Propensity-score matched comparison of renal and neurohormonal effects of catheter ablation for frequent premature ventricular contractions in patients with and without systolic dysfunction.

Background: Catheter ablation (CA) for premature ventricular contractions (PVCs) restores cardiac and renal functions in patients with reduced left ventricular ejection fraction (LVEF); however, its effects on preserved EF remain unelucidated. Methods: The study cohort comprised 246 patients with a PVC burden of >10% on Holter electrocardiography. Using propensity matching, we compared the changes in B-type natriuretic peptide (BNP) levels and estimated glomerular filtration rate (eGFR) in patients who underwent CA or did not. Results: Postoperative BNP levels were decreased significantly in the CA group, regardless of the degree of LVEF, whereas there was no change in those of the non-CA group. Among patients who underwent CA, BNP levels decreased from 44.1 to 33.0 pg/mL in those with LVEF ≥50% (p = .002) and from 141.0 to 87.9 pg/mL in those with LVEF <50% (p < .001). Regarding eGFR, postoperative eGFR was significantly improved in the CA group of patients with LVEF ≥50% (from 71.4 to 74.7 mL/min/1.73 m2, p = .006), whereas it decreased in the non-CA group. A similar trend was observed in the group with a reduced LVEF. Adjusted for propensity score matching, there was a significant decrease in the BNP level and recovery of eGFR after CA in patients with LVEF >50%. Conclusions: This study showed that CA for frequent PVCs decreases BNP levels and increases eGFR even in patients with preserved LVEF.

Paget-Schroetter syndrome occurring in the nondominant hand.

Paget-Schroetter syndrome is the primary thrombotic event associated with venous thoracic outlet syndrome. It needs to be suspected when encountering localized brachial swelling and a dilated vein in patients with a history of upper limb exercise.

Higher power achieves greater local impedance drop, shorter ablation time, and more transmural lesion formation in comparison to lower power in local impedance guided radiofrequency ablation of atrial fibrillation.

BACKGROUND: Since the local impedance (LI) of the ablation catheter reflects tissue characteristics, the efficacy of higher power (HP) compared to lower power (LP) in LI-guided ablation may differ from other index-guided ablations. OBJECTIVE: This study aimed to assess the efficacy of HP ablation in LI-guided ablation of atrial fibrillation (AF). METHODS: A prospective observational study was conducted, enrolling patients undergoing de novo ablation for AF. Pulmonary vein isolation was performed using point-by-point ablation with a RHYTHMIA HDxTM Mapping System and an open-irrigated ablation catheter with mini-electrodes (IntellaNav MIFI OI). Ablation was stopped when the LI drop reached 30 ohms, three seconds after the LI plateaued, or when ablation time reached 30 s. To balance the baseline differences, a unique method was used in which the power was changed between HP (45 W to anterior wall/40 W to posterior wall) and LP (35 W/30 W) alternately for each adjacent point. RESULTS: A total of 551 ablations in 10 patients were analyzed (HP, n = 276; LP, n = 275). The maximum LI drop was significantly larger (HP: 28.3 ± 5.4 vs. LP: 24.8 ± 6.3 ohm), and the time to minimum LI was significantly shorter (HP: 15.0 ± 6.3 vs. LP: 19.3 ± 6.6 s) in the HP setting. The unipolar electrogram analysis of three patients revealed that the electrogram indicating transmural lesion formation was observed more frequently in the HP setting. CONCLUSION: In LI-guided ablation, the HP could achieve a larger LI drop and shorter time to minimum LI, which may result in more transmural lesion formation compared to a LP setting.

The angle of the tines before the pull and hold test predicts engagement of the tines in Micra leadless pacemaker implantation.

Background: Micra leadless pacemaker is secured to the myocardium by engagement of at least 2/4 tines confirmed with pull and hold test. However, the pull and hold test is sometimes difficult to assess. This study was performed to evaluate whether the angle of the tines before the pull and hold test predicts engagement of the tines in Micra leadless pacemaker implantation. Methods: We retrospectively enrolled 93 consecutive patients (52.7% male, age 82.4 ± 9.4 years), who received Micra implantation from September 2017 to June 2020 at our institution. After deployment and before the pull and hold test, the angle of the visible tines to the body of the pacemaker was measured using the RAO view of the fluoroscopy image. The engagement of the tines was then confirmed with the pull and hold test. Results: A total of 326 tines were analyzed. The angle of the engaged tines was significantly lower than the non-engaged tines (9.2 degrees [4.0-14.0] vs. 16.6 degrees [14.2-18.8], p < .0001). All tines with angles <10 degrees were engaged. In higher angles, engagement could not be predicted. Conclusion: A low angle of the tines before the pull and hold test can predict engagement of the tines in Micra leadless pacemaker implantation. The tines which are already open after deployment may be presumed that they are engaged.

Leadless pacemaker implantation sites confirmed by computed tomography and their parameters and complication rates.

BACKGROUND: Implantations of leadless pacemakers in the septum lower the risk of cardiac perforation. However, the relationship between the implantation site and the success rate, complication rate, and pacemaker parameters are not well-investigated. METHODS: Patients who underwent leadless pacemaker implantation with postprocedural computed tomography (CT) between September 2017 and November 2020 were analyzed. Septum was targeted with fluoroscopic guidance with contrast injection. We divided patients into two groups based on the implantation site confirmed by CT: septal and non-septal, which included the anterior/posterior edge of the septum and free wall. We compared the complication rates and pacemaker parameters between the two groups. RESULTS: A total of 67 patients underwent CT after the procedure; among them, 28 were included in the septal group and 39 were included in the non-septal group. The non-septal group had significantly higher R wave amplitudes (6.5 ± 3.3 vs. 9.7 ± 3.9 mV, p = .001), lower pacing threshold (1.0 ± 0.94 vs. 0.63 ± 0.45 V/0.24 ms, p = .02), and higher pacing impedance (615 ± 114.1 vs. 712.8 ± 181.3 ohms, p = .014) after the procedure compared to the septal group. Cardiac injuries were observed in four patients (one cardiac tamponade, one possible apical hematoma, two asymptomatic pericardial effusion), which were only observed in the non-septal group. CONCLUSIONS: Leadless pacemaker implantation may be technically challenging with substantial number of patients with non-septal implantation when assessed by CT. Septal implantation may have a lower risk of cardiac injury but may lead to inferior pacemaker parameters than non-septal implantation.

Outcomes of deep sedation for catheter ablation of paroxysmal supraventricular tachycardia, with adaptive servo ventilation.

BACKGROUND: Catheter ablation for paroxysmal supraventricular tachycardia (PSVT) is an established treatment, but the effect of deep sedation on PSVT inducibility remains unclear. AIM: We sought to examine PSVT inducibility and outcomes of catheter ablation under deep sedation using adaptive servo ventilation (ASV). METHODS: We retrospectively evaluated consecutive patients who underwent catheter ablation for PSVT under deep sedation (Propofol + Dexmedetomidine) with use of ASV. Anesthetic depth was controlled with BIS™ monitoring, and phenylephrine was administered to prevent anesthesia-induced hypotension. PSVT induction was attempted in all patients using extrastimuli at baseline, and after isoproterenol (ISP) infusion when necessary. RESULTS: PSVT was successfully induced in 145 of 147 patients, although ISP infusion was required in the majority (89%). The PSVT was atrioventricular nodal reentrant tachycardia (AVNRT) in 77 (53%), atrioventricular reciprocating tachycardia (AVRT) in 51 (35%), and atrial tachycardia (AT) in 17 (12%). A higher ISP dose was required for AT compared to other PSVT (AVNRT: 0.06 (IQR 0.03-0.06) vs AVRT: 0.03 (0.02-0.06) vs AT: 0.06 (0.03-0.12) mg/h, P = .013). More than half (51%) of the patients developed hypotension requiring phenylephrine; these patients were older. Acute success was obtained in 99% (patients with AVNRT had endpoints with single echo on ISP in 46%). Long-term success rate was 136 of 144 (94%) (AVNRT 96%, AVRT 92%, and AT 93%). There were no complications related to deep sedation. CONCLUSIONS: Deep sedation with use of ASV is a feasible anesthesia strategy for catheter ablation of PSVT with good long-term outcome. PSVT remains inducible if ISP is used.

Clinical impact of serial change in brain natriuretic peptide before and after catheter ablation in patients with atrial fibrillation and heart failure.

BACKGROUND: Brain natriuretic peptide (BNP) predicts the prognosis in patients with atrial fibrillation (AF) and heart failure (HF); however, the level of BNP can change immediately after restoration of sinus rhythm. We aimed to investigate the clinical impact of serial change in BNP level before and after catheter ablation for AF, on the prognosis. METHODS: In this retrospective single center study, 162 consecutive patients (67±9 years, 66.7% male) with AF and concomitant HF who underwent catheter ablation were examined. We analyzed the cardiac rhythm and % change in BNP pre- and post-ablation. RESULTS: BNP increased by 32.7% (-4.5% to 51.3%) in patients with sinus rhythm at baseline (sinus rhythm group: N=50) and decreased by 47.6% (20.9 to 61.6%) in patients with AF rhythm at baseline. Patients with AF rhythm at baseline were categorized into two groups according to the median value of reduction in % BNP; patients with good % BNP reduction (good BNP-R group; N=56), and with poor % BNP reduction (poor BNP-R group; N=56). Although the rate of recurrence of AF after ablation was comparable between the good and poor BNP-R groups, poor BNP-R was an independent predictor of subsequent composite events including HF hospitalization, ischemic stroke, and all cause of death after ablation, even after adjusting for other confounders (hazard ratio: 6.85, 95% confidence interval: 2.16 to 21.7, p-value=0.001). In the longitudinal analysis of echocardiographic parameters, shortening of the left ventricular end-diastolic diameter with preserved ejection fraction was evident except in the poor BNP-R group. CONCLUSION: In patients with AF and HF, poor % BNP reduction was an independent predictor of adverse outcome, although the rate of recurrence of AF was comparable. Serial BNP measurement might help in better identification of high-risk patients in whom sinus rhythm is restored with catheter ablation.

Risk factors for venous bleeding complication at the femoral puncture site after catheter ablation of atrial fibrillation.

BACKGROUND: Venous bleeding complication is often observed after catheter ablation of atrial fibrillation (AF), but the risk factors remain unclear. METHODS: We retrospectively evaluated 570 consecutive patients who underwent catheter ablation of AF from April 2012 to March 2017. After the procedure, the sheaths were removed, and hemostasis was obtained by manual compression followed by application of rolled gauze with elastic bandage and continuous pressure to the puncture site. We evaluated the risk factors for venous bleeding complications defined as hemorrhage from the puncture site that needed recompression after removal of the elastic bandage and rolled gauze. RESULTS: After excluding 11 patients because of missing data, 559 patients (395 [70.7%] men, mean age: 65.6 ± 8.7 years) were included for analysis. Venous bleeding complication was observed in 213 patients (38.1%). In the multivariate logistic regression analysis, low body mass index (BMI; odds ratio [OR] 0.95, 95% CI 0.90-1.00, P = .04), short compression time (OR 0.77, 95% CI 0.68-0.88, P < .001), and antiplatelet therapy (OR 1.86, 95% CI 1.09-3.16, P = .02) were independent risk factors for venous bleeding complication. CONCLUSIONS: Low BMI, short compression time, and antiplatelet therapy were independent risk factors for venous bleeding complication after catheter ablation of AF. Longer compression time may be needed for patients with low BMI and/or those receiving antiplatelet therapy.

Significance of Sarcopenia Evaluation in Acute Decompensated Heart Failure.

In patients with chronic heart failure (HF), the clinical importance of sarcopenia has been recognized in relation to disease severity, reduced exercise capacity, and adverse clinical outcome. Nevertheless, its impact on acute decompensated heart failure (ADHF) is still poorly understood. Dual-energy X-ray absorptiometry (DXA) is a technique for quantitatively analyzing muscle mass and the degree of sarcopenia. Fat-free mass index (FFMI) is a noninvasive and easily applicable marker of muscle mass.This was a prospective observational cohort study comprising 38 consecutive patients hospitalized for ADHF. Sarcopenia, derived from DXA, was defined as a skeletal muscle mass index (SMI) two standard deviations below the mean for healthy young subjects. FFMI (kg/m2) was calculated as 7.38 + 0.02908 × urinary creatinine (mg/day) divided by the square of height (m2).Sarcopenia was present in 52.6% of study patients. B-type natriuretic peptide (BNP) levels were significantly higher in ADHF patients with sarcopenia than in those without sarcopenia (1666 versus 429 pg/mL, P < 0.0001). Receiver operator curves were used to compare the predictive accuracy of SMI and FFMI for higher BNP levels. Areas under the curve for SMI and FFMI were 0.743 and 0.717, respectively. Multiple logistic regression analysis showed sarcopenia as a predictor of higher BNP level (OR = 18.4; 95% CI, 1.86-181.27; P = 0.013).Sarcopenia is associated with increased disease severity in ADHF. SMI based on DXA is potentially superior to FFMI in terms of predicting the degree of severity, but FFMI is also associated with ADHF severity.

Relationship Between Glucose Fluctuations and ST-Segment Resolution in Patients With ST-Elevation Acute Myocardial Infarction.

This study was conducted to assess whether any relationships exist between glucose fluctuations and electrocardiographic surrogate markers of reperfusion injury in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).We prospectively studied 63 consecutive patients with STEMI undergoing primary PCI. Patients had either diabetes (n = 30), impaired glucose tolerance (n = 26), impaired fasting glucose (n = 1), or normal glucose tolerance (n = 6). STsegment resolution (STR, %) was measured using electrocardiograms recorded 60 minutes after PCI. STR was categorized as ≥ 30% and < 30%. Glucose fluctuations were assessed by the following parameters obtained from a continuous glucose monitoring system: mean amplitude of glucose excursion (MAGE, mg/dL); and area under curve with reference to mean blood glucose (AUCMBG, mg/ dL/day).Both MAGE and AUCMBG were significantly higher in STR < 30%. In univariate analysis, MAGE ≥ 70 mg/dL (OR = 17.0; 95%CI, 1.93-150.12; P < 0.01), AUCMBG ≥ 20 mg/dL/day (OR = 10.9; 95%CI, 1.92-61.77; P < 0.01), and reperfusion arrhythmias (OR = 7.6; 95%CI, 1.32-44.29; P < 0.05) were significantly associated with suboptimal STR. Multiple logistic regression analysis showed only MAGE ≥ 70 mg/dL was predictive of suboptimal STR (OR = 22.5; 95%CI, 2.43-208.66, P < 0.01).Parameters of glucose fluctuations correlated with electrocardiographic surrogate markers of impaired myocardial salvage in STEMI after reperfusion therapy. Our results suggest that glucose fluctuations may represent a potential therapeutic target to reduce myocardial reperfusion injury in STEMI.