Prognostic efficacy of a post-discharge visiting program for patients with heart failure.

We aimed to investigate the impact of post-discharge scheduled hospital visits on readmission due to heart failure (HF). In this retrospective study, a total of 245 patients (N = 101 in the scheduled hospital visit group, N = 144 in the non-scheduled hospital visit group) who were alive with free from readmission due to HF for 90 days after discharge were enrolled. The patients had been hospitalized with acute decompensated HF between August 2018 and July 2019. Scheduled hospital visits were recommended 90 days after the patients had been discharged. After checking their self-care adherence, nurse-led self-care maintenance and monitoring were provided. To determine the effectiveness of the scheduled hospital visits, we conducted landmark analyses divided into two periods: Scheduled visits within 180 days, and after 180 days. The readmission rate due to HF within 180 days was lower in the scheduled visit group. In the landmark analysis, the 1-year incidence rate of readmission was significantly lower in patients with a scheduled hospital visit than in those without, in the period within 180 days (2.0% vs 9.0%, P = 0.029) but not after 180 days. After adjusting for age and estimated glomerular filtration rate as confounders, scheduled hospital visits tended to reduce readmission due to HF (P = 0.060); however, readmission was significantly reduced in the period within 180 days (P = 0.007). In conclusion, scheduled hospital visits at 90 days after discharge may be beneficial in delaying readmission due to HF by reducing risk of readmission during the early post-visit period.

Regional left atrial conduction velocity in the anterior wall is associated with clinical recurrence of atrial fibrillation after catheter ablation: efficacy in combination with the ipsilateral low voltage area.

BACKGROUND: Left atrial (LA) conduction velocity (CV) is an electrical remodeling parameter of atrial fibrillation (AF) substrate. However, the pathophysiological substrate of LA-CV and its impact on outcomes after catheter ablation for AF have not been well evaluated. METHODS: We retrospectively evaluated 119 patients with AF who underwent catheter ablation and electroanatomical mapping during sinus rhythm. To measure regional LA-CV, we took triplet sites (A, B, and C) on the activation map and calculated the magnitude of the matched orthogonal projection vector between vector-AB and vector-AC, indicating two-dimensional CV. The median of the LA-CVs from four triad sites in both the anterior and posterior walls was set as the 'model LA-CV'. We evaluated the impact of the model LA-CV on recurrence after ablation and relationship between the model LA-CV and LA-low voltage area (LVA) of < 0.5 mV. RESULTS: During the 12-month follow-up, 29 patients experienced recurrence. The LA-CV model was significantly correlated with ipsilateral LVA. The lower anterior model LA-CV was significantly associated with recurrence, with the cut-off value of 0.80 m/s having a sensitivity of 72% and specificity of 67%. Multivariable analysis revealed that the anterior model LA-CV (hazard ratio, 0.09; 95% confidence interval, 0.01-0.94; p = 0.043) and anterior LA-LVA (hazard ratio, 1.06; 95% confidence interval, 1.00-1.11; p = 0.033) were independently associated with AF recurrence. The anterior LA-LVA was mildly correlated with the anterior model LA-CV (r = -0.358; p < 0.001), and patients with both lower LA-CV and greater anterior LA-LVA based on each cut-off value had the worst prognosis. However, decreased LA-CV was more likely to be affected by the distribution pattern of the LVA rather than the total size of the LVA. CONCLUSION: Decreased anterior LA-CV was a significant predictor of AF recurrence and was a useful electrical parameter in addition to LA-LVA for estimating AF arrhythmogenicity.

Efficacy and feasibility of cryoballoon ablation for atrial fibrillation in patients with heart failure: A large-scale multicenter study.

INTRODUCTION: Data are limited regarding outcomes of cryoballoon ablation for atrial fibrillation (AF) in patients with heart failure (HF). This large-scale multicenter study aimed to evaluate the prognosis of patients with HF after cryoballoon ablation for AF. METHODS: Among 3655 patients undergoing cryoballoon ablation at 17 institutions, 549 patients (15%) (391 with paroxysmal AF and 158 with persistent AF) diagnosed with HF preoperatively were analyzed. Clinical endpoints were recurrence, mortality, and HF hospitalization after ablation. RESULTS: Most patients had a preserved left ventricular ejection fraction (LVEF) ≥ 50%. During a mean follow-up period of 25.7 months, recurrence, all-cause death, and HF hospitalization occurred in 29%, 4.0%, and 4.8%, respectively. Cardiac function on echocardiography and B-type natriuretic peptide (BNP) levels significantly improved postoperatively, and the effect was more pronounced in the nonrecurrence group. Major complications occurred in 33 patients (6.0%), but most complications were phrenic nerve palsy (3.6%). Although death and HF hospitalization occurred more frequently in patients with LVEF ≤ 40% (n = 73) and New York Heart Association (NYHA) class III-IV (n = 19) than other subgroups, the BNP levels, and LVEF significantly improved after ablation in all LVEF and NYHA class subgroups. High BNP levels, NHYA class, CHADS2 score, and structural heart disease, but not postablation recurrence, independently predicted death, and HF hospitalization on multivariate analysis. The patients with tachycardia-induced cardiomyopathy had better recovery of BNP levels and LVEF after ablation than those with structural heart disease. CONCLUSIONS: Cryoballoon ablation for AF in HF patients is feasible and leads to significantly improved cardiac function.

Long P-wave duration immediately after pulmonary vein isolation on radiofrequency catheter ablation for atrial fibrillation predicts clinical recurrence: correlation with atrial remodeling in persistent atrial fibrillation.

P-wave morphology reflects atrial remodeling and indicates prognosis after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). The impact of p-wave morphology after excluding the effect of pulmonary vein (PV) substrate on outcomes is unknown. We evaluated the p-wave morphology on electrocardiography immediately after PV isolation for clinical outcomes. Eighty-four consecutive patients (47 with paroxysmal AF and 37 with persistent AF) who underwent RFCA were included. P-wave duration (PWD) and amplitude in all leads were examined during sinus rhythm immediately after PV isolation. We evaluated the relationship between electrocardiogram parameters and AF recurrence, according to the type of AF and following ablation, and the correlation with left atrial (LA) volume, low voltage ratio, and fixed conduction time. During 12 months of follow-up, 20 patients experienced recurrence. The cut-off value of PWD > 120 ms in lead I showed a sensitivity of 75% and specificity of 69% for predicting recurrence. PWD was significantly correlated with LA volume, low voltage, and conduction velocity. Significantly higher recurrence rates were observed in patients with PWD > 120 ms than in those with PWD ≤ 120 ms (p < 0.001), and the difference was more pronounced in patients with persistent AF. Multivariate analysis demonstrated that PWD > 120 ms was independently associated with recurrence in the total population (hazard ratio 2.00; 95% confidence interval 1.27-3.22; p = 0.003) and in patients with persistent AF. In conclusion, long PWD after PV isolation predicts AF recurrence, which might be associated with the extent of the LA substrate in persistent AF.

＜Editors' Choice＞ Prognostic utility of multipoint nutritional screening for hospitalized patients with acute decompensated heart failure.

This study aimed to evaluate the impact of serial changes in nutritional status on 1-year events including all-cause mortality or rehospitalization owing to heart failure (HF) among hospitalized patients with acute decompensated HF (ADHF). The study subjects comprised 253 hospitalized patients with ADHF. The controlling nutritional status (CONUT) score was assessed both at hospital admission and discharge. The subjects were divided into three groups according to nutritional status using CONUT score: normal (0 and 1), mild risk (2-4), and moderate to severe risk defined as malnutrition (5-12). We observed nutritional status was improved or not. The incidence of malnutrition was 30.4% at hospital admission and 23.7% at discharge, respectively. Malnutrition was independently associated with 1-year events among hospitalized patients with ADHF. Presence or absence of improvement in nutritional status was significantly associated with 1-year events (P < 0.05), that was independent of percentage change in plasma volume in multivariate Cox regression analyses. We determined a reference model, including gender and estimated glomerular filtration rate, using multivariate logistic regression analysis (P < 0.05). Adding the absence of improvement in nutritional status during hospitalization to the reference model significantly improved both NRI and IDI (0.563, P < 0.001 and 0.039, P = 0.001). Furthermore, malnutrition at hospital discharge significantly improved NRI (0.256, P = 0.036) In conclusion, serial changes in the nutritional status evaluated on the basis of multiple measurements may provide more useful information to predict 1-year events than single measurement at hospital admission or discharge in hospitalized patients with ADHF.

Periprocedural Management of Cardiac Tamponade During Catheter Ablation for AF Under Uninterrupted DOAC and Warfarin.

OBJECTIVES: This was a retrospective analysis of a registry of patients who underwent catheter ablation for atrial fibrillation (AF) under uninterrupted direct oral anticoagulant (DOAC) and warfarin administration. BACKGROUND: Uninterrupted DOAC used during catheter ablation for AF causes a life-threatening bleeding risk of cardiac tamponade. METHODS: Of 3,149 catheter ablation procedures for AF with uninterrupted oral anticoagulants used in 2,406 patients in 3 institutions, DOAC and warfarin were administered in 1,896 and 1,253 procedures, respectively. Among them, cardiac tamponade requiring pericardiocentesis and surgical intervention occurred in 13 (0.7%) and 11 (0.9%) procedures in the DOAC and warfarin groups, respectively. In this study, the outcomes between these 2 groups were compared. RESULTS: The total blood volumes drained after pericardiocentesis was 300 (190 to 715) ml and 300 (200 to 380) ml in the DOAC and warfarin groups, respectively (p = 0.697). Approximately two-thirds of patients (9 in the DOAC group and 7 in the warfarin group) recovered with only pericardiocentesis and protamine infusion (including vitamin K in the warfarin group) in both groups. Two patients in the DOAC group underwent surgical intervention but recovered uneventfully, whereas none of the patients taking warfarin required surgical intervention. DOAC and warfarin were successfully resumed 2.0 (2.0 to 5.0) days and 4.0 (2.0 to 5.5) days after tamponade in all patients without an increase in effusion (p = 0.102). CONCLUSIONS: Managing cardiac tamponade under uninterrupted DOAC administration was feasible. Early intensive treatment resulted in hemostasis in most patients. However, surgical intervention was required in some cases refractory to the initial treatment.

Hemorrhagic Pericardial Cyst Complicated with Constrictive Pericarditis.

Pericardial cysts are rare abnormalities and are usually asymptomatic. Although several case reports on their diagnosis and treatment have been published, those on hemorrhagic pericardial cysts remain limited. We herein report the case of a 70-year-old man with a hemorrhagic pericardial cyst complicated with constrictive pericarditis 2 years after the initial diagnosis.

Comparison of two dosing methods for immediate administration of tolvaptan in acute decompensated heart failure.

BACKGROUND: The clinical dosing method for tolvaptan in patients with acute heart failure (HF) is still unclear. We aimed to compare the differences in clinical effect between two dosing regimens: once-daily 7.5mg and twice-daily 3.75mg. METHODS: In this randomized trial, tolvaptan was administered within 12h from hospital admission. The primary outcome was the serial change in congestion scores measured every day from enrollment until dosing day 7. Outcomes including safety parameters were also evaluated. RESULTS: The subjects were assigned to either the once-daily 7.5mg dosing regimen (N=15) or the twice-daily 3.75mg dosing regimen (N=16). The time-course changes in body weight, serum sodium and creatinine levels, systolic blood pressure, daily urine output, and congestion scores were similar between the two groups. In the twice-daily 3.75mg dosing group, the serum sodium levels on days 3 and 4 were significantly (p<0.05) increased compared with those on day 1. The congestion scores significantly (p<0.05) decreased from day 2 to day 7 in both groups compared with those on day 1. However, the difference in the serial change in the congestion scores did not reach statistical significance. CONCLUSIONS: Our present results suggest that the early administration of tolvaptan within 12h after hospital admission significantly improved congestion from the first day after administration by either dosing regimen, i.e. once-daily 7.5mg or twice-daily 3.75mg in patients with acute HF.

Feasibility and safety of uninterrupted dabigatran therapy in patients undergoing ablation for atrial fibrillation.

OBJECTIVE: Uninterrupted oral warfarin strategy has become the standard protocol to prevent complications during catheter ablation (CA) for the treatment of atrial fibrillation (AF). However, little is known about the safety and efficacy of uninterrupted dabigatran therapy in patients undergoing CA for AF. Therefore, this study investigated the safety and efficacy of uninterrupted dabigatran therapy and compared the findings with those for uninterrupted warfarin therapy. METHODS: Bleeding and thromboembolic events during the periprocedural period were evaluated in 363 consecutive patients who underwent CA for AF at Nagoya University Hospital, and received uninterrupted dabigatran (n=173) or uninterrupted warfarin (n=190) for periprocedural anticoagulation. RESULTS: A total of 27 (7%) patients experienced either bleeding or thromboembolic complications. Major bleeding complications occurred in 2 (1%) patients in the dabigatran group (DG) and 2 (1%) patients in the warfarin group (WG). Eight (5%) patients in the DG and 9 (5%) patients in the WG experienced groin hematoma, a type of minor bleeding complication. Meanwhile, no patient in the DG and 1 (1%) in the WG developed cerebral ischemic stroke. Overall, there was no significant difference between the groups for any category. The activated partial thromboplastin time (APTT) independently predicted periprocedural complications in the DG. CONCLUSION: Uninterrupted dabigatran therapy in CA for AF thus may be a safe and effective anticoagulant therapy, and appears to be closely similar to continuous warfarin; however, it is essential to pay close attention to the APTT values when using dabigatran during CA.

Efficacy and safety of apixaban in the patients undergoing the ablation of atrial fibrillation.

INTRODUCTION: Apixaban, a factor Xa (FXa) inhibitor, is a new oral anticoagulant for stroke prevention in atrial fibrillation (AF). However, little is known about its efficacy and safety as a periprocedural anticoagulant therapy for patients who had undergone catheter ablation (CA) for AF. METHODS AND RESULTS: We evaluated 342 consecutive patients who underwent CA for AF between April 2013 and March 2014 and received apixaban (n = 105) and warfarin (n = 237) for uninterrupted periprocedural anticoagulation. We retrospectively investigated the occurrence of bleeding and thromboembolic complications during the procedural period and compared them between the apixaban group (AG) and warfarin group (WG). Thromboembolic complications occurred in one (0.4%) patient in the WG. Major and minor bleeding complications occurred in one (1%) and four (4%) patients in the AG, and three (1%) and 12 (5%) patients in the WG. No significant difference in complications was observed between the AG and WG. Of importance, adverse event rates did not differ between the two groups after adjusting by a propensity score analysis. In preoperative tests of blood coagulation, there were significant differences in the prothrombin time, activated partial thromboplastin time, FXa activity, and prothrombin fragment 1 + 2 (F1+2) levels between the AG and WG. CONCLUSION: The use of apixaban during the periprocedural period of AF ablation seemed as efficacious and safe as warfarin.

Clinical characteristics and predictors of super-response to cardiac resynchronization therapy: a combination of predictive factors.

BACKGROUND: Patients with greater improvement of cardiac function after cardiac resynchronization therapy (CRT) implantation are identified as "super-responders." However, it remains unclear which kind of preimplant assessments could accurately predict outcomes after CRT. Thus, we aimed to examine the essential predicting factors for super-response to CRT, and to construct an accurate predictable model. METHODS: We retrospectively analyzed the CRT patients who underwent implantation at Nagoya University Hospital. Super-responders are defined as those who show a relative reduction in left ventricular end-systolic volume ≥30% after 6 months of CRT. RESULTS: Eighty patients (mean age, 67.8 ± 10.2 years) were included. Twenty-two patients received upgrading procedure to CRT implantation. Six months after the implantation, 29 patients (36%) were super-responders. Multiple logistic regression analysis shows that consistent right ventricular pacing with a previous device (odds ratio [OR] 7.28, 95% confidence interval [CI] 1.52-34.9; P = 0.013), lack of prior history of ventricular arrhythmia (OR 5.32, 95% CI 1.52-18.6; P = 0.009), and smaller left atrial diameter (LAD) (OR 0.92, 95% CI 0.86-0.98; P = 0.014) are independent predictors for CRT super-responders. The use of a combination of these predictive factors could increase the certainty with which a greater response to CRT is predicted and the presence of such a combination could improve prognosis. CONCLUSION: Greater response to biventricular pacing occurs more frequently in patients with consistent right ventricular pacing, lack of prior history of ventricular arrhythmia, and smaller LAD. An association between patient background characteristics and a super-response to CRT was also identified.

Clinical outcome of implantable cardioverter defibrillators with recalled and non-recalled leads in Japanese patients. Increased failure rate of the Sprint Fidelis lead.

BACKGROUND: In recent years, there has been a series of recalls of popular implantable cardioverter defibrillators leads, and several reports have demonstrated an increasing rate of failure of such leads over time in Caucasian patients. However, little is known about the performance of these leads in Asian patients. The aim of this study was to investigate the rate of failure of the recalled leads and the characteristics as compared with non-recalled leads in Japanese patients. METHODS AND RESULTS: A retrospective chart review was conducted in 214 patients (75 Sprint Fidelis, 8 Riata, and 131 Sprint Quattro leads) who underwent implantation and follow-up at Nagoya University Hospital. During the follow-up period, 14 Sprint Fidelis leads (19%) and 1 Riata lead (13%) failed, but no abnormality was found in the Sprint Quattro, non-recalled leads. Five patients (4 Sprint Fidelis and 1 Riata, 33% of lead failure patients) received inappropriate shocks. The 3-, 4-, and 5-year lead survival rates in Sprint Fidelis leads were 95.1% (95% confidence interval [CI]: 89.6%-100%), 89.8% (95% CI: 82.1%-97.6%), and 88.0% (95% CI: 79.6%-96.4%), respectively. A previous device implantation before Sprint Fidelis lead was the only significant predictor for lead fracture (hazard ratio, 5.33; 95% CI: 1.55-18.4; P=0.008). CONCLUSIONS: The rate of Sprint Fidelis lead failure continues to increase over time in Japanese patients.