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INTRODUCTION Some patients have late recurrence after acutely successful radiofrequency catheter ablation (RFCA) of premature ventricular complexes (PVCs). The aim of this study was to evaluate predictors of long-term success following acutely successful PVC RFCA. METHODS We identified consecutive patients at our institution with frequent PVCs undergoing RFCA and reviewed procedural data and medical records. Acute success was defined as elimination of targeted PVCs for at least 30-min after RFCA. Long-term success was defined as absence of targeted PVCs during all follow-up visits and PVC-burden

Eosinophilic esophagitis (EoE) is an immune or antigen-mediated chronic inflammatory esophageal disorder that is relatively rare in Asian countries. The main symptoms of EoE are dysphagia and food impaction. Although chest pain is a symptom of EoE, it is also a symptom of coronary heart disease. This paper reports a case of EoE with angina pectoris in a 45-year-old male who was referred to the authors’ hospital for chest pain. He was diagnosed with angina pectoris because of mild stenosis in the left coronary artery on coronary angiography. On the other hand, the symptoms did not improve with angina medication therapy. Therefore, he underwent a chest CT scan, which revealed esophageal thickening. Esophagogastroduodenoscopy was performed. His endoscopic findings showed linear furrows with edema, and >90 eosinophils existed per high-power field on the histology findings. He was diagnosed with EoE. Through additional examinations, he was also diagnosed with asthma. The patient was treated with a proton pump inhibitor and a fluticasone inhaler. His symptoms and abnormal endoscopic findings disappeared after eight weeks of treatment. This case shows that physicians should consider the possibility of the symptoms for EoE when unexplained chest pain persists.

Background No independently validated score currently exists for risk stratification of patients with frequent premature ventricular complexes (PVCs). Objectives The purpose of this study was to develop a risk score to predict adverse events in patients with frequent PVCs. Methods We analyzed consecutive patients between 2012 and 2017 undergoing 14-day continuous monitoring with frequent PVCs (>5%) and concurrent echocardiography. We performed binary logistic regression to determine multivariate predictors of adverse left ventricular remodeling (left ventricular ejection fraction [LVEF] 75 mL/m2). A risk score was created using the log(odds ratio (OR)) of these predictors and validated prospectively to determine the risk of future adverse events in those with baseline LVEF >45%. An adverse event was defined as LVEF decline by 10%, heart failure hospitalization, or cardiovascular mortality. Two validation cohorts were used: follow-up from the original derivation cohort (cohort 1) and an independent Korean PVC registry (cohort 2). Results The derivation cohort comprised 206 patients with a mean PVC burden of 11.6% ± 6.2% and considerable daily fluctuation (minimum burden 7.3% ± 6.2% vs maximum 17.9% ± 8.0%). Independent predictors of adverse remodeling were as follows: superiorly directed PVC axis (OR 2.7; 1 point), PVC burden 10%–20% (OR 3.5; 2 points) and >20% (OR 4.4; 3 points), PVC coupling interval >500 ms (OR 4.7; 4 points), nonsustained ventricular tachycardia (OR 5.3; 4 points), which form the ABC-VT risk score. This score predicted future adverse events in both validation cohorts: cohort 1, hazard ratio 1.43; 95% confidence interval 1.19–1.73; P Conclusion The ABC-VT score is a simple tool that predicts adverse left ventricular remodeling and future clinical deterioration in patients with frequent PVCs.

Background Frequent ventricular premature depolarizations (VPDs) can cause reversible cardiomyopathy (CMP). However, many patients maintain a normal left ventricular (LV) function with a high VPD burden. The electrocardiographic characteristics of VPD‐induced CMP have not been elucidated. Methods One hundred and eighty (91 men, age; 51 ± 15 years) patients with frequent idiopathic VPDs (>10% VPDs/day or >10 000 VPDs/day) were studied. All patients underwent successful ablation and were then divided into two groups according to the echocardiographic findings before and after the ablation procedure. Results Group A (n = 139) had a normal LV function with VPD frequencies, and Group B (n = 41) had reversible LV dysfunction after ablation. The VPD QRS duration (QRSd) was wider in patients with CMP (Group A vs Group B; 137.2 ± 12.0 milliseconds vs 159.7 ± 5.3 milliseconds, P, Figure 1 Eletrocardiographic parameters. A, CI and post‐VPD CI; B, QR and RS interval and amplitude; C, r/R transition interval; D, Initial and terminal Angle of VPD. Abbreviations: CI, coupling interval; SCL, sinus cycle length; VPD, ventricular premature depolarization

Objectives Intracoronary injection of acetylcholine (Ach) has been shown to induce significant coronary artery spasm (CAS) in patients with vasospastic angina. Clinical significance and angiographic characteristics of patients with ischemic electrocardiogram (ECG) changes during the Ach provocation test are not clarified yet. Methods A total 4,418 consecutive patients underwent coronary angiography with Ach provocation tests from 2004 to 2012 were enrolled. Ischemic ECG changes were defined as transient ST-segment depression or elevation ( > 1 mm) and T inversion with/without chest pain. Finally, a total 2,293 patients (28.5% of total subjects) proven CAS were enrolled for this study. Results A total 119 patients (5.2%) showed ECG changes during Ach provocation tests. The baseline clinical and procedural characteristics are well balanced between the two groups. Ischemic ECG change group showed more frequent chest pain, higher incidence of baseline spasm, severe vasospasm, multi-vessel involvement, and more diffuse spasm ( > 30 mm) than those without ischemic ECG changes. At 5 years, the incidences of death, major adverse cardiac events (MACE) and major adverse cardiac and cerebral events (MACCE) were higher in the ischemic ECG change group despite of optimal medical therapy. Conclusions The patients with ischemic ECG changes during Ach provocation tests were associated with more frequent chest pain, baseline spasm, diffuse, severe and multi-vessel spasm than patients without ischemic ECG changes. At 5-years, the incidences of death, MACE and MACCE were higher in the ischemic ECG change group, suggesting more intensive medical therapy with close clinical follow up will be required.

Introduction: Some patients(pts) have late recurrence after acutely successful radiofrequency catheter ablation(RFCA) of premature ventricular complexes (PVC). Hypothesis: The aim of this study was to evaluate predictors of long term success following acutely successful PVC ablation. Methods: From 2016-19, we identified consecutive pts at our institution with frequent PVCs undergoing RFCA and reviewed procedural data and medical records. Earliest local activation on the intracardiac bipolar and unipolar electrogram was measured using digital calipers. Acute success was defined as elimination of targeted PVC for at least 30 mins after RFCA. Long term success was defined as absence of PVC on 12 lead ECG during all follow up (f/u) visits and PVC burden reduction >80% or PVC burden Results: Among 241 pts, 161 (66.8%) pts had long term success with mean f/u of 17.6±5.8 months.In univariate analysis, diabetes mellitus and alcohol use were associated with PVC recurrence while age, female sex, acute success, ablation time, right ventricular PVC origin, single PVC morphology (sPVC), and earliest bipolar activation>24msec pre-QRS were associated with long-term success. In multivariate analysis, female sex, sPVC and earliest activation >24 msec preQRS were independent predictors of long term success at 1 year. The positive predictive value of earliest bipolar onset preQRS of PVC>24msec for long term success was 0.77(P Conclusions: Female gender, sPVC, and earliest onset of bipolar electrogram preQRS>24msec were predictors of long term success in patients with PVC undergoing RFCA. If local onset is

Electrocardiographic (ECG) criteria identifying right- and left-sided outflow tract origins have been established. The purpose of this study was to define the criteria for premature ventricular contractions (PVCs) originating from the right coronary cusp (RCC) adequately. We analyzed ECG and electrophysiologic study data from patients who underwent successful ablation of PVCs originating from the RCC and right ventricular outflow tract (RVOT). Eighteen RCC and 28 septal RVOT PVCs were studied. Among these 18 successful RCC PVCs, a predominantly positive QRS in lead I in 18/18 (100%), longer V1–2 R-wave duration (81.4 ± 31.1 vs 44.8 ± 7.0 ms, P = .02), V1–2 R wave duration index (RWDI) (51.3 ± 22.0 vs 31.2 ± 7.5%, P = .06) were observed compared to those with posteroseptal RVOT. Local ventricular activation time preceding QRS onset was significantly earlier (−38 ± 12 ms) at the successful RCC ablation site compared to the failed ablation site of the septal RVOT (−22 ± 8 ms), even without good pace mapping at the RVOT (P

BACKGROUND Recent studies have demonstrated that angiotensin receptor neprilysin inhibitors (ARNIs) can reverse the cardiac remodeling effects that occur in heart failure with reduced ejection fraction (HFrEF). These studies have also suggested that ARNIs have favorable effects on ventricular dyssynchrony. We assessed the changes in QRS duration associated with ARNIs in patients with HFrEF. METHODS We retrospectively investigated patients with HFrEF (defined by a left ventricular ejection fraction [LVEF] ≤ 35%) who were treated with ARNIs for at least six months. We divided the patients into QRS shortening and non-QRS shortening groups according to their electrocardiogram (ECG) findings. We also compared changes in echocardiographic parameters between the groups. RESULTS A total of 68 patients with HFrEF were included (mean age: 62.5 years, 74.6% male). Twenty-one patients had significant ischemic heart disease (IHD). Thirty-five patients exhibited QRS-duration shortening on follow-up ECGs (mean change: -7.8 msec), and 33 patients showed no changes or increased QRS duration (mean change: 5.1 msec). The QRS shortening group exhibited significant improvement in LVEF (12.5 ± 15.3% vs. 1.7 ± 9.5%; p < 0.001) when compared with the non-QRS shortening group. The QRS shortening group also had significantly lower LV end-diastolic dimension (LVEDD), LV end-systolic dimension (LVESD) and LV mass index (LVMI) than did the non-QRS shortening group. The change in QRS duration was significantly correlated with the change in LVEF (r = -0.329, p = 0.011) and LVESD (r = 0.298, p = 0.022). CONCLUSIONS Among patients with HFrEF treated with ARNIs, the QRS shortening group showed favorable LV systolic function recovery, and reversal of cardiac remodeling compared to those of the non-QRS shortening group. Change in the QRS duration, which reflects LV synchrony, may be associated with response to ARNIs in patients with HFrEF.

Background An implantable loop recorder (ILR) is an effective tool for diagnosing unexplained syncope (US). We examined the diagnostic utility of an ILR in detecting arrhythmic causes of US and determining which clinical factors are associated with pacemaker (PM) implantation. Methods This retrospective, multicenter, observational study was conducted from February 2006 to April 2018 at 11 hospitals in Korea. Eligible patients with recurrent US received an ILR to diagnose recurrent syncope and document arrhythmia. Results A total of 173 US patients (mean age, 67.6 ± 16.5 years; 107 men [61.8%]) who received an ILR after a negative conventional workup were enrolled. During a mean follow-up of 9.4 ± 11.1 months, 52 patients (30.1%) had recurrent syncope, and syncope-correlated arrhythmia was confirmed in 34 patients (19.7%). The ILR analysis showed sinus node dysfunction in 24 patients (70.6%), supraventricular tachyarrhythmia in 4 (11.8%), ventricular arrhythmia in 4 (11.8%), and sudden atrioventricular block in 2 (5.9%). Overall, ILR detected significant arrhythmia in 99 patients (57.2%) irrespective of syncope. Among patients with clinically relevant arrhythmia detected by ILR, PM implantation was performed in 60 (34.7%), an intra-cardiac defibrillator in 5 (2.9%), and catheter ablation in 4 (2.3%). In a Cox regression analysis, history of paroxysmal atrial fibrillation (PAF) (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.33–4.12; P < 0.01) and any bundle branch block (BBB) (HR, 2.52; 95% CI, 1.09–5.85; P = 0.03) were significantly associated with PM implantation. Conclusion ILR is useful for detecting syncope-correlated arrhythmia in patients with US. The risk of PM is high in US patients with a history of PAF and any BBB., Graphical Abstract

Background Stroke and thromboembolic events may still occur in “clinically low‐risk” atrial fibrillation ( AF ) patients as categorized by CHA 2 DS 2 ‐ VAS c score. Our aim was to assess the proportion of “clinically low‐risk” patients using a nongender CHA 2 DS 2 ‐ VAS c (ie, CHA 2 DS 2 ‐ VA ) score of 0 to 1 among patients who experienced AF ‐associated stroke and to identify markers associated with stroke in “clinically low‐risk” patients. Methods and Results We retrospectively recruited nonvalvular AF patients who experienced embolic stroke between 2013 and 2016 from 9 institutes in Korea. AF patients with CHA 2 DS 2 ‐ VA score of 0 to 1 at the time of stroke were analyzed and compared with “clinically low‐risk” AF patients without stroke. A total of 3033 subjects with AF ‐associated stroke were recruited. Of these, 583 patients (19.2%) had CHA 2 DS 2 ‐ VA score of 0 to 1. On multivariate analysis, age (≥60 years), N‐terminal pro B‐type natriuretic peptide (≥300 pg/mL), creatinine clearance (ABCD score) to the “clinically low‐risk” patients, the c‐index was 0.858 (95% CI 0.838–0.877; P Conclusions The present study suggests a new insight into how additional use of markers can further refine stroke risk differentiation among AF patients initially classified as “clinically low‐risk.” Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 03147911.

Backgrounds: Identification of precursors of atrial fibrillation (AF) may lead to early detection and prevent associated morbidity and mortality. Atrial premature complexes (APCs) are commonly seen in healthy subjects. However, there was limited data about the clinical and electrocardiographic (ECG) characteristics for prediction of new-onset AF in asymptomatic patients with APCs in the long-term follow up. Methods: The Kosin University (No. 2014-02-04) 24-h holter monitoring, echocardiography, ECG database were reviewed from 2008 to 2016 to identify new- onset AF in patients with APCs. We analyzed demographic and clinical features and the nature of the APCs by ECG according to new-onset AF in those patients. Results: Among 652 patients who underwent 24-h holter monitoring, 226 (34.4%) patients had new-onset AF. There was no difference of the baseline characteristics between new-onset AF group and non-AF group. In univariate analysis, hypertension (HTN), renal failure (CRF), high APC burdens, fastest APC running heart rate (HR), minimal HR, left ventricular ejection fraction (LVEF), left atrial volume index, peak mitral flow velocity of the early rapid filling wave and tricuspid regurgitation grade were significantly associated with new-onset AF. In multivariate analysis, higher APCs burden (P = 0.047), higher fastest APCs running HR (P = 0.034) and lower minimal HR (P = 0.025) were independent risk factors for new-onset AF in asymptomatic patients with APCs. Conclusion: Higher APCs burden, higher fastest APCs running HR and lower minimal HR were associated with new-onset AF in asymptomatic patients with APCs in the long-term follow up. Keywords: Atrial premature complex, New onset atrial fibrillation, Electrocardiographic characteristics, Clinical outcomes

Introduction: Premature ventricular complex (PVCs) detected from long-term ECG recordings have been associated with an increased risk of ischemic stroke. However, there was limited data about the association between high PVCs burdens (>10%) and stroke-like symptoms without a prior diagnosis of stroke or transient ischemic attack in the long-term follow up. Methods: The Kosin University 24-hours holter monitoring, echocardiography, electrocardiogram (ECG) database were reviewed from 2013 to 2015 to identify patients with frequent PVCs (>10%). We compared the long-term clinical outcomes between the patients with frequent PVCs (>10%) and control group without PVC. Results: Among 572 patients who underwent 24-hours holter monitoring, finally, 373 consecutive patients (mean age; 59.5 ± 15.8 years, 45.2% male) were enrolled. Among them, 203(54.4%) patients had high PVCs burdens (>10%). There was no difference of the baseline characteristics. In the long term follow-up, PVCs burden was not associated with PVCs -related symptoms (P = 0.210). In univariate analysis, female, non-sustained ventricular tachycardia (VT), sinus QRS duration, PVC coupling interval (CI), post- PVC CI, and late precordial R-wave transition of PVCs were associated with PVCs-related symptoms. In multivariate analysis, non-sustained VT (P = 0.022) and late precordial R-wave transition of PVCs (P = 0.044) were independent risk factors for PVCs-related stroke-like symptoms with frequent idiopathic PVCs > 10%. Conclusion: High PVCs burdens (>10%) were associated with and stroke-like symptoms without a prior diagnosis of stroke or transient ischemic attack in the long-term follow up, suggesting more intensive medical therapy with close clinical follow-up will be required. Keywords: Premature ventricular complex, Stroke-like symptoms, Transient ischemic attack, Clinical outcomes

Premature ventricular contraction (PVC) QRS duration (QRSd) and high PVCs burden are known as a risk factor of PVC-induced cardiomyopathy (CMP). The aim of this study is to find useful algorithm to predict PVC-induced CMP.180 patients (99 males, 51±14years) with frequent PVCs (10%/24h), who underwent successful PVC ablation, were studied. Typical PVC-related symptoms were defined as the presence of palpitations or dropped beats during PVC. Group A (n=144) was symptomatic and Group B (n=36) was asymptomatic.The incidence of CMP was significantly higher in group B (group A=19%, group B=66%, p0.001). In group A, there were significant differences, between the patients with normal EF and CMP, in terms of sex (p=0.005), daily PVC burden (p=0.012), distribution of PVCs with a LV site (p0.009), and PVC QRSd (p0.001). In group B, the PVC QRSd was significantly wider in patients with CMP. Multivariate analysis showed that PVC QRSd (p0.001), PVC burden (p=0.022), and LV site (p=0.043) were risk factors for CMP.Using our scoring algorithm for this patient sample, we are able to predict the development of PVC-induced CMP with 80% sensitivity, 81% specificity, 64% positive predictive value, and 91% negative predictive value.

Background Functional remodeling of left atrium (LA) after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) has not been fully elucidated. This study aimed to determine the impact of RFCA on LA transport function in patients who maintained sinus rhythm (SR) after AF ablation. Methods and Results A total of 96 patients [paroxysmal AF (PAF) = 52] who maintained SR during 1 year after AF ablation were enrolled. Multi-slice computed tomography was performed to determine LA volume (LAV) and LA emptying fraction (LAEF) at pre-RFCA and 1-year post-RFCA. Creatine kinase-MB (CK-MB) and troponin-T levels were analyzed one-day post-RFCA. At 1-year post-RFCA, mean LAV and LAEF decreased in overall patients. Based on LAEF change (ΔLAEF) cut off of 5.0%, LAEF reduced in 41 patients (worsened group) and improved or showed no change in 55 patients (preserved group). Compared with preserved group, worsened group had a higher proportion of PAF, higher levels of CK-MB and troponin-T, and additional LA ablation. ΔLAEF was inversely correlated with CK-MB and troponin-T levels. Subgroup analysis showed that LAEF significantly decreased in PAF patients who underwent additional LA ablation. Multivariate analysis revealed that high baseline LAEF and additional LA ablation were independent predictors for worsened LAEF. Conclusions Although SR was maintained for 1 year after AF ablation, LAEF as well as LAV decreased. The extent of LAEF deterioration was significantly associated with the amount of iatrogenic myocardial damage. Our data indicate that extensive atrial ablation may lead to LA functional deterioration, especially in patients with PAF. This article is protected by copyright. All rights reserved

BACKGROUND In this study, we aimed to investigate the relationship between echocardiographic epicardial fat thickness (EFT), neutrophil to lymphocyte ratio (NLR; an important inflammatory marker), and diurnal blood pressure (BP) changes in patients with recently diagnosed essential hypertension. METHODS A total of 647 patients underwent echocardiography and 24 hours of ambulatory BP monitoring. EFT was measured by echocardiography, while NLR was measured by dividing the neutrophil count by the lymphocyte count. Patients were categorized into three groups according to BP pattern: the normotensive group, the dipper group, and the non-dipper group. RESULTS The mean EFT was highest in the non-dipper group (non-dipper group, 7.3 ± 3.0 mm; dipper group, 6.1 ± 2.0 mm; control group, 5.6 ± 2.0 mm; p < 0.001). NLR was also highest in the non-dipper group (non-dipper, 2.75 ± 2.81; dipper, 2.01 ± 1.32; control, 1.92 ± 1.11; p < 0.001). EFT was significantly correlated with age (r = 0.160, p < 0.001) and NLR (r = 0.353, p < 0.001). Furthermore, an EFT ≥ 7.0 mm was associated with the non-dipper BP pattern with 51.3% sensitivity and 71.6% specificity [95% confidence interval (CI) = 0.56-0.65, p < 0.001]. In a multivariate analysis, EFT [adjusted odds ratio (OR) = 3.99, 95% CI = 1.22-13.10, p = 0.022] and NLR (OR = 1.34, 95% CI = 1.05-1.71, p = 0.018) were independent parameters that distinguished a non-dipper pattern after adjustment for cardiovascular risk factors. CONCLUSION EFT and NLR are independently associated with impaired diurnal BP profiles in hypertensive individuals. EFT (as measured by echocardiography) and NLR appear to be helpful in stratifying cardiometabolic risk.

Background ECG features for predicting successful ablation sites of outflow tract (OT) premature ventricular complex (PVCs) have been previously presented, but effective predictors of right coronary cusp (RCC) remain elusive. Methods 106 patients (59 males, 56±14years) who underwent successful PVC ablation were studied. Various ECG patterns and measurements were analyzed to identify the unique features of RCC PVC origins. The R-wave duration index (RWDI) was calculated as a percentage by dividing the QRS complex duration by the longest R-wave duration in lead V 1 or V 2 . Results Successful ablation sites were the RCC in 18 patients, the left coronary cusp (LCC) in 20, the RCC/LCC junction (RLJ) in 22, the AIV/GCV in 11 and the right ventricular outflow tract in 35. Forty-seven patients had dominantly positive forces in lead I. Among these 47 patients, 19 were ablated from the RCC (18/18, 100%), eighteen from the RVOT (18/35, 51%), five from the LCC (5/20, 25%), and five from the RLJ (6/22, 27%). The S-wave amplitude in lead aV L was significantly smaller in RCC than LCC or RLJ PVCs (0.1±0.3mV vs. 1.1±0.5mV, p 1–2 RWDI was significantly greater in RCC than RVOT PVCs (51.8±20.5% vs. 30.8±13.9%, p 43.6% for R-wave duration index in V 1 or V 2 (AUC: 0.83, p Conclusions The presence of a dominant positive lead I, RWDI >43.6% and S-wave amplitude in aV L

Background Angina pectoris with a normal coronary angiogram, termed microvascular angina (MVA), is an important clinical entity; however, its causes remain unclear. Autonomic dysfunction is one of the possible causes. Therefore, this study aimed to investigate parasympathetic dysfunction assessed by heart rate recovery (HRR) and increased sympathetic activity assessed by exaggerated blood pressure (BP) response (EBPR) to exercise in MVA. Methods The study participants were consecutive patients with anginal chest pain who underwent both coronary angiography with an ergonovine provocation test and a treadmill exercise test between January 2008 and February 2015. Patients with significant coronary artery disease (coronary artery stenosis ≥50%) or significant coronary artery spasm (≥90%) were excluded. Based on the treadmill exercise test, patients were categorized into the microvascular angina (MVA) group (patients with uniform ST depression ≥1 mm) and the control group. HRR was defined as peak heart rate minus heart rate after a 1 min recovery; blunted HRR was defined as ≤12 beats/min. EBPR was defined as a peak exercise systolic BP ≥210 mmHg in men and ≥ 190 mmHg in women. These parameters were compared between patients with MVA and the controls. Results Among the 970 enrolled patients (mean age 53.1 years; female 59.0%), 191 (20.0%) were diagnosed with MVA. In baseline characteristics, the MVA group had older participants, female predominance, and a higher prevalence of hypertension. The MVA group showed significantly lower HRR 1 min (24.9 ± 15.9 vs. 31.3 ± 22.7, p

Background Autonomic nervous system activity has been shown to be altered in patients with vasospastic angina (VA). Heart rate recovery (HRR) is a simple, non-invasive measurement of autonomic nervous system dysfunction. We aimed to investigate whether HRR is related to VA, as established by an ergonovine test. Methods A total of 976 consecutive patients (47.5% male, mean age 55 years) without significant coronary artery disease who underwent both an ergonovine provocation test and a treadmill exercise test were enrolled. The relationship between VA and HRR was evaluated. Results A total of 30.7% (300/976) of patients were diagnosed with VA, as documented by the ergonovine provocation test. HRR was significantly reduced in patients with VA compared to patients without VA (24.6 ± 18.0 vs. 30.5 ± 22.2, p

BACKGROUND/AIMS There have been reports that interatrial septal (IAS) thickness is increased in patients with atrial fibrillation (AF). This study was performed to investigate whether IAS thickness determined by transthoracic echocardiography (TTE) represents the amount of left atrium (LA) structural and functional remodeling. METHODS The study population consisted of 104 consecutive patients who underwent catheter ablation (CA) for AF (paroxysmal atrial fibrillation [PAF], 82; persistent atrial fibrillation [PeAF], 22). IAS thickness and left atrium volume (LAV) using TTE, and LA voltage (LA(VOL)) using 3-dimensional electroanatomical mapping system were assessed during sinus rhythm. RESULTS IAS thickness was significantly correlated with maximal LAV (LAV(max)) (r = 0.288, p = 0.003), mean LA(VOL) (r = -0.537, p < 0.001), total left atrium emptying fraction (LAEF(total); r = -0.213, p = 0.030), and active LAEF (LAEF(active); r = -0.249, p = 0.014). IAS thickness was greater in the high-risk group (≥ 2) compared to other groups according to CHA2DS2-VASc score (p = 0.019). During a follow-up of 19.6 months, 23 subjects (22.1%; PAF, 17; PeAF, 6) had recurrence of arrhythmia. Univariate analysis showed that LAV(max), minimal LAV, mean LA(VOL), LVEF(total), LVEF(active), and IAS thickness were associated with recurrence of arrhythmia. However, on multivariate analysis, only mean LA(VOL) and LAEF(active) were independent risk factors for recurrence. CONCLUSIONS Although IAS thickness showed significant correlations with parameters for LA structural and functional remodeling, this parameter alone could not independently predict recurrence of arrhythmia after CA for AF.

Background Major adverse cardiovascular events (MACEs) in patients with or without cardiovascular disease (CVD) are greatly affected by various factors associated with metabolism and inflammation. Objective To determine which clinical parameters at treatment are associated with the development of 2-year and 5-year MACEs in high-risk patients with CVD who have undergone drug-eluting stent (DES) implantation. Method The present study involved a total of 432 patients who underwent percutaneous coronary intervention with DES. Variables representing the average and absolute amount of change in clinical parameters over the 12-month follow-up were assessed for association with 2-year and 5-year development of MACE. The study population was divided into quartiles for the variable showing the highest correlation to MACE development. Estimated incidence of 2-year and 5-year MACEs for each of the quartiles was determined by survival curve analysis, and subgroup analysis was performed for patients with diabetes and statin users. Results Absolute change in fasting plasma glucose (FPG) over 12months showed the highest correlation with 2-year and 5-year MACE development. The estimated incidence of MACE increased with increasing quartiles for absolute change in FPG. The association between absolute change in FPG and MACE development exhibited a stronger relationship for the specific subgroups of patients with diabetes and statin users. Increases and decreases in FPG had a comparable contribution to MACE development. Conclusion A greater absolute change in FPG over 12months post-PCI is an independent risk factor for 2-year and 5-year MACE development in DES-implanted patients, especially in the diabetes and statin users.

Aims Left atrial (LA) fibrosis caused by various pathological stimuli is a common finding. However, the difference of atrial remodelling via haemodynamic change in diverse cardiomyopathy has not been elucidated. Methods and results Male Sprague-Dawley rats (6–8 weeks, n = 180) were randomly assigned to three groups and corresponding sham control groups: (i) ischaemic cardiomyopathy, (ii) left ventricular hypertrophy (LVH), and (iii) dilated cardiomyopathy. At 12 weeks after operation, atrial fibrillation (AF) inducibility and duration were assessed by in vivo burst transoesophageal pacing. Using the Langendorff apparatus, left ventricular (LV) function and pressure were measured. The expression of connexin-43 (Cx43) and alpha-smooth muscle actin (α-SMA) in atrial tissues was assessed by quantitative real-time polymerase chain reaction and immunohistochemical staining. Fibrosis was analysed by Masson's trichrome staining. Compared with controls, the LA weight/heart weight ratio was increased in the LVH group alone, and was significantly correlated with AF duration ( P < 0.001, R = 0.388). Atrial fibrillation inducibility and duration were higher and longer only in the LVH group ( P = 0.002, 0.079, respectively), and isolated LV diastolic dysfunction and elevated LV pressure were observed. Although α-SMA expression and fibrosis were increased in all three cardiomyopathy models, down-regulation of Cx43 expression in the LA was observed in the LVH group alone. Conclusion Chronic pressure overload in the absence of LV systolic dysfunction resulted in LA hypertrophy and increased susceptibility to AF, which might be related to conduction abnormality via decreased expression and lateral distribution of Cx43 as well as interstitial fibrosis.

Background Although a large isolated surface area of the left atrium (LA) may improve the success rate of catheter ablation (CA) for paroxysmal atrial fibrillation (AF), little is known about the relation between clinical outcomes and the amount of atrial mass reduction (AMR: ratio of total isolated and ablated areas to LA surface area) in different ablation strategies for patients with long-standing persistent AF (L-PeAF). Methods We randomly assigned 119 consecutive L-PeAF patients to adjunctive linear ablation ( n =60) or complex fractionated atrial electrogram (CFAE)-guided ablation ( n =59) after circumferential antral pulmonary vein isolation (PVI). Linear lesions included roof and anterior lines with conduction block. LA defragmentation was performed with an automated CFAE-detection algorithm. Cavotricuspid isthmus block was performed in all patients. Creatine kinase-MB (CK-MB) and troponin-T levels were measured 1day post-CA. Results CK-MB and troponin-T levels were higher, ablation time was longer, and AMR was greater in the CFAE-guided ablation group than in the linear ablation group. AF termination during CA was more frequently observed in the linear ablation group than in the CFAE-guided ablation group ( P =0.031). Twelve months after a single procedure, recurrence occurred in 16 (26.7%) patients with linear ablation and 27 (45.8%) patients with CFAE-guided ablation ( P =0.023). On multivariate analysis, LA volume and ablation method were the only independent risk factors for arrhythmia recurrence. Conclusion Conduction block through linear lines+PVI was an efficient ablation strategy for L-PeAF, whereas the AMR amount did not influence clinical outcomes.

Introduction The gold standard for evaluating stent expansion after percutaneous coronary intervention (PCI) is intravascular ultrasound (IVUS). However, the routine use of this modality is costly and time consuming. StentBoost is a new imaging technique that improves fluoroscopy-based assessments of stent expansion. The purpose of this study was to evaluate the effect of StentBoost imaging-guided PCI on mid-term angiographic and clinical outcomes. Methods and results A total of 870 consecutive patients were recruited (mean age: 64.34±11.61; men: 64.5%), all of whom underwent PCI with drug-eluting stents (DESs). The subjects were divided into a no StentBoost group (n=569 patients) and a StentBoost group (n=301 patients). The 6-month angiographic and 12-month clinical outcomes were compared between the two groups. At 1month, clinical outcomes were similar between the two groups. At 6months, the StentBoost group had significantly lower rates of late loss (0.32±0.40 vs. 0.48±0.59; p=0.005) and binary restenosis (1.2% vs. 8.3%; p=0.029) compared with the no-StentBoost group. At 12months, StentBoost group had significantly lower the incidence of target lesion revascularization (TLR) (1.7% vs. 7%; p=0.034) and TLR-major adverse cardiac events (6% vs. 13.2%; p=0.037) compared with the no-StentBoost group. Conclusion We conclude that the routine clinical use of StentBoost during PCI can be useful, and results in better medium-term angiographic and clinical outcomes.

Extracellular fluid (ECF) is associated with blood pressure, but reports on the status of the ECF volume in hypertension have been inconsistent. The aim of this study was to assess the ECF volume status in hypertensives with regard to body size in a large cohort. We performed a single-center case-control observation study for patients who visited the outpatient hypertension clinic and health examination center. For all eligible participants, we examined the body composition, including fluid compartments, using a noninvasive bioimpedance analysis. Of 2934 subjects (women 1365, 57.5 ± 12.2 years), 1166 subjects were normotensive and 1768 subjects were hypertensive. The ECF volume was larger in female hypertensives than in normotensives but was not different between the male groups. However, the relative ECF, defined as the ratio of ECF to body mass index (BMI), was significantly lower in hypertensives of both genders (P

Background Elevated right ventricle (RV) pressure and/or volume can place stress on the right bundle branch block (RBBB) and its associated Purkinje network, which can affect its electrical properties, resulting in conduction delay or block. We hypothesized that prolonged R′ wave duration in lead V1 would extend the later portion of the QRS complex and can act as an indicator of reduced RV function in patients with RBBB. Method Kosin University Gospel Hospital echocardiography and electrocardiography (ECG) database was reviewed to identify patients with complete RBBB between 2013 and 2015. ECGs recorded closest to the time of the echocardiography were carefully reviewed, and QRS and R′ wave duration were measured. RV systolic dysfunction was defined as an RV fractional area change (FAC) less than 35%, as indicated by echocardiography guidelines. Results Compared to patients with normal RV function (n = 241), patients with RV dysfunction (n = 123) showed prolonged QRS duration (145.3 ± 19.3 ms vs. 132.2 ± 13.4 ms, p

An asymptomatic 31-year-old man with chronic hepatitis B and a 7-year history of lamivudine use was referred to our hospital for evaluation of a heart murmur. The patient had no family history of congenital heart disease or collagen vascular disease. Cardiac auscultation revealed a grade 3/6 continuous murmur at the right parasternal border. Transthoracic echocardiography revealed a round, tunnel-like structure from the left aortic sinus to the right atrium (RA; Figure 1A and 1B, arrows, and Movie IA and IB in the online-only Data Supplement) without any evidence of RA or right ventricular enlargement. Modified parasternal short-axis view (Figure 1C and Movie II in the online-only Data Supplement) of the aortic valve level demonstrated an anastomosis site to the RA with continuous turbulent flow on color Doppler examination. Continuous-wave Doppler obtained from the shunt indicated a high flow velocity with systolic and diastolic pattern at the anastomosis site to the RA (Figure 1D). Cardiac catheterization showed a normal pulmonary artery pressure (systolic/diastolic, 24/7 mm Hg) and normal mean RA pressure (4 mm Hg), and the Qp/Qs ratio was 1.3:1. Aortography confirmed a large tunnel beginning in the left aortic sinus and ending in the RA (Figure 2, asterisk, and Movie III in the online-only Data Supplement), with normal-looking left coronary arteries arising independently from different proximal portions of the tunnel. Importantly, no coronary myocardial branches originated from the tunnel, which is the …

Background Despite intensive anti-hypertensive treatment, overall control rates of only 30 ~ 50 % have been reported in patients with hypertension (HTN). However, clinical significance and angiographic characteristics of patients with uncontrolled HTN following Below-the-knee arteries (BTK) interventions in patients with critical limb ischemia (CLI) are not clarified yet as compared to those with controlled HTN. Methods A total 165 consecutive hypertensive patients with BTK lesions from August 2004 to November 2012 were enrolled for this study. Uncontrolled HTN was defined as a blood pressure of > 140 mmHg systolic and 90 mmHg diastolic under anti-hypertensive treatment. A total of 112 patients (67.8 %) had uncontrolled HTN. We compared the clinical and angiographic characteristics of patients with uncontrolled HTN following BTK interventions to those with controlled HTN at 12-month follow-up. Results The baseline characteristics are well balanced between the two groups. At 12 months, there was no difference in the incidence of mortality, target lesion revascularization (TLR), target extremity revascularization (TER), and limb salvage rate in both groups. However, amputation rates were higher in patients with controlled HTN (33.9 vs. 19.6 %, P = 0.045). Conclusion Regardless of blood pressure control, HTN itself was an independent risk factor for BTK lesions, suggesting more intensive medical therapy with close clinical follow up will be required for all BTK patients with HTN.

High-dose aspirin has been reported to aggravate coronary artery spasm (CAS). However, it is unknown whether low-dose aspirin (LDA; 100mg) has deleterious impact on CAS. We assessed the impact of LDA on CAS induced by intracoronary acetylcholine (ACh) provocation test. A total of 2789 consecutive patients without significant coronary artery disease who underwent ACh test between November 2004 and March 2010 were enrolled. The patients were divided into two groups: the aspirin group taking LDA before ACh test (n=221) and the no aspirin group not taking aspirin (n=2568). At baseline, the prevalence of old age, diabetes mellitus, hypertension, and hyperlipidemia were higher in the aspirin group. During the ACh test, the incidence of significant CAS, ischemic chest pain, as well as severe and multivessel spasm was higher in the aspirin group. The response rate to lower ACh dose was higher in the aspirin group. Multivariate analysis showed that the previous use of LDA was an independent predictor of CAS (adjusted odds ratio, 1.6, 95% confidence interval, 1.0–2.3; p=0.031). However, it is likely that the association of LDA and CAS that we have observed is not causal but may be hypothesis generating due to significant baseline differences. Further, male gender, old age, lipid-lowering drugs, baseline spasm, and myocardial bridge were independent predictors of CAS. LDA was more frequently associated with CAS and ischemic symptoms, as well as severe and multivessel spasm, suggesting the patients who have received LDA would require more intensive medical therapies and close follow up.

Atrial fibrillation (AF) is the most common sustained arrhythmia. AF is caused by inflammation, oxidative stress, and various structural heart diseases. An important key factor in AF promotion is that atrial cardiomyocytes have constitutively active acetylcholine-activated K+ (IKACh) current that is enhanced by the tachycardia. Furthermore, it is known that heat shock proteins (HSPs) are involved in the protection against different forms of cellular stress and recent investigators reported that the HSP inducing compound geranylgeranylacetone (GGA, also known as teprenone) prevents atrial remodeling and attenuates the promotion of AF. Whether GGA and GGA-derivatives prevent the acetylcholine-activated K+ current is unknown. Methods: We examined the effect of HSP inducer GGA and 5 derivatives on IKACh current in mouse atrial cardiomyocytes. In the present study, the IKACh current was recorded using a nystatin-perforated whole cell patch-clamp technique following activation by acetylcholine (10 μM for 2 min). After the measurement of the baseline IKACh current, atrial cardiomyocytes were treated with GGA 10μM or a derivative of GGA (NYK9274, NYK9308, NYK9354, NYK9356 or NYK9376) for 10min and the IKACh current was re-measured. Results: IKACh current in mouse atrial cardiomyocyte treated with acetylcholine (10 μM) was significantly increased, which was markedly attenuated by GGA 10μM treatment (n=5, peak; 54±11.2%, quasi-steady-state; 58±11.4%, p Conclusion: This study provides important evidences that the HSP inducer GGA facilitates its potent antiarrhythmic effect by inhibiting IKAch, which underlies electrical remodeling in mammalian atrial cardiomyocytes. Furthermore, two GGA derivatives, NYK9308 and NYK9356, with improved pharma-chemical properties compared to GGA, reveal similar protective effects compared to GGA, and provide important background information for the use of GGA and GGA-like compounds in patients with AF.

Objectives Relationship between atrial fibrillation (AF) and inflammation was shown in previous studies. However, there was limited data about the association between the periodontitis and AF in the long-term follow-up. The aim of this study was to evaluate the impact of periodontitis on long-term clinical outcomes in patients with AF. Methods The Kosin University echocardiography, ECG and periodontitis database were reviewed from 2013 to 2015 to identify patients with AF. Those patients were divided into two groups according to the presence of periodontitis and clinical events including any arrhythmic attack, thromboembolic and bleeding and death were collected during a median of 18 months. Results Among 227 patients with AF, 47 (20.7%) patients had periodontitis. Major adverse cardiac events (MACE) were significantly higher in patients with periodontitis compared with those without periodontitis (p

There was limited data about the impact of alfa- and beta-blocker(BB), Carvedilol on the long-term clinical outcomes with benign prostatic hypertrophy(BPH). A total of 448 patients with BPH were consecutively enrolled(mean age; 69.2±10.9 years) at Kosin university gospel hospital from 2013 to 2016

We present an adult female patient who developed irreversible paraplegia and areflexia four days post intrathecal chemotherapy with methotrexate, cytosine arabinoside and hydrocortisone. On magnetic resonance imaging (MRI) of the lumbar spine, diffuse gadolinium enhancement of the anterior spinal nerve roots (ventral roots) was detected. Methylprednisolone was intravenously administered at a daily dose of 30mg/kg for three days. Despite this treatment, flaccid weakness in the lower extremities and urinary retention persisted. Following consolidation chemotherapy, no improvement in neurologic status was noted. Six months later, a follow-up MRI revealed severe atrophy of the thoracic spinal cord.

Hypertrophic cardiomyopathy (HCM) is a cardiac disease associated with a high incidence of atrial fibrillation (AF). Recent studies have suggested that interventricular septum thickness may influence the risk stratification of patients with AF. We evaluated the effects of septal hypertrophy on morbidity and mortality in patients with HCM. Patients were followed for a median of 6.1 years and were divided into two groups according to the extent of septal hypertrophy. A total of 1,360 HCM patients were enrolled: 482 (33%) apical or apicoseptal, 415 (28%) asymmetric septal, 388 (27%) basal septal, 38 (2.6%) concentric, and 37 (2.5%) diffuse and mixed type. Ninety-two all-cause deaths and 21 cardiac deaths occurred. The total event rates were significantly higher for patients with HCM with more extensive septal hypertrophy (group A) compared to those with HCM ± focal septal hypertrophy (group B), regardless of type (p

Structural remodeling of the left atrium is a risk factor for recurrent arrhythmia after catheter ablation for atrial fibrillation; however, data are sparse regarding the role of functional left atrial remodeling in predicting procedural outcomes. We evaluated whether left atrial transport function could be used to predict recurrent atrial fibrillation. From July 2008 through August 2010, we enrolled 202 consecutive patients who underwent catheter ablation for atrial fibrillation (paroxysmal=120, persistent=82). Left atrial volumes (LAVs) were measured by means of multislice computed tomography at every 10% of the R-R interval, and measurements were adjusted for body surface area to yield the LAV index (LAVI) at baseline. The left atrial emptying fraction (LAEF) was calculated according to LAV differences. During the mean follow-up period of 10 ± 4 months after a single ablation procedure, atrial fibrillation recurred in 59 patients (paroxysmal=19, persistent=40). Multivariate analysis revealed that persistent atrial fibrillation, early mitral inflow velocity, LAVImax, LAVImin, LAEF, LAVImax/LAEF, and LAVImin/LAEF were all independent predictors of atrial fibrillation, but the best predictor was LAVImin/LAEF (β=1.329, P=0.001). The cutoff value was 1.61 (mL/m2)/%, and the sensitivity and specificity were 74.6% and 62.2%, respectively (area under the curve=0.761). Our study shows that adjusted left atrial emptying fraction with use of multislice computed tomography might be a useful, noninvasive method to select patients for ablation.

BACKGROUND High ventricular premature depolarization (VPD) burden is associated with left ventricular (LV) dysfunction that typically resolves after successful ablation. Some patients, however, have persistent LV dysfunction, even after successful radiofrequency (RF) ablation. Identifying factors associated with irreversibility of LV cardiomyopathy (CMP) may help predict clinical outcome. METHODS AND RESULTS Patients with frequent VPD (>10%/day) who underwent successful VPD suppression were divided into 2 groups according to transthoracic echocardiography (TTE) before and after suppression: group A (n=38) had depressed LV function that normalized after VPD suppression; group B (n=19) had depressed LV function before and after suppression. Of 57 patients (43 men; mean age, 54±15 years), RF ablation was performed in 39. Clinical, electrocardiographic, and TTE parameters were compared between groups. LV end-diastolic dimension (LVEDD; group A vs. B: 54±5 mm vs. 60±10 mm, P=0.01), end-systolic dimension (group A vs. B: 42±6 mm vs. 48±11 mm, P=0.01) before VPD suppression differed significantly between groups. Pre-suppression LVEDD was ≤66 mm in all reversible-CMP patients. LVEDD >66 mm predicted irreversible CMP with 50% sensitivity, 100% specificity, 100% positive predictive value, and 81% negative predictive value. CONCLUSIONS LVEDD was a good predictor of irreversible LV CMP with frequent VPD, with 50% sensitivity and 100% specificity.

BACKGROUND AND OBJECTIVES: Frequent ventricular premature complex (VPC) is one of the most common arrhythmia syndromes. Symptoms observed frequently with this arrhythmia syndrome remain limited. We sought to identify predictors of VPC-related symptoms by analyzing demographic information, VPC burden, and VPC surface electrocardiogram characteristics. SUBJECTS AND METHODS: We prospectively enrolled 109 patients with idiopathic outflow tract VPCs (63 males, 49±16 years old). They were divided into Group A (n=30, without VPC-related symptoms of palpitations or "dropped beats") and Group B (n=79, with VPC-related symptoms). Measured parameters were sinus and VPC QRS width, coupling interval (CI) between the previous sinus beat and VPC, CI ratio (%, CI/sinus cycle length), post-VPC CI and CI ratio, and VPC amplitude. RESULTS: Both groups had similar age (p=0.22), daily VPC burden (p=0.15), and VPC site of origin (p=0.36). The VPC CI ratio was higher in Group B (60±15%) than in Group A (49±22%) (p=0.01). CONCLUSION: VPC-related symptoms are associated with a higher VPC CI ratio (>50%). The physiologic basis for these results deserves further study.

Aims Most patients with idiopathic ventricular premature depolarizations (VPDs) complain of symptoms related to this arrhythmia, but some patients are asymptomatic even with a high VPD burden. Our understanding of the relationship between symptoms and cardiomyopathy related to this arrhythmia remains limited. Methods and Results We evaluated 801 subjects (381 men; mean age, 55 ± 17 years) who visited our outpatient clinic. All subjects were diagnosed with frequent VPDs (1% or >1000 beats/day). The patients were divided into two groups according to the presence or absence of typical VPD symptoms (palpitations or skipped beats during VPDs): symptomatic patients ( n = 455) and asymptomatic patients ( n = 346). Clinical and electrocardiogram parameters were compared between these two groups. In the symptomatic group, palpitations were the most frequent symptom (91%). Daily VPD burden ( P = 0.90) and electrocardiogram parameters ( P >0.05) did not differ significantly between groups. The incidence of frequent VPDs with left ventricular dysfunction was significantly higher in the asymptomatic group (symptomatic patients, 3.0%; asymptomatic patients, 10.5%; P < 0.001). Conclusion The absence of typical VPD-related symptoms may be a risk factor for cardiomyopathy and be associated with an adverse outcome.

Background: There was limited data about the clinical and ECG characteristics for prediction of new-onset LV dysfunction in patients with frequent idiopathic VPCs >10% in the long-term follow up. Methods: The Kosin University 24-hours holter monitoring, echocardiography, ECG database were reviewed

Purpose Our objective was to compare the efficacy of dronedarone and propafenone in maintaining sinus rhythm in patients with atrial fibrillation (AF) after electrical cardioversion. Methods In this single-center, open-label, randomized trial, we randomly assigned patients with AF after electrical cardioversion to receive dronedarone 400 mg BID or propafenone 150 mg TID. Follow-up clinical evaluations were conducted at 1, 2, 3, and 6 months of treatment. The primary end point was the time to the first recurrence of AF. Findings A total of 98 patients were enrolled (79 men; mean age, 59.2 years; n = 49 per group). The median times to first recurrence of AF were 31 days in the dronedarone group and 32 days in the propafenone group (P = 0.715). The median (interquartile range) ventricular rates at first recurrence of AF were 76.5 (67.3–86.5) beats/min in the dronedarone group and 83.0 (71.0–96.0) beats/min in the propafenone group (P = 0.059). Implications Dronedarone and propafenone had similar efficacies in maintaining sinus rhythm in patients with AF after electrical cardioversion. The ventricular rate at the first recurrence of AF was numerically but not statistically significantly lower in the dronedarone group than in the propafenone group. ClinicalTrials.gov identifier: NCT01991119.