Efficacy of Cutting Balloon Angioplasty for Chronic Total Occlusion of Femoropopliteal Arteries.

BACKGROUND: Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion subset where maintaining long-term patency after endovascular treatment is challenging. We evaluated the efficacy of cutting balloon angioplasty (CBA) for de novo FP-CTOs in patients with symptomatic lower limb ischemia. METHODS: Seventy-three limbs of 67 symptomatic patients with de novo FP-CTOs successfully recanalized using CBA alone were enrolled in this study. Primary patency was defined as the absence of recurrent symptoms and no deterioration of the ankle-brachial index (ABI) >0.10 from the immediate postinterventional value. RESULTS: The mean age was 73.5 ± 7.3 years, and 59.7% of patients had diabetes mellitus. Most lesions were classified as Trans-Atlantic Inter-Society Consensus II type C (n = 18; 24.7%) or type D (n = 44; 60.3%), with mean lesion and occluded lengths of 24.8 ± 11.4 and 17.8 ± 11.2 cm, respectively. No procedure-related adverse events occurred, except one distal embolization. The ABI significantly increased after intervention from 0.52 ± 0.12 to 0.80 ± 0.15 (P < 0.0001), with marked improvement in clinical symptoms (Rutherford stage: 2.7 ± 1.0 to 1.1 ± 1.2, P < 0.0001). The mean follow-up period was 31.2 ± 18.0 months, and the primary patency rates at 12 and 24 months were 75.3% and 60.6%, respectively. The independent predictive factors of failed patency were baseline hemoglobin A1c (P = 0.031, hazard radio [HR] 1.51 per 1%), occluded length ≥15 cm (P = 0.036, HR 2.90), and severe dissection (P = 0.033, HR 2.85). Vessel calcification and diameter did not affect primary patency. CONCLUSIONS: CBA is a feasible option for endovascular treatment of FP-CTOs. Diabetic status, occlusion length, and severe dissection after CBA are independent negative predictors of long-term patency.

Real-time transesophageal echocardiography facilitates antegrade balloon aortic valvuloplasty.

We report two cases of severe aortic stenosis (AS) where antegrade balloon aortic valvuloplasty (BAV) was performed under real-time transesophageal echocardiography (TEE) guidance. Real-time TEE can provide useful information for evaluating the aortic valve response to valvuloplasty during the procedure. It was led with the intentional wire-bias technique in order to compress the severely calcified leaflet, and consequently allowed the balloon to reach the largest possible size and achieve full expansion of the aortic annulus.

Preferential Conduction Properties Along The Left Lateral Ridge And The Arrhythmogenicity Of The Left Pulmonary Veins In Patients With Atrial Fibrillation.

PURPOSE: In this study, we examined the hypothesis that the preferential conduction property along left lateral ridge (LLR) might affect the arrhythmogenicity of left pulmonary veins (LPVs). METHODS: The study population included 40 consecutive AF patients. Radiofrequency energy (RF) was sequentially delivered along the LLR from a lower to upper manner during postero-lateral CS pacing during an isoproterenol infusion. RESULTS: The conduction time during pacing from the CS was significantly prolonged during radiofrequency (RF) deliveries (before vs. after, upper; 91±26ms vs. 127±38ms, p<0.001, lower; 86±21ms vs. 103±22ms, p<0.001). Remarkable prolongation of more than 30ms was observed in 19 of 40 patients (48%) (both LPVs, 6; only the upper LPVs, 12; and only the lower LPV, 1). Sites with a remarkable prolongation were observed at the carina between the LPVs,[4] anterior site of the upper LPV carina,[10] anterior wall of the lower LPV,[3] and bottom of the lower LPVs [2] Thirty-three arrhythmogenic foci (AMF) from the LPVs were observed in 23/40 patients (56%). The conduction time during pacing from the LPVs during the RF delivery was significantly longer in the patients with AMF from the upper LPV than in those patients without (107±36ms vs. 146±40ms, p<0.01). CONCLUSION: The LLR includes the preferential conduction properties between the CS and LPVs, and the observation of the serial changes during the RF delivery could provide us information about the LPVs arrhythmogenicity.

Features of intrinsic ganglionated plexi in both atria after extensive pulmonary isolation and their clinical significance after catheter ablation in patients with atrial fibrillation.

BACKGROUND: The features of intrinsic ganglionated plexi (GP) in both atria after extensive pulmonary vein isolation (PVI) and their clinical implications have not been clarified in patients with atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to assess the features of GP response after extensive PVI and to evaluate the relationship between GP responses and subsequent AF episodes. METHODS: The study population consisted of 216 consecutive AF patients (104 persistent AF) who underwent an initial ablation. We searched for the GP sites in both atria after an extensive PVI. RESULTS: GP responses were determined in 186 of 216 patients (85.6%). In the left atrium, GP responses were observed around the right inferior GP in 116 of 216 patients (53.7%) and around the left inferior GP in 57 of 216 (26.4%). In the right atrium, GP responses were observed around the posteroseptal area: inside the CS in 64 of 216 patients (29.6%), at the CS ostium in 150 of 216 (69.4%), and in the lower right atrium in 45 of 216 (20.8%). The presence of a positive GP response was an independent risk factor for AF recurrence (hazard ratio 4.04, confidence interval 1.48-11.0) in patients with paroxysmal, but not persistent, AF. The incidence of recurrent atrial tachyarrhythmias in patients with paroxysmal AF with a positive GP response was 51% vs 8% in those without a GP response (P = .002). CONCLUSION: The presence of GP responses after extensive PVI was significantly associated with increased AF recurrence after ablation in patients with paroxysmal AF.

Macro-reentrant atrial tachycardia conducting through a left superior vena cava after catheter ablation in a patient with paroxysmal atrial fibrillation.

A left superior vena cava can be a cause of cardiac rhythm or conduction abnormalities, and can also be the arrhythmogenic source of atrial fibrillation (AF) with connections to the coronary sinus and left atrium. In the present study, we report a case with a macro re-entrant atrial tachycardia that coursed through the left superior vena cava after a previous AF ablation, which successfully ablated paroxysmal AF.

Residual arrhythmogenic foci predict recurrence in long-standing persistent atrial fibrillation patients after sinus rhythm restoration ablation.

BACKGROUND: The mechanism of persistent atrial fibrillation (AF) is multifactorial, and arrhythmogenic foci (AMF) might be involved in the occurrence of persistent AF. In this study, we examined the electrophysiological features of AMF during and immediately after ablation, and evaluated the relationship between the presence and number of residual AMF on the risk of AF recurrence after a vigorous sinus rhythm restoration ablation in patients with long-standing persistent AF. METHODS: The study consisted of 117 consecutive patients with persistent AF who underwent catheter ablation (CA). We performed direct cardioversion to restore sinus rhythm before the pulmonary vein (PV) isolation and at the end of the CA. Then we evaluated the features of the AMF inducible with isoproterenol and the pacing-based AF inducibility. RESULTS: After the completion of ablation, AF could still be induced in 37 of 117 patients (31.6%). Spontaneous PV AMF during CA were observed in 104 of 117 patients (91%), and non-PV AMF in 63 of 117 (54%). Residual non-PV AMF were significantly associated with the pacing-based AF inducibility and an enlarged left atrial volume. In the multivariate analysis, the AF duration (1.01 [range, 1.00-1.02] months; P = 0.012), left atrial volume (1.01 [range, 1.01-1.02] mm; P = 0.006), and residual AMF (3.95 [range, 1.32-11.8] yes, no; P = 0.004) were independent risk factors for recurrent AF. CONCLUSIONS: Residual AMF are associated with an increased long-term AF recurrence after sinus rhythm restoration ablation for long-standing persistent AF.

Feasibility and safety of a virtual 3-Fr sheathless-guiding system for percutaneous coronary intervention.

OBJECTIVES: To evaluate the feasibility and safety of a virtual 3-Fr system [5-Fr sheathless-guiding catheter (GC)] for percutaneous coronary intervention (PCI). BACKGROUND: The use of miniaturized devices for PCI is gaining popularity because of increased patient comfort and decreased risk of access site complications. METHODS: From July 2010 to December 2012, consecutive patients who underwent elective PCI (planned or ad hoc PCI) at our hospital were enrolled. PCI using the virtual 3-Fr system was attempted as our initial strategy, unless a 6-Fr or larger GC was considered to be suitable [lesions with heavy calcification, large (>2 mm) side branches, or chronic total occlusion]. RESULTS: Five hundred sixty-six patients underwent elective PCI during the study period, and 132 patients who met the criteria underwent PCI using the virtual 3-Fr system. Procedures using the virtual 3-Fr system were successful in 126 patients (95%); 111 (84%) were performed using the transradial approach, 110 (83%) were ad hoc procedures, and 45 (31%) were complex coronary lesions (type B2 or C). Six patients required conversion to a conventional 5- or 6-Fr sheath and catheter system. No intraoperative complications occurred, and radial artery patency was achieved in all patients who underwent transradial procedures. CONCLUSIONS: PCI using the virtual 3-Fr system is a feasible and viable alternative to conventional procedures that use a sheath and GC in appropriately selected patients. This small-caliber system may minimize endovascular trauma, particularly during transradial coronary procedures.

Direct aspiration of large thrombi in acute myocardial infarction using a standard 6 Fr guide catheter via the transradial approach.

A large thrombus load on the culprit coronary artery of patients with acute myocardial infarction (MI) is associated with increased procedural complications and adverse coronary events following angioplasty. This case series describes effective removal of large, occlusive thrombi in acute MI via direct aspiration using a standard 6 Fr guide catheter, following failed conventional catheter aspiration. This procedure is a simple and rapid alternative for challenging thrombi-containing coronary lesions when current thrombectomy catheters fail.

Transcollateral retrograde approach with rendezvous technique for recanalization of chronically occluded tibial arteries.

PURPOSE: To describe a novel technique using an antegrade wire in a retrograde microcatheter advanced through a transcollateral vessel for recanalization of challenging infrapopliteal chronic total occlusions. TECHNIQUE: A 75-year-old diabetic man presented with critical limb ischemia manifested as nonhealing ulcers on the toes. Baseline angiography revealed a blunt, long, total occlusion of the anterior tibial artery. A retrograde microcatheter was advanced over a guidewire tracking the collateral channel from the planter artery. Antegrade and retrograde microcatheters were aligned inside the occluded lesion. An antegrade wire was then advanced further down through the retrograde microcatheter. Final angiography of the anterior tibial artery following balloon dilation demonstrated a satisfactory result, without evidence of significant residual stenoses or flow-limiting dissections. Complete wound healing was achieved at 3 weeks. CONCLUSION: This alternative wire method may be useful when traditional interventional approaches are unfeasible.

Comparison of two-dimensional and real-time three-dimensional transesophageal echocardiography in the assessment of aortic valve area.

BACKGROUND: The accuracy of two-dimensional transesophageal echocardiography (2D-TEE) for the measurement of aortic valve area (AVA) in patients with aortic stenosis (AS) depends upon the cross-section selected for imaging. Real-time three-dimensional transesophageal echocardiography (3D-TEE) may overcome this limitation of 2D-TEE. The goal of this study was to compare 3D-TEE with 2D-TEE for the measurement of AVA. METHODS AND RESULTS: Twenty-five patients with AS underwent TEE. In 2D-TEE, the aortic valve image was obtained at the orifice level in the short-axis view, and AVA was measured by planimetry of the acquired images (2D-AVA). In 3D-TEE, 3D data containing the entire aortic valve were obtained. Then, a short-axis cross-section containing the smallest orifice in mid-systole was cut from the 3D data during image postprocessing, and the AVA was measured by planimetry (3D-AVA). The 3D-AVA was significantly smaller than the 2D-AVA (0.79±0.35cm(2) vs. 0.93±0.40cm(2), p<0.0001), but there was a strong correlation between 3D-AVA and 2D-AVA (R=0.94). Although the frame rate was lower in 3D-TEE than in 2D-TEE (17±6Hz vs. 58±16Hz), the 3D-AVA determined at each frame during systole showed that the difference between 3D-AVA and 2D-AVA was not explained by the lower frame rate. The time required for image acquisition of the aortic valve was shorter with 3D-TEE than with 2D-TEE (p=0.0005). CONCLUSIONS: The geometric AVA is smaller with 3D-TEE than with 2D-TEE, and the difference is not due to the lower frame rate of 3D-TEE. The improved accuracy of 3D-TEE along with reduced image acquisition time indicates that 3D-TEE is superior to 2D-TEE for the assessment of AVA.

Inducible atrial tachycardias with multiple circuits in a stepwise approach are associated with increased episodes of atrial tachycardias after catheter ablation.

BACKGROUND: Atrial tachycardia (AT) is commonly observed during catheter ablation (CA) in patients with atrial fibrillation (AF) undergoing a stepwise extensive CA. In this study, we examined the hypothesis that the presence of multiple inducible ATs (multiple-ATs), which allow for latent multiple reentrant circuits, might increase the potential for following AT episodes after CA. METHODS AND RESULTS: The study population consisted of 347 consecutive AF patients undergoing CA with a stepwise approach. A total of 366 ATs (tricuspid isthmus dependent, 101; mitral annulus, 62; septal, 26; roof dependent, 22; left atrial anterior wall, 13; upper loop, 8; surrounding the left pulmonary veins, 6; surrounding the right pulmonary veins, 6; left atrial appendage, 4; and Cs ostium, 3) occurring during the CA were found in 216 (62.2%) of 347 patients. Multiple-ATs (≥2) during the CA were observed in 93 (26.8%) of 347 patients. The incidence of AT episodes significantly increased as the number of inducible ATs increased (no AT, 7.8%; single AT, 13.7%; and multiple-ATs, 24.2%; P < .001), and multiple-ATs were an independent risk factor for AT episodes (3.07 [1.39-6.78]; P = .005). The impact of the multiple-ATs on the AT episodes was pronounced especially in the patients with coinducible residual AF (with coresidual AF vs without coresidual AF, 8.1% vs 47.7%; P < .001). CONCLUSIONS: The presence of an atrial substrate allowing for multiple-ATs was associated with increased AT episodes during follow-up.

Local coronary flow is associated with an unsuccessful complete block line at the mitral isthmus in patients with atrial fibrillation.

BACKGROUND: The addition of a mitral isthmus (MI) block line after pulmonary vein isolation could lead to a favorable outcome of catheter ablation in patients with atrial fibrillation (AF). However, it is sometimes tough to create a complete MI block line, and the cooling effect because of the local coronary flow may prevent the creation of a successful MI block line. METHODS AND RESULTS: This study enrolled 81 AF patients in whom the creation of an MI block line was attempted in those with persistent or pacing-inducible AF after pulmonary vein isolation. A local coronary artery (LCA) across the MI block line was observed in 43 (53%) of 81 patients, and a bidirectional MI block was successfully accomplished in 53 (65%) of 81 patients, at the estimated MI line. The ratio of a successful MI block line was significantly lower in the patients with an LCA than in those without an LCA (42% versus 92%; P<0.001). The mean diameter of the coronary sinus (0.59 ± 0.18 versus 0.82 ± 0.22 cm; P<0.001) and length of the estimated MI line (33.4 ± 9.9 versus 29.4 ± 7.1 mm; P=0.032) were significantly shorter in the patients with a successful MI block line than in those without a successful MI block line. In the multivariable analysis, an LCA at the MI and a larger coronary sinus diameter were independent risk factors for an unsuccessful MI block line. CONCLUSIONS: Local coronary flow at the MI is associated with an increased incidence of an unsuccessful MI block line.

Cough syncope induced by gastroesophageal reflux disease.

A 52-year-old Japanese man was admitted to our hospital for evaluation of syncope and convulsions. An electrocardiogram on admission revealed normal sinus rhythm. However, after repeated bouts of coughing, the heart rate showed bradycardia associated with convulsion. He was diagnosed with cough syncope secondary to laryngopharyngitis, which was caused by gastroesophageal reflux disease (GERD). Once the patient was administrated lansoprazole (Takeda Pharmaceutical Co., Osaka, Japan) for GERD, the syncope disappeared. The causes of syncope are diverse and may manifest in disorders of different organ systems in the body. Therefore, clinicians should perform a careful whole body examination to obtain the correct diagnosis.

Left ventricular remodeling after myocardial infarction in antecedent hypertensive patients.

Antecedent hypertension adversely affects mortality and heart failure after myocardial infarction (MI). In addition, accelerated ventricular remodeling is a contributor to the increased mortality observed after MI. The purpose of this study was to assess the relationship of antecedent hypertension to ventricular remodeling after MI. Ninety-four patients presenting with a first acute MI who were treated with reperfusion therapy within 12 h of their symptom onset were enrolled in this study. All of them underwent left ventriculography immediately after reperfusion therapy and again at 6 months after the occurrence of MI. Patients were divided into two groups: a hypertensive group and a normotensive group. End-diastolic volume index (EDVI), end-systolic volume index (ESVI), and ejection fraction (EF) values in the acute phase were compared to those at 6 months after acute MI in either group. The hypertensive group showed a significant increase in both EDVI and ESVI after 6 months, whereas the normotensive group did not. In addition, there was no change in EF in the hypertensive group, whereas EF increased significantly after 6 months in the normotensive group. As a result, the percent changes in ESVI and EF were significantly different between the hypertensive group and normotensive group. The results demonstrated that antecedent hypertension interacts with ventricular cavity dilatation after MI.