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Background and Objective: Ectopic beats originating from the pulmonary vein (PV) trigger atrial fibrillation (AF). The purpose of this study was to clarify the electrophysiological determinant of AF initiation from the PVs. Methods: Pacing studies were performed with a single extra stimulus mimicking an ectopic beat in the left superior pulmonary veins (LSPVs) in 62 patients undergoing AF ablation. Inducibility of AF, effective refractory period (ERP) and conduction properties within the PVs were analyzed. Results: A single extra stimulus in LSPV induced AF in 20 patients (32% of all patients) at the mean coupling interval (CI) of 172 ms. A CI-dependent anisotropic conduction at the AF onset was visualized in a 3D-mapping. Onset of AF was site-specific with reproducibility in each individual. Mean ERP in LSPV in the AF inducible group was shorter than that in the AF non-inducible group (182 ± 55 ms vs 254 ± 51 ms, P

Background Catheter ablation for atrial fibrillation is an effective treatment; however, periesophageal vagal nerve injury is not rare and sometimes results in acute gastroparesis (AGP) after atrial fibrillation ablation (AFA). We sought to investigate the incidence and risk factors of AGP via preprocedural computed tomography (CT) analysis. Methods We retrospectively reviewed 422 patients who underwent index AFA at our center. Using contrast‐enhanced CT performed before ablation, the anatomical characteristics of the esophagus were compared between patients with and without post‐ablation AGP. AGP was diagnosed by the presence of symptoms, fasting abdominal X‐ray radiography as a screening test, and additional abdominal imaging. Results Of the 422 patients (age, 67 ± 11 years; male, 68.5%; cryoballoon, 63.7%), AGP developed in 14 (3.3%) patients, and six of 14 patients were asymptomatic. AGP resolved in all patients within 4 weeks without invasive treatment. In the AGP group, the esophagus was frequently located on the vertebra (middle‐positioned esophagus) (AGP vs non‐AGP, 42.9% vs 11.5%; P = .01), and additional posterior wall ablation was frequently performed (50.0% vs 14.5%; P = .02). In the multivariate analysis, middle‐positioned esophagus (P = .02; odds ratio, 9.0; 95% confidence interval [CI], 1.5‐53.3) and additional posterior wall ablation (P = .01; odds ratio, 7.6; 95% CI, 1.5‐42.1) were independent predictors of AGP. Conclusions Anatomical evaluation of the esophagus using CT may be simple and useful for predicting AGP after AFA. High‐risk patients who have middle‐positioned esophagus or who underwent excessive posterior wall ablation should be followed up closely., This study revealed that 3.3% of patients following index atrial fibrillation ablation had acute gastroparesis (AGP) using rigorous screening tests after ablation. Middle‐positioned esophagus and posterior wall ablation were risk factors of AGP.

Background The low voltage zone (LVZ) detected with three‐dimensional electroanatomical mapping is a surrogate marker of atrial scar in patients with persistent atrial fibrillation (PeAF) and is associated with poor clinical outcomes after catheter ablation. However, fewer studies have reported the relationship between responsiveness to antiarrhythmic drugs and the LVZ. Methods We retrospectively analyzed 76 patients who underwent catheter ablation for PeAF at our center. Rhythm control with bepridil was initiated before ablation in all patients, and electrical cardioversion was performed in cases of failure to restore sinus rhythm with bepridil alone. Patients with successful sinus restoration with bepridil alone (≤200 mg/d) were defined as “responders”, while those who required electrical cardioversion as well were defined as “non‐responders”. We compared the LVZ ratio (ratio of the LVZ surface area to the left atrium surface area on three‐dimensional electroanatomical mapping) and the recurrence‐free rate after ablation between the two groups. Results Of the 76 patients, 48 (63.2%) were responders to bepridil. The median LVZ ratio was significantly lower in the responder group than in the nonresponder group (7.5% vs 14.0%, P = .009). Multivariate analysis revealed that response to bepridil was an independent predictor of normal voltage (P = .02, odds ratio = 0.20, 95% confidence interval = 0.04‐0.76). The recurrence‐free rate at 1 year after catheter ablation was significantly higher in the responder group than in the nonresponder group (87.1% vs 62.3%, P = .03). Conclusions Response to bepridil is a marker of normal voltage in electroanatomical mapping and is significantly associated with better clinical outcomes after catheter ablation., Response to bepridil hydrochloride in patients with persistent atrial fibrillation is associated with normal voltage in the three‐dimensional electroanatomical mapping and better clinical outcome after catheter ablation.

Background Atrial fibrillation (AF) is a common arrhythmia in patients with hypertrophic cardiomyopathy (HCM) and can deteriorate haemodynamic status. Case summary We report a case of a 77-year-old woman with cardiogenic shock due to paroxysmal AF, complicated with HCM and aortic stenosis. Atrial fibrillation was successfully managed with temporary atrial pacing and administration of nifekalant hydrochloride without invasive mechanical circulatory support until surgery. Septal myectomy, aortic valve replacement, and pulmonary vein isolation were performed. Discussion This case suggests that atrial pacing and nifekalant may be safe and effective for rhythm control.

In the majority of cases presenting with the Mahaim fiber (MF), the MF connects the lateral right atrium (RA) to the right bundle branch or the right ventricle. We present the case of a 33‐year‐old man with antidromic atrioventricular reentrant tachycardia using MF connected to the septal RA and left ventricle (LV). Although the Mahaim potential was recorded at the septal RA, ablation at this site could not eliminate the MF and had a potential risk of injury to the atrioventricular node. Additional application at the posterior septal LV achieved successful MF ablation., Mahaim fiber was located between septal right atrium and posterior left ventricle (LV). Successful ablation was achieved at the posterior LV.

Patients with Wolff-Parkinson-White (WPW) syndrome rarely have multiple accessory pathways (APs). Here, we present a case of a 21-year-old man with the manifest type B WPW syndrome who was experiencing multiple attacks of palpitations. The electrophysiological study revealed two APs located bilaterally: the anterolateral tricuspid annulus and lateral mitral annulus. Atrial/ventricular extrastimulations induced two types of wide QRS tachycardia conducting via two APs in the clockwise and counterclockwise direction. These two APs were eliminated with careful mapping and catheter ablation.

Aims Cryoballoon ablation (CBA) is effective for atrial fibrillation (AF), however acute silent cerebral infarction (SCI) is not uncommon after CBA. This study aimed to clarify the relationship between the morphology of LAA and SCI. Methods and results From 2015 to 2019, 207 consecutive patients (65.1±11.4 years, 26.6% of female, 31.4% of persistent AF) who underwent CBA for AF at our hospital were enrolled. All patients were evaluated with computed tomography for LAA before CBA and divided into two groups as chicken wing (CW) group and non-CW group. SCI was evaluated with magnetic resonance imaging at the following day after CBA. As a result, 18.4% of patients have occurred SCI after CBA. Although the patients' background didn't differ between the two groups, the Hounsfield scale (LAA/Aorta ratio) was lower (non-CW vs. CW = 0.68±0.12 vs. 0.73±0.11, p=0.004), and LAA orifice size tended to be larger (16.9±4.6 vs. 15.8±4.1, p=0.053) in non-CW group. SCI significantly occurred in non-CW group (29.5% vs. 11.6%, p=0.003), especially in cauliflower shape of 45.0%. In multivariate analysis, non-CW (p=0.002, Odds ratio 3.2, 95% of CI 1.5–7.0), skipped DOAC before CBA (p=0.04, Odds ratio 6.1, 95% of CI 1.1–115.4), and touch-up ablation in left atrium (p=0.02, Odds ratio 2.8, 95% CI 1.2–6.5) were independent predictors of SCI. Conclusions SCI was not rare after CBA for AF. Morphology of LAA was strongly associated with SCI. Funding Acknowledgement Type of funding source: None

Background Induction test of atrial fibrillation (AF) is one of endpoint measures in catheter ablation (CA). However, its predictive value in long‐term outcome remains controversial. Methods Ninety‐eight patients (61 years, 77 males) with persistent AF who underwent pulmonary vein antrum isolation‐based CA were retrospectively analyzed. We determined whether inducibility of AF/atrial tachyarrhythmias (AT) by atrial burst pacing at the end of CA and other characteristics were associated with the recurrence of AF/AT. Atrial burst pacing was performed with 30‐beat from the coronary sinus; increasing from 240 to 320 ppm. Inducibility was defined as AF/AT lasting ≥5 minutes following atrial burst pacing. Results AF/AT was induced in 50 patients (51%). During 1 year of follow‐up, 71 patients (72.4%) had no recurrence of AF/AT. A logistic regression analysis showed that female gender (OR 3.8; P = 0.02), multiple sessions (OR 3.5; P = 0.02), and early recurrence of AF/AT (OR 5.3; P = 0.004) were associated with clinical recurrence. AF/AT Inducibility was not associated with clinical recurrence (P = 0.65). A subanalysis in patients with enlarged LA (LA diameter ≥45 mm, n = 40) showed that AF/AT inducibility was associated with recurrence (OR 8.1; P = 0.04). The positive and negative predictive values of AF/AT inducibility for AF/AT recurrence were 41 and 89%, respectively. Negative predictive value was increased to 92.3% when the inducibility was defined as AF/AT of ≥30 seconds following atrial burst pacing. Conclusions AF/AT inducibility cannot predict long‐term clinical recurrence in patients with persistent AF. However, it may have a prognostic value especially in patients with enlarged LA.

Background Pulmonary vein isolation (PVI) is an established ablation procedure for atrial fibrillation (AF), however, PVI alone is insufficient to suppress AF recurrence. Non-pulmonary vein (non-PV) trigger ablation is one of the promising strategies beyond PVI and has been shown to be effective in refractory/persistent AF cases. To make non-PV trigger ablation more standardized, it is essential to develop a simple method to localize the origin of non-PV triggers. Methods We retrospectively analyzed 37 non-PV triggers in 751 ablation sessions for symptomatic AF from January 2017 to December 2020. Regarding non-PV triggers, intra-atrial activation interval from the earliest in right atrium (RA) to proximal coronary sinus (CS) (RA-CSp) and that from the earliest in RA to distal CS (RA-CSd) obtained by a basically-positioned duodecapolar RA-CS catheter were compared among 3 originating non-PV areas [RA, atrial septum (SEP) and left atrium (LA)]. Results RA-CSp of RA non-PV trigger (56.4 ± 23.4 ms) was significantly longer than that of SEP non-PV (14.8 ± 25.6 ms, p = 0.019) and LA non-PV (-24.9 ± 27.9 ms, p = 0.0004). RA-CSd of RA non-PV (75.9 ± 32.1 ms) was significantly longer than that of SEP non-PV (34.2 ± 32.6 ms, p = 0.040) and LA non-PV (-13.3 ± 41.2 ms, p = 0.0008). RA-CSp and RA-CSd of SEP non-PV were significantly longer than those of LA non-PV (p = 0.022 and p = 0.016, respectively). Sensitivity and specificity of an algorithm to differentiate the area of non-PV trigger using RA-CSp (cut-off value: 50 ms) and RA-CSd (cut-off value: 0 ms) were 88% and 97% for RA non-PV, 81% and 73% for SEP non-PV, 65% and 95% for LA non-PV, respectively. Conclusions The analysis of intra-atrial activation sequences was useful to differentiate non-PV trigger areas. A simple algorithm to localize the area of non-PV trigger would be helpful to identify non-PV trigger sites in AF ablation.

Background Atrial functional mitral regurgitation (AFMR) occurs in patients with atrial fibrillation. However, morphological mechanisms of AFMR are poorly understood. Purpose The purpose of this study was to examine the morphological characteristics in patients with AFMR. Methods Among consecutive 795 patients undergoing initial radiofrequency catheter ablation (RFCA) at our hospital, twenty-five patients with persistent AF accompanied by AFMR (≥ moderate) before RFCA (AFMR group) were studied. Age-matched 25 patients with persistent AF without MR were defined as a control group. Results Left ventricular ejection fraction (LVEF) was lower and left atrium volume index was larger in the AFMR group (Table). Mitral valve annulus diameter and length of anterior mitral leaflet (AML) were similar between groups, whereas length of posterior mitral leaflet (PML) was significantly shorter in the AFMR group. Smaller tethering angle of AML (γ in the figure) and shorter tethering height were significantly associated with the occurrence of AFMR, which were different from morphology of functional mitral regurgitation in patients with dilated LV. Multiple regression analysis revealed that less tenting height (p Echocardiographic parameters AFMR (n=25) Control (n=25) P value Age, y 69±8 66±10 NS Male, n (%) 9 (36) 20 (80) P=0.001 LVEF,% 60±9 67±6 P=0.004 LAD, mm 44±5 41±7 NS LAVI, ml/m2 56±17 41±13 P Conclusions AFMR occurs in patients with unique morphological features, such as less tethering height and LA dilatation toward the posterior.

The pathophysiology of non-pulmonary vein (PV) triggers of atrial fibrillation (AF) is unclear. We hypothesized that left atrial non-PV (LANPV) triggers are associated with atrial tissue degeneration. This study analyzed 431 patients that underwent catheter ablation (mean age 62 yrs, 303 men, 255 paroxysmal AF [pAF] patients). Clinical and electrophysiological characteristics of non-PV trigger were analyzed. Fifty non-PV triggers in 40 patients (9.3%) were documented; LANPV triggers were the most prevalent (n = 19, 38%). LANPV triggers were correlated with non-paroxysmal AF (non-pAF) (OR 3.31, p = 0.04) whereas right atrial non-PV (RANPV) triggers (n = 14) and SVC triggers (n = 17) were not. The voltage at the LANPV sites during SR was 0.3 ± 0.16 mV (p

Background Rhythm control before catheter ablation for persistent atrial fibrillation (PeAF) can improve clinical outcomes. We sought to investigate the efficacy of pretreatment with bepridil prior to cryoballoon ablation (CBA) with respect to clinical outcomes in patients with PeAF. Methods We retrospectively analyzed 65 consecutive patients with PeAF who underwent CBA following pretreatment with bepridil hydrochloride (bepridil). Electrical cardioversion was additionally performed in cases involving failure of pharmacological sinus restoration before CBA. The primary endpoint was survival free from atrial tachyarrhythmia at the one-year follow-up, and the secondary endpoints were changes in P-wave morphology and left atrium diameter (LAD) before CBA. Results At the one-year follow-up, 51 patients (78.5%) achieved the primary endpoint (non-recurrence group). Compared to the P-wave duration (Pdur) and dispersion at the time of sinus restoration, they significantly shortened at the time of CBA in the non-recurrence group, while they did not change in the recurrence group. There were no changes in LAD in both groups. Multivariate analysis revealed that refractoriness of bepridil (p = 0.03, odds ratio = 4.72, 95% confidence interval = 1.18–18.92), and longer Pdur at admission for CBA (p = 0.003, odds ratio = 1.08, 95% confidence interval = 1.01–1.14) were independent predictors of recurrence. Conclusions Rhythm control with bepridil induced electrical reverse remodeling; bepridil may improve clinical outcomes after CBA.

A 44-year-old man was admitted to our hospital due to heart failure. Transthoracic echocardiography demonstrated global hypokinesis with an ejection fraction of 25%, prominent trabeculation and deep intertrabecular recesses, and apical aneurysm with multiple thrombi (10×13 mm in the inferior wall, 15×8 mm in the anterior wall). Cardiac magnetic resonance imaging showed an increased ratio of noncompacted (NC) to compacted (C) myocardium (NC/C ratio >2.3) and apical aneurysm. Coronary angiography revealed no significant stenosis. He was therefore diagnosed with left ventricular noncompaction complicated by apical aneurysm. Four weeks after starting anticoagulation, the multiple apical thrombi disappeared without clinical signs of embolism.

BackgroundThe prevalence of severe sclerotic aortic stenosis (ScAS) in those at least ≧80 years old has been increasing in Japan; however, the prognosis of these Japanese patients without surgical treatment has not been reported.Methods and resultsNinety consecutive patients with medically treated severe ScAS were prospectively studied. To assess further event-free survival rate (EFSR) from either cardiac (heart failure or cardiac death) events or noncardiac deaths, they were divided into three groups based on aortic valve area (AVA) at the initial diagnosis (group A: AVA≦0.6cm2, group B: 0.6cm2