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Atrial fibrillation (AF) ablation can improve left ventricular ejection fraction (LVEF) and renal function and can even reduce mortality in patients with impaired LVEF. However, the effect of post-ablation cardiorenal dysfunction on the prognosis of patients with impaired LVEF who underwent AF ablation remains unclear. Of the 1243 consecutive patients undergoing AF ablation, the prognosis of 163 non-dialysis patients who underwent AF ablation with 50% LVEF was evaluated. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, and a need for modification of the treatment for heart failure. During the median follow-up of 4.2 years after the first AF ablation procedure, the primary outcome occurred in 30 of 163 patients (18%). The receiver operating characteristic curve analysis demonstrated that the post-LVEF (LVEF within 1 year after the procedure, and before the occurrence of primary outcome) had larger areas under the curve (0.70) than the pre-LVEF (LVEF before the procedure), and the most optimal cutoff value was LVEF ≤ 42%. Multivariate analysis demonstrated that patients with post-LVEF ≤ 42% and worsening renal function (WRF; an absolute increase in serum creatinine [SCr] ≥ 0.3 mg/dL compared with the SCr at baseline within 1 year after the procedure and before the occurrence of primary outcome) had a 3.4- to 4.3-fold and 3.4- to 3.7-fold higher risk of the primary outcome compared with those without these predictors, respectively. Patients were categorized using post-LVEF ≤ 42% and WRF as follows: group 1 (post-LVEF 42% without WRF), group 2 (post-LVEF ≤ 42% without WRF), group 3 (post-LVEF 42% with WRF), and group 4 (post-LVEF ≤ 42% with WRF). Group 4 had a 15.8-fold (P = 0.0001) higher risk of the primary outcome compared with group 1 after adjusting for pre-procedural factors. In patients with impaired LVEF undergoing AF ablation, post-LVEF ≤ 42% and WRF were independent predictors of poor prognosis. The combination of post-LVEF ≤ 42% and WRF is strongly associated with a poor prognosis in patients with AF undergoing ablation, who with these post-ablation cardiorenal dysfunction may have to be treated more intensively after AF ablation.

Transvenous lead extraction (TLE) for cardiac implantable electric device (CIED) infection is becoming increasingly common, but is believed to be particularly risky in elderly patients. This study aimed to clarify the safety and effectiveness of TLE in the elderly, evaluating the use of both non-laser and laser extraction tools. We retrospectively analyzed the characteristics, device type, indications, procedures, and clinical results in younger (YG; age: 15–79 years; n = 48) and elderly groups (EG; age: ≥ 80 years; n = 27) of patients who underwent percutaneous TLE between April 2014 and December 2019 at our hospital. The average age was 68 and 88 years in the YG and EG, respectively. Indications for TLE were infection in 33 (68.8%) patients and other in 15 (30.6%) patients in the YG, and infection in all 27 (100%) EG patients. Bloodstream infection was detected in 9 and 4 patients in the YG and EG, respectively, with methicillin-resistant Staphylococcus epidermidis being the most common causative pathogen. All TLE procedures were performed under general anesthesia in an operating room with cardiovascular surgeon backup. An excimer laser sheath (76 leads), a laser followed by a mechanical sheath (45 leads), Evolution RL® (17 leads), a mechanical sheath (9 leads), and manual traction (one lead) were employed to extract a total of 148 leads (98 and 50 in the YG and EG, respectively). A mechanical sheath or Evolution RL® was more frequently used in the YG. The respective average implantation durations in the YG and EG were 5.3 and 5.0 years, respectively, which were comparable (p = 0.46). Procedural success rates were identical between the YG and EG (99% vs. 100%, respectively). There was only one procedure-related complication in the entire cohort (cardiac tamponade in a YG patient). Taken together, the success rates of TLE were high in the EG, with no complications, with extraction being the indication for infection in all EG patients. Percutaneous TLE was safe and effective in elderly patients using both non-laser and laser techniques.

An important step in diagnosing myopotential oversensing is to confirm its reproducibility using specific provocation maneuvers. Although most maneuvers involve the co-contraction of many muscles, no attempt has been made to assess relevant muscle activities by electromyography. We describe a case with an implantable cardioverter defibrillator (ICD) whose myopotential oversensing was provoked by simultaneous straining and leftward twisting. Simultaneous recordings from real-time ICD telemetry and myopotentials of the rectus abdominis, oblique abdominis, and diaphragm on electromyography during the provocation maneuvers were conducted. It was shown that all three muscles contracted simultaneously during the provocation maneuvers; the diaphragm activity was the main source of noise oversensing, and the twist itself caused oversensing possibly due to the change in the position of the lead. In conclusion, the electromyographic assessment of relevant muscle activities may be useful in assessing each muscle's role and its contribution to myopotential oversensing, especially in a patient whose myopotential oversensing requires complex maneuvers to be provoked.

There are some cases that are difficult to cure with only circumferential pulmonary vein isolation (CPVI) of persistent atrial fibrillation (PerAF). Recently, prolonged interatrial conduction times (IACTs), which seem to be associated with progressive remodeled atria, have been reported as a predictor of new-onset AF. This study aimed to investigate the prognostic value of a prolonged IACT for predicting AF recurrences after CPVI of PerAF. One hundred thirteen patients who underwent CPVI without an empirical substrate modification of PerAF were retrospectively analyzed. The IACT was defined as the interval from the earliest P-wave onset on the ECG to the latest activation in the coronary sinus and was measured after achieving the CPVI and conversion to sinus rhythm. During a mean 22.7-month follow-up after the initial procedure, 56 patients (50%) had AF recurrences. Patients with AF recurrence had a longer IACT than those without AF recurrence (p

Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients is highly associated with deterioration of their clinical condition, such as worsening heart failure symptoms, and an increased thromboembolic stroke risk and cardiac mortality rate. This study aimed to investigate the long-term clinical course after catheter ablation (CA) in HCM patients with AF. Among 566 primary HCM patients at our institution, 94 who underwent rhythm control therapy to manage AF from 2002 to 2016 were retrospectively analyzed. The eligible patients were divided into two groups: those who managed AF with CA (n = 34) and those without CA (n = 60). The endpoints were the incidence of initial clinical events, including HCM-related death or an unplanned heart failure hospitalization, or new-onset thromboembolic strokes. During a mean follow-up of 5.8 years, 6% in the CA group and 28% in the non-CA group had a progression of the AF type into permanent AF (Log-rank: p = 0.012). In the Kaplan-Meyer curve analyses, the incidence of clinical events was significantly lower in the CA group than non-CA group (p = 0.025). The annual rates for the incidence of clinical events were 1.2% in the CA group and 6.7% in the non-CA group. In a Cox multivariate analysis, CA therapy (adjusted hazard ratio 0.22; 95% confidence interval: 0.05–0.97; p = 0.046) was the only independent predictor of the incidence of clinical events. In conclusion, CA may be associated with a favorable long-term clinical course in HCM patients with AF.

A 72-year-old female with idiopathic dilated cardiomyopathy underwent a generator exchange for a cardiac resynchronization therapy defibrillator with a full-pocket capsulectomy. The lead position after the operation was identical to that before the operation on the chest X-ray. After 4 months, a subacute exacerbation of her heart failure was caused by cardiac resynchronization therapy failure due to a dislodgement of the left ventricular lead. An aggressive adhesiotomy of the connective tissue around the leads made it possible for the lead to retract by a ratchet-like movement through the suture sleeve, so-called "ratchet syndrome", after the generator exchange.

Hyaluronan (HA), a primary component of the extracellular matrix, is associated with several cardiovascular diseases. However, its precise cardiac origin and role in atrial fibrillation (AF) remain unclear. We investigated chamber-specific HA levels in patients with paroxysmal AF (PAF) or persistent AF (PSAF). The levels of HA, a diacron-reactive oxygen metabolite (dROM) as a marker for oxidative stress, at different cardiac sites, and peripheral brain natriuretic peptide (BNP) levels were measured in patients with PAF (n = 50) or PSAF (n = 35). HA levels in the coronary sinus (CS-HA) were significantly higher than those other sites, in both PAF and PSAF patients, and CS-HA levels were significantly higher in PSAF patients than in PAF patients [37.1 (interquartile range, 31.2–48.3) vs. 30.6 (23.7–40.2) pg/mL, P

We describe a case with a focal atrial tachycardia (AT) masquerading as perimitral atrial flutter revealed after circumferential pulmonary vein antral isolation for atrial fibrillation. It was successfully terminated and became noninducible by a point ablation on the left atrial anterior wall (LAAW) near the mitral annulus in contact with the aortic root and on the left superior pulmonary vein-left atrial appendage ridge, without any linear ablation, using electroanatomical mapping and conventional precise mapping with a maximum amplified gain within the low-voltage area. The AT revealed in our case was an LAAW-aorta contiguity area-related AT.

Previous studies indicated that women were less likely to experience ventricular arrhythmia recurrence than men among patients with coronary artery disease and implantable cardioverter defibrillator (ICD). However, it is not clear whether the risk for ventricular tachyarrhythmia is gender-dependent in patients with nonischemic dilated cardiomyopathy. This study included 173 consecutive nonischemic dilated cardiomyopathy patients with a left ventricular ejection fraction of45% (122 men and 51 women), who received ICD therapy between 1990 and 2008. The average follow-up period was 33 +/- 28 months. There was no significant difference in event-free rates of appropriate ICD therapy between genders for all patients (P = 0.15) and by indication of ICD (primary prevention: P = 0.43, secondary prevention: P = 0.24). There was also no significant difference in event-free rates of electrical storm between genders (P = 0.17). In high-risk patients with nonischemic dilated cardiomyopathy who received ICD, there was no gender difference in the incidence of appropriate ICD therapy or electrical storm.

Little is known about the outcome of catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) and a severely reduced left ventricular ejection fraction (LVEF). We aimed to clarify the effectiveness of catheter ablation of AF in patients with a severely low LVEF. This retrospective study included 18 consecutive patients with HF and an LVEF of ≤35 % who underwent catheter ablation of AF. We investigated the clinical parameters, echocardiographic parameters and the incidence of hospitalizations for HF. During a median follow-up of 21 months (IQR, 13–40) after the final procedure (9 with repeat procedures), 11 patients (61 %) maintained sinus rhythm (SR) (6 with amiodarone). The LVEF and NYHA class significantly improved at 6 months after the CA in 12 patients (67 %) who were in SR or had recurrent paroxysmal AF (from 25.8 ± 6.3 to 37.0 ± 11.7 %, P = 0.02, and from 2.3 ± 0.5 to 1.5 ± 0.7, P < 0.01, respectively) but not in patients who experienced recurrent persistent AF. The patients with SR or recurrent paroxysmal AF had significantly fewer hospitalizations for HF than those with recurrent persistent AF after the AF ablation (log-rank test; P < 0.01). Catheter ablation of AF improved the clinical status in patients with an LVEF of ≤35 %. A repeat ablation procedure and amiodarone were often necessary to obtain a favorable outcome.

Although the incidence of causing an atrioesophageal fistula during pulmonary vein isolation is very low, this type of injury results in a very high mortality rate. To prevent this complication, keeping a safe distance from the esophagus to the ablation lesion is a simple but safe method. We report a case in which we were able to shift the position of the esophagus by positioning the patient in a lateral posture in order to keep the esophagus at a safe distance from the pulmonary vein antrum, resulting in performance of a safe and successful pulmonary vein antrum isolation.

The noninvasive evaluation of ventricular T-wave alternans (TWA) in patients with lethal ventricular arrhythmias is an important issue. In this study, we propose a novel algorithm to identify T-wave current density alternans (TWCA) using synthesized 187-channel vector-projected body surface mapping (187-ch SAVP-ECG). We recorded 10 min of 187-ch SAVP-ECG using a Mason–Likar lead system in the supine position. A recovery time (RT) dispersion map was obtained by averaging the 187-ch SAVP-ECG. The TWCA value was determined from the relative changes in the averaged current density in the T-wave zone (Tpeak ± 50 ms) for two T-wave types. We registered 20 ECG recordings from normal controls and 11 ECG recordings from nine subjects with long QT syndrome (LQT). We divided LQT syndrome subjects into two groups: group 1 provided 9 ECG recordings without visually apparent TWAs, and group 2 provided 2 ECG recordings with visually apparent TWAs. The QTc interval values in the LQT groups were higher than those in the control (515 ± 60 ms in LQT G-1, 600 ± 27 ms in LQT G-2 vs. 415 ± 19 ms in control, P

We studied the anatomical structure of the isthmus between the inferior vena cava and tricuspid annulus in humans with a three-dimensional electroanatomical mapping system (CARTO, Biosense, Haifa, Israel). Fifteen patients with atrial flutter were studied. Thirteen patients had underlying heart disease. We investigated the anatomical structure of the isthmus with cross sections made from the three-dimensional right atrial map. The cross sections of the isthmus showed a concave shape in 7 patients (47%: group A), convex shape in 2 (13%: group B), and complex shape in 6 (40%: group C). The distance between the IVC and TA was 34+/-17 mm (group A), 25+/-2 mm (group B), 34+/-16 mm (group C), and 32+/-15 mm (Total), respectively. The distance between the top and bottom was 6+/-5 mm (group A), 3 mm (group B), 6+/-3 mm (group C), and 6+/-4 mm (total), respectively. Seven of 15 patients exhibited an uneven surface of more than 5 mm in depth and 4 of 15 patients had one of more than 10 mm. The anatomical structure of the isthmus varies. To carry out precise catheter ablation, these variations should be taken into consideration to ensure an effective procedure.