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Background— The influences of antiplatelet therapy discontinuation on the risk of stent thrombosis and long-term clinical outcomes after drug-eluting stent implantation have not yet been addressed adequately. Methods and Results— In an observational study in Japan, 2-year outcomes were assessed in 10 778 patients undergoing sirolimus-eluting stent implantation. Data on status of antiplatelet therapy during follow-up were collected prospectively. Incidences of definite stent thrombosis were 0.34% at 30 days, 0.54% at 1 year, and 0.77% at 2 years. Thienopyridine use was maintained in 97%, 62%, and 50% of patients at 30 days, 1 year, and 2 years, respectively. Patients who discontinued both thienopyridine and aspirin had a significantly higher rate of stent thrombosis than those who continued both in the intervals of 31 to 180 days, 181 to 365 days, and 366 to 548 days after stent implantation (1.76% versus 0.1%, P P =0.02; and 2.1% versus 0.14%, P =0.004, respectively). When discontinuation of aspirin was taken into account, patients who discontinued thienopyridine only did not have an excess of stent thrombosis in any of the time intervals studied. Adjusted rates of death or myocardial infarction at 24 months were 4.1% for patients taking thienopyridine and 4.1% for patients not taking thienopyridine ( P =0.99) in the 6-month landmark analysis. Conclusions— Discontinuation of both thienopyridine and aspirin, but not discontinuation of thienopyridine therapy only, was associated with an increased risk of stent thrombosis. Landmark analysis did not suggest an apparent clinical benefit of thienopyridine use beyond 6 months after sirolimus-eluting stent implantation.

Backgrounds: Recent studies reported that the ablation strategies including ganglionated plexi ablation, linear ablation and ablation of complex and fractionated electrograms and atrial fibrillation (AF) rotors in conjunction with pulmonary vein isolation (PVI) were superior to the conventional ablation strategy aimed to eliminate AF triggers in terms of post-ablation clinical outcomes. It is controversial whether addition of above-mentioned supplementary ablation to PVI improves post-ablation clinical outcomes in persistent AF (PeAF). Purposes: To test the post-ablation clinical outcomes of our ablation strategy exclusively targeting AF triggers in paroxysmal (PAF) and PeAF, and to compare the post-ablation clinical outcomes between PAF and PeAF in a single center large series. Methods: Consecutive 1183 patients (pts) (age: 64±11 years, LA diameter: 40±6mm) with PAF (988 pts (84%)) or PeAF (195 pts (16%), AF duration: 5±3 months (range: 1-11)) who received ablation procedures in our institution were included. Irrespective of AF types, the procedure consisted of encircling PVI (EPVI) and SVC isolation (SVCI) in all pts, and additional ablation targeting non-PV, non-SVC AF triggers if spontaneous AF initiation was observed by high dose (100-400μg/hr) isoproterenol (ISP) infusion and bolus administration of 40mg of adenosine triphosphate (ATP) during ISP infusion. Procedure end point was complete elimination of spontaneous AF initiation on by ISP infusion and ATP boluses. Results: Total of 1949 procedures were performed in all 1183 pts (1.3±0.5/pt, range: 1-4). EPVI and SVCI were successful in all pts. Non-PV, non-SVC AF triggers were identified in 50 pts (4%) and eliminated by focal ablation in 42 (84%). Kaplan-Meier analysis revealed similarly favorable recurrence-free survivals after the last ablation procedure without antiarrhythmic drugs (blanking period of 1 month) in both PAF and PeAF groups (945 (96%)/988 vs. 190 (97%)/195; p>0.05, follow-up period: 414±245 days (median: 395)). Conclusions: This study exhibited that post-ablation recurrence-free survivals were similar between PAF and PeAF, even if only AF triggers were targeted. An ablation strategy targeting only AF triggers may be sufficient in both PAF and PeAF.

Backgrounds: Catheter ablation (CA) for non-paroxysmal atrial fibrillation (AF)(non-PAF) is less successful in patients (pts) with highly remodeled atria. It is still controversial that how far CA should be indicated in non-PAF pts with highly remodeled atria. Impacts of successful pharmacological cardioversion of non-PAF by oral amiodarone (AMD) on post-CA clinical outcomes remain to be evaluated. Purposes: To assess efficacy of oral AMD and implications of successful cardioversion by AMD in advance to CA on post-CA clinical outcomes in non-PAF pts. Methods: In consecutive 418 non-PAF pts (age: 63±9 years, AF duration: 28±37 months, LA diameter: 44±5mm), oral AMD (300 mg/day for 2 weeks and 100 mg/day thereafter) was initiated at outpatient clinic one month prior to the initial CA procedure. Recurrence-free survival after last CA procedure was compared between those with successful pharmacological conversion to sinus rhythm, atrial flutter or atrial tachycardia by the time of the initial CA procedure (Group non-AF) and those without (Group AF) . Results: At the beginning of initial CA procedure, 79 pts were in sinus rhythm, 8 in typical atrial flutter, 3 in atrial tachycardia (Group non-AF: 90 pts (22%)) and the remaining 328 still in AF (Group AF: 78%) . During follow-up period of 287±204 days after last CA procedure (procedure number:1.6±0.7/pt, range: 1-4), 45 pts (11%) were followed up while taking AMD, whereas the other 373 pts (89%) without any antiarrhythmic drugs. Kaplan-Meier analysis revealed that recurrence-free survival after last CA procedure was significantly higher in Group non-AF than in Group AF (88 (98%) vs. 291 (89%) pts; p=0.02) . Group non-AF pts exhibited significantly shorter AF duration (9±9 (range: 1-46) vs. 33±41 months (range: 1-240): p and smaller LA diameter (42±5 (range: 28-54) vs. 44±5 mm (range: 31-61): p as compared with those in Group AF pts. Conclusions: Successful cardioversion by AMD in advance to CA was correlated with higher recurrence-free survival after last CA procedure. This simple criterion is helpful to find pts with less remodeled atria and good candidates for CA who will benefit from CA in non-PAF pts.

Backgrounds: The electrical isolation of the thoracic veins to eliminate triggers of atrial fibrillation (AF) is the mainstay of catheter ablation (CA) for AF. AF is sometimes triggered by repetitive firings from the non-PV, non-SVC (nPVnSVC) foci, and their characteristics have not been fully elucidated. Purposes: To elucidate the incidence, characteristics and efficacy of CA of the nPVnSVC foci in AF patients (pts). Methods: Consecutive 1491 pts who received CA for AF (1080 males, age: 64±10 years, paroxysmal: 995, non-paroxysmal: 496) were included in this study. In index procedures, PV and SVC isolation were performed in all pts without subsequent provocation of nPVnSVC triggers. In repeat procedures, high dose isoproterenol (up to 400μg/hr) and boluses of adenosine triphosphate were given to provoke AF initiation by nPVnSVC triggers and focal ablation of all AF triggers was performed. Results: Among 2097 procedures in all 1491 pts, 58 AF triggers from nPVnSVC foci were provoked in 55 pts (3.7%; 30 paroxysmal and 25 non-paroxysmal AF pts) during 57 procedures (12 index and 45 repeat procedures). The pts with nPVnSVC triggers were significantly more likely to be females (42 vs 28%; P=0.03). The trigger foci were localized in the RA (20 foci; CS os in 8, crista terminalis in 7, IVC os in 3 and tricuspid annulus in 2), LA (24 foci; anterior (6), inferior (3) and posterior wall (3), roof in 3, mitral annulus in 3, Marshall vein in 5 and appendage in 1) and septum (14 foci; left (7) and right side (2) of fossa ovalis, high right septum in 4 and non-coronary cusp of the aortic sinus in 1). All AF triggers were eliminated in 46 pts (84%), while in the others they were not. During follow-up after the last procedure (284±218 days), recurrence-free survival was similar in those with and without nPVnSVC triggers (91 vs 95%; P=0.05), although mean procedure number was significantly larger in those with nPVnSVC triggers than in those without (2.1±0.6 vs 1.4±0.6 times/pt; P Conclusions: The nPVnSVC triggers were observed in 3.7% of all AF pts. The location of the triggers could be clustered to the several anatomical regions. Successful elimination of nPVnSVC triggers contributed to high post-ablation recurrence-free survival that was similar to that in those without nPVnSVC triggers.

Background: The reentry circuit of the slow-fast AV nodal reentrant tachycardia (AVNRT) has not been precisely delineated. Although conventional right-sided slow pathway ablation at the inferoseptal to midseptal tricuspid annulus (TA) or inside the coronary sinus (CS) is effective in most slow-fast AVNRT cases, rare cases of the left-variant form resistant to the conventional right-sided slow pathway ablation and requiring the left-sided ablation along the mitral annulus (MA) have been reported. Purpose: To evaluate the effects of the left-sided ablation along the MA in patients with the slow-fast AVNRT resistant to the conventional right-sided slow pathway ablation. Methods & Results: In 5 out of 250 cases with the slow-fast AVNRT who underwent the slow pathway ablation, extensive right-sided slow pathway ablation at the mid to inferoseptal TA, CS ostium or inside the CS (>10 applications) failed to eliminate tachycardia inducibility. In those 5 cases, the left-sided ablation along the inferoseptal to inferolateral MA with transseptal approach was performed during the sinus rhythm. In 2 cases, accelerated junctional rhythm was induced during the ablation along the MA and tachycardias were rendered non-inducible (upto one AV nodal echo beat). In other 2 cases, accelerated junctional rhythm was not induced during the ablation along the MA, but tachycardia became non-sustained (2-5 AV nodal echo beats). In the remaining one case, tachycardia still remained inducible even after extensive left-sided ablations. Conclusion: The left-variant forms of the slow-fast AVNRT were observed in 1.6% of all slow-fast AVNRT cases and the slow pathway ablation along the inferoseptal to inferolateral MA was effective for eliminating the tachycardia inducibility. The left-sided deviation of the reentrant circuit might explain the resistance to the right-sided slow pathway ablation and efficacy of the left-sided ablation along the MA in those cases.