up data ­.

BACKGROUND: There are no reports about the long-term follow-up data of patients with aortic plaques among the Japanese population. The purpose of this study was to clarify the frequency of patients with severe aortic plaques and the impact of aortic plaque morphology on the prognosis. METHODS AND RESULTS: We retrospectively investigated 1,570 consecutive patients who underwent transesophageal echocardiography. Survival rate and subsequent embolic event rate were compared between patients with severe aortic plaque (>5 mm in thickness) and control patients. The relationship between aortic plaque morphology and prognosis was also estimated according to the presence of ulceration, calcification, hypoechoic plaques, and mobile plaques. The mean follow-up period was 8.7 years. Among 1,570 patients, severe aortic plaque was detected in 92 patients (5.9%). These 92 patients showed a significantly low survival rate and high subsequent embolic event rate compared to control patients (5-year survival rate: 69% vs 94%; 5-year embolic event free rate: 52% vs 95%). Among patients with severe aortic plaque, only ulceration was associated with a low survival rate (hazards ratio: 2.4, 95% confidence interval (CI): 1.1-5.2) and only mobile plaque was associated with a high embolic event rate (hazards ratio: 2.2; 95%CI: 1.1-5.1). CONCLUSIONS: Aortic plaque >5 mm in thickness was a predictor of poor prognosis. In the presence of aortic plaque >5 mm, ulceration was a predictor of a low survival rate and mobile plaque was a predictor of a high embolic event rate.

Left atrial appendage contributes to left atrial booster function after the maze procedure: quantitative assessment with multidetector computed tomography.

OBJECTIVE: Although the left atrial appendage (LAA) is excised to prevent thrombosis in the maze procedure, it remains unclear whether LAA is retained in expectation of LAA booster function. Therefore, we quantitatively assessed LAA size and function after the maze procedure in patients with chronic atrial fibrillation (AF) and mitral valve disease (MVD), and compared with those in patients with sinus rhythm after coronary artery bypass grafting (CABG). METHODS: We studied 23 patients (maze group: 65.0 + or - 9.2 (SD) years) undergoing the maze procedure for chronic AF and mitral valve surgery and 16 patients having sinus rhythm after CABG (CABG group: 66.5 + or - 9.3 years). The maze procedure was conducted by radiofrequency (RF) ablation and LAA was preserved in all cases. Left atrium (LA) and LAA volume and booster function were quantitatively evaluated by multidetector computed tomography (MDCT) at 11.7 + or - 10.4 months (maze group) and 16.8 + or - 19.9 months (CABG group) after the surgery. RESULTS: In all 23 patients of the maze group, sinus rhythm was well restored. LAA was clearly visualised without thrombi in all 39 patients. The maximal LA volume in the maze group was 128.8 + or - 54.6 ml, being larger than 105.3 + or - 36.1 ml in the CABG group. LA ejection fraction (EF) in the maze group was 16.1 + or - 7.0%, being significantly lower than 26.8 + or - 8.7% in the CABG group. Meanwhile, the maximal LAA volume in the maze group was significantly larger (16.9 + or - 7.3 ml vs 8.4 + or - 4.7 ml), but LAA EF (34.1 + or - 12.8% vs 36.1 + or - 7.4%) was comparable in the two groups. CONCLUSION: LAA largely contributes to LA booster function, particularly in the maze group, because LA booster function is deteriorated in this group of patients.

Cardiac tamponade during transesophageal echocardiography in a patient with infective endocarditis.

An 81-year-old man with a history of diabetes mellitus and end-stage renal disease was admitted because of infective endocarditis. During transesophageal echocardiography (TEE), pericardial effusion rapidly increased and led to cardiac tamponade. Despite intensive therapy, the patient did not recover. Autopsy showed hemopericardium, ruptured sinus of Valsalva, and vegetation on the aortic valve. Our case suggests that cardiac tamponade due to the rupture of a sinus of Valsalva can occur in patients with aortic valve endocarditis complicated by perivalvular abscess. Therefore, we must be aware of this devastating complication and take preventive measures when performing TEE in such patients.

Usefulness of contrast echocardiography for detecting right-to-left cardiac shunts during the diagnosis of hypoxemia: 2 case reports.

We report two cases in which contrast echocardiography was useful for detecting right-to-left shunt. In case 1, a 53-year-old man was admitted to our hospital after being diagnosed with acute heart failure. Even after improvement of the heart failure, hypoxemia remained. Contrast echocardiography was performed. When contrast medium was injected into the left antecubital vein, it directly drained into the left atrium. When contrast medium was injected into the right antecubital vein, it drained into the right atrium not the left atrium. These findings proved the existence of a right-to-left shunt. In case 2, a 68-year-old man felt dyspnea on mild effort, especially when sitting in an anteflexing posture. In room air, his SpO2 was 95% when sitting in a resting posture and 79% when in an anteflexing sitting posture. Contrast echocardiography was performed. A patent foramen ovale (PFO) was proved using the Valsalva maneuver, and the contrast medium drained from right atrium into the left atrium via the PFO. He underwent patch closure of the PFO, and his symptoms disappeared. Contrast echocardiography should be performed for the diagnosis of chronic hypoxemia for which causes are not detected with routine clinical examinations, in order to confirm right-to-left shunt.

Type-1 diabetes mellitus with insufficient serum immunoreactive insulin elevation after subcutaneous NPH-insulin injection.

We report a case of Type-1 diabetes with insufficient serum immunoreactive insulin (IRI) elevation after subcutaneous NPH-insulin injection. Favorable glycemic control was achieved by a continuous subcutaneous insulin infusion (CSII) using regular insulin. A 34-year-old woman with Type-1 diabetes (height 158 cm, weight 43.4 kg) was admitted to our hospital to improve glycemic control. On admission, her glycosylated hemoglobin (HbA(1c)) level was 10.9% and her fasting plasma glucose (FPG) level was 332 mg/dl. After admission, her insulin regimen was altered from two injections a day using premixed insulin to four injections a day using regular insulin before each meal and NPH insulin at bedtime. Although the dosage of NPH insulin at bedtime was increased to 32 U/day, there was no improvement in the FPG level. The peak IRI value after NPH insulin injection was not observed but that after the regular insulin injection was observed. Therefore, her insulin administration regimen was changed to CSII, using regular insulin alone. Her fasting plasma glucose level decreased, glycosylated hemoglobin (HbA(1c)) level improved to 7.0%, her body weight increased to 46.6 kg 4 months after starting CSII.