Predictors of Recurrence after Catheter Ablation of Paroxysmal Atrial Fibrillation in Different Follow-Up Periods.

Background and objectives: Pulmonary vein (PV) reconnection is a major reason for recurrence after catheter ablation of paroxysmal atrial fibrillation (PAF). However, the timing of the recurrence varies between patients, and recurrence >1 year after ablation is not uncommon. We sought to elucidate the characteristics of atrial fibrillation (AF) that recurred in different follow-up periods. Materials and Methods: Study subjects comprised 151 consecutive patients undergoing initial catheter ablation of PAF. Left atrial volume index (LAVi) and atrial/brain natriuretic peptide (ANP/BNP) levels were systematically measured annually over 3 years until AF recurred. Results: Study subjects were classified into four groups: non-recurrence group (n = 84), and short-term- (within 1 year) (n = 30), mid-term- (1-3 years) (n = 26), and long-term-recurrence group (>3 years) (n = 11). The short-term-recurrence group was characterized by a higher prevalence of diabetes mellitus (hazard ratio 2.639 (95% confidence interval, 1.174-5.932), p = 0.019 by the Cox method), frequent AF episodes (≥1/week) before ablation (4.038 (1.545-10.557), p = 0.004), and higher BNP level at baseline (per 10 pg/mL) (1.054 (1.029-1.081), p < 0.0001). The mid-term-recurrence group was associated with higher BNP level (1.163 (1.070-1.265), p = 0.0004), larger LAVi (mL/m2) (1.033 (1.007-1.060), p = 0.013), and longer AF cycle length at baseline (per 10 ms) (1.194 (1.058-1.348), p = 0.004). In the long-term-recurrence group, the ANP and BNP levels were low throughout follow-up, as with those in the non-recurrence group, and AF cycle length was shorter (0.694 (0.522-0.924), p = 0.012) than those in the other recurrence groups. Conclusions: Distinct characteristics of AF were found according to the time to first recurrence after PAF ablation. The presence of secondary factors beyond PV reconnections could be considered as mechanisms for the recurrence of PAF in each follow-up period.

Electrophysiological relation between the superior vena cava and right superior pulmonary vein in patients with paroxysmal atrial fibrillation.

INTRODUCTION: The superior vena cava (SVC) is a main source of nonpulmonary vein (PV) ectopies initiating atrial fibrillation (AF). Empiric SVC isolation may improve rhythm outcomes after catheter ablation of AF. Because the SVC passes immediately adjacent to the right superior PV (RSPV), an electrophysiological relation could be present between the two structures. The present study aimed to estimate the interrelation between the SVC and RSPV by evaluating arrhythmogenic activities observed during catheter ablation of AF. METHODS AND RESULTS: Study subjects comprised 121 consecutive patients referred for catheter ablation of paroxysmal AF. Isoproterenol infusion was used to induce ectopies and AF. Patients were divided into two groups depending on the presence of arrhythmogenic SVC: arrhythmogenic-SVC (A-SVC) and nonarrhythmogenic SVC (Non-A-SVC) groups. The prevalence of females was higher and body surface area was smaller in the A-SVC group (N = 22) than Non-A-SVC group (N = 99). Arrhythmogenic activities were observed in 60 (49%) RSPVs, 24 (20%) right inferior PVs, 72 (59%) left superior PVs, and 31 (25%) left inferior PVs. Arrhythmogenic RSPVs were more prevalent in the A-SVC group than Non-A-SVC group (86% vs. 41%, P = 0.0001), whereas these prevalences in the other three PVs were not different between groups (P >0.3). In multivariable analysis, arrhythmogenic RSPV was the only independent predictor of arrhythmogenicity of the SVC (OR, 8.53; 95% CI 2.31-31.46; P = 0.001). CONCLUSIONS: An electrophysiological interrelation may be present between the SVC and RSPV in patients with paroxysmal AF. Semiempiric SVC isolation limited to patients with an arrhythmogenic RSPV may be a more efficient treatment strategy.

[Acquired Left Ventricular-right Atrial Communication due to Infective Endocarditis;Report of a Case].

A 77-year-old woman presented with a 3-week history of low grade fever, appetite loss and dizziness. An electrocardiogram showed complete heart block. Echocardiography demonstrated severe aortic valve stenosis and a mass of probable vegetation 2 cm in diameter on the atrioventricular septum in the right atrium (RA), but no obvious intra-cardiac fistula. There was no growth of organism in blood cul tures. In the 4th week after admission, a harsh and continuous cardiac murmur was detected for the 1st time. Portable echocardiography revealed disappearance of the mass in the RA, and showed an intra-cardiac shunt from the left ventricle( LV) to RA. The shunt was closed by autologous pericardial patch form LV side and directly with mattress suture form RA side during the emergency operation. The aortic valve was replaced with bio-prosthetic valve (SJM Trifecta 19 mm). No organism was detected in the excised tissue, but antibiotics were continued for 2 months until a permanent pacemaker was inserted.

Elevated plasma norepinephrine level and sick sinus syndrome in patients with lone atrial fibrillation.

OBJECTIVE: Plasma norepinephrine (NE) level can be a guide to mortality in patients with heart failure. This study aimed to evaluate the significance of plasma NE level compared with plasma natriuretic peptides (atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP)) levels in patients with atrial fibrillation (AF). METHODS: Included in this study were 137 consecutive patients referred for catheter ablation of lone AF (paroxysmal in 90 and persistent in 47 patients). Blood samples for measurements of ANP, BNP and NE were drawn in the supine position before the procedure. RESULTS: ANP, BNP and NE levels were greater in patients with persistent AF than in patients with paroxysmal AF (median (25th-75th centile)=28 (18-49) vs 69 (36-106), p<0.0001; 28 (15-50) vs 94 (39-156), p<0.0001; and 315 (223-502) vs 382 (299-517) pg/mL, p=0.04, respectively). NE level correlated weakly with ANP and BNP levels (r=0.28 and r=0.23, respectively, p<0.01 for both). BNP and NE levels differed between patients with and without recurrence of AF (55 (26-135) vs 35 (18-64), p=0.005 and 431 (323-560) vs 302 (225-436) pg/mL, p<0.001, respectively). Of note, only NE level was significantly greater in patients with symptomatic sick sinus syndrome (SSS) (n=21) than in those without SSS (560 (466-632) vs 321 (242-437) pg/mL, p<0.0001). Logistic regression analysis showed NE level to be the only independent discriminator for SSS (OR 1.006, 95% CI 1.002 to 1.010, p=0.001). CONCLUSIONS: An increase in plasma NE level was observed in patients with AF and SSS. Although this implies a pathophysiological link between clinical manifestation of SSS and the autonomic nervous dysfunction, further studies are needed to clarify the mechanisms for this novel finding.

Drug-eluting versus bare-metal stents in large coronary arteries of patients with ST-segment elevation myocardial infarction: findings from the ICAS registry.

BACKGROUND AND PURPOSE: There are a few retrospective subgroup analyses or registries of large-vessel (≥ 3.5mm) stenting. We investigated clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare-metal stents (BMS) in large coronary vessels. METHODS AND SUBJECTS: Of 1100 STEMI patients registered in the Ibaraki Cardiovascular Assessment Study (ICAS) multicenter registry from April 2007 to June 2012 who underwent PCI, we enrolled 454 patients (65.8 ± 12.7 years old, 81% male) with ≥ 3.5-mm stents. We excluded 53 patients with cardiogenic shock or left main trunk lesions. The remaining 401 patients were divided into Group-D, PCI with DES (n = 184), and Group-B, PCI with BMS (n = 217). Propensity score analysis matched 1:1 according to treatment with DES (n = 101) or with BMS (n = 101). We evaluated major adverse cardiac and cerebrovascular events (MACCE) and incidence of stent thrombosis (ST). MACCE was defined as all-cause death, myocardial infarction (MI), target-vessel revascularization (TVR), or cerebrovascular accident (CVA). ESSENTIAL RESULTS: During a mean follow-up period of 526 days, all-cause death, MI, CVA, MACCE, and ST were not significantly different in Group-D versus Group-B (all-cause death: 4.35% vs. 4.61%, p = 0.90; MI: 0% vs. 0%; CVA: 2.72% vs. 3.23%, p = 0.76; MACCE: 15.2% vs. 20.3%, p = 0.19; and ST: 0.0% vs. 1.38%, p = 0.11). After adjusting for age, insulin use, multivessel disease, intra-aortic balloon pump use, culprit lesions, and estimated glomerular filtration rate <60 ml/min/1.73 m(2), MACCE was not significantly different between the groups (odds ratio: 0.69; 95% CI: 0.40-1.23; p = 0.21). However, TVR was significantly lower in Group-D than Group-B in Kaplan-Meier analysis (p = 0.048) after propensity score matching. PRINCIPAL CONCLUSION: There was no advantage to using a DES in large vessels for preventing a hard endpoint, whereas DES use resulted in a significant reduction in TVR in the patients with STEMI in this registry.

Troponin elevation after radiofrequency catheter ablation of atrial fibrillation: relevance to AF substrate, procedural outcomes, and reverse structural remodeling.

BACKGROUND: Although radiofrequency ablation creates myocardial necrosis leading to troponin T (TnT) release into the systemic circulation, the significance of TnT elevation after atrial fibrillation (AF) ablation is unknown. OBJECTIVE: To demonstrate a possible mechanism of reverse structural remodeling in the left atrium (LA) by evaluating postprocedural TnT elevation. METHODS: This study included 106 patients with an enlarged LA (paroxysmal AF, n = 43; persistent AF, n = 63). All patients underwent pulmonary vein isolation alone in the index procedure. Left atrial volume indexed to body surface area (LAVi) was measured by echocardiography before ablation and 6 months after sinus rhythm restoration. Patients were divided into responders (n = 53) and nonresponders (n = 53) based on a cutoff value of 23% reduction in LAVi. The TnT level was measured 12 hours postprocedure. RESULTS: LAVi decreased from 43 ± 13 to 33 ± 12 mL/m(2) (P < .0001). The TnT level was higher in responders than in nonresponders (1.31 ± 0.34 µg/L vs 0.88 ± 0.29 µg/L; P < .0001) and correlated linearly with percent reduction in LAVi (R = .54; P < .0001). Also in multivariate analysis, the TnT level was the only independent predictor for responders (odds ratio 90.1; 95% confidence interval 14.95-543.3; P < .0001). The TnT level in patients who required a repeat procedure (n = 30) was lower than that in patients who did not require a repeat procedure only in the persistent AF group (0.92 ± 0.38 µg/L vs 1.16 ± 0.37 µg/L; P = .01). CONCLUSION: Greater elevation of the TnT level was related both to favorable outcomes after ablation and to greater reversal of structural remodeling. Postprocedural TnT level may be reflective of the preservation of healthy LA myocardium.

Initial culprit-only versus initial multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: results from the Ibaraki Cardiovascular Assessment Study registry.

We investigated clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) treated for initial culprit-only or by initial simultaneous treatment of nonculprit lesion with culprit lesion. Optimal management of multivessel disease in STEMI patients treated by primary percutaneous coronary intervention (PCI) is still unclear in the drug-eluting stent era. We compared clinical outcomes of 274 STEMI patients (69.3 ± 11.8 years, 77 % men) in the Ibaraki Cardiovascular Assessment Study registry who underwent initial culprit-only (OCL, n = 220) or initial multivessel PCI of nonculprit lesion with culprit lesion (NCL, n = 54) from April 2007 to August 2010. Major adverse cardiac and cerebrovascular events (MACCE) included all-cause death, myocardial infarction (MI), target-vessel revascularization (TVR), and cerebrovascular accident (CVA). Patients in the NCL group were older and had higher Killip class and lower estimated glomerular filtration rate than those in the OCL group. MI, TVR, CVA, and stent thrombosis were not significantly different between the two groups. Incidences of all-cause death and MACCE were lower in the OCL than in the NCL group (all-cause death: 10.9 % vs 31.5 %, P < 0.05; MACCE: 27.7 % vs 46.2 %, P < 0.05). After adjusting for patient characteristics, NCL remained at significantly higher risk compared with OCL for in-hospital and all-cause death (P = 0.001, respectively), and MACCE were not significantly different (odds ratio 1.95, 95 % confidence interval 0.94-4.08; P = 0.07) between groups. Initial multivessel PCI was associated with significantly increased risk of in-hospital death, all-cause death, and MACCE, which was somewhat attenuated in a multivariable model, but the numerically excessive risk with NCL still persisted.

Triple antithrombotic therapy is the independent predictor for the occurrence of major bleeding complications: analysis of percent time in therapeutic range.

BACKGROUND: Triple antithrombotic therapy increases the risk of bleeding events in patients undergoing percutaneous coronary intervention. However, it remains unclear whether good control of percent time in therapeutic range is associated with reduced occurrence of bleeding complications in patients undergoing triple antithrombotic therapy. METHODS AND RESULTS: This study included 2648 patients (70 ± 11 years; 2037 men) who underwent percutaneous coronary intervention with stent in the Ibaraki Cardiovascular Assessment Study registry and received dual antiplatelet therapy with or without warfarin. Clinical end points were defined as the occurrence of major bleeding complications (MBC), major adverse cardiac and cerebrovascular event, and all-cause death. Among these 2648 patients, 182 (7%) patients received warfarin. After a median follow-up period of 25 months (interquartile range, 15-35 months), MBC had occurred in 48 (2%) patients, major adverse cardiac and cerebrovascular event in 484 (18%) patients, and all-cause death in 206 (8%) patients. Multivariable Cox regression analysis revealed that triple antithrombotic therapy was the independent predictor for the occurrence of MBC (hazard ratio, 7.25; 95% confidence interval, 3.05-17.21; P<0.001). The time in therapeutic range value did not differ between the patients with and without MBC occurrence (83% [interquartile range, 50%-90%] versus 75% [interquartile range, 58%-87%]; P=0.7). However, the mean international normalized ratio of prothrombin time at the time of MBC occurrence was 3.3 ± 2.1. Triple antithrombotic therapy did not have a predictive value for the occurrence of all-cause death (P=0.1) and stroke (P=0.2). CONCLUSIONS: Triple antithrombotic therapy predisposes patients to an increased risk of MBC regardless of the time in therapeutic range.

Addition of spironolactone to an angiotensin-converting enzyme inhibitor decreases lung congestion and edema in Dahl hypertensive rats.

We investigated the effect of adding spironolactone to treatment with an angiotensin-converting enzyme (ACE) inhibitor, imidapril, in Dahl salt-sensitive (DS) hypertensive heart failure rats with preserved systolic function. Male DS rats were fed laboratory chow containing 8% NaCl from 7 weeks of age. Rats were divided into four groups and treated for 9 weeks with vehicle alone (water; n = 23), the ACE inhibitor imidapril (1 mg kg(-1) day(-1); n = 16), spironolactone (2 mg kg(-1) day(-1); n = 15), or a combination of imidapril and spironolactone at the doses above (n = 16). The left ventricular weight to body weight (BW) ratio was significantly lower in the imidapril group (3.28 +/- 0.30 mg g(-1)) and the combination group (3.34 +/- 0.38 mg g(-1)) than in the vehicle group (3.71 +/- 0.46 mg g(-1)). Adding spironolactone to imidapril inhibited an increase in the ratio of lung weight to BW (4.38 +/- 0.50 mg g(-1)) related to high salt intake, while monotherapy (imidapril group, 4.61 +/- 0.90 mg g(-1); spironolactone group, 5.40 +/- 2.50) did not significantly change the ratio from that seen with vehicle treatment (6.32 +/- 3.62 mg g(-1)). All active treatments (imidapril, 0.66% +/- 0.67%; spironolactone, 0.51% +/- 0.55%; both together, 0.31% +/- 0.26%) inhibited a salt-intake related increase in the percentage area representing fibrous tissue compared with vehicle treatment alone (1.81% +/- 1.51%). These findings suggest that adding spironolactone to an ACE inhibitor is more effective in improving pulmonary congestion and edema in hypertensive heart failure with preserved systolic function than an ACE inhibitor alone.