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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

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.

As different from radiofrequency current energy, cryofreezing energy is able to provide reversible effects on cardiac tissue, called “cryomapping,” which enables us to predict the effects of a subsequent application of ablative energy. Cryomapping is able to delineate the anatomical location of the lower common pathway of atrioventricular nodal reentrant tachycardia.

Pulmonary vein isolation (PVI) with a cryoballoon (CB) is an effective treatment for atrial fibrillation (AF). The efficacy of CB PVI for elderly patients with AF remains unclear.We aimed to analyze the clinical outcomes of CB ablation compared with radiofrequency (RF) ablation in elderly patients with AF.This was a single-center retrospective study of 305 patients older than 75 years with paroxysmal and persistent AF who underwent PVI between January 2012 and August 2017. Patients were matched according to propensity scores in a logistic regression model. The end point of this study was AF/atrial tachycardia recurrence at 12-month follow-up.In total, 198 patients (99 matched pairs) were analyzed. The ratio of paroxysmal AF was 83%, and the mean age was 78 ± 2 years. The mean procedure time was significantly lower in the CB group (134 ± 62 minutes vs 190 ± 51 minutes; P.001). There was no significant difference between the groups in terms of success rate at 12 months after the procedure (CB 80.5% vs RF 79.4%; P = .72) or incidence of complications (CB 12% vs RF 16%; P = .80). Kaplan-Meier estimates revealed no significant difference between clinical outcomes after PVI with a CB or RF for elderly patients with non-pulmonary vein foci that were all successfully ablated (CB 68.8% vs RF 68.4% at 12 months; P = .835).The efficacy of PVI with a CB might be comparable to that of PVI with RF in AF patients older than 75 years and involve a shorter procedure time.

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.

A 46‐year‐old female with a body mass index of 38.9 kg/m2 and no organic heart disease underwent a subcutaneous implantable cardioverter‐defibrillator implantation for secondary prevention of sudden cardiac death in the setting of idiopathic ventricular fibrillation. Defibrillation threshold (DFT) testing during implantation detected high shock impedance and high DFT. Fluoroscopy revealed subcoil fat between the lead and the sternum, which we suspected was the reason for the high shock impedance and high DFT. We repositioned the lead to a site just above the sternum and the shock impedance and DFT improved to within the respective normal ranges.

We present a case of a 37-year-old female who complained of frequent palpitations caused by an atrial tachycardia and atrial premature contractions. Angiography revealed that the coronary sinus was occluded at the ostium and connected to a persistent left superior vena cava. An electrophysiological study and three-dimensional mapping revealed that the origin of the atrial tachycardia and atrial premature contractions was at the coronary sinus ostium in the right atrium. After repeat applications of radiofrequency energy at that site, no further atrial tachycardia or atrial premature contractions were induced by atrial burst pacing. To the best of our knowledge, this is the first report of an atrial tachycardia originating from an occluded coronary sinus ostium.

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.

Treatment of ventricular arrhythmias (VAs) commonly involves ablating sites showing electrograms with the earliest activity relative to the VA, but there is no threshold value for prematurity guaranteeing success. Ablation of sites with great prematurity can still result in failure.We hypothesized that isochronal map area (ISCA), derived from isochrones indicating electrogram prematurity, could help identify ablation targets in VA patients, as well as predict outcome. Specifically, we hypothesized that smaller ICSA for a given prematurity value would indicate a shallower arrhythmogenic focus leading to a higher likelihood of successful ablation.We studied ICSA in 29 patients (12 males, 57 [17-65] years old) undergoing VA ablation. The VAs originated from the right and left ventricles in 11 and 18 patients, respectively. The earliest activation site of the VAs, ECG morphology of sinus beats and premature ventricular complexes (PVCs), and ISCA of activation preceding PVCs were evaluated.RF ablation at the site showing earliest prematurity resulted in VA elimination in 21 patients (success group). The 5-ms ISCA was smaller in the success group than in the failure group (0.2 [0.1-0.6] versus 1.0 [0.8-1.5] cm2, respectively; P < 0.01). No significant difference was noted in prematurity itself (36 [30-45] versus 30 [29-33] ms, respectively; P = 0.07). The cut-off value of the 5 ms ISCA for successful RF ablation was 0.7 cm2 with 87.5% sensitivity and 85.6% specificity.Isochrones of activity preceding PVCs appear to contain information beyond prematurity values and may help dictate suitable areas for successful ablation of VAs.

BACKGROUND Efficacy of catheter ablation (CA) of asymptomatic persistent atrial fibrillation (AF) remains unclear. We assessed the quality of life (QOL), exercise performance (EP), and plasma B-type natriuretic peptide (BNP) levels following CA in patients with asymptomatic AF.Methods and Results:We enrolled 34 patients with asymptomatic persistent AF. QOL, was assessed by 2 questionnaires: the Short Form-36 (SF-36) and a QOL questionnaire specific for AF (AFQLQ). The QOL, EP, and plasma BNP level were examined before and 6 months after CA. In the SF-36 survey 5 of 8 components and all 3 subsets of the AFQLQ significantly improved in the patients without recurrences (30 patients, 88%), but there were no differences in those with recurrences. In patients without recurrences, there was an increase in the metabolic equivalents of task (10.2±2.3 vs. 11.6±2.3 METs, P

Background Little is known about the long-term outcome and recurrent form recurrence after catheter ablation of atrial fibrillation (AF) in patients with long-standing persistent AF. Methods Two hundred thirty-six patients with persistent AF (193 men; age, 61.5±10.7 years) were enrolled, and were classified according to the duration of AF: AF duration of

Data on uninterrupted rivaroxaban taken preoperatively for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is limited. The aim was to evaluate safety and efficacy of rivaroxaban taken in the morning for AF ablation, especially with regard to asymptomatic cerebral emboli (ACE) and anticoagulation parameters. We prospectively evaluated 147 consecutive patients who underwent RFCA (mean age 66, 110 patients with paroxysmal AF), 76 of whom were on rivaroxaban, 71 on warfarin. The drugs were continued throughout the periprocedural period, including the morning of RFCA. Heparin infusion was maintained during RFCA to achieve an activated clotting time (ACT) of >300 s. There were no significant differences in basic patient characteristics and ablation procedure between the two groups. ACT during the procedure correlated significantly with prothrombin time and international normalized ratio in each group (correlation coefficient 0.799 in rivaroxaban, 0.705 in warfarin, p

A 63-year-old man was admitted to our emergency department with an episode of sudden cardiopulmonary arrest attributable to ventricular fibrillation (Figure 1). Before admission, cardiopulmonary resuscitation by a bystander and emergency personnel with two 200-J direct-current shocks was conducted; thereafter, spontaneous circulation returned. The patient’s vital signs and level of consciousness were normal at admission. ECG at admission revealed a sinus rhythm with ST elevation in leads aVR and V1, and ST depression in leads II, III, aVF, and V3 through 6. Echocardiography …

Background: Periprocedural anticoagulation with warfarin was reported to reduce the risk of stroke without increasing the risk of bleeding complications for radiofrequency catheter ablation of atrial fibrillation in US population. Methods and Results: The outcome of thromboembolic and hemorrhagic complication was surveyed in 20 consecutive patients who underwent pulmonary vein isolation in our hospital without discontinuance of warfarin. In these patients, the INR was aimed to keep >2.0. After the transseptal puncture, a heparin bolus (2000–5000 U) was administered, followed by additional heparin bolus and infusion to keep the activated clotting time (ACT) >350. As a result, no periprocedural stroke/transient ischemic attack was reported. Bleeding complications that need transfusion and/or prolongation of hospitarization occurred in 3 (15%) patients (1 cardiac tamponade, 1 massive hematoma, and 1 outside bleeding from venous puncture site). In 2 (10%) patients, ACT was inappropriately prolonged (>800) by initial 5000 U of heparin bolus. Conclusion: It is suggested that above mentioned control of periprocedural INR and ACT during procedure may increase hemorrhagic events in Japanese patients who undergo pulmonary vein isolation. In the case whose INR is >2.0, initial heparin bolus may be ristricted

A 68 year-old man who had ischemic cardiomyopathy (ejection fraction 40%), with prior coronary artery bypass graft and ventricular septal perforation (VSP) repair, was admitted due to ventricular tachycardia (VT) with left bundle branch block morphology, and QR pattern in inferior leads. Electro anatomical voltage map (CARTO) during sinus rhythm (SR) demonstrated large low voltage zone (low-VZ) (