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Literature describing recovery of left ventricular (LV) function post sacubitril/valsartan treatment and the optimal management of heart failure (HF) patients receiving sacubitril/valsartan remain sparse.We recruited 437 consecutive chronic HF patients with baseline left ventricular ejection fraction (LVEF) less than 40%, who were treated with sacubitril/valsartan. All patients underwent routine echocardiographic measurement.During treatment period, recovery of LVEF to 50% or greater was observed in 77 (17.6%) patients. After multivariate analysis, recovery of LV dysfunction was associated with non-ischemic etiology of HF, smaller baseline LV end-diastolic diameter (LVEDD), and higher initial dosage of sacubitril/valsartan. Compared to those without recovery of LV dysfunction, death from cardiovascular causes or first unplanned hospitalization for HF (CVD/HFH) were significantly lower in patients with LVEF recovery [11.7% vs. 24.4%, hazard ratio (HR) 0.42, p = 0.014]. Among patients with recovery of LVEF, 51 patients continued to receive the same dosage of sacubitril/valsartan had higher LVEF and were less likely to have deterioration of LVEF than the other 26 patients who received either tapering dose of sacubitril/valsartan or switching from sacubitril/valsartan to renin-angiotensin-system blockers (LVEF 56.4 ± 5.3% vs. 45.0 ± 12.8%, p 0.001; ΔLVEF 1.2 ± 5.1% vs. -9.3 ± 12.0%, p 0.001). CVD/HFH occurred more frequently in the taper group than the maintenance group (23.1% vs. 5.9%, HR 0.22, p = 0.035).Non-ischemic etiology of HF, smaller baseline LVEDD, and higher initial dosage of sacubitril/valsartan could predict better recovery of LV function. Among patients with functional recovery, tapering sacubitril/valsartan dose was associated with deterioration of recovered heart function and had less favorable prognosis during follow-up.

Background Angiotensin receptor and neprilysin inhibition (ARNI) has been shown to reduce cardiovascular mortality by 20% as compared with enalapril in a randomized controlled trial. However, there is a paucity of real-world data on the effects of ARNI in heart failure patients with reduced ejection fraction (HFrEF), especially those with concurrent renal impairment or hypotension. Methods Between 2016 and 2017, we recruited 466 HFrEF patients treated with sacubitril/valsartan (Group A) and 466 patients managed with standard HF treatment without ARNI (Group B) in a HF referral center. Baseline characteristics and clinical outcomes were collected between both groups. Results Baseline characteristics were comparable between the two groups. During a follow-up period of 15 months, death from cardiovascular causes or first unplanned hospitalization for HF occurred in 100 patients in Group A (21.5%) and 144 in Group B (30.9%, hazard ratio 0.66; 95% CI 0.51–0.85; p = 0.001). The incidences of deaths from any causes, cardiovascular death, sudden death, and HF re-hospitalization were all significantly lower in Group A than Group B patients. Among patients with different chronic kidney disease stages and normotensive patients, treatment with sacubitril/valsartan showed more favorable outcomes than treatment with standard HF care without ARNI. However, in patients with baseline systolic blood pressure lower than 100 mmHg, there were no significant differences of outcomes in both groups. Among Group A patients, escalation of sacubitril/valsartan was associated with better outcomes. Conclusions Our study demonstrated the effectiveness of sacubitril/valsartan on HFrEF patients in real world practice, including those with advanced renal impairment.

Aims Acute myocardial infarction (AMI) and stroke are important causes of mortality and morbidity. Our aims are to determine the comparative epidemiology of AMI and ischaemic stroke; and examine the differences in cardiovascular outcomes or mortality occurring after an AMI or stroke. Methods and results The Singapore National Registry of Diseases Office collects countrywide data on AMI, stroke, and mortality. Index events of AMI and ischaemic stroke between 2007 and 2012 were identified. Patients were then matched for occurrences of subsequent AMI, stroke, or death within 1-year of the index event. There were 33 222 patients with first-ever AMI and 20 982 with first-ever stroke. AMI patients were significantly more likely to be men (66.3% vs. 56.9%), non-Chinese (32.1% vs. 24.1%), and smokers (43.1% vs. 38.6%), but less likely to have hypertension (65.6% vs. 79%) and hyperlipidaemia (61.1% vs. 65.5%), compared with stroke patients. In total 6.8% of the AMI patients had recurrent AMI, whereas 4.8% of the stroke patients had recurrent stroke within 1 year; 31.7% of the AMI patients died, whereas 17.1% of the ischaemic stroke patients died within 1 year. Older age, Malay ethnicity, and diabetes mellitus were statistically significant risk factors for all-cause mortality and for the composite endpoint of AMI, stroke, and all-cause mortality, at 1 year. Conclusions Risk profiles of patients with AMI and stroke are significantly different. Patients suffer recurrent events in vascular territories similar to the index event. Age and diabetes mellitus are significant predictors of recurrent vascular events and mortality.

INTRODUCTION Rhodiola, a popular plant in Tibet, has been proven to decrease arrhythmia. The aim of this study was to elucidate the molecular mechanism and electrophysiological properties of rhodiola in the suppression of atrial fibrillation. METHODS This study consisted of 3 groups as follows: Group 1: normal control rabbits (n = 5); Group 2: rabbits with heart failure (HF) created by coronary ligation and who received 2 weeks of water orally as a placebo (n = 5); and Group 3: rabbits with HF who received 2 weeks of a rhodiola 270 mg/kg/day treatment orally (n = 5). The monophasic action potential, histology, and real-time polymerase chain reaction (RT-PCR) analysis of ionic channels and PI3K/AKT/eNOS were examined. RESULTS Compared with the HF group, attenuated atrial fibrosis (35.4 ± 17.4% vs. 16.9 ± 8.4%, P = 0.05) and improved left ventricular (LV) ejection fraction (51.6 ± 3.4% vs. 68.0 ± 0.5%, P = 0.001) were observed in the rhodiola group. The rhodiola group had a shorter ERP (85.3 ± 6.8 vs. 94.3 ± 1.2, P = 0.002), APD90 (89.3 ± 1.5 vs. 112.7 ± 0.7, P < 0.001) in the left atrium (LA), and decreased AF inducibility (0.90 ± 0.04 vs. 0.42 ± 0.04, P < 0.001) compared with the HF group. The mRNA expressions of Kv1.4, Kv1.5, Kv4.3, KvLQT1, Cav1.2, and SERCA2a in the HF LA were up-regulated after rhodiola treatment. The rhodiola-treated HF LA demonstrated higher mRNA expression of PI3K-AKT compared with the HF group. CONCLUSIONS Rhodiola reversed LA electrical remodeling, attenuated atrial fibrosis and suppressed AF in rabbits with HF. The beneficial electrophysiological effect of rhodiola may be related to upregulation of Kv1.4, Kv1.5, Kv4.3, KvLQT1, Cav1.2, SERCA2a, and activation of PI3K/AKT signaling.

Atrial fibrillation (AF) can be associated with an increased risk of developing coronary artery disease (CAD) due to mechanisms of inflammation, endothelial dysfunction and adverse atrial remodelling. It is unclear if adverse coronary events can be further reduced after successful catheter ablation of AF. We hypothesise that AF ablation and sinus maintenance could reduce future adverse cardiac events in patients with underlying CAD.A total of 310 patients with drug-refractory paroxysmal AF and prior history of percutaneous coronary intervention (PCI) for underlying CAD were recruited in the retrospective case control study. Of these, 155 patients underwent AF ablation (the Ablation Group), while 155 patients received medical treatment (the Medical Group). All patients were followed up for major adverse cardiac events, including acute coronary syndrome requiring hospitalisation, stroke, pulmonary embolism and mortality.The clinical characteristics were comparable between the two groups, except for higher antiarrhythmic drug use in the Medical Group. During a follow-up duration of 61±32 months, all-cause mortality (8.4% vs. 1.3%, p=0.004) and the overall major adverse events (47.7% vs. 12.3%, p0.001) were significantly higher in the Medical Group than the Ablation Group. There were also more instances of stroke (10.3% vs. 3.2%, p=0.013) and acute coronary syndrome requiring hospitalisation (29% vs. 7.1%, p0.001) in the Medical Group than the Ablation Group. Multivariate analysis confirmed that non-ablation was an independent risk factor for major adverse events (p0.001, HR 3.4, 95% confidence interval 1.9-5.9).In PAF patients with established CAD who underwent PCI, catheter ablation could lead to fewer major adverse cardiac events compared to medical therapy.

Background Radiofrequency ablation of ventricular arrhythmias (VAs) originating from the continuum between the aortic sinus of Valsalva (ASV) and the left ventricular (LV) summit is a challenge. Objectives The objectives of this study were to investigate the electrocardiographic, electrophysiological, and anatomical characteristics of VAs and to develop an algorithm for predicting the successful ablation site. Methods We recruited 66 patients (mean age, 47 ± 15 years; 42 male patients) with symptomatic VAs originating from the continuum between the ASV and the LV summit who underwent radiofrequency ablation. Patients were classified into 4 groups (group 1: ASV, n=20; group 2: subvalvular region, n=15; group 3: great cardiac vein/anterior interventricular vein [GCV/AIV], n=16; group 4: epicardium requiring pericardial access, n=15). The QRS morphological characteristics of VAs were compared between the 4 groups. Results Electrocardiographic analysis revealed that the aVL/aVR Q-wave ratio is useful in the prediction of successful ablation sites in the ASV, subvalvular area, GCV/AIV, and epicardium requiring pericardial access at cutoff values of ≤1.415, 1.416–1.535, 1.536–1.740, and >1.740, respectively. The aVL/aVR Q-wave ratio was well correlated with the distance between the successful ablation site and the tip of the LV summit. A distance of >18.9 mm and an LV myocardial thickness of >9.1 mm predicted the need for the epicardial or GCV/AIV approaches. There were no major procedural complications. Eight patients (12.1%) developed VA recurrence during a mean follow-up of 15.9 months (interquartile range 9.2–24.2 months). Conclusion The aVL/aVR Q-wave ratio is a useful parameter for predicting the successful ablation sites of VAs originating from the continuum between the ASV and the LV summit.

Hyperthyroidism is a known reversible cause of atrial fibrillation (AF). However, some patients remain in AF despite restoration of euthyroid status.The purpose of this study was to compare the electrophysiologic characteristics and long-term ablation outcome in AF patients with and without history of hyperthyroidism.The study enrolled 717 consecutive patients with AF who underwent first AF ablation, which involved pulmonary vein (PV) isolation in paroxysmal AF and additional substrate modification in nonparoxysmal AF patients. Eighty-four patients (12%) with hyperthyroidism history were compared to those without. Euthyroid status was achieved for ≥3 months before ablation in hyperthyroid patients.Patients with hyperthyroid history were associated with older age, more female gender, lower mean right atrial voltage, higher number of PV ectopic foci (1.3 ± 0.4 vs 1.0 ± 0.2, P.01), and higher prevalence of non-PV foci (42% vs 23%, P.01). Ectopic foci from ligament of Marshall were demonstrated more often in hyperthyroid patients (7.1% vs 1.6%, P.01) in whom alcohol ablations were required. After propensity score matching for potential covariates, history of hyperthyroidism was an independent predictor of AF recurrence after single procedure (hazard ratio 2.07, 95% confidence interval 1.27-3.38). AF recurrence rates after multiple procedures were not different between patients with and those without hyperthyroid history.Patients with hyperthyroid history had a significantly higher number of PV ectopies and higher prevalence of non-PV ectopic foci compared to euthyroid patients, which resulted in a higher AF recurrence rate after a single procedure.

A 44 year old male with idiopathic dilated cardiomyopathy was undergoing persistent atrial fibrillation (AF) ablation. Following antral ablation, AF terminated into a regular narrow complex rhythm. Earliest activation was mapped to a focus in the superior vena cava (SVC) which was conducted in a 2:1 ratio to the atria which in turn was conducted with 2:1 ratio to the ventricles, resulting in an unusual 4:2:1 conduction of the SVC tachycardia. 1:1 conduction of the SVC tachycardia to the atrium preceded initiation of AF. During AF, SVC tachycardia continued unperturbed. Sinus rhythm was restored following catheter ablation of the focus.

Substrate Modification in Persistent Atrial Fibrillation Introduction The optimal substrate ablation approach in patients with persistent atrial fibrillation (Per AF) remains unclear. This was a prospective randomized study comparing the efficacy of limited (continuous complex fractionated atrial electrogram, CFAE

Background Sudden cardiac death (SCD) occurs commonly after heart transplantation (HTX). The utilization of surface electrocardiography (ECG) to assess post-HTX SCD has not been investigated thoroughly. This study aimed to investigate the specific changes in surface ECG in HTX patients with SCD. Methods A total of 227 HTX patients (age 48±14y/o, mean donor age 34±14y/o, 173males) were followed up regularly at the outpatient clinic. Twelve-lead ECG's were recorded during 1–2 monthly visits. Serial ECG parameters and relevant clinical data were collected and analyzed. Results During the follow-up period of 96±51months, SCD occurred in 28 (12.3%) patients. The baseline ECG parameters were comparable between patients with and without SCD. Important ECG trends of rising rest heart rates and prolongation of corrected QT (QTc) and JT (JTc) intervals were observed prior to development of SCD. After adjustment for other clinical variables, the independent predictors for SCD were older donor age (p=0.014, OR 1.05, 95% CI 1.01–1.09), faster heart rate (p=0.006, OR 1.06, 95% CI 1.02–1.1) and longer JTc interval (p=0.015, OR 1.03, 95% CI 1.01–1.06). SCD occurred in 71.4% patients presenting with all three risk predictors. Conclusions Besides older donor age, important ECG signs, including prolongation of the JTc interval and increased heart rate during post HTX follow up, could predict SCD.

Several coronary disease scoring systems have been developed to predict procedural risk during revascularization. Many vary in complexity, do not specifically account for myocardium at risk, and are not applicable across all patient subsets. The British Cardiovascular Intervention Society myocardial jeopardy score (BCIS-JS) addresses these limitations and is applicable to all patients, including those with coronary artery bypass grafts or left main stem disease. We assessed the prognostic relevance of the BCIS-JS in patients undergoing percutaneous coronary intervention (PCI). A total of 663 patients who underwent PCI with previous left ventricular function assessment were retrospectively assessed for inclusion, incorporating 221 with previous coronary artery bypass grafting. Blinded observers calculated the BCIS-JS, before (BCIS-JS(PRE)) and after (BCIS-JS(POST)) PCI, using the revascularization index (RI) (RI = [BCIS-JS(PRE) - BCIS-JS(POST)]/BCIS-JS(PRE)), quantifying the extent of revascularization, 1 indicating full revascularization and 0 indicating no revascularization. The primary end point all-cause mortality, tracked via the Office of National Statistics. A total of 660 patients were included (66 ± 10.7 years), with 43 deaths (6.5%) occurring during 2.6 ± 1.1 years after PCI. All-cause mortality was directly related to BCIS-JS(PRE) (hazard ratio [HR] 2.96, 95% confidence interval [CI] 1.71 to 5.15, p = 0.001) and BCIS-JS(POST) (HR 4.02, 95% CI 2.41 to 6.68, p = 0.001). A RI of0.67 was associated with increased mortality compared to a RI of ≥0.67 (HR 4.13, 95% CI 1.91 to 8.91, p = 0.0001). On multivariate analysis, a RI0.67 (HR 1.99, 95% CI 1.03 to 3.87, p = 0.04), left ventricular dysfunction (HR 2.03, 95% CI 1.25 to 3.30, p = 0.004) and renal impairment (HR 3.75, 95% CI 1.48 to 8.64, p = 0.005) were independent predictors of mortality. In conclusion, the BCIS-JS predicts mortality after PCI and can assess the degree of revascularization, with more complete revascularization conferring a survival advantage in the medium term.

Background: Patients with diabetes mellitus have worse long-term outcomes after acute myocardial infarction (AMI) than non-diabetics. This may be related to differential contribution of neutrophil and lymphocyte to inflammation during AMI in diabetics vs. non-diabetics. We aim to determine the predictive value of neutrophil-to-lymphocyte ratio (NLR) for major adverse events post-AMI in Type 2 diabetics vs. non-diabetics. Methods and Results: A total of 2559 consecutive patients admitted for AMI (61 ± 14 years, 73% male and 43% diabetic) were analyzed. A complete blood count was obtained and the NLR computed for each patient on admission. Across the cohort, the 1-year reinfarction rate was 8.4% ( n = 214) and 1-year mortality was 14.5% ( n = 370). Univariate determinants of the composite endpoint included age, hypertension, hyperlipidemia, smoking, revascularization and NLR ( P

Background In clinical heart failure (HF), inefficient propagation of blood through the left ventricle (LV) may result from suboptimal vortex formation (VF) ability of the LV during early diastole. We aim to (i) validate echocardiographic-derived vortex formation time (adapted) (VFTa) in control subjects and (ii) examine its utility in both systolic and diastolic HF. Methods Transthoracic echocardiography was performed in 32 normal subjects and in 130 patients who were hospitalized with HF [91, reduced ejection fraction (rEF) and 39, preserved ejection fraction (pEF)]. In addition to biplane left ventricular ejection fraction (LVEF) and conventional parameters, the Tei index and tissue Doppler (TD) indices were measured. VFTa was obtained using the formula: 4 × (1 − β )/ π × α ³ × LVEF, where β is the fraction of total transmitral diastolic stroke volume contributed by atrial contraction (assessed by time velocity integral of the mitral E- and A-waves) and α is the biplane end-diastolic volume (EDV)1/3 divided by mitral annular diameter during early diastole. VFTa was correlated with demographic, cardiac parameters, and a composite clinical endpoint comprising cardiac death and repeat hospitalization for HF. Results Mean VFTa was 2.67 ± 0.8 in control subjects; reduced in HF, preserved EF HF, 2.21 ± 0.8; HF with reduced EF, 1.25 ± 0.6 ( P < 0.001). It was not affected by age, gender, body surface area but was correlated positively with TD early diastolic myocardial velocities ( E′ , septal, r = 0.46; lateral, r = 0.43), systolic myocardial velocities ( S′ , septal, r = 0.47; lateral, r = 0.41), and inversely with the Tei index ( r = −0.41); all P s < 0.001. Sixty-two HF patients (49%) met the composite endpoint. VFTa of

The endothelial progenitor cell (EPC)-capture stent promotes endothelialization and preliminary studies have suggested its safety and feasibility in ST-elevation myocardial infarction (STEMI). Detailed late clinical follow-up and angiographic analyses are, however, limited. We sought to determine late angiographic and clinical outcomes of the Genous EPC-capture stent in primary angioplasty. EPC-capture stents were implanted during primary angioplasty in 489 consecutive patients presenting with STEMI from 2004 through 2008. The first 100 consenting patients undergoing successful stent implantation scheduled to undergo relook coronary angiography at 6 to 12 months were enrolled. Ninety-five patients with 96 lesions were analyzed independently. Mean duration of follow-up coronary angiography was 245 days. In-stent late luminal loss measured 0.87 ± 0.67 mm. Binary restenosis (defined as >50% diameter stenosis) was 28%, with diffuse in-stent restenosis (Mehran class II) as the predominant pattern. Of 27 patients with binary restenosis, 14 (52%) were symptomatic, with 10 patients undergoing target lesion revascularization. Asymptomatic patients had significantly larger reference vessel and in-stent minimal luminal diameters (2.77 ± 0.39 vs 2.54 ± 0.44 mm, p = 0.040; 2.74 ± 0.34 vs 2.31 ± 0.72 mm, p = 0.004, respectively). Follow-up late loss and diameter stenoses were also in favor of the asymptomatic group. Major adverse cardiac event rate was 16% at a mean follow-up of 34 months. There were no cases of Academic Research Consortium-defined stent thrombosis. In conclusion, implantation of the EPC-capture stent during primary angioplasty is associated with a favorable late clinical outcome but with higher than anticipated angiographic late loss.

Background We investigated the prevalence and predictors of obstructive sleep apnea in patients admitted to the hospital for acute myocardial infarction and whether OSA has any association with microvascular perfusion after primary percutaneous coronary intervention. Methods Recruited patients were scheduled to undergo an overnight sleep study between 2 and 5 days after primary PCI. An apnea-hypopnea index of ≥ 15 was considered diagnostic of OSA. Impaired microvascular perfusion after primary PCI was defined as an ST-segment resolution of ≤ 70%, myocardial blush grade 0 or 1, or a corrected Thrombolysis in Myocardial Infarction [antegrade flow scale] frame count > 28. Results Sleep study was performed in 120 patients and completed in 105 patients (study cohort, mean age 53 ± 10 years, male 98%) with uncomplicated myocardial infarction. An AHI was ≥ 15 in 69 patients (OSA-positive), giving a prevalence of 65.7%. Diabetes mellitus was found to be a significant risk factor for OSA (odds ratio, 2.86; 95% confidence interval, 1.06 to 8.24; p=0.033). There were no differences between OSA-positive and OSA-negative groups with regard to the percentage of patients with ≤ 70% ST-segment resolution (73% vs 64%, respectively; p=0.411), myocardial blush grade 0 or 1 (39.1% vs 38.9%, respectively; p=1.000), or corrected TIMI frame count > 28 (21.7% vs 25.0%, respectively; p=0.807). Conclusions We found a high prevalence of previously undiagnosed OSA in patients admitted with acute myocardial infarction. Diabetes mellitus was independently associated with OSA. No evidence indicated that OSA is associated with impaired microvascular perfusion after primary PCI.

Background The prognostic significance of premature atrial complex ( PAC ) burden is not fully elucidated. We aimed to investigate the relationship between the burden of PAC s and long‐term outcome. Methods and Results We investigated the clinical characteristics of 5371 consecutive patients without atrial fibrillation ( AF ) or a permanent pacemaker ( PPM ) at baseline who underwent 24‐hour electrocardiography monitoring between January 1, 2002, and December 31, 2004. Clinical event data were retrieved from the Bureau of National Health Insurance of Taiwan. During a mean follow‐up duration of 10±1 years, there were 1209 deaths, 1166 cardiovascular‐related hospitalizations, 3104 hospitalizations for any reason, 418 cases of new‐onset AF , and 132 PPM implantations. The optimal cut‐off of PAC burden for predicting mortality was 76 beats per day, with a sensitivity of 63.1% and a specificity of 63.5%. In multivariate analysis, a PAC burden >76 beats per day was an independent predictor of mortality (hazard ratio: 1.384, 95% CI : 1.230 to 1.558), cardiovascular hospitalization (hazard ratio: 1.284, 95% CI : 1.137 to 1.451), new‐onset AF (hazard ratio: 1.757, 95% CI : 1.427 to 2.163), and PPM implantation (hazard ratio: 2.821, 95% CI : 1.898 to 4.192). Patients with frequent PAC had increased risk of mortality attributable to myocardial infarction, heart failure, and sudden cardiac death. Frequent PAC s increased risk of PPM implantation owing to sick sinus syndrome, high‐degree atrioventricular block, and/or AF . Conclusions The burden of PAC s is independently associated with mortality, cardiovascular hospitalization, new‐onset AF , and PPM implantation in the long term.

Ventricular arrhythmia (VA) can occur during propafenone therapy in atrial fibrillation (AF) patients with structurally normal heart.The purpose of this study was to evaluate the incidence and characteristics of propafenone-associated VAs in AF patients with structurally normal heart.We studied and compared the risk of new-onset VAs between AF patients with structurally normal heart taking and those not taking propafenone in a nationwide longitudinal cohort in Taiwan (n = 127,197 since 2000). We then investigated the association between propafenone and VA in AF patients with structurally normal heart in a single-center database (n = 396).In the nationwide cohort, 102 patients (0.008% per patient-year) developed ventricular tachycardia (VT)/ventricular fibrillation (VF) during a follow-up period of 9.8 ± 3.5 years. After multivariate Cox regression analysis, propafenone treatment was a significant risk factor for new-onset VT/VF with a hazard ratio (HR) of 3.59 (95% confidence interval [CI] 1.30-9.89, P = .0136). Propafenone treatment offered protection against ischemic stroke with HR 0.649 (95% CI 0.55-0.77, P.001). In the single-center study using ECG and medical records, the presence of inferior J wave, wider QRS, and old age were independent risk factors for VA after adjustment for clinical, biochemical, and echocardiographic variables.Albeit with low incidence, propafenone therapy for AF was associated with new-onset VA in the nationwide longitudinal cohort study in Taiwan. Old age, presence of inferior lead J wave, and wider QRS on ECG were significant risk factors in our single-center study.

Background Radiofrequency catheter ablation (RFCA) is an effective therapeutic strategy in eliminating drug-refractory idiopathic right ventricular outflow tract ventricular arrhythmias (RVOT VAs). It remains unclear what factors affect early and late VA recurrences after ablation. Objective The aim of our study was to elucidate the differences between early and late recurrences after acute successful RFCA of RVOT VAs in a long-term follow-up. Methods A total of 220 patients with acute successful RFCA of RVOT VAs were enrolled. Detailed clinical characteristics and assessments by noninvasive and invasive electrophysiology study were explored to predict the overall, early (≤1 year), and late VA (>1 year) recurrences. Results During a mean follow-up of 34.15 ± 33.74 months, 45 of 220 patients (20.5%) documented recurrence of RVOT VAs after the initial RFCA. Of these patients, 26 patients (57.8%) with recurrent VAs showed similar morphology, and 19 (42.2%) were different. Patients with recurrent VAs were associated with a higher incidence of hypertension, higher systolic blood pressure, identification of foci by pace mapping alone, shorter earliest activation time, more radiofrequency pulses required, and VA originating from the anterior free wall. Multivariate analysis demonstrated that mapping strategy and shorter earliest activation time preceding VA were associated with early recurrences (hazard ratio [HR] 2.26; 95% confidence interval [CI] 1.49–3.42; P P = .008, respectively), whereas hypertension was associated with late recurrence (HR 3.48; 95% CI 1.34–9.07; P = .001). Conclusion RFCA is an effective strategy in the elimination of RVOT VAs. However, early and late recurrences occur commonly. Patients with early and late VA recurrences demonstrated nonuniform patterns of clinical characteristics and electrophysiological properties.

Sudden cardiac death (SCD) is the most catastrophic presentation in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C).To investigate the seasonal variations in the frequency of SCD and ventricular tachyarrhythmia in patients with AVRD/C and to elucidate the meteorological factors that trigger these events.From 1998 to 2012, we enrolled 88 consecutive patients with ARVD/C from Taipei City. The cohort included 20 living patients who received implantable cardioverter-defibrillator (ICD) and 68 autopsied patients with SCD from the Taiwan National Forensic Institute registry. The baseline clinical characteristics, seasonal distribution, and associated meteorological factors were explored to predict the occurrences of events, which include appropriate ICD interventions and SCD.There were 106 events, including 38 (35.8%, 1.9 episodes per patient) appropriate ICD interventions in living patients with ARVD/C and 68 (64.2%) SCD events. The seasonal peak occurred predominantly in summer (P.05) in both groups. For meteorological factors, the onset of event was associated with higher average daily temperature and longer sunshine duration. The variation in humidity within 3 days of events was significantly increased. After multivariate logistic regression analysis, higher average daily temperature and larger variation in humidity were associated with increase in events (odds ratio 1.23, 95% confidence interval 1.16-1.31, P.001, and odds ratio 1.19, 95% confidence interval 1.15-1.23, P.001, respectively).There was seasonal variation with a summer peak in the occurrence of ventricular arrhythmias and SCD in patients with ARVD/C. Meteorological factors including higher temperature and larger variation in humidity within 3 days of events were independently associated with the development of events.

Background Patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) carry the risk of ventricular arrhythmias and sudden cardiac death (SCD). This study investigated the prognostic information of modified moving average T-wave alternans (MMA TWA) in patients with ARVD/C. Methods A total of 63 consecutive patients (mean age, 44.7 ± 14.8 years; 38 men) with ARVD/C were enrolled. Baseline characteristics and structural and electrocardiographic parameters were obtained. All patients underwent ambulatory electrocardiographic examination at the time of diagnosis, and MMA TWA data were exported for further analysis. Events were defined as documented SCD or ventricular tachyarrhythmias during clinical follow-up. Results During a mean follow-up of 28.1 ± 15.4 months, 19 of 63 (30.2%) patients experienced events, including SCD in 2 patients (10.5%) and ventricular tachyarrhythmias in 17 patients (89.5%). Patients with events had higher TWA within modified V 5 and V 1 channels than did those without events (54.7 ± 24.9 μV vs 35.0 ± 18.3 μV; P = 0.004; 58.8 ± 27.6 μV vs 38.4 ± 18.6 μV; P = 0.007, respectively). After multivariate Cox regression analysis, maximal TWA derived from either the modified CM 5 or NASA channel predicted the occurrence of events ( P 66 μV, maximal TWA yielded a sensitivity and a specificity of 89.5% and 90.5%, respectively, in predicting SCD or ventricular tachyarrhythmias. Conclusions The initial analysis of MMA TWA could provide prognostic implications in the prediction of SCD or ventricular tachyarrhythmias in patients with ARVD/C.

Long-Term Outcome of NPV AF Ablation. Introduction: Data regarding the long-term outcome of catheter ablation in patients with nonpulmonary vein (NPV) ectopy initiating atrial fibrillation (AF) are limited. We aimed to evaluate the long-term result of patients with AF who had NPV triggers and underwent catheter ablation. Methods and Results: The study included 660 consecutive patients (age 54 ± 11 years old, 477 males) who had undergone catheter ablation for AF. Group 1 consisted of 132 patients with AF initiating from the NPV, and group 2 consisted of 528 patients with AF initiating from pulmonary vein (PV) triggers only. Patients from Group 1 were younger than those from Group 2 (51 ± 12 years old vs 54 ± 11 years old, P = 0.001) and were more likely to be females (34.4% vs 25.8%, P = 0.049). The incidences of nonparoxysmal AF (36.4% vs 16.3%, P < 0.001) and right atrial (RA) enlargement (31.3% vs 19%, P = 0.004) were higher, and the biatrial substrates were worse in Group 1 than those in Group 2 (left atrial voltage 1.5 ± 0.7 mV vs 1.9 ± 0.7 mV, P < 0.001, RA voltage 1.6 ± 0.5 mV vs 1.8 ± 0.6 mV, P = 0.014). During a follow-up period of 46 ± 23 months, there was a higher AF recurrence rate in Group 1 than in Group 2 (57.6% vs 38.8%, P < 0.001). The independent predictors of AF recurrence were NPV trigger (P < 0.001, HR 2, 95% CI 1.4–2.85), nonparoxysmal AF (P = 0.021, HR 1.55, 95% CI 1.07–2.24), larger left atrial diameter (P = 0.002, HR 1.04, 95% CI 1.02–1.07) and worse left atrial substrate (P = 0.028, HR 1.3, 95% CI 1.03–1.64). Conclusion: Compared to AF originating from the PV alone, AF originating from the NPV ectopy showed a worse outcome. (J Cardiovasc Electrophysiol, Vol. 24, pp. 250-258, March 2013)

BACKGROUND The presence of ischemic mitral regurgitation (IMR) after ST-segment elevation myocardial infarction (STEMI) portends a poorer prognosis. The possible influence of reperfusion therapy in restoring mitral valve competence in inferoposterior STEMI has not been well elucidated. METHODS AND RESULTS We studied 423 consecutive patients with a first inferoposterior STEMI and determined the presence of IMR in patients treated with reperfusion therapy versus medical therapy. A primary percutaneous coronary intervention (PCI) was performed in 186 patients; 74 patients underwent thrombolysis, 63 patients had rescue PCI whereas 54 patients were treated medically. The mean time interval between STEMI presentation and echocardiography was 14 ± 27 days. Patients receiving reperfusion therapy had less moderate or severe IMR (2.5 vs. 11.1%, P=0.001). The presence of IMR between the primary PCI and the thrombolytic groups was similar (52.2 vs. 60.8%, P=NS). Left ventricular ejection fraction (47.7 ± 10.3 vs. 53.1 ± 11.4%, P

Background: Endothelial progenitor cell (EPC) capture stent is designed to promote rapid endothelization and healing and is potentially useful in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We studied the intermediate-term efficacy and safety of EPC stent and compared that with sirolimus-eluting bioabsorbable polymer stent (CURA) and bare metal stent (BMS) in AMI patients. Methodology: Patients presenting with AMI who underwent primary PCI with the respective stents between January 2004 and June 2006 were enrolled in the single-center clinical registry. The study end-points were major adverse cardiac events (MACE) and stent thrombosis. Results: A total of 366 patients (EPC = 95, CURA = 53, BMS 218) were enrolled. Baseline demographics including age, gender, diabetes, renal impairment, predischarge left ventricular ejection fraction, and creatinine kinase level were comparable among the groups. Procedural success rate was 99.5%. Post-procedural thrombolysis in myocardial infarction (TIMI) 3 flow was achieved in EPC 91.6%, CURA 96.2%, and BMS 88.5% (P = 0.209). At 2 years, the MACE rate was EPC 13.7%, CURA 15.1%, and BMS 19.7% (P = 0.383). Target vessel revascularizations (TVR) were EPC 4.2%, CURA 9.4%, and BMS 6.0% (P = 0.439). Nonfatal myocardial infarctions were EPC 1.1%, CURA 3.8%, and BMS 4.1% (P = 0.364). One patient in the EPC group had acute stent thrombosis. There was no late stent thrombosis in the EPC group. Conclusion: EPC stent appeared to be safe and had comparable clinical efficacy with a BMS when used in the AMI setting. At 2-year follow-up, the EPC group showed favorable, single-digit TVR rate and stent thrombosis remained a low-event occurrence. (J Interven Cardiol 2010;23:101-108)

Background: Endothelial progenitor cell (EPC) capture stent (Genous ™ , OrbusNeich), is designed to promote rapid endothelization and healing and is potentially useful in patients undergoing primary percutaneous coronary intervention (PPCI) for acute ST-segment elevation myocardial infarction (STEMI). We compare its clinical efficacy and safety with a sirolimus-eluting (SES) bioabsorbable polymer-coated stent (Cura ™ , OrbusNeich) and a bare metal stent (BMS) (Liberte ™ , Boston scientific) in patients presenting with STEMI. Methods: All patients presented to our center with STEMI and received PPCI with either EPC, SES or BMS stents between Jan 2004 and June 2006 were enrolled in the cohort study. The study endpoints were major adverse cardiac events (MACE) defined as composite end point of death, myocardial infarction (MI) and target vessel revascularization (TVR) at 2 years as well as acute, subacute and late stent thrombosis. Results: A total of 366 patients (EPC=95, SES=53, BMS 218) were enrolled. Baseline demographics in terms of age, gender, diabetes mellitus, baseline renal impairment, pre-discharge left ventricular ejection fraction, cardiogenic shock were comparable among the 3 groups. Procedural success rate was high at a mean of 99.5%. Post-procedural TIMI 3 flow was achieved in EPC 91.6%, SES 96.2% and BMS 88.5%. The MACE and stent thrombosis results at 2 years are shown in the table . Conclusion: The MACE rates among patients who underwent PPCI were similar in all 3 stent groups at 2 years follow-up. There was no difference in TVR rate and stent thrombosis remains a low event occurrence. None of the patients in the EPC stent group developed late stent thrombosis at 2 years follow up.

A 25-year-old female with history of intravenous drug abuse was admitted with tricuspid valve infective endocarditis. Echocardiogram demonstrated a large vegetative mass (arrow) in the right atrium (RA) ( Panels A and B ). She underwent excision of the mass, pericardial reconstruction of the tricuspid valve …

Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by the presence in the serum of antibodies against various organs. Patients with SLE have an increased risk of atherosclerosis and thrombosis. Coronary artery disease is now one of the most important causes of death in patients with SLE [1]. It was reported that middleagedwomenwith SLEwere over 50 timesmore likely to have a myocardial infarction (MI) than women of similar age [2]. Apart from traditional risk factors like smoking and diabetes mellitus, SLE patients have other non-traditional risk factors that predispose them to coronary thrombosis. These include the presence of anti-phospholipid antibodies, anti-oxidized low-density lipoprotein antibodies, lipid peroxidation, hyperhomocysteinemia and cumulative SLE activity [3]. Percutaneous coronary intervention (PCI) has been proven to be an effective treatment for obstructive coronary artery disease. Despite an increased risk of developing coronary artery disease, the safety and long-term efficacy of PCI in this specific patient cohort has not been studied. We present the long-term follow-up (N3 years) data of a cohort of SLE patients who have undergone PCI using bare metal stents or drug-eluting stents.

A 61-year-old lady with known dextrocardia and paroxysmal atrial fibrillation (AF) was referred for ablation. Computed tomography (CT) of the thorax (frontal plan as shown in Figure 1 …