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The impact of rhythm outcomes on heart failure (HF) hospitalizations remains unknown after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). We sought to elucidate whether AF recurrence was associated with HF hospitalizations after AF RFCA. We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry), enrolling 5,010 consecutive patients (age 64 ± 10 years, 27.3% female, and 35.7% nonparoxysmal AF) who underwent an initial AF RFCA at 26 centers. The median follow-up duration was 2.9 years. The cumulative 3-year incidence of HF hospitalizations after the initial RFCA was 1.84% (0.69%/year). Hospitalized patients with HF were older with a higher prevalence of nonparoxysmal AF, renal dysfunction, diabetes, and underlying heart disease pre-RFCA. HF hospitalizations occurred more often in patients with than without recurrences (3.27 vs 0.84%, log-rank p0.0001). After adjusting for confounders using a Cox model, AF recurrence remained an independent predictor of HF hospitalizations (hazard ratio [HR] 2.84, 95% confidence interval [CI] 1.80 to 4.47, p0.0001). AF recurrence was a distinct HF hospitalization risk in patients with a left ventricular ejection fraction ≥50% (HR 4.54, 95% CI 2.38 to 8.65, p0.0001) but not50% (HR 1.31, 95% CI 0.65 to 2.62, p = 0.45), with significant interactions. Furthermore, patients with AF recurrences within 1 year had a greater HF hospitalization risk after 1 year (1.61% vs 0.79%, log-rank p = 0.019). In conclusion, AF recurrence after RFCA was independently associated with HF hospitalizations.

The Task Force on Rotational Atherectomy of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed the expert consensus document to summarize the techniques and evidences regarding rotational atherectomy (RA) in 2020. Because the revascularization strategy to severely calcified lesions is the hottest topic in contemporary percutaneous coronary intervention (PCI), many evidences related to RA have been published since 2020. Latest advancements have been incorporated in this updated expert consensus document.

Background Pulmonary vein (PV) reconnection is the main cause of atrial fibrillation (AF) recurrence. This study aimed to examine the effect of first‐pass PV isolation (PVI) on PV reconnection frequency during the procedure and on AF ablation outcomes. Methods This retrospective study included 446 patients with drug‐refractory AF (370 men, aged 64 ± 10 years) who underwent initial PVI using an open‐irrigated contact force catheter between January 2015 and October 2016. We investigated the effect of first‐pass PVI on PV reconnection during spontaneous PV reconnection and dormant conduction after an adenosine triphosphate challenge. Results First‐pass PVI was achieved in 69% (617/892) of ipsilateral PVs, of which we observed PV reconnection during the procedure in 134 (22%) PVs. This value was significantly lower than that observed in those without first‐pass PVI (50%, 138/275) (P, The 2‐year AF recurrence‐free rate was significantly higher in the first‐pass group than in the other group (75% vs. 59%, log‐rank P = 0.032). Absence of first‐pass PVI was associated with a higher frequency of spontaneous PV reconnection and dormant conduction and poor ablation outcomes. First‐pass isolation may be a useful marker for better PVI durability.

During removal of an entrapped guidewire, the core wire can fracture, allowing stretching of the spring wire while the distal guidewire is still entrapped. We resolved this issue with rotational atherectomy, allowing cutting of the spring wire at the intended site, regardless of the proximal spring wire fracture. (Level of Difficulty: Advanced.), Central Illustration

BACKGROUND The impact of chronic kidney disease (CKD) on long-term outcomes following acute myocardial infarction (AMI) in the era of modern primary PCI with optimal medical therapy is still in debate.Methods and Results:A total of 3,281 patients with AMI were enrolled in the J-MINUET registry, with primary PCI of 93.1% in STEMI. CKD stage on admission was classified into: no CKD (eGFR ≥60 mL/min/1.73 m2); moderate CKD (60>eGFR≥30 mL/min/1.73 m2); and severe CKD (eGFR

Background: Global longitudinal strain (GLS) can predict prognosis after myocardial infarction (MI). Tissue mitral annular displacement (TMAD) is another index of longitudinal left ventricular deformity, and is less dependent on image quality than GLS. We investigated the relationship between TMAD and GLS, and their ability to predict outcomes after MI. Methods and Results: GLS and TMAD were measured on echocardiograms 2 weeks after MI in 246 consecutive patients (median age 62 years, 85.7% male). TMAD was measured from apical 4- and 2-chamber views (TMAD4ch and TMAD2ch, respectively), and a mean value (TMADav) was calculated. TMAD4ch, TMAD2ch, and GLS were successfully measured in 240 (97.5%), 210 (85.3%) and 214 patients (87.0%), respectively. All TMAD parameters were significantly correlated with GLS (R=0.71-0.75) and left ventricular ejection fraction (LVEF; R=0.48-0.53). TMAD parameters were weakly correlated with peak creatine kinase (CK; R=0.20) and CK-MB (R=0.21-0.25). GLS and TMADav were significantly associated with LVEF after 6 months (R=0.48-0.53) and all-cause mortality during the follow-up period (median 1,242 days). TMADav discriminated patients with higher all-cause mortality when patients were divided into 3 groups, namely upper 25%, middle range, and lower 25% of TMADav (P=0.041, log-rank test). GLS detected high-risk patients using 15.0% as a cut-off value. Conclusions: TMAD could be a simple and reliable alternative to GLS for predicting outcomes in patients with MI.

Left atrial (LA) function can help predict various cardiovascular events. Catheter ablation for atrial fibrillation (AF) modifies baseline LA function through the maintenance of sinus rhythm and myocardial injury. We investigated the impact of post-ablation LA function on recurrence of AF after ablation and identified the predictors of reduced post-ablation LA function. A total of 616 patients who underwent AF ablation (paroxysmal, N = 310; non-paroxysmal, N = 306) were retrospectively examined with cardiac computed tomography at baseline and 3 months after the final ablation procedure. Post-ablation LA emptying fraction (LAEFpost) was calculated. We evaluated the association between LAEFpost and recurrence of AF after the final ablation procedure. Further, we assessed the predictors of reduced LAEFpost. The recurrence rate of AF was 72.7% after the final ablation procedure [median follow-up 48 months (48.0, 48.0), total number of ablation sessions: 1.4 ± 0.7]. Multivariate analysis revealed that LAEFpost was associated with the recurrence of AF (hazard ratio/10% increase: 0.62, 95% confidence interval: 0.51–0.75, P

Background It has been considered impossible to perform antegrade dissection and reentry (ADR) by simply puncturing with a guidewire using the intravascular ultrasound (IVUS) observation without the support of the Stingray system. Case summary A 78-year-old man suffered from effort angina pectoris due to a chronic total occlusion (CTO) lesion in the left circumflex coronary artery. A retry percutaneous coronary intervention for the CTO lesion was attempted at our hospital. The J-CTO score was 3. The first guidewire entered the subintimal space. We moved onto Stingray-ADR using the angiographic observation, but the guidewire could not be led into the true lumen. AnteOwl WR-IVUS (AO-IVUS) observation revealed a distal true lumen in which the inner lumen was maintained 5 mm beyond the CTO exit. We decided to perform the tip detection-ADR using the AO-IVUS observation. The tip detection method allowed the tip of the penetration wire to puncture the wall between the subintima and the true lumen in an exactly vertical direction, resulting in the successful creation of a reentry point. The CTO lesion was dilated with one drug-eluting stent, and normal antegrade blood flow was achieved. Discussion Since the tip detection method enables accurate punctures, it may allow for ADR by simply puncturing using a guidewire. Due to this method being performed using the IVUS observation, it is likely more reliable than Stingray-ADR using the angiographic observation.

Left ventricular (LV) reverse remodeling (LVRR) after catheter ablation of atrial fibrillation (AFCA) has not been fully described. This study investigated the predictors and clinical outcomes of LVRR after AFCA in patients with LV systolic dysfunction.Of 3319 consecutive patients who underwent first-time AFCA between January 2012 and October 2019, 376 with a baseline LV ejection fraction of50% were retrospectively evaluated. They were subjected to 256-slice multidetector computed tomography (MDCT) scanning at baseline and 3 months after AFCA. The LVRR was defined as a decrease in the LV end-systolic volume of ≥15%.The prevalence of LVRR was 83% (n = 306). Multivariate logistic regression analysis including age, body mass index, diabetic status, beta-blocker use, and LV diastolic diameter revealed that the predictors of LVRR were non-paroxysmal atrial fibrillation (AF) (odds ratio, 2.68; 95% confidence interval, 1.42-5.05; p = 0.002) and absence of apparent underlying structural heart disease (4.81; 2.31-10.0; p0.001). The prevalence of LVRR differed depending on AF recurrence pattern prior to the post-MDCT [no episode vs. paroxysmal episode (lasting7 days) vs. persistent episode (lasting ≥7 days), 84% vs. 81% vs. 63%, respectively, p = 0.023]. During a median follow-up of 32 months, the incidence of paroxysmal form of AF recurrence was similar, whereas persistent form of AF recurrence was less frequent in patients with LVRR (10.5% vs. 18.6%, p = 0.018). Heart failure hospitalizations (2.3% vs. 15.7%, p0.001), cardiovascular deaths (0.7% vs. 4.3%, p = 0.015), and all-cause deaths (1.3% vs. 5.7%, p = 0.018) were similarly less frequent in those with LVRR.LVRR after AFCA, which was predicted by non-paroxysmal AF without any apparent structural heart disease at baseline, was associated with persistent form of AF recurrence prior to the evaluation. LVRR was associated with favorable clinical outcomes.

Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2°P) is a contemporary risk scoring system for secondary prevention based on nine clinical factors. However, this scoring system has not been validated in other populations. The aim of this study was to validate the TRS2°P in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) in a nationwide registry cohort. Among 3283 consecutive patients with AMI enrolled in the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET), a total of 2611 patients who underwent primary PCI were included in this study. The performance of the TRS2°P to predict major adverse cardiovascular events (MACE) composed of all-cause death, non-fatal MI, and non-fatal stroke up to 3 years in the present cohort was evaluated. The TRS2°P had modest discriminative performance in this J-MINUET cohort with a c-statistic of 0.63, similar to that in the derived cohort (TRA2°P-TIMI50, c-statistic 0.67). A strong graded relationship between the TRS2°P and 3-year cardiovascular event rates was also observed in the J-MINUET cohort. Age ≥ 75 years, Killip ≥ 2, prior stroke, peripheral artery disease, anemia, and non-ST-elevation myocardial infarction were identified as independent factors for the incidence of MACE. The TRS2°P modestly predicted secondary cardiovascular events among patients with AMI treated by primary PCI in a nationwide cohort of Japan. Further studies are needed to develop a novel risk score better predicting secondary cardiovascular events.

Although gender difference in long-term outcomes after acute myocardial infarction have been shown previously, impact of age on gender difference is still controversial. This study focused on the association between age and gender difference in long-term outcome. We analyzed data from 3,283 consecutive patients who were included in a prospective, nationwide, multicenter registry (Japan Registry of Acute Myocardial Infarction Diagnosed by Universal Definition) from 2012 to 2014. The primary end point was the major adverse cardiovascular event (MACE), which was defined as a composite of death, myocardial infarction, stroke, heart failure, and revascularization for unstable angina during 3 years. Patients were divided into 4 strata according to age: those with age65 years (group 1: n = 1161), 65 to 74 years (group 2: n = 954), 75 to 84 years (group 3: n = 866) and 84years (group 4: n = 302). Although the crude incidence of 3-year MACE was significantly higher in women than men (36.4% vs. 28.5%, p0.001), there was not significant gender difference in each group (group 1, 19.6% vs 19.0%, p = 0.74; group 2, 33.1% vs 28.3%, p = 0.25; group 3, 38.9% vs 39.6%, p = 0.54; and group 4, 54.0% vs 56.8%, p = 0.24). In conclusion, although women had higher crude incidence of 3-year MACE than men, there was no gender difference in each group.

BACKGROUND Whether all atrial fibrillation (AF) patients should be evaluated for sleep apnea before catheter ablation (CA) remains controversial. Watch-type peripheral arterial tonometry (W-PAT) is a home sleep testing device and an easier tool for diagnosing sleep apnea than polysomnography. We investigated the prevalence and predictors of sleep apnea using W-PAT in unscreened sleep apnea patients with AF before CA.Methods and Results:The study was conducted under a retrospective, single-center, observational design. We included 776 consecutive patients who underwent both W-PAT and AF ablation. Sleep apnea assessments were successfully performed in 774 patients (99.7%; age 65±11 years, 73.3% male; body mass index [BMI] 24.1±3.5, 56.8% paroxysmal AF). The mean apnea-hypopnea index (AHI) was 20.1±15.6. Although 81.7% of the patients had normal Epworth sleepiness scores (mean 6.5), only 88 (11.4%) had a normal AHI (AHI

Background The prevalence of acute myocardial infarction (AMI) in elderly people is increasing worldwide. However, their characteristics and prognosis have been rarely investigated. This study aimed to investigate the characteristics and prognosis in elderly patients with cardiac troponin-positive AMI. Methods Consecutive patients with AMI from the J-MINUET study were divided into the following 3 groups: patients aged less than 65 years, those aged between 65 and 79 years, and those aged 80 years or over. Their characteristics and in-hospital outcomes were compared. Results Patients with AMI aged 80 years or over had the highest incidence of female gender, and the highest incidence of hypertension, chronic kidney disease, and cardiovascular disease, such as peripheral artery disease, atrial fibrillation, and stroke, whereas they had the lowest body mass index, and the lowest incidence of current smoker, diabetes mellitus, and dyslipidemia. Patients with AMI aged 80 years or over had significantly longer onset to door time and longer door to device time, and lower peak creatine kinase (CK). The incidence of ST-segment elevation myocardial infarction (STEMI) was the lowest in the AMI patients aged 80 years or over, but the patients had a higher incidence of in-hospital death and cardiac failure than the other two groups. In addition, the presentation with STEMI and non-ST-segment elevation myocardial infarction with CK elevation among patients aged 80 years or over showed the highest incidence of in-hospital death and cardiac failure. Conclusions J-MINUET showed different clinical characteristics between the aged and younger populations. The incidence of in-hospital death and cardiac failure in patients aged 80 years or over with AMI was poorer than their younger counterparts.

Beta-blockers are associated with several clinical benefits in patients with reduced left ventricular ejection fraction (REF) after acute myocardial infarction (AMI), such as lower rates of mortality, recurrence of myocardial infarction, and heart failure. However, the long-term prognosis of beta-blockers has rarely been investigated in patients with non-REF after AMI. This study aimed to investigate the clinical benefits of beta-blockers in these patients.A total of 3281 consecutive patients who were hospitalized within 48 h after AMI were registered in the J-MINUET study. Patients who underwent primary percutaneous coronary intervention (PCI) and had a left ventricular ejection fraction ≥40 % were enrolled, and patients who died during admission were excluded. Included patients were divided into two groups according to the prescription of beta-blockers at discharge. Their characteristics and clinical outcomes were compared.The number of AMI patients treated with beta-blockers was 1353 (70.4 %). Patients who received beta-blockers were younger and had a higher incidence of hypertension, dyslipidemia, and ST-segment elevation myocardial infarction than those who did not receive beta-blockers. The peak creatine kinase level after primary PCI was significantly higher in patients who received beta-blockers. These patients also had a lower incidence of a composite of all-cause death, myocardial infarction, and stroke compared to those that did not receive beta-blockers (7.3 % vs. 11.9 %, p = 0.001). Multivariate analysis showed that beta-blocker use was an independent factor for better clinical outcomes.The J-MINUET study revealed the clinical benefit of beta-blockers in AMI patients with non-REF after primary PCI.

An 84-year-old man was admitted to the authors’ hospital for the treatment of intermittent claudication. Angiography revealed an exophytic calcified nodules in the distal superficial femoral artery. Angioscopy also revealed abundant exophytic atherosclerotic calcification. Histology confirmed the diagnosis. (Level of Difficulty: Beginner.), Graphical abstract

Rotational atherectomy (RA) has been widely used for percutaneous coronary intervention (PCI) to severely calcified lesions. As compared to other countries, RA in Japan has uniquely developed with the aid of greater usage of intravascular imaging devices such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT). IVUS has been used to understand the guidewire bias and to decide appropriate burr sizes during RA, whereas OCT can also provide the thickness of calcification. Owing to such abundant experiences, Japanese RA operators modified RA techniques and reported unique evidences regarding RA. The Task Force on Rotational Atherectomy of the J apanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document to summarize the contemporary techniques and evidences regarding RA.

AimThe impact of sex differences on the clinical outcomes of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is controversial. We investigated the sex differences regarding the efficacy and clinical outcomes of RFCA of AF.Methods and resultsWe conducted a large-scale, prospective, multicentre, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centres (64 ± 10 years; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years. Female patients (n = 1369, 27.3%) were older (female vs. male, 68 ± 9 vs. 63 ± 11 years, P ConclusionsFemales experienced more frequent AF recurrences probably due to non-PV arrhythmogenicity and de novo pacemaker implantations than males during the long-term follow-up after RFCA of AF.

The newer chronic total occlusion–specific intravascular ultrasound AnteOwl WR-based 3-dimensional wiring technique using the tip detection method allowed us easily to succeed in treating chronic total occlusion lesions that were previously unsuccessfully treated using Navifocus WR intravascular ultrasound. (Level of Difficulty: Advanced.), Graphical abstract, The newer chronic total occlusion–specific intravascular ultrasound AnteOwl WR-based 3-dimensional wiring technique using the tip detection method allowed…

Background Left atrial (LA) size is an established predictor of recurrence after catheter ablation for paroxysmal atrial fibrillation (PAF). We investigated the impact of baseline LA function on recurrence after PAF ablation and compared the predictive values of LA function with those of LA size. Methods We retrospectively investigated 292 consecutive patients who underwent PAF ablation (median follow-up: 3.0 years). All patients had their preoperative LA volume (LAV) assessed using cardiac computed tomography under sinus rhythm. We used LA emptying fraction (LAEF) as an indicator of LA function and assessed the association between baseline LAEF and recurrence after initial ablation using a multivariate Cox hazard model. Then, we performed receiver operating characteristic analysis for predicting recurrence after single and multiple procedures and compared the c-statistics of LAEF and indexed maximum and minimum LAV (LAVImax and LAVImin) Results In a multivariate Cox hazard model, LAEF was strongly associated with recurrence after a single procedure [hazard ratio (HR): 0.968, 95% confidence interval (CI): 0.951–0.985, p Conclusions LAEF was associated with recurrence after PAF ablation. LA function is a more useful predictor than LA size.

Discordant results have been reported on outcomes of acute myocardial infarction (AMI) patients who present during off-hours.We investigated 3283 consecutive patients with AMI who were selected from the prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation (defined as weekends, holidays, and weekdays from 8:01 PM to 7:59 AM) at hospitals on long-term clinical outcomes. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina for up to 3 years from the index event.During off-hours, 52% of patients presented. Primary percutaneous coronary intervention was performed in 85% of patients, and the door-to-balloon time was comparable between off-hours and regular hours (74, interquartile range [IQR] 52 to 113 versus 75, IQR 52 to 126 minutes, P = 0.34). Rate of overall primary endpoint overall did not overall significantly differ (25.3% versus 23.5%, log-rank P = 0.26), in patients with ST-elevation myocardial infarction (STEMI) (log-rank P = 0.93) and in patients with non-ST-elevation myocardial infarction (NSTEMI) (log-rank P = 0.14). Multivariate Cox regression analysis showed that off-hours presentation was not significantly associated with long-term clinical events in all cohorts.The impact of presentation during off-hours or regular hours on the long-term clinical outcomes of Japanese patients with AMI is comparable in contemporary practice.

Objectives The study assessed the efficacy of the tip detection method during intravascular ultrasound (IVUS)–based 3-dimensional (3D) wiring with a new chronic total occlusion (CTO)–specific IVUS system (AnteOwl IVUS [AO-IVUS]) for CTO percutaneous coronary intervention (PCI). Background The study developed angiography-based 3D wiring for CTO-PCI. Previously, the authors produced a short-tip CTO-specific IVUS system (Navifocus WR IVUS [Navi-IVUS]), which has been upgraded into the AO-IVUS system by adding a pullback transducer system for IVUS-based 3D wiring. Methods A CTO lesion 20 mm in length composed of 2.5% agar was experimentally inserted into the coronary artery of a beating heart model. The target (a microcatheter with a 0.6-mm lumen) was placed in the distal part of the CTO lesion. IVUS-guided wiring was performed to insert the guidewire into the target using the Navi-IVUS and then using the AO-IVUS 8 times each. In wiring with AO-IVUS, the IVUS-based 3D wiring using the tip detection method was performed. The crossing time and the number of punctures to the target were calculated. Results The crossing time was significantly shortened and the number of punctures was significantly reduced in AO-IVUS–based wiring compared with Navi-IVUS–based wiring (median crossing time 80.5 [interquartile range: 44.0 to 112.3] s vs. 333.0 [interquartile range: 88.8 to 790.0] s; p = 0.036; median 1.0 [interquartile range: 1.0 to 2.0] puncture vs. 24.0 [interquartile range: 5.8 to 52.5] punctures; p = 0.001). Conclusions The tip detection method enables the authors to easily perform the IVUS-based 3D wiring, and the new CTO IVUS system will facilitate this method in clinical practice.

We carried out a randomized controlled trial using ipragliflozin. We analyzed changes in diastolic function using echocardiography in patients with type 2 diabetes and heart failure with preserved ejection fraction.We carried out an open-label, multicenter, randomized, two-arm interventional trial. A total of eligible 68 participants were randomly assigned into two groups (ipragliflozin group n = 36; conventional treatment group n = 32). Primary end-points were the change in E/e' and e'. Secondary end-points were other parameters of echocardiography, plasma NT-proBNP level, New York Heart Association class, hemoglobin A1c and blood pressure.After 24 weeks of follow up, E/e' decreased in both groups (ipragliflozin: 11.0 vs 10.4; conventional treatment 10.5 vs 10.1; multivariate-adjusted P = 0.95). There were no significant differences in the amount of change in E/e', e', echocardiography parameters, plasma NT-proBNP level, New York Heart Association class, hemoglobin A1c and blood pressure between the two groups. In the subgroup analysis, ipragliflozin treatment decreased in left ventricular mass index in patients aged ≥70 years and also decreased in NT-proBNP levels in patients with baseline NT-proBNP ≥400 pg/mL.In this randomized controlled study carried out in patients with type 2 diabetes and heart failure with preserved ejection fraction, 24-week ipragliflozin treatment did not improve left ventricular diastolic function compared with conventional treatment. As the subgroup, ipragliflozin treatment decreased in left ventricular mass index in participants aged ≥70 years. Geriatr Gerontol Int 2022; 22: 298-304.

Coronary perforations during chronic total occlusion percutaneous coronary intervention (CTO-PCI) are potential complications and reportedly associated with adverse events. This study aimed to describe the clinical characteristics and timing of perforations during CTO-PCI. Data from the Japanese CTO-PCI expert registry included 8,760 patients who underwent CTO-PCI between January 2014 and January 2019. The major adverse cardiac and cerebrovascular events were defined as death, tamponade, myocardial infarction, stent thrombosis, stroke, and revascularization. The guidewire manipulation time was defined as the time required to cross the CTO without perforation. Among these patients, 333 (3.8%) developed perforation during the CTO crossing attempt. Of the 333 patients, 29 developed cardiac tamponades (8.7%). Perforations more frequently occurred in a retrograde wiring than in an anterograde wiring (6.6% vs 1.7%, p0.0001). A longer guidewire manipulation time was associated with the occurrence of perforation (median 101 minutes [interquartile range 59 to 150 minutes] in the perforation group vs 54.9 minutes [interquartile range 21.1 to 112.7 minutes] in the nonperforation group, p0.0001). Risk factors for perforation were age, history of coronary bypass graft, right coronary artery lesion, de novo lesion, use of a stiff guidewire, and guidewire manipulation time of60 minutes during anterograde wiring and age, non-left anterior descending artery lesion, use of a polymer-jacketed guidewire, and use of epicardial channel during retrograde wiring. In conclusion, risk factors for perforation were different between anterograde and retrograde wirings. A prolonged guidewire manipulation time was associated with the occurrence of perforation, especially during anterograde wiring.

It is known that incidence and short-term mortality rate of acute myocardial infarction (AMI) tend to be higher in the cold season. The aim of our study was to investigate the association of onset-season with patient characteristics and long-term prognosis of AMI. This was a prospective, multicenter, Japanese investigation of 3,283 patients with AMI who were hospitalized within 48 h of symptom onset between July 2012 and March 2014. Patients were divided into 3 seasonal groups according to admission date: cold season group (December–March), hot season group (June–September), and moderate season group (April, May, October, and November). We identified 1356 patients (41.3%) admitted during the cold season, 901 (27.4%) during the hot season, and 1026 (31.3%) during the moderate season. We investigated the seasonal effect on patient characteristics and clinical outcomes. Baseline characteristics of each seasonal group were comparable, with the exception of age, Killip class, and conduction disturbances. The rates of higher Killip class and complete atrioventricular block were significantly higher in the cold season group. The 3-year cumulative survival free from major adverse cardiac events (MACE) rate was the lowest in the cold season (67.1%), showing a significant difference, followed by the moderate (70.0%) and hot seasons (72.9%) (p

Beta-blockers are standard therapy for acute myocardial infarction (AMI). However, despite current advances in the management of AMI, it remains unclear whether all AMI patients benefit from β-blockers. We investigated whether admission heart rate (HR) is a determinant of the effectiveness of β-blockers for AMI patients. Methods and Results: We enrolled 3,283 consecutive AMI patients who were admitted to 28 participating institutions in the Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) study. According to admission HR, we divided patients into 3 groups: bradycardia (HR60 beats/min, n=444), normocardia (HR 60 to ≤100 beats/min, n=2,013), and tachycardia (HR100 beats/min, n=342). The primary endpoint was major adverse cardiac events (MACE), including all-cause death, non-fatal MI, non-fatal stroke, heart failure (HF), and urgent revascularization for unstable angina, at 3-year follow-up. Beta-blocker at discharge was significantly associated with a lower risk of MACE in the tachycardia group (23.6% vs. 33.0%; P=0.033), but it did not affect rates of MACE in the normocardia group (17.8% vs. 18.4%; P=0.681). In the bradycardia group, β-blocker use at discharge was significantly associated with a higher risk of MACE (21.6% vs. 12.7%; P=0.026). Results were consistent for multivariable regression and stepwise multivariable regression.Admission HR might determine the efficacy of β-blockers for current AMI patients.

Objectives This study sought to compare the procedural outcomes of percutaneous coronary intervention for chronic total occlusion between the periods before and after introduction of 3-dimensional (3D) wiring. Background Previously, we reported a 3D wiring method by which the operator can construct real-time mental 3D images from 2 perpendicular angles of X-ray system monitor during percutaneous coronary intervention for chronic total occlusion. Methods A total of 137 chronic total occlusion lesions that could not be passed by tapered soft wires in our hospital between 2012 and 2017 were retrospectively enrolled in the study. Results Overall success rate was significantly higher in the 3D wiring group (n = 69) than the non-3D wiring group (n = 68) (98% vs. 90%, respectively; p = 0.027). In the primary antegrade cases, the first antegrade approach time was significantly shorter in the 3D wiring group than the non-3D wiring group (42 ± 29 vs. 30 ± 16 min, respectively; p = 0.01). In cases where the antegrade approach was continued throughout the procedure, the success rate was significantly higher in the 3D wiring group than the non-3D wiring group (100% vs. 89.2%, respectively; p = 0.033). Vessel perforation by the antegrade wire tended to be lower in the 3D wiring group than the non-3D wiring group (1% vs. 11%, respectively; p = 0.055). Conclusions 3D wiring enables accurate guidewire control, which improves the success rate of antegrade wiring and reduces the antegrade procedure time, resulting in improvement of the overall success rate.

BACKGROUND Automated ablation lesion annotation with optimal settings for parameters including contact force (CF) and catheter stability may be effective for achieving durable pulmonary vein isolation. Methods and Results: We retrospectively examined 131 consecutive patients who underwent initial catheter ablation (CA) for paroxysmal atrial fibrillation (PAF) by automatic annotation system (VISITAG module)-guided radiofrequency CA (RFCA) (n=61) and 2nd-generation cryoballoon ablation (CBA) (n=70) in terms of safety and long-term efficacy. The automatic annotation criteria for the RFCA group were as follows: catheter stability range of motion ≤1.5 mm, duration ≥5 s, and CF ≥5 g. We ablated for >20 s with a force-time integral >150 gs at each site, before moving to the next site. Each interlesion distance was

Long-term clinical outcomes among patients with cardiogenic shock (CS) and heart failure (HF) who survive the early phase of acute myocardial infarction (AMI) remain uncertain. We investigated 3283 consecutive patients with AMI, selected from a prospective, nation-wide multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014. The 3263 eligible patients were divided into the following three groups: CS-/HF- group (n = 2467, 75.6%); CS-/HF+ group (n = 479, 14.7%); and CS+ group (n = 317, 9.7%). The thirty-day mortality rate in CS+ patients was 32.8%, significantly higher than in CS- patients. Among CS+ patients, multivariate logistic regression analysis identified statin use before admission (Odds ratio (OR) 0.32, 95% confidence interval (CI) 0.14-0.66, P = 0.002), renal deficiency (OR 8.72, 95%CI 2.81-38.67, P0.0001) and final thrombolysis in myocardial infarction flow grade (OR 0.42, 95%CI 0.18-0.99, P = 0.046) were associated with 30-day mortality. Landmark Kaplan-Meier analysis showed that mortality rates after 30 days were comparable between CS+ and CS-/HF+ groups but were lower in the CS-/HF- group. Multivariate Cox hazard analysis also showed that hazard risk of mortality after 30 days was comparable between the CS+ and CS-/HF+ groups (Hazard ratio (HR) 1.03, 95%CI 0.63-1.68, P = 0.90), and significantly lower in the CS-/HF- group (HR 0.44, 95%CI 0.32-059, P0.0001). In conclusion, AMI patients with CS who survived 30 days experienced worse long-term outcomes compared with those without CS up to 3 years. Attention is required for patients who show HF on admission without CS to improve long-term AMI outcomes.

Red cell distribution width (RDW) is reportedly associated with cardiovascular events, including atrial fibrillation (AF). We investigated whether the RDW values were associated with the outcomes of catheter ablation for AF. This retrospective multicenter study included 501 patients with AF (239 paroxysmal AF cases, 196 persistent AF cases, and 66 long-standing persistent AF cases) who underwent initial AF ablation between March 2017 and May 2018. The RDW values were evaluated before and at 1–3 months after the procedure. The patients were stratified based on the recurrence of AF within 1 year after the index procedure with a blanking period of 3 months into recurrence group (107 patients, 21.4%) and no-recurrence group (394 patients, 78.6%). There were no significant differences in preoperative RDW values between the groups (p = 0.37). The RDW value did not change significantly after the ablation in the recurrence group (13.55–13.60%, p = 0.37), although it decreased significantly in the no-recurrence group (13.64–13.37%, p

Background: Lethal arrhythmias including ventricular tachycardia and fibrillation (VT/VF) are common complications of acute myocardial infarction (AMI). Predictors of in-hospital VT/VF after AMI, however, have not been thoroughly investigated. In this study, we sought to elucidate the predictors of in-hospital VT/VF events after AMI in the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). Methods and Results: In-hospital VT/VF was defined as a hemodynamically unstable VT or VF in the first week of hospitalization, on which the patients were classified as the VT/VF group. Of the patients in the J-MINUET study, 3,175 were finally enrolled in this study. A total of 114 patients had VT/VF. On multivariate logistic analysis, maximum creatine kinase >3,000 IU/L (adjusted OR, 1.67; 95% CI: 1.085–2.572; P=0.02), Killip class III or IV (adjusted OR, 8.93; 95% CI: 5.668–14.082; P

Aims The HFA‐PEFF score is a part of the stepwise diagnostic algorithm of heart failure with preserved ejection fraction (HFpEF). We aimed to evaluate the prognostic significance of the HFA‐PEFF score on the clinical outcomes in patients with HFpEF. Methods and results The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with preserved Ejection Fraction (PURSUIT‐HFpEF) study is a prospective, multicentre, observational study in which collaborating hospitals in Osaka record clinical, echocardiographic, and outcome data of patients with acute decompensated heart failure with preserved left ventricular ejection fraction (≥50%) [UMIN‐CTR ID: UMIN000021831]. Acute decompensated heart failure was diagnosed on the basis of the following criteria: (i) clinical symptoms and signs according to the Framingham Heart Study criteria; and (ii) serum N‐terminal pro‐B‐type natriuretic peptide level of ≥400 pg/mL or brain natriuretic peptide level of ≥100 pg/mL. The HFA‐PEFF score has functional, morphological, and biomarker domains. We evaluated the prognostic significance of the HFA‐PEFF score (calculated based on the data at hospital discharge) on post‐discharge clinical outcomes in this cohort. The primary endpoint of the present study was a composite of all‐cause death and heart failure readmission. Between June 2016 and December 2019, 871 patients were enrolled from 26 hospitals (mean follow‐up duration 399 ± 349 days). A total of 804 patients were finally analysed after excluding patients with scores of 0 (N = 5) and 1 (N = 15) from 824 patients with available HFA‐PEFF score based on the echocardiographic and laboratory data at discharge. According to the laboratory and echocardiographic data at the time of discharge, 487 patients (59.1%) were diagnosed as HFpEF (HFA‐PEFF score ≥ 5) while 317 patients (38.5%) had intermediate score. Kaplan–Meier analysis divided by the HFA‐PEFF score [low, score 2–5 (N = 494) vs. high, score 6 (N = 310)] indicated that the HFA‐PEFF score successfully stratified the patients for the primary endpoint (log‐rank test P

Funding Acknowledgements Type of funding sources: None. Background Quantification of left ventricular (LV) dyssynchrony is of great interest for resynchronization therapy (CRT). Recently, cardiac computed tomography (CCT) is feasible for evaluation of dyssynchrony. Our aim was to assess a novel simplified approach using CCT to quantify LV dyssynchrony. Methods We studied 346 consecutive patients with a wide range of QRS width and ejection fractions (EF). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT (Brilliance 256 iCT, Philips Medical Systems) was performed before CRT. After CCT scan, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and a time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software "Myocardial Contraction Map" (Argus, Inc Ehime, Japan). The standard deviation of all segments modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT. Results %SD was feasible in all patients, respectably. %SD was significantly different between the different QRS duration groups; narrow QRS (150 ms): 14 ± 7% (p Conclusion This novel simplified approach by CCT can quantify dyssynchrony in different QRS duration and morphology groups. This method has promise for clinical applications to the evaluation of patients for CRT. Abstract Figure.

Background: Heart failure (HF) is the leading cause of death in patients with atrial fibrillation (AF). Radiofrequency catheter ablation (RFCA) of AF is effective for maintaining sinus rhythm though its impact on heart failure still remains controversial. Purpose: We sought to elucidate whether AF recurrence following RFCA was associated with subsequent HF hospitalizations. Methods: We conducted a large-scale, prospective, multicenter, observational study. A total of 4931 consecutive patients who underwent an initial RFCA for AF with longer than 1-year of follow-up in 26 centers were enrolled (average age, 64±10 years; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years. The primary endpoint was an HF hospitalization more than 1-year after the index RFCA. We compared the patients without AF recurrences (group A) to those with AF recurrences within 1-year post RFCA (group B). Results: The 1-year cumulative incidence of AF recurrences after a single procedure was 30.7% (group A=3418, group B=1513 patients). Group B had a lower body mass index (group A vs. group B,24.1±3.6 vs. 23.8±3.4 kg/m 2 , p=0.014), longer history of AF (1.9 vs. 3.1 years, p Conclusions: Among AF patients receiving RFCA, those with AF recurrences were at a greater risk of subsequent heart failure hospitalizations than those without AF recurrences. Recognition that AF recurrence following RFCA is a risk factor for a subsequent HF-related hospitalization is appropriate in clinical practice.

Introduction: Diabetes is observed in about third of patients with heart failure with preserved ejection fraction (HFpEF), and it is not well elucidated how it would affect the clinical conditions of HFpEF. We investigated the physical and echocardiographic characteristics of diabetes patients in a large-scale, registration study of HFpEF. Methods: We analyzed clinical and echocardiography data obtained at admission and just before hospital discharge in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction), which is a multicenter registration study of patients who were hospitalized for HFpEF. Results: We enrolled 862 patients who were hospitalized for HFpEF between June, 2016 and December, 2019 (Age 81±9 years, male gender 44.5%) for the present study. Diabetes was observed in 287 patients (33.3%), and their age was higher (82±8 years vs. 80±9 years, p=0.003) and body mass index before discharge was larger (23.2±4.7 kg/m2 vs. 21.1±4.6 kg/m2, p Conclusions: The present study implied that diabetic patients with HFpEF have more fluid retention before hospitalization than non-diabetic ones, which could affect the changes in diastolic pressure.

Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2°P) is a contemporary risk scoring system for secondary prevention based on nine clinical factors. However, this scoring system has not been validated in other populations. The aim of this study was to validate the TRS2°P in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) in a nationwide registry cohort. Among 3283 consecutive patients with AMI enrolled in the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET), a total of 2611 patients who underwent primary PCI were included in this study. The performance of the TRS2°P to predict major adverse cardiovascular events (MACE) composed of all-cause death, non-fatal MI, and non-fatal stroke up to 3 years in the present cohort was evaluated. The TRS2°P had modest discriminative performance in this J-MINUET cohort with a c-statistic of 0.63, similar to that in the derived cohort (TRA2°P-TIMI50, c-statistic 0.67). A strong graded relationship between the TRS2°P and 3-year cardiovascular event rates was also observed in the J-MINUET cohort. Age ≥ 75 years, Killip ≥ 2, prior stroke, peripheral artery disease, anemia, and non-ST-elevation myocardial infarction were identified as independent factors for the incidence of MACE. The TRS2°P modestly predicted secondary cardiovascular events among patients with AMI treated by primary PCI in a nationwide cohort of Japan. Further studies are needed to develop a novel risk score better predicting secondary cardiovascular events.

Catheter ablation (CA) of atrial fibrillation (AF) improves cardiac function, resulting in a decrease in plasma brain natriuretic peptide (BNP) levels in patients with reduced left ventricular ejection fraction (LVEF). This study sought to examine the pre-procedural and post-procedural correlations between BNP levels and cardiac function and the associations between the BNP levels and recurrence after CA in patients with AF and reduced LVEF. Of 3142 consecutive patients who underwent first-time CA of AF at our institute, a total of 217 patients with LVEF50% were enrolled. Significant decrease in BNP levels (from a median of 198 [interquartile range 113 to 355] to 47.7 [22.7 to 135] pg/ml, p0.001) and improvement in LVEF (from 39±9% to 61±16%, p0.001) were observed 3 months after CA. There was a linear correlation between log-transformed BNP levels and cardiac measures (LVEF: r = -0.64; LV end-diastolic volume: r = 0.25; LV end-systolic volume: r = 0.43; left atrial volume: r = 0.52; all p0.001). During a median follow-up of 35 months, AF recurrence after a 3-month blanking period was observed in 80 patients (37%). Cox proportional hazard regression analysis after adjustment for cardiac measures significant in univariate analysis revealed that early recurrence within the blanking period (hazard ratio, 4.88; 95% confidence interval, 2.89 to 8.25) and elevated post-procedural BNP levels (2.02 per unit log increase; 1.14 to 3.56) were significant predictors of AF recurrence, but pre-procedural BNP was not. In conclusion, post-procedural BNP levels at the end of the blanking period predicted subsequent AF recurrence in patients with reduced LVEF, independent of early recurrence.

Background: Early recurrence of atrial tachyarrhythmia (ERAT) during a 90-day blanking period (BP) often occurs after atrial fibrillation (AF) ablation. Left atrial reverse remodeling (LARR), which is the reduction in LA volume (LAV), also occurs during the BP. Both ERAT and LARR are associated with late recurrence (LR, greater than 90 days after ablation). We investigated the association between ERAT and LARR following non-paroxysmal AF (NPAF) ablation. Methods: We retrospectively reviewed 330 consecutive patients undergoing initial NPAF ablation (median follow-up: 4.0 years). Based on the timing of the final ERAT, we divided the patients into No-ERAT (N = 154, without ERAT), Early (N = 39, 0–7 days after ablation), Intermediate (N = 67, 8–30), and Late-ERAT (N = 70, 31–90) groups. We assessed the extent of LARR, defined as the percentage of decrease in LAV (%ΔLAV). The %ΔLAV cutoff value was determined by receiver operating characteristic analysis, and incorporated into a multivariate analysis to assess the association between ERAT and LARR. Results: Late-ERAT was associated with LR (hazard ratio: 6.31, 95% confidence interval (CI): 4.21–9.47, p = 0.0001). The %ΔLAV in the Late-ERAT group was significantly smaller than the other groups (p