Impact of carotid atherosclerosis in CHA2DS2-VASc-based risk score on predicting ischemic stroke in patients with atrial fibrillation

Background/Aims@#Vascular disease is an established risk factor for stroke in patients with atrial fibrillation (AF), which is included in CHA2DS2-VASc score. However, the role of carotid atherosclerosis remains to be determined. @*Methods@#Three hundred-ten patients with AF who underwent carotid sonography were enrolled. @*Results@#During a median follow-up of 31 months, 18 events (5.8%) of stroke were identified. Patients with stroke had higher carotid intima-media thickness (CIMT) (1.16 ± 0.33 mm vs. 0.98 ± 0.25 mm, p = 0.017). CIMT was significantly increased according to the CHA2DS2-VASc score (p < 0.001) and it was correlated with left ventricular mass index and early diastolic mitral annular velocity (e’), a ratio of early transmitral flow velocity to e’ (E/e’) and pulmonary artery systolic pressure (all p < 0.05). Cox regression using multivariate models showed that carotid plaque was associated with the risk of stroke (hazard ratio, 3.748; 95% confidence interval [CI], 1.107 to 12.688; p = 0.034). C-statistics increased from 0.648 (95% CI, 0.538 to 0.757) to 0.716 (95% CI, 0.628 to 0.804) in the CHA2DS2-VASc score model after the addition of CIMT and carotid plaque as a vascular component (p = 0.013). @*Conclusions@#Increased CIMT and presence of carotid plaque are associated with a high risk of ischemic stroke, and CIMT is related to myocardial remodeling and diastolic dysfunction, suggesting that carotid atherosclerosis can improve risk prediction of stroke in patients with AF, when included under vascular disease in the CHA2DS2-VASc scoring system.

Gender-related Difference in Clinical Outcome of the Patient with Atrial Fibrillation after Radiofrequency Catheter Ablation

BACKGROUND AND OBJECTIVES: Previous studies provided controversial result about gender differences in the clinical outcome after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). We assessed pure difference after adjustment of referral bias. METHODS: The clinical outcomes including freedom from AF/atrial tachycardia (AT) recurrence after RFCA were compared between women and men in 1:1 confounding factor matching with age, AF type, periods since diagnosis (±12 months), and procedure era (±12 months). Subgroup analysis was performed in categories defined by AF type and age of 55 (mean menopausal age of Asian women). RESULTS: Total 1,875 patients with AF underwent 2,307 RFCA between January 1998 and May 2014 in a single center. Total 367 women (19.6%, 59±10 years) who had undergone first ablation were included. Women had larger left atrial diameter index (26±4 vs. 23±4 mm/m2; p < 0.001) and higher peri-procedural complications (9.2% vs. 4.9%; p=0.030) compared to men. The freedom from AF/AT recurrence after RFCA was not different between both groups (71% vs. 76%; log-rank p=0.131, mean follow-up of 55 months). Women with non-paroxysmal AF (PAF) had significantly worse outcome (54% vs. 69%; p=0.014), especially in subgroup with age ≤55 (48% vs. 71%; p=0.010). In multivariate analysis, female gender was an independent predictor of recurrence in subgroup with non-PAF and age ≤55 (hazard ratio [HR], 2.539; 95% confidence interval [CI], 1.112–5.801; p=0.027). CONCLUSIONS: The clinical outcome after RFCA was not different between both genders regardless of referral bias. However, the gender difference became evident in patients under 55 years with non-PAF.

Gender-related Difference in Clinical Outcome of the Patient with Atrial Fibrillation after Radiofrequency Catheter Ablation

BACKGROUND AND OBJECTIVES@#Previous studies provided controversial result about gender differences in the clinical outcome after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). We assessed pure difference after adjustment of referral bias.@*METHODS@#The clinical outcomes including freedom from AF/atrial tachycardia (AT) recurrence after RFCA were compared between women and men in 1:1 confounding factor matching with age, AF type, periods since diagnosis (±12 months), and procedure era (±12 months). Subgroup analysis was performed in categories defined by AF type and age of 55 (mean menopausal age of Asian women).@*RESULTS@#Total 1,875 patients with AF underwent 2,307 RFCA between January 1998 and May 2014 in a single center. Total 367 women (19.6%, 59±10 years) who had undergone first ablation were included. Women had larger left atrial diameter index (26±4 vs. 23±4 mm/m2; p < 0.001) and higher peri-procedural complications (9.2% vs. 4.9%; p=0.030) compared to men. The freedom from AF/AT recurrence after RFCA was not different between both groups (71% vs. 76%; log-rank p=0.131, mean follow-up of 55 months). Women with non-paroxysmal AF (PAF) had significantly worse outcome (54% vs. 69%; p=0.014), especially in subgroup with age ≤55 (48% vs. 71%; p=0.010). In multivariate analysis, female gender was an independent predictor of recurrence in subgroup with non-PAF and age ≤55 (hazard ratio [HR], 2.539; 95% confidence interval [CI], 1.112–5.801; p=0.027).@*CONCLUSIONS@#The clinical outcome after RFCA was not different between both genders regardless of referral bias. However, the gender difference became evident in patients under 55 years with non-PAF.

Preexcitation Syndrome with a Mahaim-type Accessory Pathway

Wide QRS complex tachycardia with a left bundle branch block pattern can be caused by supraventricular tachycardia with aberrant conduction, preexcitation syndrome mediated through a right-sided accessory pathway, and/or ventricular tachycardia. The use of atrial pacing maneuvers can be beneficial for unmasking minimal preexcitation to differentiate between these conditions. Here, we report a case of successful radiofrequency catheter ablation of a Mahaim fiber in a patient with wide QRS complex tachycardia.

The Role of Intravenous Dopamine on Hemodynamic Support during Radiofrequency Catheter Ablation of Poorly Tolerated Idiopathic Ventricular Tachycardia

BACKGROUND AND OBJECTIVES: Hemodynamically unstable idiopathic ventricular tachycardias (VTs) are a challenge for activation or entrainment mapping technique. Mechanical circulatory support is an option, but is not always readily available. In this study, we investigated the safety and efficacy of hemodynamic support using intravenous (IV) dopamine solely during radiofrequency catheter ablation (RFCA) of hemodynamically unstable VT. SUBJECTS AND METHODS: Seven out of 86 patients with hemodynamically unstable idiopathic VT underwent de novo RFCA using dopamine in our single center. They were included in the study and reviewed retrospectively to investigate the procedural characteristics and outcomes. RESULTS: All patients were male, and the mean age was 50.7±5.3 years. One patient had implantable cardioverter-defibrillator for the secondary prevention. No evidence of myocardial ischemia was found in all patients. During the procedure, the mean blood pressure during VT without dopamine was 52.3±4.1 mmHg and increased to 82.6±3.8 mmHg after administering dopamine (Δ28.8±3.2 mmHg; total average dopamine dosage was 1266.1±389.6 mcg/kg). In all patients, activation mapping was safely applied, and VTs were terminated during energy delivery. Non-inducibility of clinical VT was achieved in all cases. There was no evidence of deterioration due to hypoperfusion during the peri-procedural period. No recurrence of ventricular tachyarrhythmias was observed in any of the patients, during a median follow-up of 23.0±6.1 months. CONCLUSION: Hemodynamic support using IV dopamine during RFCA of hemodynamically unstable idiopathic VT facilitated detailed mapping to guide successful ablation.

Progression of Left Ventricular Pseudoaneurysm after an Acute Myocardial Infarction

Left ventricular (LV) pseudoaneurysms rarely occur, but are detected more often with the development of new diagnostic tools. Since LV pseudoaneurysms are life-threatening, early surgical intervention is recommended. This report describes an 87-year-old woman with heart failure and a large LV pseudoaneurysm which progressed from a small LV pseudoaneurysm after an acute myocardial infarction over a 1-year period.

A case of recurrent lead fracture and complete dislocation after permanent pacemaker implantation / 대한내과학회지

With the increased use of implantable cardiac devices, the incidence of hardware problems has also increased. Some of the hardware problems might be induced by patient factors. We experienced recurrent pacemaker lead fracture and dislocation after permanent pacemaker implantation. The patient was a bus driver who used his left arm vigorously when he turned the steering wheel. After a new lead was inserted via an axillary vein approach and the patient changed his occupation, no more lead problems have occurred. When a recurrent hardware problem with an implantable pacemaker or defibrillator occurs, patient factors related to anatomy or behavior must be considered.

Two Cases of Incidentally Diagnosed Idiopathic Left Atrial Appendage Ostial Stenosis

We report here on 2 cases of idiopathic left atrial appendage ostial stenosis (LAA), and this rare finding was detected on transesophageal echocardiography. Its clinical implication is still unknown, given the small number of reported cases. Incompletely ligated LAA has characteristics similar to those observed in idiopathic LAA ostial stenosis, including the narrowed orifice, the small LAA cavity and the accelerated blood flow across the stenotic area. Since the incompletely ligated LAA has been reported to be complicated with thromboembolic events, we can assumed that the patients with idiopathic LAA ostial stenosis have a higher risk of thromboembolism than those with a normal LAA structure.