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Background Recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI) is associated with left atrial (LA) remodeling; however, its association with right atrial (RA) remodeling remains unclear. Objective This study aimed to identify whether RA structural remodeling could predict recurrence of AF after PVI. Methods This study prospectively analyzed 245 patients with AF who had undergone PVI. RA and LA volumes were determined by contrast‐enhanced computed tomography. Atrial structural remodeling was defined as an atrial volume of ≥110 mL according to previous reports and receiver operating characteristic curve analysis. Results After excluding 32 patients, 213 patients were analyzed. During a follow‐up period of 12 months, 41 patients (19%) demonstrated atrial arrhythmia recurrence after PVI. With the Cox proportional‐hazards model, RA structural remodeling was the only predictor of arrhythmia recurrence (hazard ratio, 1.012; 95% confidence interval 1.003‐1.021; P = .009). Kaplan–Meier analysis showed that arrhythmia recurrence was more frequent in the RA structural remodeling group compared with the group without RA remodeling (log‐rank, P, A greater incidence of recurrence was observed in the presence of RA structural remodeling regardless of the AF type. RA structural remodeling was a useful predictor of clinical outcomes after PVI.

Aim: Arterial stiffness results in elevated left ventricular filling pressure and can promote atrial remodeling due to chronic pressure overload. However, the impact of arterial stiffness on the process of atrial remodeling in association with atrial fibrillation (AF) has not been fully evaluated. Methods: We enrolled 237 consecutive patients diagnosed with AF who had undergone ablation; data from 213 patients were analyzed. Cardio-ankle vascular index (CAVI) was used as a marker of arterial stiffness. The left atrial (LA) and right atrial (RA) volumes were determined by computed tomography imaging; atrial conduction and voltage amplitude were evaluated using a three-dimensional electromapping system used to guide the ablation procedure. Result: In univariate analysis, CAVI significantly correlated with atrial structural and electrical remodeling (LA volume index, r =0.297, P =0.001; RA volume index, r =0.252, P =0.004; LA conduction velocity, r =0.254, P = 0.003; LA mean voltage, r =−0.343, P =0.001, RA mean voltage; r =−0.245, P =0.015). Multivariate regression analysis revealed that CAVI and plasma levels of N-terminal B-type natriuretic peptide were independent determinants of LA and RA remodeling, respectively. On the other hand, age and LA conduction velocity were independent variables with respect to CAVI. Age-adjusted CAVI was highest in long-standing persistent AF when compared with measures of persistent or paroxysmal AF. Conclusion: CAVI was closely associated with biatrial remodeling in patients diagnosed with AF. These results suggest that arterial stiffness may play a significant role with respect to disease progression.

There are only few reports on surgery for partial atrioventricular septal defect( pAVSD) in patients aged over 70 years. This report is about successful surgical correction of pAVSD in a 79-year-old women. Echocardiography showed left-sided atrioventricular valve regurgitation with cleft and ostium primum atrial septal defect, but without ventricular septal defect. Accordingly, she was diagnosed with pAVSD. Treatment plan included direct cleft closure, patch closure for the ostium primum atrial septal defect, and right atrioventricular annuloplasty. The postoperative course was uneventful. She was followed up without complications for four years. To the best of our knowledge, our patient is the oldest to undergo such surgical techniques in Japan to date.

Atrial remodeling associated with atrial fibrillation (AF) and sleep apnea is well known. Although sleep apnea is known to be associated with left atrial (LA) remodeling, its association with right atrial (RA) remodeling remains unclear. The study aimed to investigate the effect of sleep apnea on RA remodeling.We enrolled 141 AF patients who had undergone ablation. Sleep study results were evaluated using a portable sleep apnea test device. RA and LA volumes were determined by computed tomography (CT), and atrial structural remodeling was defined as atrial volume on CT≥110mL according to previous reports. The atrial substrate was evaluated by three-dimensional electroanatomical mapping.After excluding 30 patients who received more than one catheter ablation or who could not receive enhanced CT, 111 patients were finally analyzed. The patients were classified into four groups according to the presence of RA and/or LA enlargement. Significant differences in AF type, N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and apnea-hypopnea index (AHI) were observed among the four groups. In univariate analysis, AHI values correlated with NT-proBNP levels (r=0.293, p=0.002), left ventricular ejection fraction (r=-0.198, p=0.044), LA volume (r=0.370, p0.001), and RA volume (r=0.465, p0.001). Multiple regression analysis showed that AHI was an independent predictor of increased RA volume, and LA was excluded as a multiple risk factor in AHI. AF type-adjusted AHI levels correlated with RA volume, and RA remodeling correlated with the percentage of LA low-voltage area.Sleep apnea was strongly associated with RA structural remodeling regardless of paroxysmal and non-paroxysmal AF, and this relationship was more prominent than the effect of LA. Our results suggest that the association between sleep apnea and RA dilatation should be given attention.

Background Radiofrequency catheter ablation (RFCA) is an effective therapy for atrial fibrillation (AF). However, it the problem of AF recurrence remains. This study investigates whether a deep convolutional neural network (CNN) can accurately predict AF recurrence in patients with AF who underwent RFCA, and compares CNN with conventional statistical analysis.Methods and Results:Three-hundred and ten patients with AF after RFCA treatment, including 94 patients with AF recurrence, were enrolled. Nine variables are identified as candidate predictors by univariate Cox proportional hazards regression (CPH). A CNNSurv model for AF recurrence prediction was proposed. The model's discrimination ability is validated by a 10-fold cross validation method and measured by C-index. After back elimination, 4 predictors are used for model development, they are N-terminal pro-BNP (NT-proBNP), paroxysmal AF (PAF), left atrial appendage volume (LAAV) and left atrial volume (LAV). The average testing C-index is 0.76 (0.72-0.79). The corresponding calibration plot appears to fit well to a diagonal, and the P value of the Hosmer-Lemeshow test also indicates the proposed model has good calibration ability. The proposed model has superior performance compared with the DeepSurv and multivariate CPH. The result of risk stratification indicates that patients with non-PAF, higher NT-proBNP, larger LAAV and LAV would have higher risks of AF recurrence. Conclusions The proposed CNNSurv model has better performance than conventional statistical analysis, which may provide valuable guidance for clinical practice.

A healthy 73-year-old woman unpredictably developed Takotsubo cardiomyopathy syndrome (TTS) during Holter-electrocardiogram (ECG) recording. Thus, the complete chronological ECG data on the actual onset day of TTS were obtained. Many heart rate variability (HRV) parameters, including the low-frequency components (LF) and the high-frequency components (HF), on the actual onset day and in the healing phase were calculated. The interesting facts on the actual onset day were that the suppression of both LF and HF appeared earlier than the changes of the ECG waveform; and the LF/HF ratio remained within the normal range, although both LF and HF were markedly suppressed. The abnormality on the actual onset day was clear compared with the healing phase. It is noteworthy to obtain the chronological ECG data on the actual onset day of TTS in a healthy patient. The present data are unique in terms of being analyzed on the actual onset day. Although the HRV parameters, including LF and HF, were obviously abnormal, there is some skepticism about using HRV parameters as indices of cardiac autonomic activity. In the present case, it was concluded that the abnormality of cardiac autonomic activity contributed to the onset of TTS. These data are unlikely to ever be replicated, and we hope that this report helps elucidate the TTS mechanism.

Background Atrial fibrillation (AF) induces functional mitral regurgitation (FMR) and tricuspid regurgitation (FTR) during atrial remodeling. FMR and FTR are associated with AF prognosis, but the effects for AF recurrence after ablation have not been determined conclusively. Methods Two hundred thirty nine patients who underwent AF ablation were enrolled. Forty five patients were excluded. In total, 194 patients were analyzed. FMR and FTR were assessed by echocardiography. The left atrial volume index (LAVI) was evaluated by contrast-enhanced computed tomography. Results Significant FMR and moderate FTR were observed in 15 (7.7%) and in 25 (12.9%) patients, respectively. The severity of tricuspid regurgitation (TR) significant correlated with age, NT-proBNP, and LAVI. During a 13.4 month follow-up period of, 39 patients (20.1%) demonstrated AF recurrence. In the Cox proportional-hazards model, E/e’, FTR, and LAVI, were termed as predictor factors of AF recurrence (E/e’. hazard ratio [HR] = 1.117; P = 0.019, significant FTR. HR = 4.679; P = 0.041, LAVI. HR = 1.057; P = 0.003). Kaplan–Meier analysis showed that AF recurrence was more frequent in FTR compared with the nonsignificant FTR cases (log-rank, P = 0.001). Although survival analysis showed no difference with or without FMR, the presence of FMR and FTR was strongly associated with high-AF recurrence (log-rank, P = 0.004). Conclusions AF recurrence was associated with E/e’, LAVI, and extensive FTR. Specifically, the combination of FTR and FMR markedly worsens the AF prognosis.

There is increased interest in creating high-power short duration (HPSD) ablation lesions in the field of atrial fibrillation (AF) radiofrequency ablation (RFA). We evaluated the lesion characteristics and collateral damage using two separate RFA protocols setting (HPSD: 50 W and 7 s vs control: 25 W and 30 s) in vitro model. Sixteen freshly killed porcine hearts were obtained, and the atrium and ventricle slabs were harvested for ablation. The each slabs were placed in a tissue bath with circulating 0.9% NaCl at maintained temperature 37 °C. RFA was performed with 4 mm tip irrigated force sensing catheter. All lesions were ablated under recording the electrical parameters using with Ensite Navx system (St. Jude Medical, St. Paul, Minnesota). After RFA, lesion characteristics were assessed for each lesion. Thirty-five lesions were made for each ablation protocol (total 70 lesions for analysis). Ablation parameters were similar between two groups (HPSD vs control; impedance drop (Ω): 34.2 ± 13.1 vs 36.1 ± 8.65 P = 0.49, contact force (g): 13.9 ± 4.37 vs 14.6 ± 5.09, P = 0.51, lesion size index: 4.8 ± 0.52 vs 4.73 ± 0.59, P = 0.62). Although the lesion volume was similar, the HPSD ablation creates wider but more shallower lesions compared to control group (HPSD vs control; lesion volume: 29.6 ± 18.1 mm3 vs 35.5 ± 17.1 mm3 P = 0.16, lesion diameter: 4.98 ± 0.91 mm vs 4.45 ± 0.74 mm P = 0.0095, lesion depth: 2.2 ± 0.76 mm vs 2.8 ± 1.56 mm P = 0.046). Of these, 38 lesions were assessed for adjacent tissue damage and adjacent tissue damages were more frequent seen in control group (HPSD vs control; 1/19 (5.26%) vs 6/19 (31.5%), P = 0.036). Effective lesions were made with HPSD, thereby reducing RFA procedure time. Although the lesion volume was similar between two groups, collateral damage was less seen in HPSD group attributed by lesion characteristics.

A 78-year-old male with a history of a cardiac embolic stroke due to persistent AF and cerebral bleeding (CHADS2 score 4, HAS-BLED score 4) was referred to our hospital to implant a left atrial appendage (LAA) closure (LAAC) device. A trans esophageal echocardiography was performed and a high echoic lesion that was difficult to differentiate the spontaneous echo contrast or thrombus was found in the LAA cavity. After isoproterenol infusion, a high echoic lesion disappeared and we confirmed that it was not an LAA thrombus. Successful LAAC device implantation was performed without any thromboembolic events.

Low sodium levels are strongly associated with poor prognosis in acute heart failure (AHF); however, the prognostic impact of the sodium level trajectory overtime has not been determined. A secondary analysis of the AQUAMARINE study in which patients with AHF and renal impairment were randomized to receive either tolvaptan or conventional treatment was performed. Sodium levels were evaluated at the baseline and at 6, 12, 24, and 48 h. We defined 'sodium dipping' as sodium level falling below the baseline level at any time point. The primary endpoint was the combined event of all-cause death and heart failure rehospitalization during follow-up. The analysis included 184 patients with a median follow-up of 21.1 months. Sodium levels more steeply increased during the 48 h in patients without events as compared to sodium levels in patients with events (P = 0.018 in linear-mixed effect model). The sodium dipping group (n = 100; 54.3%) demonstrated significantly less urine output, less body weight reduction, and poorer diuretic response within 48 h compared to the non-dipping group. The sodium dipping group was also significantly associated with a low combined-event-free survival after adjustment for other prognostic factors (HR 1.97; 95% CI 1.06-3.38; P = 0.033). The trajectory of sodium levels during the acute phase is associated with the prognosis of patients with AHF independently of the baseline sodium level.

Background Poor response to diuretics is associated with worse prognosis in patients with acute heart failure (AHF). We hypothesized that treatment with tolvaptan improves diuretic response in patients with AHF. Methods We performed a secondary analysis of the AQUAMARINE open-label randomized study in which a total of 217 AHF patients with renal impairment (eGFR

Background There has been no report about outcome of pitavastatin versus atorvastatin therapy in high-risk patients with hypercholesterolemia. Methods Hypercholesterolemic patients with one or more risk factors for atherosclerotic diseases (n = 664, age = 65, male = 54%, diabetes = 76%, primary prevention = 74%) were randomized to receive pitavastatin 2 mg/day (n = 332) or atorvastatin 10 mg/day (n = 332). Follow-up period was 240 weeks. The primary end point was a composite of cardiovascular death, sudden death of unknown origin, nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, or heart failure requiring hospitalization. The secondary end point was a composite of the primary end point plus clinically indicated coronary revascularization for stable angina. Results The mean low-density lipoprotein cholesterol (LDL-C) level at baseline was 149 mg/dL. The mean LDL-C levels at 1 year were 95 mg/dL in the pitavastatin group and 94 mg/dL in the atorvastatin group. There were no differences in LDL-C levels between both groups, however, pitavastatin significantly reduced the risk of the primary end point, compared to atorvastatin (pitavastatin = 2.9% and atorvastatin = 8.1%, HR, 0.366; 95% CI 0.170–0.787; P = 0.01 by multivariate Cox regression) as well as the risk of the secondary end point (pitavastatin = 4.5% and atorvastatin = 12.9%, HR = 0.350; 95%CI = 0.189–0.645, P = 0.001). The results for the primary and secondary end points were consistent across several prespecified subgroups. There were no differences in incidence of adverse events between the statins. Conclusion Pitavastatin therapy compared with atorvastatin more may prevent cardiovascular events in hypercholesterolemic patients with one or more risk factors for atherosclerotic diseases despite similar effects on LDL-C levels.

Objective To evaluate the outcomes of patients with concomitant Brugada syndrome and coronary artery vasospasm. Methods Patients diagnosed with Brugada syndrome with an implantable cardiac defibrillator were retrospectively investigated, and the coexistence of vasospasm was evaluated. The clinical features and outcomes were evaluated, especially in patients with coexistent vasospasm. A provocation test using acetylcholine was performed in patients confirmed to have no organic stenosis on percutaneous coronary angiography to confirm the presence of vasospasm. Implantable cardiac defibrillator shock status was checked every three months. Statistical comparisons of the groups with and without vasospasm were performed. A univariate analysis was also performed, and the odds ratio for the risk of implantable cardiac defibrillator shock was calculated. Patients Thirty-five patients with Brugada syndrome, of whom six had coexistent vasospasm. Results There were no significant differences in the laboratory data, echocardiogram findings, disease, or the history of taking any drugs between patients with and without vasospasm. There were significant differences in the clinical features of Brugada syndrome, i.e. cardiac events such as resuscitation from ventricular fibrillation or appropriate implantable cardiac defibrillator shock. Four patients with vasospasm had cardiac events such as resuscitation from ventricular fibrillation and/or appropriate defibrillator shock; three of them had no cardiac events with calcium channel blocker therapy to prevent vasospasm. The coexistence of vasospasm was a potential risk factor for an appropriate implantable cardiac defibrillator shock (odds ratio: 13.5, confidence interval: 1.572-115.940, p value: 0.035) on a univariate analysis. Conclusion Coronary artery vasospasm could be a risk factor for cardiac events in patients with Brugada syndrome.

A 49-year-old woman was admitted to our hospital because of repeated loss of consciousness. On arrival, she was in cardiopulmonary arrest associated with arrhythmia of Torsades de pointes, and recovered from it after cardiopulmonary resuscitation and defibrillation. The administration of a β-blocker and amiodarone was initiated to prevent ventricular tachycardia. On day 2, coronary angiography revealed non-obstructive coronary artery, and left ventriculography (LVG) exhibited hypokinesis in the anterior and apical wall. On day 20, an acetylcholine provocation test revealed a multivessel vasospasm, and LVG showed "spade-shaped left ventricle" in end-diastole because of apical hypertrophy. Transthoracic echocardiography (TTE) also showed apical wall thickness. Subsequent apical wall thickness gradually decreased and returned to normal on day 51 as observed on the TTE. Thus, we report a case of transient apical hypertrophy associated with coronary vasospasm, which was demonstrated by both the TTE and LVG. .

A 29-year-old woman who worked as a KAATSU (a type of body exercise that involves blood flow restriction) instructor visited our emergency room with a chief complaint of swelling and left upper limb pain. Chest computed tomography (CT) showed non-uniform contrast images corresponding to the site from the left axillary vein to the left subclavian vein; vascular ultrasonography of the upper limb revealed a thrombotic obstruction at the same site, leading to a diagnosis of Paget-Schroetter syndrome (PSS). We herein report our experience with a case of PSS derived from thoracic outlet syndrome (TOS), in a patient who was a KAATSU instructor.

Background Renal dysfunction is a common comorbidity in acute heart failure (AHF) patients. The prognostic significance of early treatment with tolvaptan in AHF patients complicated with renal dysfunction has not been elucidated. Methods Post hoc analysis was performed on a randomized clinical study for prespecified prognostic endpoints and prespecified subgroups. 217 AHF patients with renal dysfunction (eGFR 15 to 60mL/min/1.73m 2 ) were randomized within 6h from hospitalization to either tolvaptan treatment for 2days or conventional treatment. The primary outcome was the combined endpoint of all-cause death and HF readmission. Results During follow-up (636days, median) 99 patients experienced combined endpoint and 53 patients died. There was no significant difference in event-free survival rate for either the combined events (Log-rank: P=0.197) or all-cause death (Log-rank: P=0.894) between tolvaptan and conventional groups. In prespecified subgroup analysis, in patients whose BUN/creatinine ratio was above the median (>20), tolvaptan significantly reduced the risk of combined events (HR: 0.52, 95% CI: 0.30–0.91, P=0.021) with a significant interaction (P value for interaction=0.045). Likewise, in patients whose eGFR was 30mL/min/1.73m 2 or above, tolvaptan reduced the risk of combined events (HR: 0.54, 95% CI: 0.32–0.90, P=0.017) with a significant interaction (P value for interaction=0.015). Conclusion Short-term use of tolvaptan in acute-phase in AHF with renal dysfunction showed a neutral effect on prognosis. Patients with relatively preserved renal function and relatively high BUN/creatinine ratios are potentially favorable subgroups for treatment with tolvaptan.

Hepatic insulin signalling involves insulin receptor substrates (Irs) 1/2, and is normally associated with the inhibition of gluconeogenesis and activation of lipogenesis. In diabetes and obesity, insulin no longer suppresses hepatic gluconeogenesis, while continuing to activate lipogenesis, a state referred to as ‘selective insulin resistance'. Here, we show that ‘selective insulin resistance' is caused by the differential expression of Irs1 and Irs2 in different zones of the liver. We demonstrate that hepatic Irs2-knockout mice develop ‘selective insulin resistance', whereas mice lacking in Irs1, or both Irs1 and Irs2, develop ‘total insulin resistance'. In obese diabetic mice, Irs1/2-mediated insulin signalling is impaired in the periportal zone, which is the primary site of gluconeogenesis, but enhanced in the perivenous zone, which is the primary site of lipogenesis. While hyperinsulinaemia reduces Irs2 expression in both the periportal and perivenous zones, Irs1 expression, which is predominantly in the perivenous zone, remains mostly unaffected. These data suggest that ‘selective insulin resistance' is induced by the differential distribution, and alterations of hepatic Irs1 and Irs2 expression., Type 2 diabetes and obesity are associated with increased hepatic gluconeogenesis and lipogenesis, known as selective insulin resistance. Here Kubota et al. explain selective insulin resistance in the liver with the zonal distribution and selective insulin-mediated regulation of Irs1 and Irs2.

Recently, incretin-related agents have been reported to attenuate insulin resistance in animal models, although the underlying mechanisms remain unclear. In this study, we investigated whether anagliptin, the dipeptidyl peptidase 4 (DPP-4) inhibitor, attenuates skeletal muscle insulin resistance through endothelial nitric oxide synthase (eNOS) activation in the endothelial cells. We used endothelium-specific Irs2-knockout (ETIrs2KO) mice, which show skeletal muscle insulin resistance resulting from a reduction of insulin-induced skeletal muscle capillary recruitment as a consequence of impaired eNOS activation.In vivo, 8-week-old male ETIrs2KO mice were fed regular chow with or without 0.3% (wt/wt) DPP-4 inhibitor for 8 weeks to assess capillary recruitment and glucose uptake by the skeletal muscle. In vitro, human coronary arterial endothelial cells (HCAECs) were used to explore the effect of glucagon-like peptide 1 (GLP-1) on eNOS activity.Treatment with anagliptin ameliorated the impaired insulin-induced increase in capillary blood volume, interstitial insulin concentration and skeletal muscle glucose uptake in ETIrs2KO mice. This improvement in insulin-induced glucose uptake was almost completely abrogated by the GLP-1 receptor (GLP-1R) antagonist exendin-(9-39). Moreover, the increase in capillary blood volume with anagliptin treatment was also completely inhibited by the NOS inhibitor. GLP-1 augmented eNOS phosphorylation in HCAECs, with the effect completely disappearing after exposure to the protein kinase A (PKA) inhibitor H89. These data suggest that anagliptin treatment enhances insulin-induced capillary recruitment and interstitial insulin concentrations, resulting in improved skeletal muscle glucose uptake by directly acting on the endothelial cells via NO- and GLP-1-dependent mechanisms in vivo.Anagliptin may be a promising agent to ameliorate skeletal muscle insulin resistance in obese patients with type 2 diabetes.

Background Dabigatran is a direct thrombin inhibitor and an anticoagulant that is prescribed to prevent ischemic stroke and systemic embolism in non-valvular atrial fibrillation. Dabigatran (150 mg twice daily) is non-inferior to warfarin for the prevention of stroke and systemic embolism. A dose reduction to 110 mg twice daily should be considered for patients with decreased renal function, elderly patients, and those with a history of gastrointestinal bleeding. A small number of patients are prescribed 75 mg twice daily; however, excessive dose reduction below that indicated on the package insert may decrease the effectiveness of dabigatran. In this study, we investigated the incidence of thromboembolic events and hemorrhagic complications in patients receiving different doses of dabigatran, including patients receiving the very low-dose of 75 mg twice daily. Methods Five hospitals in Meguro and Setagaya areas of Tokyo were included in this study. The subjects were patients receiving dabigatran in the hospitals from March 2011 to February 2014. Thromboembolic events (stroke, systemic embolism, and transient cerebral ischemic attack) and hemorrhagic complications occurring before December 2014 were retrospectively evaluated. Results A total of 701 subjects received dabigatran during the study period: 187 patients (26.7%) received 150 mg twice daily (normal dose), 488 patients (69.6%) received 110 mg twice daily (low-dose), and 26 patients (3.7%) received 75 mg twice daily (very low-dose). Thromboembolism occurred in 4 (2.1%), 11 (2.3%), and 3 patients (11.5%), in the normal dose, low-dose, and very low-dose groups, respectively. The odds ratio of the 75 mg dose to the 150 and 110 mg doses was 5.73 (95% CI, 1.55–21.2; p = 0.009), and the incidence with the 75 mg dose was higher than that with the other doses. Although the number of events was limited, it should be noted that 3 patients in the very low-dose group had thromboembolic events. Conclusions The results suggest that sufficient anticoagulation efficacy may not be maintained when the dabigatran dose is excessively reduced to 75 mg twice daily.

A 70-years-old male with a history of hypertension and drug resistant paroxysmal atrial fibrillation (AF) presented to our hospital for catheter ablation to his symptomatic AF. He had no prior surgical or percutaneous procedure to close or exclude the left atrial appendage (LAA). A transesophageal echocardiography (TEE) was performed to rule out intra-cardiac thrombus prior to the ablation procedure. Although the TEE imaging at multiple acquisition angles was obtained, the LAA could not be visualized and an absence of the LAA was suspected. An absence of the LAA was confirmed using cardiac computed tomography (CT), which included 3D reconstruction. Additionally, the LAA was not visualized with left atrium (LA) angiography. During the ablation procedure, 3D voltage mapping in LA was created and no low voltage area or abnormal potential was recorded around the usual root location of the LAA. Successful electrical pulmonary vein isolation was achieved with no major complications. After six months of follow-up, the patient remained in sinus rhythm without any antiarrhythmic drugs and showed no related clinical symptoms. He stopped his anticoagulation therapy due to lack of evidence of AF recurrence and an absence of LAA. Multimodality imaging allowed us to identify the congenital absence of LAA.

Objective: The objective of this study was to clarify whether or not pulse volume recoding (PVR) parameters have screening capability equivalent to ankle-brachial pressure index after walking (Ex-ABI) for patients with 0.91 or higher ABI. Patients and Methods: The subjects were 87 patients (147 limbs) with symptoms of lower extremities with 0.91 or higher ABI. In all patients, upstroke time (UT), percentage of mean artery pressure (%MAP) of PVR and Ex-ABI were measured, and computed tomographic angiography (CTA) was concomitantly performed. Results: Area under the curve (AUC) of receiver operating characteristics (ROC) curves of Ex-ABI, %MAP, and UT were 0.90, 0.70, and 0.81, respectively. A significant difference was noted in AUC between Ex-ABI and %MAP (p

A 33-year-old male was referred to our institute with acute heart failure. The patient was found to have a unicuspid aortic valve (UAV) and severe aortic stenosis. He had been followed at a local university hospital during childhood. However, he stopped visiting the outpatient clinic after becoming an adult. His condition subsequently worsened, and he ultimately presented to our hospital with cardiogenic shock. In Japan, some adult congenital heart disease (ACHD) patients continue to be followed by pediatric cardiologists, though the patterns of practice are variable. This report describes the case of a patient who became lost to follow-up in early adulthood. We thus focus on this ACHD case as an example of the effects of inadequate communication among doctors and the need to establish better ACHD management protocols for treating this patient population.

Chronic total occlusion (CTO) lesions are a challenging issue. When dealing with complex CTO lesions in patients undergoing percutaneous coronary intervention (PCI), it is important to evaluate not only the CTO lesion itself but also atherosclerotic lesions of the whole coronary artery tree. The utility of the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery Trial) score in patients with CTO undergoing PCI is unclear.This retrospective study included 304 consecutive patients with CTO lesions who underwent PCI. Primary endpoints were procedural failure and major adverse cardiac events (MACE) within 30 days. The SYNTAX and J-CTO (Multicenter CTO Registry in Japan) scores were assessed before the procedures, and patients were divided into two groups according to SYNTAX criteria: high ( 22; n = 158) and low (≤ 22; n = 146) SYNTAX scores.Procedural success was achieved in 252 patients (82.9 %). Patients with a high SYNTAX score had significantly lower procedural success than those with a low SYNTAX score (74.7 % versus 91.8 %, p 0.0001). There were 13 MACE (8.2 %) in patients with high SYNTAX scores and two MACE (1.4 %) in those with low scores. The SYNTAX and J-CTO scores had odds ratios of 3.33 (95 %CI, 1.44-7.74) and 3.64 (95 %CI, 1.24-10.66) for procedural failure. A higher SYNTAX score ( 22) was also an independent predictor of 30-day MACE after PCI (odds ratio = 4.80, 95 %Cl 1.03-22.42).The SYNTAX score is predictive of procedural failure, as is the J-CTO score. Furthermore, a higher SYNTAX score is strongly associated with an increased risk of 30-day MACE. The SYNTAX score is useful for clinical decision making when treating patients with complex CTO lesions.

Hemodialysis (HD) patients with critical limb ischemia (CLI) suffer chronic inflammation and repeated infection, require intervention, and may have a protracted hospital stay. Therefore, early prediction is particularly important for management of CLI in patients with suspected peripheral artery disease. The purpose of this study is to develop a simple score for predicting the incidence of CLI in HD patients with suspected peripheral artery disease. The subjects were 139 asymptomatic patients receiving maintenance HD and with ABI

Introduccion y objetivos En estudios previos se ha descrito que la intervencion coronaria aplicada a lesiones complejas presenta una correlacion independiente con las hemorragias mayores. La puntuacion SYNTAX es un instrumento angiografico utilizado para evaluar el grado de complejidad de las enfermedades arteriales coronarias. El objetivo de este estudio es evaluar la capacidad de la puntuacion SYNTAX para predecir hemorragias mayores tras el implante de stents liberadores de farmacos. Metodos Se analizo a un total de 722 pacientes sometidos a implante de stents liberadores de farmacos de una poblacion de pacientes consecutivos incluidos en el estudio entre enero de 2007 y abril de 2010. Se investigo la incidencia de hemorragias mayores y trombosis del stent durante un periodo de 2 anos. La hemorragia mayor se evaluo mediante la puntuacion CRUSADE y los criterios del Bleeding Academic Research Consortium. Se estratifico a los pacientes en los siguientes grupos segun los criterios del ensayo SYNTAX: baja (= 22; n = 484), intermedia (23-32; n = 128) y alta (= 33; n = 110). Resultados Se observaron hemorragias mayores en 47 pacientes (6,5%) en el periodo de estudio de 2 anos, y hubo 12 episodios de trombosis del stent (1,7%). Las tasas de hemorragia mayor en los pacientes de los terciles bajo, intermedio y alto de la puntuacion SYNTAX fueron del 2,9, el 7,8 y el 20,9% respectivamente (p < 0,0001). La puntuacion SYNTAX mostro una hazard ratio ajustada de hemorragia mayor a los 2 anos de 1,81 (intervalo de confianza del 95%, 1,27-2,57). El valor predictivo del area bajo la curva de caracteristicas operativas del receptor ajustada por hemorragia mayor mejoro significativamente tras la inclusion de la puntuacion CRUSADE (estadistico C, 0,890 frente a 0,812). Conclusiones Aunque la puntuacion SYNTAX puede predecir el riesgo de hemorragias mayores, el valor predictivo de la puntuacion CRUSADE fue superior. Estas puntuaciones pueden resultar de utilidad en la toma de decisiones clinicas respecto a las estrategias de revascularizacion y la duracion optima del tratamiento antiagregante plaquetario doble tras implante de stents liberadores de farmacos.

Previous studies have reported that coronary intervention for complex lesions is independently correlated with major bleeding. The SYNTAX score is an angiographic tool used to grade the complexity of coronary artery diseases. The aim of this study was to assess the ability of the SYNTAX score to predict major bleeding following drug-eluting stent implantation.We analyzed 722 patients who underwent drug-eluting stent implantation in an all-comers population between January 2007 and April 2010. The incidence of major bleeding and stent thrombosis was investigated during a 2-year period. Major bleeding was evaluated using the CRUSADE score and Bleeding Academic Research Consortium criteria. Patients were stratified into the following groups according to the SYNTAX trial: low (≤ 22; n=484), intermediate (23-32; n=128), and high (≥ 33; n=110).Major bleeding was observed in 47 patients (6.5%) during the 2-year period, and there were 12 incidents of stent thrombosis (1.7%). Major bleeding rates for patients in the low, intermediate, and high SYNTAX score tertiles were 2.9%, 7.8%, and 20.9%, respectively (P.0001). The SYNTAX score had an adjusted hazard ratio of 1.81 (95% confidence interval, 1.27-2.57) for 2-year major bleeding. The predictive value of the adjusted area under the receiver operating characteristic curve for major bleeding significantly improved after inclusion of the CRUSADE score (C statistic, 0.890 vs 0.812).Although the SYNTAX score can predict major bleeding risk, the predictive value of the CRUSADE score was higher. These scores may be useful in clinical decision-making on revascularization strategies and on the optimal duration of dual antiplatelet therapy following drug-eluting stent implantation.

Defibrillation threshold (DFT) testing during implantable cardioverter defibrillator (ICD) implantations is considered necessary for appropriate shock therapy and to measure the safety margin. However, the relationship between the DFT with modern era devices and the clinical outcome, including the total mortality is limited, which may lead to DFT testing itself being questioned. This study aimed to evaluate the relationship between the DFT and clinical outcome in ICD recipients.We enrolled 81 consecutive patients (66 males, aged 64.6 ± 13.8 years) who received an ICD implantation and underwent DFT testing. The DFT was measured with a step-by-step method in the patients upon implant. Further, we evaluated the relationship between the DFT and the clinical outcome, which included major cardiac adverse events and any cause of death.The mean DFT was 11.6 ± 9.24J in total. In 40 patients (49.4%), VF was terminated by a low output (5J), whereas 11 patients (13.6%) had a high DFT. The rates of atrial fibrillation were significantly higher in the high DFT group (63.6% versus 24.2%, P = 0.007). During the observational period (median 432 days; range from 151 days to 1146 days), the incidence of clinical events occurred in 22 patients (27.2%) in total. In a multivariate analysis, a high DFT was the only predictive factor for the incidence of the clinical outcome (OR 4.54, 95% CI 1.03-21.9, P = 0.045).

Aims To report a case of unexpected pulmonary hypertensive crisis caused by endothelin release from melanoma cells after surgery for choroidal melanoma. Main methods A 56-year-old man suddenly developed dyspnea after resection of choroidal melanoma. Worsening hypoxia required intensive treatment, including percutaneous cardiopulmonary support, after which a series of tests were immediately performed. The tentative diagnosis was idiopathic pulmonary arterial hypertension. Key findings Previous studies noted a significant association between melanoma and endothelin (ET)-1. We hypothesized that a substantial amount of ET-1 had been released from malignant melanoma cells during resection, thus triggering the pulmonary hypertensive crisis in our patient. The patient fully recovered after intensive treatment and administration of the endothelin receptor antagonist bosentan. Significance The success of bosentan treatment, along with the extremely high level of ET-1 on pathologic analysis, confirmed our hypothesis regarding the increase in plasma ET-1 level.

Background Pacemaker generators are routinely implanted in the anterior chest. However, where to place the generator may need to be considered from the mental, functional, and cosmetic standpoints. Methods In this study, we performed the left axillary pacemaker generator implantation with a direct puncture of the left axillary vein in 40 consecutive patients, and evaluated the late safety and efficacy of this implantation. Complications, changes in the lead sensing, pacing threshold, and impedance were used as safety indexes for a mean follow-up of 3.4 years. In addition, the efficacy was also evaluated by comparing their questionnaire survey results to 119 patients in a control group of anterior chest implantation. Results Lead dislodgements were observed in two patients of the experiment group. There were no migrations of generators from the implantation site or abnormal variations in the pacing threshold, lead sensing, or impedance. In the left anterior chest and left axillary groups, 85% and 10% of the patients were worried about an external impact, 80% and 25% were worried about electromagnetic interference, and 68% and 0% answered that the pacemaker implantation site was noticeable, respectively. Apparently, more patients had a sense of security and cosmetic satisfaction with the left axillary implantation. Conclusion The left axillary generator implantations may reduce the mental burden and cause no safety concerns, and may be performed if functional or cosmetic outcomes are required.

Causative arrhythmias of sudden cardiac arrest (SCA) are changing in this age of improved coronary care.The purpose of this study was to examine the frequency of terminal arrhythmias and the electrical events prior to SCA.We analyzed 24-hour Holter recordings of 132 patients enrolled from 41 institutions who either died (n = 88) or had an aborted death (n = 44). The Holter recordings were obtained for diagnosing and evaluating diseases and arrhythmias in those without any episodes suggestive of SCA.In 97 patients (73%), SCA was associated with ventricular tachyarrhythmias and in 35 (27%) with bradyarrhythmias. The bradyarrhythmia-related SCA patients were older than those with a tachyarrhythmia-related SCA (70 ± 13 years vs. 58 ± 19 years, P.001). The most common arrhythmia for a tachyarrhythmia-related SCA was ventricular tachycardia degenerating to ventricular fibrillation (45%). The bradyarrhythmia-related SCA was caused by asystole (74%) or AV block (26%). Spontaneous conversion was observed in 37 patients (38%) with ventricular tachyarrhythmias. Of those, 62% of the patients experienced symptoms including syncope, chest pain, or convulsion. Multivariate logistic analysis revealed that independent predictors of mortality for tachyarrhythmia-related SCAs were advanced age (odds ratio 1.04, 95% confidence interval 1.02-1.08) and ST elevation within the hour before SCA (odds ratio 3.54, 95% confidence interval 1.07-13.5). In contrast, the presence of preceding torsades de pointes was associated with spontaneous conversion (odds ratio 0.20, 95% confidence interval 0.05-0.66).The most frequent cause of SCA remains ventricular tachyarrhythmias. Advanced age and ST elevation before SCA are risk factors for mortality in tachyarrhythmia-related SCAs.

PurposePatients with normal stress myocardial perfusion imaging (MPI) results generally have an excellent prognosis with

AIM Reactive hyperemia peripheral arterial tonometry (RH-PAT) can be used to noninvasively assess the vascular function with respect to the digital microcirculation. Abnormalities are associated with coronary endothelial dysfunction. We therefore investigated whether impaired digital reactive hyperemia is associated with restenosis after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). METHODS This study included 86 patients with ACS who underwent successful primary PCI of native vessels for de novo lesions. The reactive hyperemia index (RHI) was calculated using RH-PAT at three weeks and eight months after ACS. The RHI was defined as the ratio of the digital pulse volume during reactive hyperemia to that observed at baseline. Restenosis was defined as diameter stenosis of ≥ 50% in the in-segment area based on the findings of quantitative coronary angiography performed at eight months. RESULTS Restenosis was detected in 17 patients (20%). There were no differences in the RHI at three weeks between the patients with and without restenosis (1.70 vs. 1.87; p=0.13); however, the RHI values at eight months were significantly attenuated in the patients with restenosis versus those without (1.75 vs. 2.12; p=0.03). A univariate logistic regression analysis showed that the eight-month RHI (＜2, obtained from a receiver operating characteristic analysis) was a significant risk factor for restenosis (odds ratio: 4.23, 95% confidence interval: 1.25 to 14.28, p=0.02). CONCLUSIONS Impairment of the digital hyperemic response at eight months is associated with restenosis after primary intervention in patients with ACS, suggesting the potential of RH-PAT as a noninvasive test for identifying patients with a high risk of restenosis.

It is uncertain whether dynamic variation in the diameter of the aortic annulus occurs during the cardiac cycle in humans. The purpose of this study was to analyze cyclic changes of the aortic annulus using speckle-tracking trans-esophageal echocardiography. The subjects were 40 patients with aortic stenosis and 40 controls. Absolute and relative changes in the diameter of the aortic annulus and the times at which the maximum and minimum diameters occurred during the cardiac cycle were determined using speckle-tracking trans-esophageal echocardiography. The maximum and minimum diameters were 22.9 ± 2.7 and 20.0 ± 2.9 mm, respectively, in controls. The change in diameter of the aortic annulus was 2.9 ± 0.7 mm, and the relative change was 12.9 ± 3.5%. The maximum aortic annulus diameter was reached at the onset of aortic valve opening, and the minimum diameter occurred in the rapid filling phase. The change in diameter of the aortic annulus was significantly smaller (2.2 ± 0.6 mm vs. 2.9 ± 0.7 mm, p < 0.0001), and the time to reach the maximum diameter was significantly longer (98.5 ± 17.5 ms vs. 83.4 ± 18.2 ms, p = 0.0004), in the aortic stenosis group than in the control group. The study found that dynamic changes of the aortic annulus occur in the cardiac cycle and can be measured using speckle-tracking trans-esophageal echocardiography. We also found that aortic stenosis has an effect on the extent and timing of these changes. This suggests that accurate assessment of aortic annulus diameter requires consideration of the timing of the cardiac cycle.