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Introduction: Comparative occurrence of ischemic stroke for rhythm versus rate control in patients with non-valvular atrial fibrillation (NVAF) has been still inconclusive. The aim of this study was to compare differences of ischemic stroke occurrence between the rhythm and rate control strategies in AF patients. Methods: The CODE-AF registry prospectively enrolled 6,280 consecutive patients who were treated for NVAF at 10 tertiary referral centers in South Korea. Of these, 2,513 (40.0%) NVAF patients (age, 67±10 years; male, 61.8%) were clinically followed up for 1-year and divided into rate control 1,233 (49.0%) and rhythm control 1280 (51.0%) group. Results: Those treated with the rhythm control group were younger, and had less proportions of underlying disease compared to those treated with the rate control strategy. After propensity score matching analysis, 1,800 of these patients was compared and analyzed between rate control and rhythm control group. Those treated with the rhythm control group were similar in the baseline characteristics including CHA 2 DS 2 -VASC score compared to those treated with the rate control strategy. The rate of oral anticoagulation, all bleeding, and hospitalization were also similarly between two groups. The incidence rate of ischemic stroke in the rhythm control group was significantly lower than rate control group (0.7 vs. 6.9 per 1000 person-years, p=0.011). Conclusion: In this national prospective AF cohort, the rhythm control strategy demonstrated beneficial effect to lower the risk of ischemic stroke during 1-year follow-up compared to rate control strategy.

BACKGROUND The Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial Part II (STAR-AF2) emphasized the importance of circumferential pulmonary vein isolation (CPVI) during AF ablation. Methods and Results: This study involved 2,297 consecutive patients (mean age, 58±11 years; 73.1% male, 70.1% paroxysmal AF) undergoing AF ablation from 2009 to 2017. We investigated the ablation lesion set, ablation time, catheter type, and clinical outcomes. Over the 9 years, the extra-pulmonary vein (PV) left atrial (LA) ablation rate (76.8% to 19.4%, P

Background: Catheter ablation of persistent atrial fibrillation (AF) is still challenging and is characterized by a significant AF recurrence rate; however, no optimal extra-pulmonary vein lesion set is known. We previously reported the clinical feasibility of in silico simulation-guided AF catheter ablation. Methods: We randomly assigned 118 patients with persistent AF (77.8% men, age 60.8 ± 9.9 years) to the simulation-guided ablation group (53 patients) and the empirical ablation group (55 patients) based on the operators' experience. For in silico ablation, four virtual linear and one electrogram-guided lesion sets were tested on patient heart computed tomogram-based models, and the lesion set with the fastest termination time was reported to the operator in the simulation-guided ablation group. The primary outcome was freedom from atrial tachyarrhythmias lasting longer than 30 seconds after a single procedure. The duration of the follow-up was 31.5 ± 9.4 months. Findings: Virtual in silico ablation procedures were successful in 95.2% of the patients (108/118). The clinical recurrence rate was significantly lower after a simulation-guided ablation than after an empirical ablation (20.8% vs. 40.0%, log-rank p = 0.042). Simulation-guided ablation was independently associated with a better long-term rhythm outcome of persistent AF ablation (HR = 0.29 [0.12-0.69], p = 0.005). The superiority of the rhythm outcome of the simulation-guided ablation was more significant in males, non-obese patients with a less remodeled atrium (left atrial dimension

Background Left ventricular late gadolinium enhancement (LV-LGE) by cardiac magnetic resonance (CMR) imaging has been associated with adverse clinical outcomes in patients with non-ischemic cardiomyopathy (NICM). However, an association between the characteristics of the LGE and arrhythmic risk has not been demonstrated consistently. This study evaluated the impact of the LV-LGE characteristics on the arrhythmia risk in patients with NICM. Methods This study enrolled 365 consecutive patients (54±15years) with NICM who underwent CMR imaging. All patients were monitored for the following outcomes: major arrhythmic events (MA), including sustained ventricular tachycardia, an appropriate implantable cardioverter–defibrillator intervention, ventricular fibrillation and sudden cardiac death. Results During 44.3±36.4months of follow-up, 44 (12.1%) patients experienced MA. LV-LGE was observed in 40 (90.9%) and 221 (68.8%) patients with and without MA, respectively. LV-LGE was more frequently observed in the MA group (p=0.002). The age- and sex-adjusted hazard ratio (HR) of MA was increased in patients with LGE extent≥8% (HR 8.45, 95% confidence interval (CI) 2.91–24.6), and those with subendocardial (HR 6.98, 95% CI 1.74–28.0) and subepicardial LGE patterns (HR 7.2, 95% CI 1.61–35.6). In multivariable models adjusted for other clinical variables, only the subepicardial LGE pattern had 7.2 (95% CI, 1.61–32.6, p=0.01) time increase in the MA risk. Conclusions LV-LGE in patients with NICM is not uncommon. The subepicardial pattern of the LV-LGE was an independent predictor of MA, suggesting that specific patterns of the LV-LGE are closely related to the severity of arrhythmic events.

Systemic inflammation plays an important role in the pathogenesis of atrial fibrillation (AF). However, little evidence exists whether the risk of AF is increased in autoimmune rheumatic disease (ARD).In 20,772 consecutive ARD patients (mean age 42±17years, 13,683 female) in a tertiary hospital from 2005 to 2015, AF prevalence, comorbidities and cardiovascular (CV) outcomes were evaluated.AF was observed in 235 (1.1%) patients. The mean duration to AF diagnoses was 5.9±2.4years. Compared with patients without AF, AF patients were older, and had a higher CRP level (5.1±0.7 vs. 2.7±0.2mg/L, p=0.01), higher incidence of hypertension, heart failure and coronary artery disease. The AF prevalence was higher in inflammatory myositis (3.5%) and systemic sclerosis (2.3%) than that in other ARDs (all p0.05). In the multivariate analysis, the independent predictors of AF were an older age (HR 1.05, 95% CI: 1.04-1.06, p=0.01), hypertension (HR 2.28, 95% CI: 1.70-3.06, p0.001), high CRP levels (HR 1.75, 95% CI: 1.07-2.86, p=0.04), and heart failure (HR 11.96, 95% CI: 8.13-17.60, p=0.03). During a mean follow-up period of 6.8±4.5years, ARD patients with AF had a higher all cause death (16.5% vs. 2.1%, p0.001) and incidence of strokes (1.9% vs. 0.4%, p=0.001) than non-AF patients.The incidence of AF in ARD was affected by specific disease and an inflammatory status manifested by the CRP level. AF in ARD was related to a higher mortality and strokes mandating meticulous follow-up.

Aims Atrial fibrillation (AF) is closely associated with metabolic syndrome, and the receptor for advanced glycation end products (RAGE) pathway is involved in insulin resistance and cardiac remodelling. We hypothesized that plasma level of soluble RAGE (sRAGE) would predict clinical outcome after radiofrequency catheter ablation for AF. Methods and results We measured pre-procedural plasma level of sRAGE in 496 patients who underwent AF ablation (142 patients with diabetes, 354 patients without diabetes selected by matching them with diabetic patients according to age, sex, and AF type). (i) Plasma level of sRAGE was significantly higher in diabetic patients than in non-diabetics (580.0 ± 576.4 vs. 435.8 ± 280.7 pg/mL, P = 0.005), but there was no difference in sRAGE levels between patients with clinical recurrence of AF and those without. (ii) During 24.5 ± 18.0 months of follow-up, the recurrence of AF was significantly lower in the diabetic patient group with high sRAGE (≥418 pg/mL based on the median value) than the diabetic patient group with low sRAGE (log-rank P = 0.045). This was especially pronounced in patients with paroxysmal AF and diabetes (log-rank P = 0.016), but no association was found in non-diabetics. (iii) In multivariate Cox regression analysis, high sRAGE (HR 0.395, 95% CI 0.175–0.894, P = 0.026) and paroxysmal AF (HR 0.387, 95% CI 0.179–0.835, P = 0.016) were independently associated with the favourable clinical outcome of rhythm control after AF ablation in diabetic patients. Conclusion High plasma level of sRAGE was independently associated with low AF recurrence after catheter ablation in diabetic patients, especially those with paroxysmal AF.

Background The efficacy of oral anticoagulation therapy (OAT) has not been revealed in atrial fibrillation (AF) patients with newly diagnosed cancers. This study evaluated the thromboembolic and bleeding events in AF patients with malignancies according to OAT. Methods and results In 2168 consecutive non-valvular AF patients with newly diagnosed malignancies, we analyzed the composite endpoints including major adverse cardiac events (MACEs) and major bleeding. Based on a propensity score matching, two groups with 690 matched pairs were created. Patient baseline characteristics were comparable between the matched groups. During a follow-up period of 3.9±2.8years, 72 (10%) and 65 (9%) patients had MACEs in the propensity score-matched OAT+ and OAT− groups, respectively (p=0.461). There was no significant difference in the major bleeding (10% vs. 8%, p=0.300) and composite endpoints (18% vs. 16%, p=0.181) between OAT+ and OAT− patients. During the first year after the cancer diagnosis, 66 (48%) MACEs, 52 (41%) major bleedings, and 116 (49%) composite end points of all events occurred. The optimal international normalized ratio (2.0 to 3.0) level was achieved in only 85 (12%) patients. However, 1year after cancer diagnosis, OAT+ patients with the target therapeutic range of ≥60% demonstrated better cumulative survival free of composite end point than OAT− patients (p=0.026). Conclusion During the first year after the cancer diagnosis, OAT did not improve the composite end point because of poor INR control caused by cancer treatment. However, after 1year after diagnosis of cancer, optimal anticoagulation significantly reduced the composite end point.

Most physicians regard left atrial appendage (LAA) thrombus as a contraindication for LAA occlusion due to risk of distal embolization which is a serious complication. Here we report a case of successfully implanted Amplazter cardiac plug without complication in elderly patients having LAA thrombus with recurrent embolic events despite oral anticoagulants for prevention of thromboembolic events.

Intensive blood pressure (BP) lowering in patients with hypertension at increased risk of cardiovascular disease has been associated with a lowered risk of incident atrial fibrillation (AF). It is uncertain whether maintaining the optimal BP levels can prevent AF in the general elderly population. We included 115,866 participants without AF in the Korea National Health Insurance Service-Senior (&ge, 60 years) cohort from 2002 to 2013. We compared the influence of BP on the occurrence of new-onset AF between octogenarians (&ge, 80 years) and non-octogenarians (&lt, 80 years) subjects. With up to 6.7 &plusmn, 1.7 years of follow-up, 4393 incident AF cases occurred. After multivariable adjustment for potentially confounding clinical covariates, the risk of AF in non-octogenarians was significantly higher in subjects with BP levels of &lt, 120/&lt, 80 and &ge, 140/90 mm Hg, with hazard ratios of 1.15 (95% confidence interval (CI), 1.03&ndash, 1.28, p &lt, 0.001) and 1.14 (95% CI, 1.04&ndash, 1.26, 0.001), compared to the optimal BP levels (120&ndash, 129/&lt, 80 mm Hg). In octogenarians, the optimal BP range was 130&ndash, 139/80&ndash, 89 mm Hg, higher than in non-octogenarians. A U-shaped relationship for the development of incident AF was evident in non-octogenarians, and BP levels of 120&ndash, 80 mm Hg were associated the lowest risk of incident AF. Compared to non-octogenarians, the lowest risk of AF was associated with higher BP levels of 130&ndash, 89 mm Hg amongst octogenarians.

Background and Objectives Little is known about the outcomes of outpatient clinic-based elective external cardioversion (OPC-ECV) for persistent atrial fibrillation (PeAF). We investigated the acute, short-term, and long-term elective external cardioversion (ECV) outcomes. Methods We included 1,718 patients who underwent OPC-ECV (74% male, 61.1±11.0 years old, 90.9% long-standing PeAF, 9.1% after atrial fibrillation [AF] ablation) after excluding patients with atrial tachycardia or inappropriate antiarrhythmic drug medication, and in-patient ECV. Biphasic shocks were delivered sequentially until successful cardioversion was achieved (70-100-150-200-250 J). If ECV failed at 150 J, we administered intravenous amiodarone 150 mg and delivered 200 J. Results ECV failed in 11.4%, and the complication rate was 0.47%. Within 3 months, AF recurred in 55.5% (44.7% as sustaining AF, 10.8% as paroxysmal AF), and the AF duration was independently associated (odds ratio [OR], 1.01 [1.00–1.02]; p=0.006), but amiodarone was independently protective (OR, 0.46 [0.27–0.76]; p=0.002, Log rank p

Background and Objectives Nationwide social inequalities of oral anticoagulation (OAC) usage after the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) have not been well identified in patients with atrial fibrillation (AF). This study assessed overall rate and social inequalities of OAC usage after the introduction of NOAC in Korea. Methods Between January 2002 and December 2016, we identified 888,540 patients with AF in the Korea National Health Insurance system database. The change of OAC rate in different medical systems after the introduction of NOAC were evaluated. Results In all population, overall OAC use increased from 13.2% to 23.4% (p for trend

Background and Objectives The objective of this study was to evaluate the long-term clinical outcomes and the incidence of permanent pacemaker implantation after catheter ablation in patients with of atrial fibrillation (AF) and sinus node dysfunction (SND). Methods Among 3,068 total consecutive patients who underwent AF catheter ablation (AFCA), this study included 222 (9.5%; men 53.2%, 63.7±9.2 years of age, 81.5% paroxysmal AF) with underlying SND and a regular rhythm follow-up. We analyzed the rhythm outcomes, changes in the mean heart rate or heart rate variability, and permanent pacemaker implantation rate. Results During 47.5±28.8 months of follow-up, 25 (11.3%) patients received pacemaker implantations due to symptomatic SND. More than half (56.0%, 14/25) underwent a pacemaker implantation within 3 months of the AFCA, and the annual pacemaker implantation rate was 2.0% afterwards. Both the early (68.0% vs. 31.0%, p

The long-term risks of thromboembolism and mortality are unknown in patients who survived following atrial fibrillation (AF) newly diagnosed during critical care.Using the Korean National Health Insurance Service database, we identified 30,869 adults who survived for6 months following AF newly diagnosed during critical care (ICU-AF), 269,751 control subjects with non-ICU AF (AF-control), and 439,868 control subjects without AF (No-AF) from 2005 to 2013. We performed propensity score matching and compared the risks of stroke/systemic embolism and all-cause mortality.The adjusted hazard ratios (HRs) for long-term stroke/systemic embolism in the patients with ICU-AF were 0.93 (95% CI, 0.88-0.98) compared with the AF-control group and 1.50 (95% CI, 1.42-1.60) compared with the No-AF group. The adjusted HRs of the ICU-AF group for long-term mortality were 1.73 (95% CI, 1.70-1.83) and 3.20 (95% CI, 3.08-3.33) compared with the AF-control and No-AF groups, respectively. The risks of stroke/systemic embolism and mortality were significantly higher in the ICU-AF group than in the No-AF group after excluding patients with AF recurrence (adjusted HR, 1.08; 95% CI, 1.01-1.17), regardless of the causes of critical care and cardiovascular or noncardiovascular surgery.The patients who survived following AF newly diagnosed during critical care remained at a higher risk of long-term stroke/systemic embolism and mortality than the patients without AF regardless of AF recurrence and the causes of critical care. Close follow-up and continuous anticoagulation might be needed for these patients.

Exercise intolerance among the clinical symptoms in patients with atrial fibrillation (AF) has usually been masked by their adjusted life style. We sought to assess the role of CHA2DS2-VASc score to predict exercise intolerance in asymptomatic AF patients, and further examine whether the relationship differs by age and gender. Among the 6,275 participants of the prospective Korean registry of the Comparison study of Drugs for symptom control and complication prevention of Atrial Fibrillation (CODE-AF), 1,080 AF patients who underwent exercise treadmill testing were studied. Exercise intolerance was defined as a peak exercise capacity of 7 metabolic equivalents (METs) or less, and the patients were divided into two groups for the analysis: ≤7 METs (n = 131) and >7 METs (n = 949). Patients with exercise intolerance had a significantly higher CHA2DS2-VASc score than those without (3.1 ± 1.3 vs. 2.0 ± 1.5, p 2DS2-VASc score (OR 1.54, 95% CI 1.31–1.81, p 2DS2-VASc score on exercise intolerance was significant only in male patients aged 2DS2-VASc score may be a feasible risk assessment tool to predict exercise intolerance, especially in young and middle-aged male patients with asymptomatic AF.

Purpose Catheter ablation for atrial fibrillation (AF) requires heavy anticoagulation and uncomfortable post-procedural hemostasis. We compared patient satisfaction with and the safety of unilateral groin (UG) puncture-single trans-septal (ST) ablation with conventional bilateral groin (BG) puncture-double trans-septal (DT) ablation in paroxysmal AF patients. Materials and methods We enrolled 222 patients with paroxysmal AF (59.4±10.7 years old) who were randomized in a 2:1 manner into UG-ST ablation (n=148) and BG-DT ablation (n=74) groups. If circumferential pulmonary vein isolation could not be achieved after three attempts of touch-up ablation in the UG-ST group, the patient was crossed over to BG-DT by performing a left groin puncture. Results Ten patients in the UG-ST group (6.8%) required crossover to the BG-DT approach. There were no significant differences in procedure time (p=0.144) and major complications rate (p>0.999) between the UG-ST and BG-DT groups. Access site pain (p=0.014), back pain (p=0.023), and total pain (p=0.015) scores were significantly lower for the UG-ST than BG-DT group as assessed by the Visual Analog Scale. Over 20.2±8.7 months of follow up, there was no difference in AF recurrence free-survival rates between the two groups (Log rank, p=0.984). Conclusion UG-ST AF ablation is feasible and safe, and was found to significantly reduce post-procedural hemostasis-related discomfort, compared to the conventional DT approach, in patients with paroxysmal AF.

Background Amiodarone, which inhibits CYP2C9 and P-glycoprotein, is commonly prescribed with non-vitamin K antagonist oral anticoagulants (NOACs) and polypharmacy in high-risk atrial fibrillation (AF) patients. We studied efficacy and safety of NOACs in AF patients receiving amiodarone, P-glycoprotein inhibitor, or polypharmacy. Methods After a systematic database search (Medline, EMBASE, CENTRAL, SCOPUS, and Web of Science), four phase-III randomized trials comparing NOACs and warfarin in “with/without amiodarone,” “with/without P-glycoprotein inhibitors,” or “with/without multiple (≥5, polypharmacy) concomitant drugs” subgroups were included. The outcomes were pooled using a random-effects model to determine the relative risks (RRs) for stroke/systemic thromboembolism (SSTE), major bleeding (MB), intracranial hemorrhage (ICH), and all-cause mortality. Results Among patients taking amiodarone, superiority of NOACs over warfarin in non-amiodarone users disappeared in terms of SSTE (p = 0.11), MB (p = 0.95), ICH (p = 0.26), and mortality (p = 0.32). No safety benefit (MB) of NOACs compared to warfarin was shown in patients taking P-glycoprotein inhibitors (p = 0.47), but SSTE prevention was still superior with NOACs compared to warfarin in the same patient group [RR = 0.78 (0.61–0.99), p = 0.04, I2 = 11%]. In AF patients with polypharmacy, NOACs showed a lower risk of SSTE [RR = 0.82 (0.71–0.96), p = 0.01, I2 = 0%] and mortality [RR = 0.91 (0.83–0.99), p = 0.04, I2 = 0%], but not MB (p = 0.81) compared to warfarin. Conclusions NOACs were equivalent to warfarin among AF patients with concomitant amiodarone use in terms of efficacy, safety, and mortality. There was no safety benefit of NOACs over warfarin in patients using polypharmacy or P-glycoprotein inhibitors. Systematic review registration The protocol of this meta-analysis was registered on PROSPERO under CRD42018104808 ( https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42018104808 ).

Background and Purpose- Edoxaban is a direct oral factor Xa inhibitor with proven efficacy and safety among patients with atrial fibrillation. Concerns have been raised about an excess of stroke among patients with creatinine clearance (CrCl)95 mg/mL treated with edoxaban. We assessed the real-world effectiveness and safety of edoxaban in atrial fibrillation patients in relation to CrCl. Methods- In the Korean National Health Insurance Service data during the period from January to December 2016, we identified 9537 edoxaban-treated patients. Effectiveness and safety outcomes were compared between high-dose edoxaban regimen (HDER, 60 mg daily, n=2840) and a propensity score-matched warfarin group (n=2840) and between low-dose edoxaban regimen (LDER, 30 mg daily, n=3016) and matched warfarin group (n=3016). Results- The median follow-up period was 5.0 months (interquartile range, 2-7 months). The mean age was 68 years, and 63% were men in HDER group, and the mean age was 73 years, and 52% were men in LDER group. Compared with warfarin, both HDER and LDER significantly decreased the risk for ischemic stroke or systemic embolism (S/SE; HDER: adjusted hazard ratio [aHR], 0.44; 95% CI, 0.31-0.64; LDER: aHR, 0.57; 95% CI, 0.42-0.78), major bleeding (HDER: aHR, 0.40; 95% CI, 0.26-0.61; LDER: aHR, 0.61; 95% CI, 0.43-0.85), and mortality (HDER: aHR, 0.34; 95% CI, 0.22-0.53; LDER: aHR, 0.55; 95% CI, 0.41-0.73). In patients with CrCl95 mL/min, the incidence of S/SE was higher with LDER than warfarin and comparable between HDER and warfarin group. There was lower effectiveness for the prevention of S/SE with LDER compared with warfarin at higher CrCl levels ( P for interaction=0.023). Conclusions- In real-world practice, both doses of edoxaban were associated with reduced risks for S/SE, major bleeding, and mortality compared with warfarin. LDER had lower effectiveness for the prevention of S/SE compared with warfarin at higher levels of CrCl (95 mL/min).

Purpose Label adherence for non-vitamin K antagonist oral anticoagulants (NOACs) has not been well evaluated in Asian patients with non-valvular atrial fibrillation (AF). The present study aimed to assess label adherence for NOACs in a Korean AF population and to determine risk factors of off-label prescriptions of NOACs. Materials and methods In this COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, patients with AF who were prescribed NOACs between June 2016 and May 2017 were included. Four NOAC doses were categorized as on- or off-label use according to Korea Food and Drug Regulations. Results We evaluated 3080 AF patients treated with NOACs (dabigatran 27.2%, rivaroxaban 23.9%, apixaban 36.9%, and edoxaban 12.0%). The mean age was 70.5±9.2 years; 56.0% were men; and the mean CHA₂DS₂-VASc score was 3.3±1.4. Only one-third of the patients (32.7%) was prescribed a standard dose of NOAC. More than one-third of the study population (n=1122, 36.4%) was prescribed an off-label reduced dose of NOAC. Compared to those with an on-label standard dosing, patients with an off-label reduced dose of NOAC were older (≥75 years), women, and had a lower body weight (≤60 kg), renal dysfunction (creatinine clearance ≤50 mL/min), previous stroke, previous bleeding, hypertension, concomitant dronedarone use, and anti-platelet use. Conclusion In real-world practice, more than one-third of patients with NOAC prescriptions received an off-label reduced dose, which could result in an increased risk of stroke. Considering the high risk of stroke in these patients, on-label use of NOAC is recommended.

BACKGROUND The relationship between anemia and sudden cardiac arrest (SCA) is unclear in the general population, so we assessed it in a nationwide cohort.Methods and Results: We studied 494,948 subjects (mean age, 47.8 years; 245,333 men [49.6%]) with national health check-up data from the Korean National Health Insurance Database Cohort. During a mean follow-up period of 5.4 years, SCA occurred in 616 participants (396 men, 220 women). The incidence rates of SCA increased across the 4 anemia groups in both men (0.3, 1.5, 5.3, and 4.5 per 1,000 person-years) and women (0.2, 0.5, 0.5, and 1.2 per 1,000 person-years). The SCA risk per 1-unit decrease in hemoglobin (Hb) increased by 21% and 24%, respectively, in multivariable models adjusted for cardiovascular factors, in men (95% confidence interval [CI], 13-29%; P

Chronic anticoagulation is recommended in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF). Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative to warfarin, but there are limited data to support their use in patients with HCM and AF. We sought to compare thromboembolic events, bleeding, and mortality between NOAC and warfarin in patients with HCM and AF.From the Korean National Health Insurance Service database during the period from January 1, 2011, to December 31, 2016, we identified a warfarin-treated group of patients with HCM and AF (n = 955) who were compared with a 1:2 propensity-matched NOAC treated group (n = 1,504).After a median follow-up of 16 months, the incidence rates of ischemic stroke and major bleeding were similar between NOAC- and warfarin-treated patients with HCM and AF. NOAC-treated patients had lower incidence rates for all-cause mortality (5.11 and 10.13 events per 100 person-years for NOAC and warfarin groups) and the composite of fatal cardiovascular events (0.77 and 1.80 events per 100 person-years). Compared with warfarin, use of NOACs was associated with a significantly lower risk of all cause-mortality (hazard ratio, 0.43; 95% CI, 0.32-0.57) and composite fatal cardiovascular events (hazard ratio, 0.39; 95% CI, 0.18-0.82).Compared with warfarin, patients with HCM and AF on NOACs had similar stroke and major bleeding risks, but lower all-cause mortality and composite fatal cardiovascular events. Our data suggest that patients with HCM and AF can be safely and effectively treated with NOACs.

Background Although many studies have linked elevations in fine particulate matter (PM2.5) air pollution to adverse cardiovascular outcomes, long-term exposures of PM2.5 on air pollution-related incident atrial fibrillation (AF) in general population have not yet been investigated well. Methods We included 432,587 subjects of general population not diagnosed with AF from the Korean National Health Insurance Service-National Sample Cohort from 2009 to 2013. Medical records were screened from January 2002 to investigate the subjects' disease-free baseline period. They were followed until December 2013. We matched subjects' residential ZIP code with hourly measurements of air pollutant (particulate and gaseous) concentrations and meteorological (temperature and humidity) data during the study period. Results During 1,666,528 person·years, incident AF was observed in 5825 subjects (350/100,000 person·year). We found significant associations between incident AF and long-term average concentrations of PM2.5 (HR = 1.179[1.176–1.183] for 10 μg/m3 increments, p Conclusions Even in the Asian general population, long-term exposure of PM2.5 is associated with the increased incidence of new-onset AF. It is more profound in obese male subjects > 60-year old and who have a history of hypertension or previous myocardial infarction.

INTRODUCTION The objective of the current study was to elucidate the effects of the accessory pathways (APs) on the left ventricular (LV) wall motion and radiofrequency catheter ablation (RFCA) on AP-related regional wall motion abnormality (RWMA) in patients with Wolff-Parkinson-White (WPW) syndrome. METHODS AND RESULTS We included 348 consecutive patients (age, 37.6 ± 17.3 years; men, 58.3%) with WPW syndrome who underwent RFCA for AP. We analyzed electrocardiographic data, the AP location, LV ejection fraction (LVEF), and RWMA patterns and their changes after RFCA. The locations of APs were right, septal, and left in 78, 94, and 176 patients, respectively. RWMA at the AP location (44.9%, 51.1%, and 17.6%, respectively; P

The electrophysiological features and roles of persistent left superior vena cava (PLSVC) in supraventricular tachycardia (SVT) are not known.The purpose of this study was to elucidate the electrophysiological features and roles of PLSVC in patients with SVT.We included 37 patients with PLSVC (mean age 43.5 ± 17.1 years; 35.1% men) and 510 patients without PLSVC (mean age 43.9 ± 18.8 years; 48.2% men) who underwent an electrophysiology study for SVT. The number of induced tachycardias, location of the slow pathway (SP) or accessory pathway (AP), and radiofrequency catheter ablation (RFCA) outcomes were compared between patients with and without PLSVC. During RFCA of the left AP, a coronary sinus (CS) catheter was placed into the left superior vena cava (left superior vena cava group) or the great cardiac vein (great cardiac vein group). The RFCA outcomes were compared between the groups.In patients with PLSVC, 40 tachycardias were induced: atrioventricular nodal reentrant tachycardia (AVNRT) (n = 19), atrioventricular reentrant tachycardia (n = 17), and focal atrial tachycardia (n = 4). Among patients with AVNRT, an SP in the CS was significantly more frequent in patients with PLSVC than in those without PLSVC (47.4% vs 3.8%; P.001). In patients with the left AP, the number of RFCA attempts and recurrence were lower in the great cardiac vein group than in the left superior vena cava group.An SP in the CS is prevalent in patients with AVNRT and PLSVC. It is useful to place a CS catheter into the great cardiac vein in patients with a left AP and PLSVC.

Background We evaluated the dose-dependent efficacy, safety, and all-cause mortality of non-vitamin K antagonist oral anticoagulants (NOACs) in “atrial fibrillation (AF) patients who were OAC-naive,” or “AF patients with prior-stroke history” with those who were known to be high-risk subgroups under OAC. Methods After a systematic database search (Medline, EMBASE, CENTRAL, SCOPUS, and Web of Science), five phase-III randomized trials comparing NOACs and warfarin in “OAC-naive/OAC-experienced,” or “with/without prior-stroke history” subgroups were included. The outcomes were pooled using a random-effects model to determine the relative risk (RR) for stroke/systemic thromboembolism (SSTE), major bleeding, intracranial hemorrhage, and all-cause mortality. Results 1. In OAC-naive patients, standard-dose NOACs showed superior efficacy and safety with lower mortality [RR 0.90 (0.84–0.97), p = 0.008, I 2 = 0%] compared to warfarin. 2. For OAC-experienced patients, low-dose NOACs showed equivalent efficacy but reduced risk of major bleeding [RR 0.61 (0.40–0.91), p = 0.02, I 2 = 89%], and had lower all-cause mortality [RR 0.86 (0.75–0.99), p = 0.04, I 2 = 38%] compared to warfarin. 3. For patients with prior-stroke history, low-dose NOACs showed equivalent efficacy, but reduced risk of major bleeding [RR 0.58 (0.48–0.70), p I 2 = 0%] and all-cause mortality [RR 0.76 (0.66–0.88), p I 2 = 0%] compared to warfarin. 4. Among patients without prior-stroke history, standard-dose NOAC was superior to warfarin for both SSTE prevention [RR 0.78 (0.66–0.91), p = 0.002, I 2 = 43%] and all-cause mortality [RR 0.91 (0.85–0.97), p = 0.004, I 2 = 0%]. Conclusions In conclusion, standard-dose NOAC showed lower all-cause mortality than warfarin in OAC-naive patients with AF, and low-dose NOAC was better than warfarin among the patients with prior-stroke history in terms of all-cause mortality.

Incidence of atrial fibrillation (AF) is high in patients with congenial heart disease. However, management of AF is challenging in these patients. Although radiofrequency catheter ablation (RFCA) is effective therapeutic option for AF, RFCA for AF is not common in patients who underwent Fontan operation. We present a 24-year-old woman with paroxysmal AF, who underwent lateral tunnel Fontan operation for functional single ventricle. Circumferential pulmonary vein isolation was successfully performed. However, significant pulmonary vein stenosis developed after RFCA. Pulmonary vein stenosis was successfully treated by transcatheter intervention.

Introduction Cardioembolic (CE) risks is usually considered as the main mechanism of ischemic stroke in non-valvular atrial fibrillation (NVAF) patients. However, a substantial number of ischemic strokes in NVAF patients are related to non-CE mechanisms. The aim of this study was to investigate the non-CE risk factors in ischemic stroke patients had NVAF. Methods We included 401 patients (65.6% male, 68.6 ± 9.6 years old) who had been hospitalized due to ischemic stroke and had a known or newly diagnosed NVAF. The CE (intracardiac thrombus, dense spontaneous echo contrast, or low left atrial appendage flow velocity) and non-CE (complex aortic plaque, significant carotid stenosis, or intracranial arterial stenosis) risk factors were investigated at the time of the index stroke. Results The number of CE and non-CE risk factors increased with increasing CHA2DS2-VASc scores (p for trends < 0.001). The presence of CE risk factors was independently associated with persistent atrial fibrillation (p < 0.001), body mass index (p = 0.003), heart failure (p = 0.003), and left atrial volume index (p < 0.001). In contrast, the presence of non-CE risk factors was independently associated with age (p < 0.001), hypertension (p = 0.049), diabetes (p = 0.030), and coronary artery calcium score (CACS; p < 0.001). CACS had the added value in predicting non-CE risk factors of ischemic stroke regardless of the CHA2DS2-VASc risk category (p < 0.001). Conclusion Non-CE risk factors in ischemic stroke patients with NVAF are associated with high CHA2DS2-VASc score and CACS. Atherosclerotic non-CE risk factors should be considered as potential mechanisms of stroke even in patients with AF-associated ischemic stroke.

We report on catheter ablation and clinical results in an adult with Wolff-Parkinson-White (WPW) syndrome for dyssynchrony-related dilated cardiomyopathy in the absence of supraventricular tachycardia (SVT). This patient did not have sustained SVT, but developed rapid progression of ventricular dysfunction that was not responsive to heart failure medication. Ventricular preexcitation could not be medically suppressed, but was successfully ablated. This was followed by complete resolution of ventricular dysfunction within six months.

Background: Electrophysiological procedures are challenging in pa- tients who have undergone lateral tunnel or extracardiac conduit Fontan operation because the caval veins are not connected to the cardiac atria and ventricles. This study describes our experience in managing a series of patients with Fontan circulation requiring cath- eter ablation for arrhythmias. Methods: This study included eight consecutive patients with Fontan circulation who underwent catheter ablation or pacemaker implan- tation via Fontan conduit puncture (median age (interquartile range), 21.5 (16.0-25.8) years; 5 men). Lateral tunnel and extracardiac con- duit were equally distributed among the eight patients. A standard technique for conduit puncture and subsequent electrophysiologic procedure was used. The time taken for conduit puncture was com- pared for different types of conduits. Results: The median age of patients in this series was 21.5 years (interquartile range: 16.0-25.8 years). Fontan conduit puncture via right femoral vein under intracardiac echocardiographic guidance was successfully performed without complications in seven of the eight patients. Conduit puncture failed in one patient with extracardiac conduit made of the pericardium due to interruption of both femoral veins. In three patients with Fontan conduit made of pericardium, a Bronckenbrough transseptal needle or a radiofrequency transseptal needle with a snare was used. In four patients with Fontan conduit made of Gore-tex, a radiofrequency transseptal needle with a snare, and percutaneous transluminal angioplasty balloon were used. Fontan conduit puncture time was significantly longer in patients with conduit made of Gore-tex (median time, 91 min; interquartile range, 59.8-130.5 min) than in patients with conduit made of the pericardium (median time, 11.5 min; interquartile range, 10.0-18.3 min), respectively (p=0.020). Conclusions: Conduit puncture is feasible and safe in patients with lateral tunnel and extracardiac Fontan circulation. Puncture of the Gore-tex conduit is more difficult and time consuming than punc- ture of the pericardium conduit.

Constrictive pericarditis is an uncommon post-inflammatory disorder characterized by a variably thickened, fibrotic, and frequently calcified, pericardium. Etiology of the constriction can occur for many reasons. Although foreign bodies are not the common cause of constrictive pericarditis, the long-term presence of foreign bodies, like bullets, is presumed to cause chronic constrictive pericarditis even after a very long asymptomatic period. A 69-year-old patient with atrial flutter was admitted to the hospital. A cardiac computed tomography showed a bullet located adjacent to the right atrium. The transthoracic echocardiography showed a thickened pericardium and septal bouncing motion, which were compatible with constrictive pericarditis. The history of the patient revealed an injury by gunshot during the Korean War in 1950. Radiofrequency ablation of the atrial flutter was performed, and after ablation, the bullet was removed surgically. The patient was discharged home after surgery without complications.

Long QT syndrome (LQTS) and Brugada syndrome (BrS) are well-known congenital channelopathies that can cause sudden cardiac death (SCD). Although various genetic mutations are associated with LQTS and BrS, an electrocardiogram (ECG) is typically preferred to genetic analysis as a diagnostic tool in clinical practice. However, care must be taken when using ECG in the diagnosis of LQTS or BrS, because the characteristic ECG changes of these syndromes are not observed consistently. The ECG pattern can be altered by various factors such as an aborted SCD, the autonomic nervous system, medication, circadian rhythms, and electrolyte imbalance. Here, we report our experience with a family in which the proband displayed an ECG pattern that initially suggested the presence of LQTS but was ultimately diagnosed as BrS, based on the findings of serial ECG follow-up, a drug provocation test, and genetic analysis. CASE REPORTS

Why Is Left Atrial Appendage Morphology Related to Strokes?Background A specific morphology of left atrial appendage (LAA) has been reported to be related to stroke in nonvalvular atrial fibrillation (AF) patients. However, the mechanism is not completely understood. This study evaluated whether a specific LAA morphology was related to stroke, and whether it was related to the change of flow velocity and size of LAA in AF patients. Methods The morphology, size, and flow velocity of LAA were evaluated in AF patients with ischemic strokes (stroke, n = 160) and age-matched AF patients without ischemic strokes (control, n = 200). Results Compared with control, the stroke group had a larger LA dimension (4.5 ± 0.7 vs. 4.2 ± 0.6 cm, P < 0.001), larger LAA orifice area (5.3 ± 2.1 vs. 4.1 ± 1.7 cm2, P < 0.001), and slower LAA flow velocity (37 ± 19 vs. 51 ± 20 cm/s, P < 0.001). The stroke group had the chicken wing type less frequently than the control (34% vs. 50%, P = 0.003). After an adjustment for multiple potential confounding factors, the chicken wing type LAA had a decreased stroke risk (odds ratio 0.34, 95% confidence interval 0.14–0.84, P = 0.020). Patients with a chicken wing LAA had a smaller LAA orifice area (4.4 ± 1.6 vs. 4.9 ± 2.2 cm2, P = 0.013) and higher LAA velocity (55 ± 19 vs. 41 ± 20 cm/s, P < 0.001) than those with non-chicken wing LAA. Conclusion A chicken wing type of LAA was related to the less incidence of stroke. Our results suggest that the relationship between a specific LAA morphology and stroke might be partially explained by the change of the size and flow velocity of LAA.

Implantable cardioverter-defibrillator (ICD) therapy is acknowledged as a valid treatment method for the effective prevention of sudden cardiac death, which is a major cause of mortality in adult congenital heart disease patients. But ICD implantation by the conventional transvascular approach is not always possible in patients who have undergone palliative surgery due to congenital and structural heart disease. Here, we report a case in which an ICD was transvascularly implanted in an arrhythmogenic right ventricular cardiomyopathy patient who had undergone a one-and-a-half ventricle repair.

Aims We hypothesized that P-wave amplitude in lead I is related to left atrial (LA) remodelling and inter-atrial conduction pattern, and has a predictive value for recurrence after radiofrequency catheter ablation (RFCA) among patients with paroxysmal atrial fibrillation (PAF). Methods and results A total of 525 consecutive patients with PAF (76% male, 56 ± 12 years old) who underwent RFCA were included. We compared pre-procedural sinus rhythm electrocardiograms without antiarrhythmic drug effect with LA volume (CT), LA voltage (NavX), the earliest activation site (EAS) conduction pattern of LA, and clinical recurrence rate. P-wave amplitude in lead I was significantly lower in patients with recurrence than in those that remained in sinus rhythm ( P < 0.001) during 21 ± 10-month follow-up. P-wave amplitude in lead I was linearly correlated with LA voltage ( β = 2.52, 95% CI 0.606–4.425, P = 0.010), LA conduction velocity ( β = 1.91, 95% CI 0.941–2.876, P < 0.001), and low septal displacement of EAS ( β = −1.67, 95% CI −2.352 to −0.996, P < 0.001). P-wave amplitudes

Background An implantable cardioverter-defibrillator (ICD) is the only proven effective therapeutic strategy for patients with Brugada syndrome (BS). However, it is controversial whether the device should be replaced even in patients who had never experienced appropriate ICD therapy until the time of generator replacement. Methods and results This was a nationwide, multicenter retrospective study that enrolled patients who were diagnosed with BS and had an ICD implantation between January 1998 and April 2014. Appropriate ICD therapies administered for ventricular tachyarrhythmia were evaluated during follow-up. A total of 117 patients (age 43±12years, male 115 [98.3%]) were enrolled, and the mean follow-up duration was 6.0±4.1years. Thirty-seven (31.6%) patients had experienced appropriate ICD therapy during follow-up. Of all patients, 46 underwent replacement of the device. After the first generator replacement, the incidence of appropriate ICD therapy remained as high as 65.2% in patients who previously experienced appropriate ICD therapy before generator replacement. In 30 patients who did not experience any cardiac events until the first generator change, two (8.7%) had an episode of appropriate ICD therapy afterwards. Conclusions No episode of ICD therapy before generator replacement could not guarantee a safe clinical course. ICD generator replacement should be considered even in patients without ICD therapy before.