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Background: Atrial fibrillation (AF) is an established risk factor for ischemic stroke in a general population. However, its impact in patients on hemodialysis (HD), a group with a high risk for stroke, is still controversial. Here we examined this issue in a Japanese cohort., Methods: This study was designed as a multicenter cohort study. HD patients (n = 1,067) were enrolled from 22 institutes in January 2009 and followed up for 3 years. Patients with missing data (n = 196) or kidney transplantation (n = 4) were excluded, and 867 patients contributed to the analysis of the risk of new-onset of ischemic stroke., Results: At baseline, AF was observed in 123 patients (14.2%, AF group) and not in the others (n = 744: 85.8%, non-AF group). During a follow-up period of 31.3 months, the cumulative incidence rate for ischemic stroke was significantly higher in the AF group than in the non-AF group (6.5% vs. 2.9%, p < 0.05). In Cox regression analysis, AF was a significant independent risk factor for new-onset of ischemic stroke after adjustment for age, sex, prior history of ischemic stroke, use of warfarin, dialysis vintage, comorbidity of diabetic nephropathy, and interdialytic weight gain (hazard ratio 2.17-2.68)., Conclusion: Present analyses using comprehensive adjustment for multiple confounders, including prior history of ischemic stroke, indicated that AF independently increases the risk of new-onset of ischemic stroke by more than twofold in Japanese HD patients.

Purpose: High parasympathetic nervous system (PNS) activity is accurately reflected by deceleration capacity (DC) and is involved in atrial fibrillation (AF) recurrence after catheter ablation procedure. When compared with initial catheter ablation procedure, repeated procedures for AF recurrence are followed by a lower success rates, estimated at 50%. Our objective was to evaluate the impact of PNS activity assessed by DC measured before repeated procedure on AF recurrence after repeated procedure., Methods: Consecutive patients who underwent an initial catheter ablation procedure for pulmonary vein (PV) isolation and a repeated catheter ablation procedure for AF recurrence were selected. Additional 24-h ambulatory electrocardiographic recording between procedures for DC measurement was required for inclusion. A total of 110 patients were included. Seventy-two patients underwent cryoballoon (CB) ablation and 38 patients underwent radiofrequency (RF) ablation as initial procedure, while all patients underwent RF ablation as repeated procedure., Results: DC was higher in cases with right-sided PV reconnection (p = 0.04, OR = 1.38, 95% CI = 1.08-1.78). In patients with CB ablation as initial procedure, DC was higher in patients with PV reconnection (p = 0.03, OR = 1.29, 95% CI = 1.11-1.70), and the number of reconnected PVs was higher in patients with DC ≥ 7.0 ms (median DC value used for dichotomization, p = 0.02, OR = 2.19, 95% CI = 1.10-4.37). In multivariate Cox regression, DC predicted AF recurrence after repeated ablation (p = 0.004, HR = 1.68, 95% CI = 1.35-1.82). In multivariate binary regression, DC predicted persistent AF type recurrence after repeated ablation (p = 0.01, OR = 1.50, 95% CI = 1.10-2.02)., Conclusions: DC is a novel predictor of AF recurrence and AF recurrence type after repeated catheter ablation procedure. DC may reflect the need of more intensive treatment strategies in patients with high PNS activity.

Purpose: There is still sparse information regarding phrenic nerve palsy (PNP) during the cryoablation of both right-sided pulmonary vein (PV) and its anatomical predictors., Methods: Consecutive patients who had undergone pulmonary vein isolation (PVI) using CB-A and suffered PNP during both right-sided PVs were retrospectively included in our study. Two other groups were then selected among patients who experienced PNP during RIPV application only (group 2) and RSPV application only (group 3)., Results: The incidence of PNI during both right-sided PVs cryoapplications was 2.1%, (32 of 1542 patients). There were no significant clinical differences between the 3 groups. Time from basal temperature to -40 °C significantly differed among the groups for both RIPV (p = 0.0026) and RSPV applications (p = 0.0382). Patients with PNP occurring during RSPV applications had significantly larger RSPV cross-sectional area compared to patients without PNP (p = 0.0116), while in patients with PNP during RIPV application, the angle of RIPV ostium on the transverse plane was significantly smaller compared to patients without PNP (p = 0.0035). The carina width was significantly smaller in patients with PNP occurring during both right-sided PVs cryoapplications compared to patients in which PNP occurred only during one right-sided PV application (p < 0.0001); a cutoff value of 8.5 mm had a sensitivity of 87.3% and a specificity of 75.0%., Conclusion: PNP in both right-sided PVs applications is a complication that occurred in 2.1% of cases during CB-A. Pre-procedural evaluation of right PVs anatomy might be useful in evaluating the risk of PNP.

Purpose: The purpose of this study was to analyze the efficacy and complication rates of a one-stage left unilateral thoracoscopic hybrid procedure in a series of patients with persistent and long-standing persistent atrial fibrillation (AF) in a 2-year follow-up., Methods: Fifty-one consecutive patients (34 males, 65.7 ± 8 years) having undergone hybrid isolation of pulmonary veins (PVs) and posterior wall of left atrium (LA) by means of left unilateral hybrid thoracoscopic ablation for symptomatic persistent (n = 22, 43%) and long-standing persistent atrial fibrillation (AF) (n = 29, 57%) were analyzed., Results: At a mean follow-up of 24.9 ± 11.8 months (median 24), the success rate without antiarrhythmic therapy was achieved in 68.6% of patients. Procedure-related major complications were observed in 2 patients (4%) including diaphragmatic perforation and late pericardial tamponade requiring mini left-sided thoracotomy and pericardial drainage, respectively. The success rate did not significantly differ between persistent and long-standing persistent AF (respectively, 68.2 and 69%; P = 0.89). Patients with AF relapse during the blanking period were 3.8 times more likely to have AF recurrence after 3 months from the ablation procedure., Conclusion: The hybrid one-stage left unilateral thoracoscopic procedure exhibits encouraging results in the setting of both persistent and long-standing persistent AF after a 2-year follow-up, at a low rate of adverse events.

Owing to a type error during final correction and proof data submission to the journal, there were mistakes introduced into the legends of Fig. 3 and Fig. 4 as well as into the Y-axis title of the plot of Fig. 4.

Background: The creation of a posterior box isolation of the left atrium (LAPWI) in addition to pulmonary vein isolation (PVI) with the second-generation cryoballoon (CB-A) seems to offer promising clinical outcome in patients affected by persistent atrial fibrillation (PersAF)., Aim: This work aims to study the clinical outcome of an ablation strategy based on the creation of a LAPWI during repeat procedures for recurrent AF after an index CB-A procedure for PersAF., Methods and Results: A total of 33 patients having undergone a repeat procedure consisting in redo PVI plus LAPWI for recurrent PersAF with the CB-A after an index PVI ablation were retrospective included in our study. Electrical reconnection could be documented in 18 veins (13%). The LAPW was successfully isolated solely by CB-A ablation in 30 out of 33 (91%) patients; in the remaining 3 patients, isolation of the LAPW was completed by focal tip-irrigated RF ablation. The mean number of CB-A applications required for the superior portion of the LAPW and the inferior portion of the LAPW creation were 5.4 ± 0.9 and 4 ± 0.6, respectively. After a mean follow-up of 11.8 ± 3 months, 28 patients (85%) did not experience recurrence of any atrial arrhythmias during follow-up, without the need of further ablation or class I or III AADs., Conclusion: Left posterior wall isolation with the CB-A is feasible and safe during repeat ablation procedures for recurrent PersAF. In our study, the 12-month freedom from any arrhythmia was 85% following this ablation strategy.

Purpose: The purpose of this study was to clarify the behavior of the luminal esophageal temperature (LET) in a cohort of patients undergoing second-generation cryoballoon (CB-A) for pulmonary vein isolation (PVI) and additional left atrium posterior wall (LAPW) ablation by means of CB-A., Methods: Thirty patients with symptomatic persistent AF (PersAF), having undergone PVI + LAPW cryoballoon ablation with LET monitoring., Results: Interruption of the application due to a LET below 15 °C occurred in 5 patients (16.6%), 2 at the LIPV and 3 in the LAPW. The 5 patients underwent gastroscopy the day after ablation. In all individuals, esophageal thermal lesion (ETL) was absent., Conclusion: The evaluation of LET might be an additional tool in helping to prevent damage to the esophagus during the LAPW ablation with the CB-A by stopping the freeze application when temperature reaches values of < 15 °C.

Rhamnan sulfate (RS) is a polysaccharide with a rhamnose backbone isolated from Monostroma nitidum. Like heparin, it exerts anticoagulant activity in the presence of antithrombin. Endothelial cells facilitate the crosstalk between blood coagulation and vascular inflammation. In this study, we compared the effect of RS with that of heparin on blood coagulation and vascular endothelial cells in the presence or absence of inflammatory factors, using human umbilical vein endothelial cells. We found that RS significantly enhances inhibition of thrombin and factor Xa in the presence of antithrombin as well as heparin, and that RS inhibits tissue factor expression and von Willebrand factor release from the endothelial cells treated with or without lipopolysaccharide, tumor necrosis factor-α, or thrombin. Heparin did not show any effects on endothelial cell inflammation. Our findings suggest that RS, like heparin, is an antithrombin-dependent anticoagulant and, unlike heparin, is a potent anti-inflammatory agent acting on vascular endothelial cells.

Purpose: The purpose of the present study was to assess the long-term success rate of a single 3-min freeze per vein ablation strategy in the setting of pulmonary vein isolation (PVI) by means of second-generation cryoballoon (CB-A; Arctic Front Advance, Medtronic, Minneapolis, MN, USA) in a large cohort of patients., Methods: Three hundred and one patients with drug resistant atrial fibrillation (AF) having undergone PVI by means of CB-A using a single 3-min freeze per vein ablation strategy were included in the analysis., Results: Paroxysmal AF (PAF) was documented in 70.8% of the patients, while 29.2% presented with persistent AF (PersAF). The mean number of CB applications was 1.09 ± 0.3 in the left superior pulmonary vein (LSPV), 1.04 ± 0.2 in the left inferior pulmonary vein (LIPV), 1.12 ± 0.3 in the right superior pulmonary vein (RSPV), and 1.12 ± 0.3 in the right inferior pulmonary vein (RIPV). All PVs were successfully isolated with a 28-mm CB-A only. After a mean follow-up of 38.1 ± 7.5 months, 207 (68.8%) patients were free of atrial tachyarrhythmia (ATa) recurrences following a single procedure. Specifically, 72.8% of patients presenting with PAF and 59.1% of individuals with PersAF did not experience a recurrence., Conclusions: A single 3-min freeze per vein strategy is effective in treating AF on a long term follow-up of 38 months. Specifically, it can afford freedom from ATa recurrences in 72.8% of patients affected by PAF and 59.1% of patients initially presenting with PersAF after a single CB-A procedure.

Background: Indocyanine green (ICG)-fluorescence imaging has been developed for real-time identification of hepatic tumors and segmental boundaries during hepatectomy. Fusion ICG-fluorescence imaging (real-time visualization of pseudocolor-fluorescence signals on white-light color images) may serve as a reliable navigation tool especially in laparoscopic hepatectomy, in which gross inspection and palpation are limited., Methods: The study population consisted of 41 patients undergoing laparoscopic hepatectomy. Hepatic tumors were identified by fluorescence imaging following the preoperative intravenous administration of ICG (0.5 mg/kg body weight). To visualize hepatic perfusion and segmental boundaries, ICG (1.25 mg) was injected intravenously during surgery, following closure of the proximal portal pedicle. A laparoscopic imaging system, which enabled superimposition of the pseudocolor-fluorescence images on white color images, was used for the fusion ICG-fluorescence imaging., Results: Among the 53 malignant tumors resected, fusion ICG-fluorescence imaging revealed 45 nodules (85%), including three nodules of colorectal liver metastasis unidentifiable by white-light color images or intraoperative ultrasonography. It also delineated the segmental boundaries on the hepatic raw surfaces as well as on the phrenic/visceral surfaces in all 12 patients evaluated using this technique., Conclusions: Fusion imaging enhances the feasibility of intraoperative ICG-fluorescence imaging in the identification of hepatic tumors and segmental boundaries. It may therefore help surgeons in the safe and accurate completion of laparoscopic hepatectomies.

Background: The aim of this study was to demonstrate the detailed surgical techniques of laparoscopic hepatectomy using intercostal transthoracic trocars for subcapsular tumors located in segment VII or VIII., Methods: Intercostal transthoracic trocars were used in patients undergoing laparoscopic hepatectomy for tumors located in segment VII or VIII. Following establishment of pneumoperitoneum and placement of abdominal trocars, balloon-tipped trocars were inserted into the abdominal cavity from the intercostal space and through the pleural space and diaphragm. Upon placement of the intercostal trocars, the lung edge was confirmed by ultrasonography and laparoscopic examination. Following minimal mobilization of the right liver, hemispherical wedge resection of segment VII or VIII was performed using the intercostal trocars as a camera port or for the forceps of the surgeon's left hand. After the hepatectomy, the holes in the diaphragm were sutured closed., Results: Among the 79 patients who underwent laparoscopic hepatectomy, intercostal trocars were used in 14 patients for resection of tumors located in segment VII (4 nodules) or VIII (10 nodules). The median (range) operation time and amount of blood loss for hepatectomy were 225 (109-477) min and 60 (20-310) mL, respectively. No postoperative complications associated with hepatectomy or the use of intercostal trocars occurred., Conclusions: Use of intercostal transthoracic trocars is safe and effective not only for complicated laparoscopic hepatectomy but also for hemispherical wedge resections of subcapsular hepatic tumors located in segment VII or VIII.

We have been investigating the relationship between learning and thiamine. Electrical stimulation of mesencephalic periaqueductal gray matter (PAG) is known to have an aversive effect and elicits spontaneous instrumental escape behavior. We taught rats to press a lever to escape from the pain of electrical stimulation by learning to turn a switch off. Then we examined the relationship between learning and the thiamine concentration in various portions of the brain. (1) One group of rats was given a normal diet and another group was given a thiamine-deficient diet which contained half of the amount of thiamine present in the normal diet. We measured the response time required for each rat to react by moving after an electrical impulse was applied, and the running time during which the rat was moving from the starting point to the end point to press a lever. The rats that were fed the thiamine-deficient diet showed a slower response time and a longer running time than the rats fed the normal diet. (2) We divided the rats fed the normal diet into two groups, one group trained to switch off a lever and the other group not trained for such a task. We found that the thiamine concentration in the blood of the rats in the trained group was significantly higher than that in the group without training.