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INTRODUCTION Gastric hypomotility (GH) is a major complication of atrial fibrillation (AF) ablation. We aimed to clarify whether additional cryoballoon ablation (CBA) of the left atrial (LA) roof is associated with GH. METHODS AND RESULTS This study included 54 patients with non-paroxysmal AF who underwent CBA for pulmonary vein isolation and of the LA roof line. GH was defined according to the results of esophagogastroscopy performed 2 days after ablation. GH was observed in 10 patients. There were significant differences in LA diameter (LAD), right inferior pulmonary vein (RIPV) diameter, and the height of the LA roof from the point where the LA posterior wall and esophagus make contact between patients with (GH+) and without GH (GH-) (LAD: 41.0 [36.3-41.8] mm vs. 46.5 [42.8-50.0] mm, p

Atrial fibrillation (AF) mostly originates from the pulmonary vein (PV). As a result, 70%−90% of AF patients can be successfully treated with extensive PV isolation. However, the precise identification of the site of trigger in the remaining 10%–30% with non-PV foci1, 2, 3 is often difficult. Especially in cases that require multiple electrical cardioversions because of immediate recurrence of AF after cardioversion, the mapping of origins becomes more difficult. In this case, a prominent Eustachian ridge was demonstrated as a source of AF trigger by high-density grid mapping catheter (Advisor™ HD Grid Catheter; Abbott Medical, Minneapolis, MN).

Second-generation cryoballoon (CB) ablation is effective in achieving pulmonary vein (PV) isolation (PVI) in atrial fibrillation (AF) patients. The "crosstalk" (CST) phenomenon has been reported to reduce unnecessary applications during CB ablation. Nevertheless, it is unclear under what conditions the CST phenomenon occurs.To seek the predictors of the CST phenomenon during CB-guided PVI, CST phenomenon in achieving ipsilateral superior PVI during inferior PV ablation was analyzed in AF patients who underwent de novo ablation using CB. CB occlusion status and nadir balloon temperature (NT) were compared in these patients, and all ablated superior PVs were categorized into three groups according to the necessity of the touch up ablation and effectiveness of the phenomenon.Of 1082 superior PVs, 16, 40, and 1026 were classified into the CST success, CST failure, and control groups (unnecessary CST), respectively. The proportion of superior PVs ablated with complete occlusion using the CB was significantly higher in the CST success group than in the other two groups. The proportion of superior PVs ablated with NT ≤ -46°C was higher in the CST success group than in the CST failure group. The CST phenomenon was always observed if CB ablation of the superior PVs was performed with both complete occlusion and NT ≤ -46°C and was almost always ineffective if it did not meet these two criteria (sensitivity, 100%; specificity, 93%).Successful CST ablation was highly predicted if complete PV occlusion and NT ≤ -46°C during CB ablation of the superior PVs were achieved.

Radiofrequency and cryoballoon applications around the pulmonary veins (PVs) could provoke a vagal reflex (VR) by modulating the intrinsic cardiac autonomic nervous system (ICANS).This study aimed to investigate the incidence, timing, and clinical impact of a VR provoked by a laser balloon application for a PV isolation (PVI).A total of 92 consecutive paroxysmal atrial fibrillation (PAF) patients underwent a laser balloon PVI of PAF. Acute changes in the heart rate and blood pressure were recorded. The heart rate variability (HRV) was tested by Holter ECGs before and at three months following the ablation. Three hundred forty-five out of 363 PVs were successfully isolated (97%) with laser balloon applications. A VR such as sinus bradycardia (26.1%), transient sinus arrest (9.8%), transient atrioventricular block (1.1%), or a blood pressure reduction (8.7%) was observed during the laser balloon applications for the PVI. The follow-up ended at 12 months. The HRV attenuation was comparable before and at three months after the ablation procedure between that with and without a VR (P = 0.14). The PAF recurrence rate was also comparable between the two groups (P = 0.882).The laser balloon PVI often provoked a VR, however, the modulation of the ICANS was temporary and for up to three months as measured by the HRV changes after the ablation, and the freedom from any atrial fibrillation recurrence was comparable regardless of the occurrence of a VR.

Introduction: Pulmonary vein (PV) isolation (PVI) with a balloon-based visually guided laser ablation (VGLA) is a useful tool for treating atrial fibrillation (AF), however, phrenic nerve injury (PNI) is an important complication. We investigated the predictors of developing PNI during VGLA. Methods and Results: This study included 130 consecutive patients who underwent an initial VGLA of non-valvular paroxysmal AF. During the ablation of the right-sided pulmonary veins, continuous and stable right phrenic nerve pacing was performed, and the compound motor action potentials (CMAPs) were recorded. Twenty patients developed PNI during the PVI. The patients who suffered from PNI had a significantly larger right superior PV (RSPV) ostium area (284.7 ± 47.0 mm2 vs. 233.1 ± 46.4 mm2, P < 0.01) than that of the other patients. Receiver operating characteristic analyses revealed that the area under the curve of the RSPV ostial area was 0.79 (95% confidence interval: 0.69-0.90) with an optimal cut-off point of 238.0 mm2 (sensitivity: 0.58, specificity: 0.95). In the multivariate analyses, large RSPV ostial area (HR 1.02, 95% confidence interval: 1.01-1.03, P < 0.01) and small balloon size (HR 0.72, 95% confidence interval: 0.53-0.98, P = 0.03) were independent risk factors for PNI. PNI remained in 13 patients after the procedure, but 12 of those patients recovered from PNI during the follow-up period. Conclusion: The incidence of PNI during the VGLA was relatively high, but the PNI improved in the majority of cases. During the VGLA, a large RSPV and small balloon size were predictors of PNI.

Objectives The aim of this multicenter, randomized, single-blind study was to prospectively evaluate the short-and long-term outcomes of pulmonary vein isolation (PVI) versus PVI with concomitant left atrial posterior wall isolation (PWI) using the cryoballoon in patients with symptomatic persistent/long-standing persistent atrial fibrillation (P/LSP-AF). Background Some studies have suggested a clinical benefit associated with PVI+PWI in patients with P/LSP-AF. However, there are limited safety and efficacy data on this approach using cryoballoon ablation. Methods The immediate and long-term outcomes in patients with P/LSP-AF randomized to PVI (n = 55) versus PVI+PWI (n = 55) using the cryoballoon were prospectively examined. Results Baseline characteristics were similar. PVI was achieved in all patients (21 ± 11 min). PWI was attained using 23 ± 8 min of cryoablation. Adjunct radiofrequency ablation was required in 4 of 110 patients (7.3%) to complete PVI (3 ± 2 min) and in 25 of 55 patients (45.5%) to complete PWI (4 ± 6 min). Although left atrial dwell time (113 ± 31 min vs. 75 ± 32 min; p Conclusions In patients with P/LSP-AF, PVI+PWI using the cryoballoon is associated with a significant reduction in atrial fibrillation recurrence, but similar safety, as compared with PVI alone.

Catheter manipulation in the left-sided heart is known as a risk for cerebral embolisms (CEs). However, anticoagulation therapy is terminated before catheter ablation (CA) of atrial fibrillation (AF) concerning adverse bleeding events. Little is known whether uninterrupted direct oral anticoagulants (DOACs) during perioperative period of CA could render the ablation procedure safer and reduce the incidence of CEs compared to interrupted DOACs. The aim of this study was to investigate the safety and usefulness of uninterrupted dabigatran during the periprocedural period for CA of AF.We included 333 patients with paroxysmal AF undergoing cryoballoon CA (CBA). They were prospectively divided into 2 groups based on whether DOACs were interrupted on the day of the CA (Group A, n=228) or dabigatran was not interrupted throughout perioperative period (Group B, n=105) in a non-randomized fashion. When the Group B patients had taken other DOACs rather than dabigatran before assignment, we changed those DOACs to dabigatran. Brain magnetic resonance imaging (MRI) was undertaken on the following day of the CA. Serious bleeding event cases were excluded from the study.The baseline characteristics including the CHADs2 score did not exhibit any significant differences between the groups. The brain MRI revealed an acute CEs in 82 patients, and was significantly higher in Group A than B (29% vs. 13%, respectively, p0.01). There were no significant differences regarding the bleeding events (7% vs. 4%, respectively, p=0.62).Uninterrupted dabigatran therapy during the CBA of paroxysmal AF could significantly reduce the incidence of CEs.

INTRODUCTION The left atrial (LA) posterior wall (LAPW) has been targeted to improve the clinical outcomes in patients with persistent atrial fibrillation (PersAF). This study aimed to investigate the feasibility, safety, and clinical implications of cryoballoon (CB) applications on the LAPW to accomplish electrical isolation (EI) of the LAPW with CB. METHODS A total of 100 patients (males, 84; mean age, 64 ± 10 years) with PersAF were enrolled. The first 50 patients underwent only pulmonary vein isolation (PVI) (PVI-only group) and the remaining 50 patients underwent PVI and EI of the LAPW with CB (EI-LAPW group). RESULTS One-year sinus rhythm maintenance probability was significantly higher in the EI-LAPW group than in PVI-only group (80.0% vs 55.1%, P = 0.01). The success rate of constructing an LA roof block line (LA-RB), bottom block line, and EI of the LAPW was 92%, 60%, and 58%, respectively. The nadir CB temperature (-45°C ± 4°C vs -39°C ± 5°C, P = 0.005) and anatomical angle of the left atrial roof (106°C ± 30°C vs 144°C ± 17°C, P

Background This study aimed to clarify the clinical outcomes of cryoballoon ablation of the left atrial (LA) posterior wall (LAPW), including the LA roof, in patients with non‐paroxysmal atrial fibrillation (AF). Methods We analyzed the outcomes of 284 patients with non‐paroxysmal AF, of whom 210 underwent the cryoballoon ablation of the LAPW, including the LA roof, in addition to pulmonary vein isolation with a cryoballoon. Results Complete conduction block at the LA roof was obtained in 95.7% (201/210) of patients, and LAPW was isolated in 83.3% (130/156) of patients. Over 372 (range, 208–477) days of follow‐up, atrial arrhythmia recurrence was observed in 84 (29.6%) patients, and atrial tachycardia (AT) recurrence accounted for 27.4% of cases. The prevalence of LA roof cryoballoon ablation was significantly higher in patients without recurrence than in those with recurrence (78.6% vs. 63.1%, respectively; p = .01), especially those with persistent AF recurrence (77.0% vs. 55.0%, p = .01). No significant difference was found in the prevalence of AT recurrence between patients who had undergone additional LAPW ablation and those who had not. Durable LA roof lesions were confirmed in 29 (72.5%) of 40 patients who underwent redo ablation. Conclusions Cryoballoon ablation of the LAPW leads to a sufficient acute success rate of complete conduction block and durable lesions of the LA roof without increasing AT recurrence risk. The prevalence of persistent AF recurrence decreases after additional cryoballoon ablation of the LAPW in patients with non‐paroxysmal AF., Cryoballoon ablation of the left atrial roof or the left atrial posterior wall could be performed safely. It brings sufficient efficacy in terms of reducing the recurrence as a persistent form of atrial fibrillation.

Background: Contrast computed tomography (CT) is a useful tool for the detection of intracardiac thrombi. We aimed to assess the accuracy of the late-phase prone-position contrast CT (late-pCT) for thrombus detection in patients with persistent or long-standing persistent atrial fibrillation (AF). Methods: Early and late-phase pCT were performed in 300 patients with persistent or long-standing AF. If late-pCT did not show an intracardiac contrast defect (CD), catheter ablation (CA) was performed. Immediately prior to CA, intracardiac echocardiography (ICE) from the left atrium was performed to confirm thrombus absence and the estimation of the blood velocity of the left atrial appendage (LAA). For patients with CDs on late-pCT, CA performance was delayed, and late-pCT was performed again after several months following oral anticoagulant alterations or dosage increases. Results: Of the 40 patients who exhibited CDs in the early phase of pCT, six showed persistent CDs on late-pCT. In the remaining 294 patients without CDs on late-pCT, the absence of a thrombus was confirmed by ICE during CA. In all six patients with CD-positivity on late-pCT, the CDs vanished under the same CT conditions after subsequent anticoagulation therapy, and CA was successfully performed. Furthermore, the presence of residual contrast medium in the LAA on late-pCT suggested a decreased blood velocity in the LAA (≤ 15 cm/s) (sensitivity = 0.900 and specificity = 0.621). Conclusions: Late-pCT is a valuable tool for the assessment of intracardiac thrombi and LAA dysfunction in patients with persistent or long-standing persistent AF before CA.

Introduction: The “crosstalk” (CST) ablation technique has been reported to reduce unnecessary ablation during cryoballoon (CB) ablation (CBA). Nevertheless, it is unclear which situations will necessitate the adoption of the technique. Methods and Results: The effect of the technique was analyzed in AF patients underwent CBA from July 2017 to February 2020. The balloon occlusion status and nadir temperature (NT) were compared, and all ablated PVs were categorized into three groups according to the necessity and effectiveness of the technique. Of 1082 superior PVs (SPVs), 16, 40, and 1026 were identified in the CST success group, CST failure group, and control group, respectively. The proportion of SPVs ablated with complete occlusion with CB was significantly higher in the CST success group (100%) than in the CST failure group (16.7%) or control group (49.4%) (CST success group vs. CST failure group, p

Cryoballoon ablation is an established catheter-based approach to treat atrial fibrillation (AF). However, thromboembolic events cannot be avoided during cryoablation. There is little data regarding the blood coagulation status during freezing.The thrombin antithrombin complex (TAT) and prothrombin fragment 1+2 (F 1+2) of patient blood were measured during cryoballoon application when the cryoballoon temperature reached the nadir in 63 AF patients. TAT was also measured from porcine blood during cryoballoon freezing in 5 pigs.The TAT and F 1+2 increased from 6.60 ± 5.65 to 9.16 ± 7.28 ng/mL (P = 0.004) and from 279.6 ± 146.4 to 323.6 ± 169.1 pmol/L (P = 0.003) between the control and during freezing, respectively. The TAT increased from 0.46 to 0.87 ng/mL during freezing compared to that of pre-freezing (P < 0.05), and it returned to 0.39 ng/mL in 30 minutes after an intravenous edoxaban administration (N.S.).Dabigatran failed to exert sufficient anticoagulant effects during cryofreezing. In contrast, intravenous edoxaban seemed to provoke anticoagulation effects under extreme low temperature circumstances.

Background Adenosine triphosphate (ATP) can provoke acute reconnections after pulmonary vein isolation (PVI). This study aimed to investigate dormant conduction (DC) after ablation with second-generation cryoballoon (CB). Methods Two hundred sixteen patients (148 male; age 64 ± 9 years) with atrial fibrillation (AF) were included. After a successful PVI with the CB, 20 mg of ATP was administered. All patients were followed up for 425 ± 56 days. Results Seven hundred ninety-five out of 864 (92%) PVs were successfully isolated solely by the CB. DCs were revealed in 8 (3.7%) after ATP injections. AF recurrences occurred in 2 out of 8 patients, while no AF recurrences could be documented in 6 out of 8 patients with DCs after a blanking period of 3 months (25% vs. 75%). In contrast, 29 (13.9%) patients without DCs had AF recurrences, and there was no significant difference between those with and without DCs regarding the recurrence rate of AF ( p = 0.38). There were no reliable predictors of DCs after the PVI with the CB. Conclusion The present study demonstrated a low rate of transient PV reconnection after adenosine infusion following successful PVI with the CB. There was no reliable predictor of DCs. Further studies will be needed in order to appreciate the prognostic value of adenosine testing after successful PVI with the CB.

Introduction Pulmonary vein isolation (PVI) using a cryoballoon (CB) is a useful tool for treating atrial fibrillation (AF); however, the clinical efficacy of the CB has never been fully investigated in patients with a left common pulmonary vein (LCPV). Methods and results Three hundred twenty-four consecutive paroxysmal AF patients underwent PVI with a CB. Three-dimensional computed tomography was performed in all patients before the ablation. The clinical outcomes of the AF ablation between patients with (Group A) and without an LCPV (Group B) were compared. An LCPV was observed in 27 (8%) patients. There were no significant differences in the procedure time (149±45 min vs. 143±40 min, respectively; P = 0.42) and percentage needing touch up ablation between the two groups (26% vs. 20%, respectively; P = 0.45). At a mean follow-up of 454±195days, 282 of 324 (87%) patients were free from any atrial tachyarrhythmias (ATs) after a single procedure. Twenty out of 27 (74%) Group A patients and 262 of 297 (88%) Group B patients were free from ATs (15-month Kaplan-Meier event free rate estimates, 77% and 89%, respectively; P = 0.02). A multivariate analysis identified the presence of an LCPV and the left atrial diameter as reliable predictors of recurrent ATs. Conclusions The long-term clinical outcomes of ablation of AF with the CB was worse in patients with an LCPV than in those without. The presence of an LCPV and the LA size seemed to be reliable predictors of a worse outcome. This article is protected by copyright. All rights reserved

Laserballoon-based pulmonary vein isolation has proven to be safe and effective. However, the influence of the laser energy titration on the lesion formation has never been fully investigated. The aim of this study was to determine the relationship between the delivered laser energy and lesion size, as well as the incidence of steam pop.The whole porcine heart was excised, and the left ventricular myocardium was separated into four specimens. Myocardial specimens were embedded in a warm mattress to keep the myocardial temperature around 37°C. The laserballoon was located so that the surface of the laserballoon was attached to the myocardium. The laser energy was irradiated against the surface of myocardium at 5.5, 8.5, 10.0, and 12.0 W for 3, 5, 10, and 20 seconds. The depth, surface area, and lesion volume were measured using a digital vernier caliper.At constant laser energy and time, the lesion size increased significantly with the increasing energy (P < 0.001) and application duration (P < 0.001). The steam pop was provoked when a 12.0 W laser energy was applied for longer than 16 seconds, and it occurred in 2 out of 8 lesions.The laserballoon demonstrated the ability to create a lesion formation in a dose- and time-dependent manner. Steam pop could be provoked with high-energy irradiation.

Introduction Pulmonary vein isolation (PVI) and linear ablation with a roof line and bottom line on the left atrial (LA) posterior wall (LAPW) can be achieved with a cryoballoon (CB). This study sought to investigate the long-term durability of these linear lesions. Methods and results Among 290 persistent patients with atrial fibrillation (AF) who had undergone linear ablation with a CB on the roof and bottom line of the LAPW in addition to the PVI, we analyzed those patients who underwent a re-do AF ablation. Arrhythmia recurrence was confirmed in 70 (24%) out of 290 patients, and 47 (16%) patients underwent re-do sessions. At the beginning of the re-do ablation, we examined the reconnection sites of the linear lesions on the LAPW and PVI. Maintenance of the conduction block on the LAPW roof and bottom lines was observed in 35 out of 47 patients (74.5%), and 16 out of 35 patients (45.7%), respectively. The length of the roof line was significantly shorter in patients with preservation of the conduction block on the LAPW roof than in those without (36.2 ± 6.5 mm vs 41.6 ± 4.7 mm, P = .02). Conclusion Durable lesions could be obtained after linear ablation with the CB for the LAPW roof line, especially in those with a relatively short LAPW roof line. However, patients requiring touch-up ablation with radiofrequency were included, and that was associated with a potential financial implication.

Purpose The aim of this study was to test regional pharmacological effects of an antiarrhythmic agents to predict ablative effects. Background The vein of Marshall (VOM) providing vascular access to myocardial tissue has been used for ablative purposes using ethanol. Methods A total of 35 patients (male 21, 63.2 ± 7.8 years old) were included. A balloon-tipped infusion catheter was inserted into the VOM. Endocardial ultrahigh-resolution mapping was performed along the VOM region to record the change in atrial electrograms (AEs) after VOM injection of cibenzoline of 3.5 mg during sustained atrial fibrillation (AF). Subsequently, ethanol was infused into the VOM and ablative region was mapped. Results In 17 patients (49 %), cibenzoline reduced AEs amplitude by >50%, all of which had also complete elimination of AEs following ethanol (Group A). In 18 patients (Group B), cibenzoline failed to eliminate AEs; yet, in 13 of 18 AEs were eliminated by ethanol. In the remaining five patients, ethanol did not eliminate AE. Conclusions Cibenzoline into the VOM could reliably predicts the results of subsequent ethanol infusion into the VOM using ultrahigh-resolution mapping system, which leads to avoid unnecessary permanent lesion creation by ethanol infusion.

Rapid ventricular pacing (RVP) was reported to improve the cooling effects of the cryoballoon (CB). The aim of this study was to investigate the safety and efficacy of RVP for left atrial posterior wall isolation (PWI) by the CB. One hundred consecutive patients (males 80, mean age 63 ± 10 years) with persistent atrial fibrillation underwent left atrial roof (LA-RB) and bottom block line (LA-BB) creation by CB to achieve PWI. Patients were randomized into two groups according to whether they underwent PWI with (RVP group, n = 50) or without RVP (control group, n = 50). The nadir CB temperature (NCT) during the LA-RB and LA-BB creation was significantly lower in the RVP group than control group (LA-RB − 45.7 °C and − 43.9 °C, p < 0.001, and LA-BB − 42.4 °C and − 40.0 °C, p < 0.001). The success rate of the LA-RB creation was significantly higher in the RVP group than the control group (98% vs. 88%, p = 0.039), however, there were no significant differences regarding the LA-BB creation (66% vs. 52%, p = 0.15) and PWI (66% vs. 50%, p = 0.1) between the two groups. The PWI success rate did not differ whether CB freezing was prematurely terminated due to an excessive luminal esophageal temperature (LET) drop in the RVP group (65.8% vs. 66.7%, respectively, p = 0.96). RVP significantly decreased the NCT during the CB application resulting in the significant improvement of success rate of the LA-RB. The advantage of RVP in terms of the accomplishing PWI was not affected even when the CB freezing was prematurely terminated due to an excessive LET drop.

Background The cryoballoon (CB) can be utilized for extra pulmonary vein (PV) ablation such as for a left atrial (LA) posterior wall (LAPW) isolation. However, scrutiny of the esophageal injuries during the LAPW isolation has never been performed. We sought to thoroughly investigate the esophageal lesions (ELs) and gastric hypomotility (GH) caused by an LAPW isolation using a CB. Methods A total of 101 persistent atrial fibrillation patients who underwent an LAPW isolation using a CB were enrolled. The CB was applied on the roof and bottom area of the LAPW after a PV isolation. The luminal esophageal temperature (LET) was monitored by a thermistor probe during the CB applications. When the LET reached 15°C, the freezing application was prematurely interrupted. Esophagogastroscopy was performed on the next day following the ablation. Results All PVs were successfully isolated in all patients. A successful LAPW isolation solely with CB ablation was performed in 72 (71.3%) patients. Cryofreezing applications were prematurely interrupted due to low LETs in 49 (48.5%) patients predominantly during the LA bottom line ablation. ELs and GH were observed in 11 (10.9%) and 16 patients (15.8%), respectively. The nadir LET tended to be lower in patients with ELs and GH than in those without (ELs: 14.8 ± 4.5°C vs 17.4 ± 6.0°C, P = 0.17; GH: 15.5 ± 4.5°C vs 17.5 ± 6.1°C, P = 0.23, respectively). Conclusions Esophageal complications such as ELs and GH occur during the LAPW isolation with a CB. There was no reliable predictor of those adverse events.

Introduction Adenosine triphosphate (ATP) sensitive atrial tachycardia (AT) has been treated by radiofrequency catheter ablation. Cryofreezing energy has emerged as a novel energy source for catheter ablation. The aim of this study was to investigate the efficacy and safety of cryofreezing ablation for ATP-sensitive AT. Methods and results A total of six patients with ATP-sensitive ATs were included in this study. A single atrial extrastimulation was able to initiate and terminate these ATs in all six patients. The electrophysiological findings satisfied the diagnostic criteria of ATP-sensitive AT. The ablation catheter was located at the earliest activation site of atrial excitation during the AT, and cryofreezing energy was delivered through a cryoablation catheter to perform cryomapping at temperature of -30 or -80°C. When cryomapping successfully terminated the ATs, cryoablation at a temperature of -80°C was subsequently performed. The earliest atrial activation during AT was recorded at the Koch's triangle area associated with a distinct intra-atrial activation sequence from that recorded during ventricular pacing. Cryoablation was performed at successful cryomapping sites and resulted in the complete elimination of the AT in all six patients without affecting the bidirectional atrioventricular (AV) nodal conduction. Conclusion Cryofreezing energy was safe and effective in treating ATP-sensitive ATs even in patients with its origins located in the vicinity of the AV node.

Complete occlusion of the pulmonary veins (PVs) with the cryoballoon (CB) is considered to be the crucial factor for a successful PV isolation (PVI). We investigated whether a complete occlusion was indispensable for a successful CB based PVI of every PV.Atrial fibrillation patients (n=123, 97; paroxysmal) undergoing a de novo PVI were enrolled. A total of 477 PVs were analyzed. The occlusion grade (OG) was scored as follows: OG3 (complete occlusion), OG2 (incomplete occlusion with slight leakage), OG1 (poor occlusion with massive leakage). There was no significant difference in the CB temperature (CBT) at all measured time points (from 30 to 120sec after freezing) and nadir CBT between OG2 and OG3 in all PVs except for the right inferior PV (RIPV). The RIPV isolation success rate was significantly lower for the OG2 status than OG3 (97.5 vs. 57.6%; p0.0001). In contrast, there was not significant difference in the isolation success rate of the other three PVs between OG2 and OG3. In particular, the success rate of the right superior PV (RSPV) isolation was95% for both OG2 and OG3. Phrenic nerve paralysis (PNP) was provoked during the RSPV isolation in two patients in whom the RSPVs were frozen during OG3.An OG3 may not always be required for a successful PVI of all PVs except the RIPV. OG2 could have comparable effects as OG3 in terms of a successful RSPV isolation. Not aiming for OG3 for the RSPV may reduce the risk of PNP.

Phrenic nerve (PN) injury is a typical complication of cryoballoon ablation (CBA) of pulmonary veins. The PN function is monitored by palpating the abdomen during PN pacing, and freezing is prematurely terminated when a reduction in the diaphragm movement is recognized. This study aimed to investigate the efficacy and safety of a “pull-back” maneuver to prevent PN injury. A total of 284 patients were included, and the PN function was monitored by recording the diaphragmatic compound motor action potentials (CMAP) during the cryoballoon applications for pulmonary vein (PV) isolation. When the CMAP amplitude was reduced by more than 30% compared to the control, the “pull-back” maneuver (PBM) was undertaken to prevent PN injury. The average CMAP amplitude significantly decreased from 0.81 ± 0.04 to 0.31 ± 0.21 (p

Background Phrenic nerve (PN) palsy (PNP) is the most frequent complication of cryoballoon ablation (CBA) of atrial fibrillation (AF). The major complication of this technique seems to be right-sided PN injury (PNI) following ablation of the right pulmonary veins (PVs). We sought to assess the incidence and prognosis of left-sided PNI during CBA. Methods CBA was performed in 448 patients with AF. During the ablation of the left-sided PVs, the PN was paced from the left subclavian vein with a pacing output just exceeding the threshold by 10 ∼ 20%. The right and left arm 12-lead electrocardiogram electrodes were positioned 5 cm above the xiphoid process and 16 cm along the left costal margin. The amplitude of the compound motor action potentials was recorded during the CBA. Results Two thousand one hundred seventy-eight CBA applications were delivered in 1,094 left-sided PVs. PNI occurred in 29 patients (6.5%); the PN could be captured by an increasing pacing output in 21 patients (4.7%), and premature termination of the freezing was required to avoid PNP in eight patients (1.8%). The PN function recovered before discharge; however, it took 7 months for one patient to completely recovery from the PNP. Conclusions Left-sided PNP could be provoked during a left-sided CBA procedure. Assessment of the left PN during the CBA was necessary to prevent left-sided PNP.

Background Lipoprotein(a) [Lp(a)] can influence the development and disruption of atherosclerotic plaques through its effect on lipid accumulation. The purpose of this study was to evaluate the relationship between serum Lp(a) levels and plaque morphology of an infarct-related lesion and non-infarct-related lesion of the coronary artery in acute myocardial infarction (AMI). Methods and results Coronary plaque morphology was evaluated in 68 patients (age 62.1±12.1 years, mean±SD; men n=58, women n=10) with AMI by intravascular ultrasound with radiofrequency data analysis before coronary intervention and by 64-slice computed tomography angiography within 2 weeks. Patients were divided into a group with an Lp(a) level of 25 mg/dl or more (n=20) and a group with an Lp(a) level of less than 25 mg/dl (n=48). Intravascular ultrasound with radiofrequency data analysis identified four types of plaque components at the infarct-related lesion: fibrous, fibrofatty, dense calcium, and necrotic core. The necrotic core component was significantly larger in the group with an Lp(a) level of 25 mg/dl or more than in the group with an Lp(a) level of less than 25 mg/dl (27.6±8.0 vs. 15.7±10.0%, P=0.0001). Coronary plaques were classified as calcified plaques, noncalcified plaques, mixed plaques, and low-attenuation plaques on 64-slice computed tomography angiography. Computed tomography indicated that the group with an Lp(a) level of 25 mg/dl or more had a greater number of total plaques, noncalcified plaques, and low-attenuation plaques in whole coronary arteries than did the group with an Lp(a) level of less than 25 mg/dl (5.3±1.8 vs. 3.7±2.2, P=0.0061; 4.0±2.0 vs. 1.2±1.3, P=0.0001; 2.2±2.1 vs. 0.5±0.7, P=0.0001, respectively). Conclusion Elevated serum Lp(a) levels are associated with the number of plaques and plaque morphology. Patients with a high Lp(a) level during AMI require more intensive treatment for plaque stabilization.

Introduction: High serum levels of lipoprotein (a) (Lp(a)) are associated with adverse outcomes after acute myocardial infarction (AMI). Lp(a) exerts its atherogenic and thrombogenic properties, which suggests greater lipid component of plaque and thrombi at the culprit lesion of AMI with elevated Lp(a). The risk of coronary artery disease is increased with a threshold serum Lp(a) level of 25 mg/dl. Purpose: We sought to evaluate impact of Lp(a) on myocardial viability and left ventricular function after AMI. Methods: The study included 156 patients (66±10.7 yrs, mean±sd, men 122, LAD/LCX/RCA 80/16/60) with first AMI within 24 hours from the onset who underwent emergent PCI. Serum Lp(a) was measured at admission. Serum CPK values were measured at admission and at intervals of 4 hours. Peak CPK value was determined. Within 2 weeks, Tl/BMIPP SPECT was performed to measure perfusion-metabolism mismatch score, an indicator of viable myocardium, from each total defect score of Tl/BMIPP using 17-segment model and semiquantitative visual score (0:normal, to 4:no uptake). Left ventricular ejection fraction (LVEF) was measured by two-dimensional echocardiography (2D trace) within 1 week (baseline LVEF) and at 6 months to 1 year (follow-up LVEF). Results: The study patients were divided into the group with serum Lp(a)≧25mg/dl at admission (n=42, Lp(a) 44.0±19.4mg/dl) and the group with Lp(a) Conclusions: Elevated Lp(a) was associated with less myocardial viability and less LVEF recovery after AMI.

Cardiovascular mortality in peripheral artery disease (PAD) patients is higher in critical limb ischemia (CLI) than in intermittent claudication (IC). We sought to evaluate differential characteristics of coronary artery disease (CAD) severity and prognostic biomarkers for cardiovascular events between CLI and IC patients. Coronary angiography was performed on 242 PAD patients (age 73 ± 8 years) with either CLI or IC. High-sensitivity troponin T (hs-TnT), eicosapentaenoic acid-arachidonic acid ratio (EPA/AA), and lipoprotein(a), as biomarkers for prognostic factors, were measured from blood samples. The study patients were divided into a CLI-group (n = 42) and IC-group (n = 200). The Gensini score as an indicator of coronary angiographic severity was higher in the CLI-group than in the IC-group (39.1 ± 31.2 vs. 8.5 ± 8.3, p

Two Successful Cases of Tolvaptan Therapy for Water Retention in Patients with Adult Congenital Heart Disease MASAO YAMAGUCHI, TATSUYA FUNIMAMI, TAKATOSHI SHIGETA, KENJI KOURA, GO ISHIMARU, HIROYUKI OKADA, HIROSHI INAGAKI, NOBUO TOSHIDA, TOSHIHIKO TAKAMOTO, MITSUAKI ISOBE Department of Cardiology, Soka Municipal Hospital, Soka, Japan; Tokyo Medical and Dental University Department of Cardiovascular Medicine