Pulmonary vein narrowing after visually guided laser balloon ablation: Occurrence and clinical correlates.

INTRODUCTION: There are limited data focusing on pulmonary vein (PV) narrowing following ablation using a visually guided laser balloon (VGLB). We sought to assess the frequency and predictors of PV narrowing after VGLB ablation. METHODS AND RESULTS: Patients with paroxysmal atrial fibrillation treated with VGLB were screened. Study participants underwent contrast-enhanced computed tomography (CT) scanning before and 6 months after the procedure. We defined 25% to 49%, 50% to 74%, and 75% to 100% reduction in PV cross-sectional area as mild, moderate, and severe narrowing, respectively. Of 146 PVs in 38 patients analyzed, severe narrowing developed in two right superior and one right inferior PV. Moderate or severe narrowing occurred in 40 veins (27% of all PVs, 50% of the right superior, 22% of the right inferior, 21% of the left superior, and 14% of the left inferior PV). In PVs with moderate-severe narrowing, the baseline orifice area was significantly larger (4.1 [interquartile range, 3.2-4.8] vs 2.5 [1.9-3.3] cm2 , P < .0001), the narrowest region of stenosis was significantly more distal into the vessel (1.9 [0.7-2.9] vs 0 [0-1.7] mm from the orifice, P = .0006) and the total amount of energy delivered per vein was significantly greater (5190 ± 970 vs 4626 ± 1573 J, P = .018) than in PVs with mild or no significant narrowing. The baseline orifice area independently predicted moderate-severe narrowing in multivariate analysis (odds ratio, 1.8 [1.3-2.5] per 1 cm2 increase, P = .0003). No patient exhibited any signs or symptoms of PV stenosis. CONCLUSIONS: Baseline PV orifice area, ablating distally inside the veins, and total amount of laser energy are associated with PV narrowing after VGLB ablation.

Clinical outcome of pulmonary vein isolation alone ablation strategy using VISITAG SURPOINT in nonparoxysmal atrial fibrillation.

BACKGROUND: Recent studies have shown the improvement in long-term effectiveness with standardized pulmonary vein isolation (PVI) aimed at creating durable and contiguous lesions with VISITAG SURPOINT (VS) in paroxysmal atrial fibrillation (PAF). OBJECTIVE: We aimed to assess efficacy of PVI alone strategy using VS in non-PAF patients and evaluate factors associated with corresponding clinical outcomes. METHODS: Consecutive patients who underwent PVI for persistent/long-standing persistent AF between May 2017 to July 2019 were studied retrospectively. PVI was performed with 30-50 W guided by VS (posterior target: 400-500, anterior target: 500). Left atrial voltage maps were created during atrial pacing after PVI. RESULTS: A total of 140 patients (119 males, age 62 ± 10 years, long-standing persistent AF: 35) were included and followed for median of 454 days. No adverse events were reported in any patients during periprocedural and follow-up period of up to 28 months. Kaplan-Meier analysis estimated that freedom from atrial tachycardia or AF (AT/AF) without antiarrhythmics at 1-year was 70%. Radiofrequency delivery with higher power was associated with increased first-pass isolation rate, but not with freedom from AT/AF. In multivariate analysis, long-standing persistent AF and % low-voltage zone (%LVZ) were independent predictors of clinical outcome. The best cut-off value of %LVZ for predicting AT/AF recurrence was 3.24%. Freedom from AT/AF was 88% in patients with persistent AF and %LVZ < 3.24%, while 27% in those with long-standing persistent AF and %LVZ ≥ 3.24%. CONCLUSIONS: PVI alone using VS was associated with excellent 1-year success in patients with persistent AF and %LVZ < 3.24%, but was insufficient in those with long-standing persistent AF and/or %LVZ ≥ 3.24%.

Long-Term Performance of Right Ventricular Implantable Cardioverter-Defibrillator Leads in Arrhythmogenic Right Ventricular Cardiomyopathy and Hypertrophic Cardiomyopathy.

Patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and hypertrophic cardiomyopathy (HCM) implanted with implantable cardioverter-defibrillators (ICDs) may show a large decrease in R-wave amplitude during long-term follow-up. However, it is unclear whether this decrease is higher in these patients than in those without structural heart disease. This study investigated ICD-lead intracardiac parameters over a long duration in patients with ARVC and HCM and compared these parameters with those of a control group. We included 50 patients (mean age, 55.2 ± 17.2 years; 26% female) with ICD leads in the right ventricular apex, and compared 7 ARVC and 14 HCM patients with 29 control patients without structural heart disease. ICD-lead parameters, including R-wave amplitude, pacing threshold, and impedance during follow-up, were compared. The difference in these parameters between the time of implantation and year 5 were also compared. There were no significant differences in R-wave amplitude at implantation among the 3 groups. The change in R-wave amplitude between the time of implantation and year 5 was significantly greater in the ARVC group (-3.3 ± 5.4 mV, P = 0.012) in comparison to the control group (1.3 ± 2.8 mV); the HCM group showed no significant difference (-0.4 ± 2.3 mV, P = 0.06). Thus, in the ARVC group, R-wave amplitude at year 5 was significantly lower than that in the control group (5.7 ± 4.8 mV versus 12.5 ± 4.5 mV, P = 0.001). In ARVC patients with ICDs, ventricular sensing is likely to deteriorate during long-term follow-up; however, in HCM patients, sensing may not deteriorate.

Atrial fibrillation type matters: greater infarct volume and worse neurological defects seen in acute cardiogenic cerebral embolism due to persistent or permanent rather than paroxysmal atrial fibrillation.

Aims: Some studies have shown that the type of atrial fibrillation (AF), whether paroxysmal AF (PAF) or persistent or permanent AF (PeAF), affects the incidence of ischaemic stroke. This study sought to determine the relationship between the AF pattern and the severity and brain volume of infarction in an AF population including transient ischaemic attack (TIA) patients. Methods and results: This was a retrospective observational study. We studied 161 consecutive patients who were admitted to our stroke care unit with cardiogenic embolism or TIA related to non-valvular AF (age 79 ± 9.5, 78 females, and 87 PAF patients). We evaluated the differences in severity and infarct volume between the types of AF. Additionally, we divided the patients into three groups according to severe stroke (n = 38), TIA (n = 28), and those who were neither (stroke, n = 95) for the assessment of the predictors of severe stroke and TIA. Persistent or permanent atrial fibrillation patients with acute cardiogenic stroke or TIA had worse peak National Institute of Health Stroke Scale (NIHSS) scores [PAF median 4 (range 3-14), PeAF 17 (5.8-25); P < 0.0001] and worse NIHSS scores at discharge [PAF 2.0 (1-7), PeAF 11 (3-22); P < 0.0001]. Their infarct brain volume assessed by computed tomography or magnetic resonance imaging was also larger [PAF 4.4 (1.1-32) mL, PeAF 64 (6.9-170) mL; P < 0.0001]. Multivariate analysis of severe stroke vs. non-severe stroke patients showed that having PeAF was the only independent predictor of severe stroke [odds ratio (OR) 4.27, 95% confidence interval (CI) 1.91-10.2; P = 0.0003]. Comparison of TIA vs. non-TIA patients showed that PeAF (OR 0.120, 95% CI 0.0230-0.444; P = 0.0008) and anticoagulant use (OR 8.24, 95% CI 2.15-40.8; P = 0.0018) were independent predictors of TIA. Conclusion: Cardiogenic emboli due to non-valvular PeAF are associated with a worse acute clinical course and greater volume of infarction than those due to PAF.

Safety and Efficacy of Transvenous Lead Extraction With a High-Frequency Excimer Laser　- A Single Center Experience.

BACKGROUND: Transvenous lead extractions have been performed using 40-Hz laser sheaths. Recently, a new 80-Hz laser sheath became available, but only a few reports have compared the effectiveness of the 40- and 80-Hz laser sheaths. Methods and Results: This study included 215 patients. Lead extractions using only laser sheaths were analyzed. The clinical characteristics, extraction parameters, and extraction tools were evaluated. The procedures were performed with 40-Hz sheaths in 150 patients (group 1: 270 leads) and 80-Hz sheaths in 65 (group 2: 99 leads). No statistically significant differences were observed in the clinical parameters except for sex. The mean implant duration was 95.3±86.0 and 78.2±56.8 months in groups 1 and 2, respectively (P=0.07). The respective mean laser time and number of laser pulses were 48.5±52.1 and 48.1±56.1 s (P=0.96) and 2,035.0±2,384.0 and 3,955.1±2,339.3 pulses (P<0.0001). Complete removal was achieved for 97.4% of the leads and in 98.0% in both groups (P=0.38). Major complications occurred in 2.0% and 3.1% of the patients in groups 1 and 2, respectively (P=0.94). CONCLUSIONS: Transvenous lead extraction using high-frequency laser sheaths was as highly successful as with low-frequency laser sheaths in Japanese patients.

Early Transfer of Patients with Acute Heart Failure from a Core Hospital to Collaborating Hospitals and Their Prognoses.

Japan is facing problems associated with "heart failure (HF) pandemics" and bed shortages in core hospitals that can accommodate patients with acute HF. The prognosis is currently unknown for acute HF patients who were transferred from core hospitals to collaborating hospitals during the very early treatment phase and whose treatment strategies are in place.We enrolled 166 acute HF patients who were hospitalized between January 1, 2015, and December 31, 2015, and compared the conditions of transferred patients (n = 53, median duration before transfer = 6 days) and nontransferred patients (n = 113). The transferred and nontransferred patients had similar one-year mortality rates (24.5% versus 19.5%, log-rank P = 0.27) and composite one-year mortality and HF readmission rates (35.8% versus 31.0%, log-rank P = 0.32). Multivariate analysis determined that patient transfers were not associated with a higher composite endpoint (hazard ratio, 1.08; 95% confidence interval, 0.58-1.99, P = 0.82). Transferred patients with low composite congestion scores (CCSs) had significantly lower composite endpoints than those with high CCSs (23.5% versus 57.9%, log-rank P = 0.005).Acute HF patients who were transferred did not have inferior prognoses compared with nontransferred patients when the treatment strategies were correctly assumed by cardiologists. The implementation of early and strict decongestion strategies before transfer may be important for reducing cardiovascular events.

Predictors of nonpulmonary vein triggers for atrial fibrillation: A clinical risk score.

BACKGROUND: Targeting non-pulmonary vein triggers (NPVTs) after pulmonary vein isolation may reduce atrial fibrillation (AF) recurrence. Isoproterenol infusion and cardioversion of spontaneous or induced AF can provoke NPVTs but typically require vasopressor support and increased procedural time. OBJECTIVE: The purpose of this study was to identify risk factors for the presence of NPVTs and create a risk score to identify higher-risk subgroups. METHODS: Using the AF ablation registry at the Hospital of the University of Pennsylvania, we included consecutive patients who underwent AF ablation between January 2021 and December 2022. We excluded patients who did not receive NPVT provocation testing after failing to demonstrate spontaneous NPVTs. NPVTs were defined as non-pulmonary vein ectopic beats triggering AF or focal atrial tachycardia. We used risk factors associated with NPVTs with P <.1 in multivariable logistic regression model to create a risk score in a randomly split derivation set (80%) and tested its predictive accuracy in the validation set (20%). RESULTS: In 1530 AF ablations included, NPVTs were observed in 235 (15.4%). In the derivation set, female sex (odds ratio [OR] 1.40; 95% confidence interval [CI] 0.96-2.03; P = .080), sinus node dysfunction (OR 1.67; 95% CI 0.98-2.87; P = .060), previous AF ablation (OR 2.50; 95% CI 1.70-3.65; P <.001), and left atrial scar (OR 2.90; 95% CI 1.94-4.36; P <.001) were risk factors associated with NPVTs. The risk score created from these risk factors (PRE2SSS2 score; [PRE]vious ablation: 2 points, female [S]ex: 1 point, [S]inus node dysfunction: 1 point, left atrial [S]car: 2 points) had good predictive accuracy in the validation cohort (area under the receiver operating characteristic curve 0.728; 95% CI 0.648-0.807). CONCLUSION: A risk score incorporating predictors for NPVTs may allow provocation of triggers to be performed in patients with greatest expected yield.

Impact of a formula combining local impedance and conventional parameters on lesion size prediction.

BACKGROUND: Although ablation energy (AE) and force-time integral (FTI) are well-known active predictors of lesion characteristics, these parameters do not reflect passive tissue reactions during ablation, which may instead be represented by drops in local impedance (LI). This study aimed to investigate if additional LI data improves predicting lesion characteristics and steam pops. METHODS: RF applications at a range of powers (30 W, 40 W, and 50 W), contact forces (8 g, 15 g, 25 g, and 35 g), and durations (10-180 s) using perpendicular/parallel catheter orientations were performed in excised porcine hearts (N = 30). The correlation between AE, FTI, and lesion characteristics was examined, and the impact of LI (%LI drop (%LID) defined by the ΔLI divided by the initial LI) was additionally assessed. RESULTS: Three hundred seventy-five lesions without steam pops were examined. Ablation energy (W × s) and FTI (g × s) showed a positive correlation with lesion depth (ρ = 0.824:P < 0.0001 and ρ = 0.708:P < 0.0001), surface area (ρ = 0.507:P < 0.0001 and ρ = 0.562:P < 0.0001), and volume (ρ = 0.807:P < 0.0001 and ρ = 0.685:P < 0.0001). %LID also showed a positive correlation individually with lesion depth (ρ = 0.643:P < 0.0001), surface area (ρ = 0.547:P < 0.0001), and volume (ρ = 0.733:P < 0.0001). However, the combined indices of AE × %LID (AE multiplied by %LID) and FTI × %LID (FTI multiplied by %LID) provided significantly stronger correlation with lesion depth (ρ = 0.834:P < 0.0001 and ρ = 0.809:P < 0.0001), surface area (ρ = 0.529:P < 0.0001 and ρ = 0.656:P < 0.0001), and volume (ρ = 0.864:P < 0.0001 and ρ = 0.838:P < 0.0001). This tendency was observed regardless of the catheter placement (parallel/perpendicular). AE (P = 0.02) and %LID (P = 0.002) independently remained as significant predictors to predict steam pops (N = 27). However, the AE × %LID did not increase the predictive power of steam pops compared to the AE alone. CONCLUSION: LI, when combined with conventional parameters (AE and FTI), may provide stronger correlation with lesion characteristics.

Clinical implications of local impedance measurement using the IntellaNav MiFi OI ablation catheter: an ex vivo study.

PURPOSE: Clinical implication of local impedance (LI) for radiofrequency (RF) ablation has not been fully established. This study aimed to investigate this point using IntellaNav MiFi OITM catheter. METHODS: LI and generator impedance drops (ΔLI and ΔGI) were evaluated in excised porcine hearts (N = 16) during RF applications at a range of powers (30 and 50 W), contact forces (5-40 g), and durations (10-180 s) using perpendicular or parallel catheter orientation. Additionally, temporal LI changes were assessed. RESULTS: Of the 240 lesions without steam pops (92.3%), ΔLI showed better correlations with lesion surface area (ρ = 0.55 vs 0.36, P = 0.004), maximum depth (ρ = 0.53 vs 0.14, P < 0.001), and lesion volume (ρ = 0.64 vs 0.23, P < 0.001) than ΔGI. Furthermore, %LI-drop (ΔLI/initial LI) demonstrated stronger correlations with lesion surface area (ρ = 0.60 vs 0.55, P < 0.001), maximum depth (ρ = 0.57 vs 0.53, P < 0.001), and volume (ρ = 0.69 vs 0.64, P < 0.001) than ΔLI. Parallel catheter orientation improved correlation of ΔLI with lesion surface area (ρ = 0.63 vs 0.40, P = 0.015) and depth (ρ = 0.68 vs 0.45, P = 0.008) and created a larger surface lesion (36.3[29.2-42.7] mm2 vs 28.8[21.6-34.2] mm2, P < 0.001) than the perpendicular. LI of the lesions significantly differed between baseline, immediately after RF, and 5 min after (P < 0.01). LI reaching plateau, larger initial LI, ΔLI, and %LI-drop, and larger RF power and longer duration were observed in pop lesions (P < 0.05). CONCLUSIONS: %LI-drop demonstrated a better correlation with lesion size than ΔLI. LI may be used as an additional parameter to predict lesion size and steam pops. Temporal variation and catheter orientation should be considered to interpret LI.

Transvenous excimer laser-assisted lead extraction of cardiac implantable electrical devices in the Japanese elderly population.

BACKGROUND: The feasibility and safety of lead extraction of cardiac implantable electronic devices (CIEDs) in the elderly Asian population remain uncertain. We report the outcome and safety of transvenous excimer laser-assisted lead extraction of CIEDs in Japanese patients aged ≥80 years. METHODS: Consecutive 235 patients (age 67±15 years, 167 male) undergoing lead extraction of CIED with an excimer laser system (Philips, Andover, MA, USA) were included. RESULTS: Of 235 consecutive patients, 51 (22%) were ≥80 years (age 86±5 years, 14 were aged ≥90 years; 42 had pacemakers, 3 had implantable cardioverter defibrillators, and 6 had cardiac resynchronization therapy devices). The median implant duration was 110±95 months. Patients aged ≥80 years had lower body mass index (BMI, 20.7±3.1kg/m2 vs. 22.6±3.4kg/m2, p<0.001), higher incidence of CIED infection (98% vs. 63%, p<0.010), and longer duration of hospitalization (31±17 days vs. 24 ± 31 days, p<0.001) than patients aged <80 years. There were no differences between the age groups in the rate of complete retrieval (94.1% vs. 95.1%, p=0.726) and major complications, including cardiac tamponade and cardiogenic shock (2.0% vs. 2.7%, p=1.000). CONCLUSIONS: Excimer laser-assisted lead extraction was safe and feasible in the Japanese elderly population with low BMI, despite the high likelihood of procedural complications. Early removal of infected CIEDs should be performed without delay in elderly Asian populations.

A prospective multicenter study of direct comparison of feasibility and safety of pulmonary vein isolation using the minimally interrupted apixaban between second-generation cryoballoon and radiofrequency ablation of paroxysmal atrial fibrillation: J-HIT apixaban.

BACKGROUND: The feasibility and safety of pulmonary vein isolation (PVI) using cryoballoon (CB) for paroxysmal atrial fibrillation (PAF) with minimally interrupted apixaban has not fully explored. METHODS: In this multicenter, randomized prospective study, we enrolled patients with PAF undergoing CB or radiofrequency (RF) ablation with interrupted (holding 1 dose) apixaban. The primary composite end point consisted of bleeding events, including pericardial effusion and major bleeding requiring blood transfusion, or thromboembolic events at 4 weeks after ablation; secondary end points included early recurrence of AF and procedural duration. RESULTS: A total of 250 patients underwent PVI (125 assigned to the RF ablation and 125 assigned to the CB ablation). The primary end point occurred in 1 patient in the CB ablation group (0.8%; 90% confidence interval [CI], 0.04 to 3.70) and 3 patients in the RF group (2.4%, P = .622; risk ratio, 0333; 90% CI, 0.05 to 2.20). All events were pericardial effusion, all of whom recovered after pericardiocentesis. Early recurrence of AF occurred in 4 patients (3.2%) in the RF group and in 6 patients (4.8%) in the CB group (P = .749). The procedural duration was shorter in the CB group than that in the RF group (136.5 ± 39.9 vs 179.5 ± 44.8 min, P < .001). CONCLUSION: CB ablation with minimally interrupted apixaban was feasible and safe in patients with PAF undergoing PVI, which was equivalent to RF ablation.

Bilateral cardiac sympathetic denervation of a recurrent refractory ventricular tachycardia occurring after catheter ablation of atrial fibrillation and outflow tract premature ventricular contractions.

Recent studies have demonstrated the utility of cardiac sympathetic denervation (CSD) in patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and catheter or surgical ablation. We present our experience with bilateral CSD in a patient with a recurrent VT despite attempts at treatment with catheter ablation and antiarrhythmic drugs, and this is the first description of the successful management of an idiopathic refractory VT with a bilateral CSD and concomitant oral amiodarone, occurring after catheter ablation of persistent atrial fibrillation and idiopathic outflow tract premature ventricular contractions.

Excessive Prolongation of Coagulation Time During Treatment With Direct Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation.

BACKGROUND: Conventional coagulation assays have poor sensitivity and specificity for assessing the anticoagulant effect of direct oral anticoagulants (DOACs). This study aimed to evaluate the causes and consequences of the excessive prolongation of coagulation time in patients with nonvalvular atrial fibrillation who receive DOACs. METHODS: We retrospectively analysed 1521 patients (age, 66 ± 12 years). The prothrombin time (PT) and activated partial thromboplastin time (APTT) were averaged if they were measured more than twice depending on the respective DOAC and dosage across individuals. Excessive coagulation time prolongation was defined as PT or APTT of >2 standard deviations over the median for each DOAC. RESULTS: In all, 1913 DOAC cases were found. Excessive prolongation (EP), which was noted in 88 patients (5.8%), was found to be significantly associated with inappropriately high DOAC dosage and body weight (≤ 60 kg). During follow-up (median, 8.9 months), thromboembolisms developed in 10 patients (0.66%) and bleeding events in 85 (5.6%). Bleeding events were significantly higher in patients with excessive prolongation (EP group) than in those without (P = 0.013). Of the 53 patients in the EP group, 15 (28%) were positive for antiphospholipid antibodies, 6 (11%) had inappropriately high prescription dosages, 4 (8%) had coagulation factor deficiencies, and 3 (6%) had severe liver dysfunction. CONCLUSIONS: Bleeding event rates were remarkably higher in patients receiving DOACs that caused EP of PT or APTT. Thus, following the current guidelines and administering the recommended dose of DOACs are fundamentally important. Patients with the body weight of <60 kg should be considered for dosage reduction or DOAC withdrawal.

Utility of a ripple map for the interpretation of atrial propagation during atrial tachycardia.

PURPOSE: Ripple map (RM) is a novel method for displaying activation pattern on the surface of a cardiac chamber. The aim of this study was to determine the utility of the RM in interpreting the atrial propagation in atrial tachycardia (AT) in comparison with a conventional local activation (LAT) map. METHODS: Three-dimensional electroanatomical mapping and ablation of AT were performed using multielectrode catheters and the CARTO3 ConfiDENSE Module (Biosense Webster). LAT maps and RMs were retrospectively reviewed by two independent observers who were blinded to the ablation results. RESULTS: High-density maps (1683 ± 1362 points) of 45 ATs (274 ± 64 ms; macroreentry 28, focal 17) were obtained in 39 patients. Of the 45 ATs, 41 (91%) were terminated by catheter ablation. A retrospective review of the LAT map alone by two observers resulted in correct diagnosis in 27% (12 ATs), whereas additional reviews of the RMs improved the diagnostic accuracy to 80% (36 ATs, P < 0.001). The diagnostic accuracy using the RM was equally high for macroreentrant (79%) and focal ATs (82%, P = 1.000). Of the 33 LAT maps in disagreement with the observers, adjusting the window-of-interest (WOI) after reviewing the RMs achieved diagnostic agreement of 91% (30 ATs). CONCLUSION: RMs allow us to have precise understanding of the atrial propagation on high-density CARTO maps for both focal and macroreentrant ATs, which is particularly useful for cases with difficult-to-interpret LAT maps.

Impact of impedance decrease during radiofrequency current application for atrial fibrillation ablation on myocardial lesion and gap formation.

BACKGROUND: The clinical impact of a decrease in impedance during radiofrequency catheter ablation (RFCA) has not been fully clarified. The aim of the study was to analyze the impact of impedance decrease and to determine its optimal cutoff value during RFCA. METHODS: We evaluated 34 consecutive patients (total 3264 lesions, mean age 66 ± 8.7 years, 10 females) who underwent their first ablation for atrial fibrillation (AF). The impedance decrease, average contact force (CF), application time, force-time integral (FTI), product of impedance decrease and application time (PIT), and the product of impedance decrease and FTI (PIFT) were measured for all lesions. Levels of cardiac troponin I (TrpI) were measured for assessment of myocardial injury. The incidence of intraprocedural pulmonary vein-left atrium reconnection or dormant conduction (reconnection) was determined. The relationships between the ablation parameters and the increase in TrpI (ΔTrpI) were evaluated. The predictive value of the parameters for reconnection was assessed using receiver operating characteristic (ROC) curve analysis. RESULTS: Reconnection was detected in 18 patients. Average FTI and PIT were significantly correlated with ΔTrpI (FTI: r2 = .19, P = .0090, PIT: r2 = .21, P = .0058). PIFT was correlated with ΔTrpI and was the best of the three indexes (PIFT: r2 = .29, P = .0010). In ROC curve analysis, the area under the curve for predicting reconnection was 0.71 and the optimal cutoff value was 5200 for PIFT (sensitivity 78%, specificity 63%). CONCLUSION: The combination of CF and a decrease in impedance could be important in the evaluation of myocardial lesions and reconnection during RFCA.

Comparison of direct oral anticoagulants and warfarin regarding midterm adverse events in patients with atrial fibrillation undergoing catheter ablation.

BACKGROUND: Oral anticoagulants, including direct oral anticoagulants (DOACs), are usually required in atrial fibrillation (AF) patients who are at a high risk of thromboembolism (TE), even if they had undergone catheter ablation (CA). Although several studies have reported the safety and efficacy of DOACs around CA in AF patients, there are only limited data regarding the midterm incidence of TE and bleeding complications post-CA among AF patients treated with warfarin or DOACs. METHODS: We studied 629 AF patients (mean age: 65.3 ± 10.3 years; 442 men) undergoing CA, to calculate the midterm incidence of TE and bleeding complications associated with warfarin or DOACs. RESULTS: In total, 292 patients used warfarin and 337 used DOACs (dabigatran: 90 patients; rivaroxaban: 137; and apixaban: 110). At baseline, the CHA2DS2-VASc and HAS-BLED scores were similar between the 2 groups. During a median follow-up period of 7 months, no TE complications occurred. The warfarin group had a significantly higher bleeding event rate than did the DOACs group (all bleeding complications: 32 [11.0%] vs 15 [4.5%], respectively, P = .002). The rate of all bleeding complications was significantly higher in the warfarin group than in the DOACs group (10.1% vs 3.7%, respectively, at 10 months; P = .024). In Cox proportional hazards modeling, DOAC use was significantly associated with a decreased risk of bleeding (adjusted hazard ratio: 0.497; 95% confidence interval: 0.261-0.906, P = .022). CONCLUSIONS: Direct oral anticoagulant use in AF patients undergoing CA may be associated with a similar risk of TE as warfarin but is associated with a lower risk of bleeding.

Treatment Outcomes of Anticoagulant Therapy and Temporary Inferior Vena Cava Filter Implantation for Pregnancy Complicated by Venous Thrombosis.

Objective: Although deep vein thrombosis (DVT) followed by pulmonary thromboembolism (PE) is a critical complication during pregnancy, there have been few reports about its intrapartum management. We evaluated intrapartum management by using a temporary inferior vena cava filter (IVCF) in pregnant women with PE/DVT. Materials and Methods: Eleven women with PE/DVT during pregnancy between January 2004 and December 2016 were included. The patients were hospitalized for intravenous unfractionated heparin infusion after acute PE/DVT onset. Seven patients were discharged and continued treatment with subcutaneous injection of heparin at the outpatient unit. IVCF was implanted 1-3 days before delivery in 10 patients. Anticoagulant therapy was discontinued 6-12 h before delivery. We retrospectively analyzed rates of maternal or perinatal death, and recurrence of symptomatic PE/DVT. Results: One patient was diagnosed as having PE/DVT and 10 had DVT alone. One patient suffered hemorrhagic shock during delivery; however, maternal or perinatal death and recurrence of symptomatic PE/DVT did not occur in any patient. Conclusion: Maternal or perinatal death and recurrence of symptomatic PE/DVT was not seen in women diagnosed as having PE/DVT during pregnancy and treated with anticoagulant therapy and IVCF.

Cardiac Magnetic Resonance Imaging of Very Late Intrapericardial Hematoma 8 Years after Coronary Artery Bypass Grafting.

A 55-year-old man presented with dyspnea, edema, and appetite loss. He had undergone coronary artery bypass grafting 8 years previously. He had jugular venous distention and Kussmaul's sign. Contrast-enhanced cardiac magnetic resonance imaging (CMRI) demonstrated an intrapericardial mass compressing the right ventricular (RV) cavity. T1- and T2-weighted black-blood images showed a mass with heterogeneous high signal intensity and a thick and dark rim. The mass was considered to be a chronic hematoma. After pericardiotomy with surgical removal of the hematoma, CMRI showed the marked improvement of the RV function. Late intrapericardial hematoma is rare and CMRI is useful for making a differential diagnosis.

A new mapping method to estimate exit sites of ventricular arrhythmias using intracardiac echocardiography and M-mode for catheter ablation.

BACKGROUND: Catheter ablation of premature ventricular complexes (PVCs) has been used as a curative therapy in many cases. Intracardiac ultrasound with a magnetic sensor probe has recently become available for catheter ablation. In this study, we assessed a new mapping method, contraction mapping, for determining the optimal ablation sites using intracardiac ultrasound and M-mode. This study sought to assess the accuracy of the new mapping method using intracardiac echocardiography. METHODS: Eighteen patients (10 males and eight females; mean age, 63±12 years) with 104 mapping points diagnosed as idiopathic PVCs were included in this study. At the mapping points, the time interval from the onset of the QRS to the onset of the contraction (QRS-c-time) and the local activation time were measured using M-mode with an intracardiac echo probe and using the conventional method. The correlation between the QRS-c-time and local activation time were studied. RESULTS: The QRS-c-time was significantly correlated with the local activation time (activation time=-66.8+0.882 * QRS-c-time, R2=0.728, p<0.0001). CONCLUSIONS: Contraction mapping could help determine the local activation time without the delivery of a catheter to the mapping points.

Prognosis of super-elderly healthy Japanese patients after pacemaker implantation for bradycardia.

BACKGROUND: The prognosis of super-elderly patients (age≥85 years) who undergo bradycardia pacemaker (PM) implantation remains unknown. METHODS: We retrospectively enrolled 868 patients (men 49.0%, 76.6±10.6 years) who could walk unassisted and whose expected life expectancy was more than 1 year, receiving their first bradycardia PM implantation between January 1, 2006, and June 30, 2013. Clinical outcomes were compared between super-elderly patients (n=201, mean age 88.6±3.2 years) and younger patients (n=667, 73.0±9.3 years). RESULTS: At the end of a median 1285-day follow-up, 128 patients (14.7%) died, of which 54 were cardiac deaths (42.2%). Mortality rates were similar between the groups (16.4% vs. 14.2%, log-rank p=0.56) and across different indications for implantation (atrio-ventricular conduction disturbance or sick sinus syndrome, p=0.59), initial rhythms (sinus rhythm or persistent atrial fibrillation, p=0.62), pacing modes (dual chamber pacing or VVI pacing, p=0.26), and ventricular lead positions (septum or apex, p=0.52). On Cox proportional hazard model analysis, hypertension [hazard ratio (HR)=1.74, 95% confidence interval (CI)=1.19-2.54, p=0.004], diabetes mellitus (HR=2.18, 95% CI=1.51-3.14, p<0.001), history of myocardial infarction (HR=3.59, 95% CI=2.49-5.16, p<0.001), and history of stroke (HR=2.26, 95% CI=1.51-3.37, p<0.001) were independent predictors for mortality. CONCLUSIONS: The mortality rate of super-elderly patients who had no critical illnesses and were healthy enough to walk unassisted at the time of PM implantation was not inferior to that of younger patients. Prognosis was determined by comorbidities, but not by age, PM indication, initial rhythm, pacing leads, or mode.