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Background Quadripolar left ventricular (LV) leads are capable of sensing and pacing the left ventricle from 4 different electrodes, which may potentially improve patient response to cardiac resynchronization therapy (CRT). Objective We measured 3 different time intervals: right ventricular (RV)-sensed to LV-sensed during intrinsic rhythm (RVs-LVs), RV-paced to LV-sensed (RVp-LVs), and LV-paced to LV-sensed (LVp-LVs, between distal [LV1] and proximal pole on a quadripolar LV lead), and assessed their association with CRT response in terms of LV end-systolic volume (LVESV) and a composite benefit index (CBI) comprising LVESV, LV ejection fraction (LVEF), brain natriuretic peptide level, and NYHA class. Methods A CRT-defibrillator system with quadripolar LV lead was implanted in 196 patients (mean age 69 years, mean LVEF 30%, left bundle-branch block [LBBB] 58%). Conduction intervals were measured before hospital discharge. At baseline and 7-month follow-up, echocardiographic and other components of CBI were determined. Results The mean RVs-LV1s, RVp-LV1s, and LVp-LVs delays were 68 ± 38 ms, 132 ± 34 ms, and 99 ± 31 ms, respectively. From baseline to 7 months, LVESV decreased by 17.3% ± 28.6%. The RVs-LV1s interval correlated stronger with CBI (R2 = 0.12, P < .00001) than with LVESV change (R2 = 0.05, P = .006). In contrast, RVp-LV1s did not correlate and LVp-LVs correlated only weakly with CRT response. The subgroup of patients (44%) with LBBB and RVs-LV1s above the lower quartile (≥34 ms) showed the greatest response to CRT. Conclusion The RVs-LVs interval during intrinsic rhythm is relevant for CRT success, whereas RVp-LVs and LVp-LVs intervals did not predict CRT response.

Background Fever is associated with the manifestation of Brugada phenotype and ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with Brugada syndrome (BrS). The thermal effect on the pathogenesis of functional substrates in BrS remains unknown. Objective This study aimed to elucidate the thermal effect on BrS phenotype, VT/VF, and electrophysiological characteristics of epicardial functional substrates in BrS. Methods We consecutively studied 15 patients with BrS receiving radiofrequency catheter ablation for drug-refractory ventricular tachyarrhythmias. Baseline characteristics, electrocardiographic features, and changes in epicardial functional substrates before and after epicardial warm water instillation (n = 6) were recorded and analyzed. Results A total of 15 male patients (mean age 41.3 ± 10.3 years) with type 1 BrS presenting with ventricular tachyarrhythmias were consecutively enrolled. Epicardial mapping in 11 patients demonstrated a significantly larger epicardial scar/low-voltage zone (LVZ) area within the right ventricular outflow tract and anterior right ventricular free wall than within the endocardium (6.32 ± 12.74 cm2 vs 52.91 ± 45.25 cm2; P = .007). Epicardial warm water instillation in 6 patients led to a significant enlargement of the functional scar/LVZ area (123.83 ± 35.26 cm2 vs 63.53 ± 40.57 cm2; P = .03), accelerated conduction velocity of the endocardium and epicardium without scar/LVZ area, and increased VT/VF inducibility (16.7% vs 100%; P = .02). Ablation by targeting premature ventricular complexes and/or epicardial abnormal substrates rendered noninducibility of VT/VF and prevented the recurrences of VT/VF. Conclusion Epicardial warm water instillation enhanced functional epicardial substrates, which contributed to the increased inducibility of ventricular tachyarrhythmias in BrS. Ablation by targeting the triggers and abnormal epicardial substrates provided an effective strategy for preventing ventricular tachyarrhythmia recurrences in BrS.

A relationship between serum polyunsaturated fatty acids (PUFAs) and cardiovascular disease has been reported; however, the existence of a relationship between serum PUFAs and extent of vessel disease (VD) in patients with ST elevation myocardial infarction (STEMI) remains unclear.Between July 2011 and June 2015, 866 consecutive STEMI patients underwent emergent percutaneous coronary intervention, 507 of whom were enrolled and classified into three groups according to the initial angiograms: 1VD, 294 patients; 2VD, 110 patients; and 3VD/left main trunk disease (LMTD), 103 patients. Serum levels of PUFAs, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid, and other laboratory data during hospitalization were evaluated.The serum EPA level in the 3VD/LMTD group was significantly lower than that in the 1VD group (55.5 ± 22.1 versus 66.2 ± 28.7, P = 0.002) and was slightly lower than that in the 2VD group (55.5 ± 22.1 versus 65.2 ± 28.9, P = 0.0167). Multivariate adjustment analysis revealed that age ≥ 70 years (odds ratio, 1.72; 95% confidence interval, 1.03-2.89; P = 0.038) and a low serum EPA level (odds ratio, 0.98; 95% confidence interval, 0.99-1.00; P = 0.023) were independent risk factors for 3VD/LMTD, while a low serum DHA level was not.A low serum EPA level may be more strongly related than a low serum DHA level to the extent of VD in STEMI patients. Age ≥ 70 years and a low serum EPA level may be independent risk factors for 3VD/LMTD.

In-stent restenosis after drug-eluting stent implantation (DES-ISR) in the left main coronary artery remains challenging to manage. Our aim was to assess the effectiveness of paclitaxel-coated balloon angioplasty for DES-ISR in the left main coronary artery. We identified 91 DES-ISR lesions in the

Catheter ablation of the right bundle branch was performed on an 11-month-old infant for the treatment of drug-resistant bundle branch reentrant ventricular tachycardia. The occurrence of right bundle branch block could not be used as an endpoint of treatment because the patient had presented with incomplete right bundle branch block pattern during sinus rhythm. We performed ablation of the right bundle branch and utilized changes of duration and morphology of the QRS complex as indicators. Eight years have passed with no development of any atrioventricular block or tachycardia episode.

The efficacy of drug-eluting stents (DES) has been proven, but concerns about late complications after DES have been raised. Polymers that do not increase inflammatory or hypersensitivity reactions which may contribute to late complications are needed for new generation DES. To evaluate the safety and efficacy of phosphorylcholine-polymer coating, we investigated serial clinical and angiographic outcomes after phosphorylcholine-coated stent placement. Seventy-five consecutive patients treated with a BiodivYsio phosphorylcholine-coated stent for de novo lesions at our institute between October 2001 and August 2002 were enrolled. Six-month follow-up angiography was performed in 71 lesions (94.7%), and angiographic restenosis was found in 19 lesions (26.8%). Target lesion revascularization (TLR) was performed in 10 lesions (14.1%). Eighteen-month follow-up angiography was performed in 58 (95.1%) of the remaining 61 lesions (excluding TLR lesions), and angiographic restenosis was found in only 3 lesions. The cumulative MACE-free survival rate was 86.3%, 83.6%, and 78.6% at 6-month, 18-month, and 8-year follow-up, respectively. There were no episodes of stent thrombosis. Late loss decreased significantly from 0.74 ± 0.40 mm (6-months) to 0.51 ± 0.46 mm (18-months) (P < 0.0001). Phosphorylcholine-coated stent implantation was associated with acceptable clinical and angiographic results. Phosphorylcholine-coating may be an ideal polymer for new generation DESs.

Impact of direct oral anticoagulants (DOAC) on frail and non-frail patients with atrial fibrillation (AF), in comparison with that of warfarin is unknown. We enrolled 1209 consecutive AF patients between January 2013 and December 2015. Of whom, 486 elderly patients, including 436 patients receiving

Objectives: We evaluated the predictors of recurrent restenosis and the impact of lesion length and vessel size on outcomes in patients treated with routine sirolimus-eluting stent (SES) implantation for in-stent restenosis (ISR) of bare-metal stent (BMS). Methods: In this study, 250 consecutive patients with 275 lesions after SES implantation for ISR of BMS were enrolled. Follow-up angiogram was obtained in 239 patients with 258 lesions eight months after implantation (follow-up rate: 95.6%). We compared characteristics of patients and lesions between the two groups (the recurrent restenosis group and the no-restenosis group). Results: Recurrent restenosis was angiographically documented in 43 lesions (16.7%). Recurrent restenosis was found in 30.4% with small vessel lesions (reference diameter of less than 2.5 mm, 92 lesions) and 23% with the diffuse type lesions (106 lesions). Seventy-two per cent of patients had a focal pattern of recurrent restenosis. Previously recurrent ISR lesions (odds ratio (OR) 1.94, 95% confidence interval (CI) 0.94 to 4.06, p = 0.05), reference diameter of less than 2.5 mm (OR 2.41, CI 1.05 to 5.41, p = 0.03), diffuse type restenosis (OR 4.48, CI 2.12 to 9.94, p = 0.0001) and dialysis patients (OR 4.72, CI 1.42 to 15.7, p = 0.01) were independent predictors of recurrent restenosis. Conclusions: Small vessels, diffuse type restenosis and dialysis patients were still the predictors of recurrent restenosis in patients treated with SES for ISR of BMS.

Recently, cardiac resynchronization therapy (CRT. has been established as an effective treatment for drug-resistant heart failure with left ventricular dyssynchrony in patients with a New York Heart Association class (NYHA. of III-IV. Many cases have already been treated with CRT in Japan, however, some challenges still remains, such as difficult placement of the left ventricular (LV. lead at the target site, high threshold values even after successful placement of the LV lead, and the need to reposition of the LV lead due to diaphragmatic stimulation regardless of an appropriate threshold value. In particular, those cases with high threshold values at a distal site or those in which the lead is placed at a proximal site because of diaphragmatic stimulation are prone to lead dislodgement, and re-operation may be required. We report on a patient in whom stabilization of the LV lead was obtained by placing a coronary stent in the coronary sinus wall which resulted in an improved clinical course.

This paper describes the influence of rise-time of the driving voltage on Taylor-cone formation in drop-on-demand electrospray. A thin tapered glass capillary coated by titanium was used as an ejection nozzle where a step-functioned voltage with a various rise-time was applied. The step-functioned voltage was produced by switching on the DC high voltage using a MOSFET module, and its rise-time was adjusted by changing a resistance and capacitance of the discharge circuit. Ethanol was used for the liquid material and slowly delivered to the nozzle tip. Time-resolved microscopic images of the liquid meniscus on the nozzle tip were taken by using the laser shadowgraph method. The Taylor-cone formation time, which is determined by the time difference between the MOSFET turning on and the liquid jet ejection, obviously tends to be reduced by shortening the rise-time of the voltage. This experimental result suggests that shortening the voltage rise-time significantly improves the repetition frequency of drop-on-demand electrospray.

This work reports the spray behavior when applying step voltage of the various rising time. The various rising time is achieved by insert resistance and capacitance in the experimental circuit and the experiment carried out in three kinds of rising time 12 ns, 1.1 us and 130 us. High time resolved observation system using high speed camera is synchronized with MOSFET switching module through signal generator and it can take a photo in arbitrary timing. Continuous shooting photos show the spray behavior change from temporal state to steady state same as DC voltage applying with time after the step voltage was turned on. Temporal spray behavior is made a difference in the same applied voltage and various rising time, and significant difference was seen especially in the first ejection. When applied voltage is 5.0 kV, the first ejection was observed as typical Taylor cone, distorted cone and multi jet formation in 130 us, 1.1 us and 12 ns rising time respectively. It seems that the field intensity on meniscus changes with the rising time. Therefore, it can be considered that temporally change of the field intensity make fluctuation on the meniscus and it affect to enhance the field intensity.

Recently a considerable number of patients have Non-vitamin K antagonist oral anticoagulant (NOAC) for Atrial fibrillation (AF). Some AF patients have NOAC concurrent antiplatelet therapy for atherosclerosis. However there are few reports about bleeding events among NOAC patients with concurrent

Introduction: Implantable loop recorder (ILR) has been reported to provide a symptom-rhythm correlation in patients with recurrent unexplained syncope. Method: ILR was implanted in 11 patients with recurrent unexplained syncope. Results: ILR revealed the mechanism of syncope in 5 patients (45.5%) and the median period after implantation was 52.8±31.9 days, which was a similar rate to those of previous reports. We found 3 patients with intermittent atrioventricular block and 1 patient with sick sinus syndrome whose electrophysiological study was almost normal. Conclusions: Among patients without major structural heart disease, ILR can be useful to detect the mechanism of recurrent unexplained syncope. It is particularly helpful to find intermittent bradycardia which frequently vanishes during an electrophysiology study.

Introduction: Echocardiographic parameters are useful for the prediction of the long-term preservation of sinus rhythm in patients with successful cardioversion of atrial fibrillation . We assessed the echocardiographic parameters and left atrial volume by 3D-CT in 44 consecutive patients who had undergone circumferential pulmonary vein isolation for persistent AF. Methods: Transthoracic echocardiographic data, transesophageal echocardiographic data and LAV by 3D-CT of 44 consecutive patients were analyzed. We examined left atrial appendage flow, left atrial spontaneous echocardiographic contrast, mitral valve regurgitation during TEE, and also left atrial parasternal diameter, left ventricular end-diastolic diameter, left ventricular ejection fraction in TTE. Results: At a half year follow-up, 59.1% of the patients who had undergone pulmonary vein isolation continued to have SR. LAV was significantly smaller in patients remaining in SR for a half year than in those with AF recurrence . Between SR groups and AF recurrence groups, there were no significant differences in echocardiographic parameters. Conclusions: In echocardiography and 3D-CT guided management of persistent AF, LAV will be useful to predict the long-term SR maintenance after circumferential pulmonary vein isolation.

Introduction: Fidelis implantable cardioverter-defibrillator leads are prone to fractures that lead to adverse events. Approximately 268,000 patients have Fidelis leads worldwide and about 4900 in Japan. The lead failure rate in some reports was higher than in the Medtronic performance report. Thus, we investigated the longevity of Fidelis leads and compared it with that of Quattro leads. Methods and Results: From November 2005 to May 2011, 115 Fidelis and 95 Quattro leads were implanted and followed up at our hospital. Six lead fractures occurred in the Fidelis group at 5.4 years and no lead fracture in the Quattro group at 3.4 years. No deaths or injuries occurred as a result of lead failure, but all 6 fractures caused inappropriate shocks. The survival rate in the Fidelis group at 5.4 years was 92.0%, whereas that in the Fidelis group at 3.4 years was 96.5% and in the Quattro group at 3.4 years was 100%. Conclusions: The survival rate of Fidelis leads was similar to that of the Medtronic update. The difference in the survival rate at 3.4 years was not significant between Fidelis and Quattro leads. Given the small sample size and short observation period, it is impossible to conclude that Fidelis leads are inferior to Quattro leads at 3.4 years.

Objectives The aim of this study was to investigate the efficacy of a paclitaxel-eluting balloon (PEB) for the treatment of sirolimus-eluting stent (SES) restenosis. Background Because drug-eluting stents (DES) are being used in increasingly complicated settings, DES restenosis is no longer an uncommon phenomenon, and its optimal treatment is unknown. Methods This study was a prospective single-blind randomized trial conducted in 50 patients with SES restenosis. Patients were randomly assigned to a PEB group (n = 25) or a conventional balloon angioplasty (BA) group (n = 25). The primary end point was late lumen loss at 6-month follow-up. Secondary end points included the rate of binary restenosis (in-segment analysis) and major adverse cardiac events (MACE) at 6-month follow-up. Results At 6-month angiographic follow-up (follow-up rate: 94%), in-segment late lumen loss was lower in the PEB group than in the BA group (0.18 ± 0.45 mm vs. 0.72 ± 0.55 mm; p = 0.001). The incidence of recurrent restenosis (8.7% vs. 62.5%; p = 0.0001) and target lesion revascularization (4.3% vs. 41.7%; p = 0.003) was also lower in the PEB group than in the BA group. The cumulative MACE-free survival was significantly better in the PEB group than in the BA group (96% vs. 60%; p = 0.005). Conclusions In patients with SES restenosis, PEB provided much better clinical, angiographic outcomes than conventional BA.