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Aims Hemodialysis vintage and serum phosphorus levels adversely affect outcomes in patients on hemodialysis. Whether these factors have a similar prognostic impact on patients who are on hemodialysis and have chronic limb-threatening ischemia (CLTI) has not been systematically studied. We aimed to explore the risk factors, including hemodialysis vintage and serum phosphorus levels, on clinical outcomes after endovascular therapy (EVT) in hemodialysis patients with CLTI. Methods The current study rerospectively analyzed 374 hemodialysis patients with CLTI presenting with ischemic tissue loss (age: 72.3±9.0 years, male: 73.3%, diabetes mellitus: 68.2%, Rutherford 5: 75.9%, 6: 24.1%, WIfI stage 4: 50.0%) primarily treated with EVT between April 2007 and December 2016. The primary outcome measure was 1-year amputation-free survival (AFS), while the secondary outcome measure was 1-year wound healing. Predictors for each outcome were evaluated by Cox proportional hazards model. Results Multivariate analysis significantly associated longer hemodialysis vintages with higher serum phosphorus levels (hazard ratio [HR], 0.599; 95% confidence interval [CI], 0.394-0.910; p=0.016) with 1-year AFS. Longer vintages for hemodialysis with higher serum phosphorus levels were marginally, but not significantly, associated with 1-year wound healing. (HR, 0.684; 95% CI, 0.467-1.000; p=0.050). Conclusion Longer hemodialysis vintages with higher serum phosphorus levels adversely affect outcomes after EVT for hemodialysis patients with CLTI presenting with ischemic tissue loss.

Background: The efficacy of ablation targeting low-voltage areas (LVAs) is controversial, although LVA presence is well known to be associated with AF recurrence after ablation. Atrial fibrillation (AF) substrate may not localize within LVAs. Methods and results: This observational study enrolled 405 consecutive patients who underwent an initial AF ablation procedure. The left atrial voltage map was obtained after pulmonary vein isolation. LVAs were defined as areas with voltage < 0.5 mV. To estimate whole atrial electrophysiological degeneration, mean regional voltage at each of 6 regions and left atrial total conduction velocity were measured. LVAs existed in 143 of 405 (35.3%) patients. Patients with LVAs demonstrated lower mean regional voltages throughout all 6 regions than those without LVAs (1.3 [1.8, 0.8] vs. 0.6 [1.0, 0.2] for anterior wall, p

The search for a less invasive and lower cost cryoballoon-based strategy for atrial fibrillation (AF) ablation has resulted in a simplified procedure that may be suitable for cryoballoon ablation (CBA). Here, we compared procedural characteristics and outcomes between conventional CBA and simple CBA. We enrolled 628 consecutive patients who underwent initial CBA for AF (age, 69 ± 12 years; female, 263 (42%); paroxysmal AF, 576 (92%); CHA2DS2-VASc score, 2.7 ± 1.6 points). Simple CBA was characterized by the minimal procedure required to isolate pulmonary veins, including the following: (1) CBA was performed without guidance from a 3-D mapping system; (2) a coronary sinus electrode and esophageal temperature probe were not used; (3) a waiting period after pulmonary vein isolation was not set; and AF induction by isoproterenol and atrial burst stimuli were not performed. Simple CBA was performed in 240 (38%) patients. Procedural time (49 ± 18 versus 85 ± 27 min, p

Aim: The latest Global Vascular Guidelines (GVG) recommend assessing the 2-year mortality risk in patients with chronic limb-threatening ischemia (CLTI) before revascularization. This study aimed to reveal whether the Wound, Ischemia and foot Infection (WIfI) classification, developed originally as a risk assessment tool for limb prognosis, would be useful in predicting the 2-year mortality risk in patients with CLTI in the era of GVG and WIfI. Methods: We retrospectively analyzed 849 patients with CLTI who were primarily treated with endovascular therapy (EVT) between April 2010 and December 2016. The impact of baseline characteristics, including the WIfI classification on mortality risk, was investigated using the Cox proportional hazards regression model. Results: During a mean follow-up of 19.3 months, 243 deaths were observed. The 2-year mortality rate was 32.3%. Multivariate analysis demonstrated that WIfI classification stages ( p =0.037), in addition to male sex ( p =0.010), age ( p ＜0.001), non-ambulatory status ( p ＜0.001), body mass index ( p =0.002), and hemodialysis ( p ＜0.001), were independent predictors for an increased risk of mortality, while the Rutherford classification was not. Conclusions: WIfI classification stages were independently associated with mortality risk in patients with CLTI undergoing EVT, while the Rutherford classification was not. The WIfI classification would be a practical tool for planning the revascularization strategy in CLTI treatment.

Purpose To examine the long-term clinical outcomes of patients with anti-centromere antibody (ACA)-positive critical limb-threatening ischemia (CLTI) who were treated with endovascular therapy (EVT). Materials and Methods This was a retrospective analysis using a database of 423 consecutive CLTI patients (543 limbs, Rutherford class 4–6) who underwent EVT between January 2011 and March 2013. The patients were divided into 2 groups: an ACA-positive group (10 limbs, 8 patients) and a control group (46 limbs, 43 patients). The control group was defined as female, non-dialysis, and those who were able to obtain a below-knee angiogram. Results None of the 8 ACA-positive CLTI patients had previously been diagnosed as ACA positive. No significant difference was observed in the below-the-knee lesion distribution and severity between the ACA-positive group and the control group. The median observational period was 51 months. The survival rate was 54% in the ACA-positive group and 76% in the control group at 5 years after EVT (P = .732). The freedom from major amputation rate was 60% in the ACA-positive group and 91% in the control group at 5 years after EVT (P = .029). The technical EVT success rate in the ACA-positive group was 70% (7/10). Of the successful EVT cases, 71% (5/7) of patients achieved complete wound healing or rest pain relief; however, 60% (3/5) had a recurrence of wounds. Conclusions In a series of ACA-positive patients with CLTI, successful EVT had acceptable outcomes with respect to wound healing with short-term results. However, the major amputation rate for ACA-positive patients was high in long-term follow-up.

Background: There are limited data comparing clinical outcomes between biodegradable polymer and durable polymer drug-eluting stents (BP-DES and DP-DES, respectively) in patients with end-stage renal disease (ESRD). Methods and Results: This study enrolled 229 ESRD patients who underwent successful percutaneous coronary intervention (PCI) for 400 lesions with 472 DES, with 2-year clinical outcomes compared between the BP-DES and DP-DES groups. The primary outcome measure was the incidence of target lesion revascularization (TLR), whereas secondary outcome measures were the occurrence of cardiac death (CD), myocardial infraction (MI), stent thrombosis (ST), target vessel revascularization (TVR), non-TVR, and major adverse cardiac events (MACE), defined as a composite of CD, MI, and TVR. Multivariate analysis was used to identify predictors of TLR occurrence. The 2-year incidence of TLR did not differ significantly between the BP-DES and DP-DES groups (P=0.274). In addition, there were no significant differences in the 2-year incidence of CD (P=0.144), MI (P=0.812), ST (P=0.241), TVR (P=0.434), non-TVR (P=0.375), or MACE (P=0.841) between the 2 groups. Multivariate analysis showed that diabetes (P=0.021) was independently associated with TLR occurrence. Conclusions: BP-DES and DP-DES had comparable safety and efficacy profiles over a 2-year follow-up period after PCI in ESRD patients.

Introduction: Although the presence of left atrial low-voltage areas (LVAs) is strongly associated with the recurrence of atrial fibrillation (AF) after ablation, few methods are available to classify the prevalence of LVAs. The purpose of this study was to establish a risk score for predicting the prevalence of LVAs in patients undergoing ablation for AF. Methods: We enrolled 1004 consecutive patients who underwent initial ablation for AF (age, 68 ± 10 years old; female, 346 (34%); persistent atrial fibrillation, 513 (51%)). LVAs were deemed present when the voltage map after pulmonary vein isolation demonstrated low-voltage areas with a peak-to-peak bipolar voltage of

A 61-year-old man presented with chronic limb threatening ischemia due to reocclusion of a femoropopliteal (FP) bypass using a saphenous vein graft (SVG). After performing endovascular intervention using plain angioplasty and drug-coated balloon and drug-eluting stent implantation of the proximal anastomosis of FP bypass, refractory early reocclusion occurred during the perioperative period. Thus, we decided to alternatively place a stent-graft in the occluded FP bypass. After the SVG had been dilated using a high-pressure balloon, a stent-graft was successfully placed. This alternative therapy using a stent-graft prevented SVG FP bypass reocclusion, and the patient's ulcers had completely healed within 1 month.

Purpose: To investigate the prognostic impact of infrapopliteal (IP) artery anatomic severity according to the Global Limb Anatomic Staging System (GLASS) on delayed wound healing in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This study retrospectively analyzed 639 limbs with tissue loss in 484 CLTI patients (mean age 74±10 years; 300 men) presenting IP lesions treated with endovascular therapy between April 2010 and December 2015. Two-thirds of patients had diabetes (323, 67%) and over half were on hemodialysis (255, 53%). More than a third of the limbs (251, 39%) were classified as clinical stage 4 according to the Wound, Ischemia, and foot Infection (WIfI) system. IP anatomic severity was classified based on preprocedural angiography according to the GLASS. Severity of arterial calcification was assessed using high-intensity fluoroscopy and classified into 3 groups: none (grade 0), unilateral (grade 1), and bilateral (grade 2). Poor below-the-ankle (BTA) runoff was defined as the lack of a pedal arch with 0 to 1-vessel runoff within the dorsal pedis artery and the lateral and medial plantar arteries. The outcome measure was 1-year wound healing. The association of anatomic characteristics with delayed wound healing was evaluated using Cox proportional hazards regression analysis. Outcomes are presented as the adjusted hazard ratio (HR) with 95% confidence interval (CI). Results: During a mean follow-up of 22±19 months, the 1-year cumulative wound healing rate was estimated to be 59.0% (95% CI 54.5% to 63.5%). Multivariable analysis demonstrated independent associations between delayed wound healing and IP calcification grade (HR 1.24, 95% CI 1.02 to 1.50, p=0.027) and poor BTA runoff (HR 1.39, 95% CI 1.04 to 1.85, p=0.025) but not the GLASS IP grade (HR 0.92, 95% CI 0.82 to 1.14, p=0.21). Conclusion: The current study revealed that IP arterial calcification and poor BTA runoff were significantly associated with delayed wound healing, whereas the GLASS was not predictive of wound healing.

To investigate the rate and predictors of in-stent occlusion by intravascular ultrasound (IVUS) following femoropopliteal artery stent placement.From July 2012 to June 2016, this study retrospectively investigated 191 cases of de novo femoropopliteal artery lesions (lesion length, 170 ± 97 mm; chronic total occlusion, 51%) evaluated by IVUS in 162 patients with peripheral artery disease (with critical limb ischemia of 27%) who underwent endovascular therapy using self-expanding nitinol stents. Examination by IVUS was performed to record data for vessel characteristics immediately after wire crossing and at the end of the procedure. The primary outcome measurement was the occurrence of in-stent occlusion, defined as the absence of blood flow at the treatment site by duplex ultrasonography. Predictors for in-stent occlusion were also evaluated by multivariate analysis.In-stent occlusion was observed in 15% (n = 28) of lesions, and the mean follow-up time was 19 ± 13 months. After multivariate analysis, it was found that plaque burden ≥60% after stent placement (P.001), female gender (P = .002), and Trans-Atlantic Inter-Society Consensus (TASC) II classification C and D lesions (P = .047) were significantly associated with the occurrence of in-stent occlusion.Plaque burden ≥60% after stent placement, female gender, and TASC II classification C/D lesions were significantly associated with the occurrence of in-stent occlusion after femoropopliteal artery stent placement as evaluated by IVUS.

A recently introduced grid mapping catheter (GMC) is designed for better electrode-tissue contact and can collect bipolar signals both along and across the splines, which may allow more efficient voltage map generation independent of propagation direction. We compared the GMC with a conventional circular mapping catheter (CMC) for left atrial (LA) voltage mapping.This study included 20 consecutive patients undergoing repeat ablation for recurrent atrial fibrillation who had demonstrated LA low-voltage areas (LVAs,0.10 mV). Following pulmonary vein isolation, LA voltage mapping was performed twice, once using the GMC and once using the CMC.Voltage mapping was more efficient using the GMC than the CMC in terms of mapping time (459 [404, 543] vs 602 [496, 814] seconds; P = .014) and the number of mapping points (2446 [2099, 3104] vs 1841 [1494, 2314]; P = .002). The incidence of catheter-induced ectopies was lower (44 [28, 62] vs 114 [74, 188]; P .0001) using the GMC. The GMC utilizing all bipoles detected LVAs in 85% of patients with LVAs detected by CMC. LVA measurements were significantly smaller on maps generated by the GMC using bipoles along or across the splines than those measured with the CMC (11.1 [4.6, 17.2] or 9.7 [2.5, 16.0] vs 16.4 [6.8, 26.8] cmThe GMC allowed a more efficient mapping procedure and enabled more selective identification of LVAs with smaller LVA size.

A 55-year-old male with stable angina pectoris was referred to our hospital. Coronary angiography showed severe stenosis from the proximal to the middle part of the left circumflex artery (LCX). Based on the severity of lesion calcification, we performed percutaneous coronary intervention with rotational atherectomy. After crossing a 0.014-inch guidewire, we replaced it with a rotawire using a microcatheter. Following the retrieval of the microcatheter, we noted that a radiopaque tip of the microcatheter had been detached at the site of severe stenosis in the proximal part of the LCX. We advanced a guide-extension catheter to this site and wedged the detached tip using a balloon catheter (2.0-mm diameter; 12-mm length) in the guide-extension catheter. The detached tip was successfully retrieved along with the guide-extension catheter. After passing two guidewires into the main vessel and the side branch, we dilated the lesion using a 2.5-mm non-compliant balloon. Finally, we implanted two sirolimus-eluting stents, followed by post-dilatation with a 3.75-mm non-compliant balloon. This approach resulted in excellent dilatation and blood flow. Use of the guide-extension catheter trapping technique (i.e. use of a guide-extension catheter and a small balloon catheter) resulted in the successful percutaneous retrieval of a detached microcatheter tip.

Objectives While current guidelines describe the importance of assessing limb characteristics for predicting limb prognosis in patients with critical limb ischaemia (CLI), several reports have also suggested that systemic factors are associated with limb prognosis. The aim of this study was to evaluate whether systemic factors have the same impact on wound healing as limb characteristics in CLI patients undergoing endovascular therapy. Methods A total of 735 patients who were treated for the first time for CLI with tissue loss between April 2010 and December 2015 were extracted from a prospective registry and data for the Wound, Ischaemia, and foot Infection (WIfI) classification were searched retrospectively. The predictors of wound healing were explored with Cox proportional hazards regression. Results The one year wound healing rate was 60.2% in WIfI stage 1–3 patients and 53.6% in WIfI sstage 4 (p = .01). In WIfI stage 1–3, no systemic factors were significantly associated with wound healing, whereas, in WIfI stage 4 patients. Non-ambulatory status [hazard ratio (HR) 1.98; 95% confidence interval (CI) 1.37–2.84], haemodialysis (HR 1.90; 95% CI 1.33–2.72) and an albumin level under 3.0 g/dL (HR 1.53; 95% CI 1.02–2.31), were identified as independent risk factors for failure to achieve wound healing. If none or one of these risk factors were present, wound healing was comparable with WIfI 4 and WIfI 1–3 patients (67.7% vs. 63.6%, p = .89), whereas in patients with two or more risk factors wound healing was worse in WIfI 4 than in WIfI 1–3 patients (35.7% vs. 49.5%, p = .01). Conclusion Non-ambulatory status, haemodialysis, and a low albumin level were additional systemic risk factors for impaired wound healing in patients with WIfI stage 4. The wound healing rate in WIfI stage 4 patients with one or fewer of these risk factors was comparable to that in WIfI stage 1–3.

INTRODUCTION The prevalence of atrial fibrillation (AF) increases with age. Although the efficacy of cryoballoon ablation (CB-A) in patients with AF has been demonstrated, data on the efficacy of this CB-A in elderly patients are limited. The aim of this study was to evaluate the 1-year efficacy and safety of CB-A in patients aged ≥80 years compared with those less than 80 years. METHODS A total of 49 consecutive patients ≥80 years with paroxysmal AF (PAF) who underwent CB-A were compared with 241 patients aged

Background The utility of an ultra‐high‐resolution electroanatomical mapping system (UHR‐EAM, Rhythmia) for repeat atrial fibrillation (AF) ablation has not been evaluated. Hypothesis A second AF ablation procedure performed using UHR‐EAM may demonstrate different outcomes compared with that using a conventional electroanatomical mapping system (C‐EAM, CARTO3). Method This observational study enrolled consecutive patients who underwent a second AF ablation procedure using UHR‐EAM (n = 103) and C‐EAM (n = 153). The second ablation procedure included re‐isolation of reconnected pulmonary veins (PVs) and elimination of clinical or induced non‐PV AF triggers and atrial tachycardia (AT). Other empirical ablations were additionally conducted at the discretion of the operators. Results Re‐isolation of PVs was achieved in 196 patients who had ≥1 left atrial‐PV reconnection. The elimination rate of AT was higher in the UHR‐EAM group than the C‐EAM group (87% vs 65%, P = .040), while that of non‐PV AF triggers was similar (63% vs 63%, P = 1.00). The UHR‐EAM demonstrated shorter radiofrequency application time (21.8 ± 16.8 vs 28.0 ± 21.3 minutes, P = .017), but longer fluoroscopic time (26.2 ± 12.6 vs 21.4 ± 9.3 minutes, P = .0001). No severe complication developed. The total 1‐year AF/AT‐free survival rates were similar between the two groups (off AADs, 59.2% vs 56.2%, P = .62; on AADs, 65.0% vs 69.3%, P = .49). Conclusion The efficacy and safety outcomes of repeat AF ablation using UHR‐EAM was comparable to those using C‐EAM.

When atrial fibrillation (AF) is initiated by a single or several non-pulmonary vein (PV) trigger ectopic beats, mapping the ectopy is often difficult, requiring a number of electrical cardioversion applications. Nifekalant is a rapidly activating delayed rectifier potassium channel (IKr) blocker which may suppress AF initiation without inhibiting ectopy development, thereby allowing the target ectopy to be mapped. To assess the efficacy of nifekalant in the ablation of non-PV ectopies that are unmappable due to easily initiated AF. Eleven consecutive patients were administered nifekalant to map a non-PV ectopy that was unmappable using a conventional method due to easily initiated AF. Nifekalant was intravenously administered as a bolus dose of 0.2 mg/kg, and electrical cardioversion was delivered. Additional boluses of 0.2 mg/kg were repeatedly administered until AF initiation was prevented or until the appearance of significant prolongation of QT interval. AF suppression without inhibition of ectopy development was achieved in 7 patients. These patients had a higher rate of acute elimination of the ectopy than the remaining 4 patients without AF suppression (7 [100%] vs. 1 [25%] patients, p = 0.024). In addition, patients with suppression of AF initiation had a higher AF recurrence-free rate than those without (7 [100%] vs. 1 [25%] patients, p = 0.024). Nifekalant administration appears useful in the ablation of non-PV ectopies that easily initiate AF.

Femoral-popliteal (F-P) bypass is the standard treatment for lower extremity peripheral artery disease with severe femoropopliteal (FP) artery lesions. However, in clinical settings, these patients are treated with endovascular therapy (EVT) because of frailty and difficulties with general anesthesia. We compared the clinical outcomes of F-P bypass and EVT for severe FP artery lesions and investigated the types of patients for whom EVT would be as appropriate as F-P bypass.This multicenter, retrospective study included 452 Trans-Atlantic Inter-Society Consensus (TASC) II C and D FP artery lesions in 352 patients. A total of 350 lesions in 260 patients (74 ± 9 years, 66% male, 60% claudication) were treated with EVT with nitinol self-expandable stents, and 102 lesions in 92 patients (71 ± 9 years, 75% male, 40% claudication) were treated with F-P bypass. The primary outcome measure was primary patency, and the influence of baseline characteristics on its association with the treatment strategy (EVT versus F-P bypass) was assessed using a Cox proportional hazards regression model.Kaplan-Meier analysis indicated that the 3-year primary patency rate was significantly lower for EVT than F-P bypass (60% vs. 74%, P 0.01). The body mass index (BMI) and C-reactive protein (CRP) levels significantly interacted with the treatment strategy for restenosis (P 0.05). The adjusted hazard ratios of EVT versus F-P bypass for restenosis were 0.77 (P = 0.46) in cases with a low BMI (≤18 kg/mIn TASC II C and D lesions, EVT appears to yield patency comparable to that of F-P bypass in patients with a low BMI or an elevated CRP level, but lower patency in other patients.

BACKGROUND The presence of residual left atrial low-voltage areas (LVA) has been shown to be strongly associated with atrial fibrillation (AF) recurrence after pulmonary vein isolation. A preliminary study showed that concomitant chronic kidney disease (CKD) increased the rate of AF recurrence. The association between CKD and LVA, however, has not been elucidated. In the present study, we investigated the association between CKD severity and LVA prevalence. Methods and Results: In total, 183 consecutive AF patients who underwent initial ablation for AF were enrolled in this retrospective observational study. Serum cystatin C before ablation was measured, and the estimated glomerular filtration rate (eGFR) was calculated. LVA were defined as sites of left atrial electrogram amplitude

Background: Drug-eluting stents (DESs) have been widely used for the treatment of acute coronary syndrome (ACS). However, there are few reports on early- and middle-phase arterial repair after DES implantation in ACS patients. Methods and Results: Coronary angioscopy (CAS) findings covering the early and middle phases (mean [±SD] 4±1 and 10±2 months, respectively) of arterial healing after second- and later-generation DES placement between May 2009 and January 2020 were extracted from the Kansai Rosai Hospital Cardiovascular Center database. Neointimal coverage (NIC), yellow color intensity, and the incidence of thrombus adhesion were compared between ACS and chronic coronary syndrome (CCS) in the early (54 stents of 47 lesions, 38 ACS patients; 86 stents of 70 lesions, 52 CCS patients) and middle (179 stents of 154 lesions from 136 ACS patients; 459 stents of 374 lesions from 287 CCS patients) phases. In the early phase, NIC, the incidence of thrombus adhesion (ACS, 39.1%; CCS, 38.0%), and maximum yellow color grade were similar between the 2 groups. In the middle phase, although the maximum yellow color grade was significantly higher in the ACS group (P=0.013), NIC and the incidence of thrombus adhesion (ACS, 24.6%; CCS, 23.4%) were similar in the 2 groups. Conclusions: Arterial healing assessment with CAS showed that NIC and the incidence of thrombus adhesion after DES implantation were similar between ACS and CCS patients.

Background Although several clinical reports demonstrated a durable patency rate after a novel fluoropolymer-coated paclitaxel-eluting stent (Eluvia; Boston Scientific, Marlborough, MA, USA) placement, aneurysmal degeneration after drug-eluting stent (Eluvia) placement has raised clinical concerns. Here, we report a case with progressive aneurysm formation on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery atheromatous plaque. Case presentation A 79-year-old woman with right leg intermittent claudication at 100 m distance was referred to our hospital. Pre-procedural angiography showed long-segment severe stenosis from the middle-to-distal part of the right superficial femoral artery, and a 7 mm wide drug-eluting stent (Eluvia) was placed. However, the patient had a recurrence of intermittent claudication in the right lower extremity 25 months thereafter. Angiography revealed de novo stenosis in the distal part of the popliteal artery and proximal superficial femoral artery in-stent restenosis. Subsequently, the patient underwent endovascular therapy for these lesions. In addition, intravascular ultrasound at the time of endovascular therapy revealed femoral artery enlargement with a maximum vessel diameter of 10.0 mm at the distal edge of the stent. Intermittent claudication on the right side recurred again 50 months after drug-eluting stent (Eluvia). Angiography demonstrated de novo severe stenosis from the distal part of the superficial femoral artery to the middle part of the popliteal artery. Peri-stent contrast staining was found at the distal part of the drug-eluting stent (Eluvia) site. Intravascular ultrasound showed a further enlargement of maximum vessel diameter to 12.0 mm at the distal edge of the stent. Conclusions We report a case with progressive aneurysm degeneration on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery stenosis.

Introduction: Although decompensated heart failure (DHF) can complicate catheter ablation of atrial fibrillation (AF), its incidence and risk factors have not been defined. We sought to investigate the incidence and risk factors for DHF in these patients. Methods: In total, 1004 consecutive patients who underwent initial ablation for AF (age, 68 ± 10 years old; females, 346 [34%]; and persistent AF, 513 [51%]) were enrolled. Δheart rate, which was defined as heart rate after ablation minus heart rate before ablation, were calculated. DHF was defined as heart failure requiring medical therapy during post-procedure hospitalization, or re-hospitalization due to heart failure < 90 days after the procedure. DHF was classified into early peri-procedual DHF, which occurring within 2 days after the procedure, and late peri-procedual DHF, which occurring ≥ 3 days after the procedure. Results: The incidence of DHF was 32/1004 (3%) patients. Patients with DHF had a higher prevalence of a past history of symptomatic heart failure (17/32 [53%] versus 154/972 [16%], P < 0.01) and lower Δheart rate after the procedure than those without (−16 ± 28 versus 2 ± 21 beats/min, P < 0.01). On multivariate analysis, lower Δheart rate was a significant independent predictor of early peri-procedual DHF, while early recurrence of AF was a significant independent predictor of late peri-procedual DHF. Conclusion: In patients with AF, lower Δheart rate was an independent predictor of early peri-procedual DHF, and early recurrence of AF was an independent predictor of late peri-procedual DHF.

Background: The OrsiroTM ultrathin-strut, biodegradable-polymer, sirolimus-eluting stent (O-SES) has specific characteristics regarding its components and has demonstrated comparable clinical outcomes compared with durable-polymer, drug-eluting stents (DES). However, arterial repair following deployment of the O-SES has not been elucidated to date. Methods and Results: Using data from the Kansai Rosai Hospital database between November 2010 and September 2020, we analyzed coronary angioscopy (CAS) findings a mean (±SD) of 10±2 months after implantation of an O-SES, a durable-polymer everolimus-eluting stent (XienceTM; X-EES), or a biodegradable-polymer everolimus-eluting stent (SynergyTM; S-EES). Neointimal coverage (NIC), yellow color intensity of the stented segment, and the incidence of thrombus adhesion were compared between the O-SES (66 stents from 42 patients), X-EES (119 stents from 87 patients), and S-EES (132 stents from 88 patients). NIC was significantly thinner for the O-SES than S-EES (P

Objectives: To compare long-term atrial fibrillation (AF)/atrial tachycardia (AT) recurrence rates and types of recurrent-atrial-tachyarrhythmia between treatment cohorts enrolled in the randomized controlled VOLCANO trial. Background: Although VOLCANO trial demonstrated comparable 1-year rhythm outcomes between patients with and without ablation targeting low-voltage areas (LVAs) in addition to pulmonary vein isolation among paroxysmal AF patients with LVAs, efficacy of LVA ablation on long-term outcomes are still unknown. Methods: Total of 402 paroxysmal AF patients were divided into 4 groups based on the results of voltage mapping: Group A, no LVA (n=336); group B, LVA ablation (n=30); group C, LVA presence without ablation (n=32); and group D, incomplete voltage map (n=4). Results: At 25 (23, 31) months after the initial ablation, AF/AT recurrence rates were 19% in group A, 57% in group B, 59% in group C, and 100% in group D. Recurrence rates were higher in patients with LVAs than those without (group A vs. B+C, p

Introduction Some patients fail to respond to persistent atrial fibrillation (PeAF) catheter ablation in spite of multiple procedures and ablation strategies, including low voltage area (LVA)-guided, linear, and complex fractionated atrial electrogram (CFAE)-guided ablation procedures. We hypothesized that LVA extent could predict non-response to PeAF catheter ablation in spite of multiple procedures. Methods This study included 510 patients undergoing initial ablation procedures for PeAF. LVAs were defined as regions with bipolar peak-to-peak voltages of

The size of the autologous vein graft is an important determinant of prognosis in patients with chronic limb-threatening ischemia (CLTI) undergoing bypass surgery. However, it is unclear whether reconstruction using a small vein graft would directly affect prognosis, or a subgroup having small veins would be subject to a poor prognosis. If the latter is true, having small veins would work as a marker for a poor prognosis even in patients with CLTI undergoing endovascular therapy (EVT). Therefore, we investigated the association between the size of saphenous veins and prognosis in patients with CLTI undergoing EVT.This study included 209 consecutive patients with CLTI who primarily underwent EVT between January 2017 and December 2018. The diameter of the saphenous vein was measured at three locations (saphenous-femoral junction, knee, and ankle joint) per limb before EVT by ultrasonography. A small saphenous vein was defined as the mean diameter3.0 mm.All-cause mortality rate was significantly higher in patients with a small saphenous vein than in those with non-small one (46.3% versus 10.7% at 2 years, p0.001). The multivariate Cox regression analysis revealed that a small saphenous vein was independently associated with an increased risk of all-cause mortality.Having a small saphenous vein was an independent marker for all-cause mortality in patients with CLTI undergoing EVT.

BACKGROUND Although patients with poor ability to perform activities of daily living, such as those with high Clinical Frailty Score (CFS), will often receive a cardiac implantable electric device (CIED), the indications for implantation in these patients have not been clearly defined. We investigated the association between CFS and prognosis in patients with a CIED.Methods and Results:We retrospectively enrolled 323 consecutive patients who underwent initial device implantation (age, 77 (70-83) years; male, 181 [56%] patients; high-voltage device, 49 [15%] patients), and the CFS was retrospectively estimated. Primary outcome was all-cause death, and the secondary outcome was hospitalization due to heart failure (HF). Median CFS was 4 (3-5) points. During 2 years' follow-up, all-cause death occurred in 32 patients (10%). Freedom from all-cause death was significantly lower in patients with a high CFS than in those with a low score (1-2 points: 100%, 3-4 points: 92.9%, 5-9 points: 77.3%, P

Background: Although hemodialysis vintage and serum phosphorus level adversely impact on outcomes in the field of general population on hemodialysis, it has not systematically studied whether these have similar prognostic impacts on clinical outcomes in population with chronic limb-threatening ischemia (CLTI). Methods: The current study retrospectively analyzed 374 hemodialysis patients with CLTI presenting ischemic tissue loss (age: 72.3±9.0 years, male: 73.3%, diabetes mellitus: 39.6%, Rutherford 5: 75.9%, 6: 24.1%, WIFI stage 4: 50.0%) primarily treated with endovascular therapy (EVT) between April 2007 and December 2016. Primary outcome measure was 1-year amputation-free survival (AFS), while secondary outcome measure was 1-year wound healing. Predictors for each outcome were evaluated by Cox proportional hazards model. Result: One-year rate of AFS and wound healing rate were 70.5±2.5%, and 57.1±3.0%, respectively. Multivariate analysis demonstrated that body mass index (hazard ratio [HR], 0.918; 95% confidence interval [CI], 0.859-0.981; p=0.012), non-ambulatory status (HR, 1.887; 95% CI, 1.222-2.913; p=0.004), lower serum albumin level (HR, 0.591; 95% CI, 0.414-0.844; p=0.004), WIfI stage 4 (HR, 1.782; 95% CI, 1.156-2.748; p=0.009) and longer vintages for hemodialysis with higher serum phosphorus levels (HR, 1.670; 95% CI, 1.099-2.537; p=0.016) were significantly associated with 1-year AFS (Figure), while WIfI stage 4 (HR, 0.713; 95% CI, 0.519-0.979; p=0.037) was associated and longer vintages for hemodialysis with higher serum phosphorus levels was close to significant association (HR, 0.684; 95% CI, 0.467-1.000; p=0.050) with 1-year wound healing. Conclusion: Longer hemodialysis vintage with higher serum phosphorus level would adversely affect clinical outcomes after EVT for hemodialysis patients with CLTI presenting ischemic tissue loss.

PURPOSE To determine the predictive factors for in-stent restenosis (ISR) following stent-supported endovascular therapy (EVT) with intravascular ultrasound (US) evaluation for femoropopliteal chronic total occlusion. MATERIALS AND METHODS This was a single-center, retrospective, observational study. The study included 276 lesions in 251 patients who underwent stent-supported EVT with intravascular ultrasound evaluation for femoropopliteal chronic total occlusion from July 2012 to June 2019. The wire passage route was assessed using intravascular US, and lesions were classified accordingly into 2 groups: intraluminal and subintimal passage. In this study, the intraluminal group was further divided into 3 subgroups by severity of calcification: none

Background The efficacy of low‐voltage‐area ( LVA ) ablation has not been well determined. This study aimed to investigate the efficacy of LVA ablation in addition to pulmonary vein isolation on rhythm outcomes in patients with paroxysmal atrial fibrillation ( AF ). Methods and Results VOLCANO (Catheter Ablation Targeting Low‐Voltage Areas After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation Patients) trial included paroxysmal AF patients undergoing initial AF ablation. Of 398 patients in whom a left atrial voltage map was obtained after pulmonary vein isolation, 336 (85%) had no LVA (group A). The remaining 62 (15%) patients with LVA s were randomly allocated to undergo LVA ablation (group B, n=30) or not (group C, n=32) in a 1:1 fashion. Primary end point was 1‐year AF ‐recurrence‐free survival rate. No adverse events related to LVA ablation occurred. Procedural (124±40 versus 95±33 minutes, P =0.003) and fluoroscopic times (29±11 versus 24±8 minutes, P =0.034) were longer in group B than group C. Patients with LVA s demonstrated lower AF ‐recurrence‐free survival rates (88%) than those without LVA (B, 57%, P P LVA ablation in addition to pulmonary vein isolation did not impact AF ‐recurrence‐free survival rate (group B versus C, P =0.67). Conclusions The presence of LVA was a strong predictor of AF recurrence after pulmonary vein isolation in patients with paroxysmal AF . However, LVA ablation had no beneficial impact on 1‐year rhythm outcomes. Registration URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000023403.

Purpose: To determine in a chronic limb-threatening ischemia (CLTI) population who underwent endovascular therapy (EVT) how many patients would have been categorized as preferred for bypass surgery according to the Global Vascular Guidelines (GVG) and ascertain their surgical risk. Materials and Methods: The current study analyzed 1043 CLTI patients who presented WIfI (wound, ischemia, and foot infection) stage ≥2 and underwent EVT between April 2010 and December 2017. Of these, 176 were excluded for lack of angiographic or other data, leaving 867 CLTI patients (mean age 74±10 years; 523 men) for stratification according to the GVG into bypass-preferred, indeterminate, or EVT-preferred groups. The GVG recommend bypass as the first-line treatment when the wound is severe (WIfI stage ≥3) and lesions are complex (GLASS stage III). Surgical risk was estimated using the modified PREVENT III risk score. To further stratify the bypass-preferred population according to mortality risk, a survival decision tree was constructed using recursive partitioning. Results: The bypass-preferred group accounted for 55% [95% confidence interval (CI) 51% to 58%] of the overall population. The decision tree analysis extracted a low-mortality risk subgroup with a survival rate of 99% (95% CI 98% to 100%) at 1 month and 80% (95% CI 73% to 87%) at 2 years. According to the PREVENT III score, 34% (95% CI 27% to 42%) of the low mortality risk subgroup were classified as high surgical risk. Conclusion: A high proportion of patients undergoing EVT were considered bypass preferred based on the GVG, and the survival of these patients was not significantly different whether they were high or low surgical risk.

Polymer-free biolimus A9-coated coronary stent (DCS) has novel features which lead to the expectation of better arterial healing. However, comparisons of intravascular status between DCS and drug-eluting stents (DES), and robust real-word clinical assessments of DCS have been lacking to date.From September 2017 to September 2018, we evaluated the intra-vascular status of 74 DCS implanted in 55 lesions from 43 patients using coronary angioscopy (CAS) approximately one year after implantation from a cohort of 219 lesions in 158 patients. We set 239 second-generation durable-polymer DES (DP-DES) implanted in 211 lesions from 180 patients from a cohort of 2652 lesions in 1914 patients as the control. Angioscopic images were analyzed to determine (1) the dominant degree of neointimal coverage (NIC) over the stent; (2) the heterogeneity of NIC; (3) yellow color grade of the stented segment; and (4) the presence of intra-stent thrombus. The primary outcome was the incidence of thrombus and secondary outcomes were the other CAS findings, and the 1-year clinical outcomes which included target lesion revascularization (TLR) and major adverse cardiac events (MACE). To minimize inter-group differences in baseline characteristics, propensity score matching was performed for clinical outcomes.Incidence of thrombus adhesion was similar in DCS and DP-DES groups (28.4% versus 22.6%, p=0.31). However, the dominant NIC grade was significantly higher in DCS (p0.001), while NIC was more heterogeneous in DCS than in DP-DES (p=0.001). Maximum yellow color grade was similar (p=0.22). After propensity score matching, 202 lesion pairs from 146 patient pairs were retained for analysis. The cumulative incidence of TLR (4.6% versus 3.8%, p=0.38) and MACE (11.6% versus 11.7%, p=0.84) was similar for DCS and DP-DES.DCS showed thrombus adhesion and clinical outcomes at 1 year similar to DP-DES. DCS can thus be used with similar safety and efficacy as DP-DES.

Cardiac conduction disturbance necessitating pacemaker implantation is common among elderly patients. However, patients often have comorbidities and increased frailty which may result in limited life prognosis and a high rate of procedure-related complications. We evaluated pacemaker implantation in older patients by comparing life prognosis and complication rate in patients aged ≥ and

BACKGROUND Atrial conduction velocity may represent atrial fibrillation (AF) substrate after pulmonary vein isolation (PVI). To elucidate the association between whole left atrial conduction velocity (LACV) and AF recurrence after PVI. METHODS AND RESULTS This observational study enrolled 279 patients (147 paroxysmal and 132 persistent AF) who underwent PVI alone as an initial AF ablation procedure. After PVI, the left atrium was mapped with a 20-pole multielectrode in conjunction with the CARTO3 system during 100-ppm right atrial pacing. Left atrial conduction distance and conduction time were calculated from the start to the end of the propagation wave front in the left atrium. LACVs on the anterior and posterior routes were calculated as conduction distance divided by conduction time. Anterior and posterior LACVs were slower in patients with AF recurrence than in those without (anterior, 0.79 [0.71, 0.86] vs 0.96 [0.90, 1.06] m/s, P

Background Detection of yellow plaques (YP) by coronary angioscopy (CAS) 1 year after 1st-generation drug-eluting stent (DES) implantation has been related to future coronary events. However, the association between CAS findings and clinical outcomes following 2nd-generation DES implantation has not been investigated. Methods and Results: This study included a total of 248 2nd-generation DES in 179 patients, who were examined by CAS 9±2 months after implantation. Angioscopic evaluation included dominant neointimal coverage (NIC) grade, heterogeneity of NIC, presences of YP and intrastent thrombus. The outcome measure was major adverse cardiac events (MACE) defined as a composite of cardiac death, acute myocardial infarction and any coronary revascularization. The association between the CAS findings and MACE was evaluated using the Kaplan-Meier method. A Cox proportional hazards model was used to assess the predictors of MACE. The mean follow-up duration was 1,367±843 days. Dominant NIC grade (P=0.98), heterogeneity of NIC (P=0.20) and YP (P=0.53) were not associated with the incidence of MACE. However, intrastent thrombus was significantly associated with MACE (P=0.033). Intrastent thrombus (adjusted hazard ratio: 2.22; 95% confidence interval [CI]: 1.12-4.39), acute coronary syndrome (2.83; 95% CI: 1.42-5.67) and B2/C lesion (2.13; CI: 1.12-4.05) were independent predictors of MACE. Conclusions Subclinical intrastent thrombus observed by CAS at 9 months after 2nd-generation DES implantation was independently associated with poor clinical outcome.

Predictors of outcomes in patients with heart failure with preserved left-ventricular ejection fraction (HFpEF) remain unclear. The ratio of early diastolic transmitral flow velocity to early diastolic myocardial velocity (E/e') has been proposed, but the predictive accuracy remains unsatisfactory. We hypothesized that E/e' normalized by the stroke volume (SV), E/e'/SV, could be a good predictor of outcome in HFpEF patients by reflecting the terminal slope of the end-diastolic pressure-volume relation, i.e., stiffness of the left ventricle. This pilot study was conducted to propose a novel echocardiographic index for predicting the outcomes of patients with HFpEF. Echocardiography including E/e'/SV measurement was performed in consecutive 80 HFpEF patients at discharge in index hospitalization due to HF. The end points included the readmission for heart failure and cardiovascular death at 1 year after discharge. 19 patients (24%) met the end points. Receiver-operating characteristic analysis showed that E/e''/SV was a strong predictive factor (AUC = 0.78) compared to E/e' (AUC = 0.74). Kaplan-Meier analysis showed that patients with E/e'/SV > 0.40 had a poorer prognosis than those with E/e'/SV

Pulmonary venography is routinely used to confirm pulmonary vein (PV) occlusion during cryoballoon ablation. However, this technique is significantly limited by the risks associated with contrast media, such as renal injury and contrast allergy. We hypothesized that PV occlusion can be predicted by elevation of the balloon catheter tip pressure, avoiding the need for contrast media. Forty-eight consecutive patients with paroxysmal atrial fibrillation who underwent PV isolation with the cryoballoon technique were enrolled. The balloon catheter tip pressure was measured in each PV before and after balloon inflation. We analyzed 200 applications of cryoballoon ablation in 185 PVs (excluding 3 common PVs and 1 extremely small right inferior PV) of 48 patients (age, 70 ± 11 years; male, n = 28; mean left atrial diameter, 38 ± 6 mm). Compared with patients with unsuccessful occlusion, patients with successful occlusion demonstrated a larger change in pressure after balloon inflation (6 ± 8 vs. 2 ± 4 mmHg, P

Background Association between the presence of left atrial low-voltage areas and atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) has been shown mainly in persistent AF patients. We sought to compare the AF recurrence rate in paroxysmal AF patients with and without left atrial low-voltage areas. Methods This prospective observational study included 147 consecutive patients undergoing initial ablation for paroxysmal AF. Voltage mapping was performed after PVI during sinus rhythm, and low-voltage areas were defined as regions where bipolar peak-to-peak voltage was Results Left atrial low-voltage areas after PVI were observed in 22 (15%) patients. Patients with low-voltage areas were significantly older (72±6 vs. 66±10, p p =0.002), and had higher CHA 2 DS 2 -VASc score (2.5±1.5 vs. 1.8±1.3, p =0.028). During a mean follow-up of 22 (18, 26) months, AF recurrence was observed in 24 (16%) and 16 (11%) patients after the single and multiple ablation procedures, respectively. AF recurrence rate after multiple ablations was higher in patients with low-voltage areas than without (36% vs. 6%, p p =0.001). Conclusion The presence of left atrial low-voltage areas after PVI predicts AF recurrence in patients with paroxysmal AF as well as in patients with persistent AF.

The ultrathin strut biodegradable polymer sirolimus-eluting stent (Orsiro, O-SES) exhibits satisfactory clinical outcomes. However, no report to date has documented the intravascular status of artery repair after O-SES implantation. We examined 5 O-SES placed in 4 patients (age 65 ± 12 years, male 75%) presenting with stable angina pectoris due to de novo lesions in native coronary arteries. Coronary angioscopy was performed immediately after percutaneous coronary intervention and 1 year later. Angioscopic images were analyzed to determine the following: (1) dominant grade of neointimal coverage (NIC) over the stent; (2) maximum yellow plaque grade; and (3) existence of thrombus. Yellow plaque grade was evaluated both immediately after stent implantation and at the time of follow-up observation. The other parameters were evaluated at the time of follow-up examination. NIC was graded as: grade 0, stent struts exposed; grade 1, struts bulging into the lumen, although covered; grade 2, struts embedded in the neointima, but translucent; grade 3, struts fully embedded and invisible. Yellow plaque severity was graded as: grade 0, white; grade 1, light yellow; grade 2, yellow; and grade 3, intensive yellow. Angioscopic findings at 1 year demonstrated the following: dominant NIC grade 1, grade 2, and grade 3 in 1, 2, and 2 stents, respectively; all stents were covered to some extent; focal thrombus adhesion was observed in only 1 stent. Yellow plaque grade did not change from immediately after stent implantation to follow-up. O-SES demonstrated satisfactory arterial repair 1 year after implantation.

Aim We investigated 2-year clinical outcomes after implantaton of EpicTM self-expanding nitinol stents for patients with peripheral artery disease (PAD) due to the aortoiliac occlusive disease (AIOD). Methods This study was a multicenter and retrospective study. From February 2013 through October 2014, 292 lesions (chronic total occlusion, 21%; TASC Ⅱ C/D, 35%) in 217 consecutive patients (74±8 years; male, 81%; diabetes mellitus, 47%; dialysis, 21%; critical limb ischemia, 29%) who had undergone endovascular therapy (EVT) with EpicTM self-expanding nitinol stents for PAD with AIOD were analyzed. The primary endpoints were 2-year primary patency and target lesion revascularization (TLR)-free rate. The primary patency and freedom from TLR were determined by Kaplan-Meier analysis. Additionally, predictors for loss of patency were estimated by Cox proportional hazard model. Results The mean follow-up duration was 19.1±8.5 months. Primary patency was 87.3% at 2 years. Freedom from TLR rate was 94.1% at 2 years. Multivariate analysis revealed that the presence of diabetes mellitus was associated with a loss of patency. Conclusion The EpicTM self-expanding nitinol stent was demonstrated to be safe and effectivene for AIOD when tested for two years in patients with PAD.

The impact of the severity of coronary artery disease (CAD) and left ventricular ejection fraction (LVEF) on the prognosis of patients with peripheral artery disease (PAD) has not been systematically studied. We retrospectively analysed 622 patients with PAD (intermittent claudication (IC): n = 446; critical limb ischaemia (CLI): n = 176). The association of SYNTAX score and LVEF with mortality was analysed using the Cox proportional hazard model. In patients with IC, a high SYNTAX score was significantly associated with mortality, whereas reduced LVEF was significantly associated with mortality in patients with CLI. The prognostic impact of CAD and LVEF appears different between patients with IC and CLI.

Background The reconnection of left atrial–pulmonary vein (LA-PV) conduction after the initial procedure of pulmonary vein (PV) isolation is not rare, and is one of the main cause of atrial fibrillation (AF) recurrence after PV isolation. Objective We investigated feasibility of a new ultrahigh-resolution mapping system using a 64-pole small basket catheter for the identification of LA-PV conduction gaps. Methods This prospective study included 31 consecutive patients (20 with persistent AF) undergoing a second ablation after a PV isolation procedure with LA-PV reconnected conduction at any of the 4 PVs. An LA-PV map was created using the mapping system, and ablation was performed at the estimated gap location. Results The propagation map identified 54 gaps from 39 ipsilateral PV pairs, requiring manual electrogram reannotation for 23 gaps (43%). Gaps at the anterior and carinal regions of left and right ipsilateral PVs required manual electrogram reannotation more frequently than the other regions. The voltage map could identify the gap only in 19 instances (35%). Electrophysiological properties of the gaps (multiple gaps in the same ipsilateral PVs, conduction time, velocity, width, and length) did not differ between those needing and not needing manual electrogram reannotation. During the gap ablation, either the activation sequence alteration or elimination of PV potentials was observed using a circular catheter placed in the PV, suggesting that all the identified gaps were correct. Conclusion This new electroanatomic mapping system visualized all the LA-PV gaps in patients undergoing a second AF ablation.

A bipolar voltage reflects a thick musculature where formation of a transmural lesion may be hard to achieve. The purpose of this study was to explore the association between local bipolar voltage and conduction gap in patients with persistent atrial fibrillation (AF) who underwent atrial roof or septal linear ablation. This prospective observational study included 42 and 36 consecutive patients with persistent AF who underwent roof or septal linear ablations, respectively. After pulmonary vein isolation, left atrial linear ablations were performed, and conduction gap sites were identified and ablated after first-touch radiofrequency application. Conduction gap(s) after the first-touch roof and septal linear ablation were observed in 13 (32%) and 19 patients (53%), respectively. Roof and septal area voltages were higher in patients with conduction gap(s) than in those without (roof, 1.23 ± 0.77 vs 0.73 ± 0.42 mV, p = 0.010; septal, 0.96 ± 0.43 vs 0.54 ± 0.18 mV, p = 0.001). Trisected regional analyses revealed that the voltage was higher at the region with a conduction gap than at the region without. Complete conduction block across the roof and septal lines was not achieved in 3 (7%) and 6 patients (17%), respectively. Patients in whom a linear conduction block could not be achieved demonstrated higher ablation area voltage than those with a successful conduction block (roof, 1.91 ± 0.74 vs 0.81 ± 0.51 mV, p = 0.001; septal, 1.15 ± 0.56 vs 0.69 ± 0.31 mV, p = 0.006). In conclusion, a high regional bipolar voltage predicts failure to achieve conduction block after left atrial roof or septal linear ablation. In addition, the conduction gap was located at the preserved voltage area.

An elevated left atrial pressure has been reported to play an important role in the development of atrial remodelling in atrial fibrillation (AF) patients. The study aimed at elucidating the association between the diastolic early transmitral flow velocity/mitral annular velocity (E/e', a non-invasive surrogate of left atrial pressure) and left atrial low-voltage-area existence, and the prognostic impact of the E/e' on procedural outcomes in patients undergoing AF ablation.Total of 215 consecutive patients were divided into 3 groups based on the estimated left atrial pressure: normal (E/e'8.0, n = 58), undetermined (E/e' = 8.0-14.0, n = 114), and elevated (E/e'14.0, n = 43). Left atrial endocardial voltage mapping was performed following pulmonary vein isolation. Patients with a high E/e' more frequently had low-voltage areas (E/e'8.0, 31%, E/e' = 8.0-14.0, 35%; E/e'14.0, 67%; P = 0.0001). After adjusting for other correlates, a high E/e' was an independent predictor of low-voltage-area existence (HR = 1.11, 95% CI = 1.02-1.21, P = 0.017). During a mean follow-up period of 12 ± 6 months, recurrent atrial tachyarrhythmias occurred in 22 (10%) patients after multiple (1.4 ± 0.5) procedures. Patients with an E/e'14 had more frequent recurrent atrial tachyarrhythmias after multiple ablation procedures than those with an E/e' ≤ 14 (23% vs. 7%, P = 0.001).A high E/e' obtained by pre-ablation echocardiography was associated with a left atrial arrhythmogenic substrate in patients undergoing AF ablation. Furthermore, a high E/e' predicted poor procedural outcomes after pulmonary vein isolation.

BACKGROUND The efficacy of low-voltage-guided ablation in addition to pulmonary vein (PV) isolation for atrial fibrillation (AF) has been reported with voltage mapping being performed during sinus rhythm (SR) or AF. The study aimed to compare the left atrial voltage between SR and AF in association with the electrogram waveform. METHODS This prospective observational study included 30 consecutive patients with persistent AF. After completion of PV isolation, electrogram points were taken during both SR and AF at the identical locations evenly throughout the left atrium. Electrograms were divided into two types: normal (sharp electrogram with ≤3 peaks or duration 3 peaks and duration ≥50 ms). RESULTS During SR, 14 (47%) patients had low-voltage (0.5 mV) substrate with an area of 6.8 ± 4.5 cm2 . In a total of 1,063 point pairs, 135 (13%) demonstrated a fractionated electrogram during SR and 483 (45%) during AF. The locations with fractionated electrograms during AF more frequently showed fractionation during SR compared to those with normal electrograms during AF (23% vs 5%, P < 0.0001), and had lower amplitude during SR (1.47 ± 1.29 mV vs 2.03 ± 1.19 mV, P < 0.0001). Electrogram amplitude was higher during SR than that during AF (1.77 ± 1.27 mV vs 0.96 ± 0.77 mV, P < 0.0001) with a weak correlation (r = 0.56, P < 0.0001). Subgroup analyses revealed that the correlation was relatively strong (r = 0.73, P < 0.0001) among the electrogram amplitudes with normal waveform during SR and AF. CONCLUSIONS Significant differences in electrogram voltage and fractionation degree may exist between SR and AF at the same locations in patients with persistent AF.

Cutting balloons and scoring balloons are commonly used for the preparation of calcified lesion. However, problems with crossability occasionally limit the use of cutting balloons. We prospectively selected 173 calcified lesions treated using a novel cutting balloon (Wolverine™, C group). As control, we retrospectively analyzed 146 calcified lesions treated using a scoring balloon (Lacrosse NSE ALPHA™, S group). Either intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used by the operator’s discretion. The primary outcome was delivery success, which was defined as successful passage to the target lesion immediately after IVUS or OCT evaluation. The secondary outcome was acute cross-sectional area (CSA) gain, which was defined as post-interventional minimum stent area minus pre-procedural minimum lumen area. A multivariate analysis evaluated the independent predictors for delivery success. The delivery success rate was significantly higher in the C group versus the S group (90.8% versus 79.5%, P = 0.006). However, the acute CSA gain was similar between the two groups (IVUS: 3.2 ± 1.8 mm2 versus 3.4 ± 1.9 mm2, P = 0.53; OCT: 3.6 ± 1.4 mm2 versus 4.1 ± 1.9 mm2, P = 0.11). Usage of cutting balloon was an independent predictor for delivery success even after the adjustment for the patient and lesion characteristics [odds ratio (OR): 2.72 (95% confidence interval 1.38–5.33), P = 0.004] as well as the procedural characteristics [OR: 2.34 (1.15–4.86), P = 0.018]. Novel cutting balloons demonstrated better crossability and similar acute CSA gain compared with scoring balloons in calcified lesion.

A 58-year-old male with gangrene in his left 1(st) digit due to critical limb ischemia had undergone endovascular therapy for chronic total occlusion of the left superficial femoral artery using bare-metal stents (BMSs). Angiography revealed in-stent occlusion of the BMS site when he was referred to our hospital with a recurrent ulcer at 7 years after stent implantation. As catheter-directed thrombolysis with urokinase was not effective, surgical thrombectomy was performed. His ankle-brachial index improved, and the ulcer was completely healed after thrombectomy. Pathological evaluation of the retrieved thrombi showed that it consisted of a massive erythrocyte, abundant fibrin precipitation, and fragments of atherosclerotic plaques, such as foamy macrophages and ghost images thought to be cholesterol crystals. These findings suggested that the neoatherosclerotic changes in the neointima gradually occurred in the stented segment, and neointimal disruption potentially caused the intrastent thrombotic occlusion.

Background Critical limb ischemia (CLI) is the most progressed manifestation of peripheral artery disease. Although patients with CLI commonly complicate with severely calcified lesions in infrapopliteal lesions, the prognostic impact of infrapopliteal arterial calcification on wound healing in patients with CLI has not been systematically studied. Purpose The aim of current study was to elucidate the prognostic impact of infrapopliteal arterial calcification on wound healing in CLI undergoing endovascular therapy (EVT). Methods This study enrolled 639 CLI patients with tissue loss (age 74±10 years, male 62%, diabetes 69%, hemodialysis 57%, Rutherford class 5 77%, class 6 23%) primarily treated with EVT for the infrapopliteal lesions between April 2010 and December 2015. Arterial calcification was assessed by high intensity fluoroscopy and classified into 3 groups as follows; 1) none, 2) unilateral and 3) bilateral calcification. The primary outcome measure was complete wound healing. The predictors of the outcome were evaluated by Cox proportional hazards regression analysis. Results During a mean follow-up period of 22±19 months, 1-year wound healing rate were 59.0%. In Kaplan-Meier analysis, 1-year wound healing rate was worse in patients with bilateral calcification than in those with unilateral or none calcification (Figure, 46.2% versus 55.1% versus 67.8%, P Figure 1 Conclusion Infrapopliteal Arterial calcification as well as non-ambulatory status was associated with wound healing in patients with CLI.

Background Biodegradable polymer drug-eluting stent (BP-DES) has been developed to improve clinical outcomes after percutaneous coronary intervention (PCI) for patients presenting coronary artery disease (CAD). Although BP-DES showed non-inferior safety and efficacy to durable polymer DES (DP-DES) in several randomized clinical trials, hemodialysis (HD) patients, who have been well known as high risk population for adverse events, were excluded in the most of trials. Therefore, there are limited data comparing the clinical outcomes between BP-DES and DP-DES in HD patients with CAD after PCI. Purpose The purpose of this study was to investigate clinical outcomes in HD patients after BP-DES implantation compared with those after DP-DES implantation. Methods We retrospectively analyzed 234 HD patients (male 74%, mean age 71±10 years) undergoing PCI for 404 lesions with 472 DESs (71 patients for 138 lesions with 170 BP-DESs [91 Ultimaster and 79 Synergy] and 163 HD patients for 266 lesions with 302 DP-DESs [219 Xience, 53 Promus and 30 Resolute]) from 2011 to 2017. Two-year clinical outcomes were compared between BP-DES group and DP-DES group. The primary outcome measure was the incidence of target lesion revascularization (TLR), while the secondary outcome measures were the occurrence of cardiac death (CD), stent thrombosis (ST), myocardial infraction (MI), target vessel revascularization (TVR), non-TVR and major adverse cardiac event (MACE) defined as a composite of CD, MI, and TVR. Outcome measures were estimated by the Kaplan-Meier method and the differences between BP-DES group and DP-DES group were assessed by the log-rank test. We also conducted Cox's proportional hazard model to identify predictors for TLR occurrence. Results Baseline patient and lesion characteristics were similar between the two groups. The two-year incidence of TLR was not significantly different between BP-DES group and DP-DES group (14.1% vs. 22.2%, p=0.391). The two-year incidences of CD (17.3% vs. 17.5%, p=0.381), ST (0% vs. 3.9%, p=0.133), MI (4.2% vs. 5.8%, p=0.965), TVR (21.3% vs. 27.5%, p=0.586), non-TVR (26.1% vs. 31.3%, p=0.439) and MACE (41.1% vs. 42.6%, p=0.526) were also not different between the two groups. After multivariate analysis, diabetes mellitus (hazard ratio 1.97; 95% confidence interval 1.03–3.78, p=0.004) was independently associated with TLR occurrence in HD patients. Two-year clinical outcomes of HD patient Conclusions At two-year follow-up after PCI, BP-DES had comparable safety and efficacy profiles to DP-DES in HD patients presenting CAD. Acknowledgement/Funding None

Purpose:To examine if endovascular therapy (EVT) with paclitaxel-coated stents increases the mortality risk in patients with symptomatic lower limb peripheral artery disease (PAD).Materials and Methods:A retrospective analysis was conducted of paclitaxel-coated stent use in the femoropopliteal segment of 1535 symptomatic (Rutherford category 2 to 4) patients treated between January 2010 and December 2016 at 4 hospitals in Japan. The risk of all-cause mortality was examined between the 285 patients (mean age 73±8 years; 213 men) treated with a paclitaxel-coated stent (PTX-coated group) and 1250 patients (mean age 73±9 years; 872 men) not exposed to a paclitaxel-coated device (PTX-free group) during EVT. Propensity score matching was employed to balance baseline characteristics. Cox proportional hazards models stratified on the quintiles of the propensity score were used to investigate paclitaxel-coated stent use and mortality risk as well as interactions among baseline variables and the main outcome. Interactions between a PXT-coated stent and subgroups of the PTX-free group (bare stent and angioplasty) were also investigated, as was the impact of paclitaxel dose on mortality risk. The results of regression analysis are reported as the hazard ratio (HR) and 95% confidence interval (CI).Results:The 3-year overall survival estimates were 86.4% in the PTX-coated group vs 87.7% in the PTX-free group; the corresponding 5-year estimates were 77.5% vs 73.7%, respectively. There was no significant difference in all-cause mortality between the 2 groups (HR 0.89, 95% CI 0.66 to 1.19, p=0.41). The cause of death also showed no remarkable difference between the groups. Chronic renal failure (p=0.044) and arterial calcification (p=0.022) demonstrated a significant interaction effect on the association of the use of a PTX-coated stent with all-cause mortality. No subgroup demonstrated that the use of a paclitaxel-coated stent was associated with an increased risk of all-cause mortality. A dose dependency was not evident.Conclusion:Mortality risk following application of a PTX-coated stent did not increase over 5 years, irrespective of the dose. A PTX-coated stent for femoropopliteal lesions in PAD patients is a safe treatment option.