Successful endovascular repair of complicated pseudoaneurysm using Perclose ProGlide: A novel concept.

Iatrogenic pseudoaneurysm is common vascular complications of angiographic procedures. Patients with uncomplicated pseudoaneurysms can be managed with ultrasound-guided techniques. However, for complicated pseudoaneurysms, surgical repair of the artery is mandatory. We report a case of successful repair of complicated pseudoaneurysm using an access-site closure device, Perclose ProGlide™ without a surgical approach.

Sense of Coherence as a Mediator in the Association Between Empathy and Moods in Healthcare Professionals: The Moderating Effect of Age.

While empathy is considered a critical determinant of the quality of medical care, growing evidence suggests it may be associated with both one's own positive and negative moods among healthcare professionals. Meanwhile, sense of coherence (SOC) plays an essential role in the improvement of both psychological and physical health. Reportedly, individual SOC reaches full stability after around age 30. The aim of this study was first to evaluate the mediatory role of SOC on the association between empathy and individual moods among 114 healthcare professionals in a general hospital, and then to examine the moderating effect of age on this association. Participants completed a range of self-report demographic questionnaires, Empathy Process Scale (EPS), the 13-item Antonovsky's SOC, and Profile of Mood States (POMS). Findings showed that SOC mediated the relations between empathy (EPS) and both POMS-Vigor (POMS-V: self-vigor mood) and POMS-Depression (POMS-D: self-depression mood). Notably, moderated mediation analysis revealed that there was a significant interaction (age × SOC) on self-vigor mood (POMS-V) in healthcare professionals. The indirect effect of empathy (EPS) on self-vigor mood (POMS-V) through SOC was significant at over mean age "32.83." Although there was no significant interaction with age regarding the indirect effect of empathy (EPS) on self-depression mood (POMS-D), in the sub-category level analysis of empathy (EPS), we found a significant interaction item [age × empathy for other's negative affect (EPS-N)] on SOC. This indirect effect was also significant at over mean age "32.83." Taken, together, the current study highlighted the significant mediator of SOC on that empathy amplifies self-vigor mood and attenuates self-depression mood as a protective factor among the Japanese healthcare professionals. Some components of these processes may depend on the moderating role of age, indicating that we may need to consider the SOC development with age for more effective empathy performance interventions among healthcare professionals.

Abatacept Improves Intractable Protein-Losing Enteropathy Secondary to AA Amyloidosis in a Patient With Rheumatoid Arthritis.

A 71-year-old Japanese woman with a history of rheumatoid arthritis of 50 years' duration was admitted to our hospital with refractory diarrhea. Endoscopic biopsy revealed AA amyloid deposition in the large intestine. Although the patient had been prescribed 5 tumor necrosis factor inhibitors over the past 10 years, rheumatoid arthritis was poorly controlled, with a Disease Activity Score 28 using C-reactive protein score of 6.52 on admission. Treatment with tocilizumab (8 mg/kg every 2 weeks) was initiated, but this was ineffective. After 3 months, abatacept (cytotoxic T-lymphocyte-associated antigen 4 immunoglobulin) was initiated (750 mg/mo) and the patient's diarrhea began to improve. After 3 months of abatacept treatment, serum albumin, C-reactive protein, and serum amyloid A levels had all decreased to within normal ranges. After 3 years of abatacept treatment, a repeat biopsy of the large intestine revealed a marked improvement in amyloid deposition. Interleukin 6 is a key factor in AA amyloid formation, but this case suggests that T-cell activation increases the production of cytokines (including interleukin 6) via a mechanism involving cytotoxic T-lymphocyte-associated antigen 4, resulting in a second key factor of AA amyloid formation.

An Autopsy Case of Lambl's Excrescences with Trousseau Syndrome that Caused Cardioembolic Stroke.

The frequency and risk of embolism by Lambl's excrescences (LEs) remain unclear. We herein report an autopsy case of LEs that caused cardioembolic stroke. A 74-year-old man with colon cancer was hospitalized for ischemic stroke. His D-dimer levels were elevated. Thus, a diagnosis of ischemic stroke with Trousseau syndrome was made. At the autopsy, we found LEs in the aortic valves and thromboembolism of the brain blood vessels. This finding demonstrated that fibrin clots had adhered to the LEs because of coagulation abnormalities associated with Trousseau syndrome and became embolized. This case highlights the risk of LEs in patients with coagulation abnormalities.

A trial of improvement of immunity in cancer patients by laughter therapy.

PURPOSE: The study was on the impact of laughter therapy on immunological improvement of patients with gastrointestinal cancer undergoing surgery and chemotherapy. MATERIALS & METHOD: Immunological measurements were performed in 41 cases with patients aged 68.9 years suffering from gastric or colorectal cancer. Intervention using Laughter Therapy was applied to 12 out of the 25 patients subjected to laproscopic surgery and 12 out of 19 patients subjected to chemotherapy. RESULTS: Immunity of patients within the control group who had surgery decreased. Immunity of patients within the control group who had chemotherapy decreased. With intervention of Laughter Therapy, the immunity of patients with surgery had either decreased or was the same. However, with intervention of Laughter Therapy using the Smile-Sun Method, the immunity of chemotherapy patients increased, notably in patients with colorectal cancer. The improvement of immunity within the control group was 0 out of 7. CONCLUSION: Patients with advanced cancer have lower immunity which is further decreased with surgery or chemotherapy. Chemotherapy patients who undertook the Laughter Therapy using the Smile-Sun Methodology during treatment in the hospital showed significantly higher immunity levels. The results of this study indicate that patients with gastrointestinal cancer, who undergo laparoscopic surgery or chemotherapy for stomach or colorectal cancer, benefit from a formal program of psychotherapeutic support during the in-patient hospital stay in terms of immunological improvement.

Two distinct electrocardiographic forms of idiopathic ventricular arrhythmia originating in the vicinity of the His bundle.

AIM: The objective is to assess electrocardiographic characteristics predicting the precise location of ventricular arrhythmia (VA) origin within the right ventricle (RV) close to the His bundle (HB) region. METHODS AND RESULTS: Twenty-five patients (14 men, age 65 ± 14 years) underwent successful catheter ablation of para-Hisian VA. Ventricular arrhythmias were considered to arise in the vicinity of the HB region based on the criteria that mapping exhibited the earliest RV activation before QRS onset in the HB region. Surface 12-lead electrocardiogram during the para-Hisian VAs was analysed. Of the 25 patients, 8 originated from the RV antero-septum just above the HB region, and 17 arose from the RV mid-septum just below the HB region. There was no significant difference in precedence of the local ventricular electrogram of the HB region from the onset of surface QRS during VAs. Surface electrocardiographic findings were characterized according to R-wave amplitude in lead I (0.43 ± 0.18 vs. 0.67 ± 0.19 mV, P = 0.005), mean R-wave amplitude in inferior leads (1.12 ± 0.32 vs. 0.71 ± 0.24 mV, P = 0.002), R-wave amplitude ratio of leads III/II (0.77 ± 0.10 vs. 0.50 ± 0.23, P = 0.005), incidence of S-wave in lead III [1/8 (13%) vs. 16/17 (94%), P < 0.001], and QS morphology in lead V1 [3/8 (38%) vs. 17/17 (100%), P = 0.001]. CONCLUSIONS: Despite their adjacent locations, para-Hisian VAs could be classified into two subgroups with distinctive electrocardiographic characteristics according to origin either above or below the HB region. The present findings can be helpful for planning catheter ablation of para-Hisian VAs, and can reduce the risk of inadvertent atrioventricular block.

Complex anatomy surrounding the left atrial posterior wall: analysis with 3D computed tomography.

Few studies have explored the topographic anatomy of the esophagus, posterior wall of the left atrium (LA), or fat pads using multidetector computed tomography (MDCT) to prevent the risk of esophageal injury during atrial fibrillation (AF) ablation. MDCT was performed in 110 consecutive patients with paroxysmal or persistent AF before the ablation procedure to understand the anatomic relationship of the esophagus. Two major types of esophagus routes were demonstrated. Leftward (type A) and rightward (type B) routes were found in 90 and 10% of the patients, respectively. A type A route had a larger mean size of the LA than type B. The fat pad was identifiable at the level of the inferior pulmonary vein in 91% of the patients without any predominance of either type. The thickness of the fat pad was thinner in the patients with a dilated LA (>42 mm) than in those with a normal LA size (≤42 mm) (p = 0.01). The results demonstrated that the majority of cases had a leftward route of the esophagus. There was a close association between the LA dilatation and fat pad thinning. With a dilated LA, the esophagus may become easily susceptible to direct thermal injury during AF ablation. Visualization of the anatomic relationship may contribute to the prevention of the potential risk of an esophageal injury.

Impact of coronary plaque morphology assessed by optical coherence tomography on cardiac troponin elevation in patients with elective stent implantation.

BACKGROUND: Mild elevations of cardiac troponin frequently occur after percutaneous coronary intervention (PCI), and patients with elevated post-PCI biomarkers have a worse prognosis. We used optical coherence tomography (OCT) to study the relationship between pre-PCI plaque morphology and post-PCI cardiac troponin I elevations. METHODS AND RESULTS: One hundred thirty-one patients with normal pre-PCI cardiac troponin I levels underwent OCT before nonemergency stent implantation. Clinical and OCT findings were compared between patients with (n=31, 23.7%) and without (n=100, 76.3%) post-PCI cardiac troponin I of >3 × upper reference limit (post-PCI myocardial infarction [MI]). After PCI, long-term follow-up data were collected. Post-PCI MI was associated with angiographic lesion length, type B2/C lesions, presence of thin-cap fibroatheroma, and fibrous cap thickness. In multivariable analysis, presence of thin-cap fibroatheroma (odds ratio, 10.47; 95% confidence interval, 3.74 to 29.28; P<0.001) and type B2/C lesions (odds ratio, 3.74; 95% confidence interval, 1.41 to 9.92; P=0.008) were predictors of post-PCI MI. At a median follow-up of 12 months, cardiac event-free survival was significantly worse in patients with post-PCI MI (log-rank test χ(2)=8.9; P=0.003). Cox proportional hazards analysis showed that post-PCI MI (hazard ratio, 3.67; 95% confidence interval, 1.39 to 9.65; P=0.009) and ejection fraction (hazard ratio, 0.96; 95% confidence interval, 0.92 to 0.99; P=0.029) were independent predictors of adverse cardiovascular events during follow-up. CONCLUSIONS: Type B2/C lesions and the presence of OCT-defined thin-cap fibroatheroma can predict post-PCI MI in patients treated with elective stent implantation, who may require adjunctive therapy after otherwise successful PCI.

Assessment of echo-attenuated plaque by optical coherence tomography and its impact on post-procedural creatine kinase-myocardial band elevation in elective stent implantation.

OBJECTIVES: This study examined morphological characteristics of echo-attenuated plaques by optical coherence tomography (OCT) and evaluated their influence on creatine kinase-myocardial band (CK-MB) elevation after percutaneous coronary intervention (PCI) in patients with elective stent implantation. BACKGROUND: Recent intravascular ultrasound studies have described atherosclerotic plaques with echo attenuation (EA) without associated bright echoes that are correlated with no-reflow phenomenon after PCI. METHODS: We studied 135 native de novo culprit coronary lesions in 135 patients with normal pre-PCI CK-MB levels (28 with unstable angina; 107 with stable angina) who underwent intravascular ultrasound and OCT examinations before elective stent implantation. The lesions were divided into 2 groups based on the presence or absence of EA, and OCT findings were compared. We then determined predictors of post-PCI CK-MB elevation. RESULTS: EA was found in 47 (34.8%) lesions and was associated with the presence of OCT-derived thin-capped fibroatheroma, ruptured plaques, greater lipid content, intravascular ultrasound-derived large reference and plaque area, lesion eccentricity, and microcalcification. Elevated CK-MB levels were observed in 36 (26.7%) lesions, and significantly more frequently in lesions with EA than without. In multivariable analysis, EA (odds ratio [OR]: 3.49; 95% confidence interval [CI]: 1.53 to 7.93; p = 0.003) and OCT-derived ruptured plaque (OR: 2.92; 95% CI: 1.21 to 7.06; p = 0.017) were independent predictors of post-PCI CK-MB elevation. CONCLUSIONS: Atherosclerotic plaques with EA were associated with characteristics considered to be high risk or unstable. OCT examination showed an additive predictive value to the presence of EA for post-PCI CK-MB elevation.

Catheter ablation of ventricular arrhythmias arising from the right ventricular septum close to the His bundle: features of the local electrogram at the optimal ablation site.

INTRODUCTION: The characteristics of the local electrogram at the optimal ablation site of ventricular arrhythmias (VAs) originating from the right ventricle close to the His bundle (HB) region have rarely been described. METHODS AND RESULTS: Among 190 consecutive patients with idiopathic VAs with left bundle branch block morphology and inferior-axis deviation, 16 were found to have successful ablation site in the right ventricle close to the HB region (para-Hisian group). The electrophysiologic data were compared between the patients in the para-Hisian group and those with VAs arising from the right ventricular (RV) outflow tract (RVOT group). The distal bipolar electrogram at the successful ablation sites in the para-Hisian group exhibited a significantly greater R-wave duration, lower R-wave amplitude, and slower upright deflection of the initial R wave than did those in the RVOT group (all P < 0.001). In the para-Hisian group, a total of 56 radiofrequency (RF) energy applications were delivered, of which the local electrograms at 16 successful and 40 unsuccessful ablation sites were reviewed. High-frequency R-wave potentials of the bipolar electrogram were present in 14 (88%) of the successful ablation sites. An R-wave duration of greater than 34 ms had a discriminatory power for indicating the site of a successful ablation (area under the receiver-operator characteristics curve 0.90, sensitivity 94%, specificity 80%). CONCLUSIONS: The successful ablation site of the para-Hisian VAs had distinctive local electrogram characteristics. A longer R-wave duration of the bipolar electrogram with high-frequency potentials could be a novel predictor of a successful ablation.

In vivo critical fibrous cap thickness for rupture-prone coronary plaques assessed by optical coherence tomography.

AIMS: The widely accepted threshold of <65 µm for coronary plaque fibrous cap thickness was derived from postmortem studies of ruptured plaques and may not be appropriate for in vivo rupture-prone plaques. We investigated the relationship between fibrous cap thickness and plaque rupture using optical coherence tomography (OCT). METHODS AND RESULTS: We studied 266 lesions (103 from patients with acute coronary syndrome and 163 from patients with stable angina) before percutaneous coronary intervention using OCT. Ruptured and non-ruptured lipid-rich plaques were identified and the thinnest and most representative fibrous cap thickness were determined. Cap thickness was reliably measured in 71 ruptured and 111 non-ruptured plaques. From the ruptured plaques, the median thinnest cap thickness was 54 µm (50-60). The median most representative cap thickness was 116 µm (103-136). For non-ruptured plaques, the median thinnest cap thickness was 80 µm (67-104) and 182 µm (156-216) for most representative cap thickness. In 95% of ruptured plaques, the thinnest cap thickness and most representative cap thickness were <80 and <188 µm, respectively. The best cut-offs for predicting rupture were <67 µm (OR: 16.1, CI: 7.5-34.4, P < 0.001) for the thinnest cap thickness and <151 µm (OR: 35.6, CI: 15.0-84.3, P < 0.001) for most representative cap thickness. These two measures were modestly correlated (r(2) = 0.39) and both independently associated with rupture. CONCLUSION: In vivo critical cap thicknesses were <80 µm for the thinnest and <188 µm for most representative fibrous cap thickness. Prospective imaging studies are required to establish the significance of these values.

Impact of plaque morphology on creatine kinase-MB elevation in patients with elective stent implantation.

BACKGROUNDS: The association between percutaneous coronary intervention (PCI) and subsequent myonecrosis has been widely recognized, and worse prognosis has been reported among patients with elevated post-PCI biomarkers. We used optical coherence tomography (OCT) to study the relationship between pre-PCI plaque morphology and post-PCI creatine kinase-MB (CK-MB) elevation. METHODS: One hundred and twenty-five patients with normal pre-PCI CK-MB levels underwent OCT examination before nonemergency stent implantation. Patients were divided into two groups according to the presence (Group CK, n=35) or absence (Group NCK, n=90) of post-PCI CK-MB elevation ≥ upper limit of the normal range. Clinical and the OCT findings were compared between the two groups. RESULTS: Elevated CK-MB levels was observed in 35 patients (28%). The CK-MB elevation was associated with elevated white blood cell count, type B2/C lesions, the presence of thin cap fibroatheroma (TCFA), plaque rupture, and lipid quadrants. In the multivariate analysis, the presence of TCFA (OR 4.68, 95% CI 1.88-11.64, p=0.001) and type B2/C lesions (OR 4.20, 95% CI 1.30-13.59, p=0.02) were independent predictors of post-PCI CK-MB elevation. CONCLUSIONS: TCFA and angiographically complex lesion morphology can predict post-PCI CK-MB elevation in patients treated with elective stent implantation. OCT may be useful in stratifying the risk for nonemergency stent implantation.

Collaboration between Hepatologists and Primary Care Physicians in Treating Patients with Chronic Hepatitis C.

OBJECTIVE: The purpose of this study was to assess the treatment outcome in patients with chronic hepatitis C (CHC) using the current standard antiviral therapy when patient were treated in collaboration between hepatologists and primary care physicians (PCPs). PATIENTS AND METHODS: One hundred and ten patients with CHC were treated with a combination therapy of peginterferon-alpha 2b and ribavirin. Among them, 25 patients were treated by a collaboration between hepatologists and PCPs (collaboration group), whereas 85 patients were treated with exclusively by hepatologists (noncollaboration group). The duration of the therapy was 48 weeks for 58 'difficult- to-treat' patients (genotype 1 with a high load of HCV-RNA; 1H patients) and 24 weeks for the remaining 52 patients (non-1H patients). In the collaboration group, antiviral therapy was initiated and adjusted, if needed, by hepatologists (visits every four weeks), whereas the weekly administration of peginterferon-alpha 2b was performed by PCPs. Clinical characteristics and the treatment outcome were compared between these two groups. RESULTS: The two groups had similar baseline characteristics. By intention to treat, the two groups showed similar rates of treatment-related serious adverse effects (0% vs. 1%, respectively) and dropout rates for adverse effects (8% vs. 13%, respectively). Sustained virologic response rates were also similar between the two groups, being 42% vs. 39% in the 58 1H patients (NS) and 62% vs. 64% in the 52 non-1H patients (NS), respectively. CONCLUSIONS: Collaboration between hepatologists and PCPs may be a valid treatment alternative to treat patients with CHC using the current standard antiviral therapy.

No severe pulmonary vein stenosis after extensive encircling pulmonary vein isolation: 12-month follow-up with 3D computed tomography.

Few studies have explored the utility of local electrogram-guided extensive encircling pulmonary vein isolation (EEPVI) by analyzing the pulmonary vein (PV) anatomy and occurrence of stenosis using multidetector computed tomography (MDCT). One hundred seventy-six paroxysmal atrial fibrillation (AF) patients underwent EEPVI with a double lasso technique. MDCT was performed in all patients before and at 3, 6 and 12 months after the ablation procedures to screen for PV stenosis. PV stenosis was defined as a >30% reduction in its diameter. A total of 700 PVs were analyzed. PV stenosis was observed in 15 of 700 PVs (2.1%). All stenoses were mild (mean 34.5 ± 3.3%). They were all asymptomatic, and none required treatment. After 12 months of follow-up, the PV narrowing regressed significantly compared with that at 3 months in the patients with PV stenosis (34.5 ± 3 to 30.4 ± 5%, P < 0.05). The remaining PVs exhibited a stable anatomy, and there was no significant progression of the PV narrowing. The results of this study demonstrated that detectable PV stenosis occurred in 2.1% of the PVs, and all stenoses were mild. Moreover, a significant regression of the PV narrowing was observed after 12-months of follow-up. This indicates that the local electrocardiogram-guided EEPVI was relatively safe regarding severe PV stenosis.

Local unipolar and bipolar electrogram criteria for evaluating the transmurality of atrial ablation lesions at different catheter orientations relative to the endocardial surface.

BACKGROUND: Recognition of the creation of transmural lesions (TLs) during atrial ablation procedures is important. OBJECTIVE: The purpose of this study was to characterize local unipolar electrograms (UEs) and bipolar electrograms (BEs) recorded from a TL at different catheter orientations. METHODS: In 13 porcines, 125 point-by-point ablations were performed in the smooth myocardial areas of the atria during recording of UE and BE. Catheter orientation was adjusted to be perpendicular or oblique (nonparallel; 80 sites) or parallel (75 sites) to the endocardial surface based on left atriograms. RESULTS: Microscopic examination revealed TLs in 54 sites and non-TLs in 71 sites. Irrespective of catheter orientation, the distal UE recorded from TLs consistently exhibited elimination of a negative deflection, whereas that from non-TLs did not. BE recorded from TLs with nonparallel catheter orientation consistently exhibited elimination of a positive deflection, whereas that with parallel catheter orientation exhibited one of two different patterns: (1) predominant attenuation (> or =75%) of the R wave at sites exhibiting QRS pattern preablation or (2) complete elimination of the R' wave at sites exhibiting RSR' pattern preablation. The heterogeneity of the patterns of morphologic change in BE at the different catheter orientations was due to the different degree of contribution of the proximal UE to BE. CONCLUSION: UE and BE criteria successfully differentiated TLs from non-TLs. Different BE criteria should be applied for recognizing TL formation in different catheter orientations.

Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography.

AIMS: Transradial coronary intervention (TRI) introduces a trauma to the radial artery (RA), possibly influencing quality as a bypass conduit if subsequently used. We sought to determine the acute and chronic effects of TRI on the RA by optical coherence tomography (OCT). METHODS AND RESULTS: Immediately after TRI completion, 73 RAs in 69 patients were examined. The sheath was pulled back 2 cm distal to the puncture site, and OCT imaging was performed. The acute injuries and intimal thickening were compared between first-TRI RAs and repeat-TRI RAs. Intimal tears were observed in 49 RAs (67.1%) and were more frequent in the distal than in the proximal RA (P = 0.001). Medial dissections were not uncommon (26 RAs, 35.6%). The frequency of acute injury was significantly higher in repeat-TRI RAs (P < 0.001). Intima/medial area, the maximum intimal thickness/medial thickness ratio, and per cent narrowing were all significantly greater in repeat-TRI RAs in the distal and proximal RA. Multivariate analysis revealed that a repeated TRI procedure was the only independent predictor of intimal thickening. CONCLUSION: Optical coherence tomography clearly demonstrated significant acute injuries and chronic intimal thickening of RA after TRI. Further study should evaluate the impact of these effects when TRI RAs are subsequently used as conduits, on long-term graft patency and on clinical outcomes after bypass surgery.

Clinical significance of echo signal attenuation on intravascular ultrasound in patients with coronary artery disease.

BACKGROUND: Atherosclerotic plaque that shows echo signal attenuation (EA) without associated bright echoes is sometimes observed by intravascular ultrasound but its clinical significance remains unclear. We investigated the impact of EA on coronary perfusion and evaluated the pathological features of plaque with EA. METHODS AND RESULTS: We studied 687 native coronary lesions in 687 consecutive patients (336 with acute coronary syndrome and 351 with stable angina pectoris) who underwent intravascular ultrasound before percutaneous coronary intervention. By subgroup analysis, 60 lesions (30 lesions with EA) treated with directional coronary atherectomy underwent pathological examination. The Thrombolysis in Myocardial Infarction (TIMI) flow grade and myocardial blush grade after percutaneous coronary intervention were compared between lesions with and without EA in 627 lesions except directional coronary atherectomy subgroup. EA was observed in 245 lesions (35.7%), and coronary flow after percutaneous coronary intervention was worse for lesions with EA than without (final TIMI grade of 0 to 2: 15.4% versus 2.4%, P<0.001; final myocardial blush grade of 0 to 2: 45.6% versus 21.4%, P<0.001). Multivariate analysis revealed a significant association between no reflow (TIMI grade 0 to 2) and EA (odds ratio, 5.59; 95% CI, 2.64 to 11.85; P<0.001), a baseline TIMI grade of 0 to 2 (odds ratio, 5.91; 95% CI, 2.79 to 12.5; P<0.001), and a large reference area (odds ratio, 3.08; 95% CI, 1.40 to 6.76; P=0.005) after controlling for other associated factors. Pathological examination revealed a significantly higher frequency of lipid-rich plaque with microcalcification in lesions with EA. CONCLUSIONS: Atherosclerotic plaque with EA showed a significant association with no reflow after percutaneous coronary intervention, suggesting the existence of fragile components susceptible to distal embolization.

Superior type of atypical AV nodal reentrant tachycardia: incidence, characteristics, and effect of slow pathway ablation.

BACKGROUND: Atypical atrioventricular (AV) nodal reentrant tachycardias (AVNRT) usually exhibit the earliest retrograde atrial activation (ERAA) at the right inferoseptum (Rt-IS) or proximal coronary sinus (PCS). The purpose of this study was to characterize atypical AVNRT with the ERAA at the right superoseptum (Rt-SS). METHODS: Seventy-three atypical AVNRTs induced in 63 cases were classified into the superior type with the ERAA at the Rt-SS and inferior type with the ERAA at the Rt-IS or PCS. RESULTS: There were nine superior (12%) and 64 inferior types of atypical AVNRT (88%) in seven and 56 cases, respectively. The superior type exhibited a short atrial-His interval during the tachycardia (166 +/- 41 ms), long His-atrial interval during the tachycardia (H-At:156 +/- 38 ms), and ventricular pacing at the tachycardia cycle length (TCL) (H-Ap:201 +/- 36 ms), and evidence for a lower common pathway, including second-degree AV block (four tachycardias) and an H-Ap being longer than the H-At (nine tachycardias). The TCL was shorter in the superior type than in the inferior type (322 +/- 35 vs 404 +/- 110 ms; P < 0.02). In the inferior type, all tachycardias were eliminated after the ablation at the Rt-IS (44 tachycardias) or PCS (20 tachycardias) where an ERAA was recorded. In the superior type, ablation at the Rt-IS was ineffective; however, ablation at the right midseptum eliminated seven (78%) of the nine tachycardias. CONCLUSIONS: The tachycardia circuit of the superior type might have deviated to a more superior part of Koch's triangle than that of the inferior type.