Ectopic cycle length estimation from the quantified distribution patterns of ventricular bigeminy and trigeminy.

BACKGROUND: Ectopic cycle length (ECL) and the distribution patterns of ventricular bigeminy and trigeminy, expressed as their postextrasystolic intervals (PEIs) and interectopic intervals (IEIs), have been poorly pursued. OBJECTIVE: Based on modulation theory, we hypothesized that the PEIs of bigeminy and trigeminy determine their IEIs and ECL. METHODS: Ambulatory electrocardiograms of 1290 patients with ventricular premature complexes (≥3000/day) were studied. To quantify their distribution pattern on the PEI vs IEI curve (PIC), we introduced the following 2 ratios: PEI of trigeminy to PEI of bigeminy ratio (T/B-PEI) and IEI of trigeminy to IEI of bigeminy ratio (T/B-IEI). Distribution patterns were divided into 3 types by T/B-PEI: standard type (<0.90), intermediate type (between 0.90 and 1.20), and reverse type (>1.20). ECL was defined as the average of the bigeminy and trigeminy intervals in the standard type, and bigeminy intervals in the other 2 types. RESULTS: T/B-IEI disclosed significant linear relationship with T/B-PEI (P < .0001). ECLs were longest in the standard type (1905 ± 347 ms; n = 426), followed by the intermediate type (1520 ± 239 ms; n = 607) and reverse type (1317 ± 227 ms; n = 227) (P < .0001). Trigeminy PEI/ECL in the standard type (0.450 ± 0.074) was significantly shorter than that of the other 2 types (P < .0001). CONCLUSION: We confirmed that T/B-PEI determines T/B-IEI and ECL by discriminating the 3 distribution patterns. Among them, trigeminy PEI/ECL decided the 2 types of modulation by the first sinus QRS, starting at the early delay phase or the later acceleration phase.

Characteristics and catheter ablation of focal atrial tachycardia originating from the interatrial septum.

BACKGROUND: Ablation of focal atrial tachycardia (AT) originating from the interatrial septum (IAS) is challenging because of its complex anatomy. METHODS: We studied the electrocardiographic and electrophysiologic characteristics of focal, septal AT in seven patients who underwent successful ablation. RESULTS: The site of successful ablation was at the site of earliest activation on the right side of the IAS in three patients and on the left side in four patients, >1cm away from the centre of the fossa ovalis in the septum secundum. A negative or +/- versus a positive or -/+ P wave in lead V1 during AT accurately predicted a right- versus left-sided origin of the AT, respectively. In the four left septal AT cases, right atrial activation mapping opposite the site of successful ablation revealed the presence of a small, low-frequency potential followed by a larger, high-frequency potential. In contrast, a high-frequency potential was not preceded by a low-frequency potential in the three right septal AT cases. CONCLUSIONS: Septal AT may originate from either side of the septum secundum. The P wave polarity in lead V1 accurately predicted the side of the IAS that the AT originated from. Left septal AT is characterised by the recording of double potentials reflecting far-field activation of the left-sided IAS, followed by near-field activation of the right-sided IAS, when recording from its right side, opposite the AT origin. These observations are particularly relevant when mapping an apparent right septal AT.

Impact of left atrial appendage ridge ablation on the complex fractionated electrograms in persistent atrial fibrillation.

BACKGROUND: The left atrial appendage (LAA) is a possible key contributor to the maintenance of persistent atrial fibrillation (PsAF). The effect of LAA ostial ablation on global left atrial higher-frequency sources remains unclear. METHODS: Complex fractionated electrograms (CFEs) and dominant frequency (DF) maps acquired with a NavX system in 58 PsAF patients were enrolled and examined before and after LAA posterior ridge ablation, which followed a stepwise linear ablation. RESULTS: High-density left atrial mapping identified continuous CFE sites in 50 % and high-DFs (≥ 8 Hz) in 53 % of patients at the LAA posterior ridge. In 44 patients in whom AF persisted despite pulmonary vein isolation (PVI) and linear ablation, LAA ablation significantly increased the mean CFE cycle length from 98 ± 29 to 108 ± 30 ms (P<0.0001) and decreased DF from 6.1 ± 0.8 to 5.9 ± 0.8 Hz (P<0.005) within the coronary sinus (CS). A multivariate analysis showed single-procedure failures could be predicted by the left atrial volume index and absence of continuous CFEs at the LAA posterior ridge region. The percent decrease in the global left atrial DF after LAA posterior ridge ablation was significantly lower in the patients with than in those without an enlarged left atrium (LA) (>90 mL/m(2)) (median 0 vs 4.8 %; P<0.01) and significantly lower in the patients with than in those without the absence of continuous CFEs in the LAA posterior ridge region (median 0.6 vs 4.8 %; P<0.05). CONCLUSION: These findings suggested that an approach incorporating an LAA posterior ridge ablation was effective in modifying higher-frequency sources in the global LA in PsAF patients, but a lesser effect was documented in patients with electroanatomical remodeling of the LA.

Epicardial adipose tissue-based defragmentation approach to persistent atrial fibrillation: its impact on complex fractionated electrograms and ablation outcome.

BACKGROUND: Increased epicardial adipose tissue (EAT) volume is associated with atrial fibrillation (AF). However, the efficacy of EAT-based left atrial (LA) ablation for persistent AF (PsAF) is unclear. OBJECTIVE: The purpose of this study was to assess whether EAT-based LA ablation is effective for PsAF. METHODS: In 60 PsAF patients (group I), 3-dimensional reconstructed computed tomography images depicting EAT were merged with NavX-based dominant-frequency (DF) and complex fractionated electrogram (CFE) maps obtained during AF. Pulmonary vein antrum isolation (PVAI) was followed by map-guided EAT-based ablation. Results were compared to those in a historical control group (group II, case-matched patients who underwent generalized stepwise ablation including linear plus CFE-targeted ablation). RESULTS: In 70% (n = 42) of group I patients, the LA-EAT was located at the pulmonary vein antra; anterior and inferior surfaces, roof, septum, and mitral annulus; and left atrial appendage. EAT was at or near (<3 mm) 71% (390/550) of high-DF (> -8 Hz) sites. In 41 patients with persistent AF despite EAT-targeted ablation, CFE burden decreased significantly (from 96% to 13%, P < .0001), and DF decreased within the coronary sinus (6.9 ± 0.7 Hz vs 5.9 ± 0.7 Hz, P < .0001). Radiofrequency energy duration was significantly less in group I than in group II (25 ± 6 minutes vs 31 ± 12 minutes, P < .05). During 16-month follow-up, freedom from AF on antiarrhythmic drugs was 78% vs 60% (P < .05). CONCLUSION: PVAI plus EAT-based ablation efficiently eliminates high-frequency sources and yields relatively high success. EAT-based LA ablation is a simple, clinically feasible PsAF ablation strategy.

Sudden cardiac arrest recorded during Holter monitoring: prevalence, antecedent electrical events, and outcomes.

BACKGROUND: Causative arrhythmias of sudden cardiac arrest (SCA) are changing in this age of improved coronary care. OBJECTIVE: The purpose of this study was to examine the frequency of terminal arrhythmias and the electrical events prior to SCA. METHODS: We analyzed 24-hour Holter recordings of 132 patients enrolled from 41 institutions who either died (n = 88) or had an aborted death (n = 44). The Holter recordings were obtained for diagnosing and evaluating diseases and arrhythmias in those without any episodes suggestive of SCA. RESULTS: In 97 patients (73%), SCA was associated with ventricular tachyarrhythmias and in 35 (27%) with bradyarrhythmias. The bradyarrhythmia-related SCA patients were older than those with a tachyarrhythmia-related SCA (70 ± 13 years vs. 58 ± 19 years, P < .001). The most common arrhythmia for a tachyarrhythmia-related SCA was ventricular tachycardia degenerating to ventricular fibrillation (45%). The bradyarrhythmia-related SCA was caused by asystole (74%) or AV block (26%). Spontaneous conversion was observed in 37 patients (38%) with ventricular tachyarrhythmias. Of those, 62% of the patients experienced symptoms including syncope, chest pain, or convulsion. Multivariate logistic analysis revealed that independent predictors of mortality for tachyarrhythmia-related SCAs were advanced age (odds ratio 1.04, 95% confidence interval 1.02-1.08) and ST elevation within the hour before SCA (odds ratio 3.54, 95% confidence interval 1.07-13.5). In contrast, the presence of preceding torsades de pointes was associated with spontaneous conversion (odds ratio 0.20, 95% confidence interval 0.05-0.66). CONCLUSION: The most frequent cause of SCA remains ventricular tachyarrhythmias. Advanced age and ST elevation before SCA are risk factors for mortality in tachyarrhythmia-related SCAs.

Substrate modification by adding ablation of localized complex fractionated electrograms after stepwise linear ablation in persistent atrial fibrillation.

PURPOSE: Linear left atrial (LA) ablation in patients with persistent atrial fibrillation (PsAF) resulting in the elimination of most complex fractionated electrogram (CFE) sites has been demonstrated. This study was designed to evaluate the impact of a localized CFE ablation in addition to a representative linear LA ablation in patients with PsAF. METHODS: A total of 40 consecutive patients with PsAF underwent construction of CFE and dominant frequency (DF) maps using NavX. A stepwise linear ablation including at the PV antra, septum, roof, mitral annulus, and ridge of the appendage was performed followed by additional ablation of localized CFEs detected by an automatic algorithm. RESULTS: A significant reduction in the continuous CFE burden (<50 ms) after the linear ablation (69 vs. 21 %; P < 0.0001) was confirmed, and localized CFEs (40-120 ms) were observed with a significant predilection for the anterior (30 %), posterior (30 %), and inferior LA (38 %) regions (P < 0.01). Comparing the localized CFEs with higher frequency sources, 45 % (70/156) of the localized CFE sites included continuous CFE regions, and 59 % (92/156) of those sites overlapped with the high-DF sites (>8 Hz). Additional localized CFE-targeted ablation further terminated PsAF in 20 % of the patients and further increased the mean CFE cycle length (110 ± 31 to 125 ± 39 ms; P = 0.0033) and decreased the DF (6.0 ± 0.8 to 5.7 ± 0.7 Hz; P = 0.0013) within the CS. CONCLUSIONS: The presence of localized CFE sites with a predilection for particular LA regions after a representative linear LA ablation could provide the optimal sites for selective substrate modification of the atrial fibrillation substrate in patients with PsAF.

Strong modulation of ectopic focus as a mechanism of repetitive interpolated ventricular bigeminy with heart rate doubling.

BACKGROUND: Repetitive interpolated ventricular bigeminy (RIVB) can introduce a doubling of the ventricular rate. OBJECTIVE: To clarify the mechanism of RIVB, we hypothesized that it was introduced by a strong modulation of the ventricular automatic focus. METHODS: RIVB, defined as more than 7 bigeminy events, was detected by instantaneous heart rate and bigeminy interval (BI) tachograms in 1450 successive patients with frequent ventricular premature contractions (≥3000 per day). Postextrasystolic interval bigeminy interval curves were plotted to determine the degree of modulation. Mean sinus cycle length bigeminy interval curves were plotted for selection. RIVB was simulated by using a computer-based parasystole model. RESULTS: RIVB was observed in 7 patients (age 60 ± 16 years; 2 men and 5 women) with a heart rate of 58.2 ± 6.5 beats/min during a rest period both during the day and at night. The tachograms disclosed the onset of the RIVB with a doubled ventricular rate to 112.3 ± 8.5 beats/min. On the postextrasystolic interval bigeminy interval curves, compensatory bigeminy and interpolated bigeminy constituted overlapping regression lines with slopes close to 1.00 and RIVB was located in the lower left portion. RIVB lasting for up to 3 hours was quickly detected by mean sinus cycle length bigeminy interval curve. The PQ interval immediately after RIVB was prolonged in comparison with baseline (0.18 ± 0.02 to 0.21 ± 0.02 seconds; P < .001). The simulation was able to reproduce RIVB faithfully at a slow heart rate. CONCLUSIONS: Our findings support the hypothesis that RIVB was introduced by strongly modulated ventricular pacemaker accelerated by an intervening normal QRS.

Spatial relationship between high-dominant-frequency sites and the linear ablation line in persistent atrial fibrillation: its impact on complex fractionated electrograms.

AIMS: Complex fractionated electrograms (CFEs) and high-dominant-frequency (DF) sites theoretically represent abnormal substrates and targets for atrial fibrillation (AF) ablation. The relationship between the high-DF sites in the left atrium (LA) and commonly used linear ablation line to the distribution of the CFEs in patients with persistent AF is unknown. METHODS AND RESULTS: This study enrolled 62 persistent AF patients who underwent construction of LA CFE and DF maps (>350 points/map). Circumferential pulmonary vein isolation and linear ablation including that at the septum, roof, mitral-annulus, and ridge of the appendage were performed. Multipolar catheter mapping identified sites with high DFs (≥ 8 Hz) in all patients (9.8 ± 4.6/patient). In 47 patients in whom AF persisted despite ablation, there was a significant reduction in the continuous CFE (<50 ms) burden after the linear ablation (62 vs.11%; P < 0.0001), with a decrease in both the DF within the coronary sinus (6.9 ± 0.9 vs. 5.9 ± 0.8 Hz; P < 0.0001) and CFE surface area (42.8 ± 18.8 vs. 12.6 ± 10.5 cm(2); P < 0.0001). Comparing the high-DF sites with the ablated lesions, 64% of the high-DF sites (324 of 507) were on or adjacent to the ablation lines. Residual CFEs were observed in the infero-posterior regions in 83% of the patients. Almost half of the high-DF sites away from the linear ablation line were identified in the inferior (34%) and posterior (14%) LA regions. CONCLUSION: Linear ablation resulted in the localization of the continuous CFE regions and reduced the global LA DF in patients with persistent AF. This may be related to the proximity relationship between the linear ablation lines and high-DF sites except for in the infero-posterior regions.

Catheter ablation of ventricular tachycardia originating from the left posterior papillary muscle guided by the shadow of a multipolar catheter.

A 62-year-old man without structural heart disease underwent electrophysiological testing for ventricular tachycardia (VT). Hemodynamically unstable VT was induced after isoproterenol (ISP) provocation. Electroanatomical mapping using a multipolar catheter identified the earliest activation originating from the posterior papillary muscle (PPM) where prepotentials preceding the local ventricular electrogram were observed. Irrigated radiofrequency current guided by the shadow of a multipolar catheter eliminated the VT. This case suggested that multipolar catheters may be helpful for identifying tachycardia origins arising from the PPM.

Determinants of serum high molecular weight (HMW) adiponectin levels in patients with coronary artery disease: associations with cardio-renal-anemia syndrome.

OBJECTIVE: A low serum adiponectin level is associated with a high incidence of coronary artery disease (CAD) in the healthy population. Paradoxically, serum adiponectin is elevated in patients with severe CAD or chronic heart failure. We investigated the determinants of serum high molecular weight (HMW) adiponectin in patients with CAD. PATIENTS AND METHODS: We studied 228 consecutive patients with CAD confirmed by angiography. Anemia was defined as a hemoglobin of <13.0 g/dL in men and<12.0 g/dL in women. A high plasma B-type natriuretic-peptide (BNP) was defined as >100 pg/mL. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min for more than 3 months. The patients with CAD were divided into eight groups according to the presence or absence of anemia, high BNP, and/or CKD. RESULTS: In all 228 patients with CAD, serum HMW adiponectin correlated positively with age, high-density-lipoprotein cholesterol (HDL-C), and BNP, while this parameter showed negative correlations with body mass index, insulin resistance, triglycerides, eGFR, and hemoglobin. Multivariate analysis showed that HDL-C, BNP, gender, and age were independently associated with the HMW adiponectin. Serum HMW adiponectin was lower in CAD patients with than without metabolic syndrome. Serum HMW adiponectin and the HMW/total adiponectin ratio were highest in CAD patients who had anemia, high BNP, and CKD among the groups. CONCLUSION: In patients with CAD, metabolic syndrome is associated with a lower serum HMW adiponectin, while the presence of anemia, high BNP, and CKD is associated with elevation of the serum HMW adiponectin.

A unique iatrogenic organized left atrial tachycardia with a gap conduction in previously ablated lesions.

This case concerns a 57-year-old woman with an organized left atrial tachycardia (AT) after pulmonary vein (PV) isolation. The left inferior PV (LIPV) exhibited a figure of eight tachycardia around the LIPV ostium with one loop at the anterior aspect and another at the posterior aspect, which corresponded to regular surface P waves. Although a gap ablation of fractionated electrograms changed the LIPV sequence, the atrial potentials were organized with a shortened cycle length accompanied by the same surface P-wave morphology. The elimination of the anterior loop and modification of the posterior loop after the gap ablation might have yielded that specific sequence change of the AT.

Effects of losartan on serum total and high-molecular weight adiponectin concentrations in hypertensive patients with metabolic syndrome.

High-molecular weight (HMW) adiponectin may have the most biologic activity among several isoforms. We investigated long-term effects of losartan on serum concentrations of total and HMW adiponectin in hypertensive patients with metabolic syndrome (MS) by serial measurements over 6 months. Forty hypertensive patients first received 50 mg of losartan. Upward titration of the losartan dose was implemented to reach a target blood pressure of less than 140/90 mm Hg. Serum total adiponectin and HMW adiponectin were measured at study entry (baseline), the 3-month treatment time point, and the end of the 6-month period. Non-HMW adiponectin (ie, medium- and low-molecular weight adiponectin) was calculated as total adiponectin--HMW adiponectin. Diagnosis of MS was done by current standard criteria. In hypertensive patients without MS (n = 21), the serum total adiponectin increased from 9.8 +/- 5.4 microg/mL at baseline to 11.1 +/- 6.2 microg/mL at 6 months (P < .01). Furthermore, the serum total adiponectin was significantly higher at 6 months than at 3 months (P < .01). Serum HMW adiponectin also increased from 5.7 +/- 3.9 microg/mL at baseline to 6.6 +/- 4.4 microg/mL at 6 months (P < .01). In hypertensive patients with MS, the serum total adiponectin increased from 6.0 +/- 2.7 mug/mL at baseline to 6.7 +/- 3.3 microg/mL at 3 months and to 7.0 +/- 3.1 microg/mL at 6 months (P < .01 for both). Furthermore, the serum HMW adiponectin concentration was significantly higher at 6 months than at 3 months (P < .001). However, the serum non-HMW adiponectin concentration did not change during treatment in either group. In conclusion, serum total and HMW adiponectin concentrations increase after 6 months of losartan treatment in hypertensive patients, irrespective of the presence or absence of MS.

A case of persistent atrial fibrillation cured by focal ablation in a young patient.

We present a case of a 25-year-old man who had persistent atrial fibrillation (AF) lasting for three months. The persistent AF was terminated by a 20-mg bolus infusion of adenosine triphosphate. Frequent and repetitive episodes of ectopic atrial tachycardia (EAT) emerged from the mid-portion of the saddle between the left superior and inferior pulmonary veins. The successful ablation was achieved by a focal ablation at the site with the earliest activation preceding the P-wave onset by 42 ms, and exhibited a QS pattern in the unipolar recording. This is rare case in which focal ablation could cure persistent AF.

Effects of statins on restenosis after coronary stent implantation.

Experimental data and preliminary clinical studies suggest that lipid-lowering drugs might have a beneficial effect on restenosis after coronary angioplasty. Recently, statins have been focused on prevention of restenosis after coronary stent implantation. However, their benefit has not yet been established. The authors studied the effects of statins on stent restenosis. We compared retrospectively the quantitative coronary angiographic (QCA) variables between 62 dyslipidemic patients treated with statins (pravastatin or fluvastatin) and 62 normolipidemic patients, as a control, treated without statins after undergoing successful coronary stent implantation with 6-month follow-up angiography from May 1999 to December 2002. Major cardiac events were about the same in both groups. Each of the QCA variables before and immediately after coronary stenting was similar in the 2 groups. At follow-up angiography, however, minimal lumen diameter (MLD) (2.12 -/+ 0.73 vs 1.78 -/+ 0.7; p < 0.01) was larger in the statin group than in the normolipidemia group. Both restenosis rate (15% vs 31%; p = 0.05) and target lesion revascularization rate (10% vs 24%; p = 0.05) were lower in the statin group than in the normolipidemia group. Statin reduced restenosis rate. The efficacy of statins appears to be dependent on their pleiotropic effects on vascular wall rather than on lipid-lowering effects.

Comparison of serum high-molecular weight (HMW) adiponectin with total adiponectin concentrations in type 2 diabetic patients with coronary artery disease using a novel enzyme-linked immunosorbent assay to detect HMW adiponectin.

Adiponectin (Acrp30), an adipocyte-derived protein, exists in serum as a trimer, a hexamer, and a high-molecular weight (HMW) form, including 12-18 subunits. Because HMW adiponectin may be biologically active, we measured it in serum using a novel enzyme-linked immunosorbent assay (ELISA) confirmed by gel filtration chromatography that the ELISA detected mainly adiponectin with 12-18 subunits, and we compared HMW with total adiponectin concentration in patients with type 2 diabetes. We next investigated the relationship between serum HMW and coronary artery disease (CAD) in 280 consecutive type 2 diabetic patients, including 59 patients with angiographically confirmed CAD. Total adiponectin was measured in serum by a commercially available ELISA. Like serum total adiponectin, HMW adiponectin correlated positively with HDL cholesterol and negatively with triglyceride, insulin sensitivity, creatinine clearance, and circulating inflammatory markers. Total and HMW adiponectin were significantly higher in women than in men, as was the HMW-to-total adiponectin ratio. Serum HMW and the HMW-to-total adiponectin ratio were significantly lower in men with than without CAD (P < 0.05, respectively). In women, the ratio, but neither total nor HMW adiponectin, tended to be lower when CAD was present. In conclusion, determination of HMW adiponectin, especially relative to total serum adiponectin, is useful for evaluating CAD in type 2 diabetic patients.

Variation in parasystolic cycle length.

At the time of the first visit to our clinic, an electrocardiographic examination of a 73-year-old female patient revealed ventricular premature contractions (VPCs) with variable coupling intervals that were diagnosed as parasystole. Characteristically many of the parasystoles had no sinus contractions between two consecutive VPCs, which we referred to as pure parasystole. We first repeatedly examined variations in the length of the parasystolic cycles between January 6, 1997 and March 2, 2003 using electrocardiography. The time courses recorded over this period showed that the length of the parasystolic cycle did not remain constant, but varied irregularly within a relatively narrow range. We also recorded the length of the parasystolic cycles over 3 hours using Holter monitoring. The interectopic intervals plotted against mean sinus cycle length showed that the cycle length of pure parasystoles remained almost constant at about 1,300 ms over the 3 hours. We also examined the cycle length during exercise and found that it was slightly prolonged thereafter, while the sinus cycle length was clearly shortened after exercise. The average of six deep breathing tests showed that parasystolic cycle length did not significantly differ between deep inspiration and deep expiration, whereas the sinus cycle length during expiration was significantly longer than that during inspiration. These results indicate that the responses to both exercise and deep breathing obviously differed between the parasystolic and sinus cycle lengths.

Identification of stimulation site of pacemaker lead using tissue tracking method.

PURPOSE: We aimed to identify the electrical stimulation sites of pacemaker leads using a tissue tracking method of tissue Doppler imaging. METHODS: The study group consisted of 30 patients who had undergone permanent pacemaker implantation. During tissue Doppler imaging, the initial contraction site was seen as a red area stimulated by the pacemaker lead. This red area was analyzed precisely using time-distance curves generated by tissue tracking. RESULTS: The initial contraction site of the myocardium was located in the interventricular septum in seven patients and in the apical portion of the right ventricle in 11 patients. Furthermore, analysis of time-distance curves demonstrated that one point within the red area started to move earlier than the others. CONCLUSION: The site of electrical stimulation within the myocardium can be determined from the time-distance curves generated by the tissue tracking method.

[Clinical evaluation of ECG at the onset subjective symptoms using real-time analysis electrocardiograph (event recorder)].

Examination of patient complaining of palpitation, chest pain and chest discomfort is usually performed by 12-lead electrocardiograph. However, the recording time is short and there are few opportunities to capture an ECG demonstrating conditions during subjective symptoms. To investigate the cause, we need to obtain an ECG during subjective symptoms. Thus, we frequently use a Holter ECG, which can be recorded for 24 hours. However, some patients have a low frequency of subjective symptoms, which may not appear during a 24-hour examination. We used a real-time electrocardiograph (Event Recorder CG-6106 made by Card Guard Scientific Survival Limited) as a monitor during subjective symptoms. Thereafter, ECG findings at the onset of subjective symptoms could be analyzed in 30 patients who did not have a clear cardiac disease. In this examination, arrhythmia was recorded in 25 of 30 cases. Although in these cases ECG during subjective symptoms could not be captured even when Holter examination was performed several times ECG during subjective symptoms was captured using an Event Recorder. This method using an Event Recorder is simple and convenient, moreover, is considered very useful for investigation of subjective symptoms. In the future, the use of an Event Recorder for heart-health-care in the daily life of healthy people and/or cardiac disease patient is highly anticipated.

Long-term benefits of monteplase before coronary angioplasty in acute myocardial infarction.

Patients with acute myocardial infarction were randomly assigned to receive direct percutaneous coronary intervention (PCI) or pretreatment with intravenous monteplase followed by PCI. Although the combination of monteplase and PCI did not alter mortality compared with direct PCI, there was a dramatic reduction in the cardiac event rate over a 2-year follow-up compared with direct PCI.

Isolated noncompaction of the left ventricular myocardium in an elderly patient.

Noncompaction of the ventricular myocardium (NVM) is a rare disorder of endomyocardial morphogenesis characterized by numerous, prominent trabeculations and deep intertrabecular recesses. It is commonly associated with congenital heart disease, but the isolated form (INVM) is not associated with other structural heart diseases. Clinical reports of INVM have been limited to a few case reports and small series of pediatric patients. INVM is considered to be a form of congenital abnormal endomyocardial morphogenesis caused by abnormal cessation of the embryonic development of the ventricular myocardium; most reported cases have been pediatric patients, and autopsy cases of elderly patients have been quite rare. In the present case, an elderly female had INVM associated with severely disturbed left ventricular (LV) function and an enlarged left ventricle similar to dilated cardiomyopathy. The echocardiogram showed prominent trabeculations and deep intertrabecular recesses of the LV walls, especially in the posterior and apical areas. LV contrast echocardiography revealed markedly protruberant trabeculations, which were also observed with computed tomography. Five years later, the patient died of refractory heart failure and ventricular fibrillation. The autopsy revealed numerous excessively prominent trabeculations in the LV myocardium, with deep intertrabecular recesses containing thrombi.