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Background: Atrial fibrillation (AF) and recurrence of AF after pulmonary vein isolation (PVI) have been linked to sinus node dysfunction.Objective: The purpose of this study was to investigate the association between the heart rate-associated single nucleotide polymorphisms (SNPs) identified in genome-wide association studies and recurrence of AF after PVI.Methods: In this study, patients with paroxysmal AF who underwent initial PVI, including 522 patients for screening and 172 patients for replication, were recruited and 21 heart rate-associated SNPs identified in genome-wide association studies were genotyped. The association between these SNPs and the recurrence of AF was investigated.Results: Throughout the follow-up period of 21 ± 12 months, 119 patients with paroxysmal AF (22.8%) exhibited AF recurrences in the screening set. The rate of AF recurrence was significantly associated with the minor allele C of the gap junction alpha-1 protein (GJA1) rs1015451 (additive model: odds ratio 2.07; P = 9.32 × 10-7), but not with other SNPs. This association was confirmed in the replication set (allelic model: odds ratio 1.81; P = 2.70 × 10-2). Multivariate analysis revealed that the recurrence of AF after AF ablation was independently related to the GJA1 SNP rs1015451 additive model, duration of AF >1 year, AF from non-pulmonary vein foci, and thicker interventricular septum.Conclusion: The GJA1 SNP rs1015451, coding for a gap junction protein (connexin-43), may be considered a novel genetic marker for AF recurrence after PVI. [ABSTRACT FROM AUTHOR]

• FMD values were highest in the group with extremely low levels of triglycerides. • Lower triglyceride levels are associated with better endothelial function. • The group with extremely low triglycerides had fewer atherosclerosis risk factors. • The odds ratio for a lower quartile of FMD remained independently lower. Increased serum triglyceride levels are independently associated with endothelial dysfunction. However, there is little evidence to define normal levels of triglycerides and there is little information on endothelial function in subjects with extremely low levels of triglycerides. The purpose of this study was to determine the relationship between triglycerides, especially low levels of triglycerides, and vascular function. We measured flow-mediated vasodilation (FMD) in 7047 subjects and nitroglycerine-induced vasodilation (NID) in 1017 subjects. We divided the subjects into eight groups by triglyceride levels: <50 mg/dL, 50-69 mg/dL, 70-89 mg/dL, 90-109 mg/dL, 110-129 mg/dL, 130-149 mg/dL, 150-199 mg/dL, and ≥200 mg/dL. FMD was significantly higher in subjects with triglyceride levels of <50 mg/dL than in subjects with triglyceride levels of 50-69 mg/dL, 70-89 mg/dL, 90-109 mg/dL, 110-129 mg/dL, 130-149 mg/dL, 150-199 mg/dL, and ≥200 mg/dL (p =0.002, p <0.001, p <0.001, p <0.001, p<0.001, p<0.001, and p <0.001, respectively). Using triglyceride levels of >200 mg/dL as a reference, the odds ratios for a lower quartile of FMD were significantly lower in the <50 mg/dL group, 50-69 mg/dL group, 70-89 mg/dL group, and 90-109 mg/dL group after adjustment for age, gender and other cardiovascular risk factors. There was a slight negative correlation between NID and triglycerides (r =-0.074; p =0.019). However, there was no significant differences in NID among the eight groups. FMD values were highest in subjects with extremely low levels of triglycerides (<50 mg/dL). Lower triglyceride levels were associated with better endothelial function. http://www.umin.ac.jp (University Hospital Medical Information Network Clinical Trials Registry) (UMIN000012950) [ABSTRACT FROM AUTHOR]

Whether coronary plaque characteristics assessed in coronary computed tomography angiography (CCTA) in association with the coronary artery calcium score (CACS) have predictive value for coronary events is unclear. We aimed to examine the predictive value of the CACS and plaque characteristics for the occurrence of coronary events. Among 2802 patients who were analyzed in the PREDICT registry, 2083 with suspected coronary artery disease (CAD) were studied using post hoc analysis. High-risk plaques were defined as having ≥2 adverse characteristics, such as low computed tomographic attenuation, positive remodeling, spotty calcification, and napkin-ring sign. An adjudicative composite of coronary events (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization ≥3 months after indexed CCTA) were analyzed. Seventy-three (3.5%) patients had coronary events and 313 (15.0%) had high-risk plaques. Multivariate Cox proportional hazard analysis showed that high-risk plaques remained an independent predictor of coronary events (adjusted hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.13–3.34, P ​= ​0.0154), as well as the log-transformed CACS (adjusted HR 1.24, 95% CI 1.11–1.39, P ​= ​0.0002) and the presence of obstructive stenosis (adjusted HR 5.63, 95% CI 3.22–10.12, P 0.0001). In subgroup analyses, high-risk plaques were independently predictive only in the low CACS class (<100). This study shows that assessment of adverse features by coronary plaque imaging independently predicts coronary events in patients with suspected CAD and a low CACS. Our findings suggest that the clinical value of high-risk plaques to CACS and stenosis assessment appears marginal. It is still unclear whether coronary plaque characteristics assessed in coronary computed tomography angiography (CCTA) in association with the coronary artery calcium score (CACS) have predictive value for coronary events. To clarify this hypothesis, we studied 2083 suspected coronary artery disease patients in this PREDICT post hoc analysis. High-risk plaque was independently predictive in the lower CACS classes (<100) but it was not independent in the high CACS class (≥100). This study shows that assessment of adverse features by coronary plaque imaging independently predicts coronary events in patients with suspected CAD and a low CACS. Our findings suggest that the clinical value of high-risk plaques to CACS and stenosis assessment appears marginal. [Display omitted] [ABSTRACT FROM AUTHOR]

Anti-inflammatory therapy targeting interleukin (IL)-1β reduced cardiovascular events in a randomized trial. We evaluated the relationship between IL-1β mRNA expression in epicardial adipose tissue (EAT) and clinically-assessed coronary atherosclerosis on computed tomography (CT). We studied 45 patients before cardiac surgery (coronary artery bypass grafting [CABG], n ​= ​18; non-CABG, n ​= ​27). EAT volume, the coronary calcium score (CCS), and the presence of non- and/or partially-calcified coronary plaques (NCPs) and high-risk coronary plaques (HRPs; minimum CT density <30 Hounsfield units and vascular remodeling index >1.1) on CT angiography were assessed. EAT samples were obtained during cardiac surgery. IL-1β mRNA expression in EAT was measured using quantitative real-time PCR and normalized to that of β-actin in each patient. There was no difference in IL-1β mRNA levels between patients who were scheduled for CABG and non-CABG surgery or among subgroups based on the CCS. However, patients with NCPs (median [interquartile range], 4.1[2.0-11.6]E-4 versus 1.8[0.6-4.5]E-4, p ​= ​0.024) and HRP (7.6[3.0-20.4]E-4 versus 1.9[0.7-4.3]E-4, p ​= ​0.0023) had higher IL-1β mRNA levels than those without these plaques. On multivariate analysis adjusted for age, sex, coronary risk factors, statin therapy, CCS, and EAT volume, the presence of HRPs was significantly correlated with elevated IL-1β mRNA levels in EAT (β ​= ​0.39, p ​= ​0.047). Our data suggest a contribution of EAT to coronary atherosclerosis through molecular behavior, such as IL-1β gene expression, which may be a new therapeutic target. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) has a genetic basis, and environmental factors can modify its actual pathogenesis.Objective: The purpose of this study was to construct a combined risk assessment method including both genetic and clinical factors in the Japanese population.Methods: We screened a cohort of 540 AF patients and 520 non-AF controls for single nucleotide polymorphisms (SNPs) previously associated with AF by genome-wide association studies. The most strongly associated SNPs after propensity score analysis were then used to calculate a weighted genetic risk score (WGRS). We also enrolled 1018 non-AF Japanese subjects as a validation cohort and monitored AF emergence over several years. Finally, we constructed a logistic model for AF prediction combining WGRS and clinical risk factors.Results: We identified 5 SNPs (in PRRX1, ZFHX3, PITX2, HAND2, and NEURL1) associated with AF after Bonferroni correction. There was a 4.92-fold difference in AF risk between the highest and lowest WGRS calculated using these 5 SNPs (P = 2.32 × 10-10). Receiver operating characteristic analysis of WGRS yielded an area under the curve (AUC) of 0.73 for the screening cohort and 0.72 for the validation cohort. The predictive logistic model constructed using a combination of WGRS and AF clinical risk factors (age, body mass index, sex, and hypertension) demonstrated better discrimination of AF than WGRS alone (AUC = 0.84; sensitivity 75.4%; specificity 80.2%).Conclusion: This novel predictive model of combined AF-associated SNPs and known clinical risk factors can accurately stratify AF risk in the Japanese population. [ABSTRACT FROM AUTHOR]

A 79-year-old man with a history of partial resection of the lung and the bladder due to cancer, hypertension, dyslipidemia, and heart failure, underwent transcatheter aortic valve replacement with a SAPIEN 3 (S3) valve (Edwards Lifesciences, Irvine, CA, USA). Preprocedural examination showed a bicuspid aortic valve and severe calcification of the leaflets. Computed tomography showed great tortuosity of the descending aorta. A 29-mm S3 valve prosthesis was advanced into the aorta, but a high degree of resistance was encountered in the middle of the descending aorta. The prosthesis was advanced to the level of aortic valve and an attempt was made to deploy the valve. However, the valve balloon did not expand. A balloon rupture was suspected. The balloon catheter was pulled back into the eSheath (Edwards Lifesciences), and the catheter and eSheath were removed together. Rupture of the balloon was confirmed. A new eSheath and prosthesis were prepared, with delivery supported with a Lunderquist guidewire (Cook Medical, Bloomington, IN, USA). The valve alignment procedure was performed in a straighter portion of the descending aorta. The new 29-mm S3 valve was then successfully implanted. < Learning objective: Rupture of the balloon during transcatheter aortic valve replacement is a rare, potentially fatal complication. A case of balloon rupture during a valve alignment procedure with successful retrieval is reported along with a review of the complication involved.> [ABSTRACT FROM AUTHOR]

Abstract Background Coronary computed tomography angiography (CCTA) not only provides information regarding luminal stenoses but also allows for visualization of mural atheromatous changes (coronary plaques). Objective We sought to elucidate whether plaques seen on CCTA enable prediction of 2-year outcomes in patients with suspected and known coronary artery disease (CAD). Methods Of 3015 patients who underwent CCTA, the images and 2-year clinical courses of 2802 patients were independently analyzed. The primary endpoint was the composite of all-cause death and acute coronary syndrome. Results During the 2-year observation period, 49 (1.7%) patients developed the primary outcome. The 2-year rates of the primary outcome in the normal (n = 515, no mural lesions), calcium (n = 654, calcified lesion alone), and plaque groups (n = 1633, presence of noncalcified or partially calcified plaques) were 0.2%, 2.0%, and 2.1%, respectively (P = 0.0028). Adverse plaque features such as low attenuation, positive remodeling, spotty calcification, and the napkin-ring sign (low-attenuation core with a higher-attenuation rim) were assessed by an independent core laboratory. Stepwise multivariate Cox proportional hazard analysis showed that a plaque with two or more characteristics (adjusted hazard ratio, 1.98; 95% confidence interval, 1.09–3.60; P = 0.0254), age of ≥67 years (mean), statin treatment after CCTA, and obstructive stenosis remained independent predictors of the primary outcome. Conclusions Plaque imaging in CCTA has predictive value for the 2-year outcome and is a useful identifier for high-risk patients among those with known and suspected CAD. [ABSTRACT FROM AUTHOR]

Background: Urinary liver-type fatty acid-binding protein (L-FABP) is a potential biomarker for acute kidney injury, and it in turn increases cardiovascular mortality. We tested whether the urinary L-FABP level predicted short- and mid-term outcomes in patients with acute heart failure.Methods and Results: We enrolled consecutive patients with acute heart failure, and measured their urinary L-FABP levels before acute treatment. Worsening renal function (WRF), defined as both an absolute increase in the serum creatinine level of ≥0.3mg/dL and a ≥25% relative increase in its level from baseline, occurred in 37 (26.8%) of 138 patients. Patients with a urinary L-FABP level above the upper normal limit (8.4 µg/g creatinine) (n = 49; 35.5%) were more likely than those with a urinary L-FABP level within normal limits (n = 89; 64.5%) to develop WRF (n = 26 [53.1%] vs n = 11 [12.4%]; P < .001). A urinary L-FABP level above the upper limit was independently associated with WRF (hazard ratio 1.8; P = .01). During 1 year of follow-up, 12 patients (8.7%) died, and urinary L-FABP level had no association with all-cause mortality. There was, however, a tendency toward a higher readmission rate in patients with a urinary L-FABP level above the upper normal limit who survived the index hospitalization (n = 46) than in those without an abnormal L-FABP level (n = 88; n = 13 [28.3%] vs n = 13 [14.8%]; log-rank P = .06).Conclusions: Increased urinary L-FABP level before treatment may predict WRF in patients with acute heart failure. Further investigation is warranted for its predictive ability of adverse outcomes. [ABSTRACT FROM AUTHOR]

Summary Objective The objective of this study was to investigate the association between obesity and sleep habits, including bedtime, wake-up time, and sleep duration variability over a week. Methods We analyzed 9289 participants in this study. Following a health examination, each participant self-reported their sleep habits using a standardized 19-item questionnaire. High sleep duration variability was defined as sleep varying ≥3 h of the difference between the longest and shortest sleep durations reported over a week-long period. Late bedtime and early wake-up time were defined as 24:00 h or later, and before 6:00 h, respectively. Obesity was defined as a body mass index (BMI) of ≥25 kg/m 2 . Subgroup analysis included age (younger group defined as age <65 years vs. elderly group defined as age ≥65 years). Results After adjusting for confounding factors and sleep duration, high sleep duration variability [odds ratio (OR), 1.20; p < 0.005] was significantly associated with a high OR of obesity. Late bedtime (OR, 1.18; p < 0.01) was significantly associated with a high OR of obesity, whereas early wake-up was not. In the subgroup analysis, high sleep duration variability had a significant association with the younger group (OR, 1.25; p < 0.001), whereas late bedtime had a significant association with the elderly group (OR, 1.36; p < 0.005). Conclusions Inappropriate sleep habits, particularly high sleep duration variability in young individuals and late bedtime in the elderly, are associated with a high prevalence of obesity, independently of sleep duration. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: This study aims to compare the image quality of coronary artery stent scans on computed tomography images reconstructed with forward projected model-based iterative reconstruction solution (FIRST) and adaptive iterative dose reduction 3D (AIDR 3D).Materials and Methods: Coronary computed tomography angiography scans of 23 patients with 32 coronary stents were used. The images were reconstructed with AIDR 3D and FIRST. We generated computed tomography attenuation profiles across the stents and measured the width of the edge rise distance and the edge rise slope (ERS). We also calculated the stent lumen attenuation increase ratio (SAIR) and measured visible stent lumen diameters. Two radiologists visually evaluated the image quality of the stents using a 4-point scale (1 = poor, 4 = excellent).Results: There was no significant difference in the edge rise distance between the two reconstruction methods (P = 0.36). The ERS on FIRST images was greater than the ERS on AIDR 3D images (325.2 HU/mm vs 224.4 HU/mm; P <0.01). The rate of the visible stent lumen diameter compared to the true diameter on FIRST images was higher than that on AIDR 3D images (51.4% vs 47.3%, P <0.01). The SAIR on FIRST images was lower than the SAIR on AIDR 3D images (0.19 vs 0.30, P <0.01). The mean image quality scores for AIDR 3D and FIRST images were 3.18 and 3.63, respectively; the difference was also significant (P <0.01).Conclusion: The image quality of coronary artery stent scans is better on FIRST than on AIDR 3D images. [ABSTRACT FROM AUTHOR]

We report on a 77-year-old man who was diagnosed with apical hypertrophic cardiomyopathy (HCM) with mid-ventricular obstruction. He had a cured hepatitis C infection. We detected occasionally increased 18 F-fluorodeoxyglucose ( 18 F-FDG) uptake on whole-body positron emission tomography (PET)/computed tomography (CT) performed to examine the involvement of bladder carcinoma. 18 F-FDG-PET was restudied following specific preparation involving an 18-h low-carbohydrate diet and following 15-h fasting plus heparin pre-administration. Increased uptake of 18 F-FDG was observed reproducibly in the hypertrophic apical to mid left ventricular myocardium, with a maximum standardized uptake value of 6.2. In contrast, relatively lower 18 F-FDG-uptake areas tended to match areas of late gadolinium enhancement on cardiac magnetic resonance (CMR). Histopathological examination of myocardial biopsy showed disarried hypertrophic myocytes with cellular infiltration. Increased uptake of 18 F-FDG may reflect the phenomenon of increased glucose utilization in hypertrophied myocardium. The increasing clinical utility of whole-body PET/CT for evaluating malignancies may increase the detection of occasional abnormal 18 F-FDG uptake in the heart. It is necessary to clarify that 18 F-FDG myocardial PET in combination with CMR may provide a more detailed risk assessment in patients with HCM. < Learning objective: Increased 18 F-fluorodeoxyglucose ( 18 F-FDG) uptake was occasionally found in the apex of the heart on whole-body positron emission tomography performed to evaluate bladder cancer involvement. Increased uptake of 18 F-FDG was observed in the hypertrophic apical to mid left ventricular myocardium, while relatively lower 18 F-FDG-uptake areas tended to match areas of late gadolinium enhancement.> [ABSTRACT FROM AUTHOR]

Background: Risk stratification for ventricular fibrillation (VF) in patients with Brugada syndrome (BrS) remains controversial.Objective: The purpose of this study was to construct a novel prediction model for VF risk in BrS patients using noninvasive parameters.Methods: A total of 143 Japanese BrS patients with VF (n = 35) and without VF (n = 108) were retrospectively enrolled. We built a logistic regression model predicting VF occurrence and evaluated it by cross-validation.Results: Frequencies of history of syncope and spontaneous type 1 ECG, r-J interval in V1, QRS duration in V6, and LAS40, Tpeak-Tend dispersion, and max T-wave alternans were significantly associated with VF occurrence in univariate analyses. The history of syncope, r-J interval in V1, QRS duration in V6, and Tpeak-Tend dispersion were identified as independent predictors by multivariate logistic regression analysis. The predictive model was constructed using all these parameters with good discrimination of VF occurrence (area under the curve 0.869 with 97.1% sensitivity and 65.7% specificity). The area under the curve based on leave-one-out cross-validation was 0.845, with 97.1% sensitivity and 63.0% specificity suggesting good performance of the model. Retrospective survival analysis revealed that the cumulative VF event rate was significantly higher in patients at high risk than in those with low risk using the log rank test (P = 2.97 × 10(-8)). Notably, no BrS patient below the cutoff value developed a subsequent VF event.Conclusion: This novel prediction method may effectively assesses VF risk in BrS patients, especially when determining implantable cardioverter-defibrillator placement for asymptomatic BrS patients. [ABSTRACT FROM AUTHOR]

Background Left atrial (LA) remodeling progresses to electrical remodeling, contractile remodeling, and subsequently structural remodeling. Little is known about the relationship between LA electrical and anatomical remodeling and LA mechanical function. Objectives We aimed to clarify the relationship between LA mechanical function using 3-dimensional speckle-tracking echocardiography (3D-STE) and LA electrical remodeling using an electroanatomic mapping system (CARTO 3) and to estimate atrial fibrillation (AF) substrate in patients with paroxysmal AF (PAF). Methods A total of 52 patients with PAF (41 (79%) men; mean age 61 ± 11 years) undergoing their initial pulmonary vein isolation (PVI) were examined. The standard deviation of the time to peak strain in each LA segment (%SD-TPS) was analyzed as an index of LA dyssynchrony using 3D-STE before PVI. Contact LA bipolar voltage and activation maps were constructed during sinus rhythm before PVI using CARTO 3. The LA total activation time was measured and low-voltage zones (LVZs) were determined with a local bipolar electrogram amplitude of <0.5 mV. The patients were divided into those with an LVZ (LVZ group; n = 23) and those without an LVZ (non-LVZ group; n = 29). Results The %SD-TPS was significantly higher (14.1 ± 5.7 vs 8.0 ± 5.1; P = .0002) in the LVZ group than in the non-LVZ group and was an independent determinant of the LVZ (odds ratio 1.21; 95% confidence interval 1.04–1.49; P = .01). In addition, the LA total activation time was weakly correlated with the %SD-TPS. Conclusion LA dyssynchrony and conduction delay exist in patients with PAF. The 3D-STE enabled noninvasive estimation of LA electrical remodeling and AF substrate. [ABSTRACT FROM AUTHOR]

Abstract: Background: At least two-thirds of cases of acute coronary syndrome are caused by disruption of an atherosclerotic plaque. The natural history of individual plaques is unknown and needs to be established. Objectives: The Plaque Registration and Evaluation Detected In Computed Tomography (PREDICT) registry is a prospective, multicenter, longitudinal, observational registry. This registry was designed to examine the relationships among coronary CT angiography (CTA) findings and clinical findings, mortality, and morbidity. The relationships among progression of coronary atherosclerosis, including changes in plaque characteristics on coronary CTA, and serum lipid levels and modification of coronary risk factors will also be evaluated. Methods: From October 2009 to December 2012, 3015 patients who underwent coronary CTA in 29 centers in Japan were enrolled. These patients were followed for 2 years. The primary end points were considered as all-cause mortality and major cardiac events, including cardiac death, nonfatal myocardial infarction, and unstable angina that required hospitalization. The secondary end points were heart failure that required administration of diuretics, target vessel revascularization, cerebral infarction, peripheral arterial disease, and invasive coronary angiography. Blood pressure, serum lipid, and C-reactive protein levels and all cardiovascular events were recorded at 1 and 2 years. If the initial coronary CTA showed any stenosis or plaques, follow-up coronary CTA was scheduled at 2 years to determine changes in coronary lesions, including changes in plaque characteristics. Conclusion: Analysis of the PREDICT registry data will clarify the relationships between coronary CTA findings and cardiovascular mortality and morbidity in a collaborative multicenter fashion. This trial is registered at www.clinicaltrials.gov as NCT 00991835. [Copyright &y& Elsevier]

Abstract: A 64-year-old woman with recurrent mitral valve stenosis was hospitalized 30 years after open commissurotomy. Severe right cerebral embolism occurred at age 58, with left hemiparesis. She was debilitated with cardiac cachexia. Based on symptomatic valvular disease findings, surgery was considered, but deemed too high risk due to the combined insufficiencies. She refused this surgical operation and requested conservative therapy. Optimized medication and cardiac rehabilitation improved her general condition allowing transfer to another hospital. We explained the short life expectancy both to her and to her family. They decided to transfer to a hospice at a chronic care hospital and she was given best supportive care. Eventually, her urine output decreased and respiration deteriorated. She and her family refused resuscitation in the event of cardiopulmonary arrest, requesting only suffering reduction. Thus, continuous intravenous infusion of morphine was started. The optimized doses for pain alleviation were determined in consultation with palliative care specialists and maximized her consciousness level for the last four days. “Heart-failure hospice” is potentially a place to die for end-of-life patients, attended by their families and healthcare providers. They need prognostic information and options for end-stage. Our experience confirms results about palliative care from previous studies conducted overseas demonstrating the effectiveness of opioids relieving end-stage symptoms. [Copyright &y& Elsevier]

Background Distal embolization during percutaneous coronary intervention (PCI) may deteriorate microvascular reperfusion in patients with ST-elevation myocardial infarction (STEMI). Reperfusion at the coronary microvascular level is important for STEMI and culprit plaque is associated with distal embolization and microvascular reperfusion. ST-segment resolution (ST-R) in the electrocardiogram reflects microvascular reperfusion after primary PCI. Longitudinal extent of lipid pool assessed by optical coherence tomography (OCT) may predict the risk of failure of microvascular reperfusion after primary PCI. Methods and results This study consisted of 39 patients with STEMI who underwent primary PCI within 24 h after the onset of chest pain. Immediately after thrombectomy, OCT was performed and length of lipid pool was measured. Microvascular reperfusion after primary PCI was assessed by ST-R, which was defined as >50% decrease in ST elevation at 1 h after primary PCI. There were 23 patients with ST-R and 16 patients without ST-R, with no significant difference in baseline clinical and angiographical variables between the 2 groups. Final thrombolysis in myocardial infarction 3 flow was obtained in all of the patients. Peak creatine kinase was significantly higher in the ST-R (−) group than in the ST-R (+) group ( p = 0.01). Length of lipid pool was 10.1 ± 2.8 mm in the ST-R (−) group and 7.8 ± 3.2 mm in the ST-R (+) group ( p = 0.02). In receiver operating characteristics curve assessing the ability of length of lipid pool to predict ST-R, area under the curve was 0.74 ( p = 0.02). Length of lipid pool >9.0 mm best predicted the absence of ST-R with sensitivity 88% and specificity 78%. Conclusions These findings suggest that length of lipid pool estimated by OCT may predict microvascular no-reflow after primary PCI. [ABSTRACT FROM AUTHOR]

Abstract: Background: The ability of coronary CT angiography (CTA) findings such as plaque characteristics to predict future coronary events remains controversial. Objective: We investigated whether noncalcified atherosclerotic lesions (NCALs) detected by coronary CTA were predictive of future coronary events. Methods: A total of 511 patients who underwent coronary CTA were followed for cardiovascular events over a period of 3.3 ± 1.2 years. The primary end point was defined as hard events, including cardiac death, nonfatal myocardial infarction, or unstable angina that required urgent hospitalization. Early elective coronary revascularizations (n = 58) were excluded. The relationship between features of NCALs and outcomes is described. Results: A total of 15 hard events (2 cardiac deaths, 7 myocardial infarctions, 6 cases of unstable angina that required urgent hospitalization) were documented in the remaining 453 patients with modest risks during a follow-up period of 3.3 ± 1.2 years. For these hard events, a univariate Cox proportional hazard model showed that the hazard ratio for the presence of >50% stenosis was 7.27 (95% CI, 2.62–21.7; P = .0002). Although the presence of NCAL by itself was not statistically significant, NCALs with low attenuation and positive remodeling (low-attenuation plaque [LAP] and positive remodeling [PR]; plaque CT number ≤34 HU and remodeling index ≥1.20) showed an adjusted hazard ratio of 11.2 (95% CI, 3.71–36.7; P < .0001). With C-statistics analysis, when both LAP and PR and >50% stenosis were added, the C-statistic was significantly improved compared with the basal model adjusted for age, sex, and log2 (Agatston score +1) (0.900 vs 0.704; P = .0018). Conclusions: Identification of NCALs with LAP and PR characteristics by coronary CTA provides additional prognostic information to coronary stenosis for the prediction of future coronary events. [Copyright &y& Elsevier]

Purpose: The aim of this study was to compare the calcium score and reproducibility of coronary artery calcium scores obtained on the four kinds of 64-detector computed tomography (CT) scanners using standard (120 kVp) and low tube voltage (80 kVp) scan techniques. Materials and Methods: We scanned 80 and 120 kVp on all scanners. We calculated Agatston, volume, and mass scores for coronary artery calcium scoring on each scanner and compared the coefficients of variation of the calcium scores to evaluate reproducibility of among CT scanners. Results: The averages of the total mean Agatston score, total mean volume score, and total mean mass score at 80kVp/120kVp were 798.9/683.8, and 627.2/567.3, and 157.1/156.7, respectively. The total mean mass score was almost constant irrespective of the tube voltage. The total mean coefficients of variation for the four CT scanners were lower at 80 than 120 kVp (4.1% vs. 10.2% [total mean Agatston score], 3.2% vs. 9.6% [total mean volume score], and 3.2% vs. 9.4% [total mean mass score]). Conclusion: Use of the low tube voltage technique can reduce variations in the coronary artery calcium scores obtained on different CT scanners. [ABSTRACT FROM AUTHOR]

Since Dr Sato at Hiroshima City Hospital first recognized and reported the concept of tako-tsubo cardiomyopathy in 1990, this disorder has become accepted worldwide as a distinct clinical entity. Tako-tsubo cardiomyopathy is an important disorder as a differential diagnosis of acute myocardial infarction. This disorder usually occurs in postmenopausal women of an advanced age, and is characterized by transient left ventricular apical wall motion abnormalities associated with emotional or physical stress. Typically, left ventricular apical wall motion abnormalities are transient and resolve during a period of days to weeks. The prognosis is generally favorable. However, several acute complications have been reported such as congestive heart failure, cardiac rupture, hypotension, left ventricular apical thrombosis, or Torsade de Pointes. Several possible mechanisms such as multivessel coronary artery spasm, coro-nary microvascular dysfunction, myocarditis, or catecholamine toxicity have been proposed to explain tako-tsubo cardiomyopathy, but its pathophysiology is not well understood. [ABSTRACT FROM AUTHOR]

Background: The indications for catheter ablation have been expanded to include persistent atrial fibrillation (AF) to enable a high degree of sinus rhythm maintenance. We occasionally encounter patients undergoing pacemaker implantation in whom sick sinus syndrome became clinically evident after ablation. This study investigated whether underlying sinus node dysfunction (SND) during persistent AF can be predicted before deciding the indications for ablation. Methods and results: In total, 87 consecutive patients with persistent AF who underwent catheter ablation between January 2010 and July 2011 were enrolled in the study. Nocturnal polysomnography as well as transthoracic and transesophageal echocardiography were performed in all patients before ablation. We used the double Lasso catheter and electroanatomical mapping-guided extensive encircling pulmonary vein isolation (EEPVI) method. We performed electrophysiological studies after EEPVI, and SND was defined as a corrected SN recovery time of ≥550 ms. SND was detected in 42 (48%) patients (SND group); the other patients showed normal sinus node function (NSN group). The apnea/hypopnea index (AHI) was significantly greater in the SND group than in the NSN group (25.7±13 vs. 17.5±11, p = 0.002). Multivariate analysis revealed that moderate to severe sleep-disordered breathing (defined as AHI ≥15) was an independent predictor of SND after catheter ablation for persistent AF. Conclusion: The results suggest that underlying SND in patients with persistent AF can be predicted by evaluating sleep-disordered breathing before catheter ablation. [ABSTRACT FROM AUTHOR]

Background: Myocardial thickness is particularly thick at the ridge between the left pulmonary vein (PV) and the left atrial appendage (LAA) by dissection. We investigated whether atrial fibrillation (AF) ablation outcome was influenced by altering ablation strategies according to the thickness of the PV-LAA ridge using preprocedural multidetector computed tomography (MDCT). Methods and results: Patients with AF scheduled for extensive encircling circumferential pulmonary vein isolation (EEPV1) (110 patients) were divided into 2 groups. In the nonmodulation group (32 patients), EEPVI lines were created using a 3.5-mm tip irrigated catheter at a maximum power of 30 W for 20-30 s at each site. In the modulation group (78 patients), ablation was extended (40-60 s) at the PV-LAA ridge if its thickness was >4.0 mm on MDCT examination. Extended ablation at the PV-LAA ridge was noted in 37 patients in the modulation group. During 25 ± 9 months of follow-up, recurrence was significantly less in the modulation group than in the nonmodulation group (10% vs. 28%; p = 0.018). Logistic regression analysis showed that modifications in the ablation time and left atrium volume index were independent predictors of arrhythmia-free recovery after ablation. Conclusions: Recurrence following EEPVI could be reduced by modifications in the ablation time at the PV-LAA ridge. [ABSTRACT FROM AUTHOR]

Background: High-frequency stimulation (HFS) of the atria induces atrial fibrillation (AF) when applied during sinus rhythm and elicits a parasympathetic response when delivered at sites where ganglionated plexi (GPs) are located. However, little is known about its impact after an electrophysiological study. Objective: To evaluate the impact of HFS on the short-term and long-term outcomes after the ablation of persistent AF. Methods: Thirty consecutive patients with persistent or long-standing persistent AF were randomly assigned to either receive HFS of the left atrium (n = 15) or not (n = 15) during their electrophysiological studies. Patients receiving HFS were examined to determine whether or not a vagal response was elicited by the HFS at sites where GPs were located before and after conventional pulmonary vein isolation without any ablation targeting the GPs. Patients not receiving the HFS underwent the ablation procedure alone. The rate of recurrence of AF within 3 months of the procedure (early recurrence [ER]) and the frequency of that occurring after that period (late recurrence) were compared between the patient groups. Results: The incidence of ER occurred more frequently in patients with HFS than in those without (80% vs 40%; P = .015), whereas the occurrence of late recurrence was similar between the 2 groups (27% vs 33%; P = .73). In the HFS group, the number of GPs decreased from 3.4 ± 1.1 to 1.5 ± 0.8 after the pulmonary vein isolation (P < .0001), and the decrease was smaller in the patients experiencing ER than in those without. Conclusion: HFS increases the incidence of ER in patients with persistent AF despite a partial GP modification resulting from the pulmonary vein isolation. [Copyright &y& Elsevier]

Rho-associated coiled-coil forming protein kinases (ROCKs), the downstream target proteins of RhoA, are ubiquitously expressed serine-threonine protein kinases. ROCKs have diverse cellular functions, e.g. smooth muscle contraction, actin cytoskeleton organization, cell adhesion, and gene expression. Accumulating evidence has revealed that ROCKs are substantially involved in cardiovascular disorders such as angina, cerebral ischemia, myocardial ischemia, and cardiac hypertrophy. So far, the significant relation-shiD of ROCKs wiun endothelial function has been reported. ROCKs inhibition by statins or other selective inhibitors leads to the upregulation and activation of endothelial nitric oxide synthase, resulting in the reduction of vascular inflammation and atherosclerosis. Meanwhile, it has been also demonstrated that endogenous nitric oxide could inhibit RhoA/ROCK signaling pathway. Taken together, there might be critical crosstalk of ROCKs with endothelial function. In addition, we further focus on leukocyte ROCK activity as a surrogate marker in patients with atherosclerosis-related diseases. Indeed, leukocyte ROCK activity has been shown to be increased in atherosclerotic patients, indicating the possible usage of leukocyte ROCK activity as a surrogate marker similar to endothelial function evaluated by flow-mediated dilation. Here, we review concerning ROCK signaling pathway, especially focusing on the crosstalk of ROCKs with endothelial function. [ABSTRACT FROM AUTHOR]

Objectives: We determined the effect of two-time inflation of the stent balloon on stent expansion and its responsible factor. Methods: Subjects included 61 patients with de novo coronary artery lesions, in whom 12 sirolimus-eluting, 27 paclitaxel-eluting, and 22 other stents were deployed twice at identi-cal inflation pressures (11.3±2.3atm) and inflation times (5, 10, 20, and 40 s). After the first and second deployments, minimum lumen diameter (MLD), minimum lumen area (MLA), and distensibility index (Dl) were determined using intravascular ultrasound. Results: After the second inflation, MLA was significantly increased (5 s: 12.9%, 10s: 14.5%, 20s: 9.4%, 40s: 9.5%). MLD and Dl were also significantly increased. In the single and double infla-tion groups, Dl in each group was significantly correlated with inflation time (single: r = 0.409, double: r = 0.351). Dl was not significantly different between double 5-s and single 10-s infla-tions, between double 10-s and single 20-s inflations, or between double 20-s and single 40-s inflations. Additional stent balloon inflation by higher pressure in 30% and another balloon in 18% of the patients were required. Conclusions: Two-time stent balloon inflation may allow better stent expansion regardless of inflation time and two-time inflation may be equivalent to longer inflation. [ABSTRACT FROM AUTHOR]

Abstract: Background: Sinus node dysfunction (SND) occasionally coexists with long-standing atrial fibrillation (AF) but is unidentifiable during AF. We aimed to identify the predictors of underlying SND when deciding the indications for long-standing persistent AF ablation. Methods: We included 105 patients undergoing ablation of long-standing persistent AF to assess the frequency of a permanent pacemaker implantation (PMI) for SND that manifested after sinus conversion and to determine the relationship between the corrected sinus node recovery time (CSNRT) and other clinical parameters obtained before the ablation including the atrial fibrillatory cycle length (AFCL). Results: We identified 7 patients (7%) requiring a PMI for SND after AF termination. The patients with a PMI were nearly all females (6/7) and had a significantly longer CSNRT (1197 ± 647 vs 612 ± 349 milliseconds; P = .0046) and more prolonged AFCL (179 ± 19 vs 153 ± 22 milliseconds; P = .0028) than those without. The age (r = 0.26; P = .011), female sex (r = 0.25; P = .012), hypertension (r = 0.22; P = .038), and AFCL (r = 0.4; P < .0001) were significantly correlated with the CSNRT. A stepwise multivariate linear regression analysis including these parameters revealed that the AFCL was the only independent determinant of the CSNRT (β = 0.38; P = .0012). A receiver operating characteristic curve identified an AFCL of more than 162 milliseconds as the optimal cutoff value for predicting SND requiring a PMI (area under the curve, 0.84; sensitivity, 86%; specificity, 74%; P = .0066). Conclusions: A prolonged AFCL was significantly associated with SND. Thus, assessing the AFCL in the patients with long-standing persistent AF may be helpful for the risk stratification of underlying SND. [Copyright &y& Elsevier]

Background: A healthy endothelium maintains vascular tone and structure. The purpose of this study was to evaluate endothelial function in corkscrew collateral arteries in Buerger disease. Methods: We measured flow-mediated vasodilation (FMD) in corkscrew arteries in 26 patients with Buerger disease, in control arteries in 26 healthy subjects, and in native arteries in 16 patients with Buerger disease. Results: Hyperemic flow was lower in corkscrew arteries than in native arteries in patients with Buerger disease and in control arteries in healthy subjects. There was no significant difference between hyperemic flow in patients with Buerger disease in whom measurements were performed in native arteries and that in healthy subjects. FMD was lower in corkscrew arteries and native arteries in patients with Buerger disease than in control arteries in healthy subjects. There was no significant difference between FMD in corkscrew arteries in patients with Buerger disease and in that in native arteries. The ratio of FMD to hyperemic flow was significantly smaller in native arteries in patients with Buerger disease than in corkscrew arteries and in control arteries in healthy subjects (5.5 ± 6.2 vs 8.8 ± 8.9 and 9.6 ± 7.6 mL/min, P < .001, respectively). There was no significant difference in the ratio of FMD to hyperemic flow between corkscrew arteries in Buerger disease and control arteries in healthy subjects. Nitroglycerin-induced vasodilation was similar in all leg arteries. Conclusions: Endothelial function of a corkscrew collateral artery in patients with Buerger disease is maintained, while endothelial function is impaired in a native artery in Buerger disease. [Copyright &y& Elsevier]