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Aims: Atrial fibrillation (AF) and heart failure (HF) affect each other and are often co‐morbid. The fact that HF development is not uncommon even after ablation suggests that we need a deeper understanding of the pathology of these conditions. Atrial myocardial degeneration is an underlying factor in AF patients and may be associated with HF development after ablation. This study aimed to investigate the impact of low‐voltage areas (LVAs) on HF prognosis after AF ablation. Methods and results: This observational study included 1481 consecutive patients undergoing initial ablation for AF. Left atrial LVAs were defined as regions with a bipolar peak‐to‐peak voltage of <0.50 mV. Patients were divided into three groups: no LVA (LVA size indexed to body surface area <3 cm2/m2, n = 1129), small LVA (3–10 cm2/m2, n = 217), and extensive LVA (≥10 cm2/m2, n = 135). A composite endpoint of HF hospitalization or death occurred more frequently in patients with larger LVAs (3.3% vs. 6.5% vs. 13.3%, P < 0.0001) during the 3‐year follow up period. The extent of LVAs was independently related to the risk of the composite endpoint with an adjusted hazard ratio of 1.55 (95% confidence interval, 1.16–2.10) for each additional step of LVA classification (P = 0.003). Conclusions: LVA presence and its extent were associated with frequent HF hospitalization and death. Underlying atrial myopathy appears to define a poor HF prognosis after AF ablation. [ABSTRACT FROM AUTHOR]

An 83-year-old woman with claudication in the right lower extremity was referred to our hospital. Since angiography showed severe stenosis with a severely calcified lesion extending from the ostial to proximal part of the right superficial femoral artery (SFA), endovascular therapy (EVT) with the Jetstream™ atherectomy system (Boston Scientific, Marlborough, MA, USA) and paclitaxel-coated balloon (PCB) was performed. Atherectomy was performed using the Jetstream™ atherectomy catheter SC 1.85, followed by an additional atherectomy using the Jetstream™ atherectomy catheter XC 2.1/3.0. Subsequently, angiography and intravascular ultrasound (IVUS) images showed the enlargement of lumen area due to the reduction of calcified plaque, but even some of the healthy media on the side free of calcified plaque had been removed. Next, a PCB dilation was performed, and the final angiography showed adequate dilation. However, the symptoms recurred 9 months after EVT. Angiography revealed an enlarged vessel suggestive of pseudoaneurysm at the ostial part of the right SFA and severe stenosis distal to the enlarged vessel. IVUS images showed a pseudoaneurysm and severe stenosis due to calcified nodules distal to the pseudoaneurysm. This case suggests that pseudoaneurysm is a potential complication of EVT with the Jetstream™ atherectomy system and PCB for SFA lesions. The Jetstream™ atherectomy system (Boston Scientific, Marlborough, MA, USA) has developed to improve outcomes for femoropopliteal artery lesions with severely calcified lesions in lower extremity arterial disease by removing calcified plaque and improving vascular compliance. Several clinical reports demonstrated durable patency rates and low complication rates after endovascular therapy using the atherectomy device. However, pseudoaneurysm is a potential complication of endovascular therapy with the Jetstream™ atherectomy system. [ABSTRACT FROM AUTHOR]

The optimal duration of atrial fibrillation (AF) persistence for predicting poor outcomes after catheter ablation of long-standing AF (LsAF) and the best ablation strategy for these patients remain unclear. We aimed to assess the impact of the duration of AF persistence on outcomes after catheter ablation of AF. We analyzed the Efficacy of Pulmonary Vein Isolation Alone in Patients with Persistent Atrial Fibrillation (EARNEST-PVI) trial data comparing pulmonary vein isolation (PVI) alone (PVI-alone) with additional linear ablation or defragmentation (PVI-plus) in persistent AF (PerAF). Patients who received catheter ablation by contact force–sensing catheter were enrolled in the study. In patients with LsAF, the optimal cutoff duration of AF persistence was evaluated. With use of the threshold, patients with LsAF were divided into 2 groups and compared with PerAF <1 year for arrhythmia-free survival after a 3-month blanking period. The optimal cutoff duration was 2.4 years. Of 458 patients, arrhythmia-free survival rates for LsAF 1–2.4 years were comparable to those of PerAF (hazard ratio [HR], 1.01; 95% CI, 0.67–1.52). However, LsAF >2.4 years had a higher recurrence risk than PerAF (HR, 2.22; 95% CI, 1.42–3.47). In LsAF >2.4 years, the PVI-plus strategy showed advantages over the PVI-alone strategy (HR, 0.36; 95% CI, 0.14–0.89). However, the interaction effect between LsAF 1–2.4 years and LsAF >2.4 years did not reach statistical significance (P =.116). Whereas LsAF 1–2.4 years has similar outcomes to those of PerAF, LsAF >2.4 years was linked to higher arrhythmia recurrence risks. For LsAF >2.4 years, the PVI-plus strategy showed a potential to be superior to the PVI-alone strategy. [Display omitted] [ABSTRACT FROM AUTHOR]

Backgrounds: Lead dislodgement is a severe complication in cardiac implantable electronic device (CIED) implantation. Inflammation after CIED implantation results in the development of adhesions between lead and tissues, resulting in the lead becoming fixed in the body. In patients with immunosuppressive therapy, however, adhesion is inhibited by anti‐inflammatory effects. However, the association between lead dislodgement and immunosuppressive therapy has not been clarified. The purpose of this study was to investigate the association between lead dislodgement and immunosuppressive therapy. Hypothesis: We hypothesized that lead dislodgement more frequently occur in patients with immunosuppressive therapy than those without. Methods: In total, 651 consecutive patients who underwent CIED implantation or lead addition (age, 76 ± 11 years; and males, 374 [58%], high voltage device, 121 [19%], lead addition 23 [4%]) were retrospectively enrolled. Immunosuppressive therapy was with regular steroids or immunosuppressants. Lead placement was guided by fluoroscopy, and active fixation leads were used. Restraint of the upper limb by chest tape was performed for 1 week after the procedure. Lead dislodgement was defined as a change in lead position and/or lead failure requiring reoperation. Results: Twenty (3.1%) patients received immunosuppressive therapy. Among these, 15 (2.3%) patients regularly took steroids and 8 (1.2%) took immunosuppressants. Lead dislodgement occurred in 10 (1.5%) patients. Lead dislodgement was more frequent in patients with immunosuppressive therapy than in those without (3 [15%] vs. 7 [1%], p = 0.003). Conclusion: In patients with CIED implantation or lead addition, lead dislodgement is more frequent in patients with immunosuppressive therapy than in those without. [ABSTRACT FROM AUTHOR]

Aims Blood stasis is crucial in developing left atrial (LA) thrombi. LA appendage peak flow velocity (LAAFV) is a quantitative parameter for estimating thromboembolic risk. However, its impact on LA thrombus resolution and clinical outcomes remains unclear. Methods and results The LAT study was a multicentre observational study investigating patients with atrial fibrillation (AF) and silent LA thrombi detected by transoesophageal echocardiography (TEE). Among 17 436 TEE procedures for patients with AF, 297 patients (1.7%) had silent LA thrombi. Excluding patients without follow-up examinations, we enrolled 169 whose baseline LAAFV was available. Oral anticoagulation use increased from 85.7% at baseline to 97.0% at the final follow-up (P < 0.001). During 1 year, LA thrombus resolution was confirmed in 130 (76.9%) patients within 76 (34–138) days. Conversely, 26 had residual LA thrombi, 8 had thromboembolisms, and 5 required surgical removal. These patients with failed thrombus resolution had lower baseline LAAFV than those with successful resolution (18.0 [15.8–22.0] vs. 22.2 [17.0–35.0], P = 0.003). Despite limited predictive power (area under the curve, 0.659; P = 0.001), LAAFV ≤ 20.0 cm/s (best cut-off) significantly predicted failed LA thrombus resolution, even after adjusting for potential confounders (odds ratio, 2.72; 95% confidence interval, 1.22–6.09; P = 0.015). The incidence of adverse outcomes including ischaemic stroke/systemic embolism, major bleeding, or all-cause death was significantly higher in patients with reduced LAAFV than in those with preserved LAAFV (28.4% vs. 11.6%, log-rank P = 0.005). Conclusion Failed LA thrombus resolution was not rare in patients with AF and silent LA thrombi. Reduced LAAFV was associated with failed LA thrombus resolution and adverse clinical outcomes. [ABSTRACT FROM AUTHOR]

Aims Understanding of the tissue cooling properties of cryoballoon ablation during pulmonary vein (PV) isolation is lacking. The purpose of this study was to delineate the depth of the tissue cooling effect during cryoballoon freezing at the pulmonary venous ostium. Methods and results A left atrial-PV model was constructed using a three-dimensional printer with data from a patient to which porcine thigh muscle of various thicknesses could be affixed. The model was placed in a 37°C water tank with a PV water flow at a rate that mimicked biological blood flow. Cryofreezing at the PV ostium was performed five times each for sliced porcine thigh muscle of 2, 4, and 6 mm thickness, and sliced muscle cooling on the side opposite the balloon was monitored. The cooling effect was assessed using the average temperature of 12 evenly distributed thermocouples covering the roof region of the left superior PV. Tissue cooling effects were in the order of the 2, 4, and 6 mm thicknesses, with an average temperature of −41.4 ± 4.2°C for 2 mm, −33.0 ± 4.0°C for 4 mm, and 8.0 ± 8.7°C for 6 mm at 180 s (P for trend <0.0001). In addition, tissue temperature drops were steeper in thin muscle (maximum temperature drop per 5 s: 5.2 ± 0.9°C, 3.9 ± 0.7°C, and 1.3 ± 0.7°C, P for trend <0.0001). Conclusion The cooling effect of cryoballoon freezing is weaker in the deeper layers. Cryoballoon ablation should be performed with consideration to myocardial thickness. [ABSTRACT FROM AUTHOR]

Introduction: Left atrial low‐voltage areas (LVAs) are known to be correlated with atrial scarring and atrial fibrillation (AF) recurrence after ablation. However, the association between LVAs and glycemic status before ablation has not been fully clarified. The purpose of this study was to investigate associations among the prevalence of diabetes mellitus (DM), glycemic control, and the prevalence of LVAs in patients with AF ablation. Methods: In total, 912 (age, 68 ± 10 years; female, 299 [33%]; persistent AF, 513 [56%]) consecutive patients who underwent initial AF ablation were included. A preprocedure glycated hemoglobin A1c (HbA1c) ≥7% was set as the cutoff for poor glycemic control in patients with DM. LVAs were defined as areas with a bipolar voltage of <0.5 mV covering ≥5 cm2 of left atrium. Results: LVAs existed in 208 (23%) patients, and 168 (18%) patients had DM. LVAs were found more frequently in patients with DM and poor glycemic control. On multivariate analysis, DM with HbA1c ≥7% was an independent predictor of LVAs (odds ratio, 3.3; 95% confidence interval: 1.6–6.7; p =.001). In patients with LVAs, freedom from AF recurrence during the 24‐month study period was significantly lower in patients who had DM with HbA1c ≥7% than in those without DM (37.9% vs. 54.7%, p =.02). Conclusion: In patients with AF ablation, LVAs were found more frequently in patients with DM and poor glycemic control. DM with HbA1c ≥7% was an independent predictor of LVAs. [ABSTRACT FROM AUTHOR]

Introduction: Atrial fibrillation (AF) is accompanied by various types of remodeling, including volumetric enlargement and histological degeneration. Electrical remodeling reportedly reflects histological degeneration. Purpose: To clarify the differences in determinants and clinical impacts among types of remodeling. Methods: This observational study included 1118 consecutive patients undergoing initial ablation for AF. Patients were divided into four groups: minimal remodeling (left atrial volume index [LAVI] < mean value and no low‐voltage area [LVA], n = 477); volumetric remodeling (LAVI ≥ mean value and no LVA, n = 361); electrical remodeling (LAVI < mean value and LVA presence, n = 96); and combined remodeling (LAVI ≥ mean value and LVA presence, n = 184). AF recurrence and other clinical outcomes were followed up for 2 and 5 years, respectively. Results: Major determinants of each remodeling pattern were high age for electrical (odds ratio = 2.32, 95% confidence interval = 1.68–3.25) and combined remodeling (2.57, 1.88–3.49); female for electrical (3.85, 2.21–6.71) and combined remodeling (4.92, 2.90–8.25); persistent AF for combined remodeling (7.09, 3.75–13.4); and heart failure for volumetric (1.71, 1.51–2.53) and combined remodeling (2.21, 1.30–3.75). Recurrence rate after initial ablation increased in the order of minimal remodeling (20.1%), volumetric (27.4%) or electrical remodeling (36.5%), and combined remodeling (50.0%, p <.0001). A composite endpoint of heart failure, stroke, and death occurred in the order of minimal (3.4%), volumetric (7.5%) or electrical (8.3%), and combined remodeling (15.2%, p <.0001). Conclusion: Volumetric, electrical, and combined remodeling were each associated with a unique patient background, and defined rhythm and other clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Recently, a new OCTARAY® mapping catheter was commercially launched. The catheter is designed to enable high‐density mapping and precise signal recording via 48 small electrodes arranged on eight radiating splines. The purpose of this study was to compare bipolar voltage and low‐voltage‐area size, and mapping efficacy between the OCTARAY catheter and the PENTARAY® catheter Methods: Twelve consecutive patients who underwent initial and second ablations for persistent atrial fibrillation within 2 years were considered for enrollment. Voltage mapping was performed twice, first during the initial ablation using the PENTARY catheter and second during the second ablation using the OCTARAY Long 3‐3‐3‐3‐3 (L3) catheter. Results: Mean voltage with the OCTARAY‐L3 catheter (1.64 ± 0.57 mV) was 32.3% greater than that with the PENTARAY catheter (1.24 ± 0.46 mV, p <.0001) in total left atrium. Low‐voltage‐area (<0.50 mV) size with the OCTARAY‐L3 catheter was smaller than that with the PENTARAY catheter (6.9 ± 9.7 vs. 11.4 ± 13.0 cm2, p <.0001). The OCTARAY‐L3 catheter demonstrated greater efficacy than the PENTARAY catheter in terms of shorter mapping time (606 ± 99 vs. 782 ± 211 s, p =.008) and more mapping points (3,026 ± 838 vs. 781 ± 342 points, p <.0001). Conclusion: The OCTARAY catheter demonstrated higher voltage recordings, narrower low‐voltage areas, and a more efficacious mapping procedure than the PENTARAY catheter. [ABSTRACT FROM AUTHOR]