Incidence, distribution, and electrogram characteristics of endocardial-epicardial connections identified by ultra-high-resolution mapping during a left atrial posterior wall isolation of atrial fibrillation.

PURPOSE: The left atrial posterior wall (LAPW) can be a target for atrial fibrillation (AF) catheter ablation but is sometimes difficult to completely isolate due to the presence of endocardial-epicardial connections. We aimed to investigate the incidence and distribution of epicardial residual connections (epi-RCs) and the electrogram characteristics at epi-RC sites during an initial LAPW isolation. METHODS: We retrospectively studied 102 AF patients who underwent LAPW mapping before and after a first-pass linear ablation along the superior and inferior LAPW (pre-ablation and post-ablation maps) using an ultra-high-resolution mapping system (Rhythmia, Boston Scientific). RESULTS: Epi-RCs were observed in 41 patients (40.2%) and were widely distributed in the middle LAPW area and surrounding it. The sites with epi-RCs had a higher bipolar voltage amplitude and greater number of fractionated components than those without (median, 1.09 mV vs. 0.83 mV and 3.9 vs. 3.4 on the pre-ablation map and 0.38 mV vs. 0.27 mV and 8.5 vs. 4.2 on the post-ablation map, respectively; P < 0.001). Receiver operating characteristic analyses demonstrated that the number of fractionated components on the post-ablation map had a larger area under the curve of 0.847 than the others, and the sensitivity and specificity for predicting epi-RCs were 95.4% and 62.1%, respectively, at an optimal cutoff of 5.0. CONCLUSIONS: Among the patients with epi-RCs after a first-pass LAPW linear ablation, areas with a greater number of fractionated components (> 5.0 on the post-ablation LAPW map) may have endocardial-epicardial connections and may be potential targets for touch-up ablation to eliminate the epi-RCs.

Catheter ablation of the left-sided variant of right top pulmonary vein in a case with persistent left superior vena cava.

A 50-year-old woman underwent catheter ablation for atrial fibrillation. Preoperative computed tomography revealed a left-sided variant of the right top pulmonary vein (PV) and a persistent left superior vena cava. The right top PV was successfully isolated through a wide antral circumferential ablation line simultaneously with the right PVs.

Status of adult outpatients with congenital heart disease in Japan: The Japanese Network of Cardiovascular Departments for Adult Congenital Heart Disease Registry.

BACKGROUND: The Japanese Network of Cardiovascular Departments for Adult Congenital Heart Disease (JNCVD-ACHD) was founded in 2011 for the lifelong care of adult patients with congenital heart disease (ACHD patients). This network maintains the first Japanese ACHD registry. METHODS AND RESULTS: From 2011 to 2019, the JNCVD-ACHD registered 54 institutions providing specialized care for ACHD patients in 32 of the 47 prefectures in Japan. The registry collected data on the disease profile for 24,048 patients from 50 institutions and the patient characteristics for 9743 patients from 24 institutions. The most common ACHDs were atrial septal defect (20.5 %), ventricular septal defect (20.5 %), tetralogy of Fallot (12.9 %), and univentricular heart (UVH)/single ventricle (SV; 6.6 %). ACHD patients without biventricular repair accounted for 37.0 % of the population. Also examined were the serious anatomical and/or pathophysiological disorders such as pulmonary arterial hypertension (3.0 %) including Eisenmenger syndrome (1.2 %), systemic right ventricle under biventricular circulation (sRV-2VC; 2.8 %), and Fontan physiology (6.0 %). The sRV-2VC cases comprised congenitally corrected transposition of the great arteries without anatomical repair (61.9 %) and transposition of the great arteries with atrial switching surgery (38.1 %). The primary etiology (86.4 %) for Fontan physiology was UVH/SV. In addition, developmental/chromosomal/genetic disorders were heterotaxy syndromes (asplenia, 0.9 %; polysplenia, 0.7 %), trisomy 21 (4.0 %), 22q11.2 deletion (0.9 %), Turner syndrome (0.2 %), and Marfan syndrome (1.1 %). CONCLUSIONS: Although the specific management of ACHD has systematically progressed in Japan, this approach is still evolving. For ideal ACHD care, the prospective goals for the JNCVD-ACHD are to create local networks and provide a resource for multicenter clinical trials to support evidence-based practice.

Prognostic Value of Apical Sparing of Longitudinal Strain in Patients with Symptomatic Aortic Stenosis.

Background: Older patients with aortic stenosis (AS) have a higher incidence of wild-type transthyretin cardiac amyloidosis (ATTR-CA). This study aimed to determine whether apical sparing of longitudinal strain (LS) could help diagnose ATTR-CA and provide useful prognostic information in symptomatic AS. Methods: We performed vendor-independent two-dimensional speckle-tracking analysis of regional and global left ventricular LS in 16 patients with ATTR-CA and 31 patients with non-obstructive hypertrophic cardiomyopathy to determine the best cutoff value of the apical sparing ratio (APSR) for diagnosing ATTR-CA. We then determined the prevalence in patients who had an APSR higher than the best cutoff value and investigated its prognostic value in 230 patients with symptomatic AS. To determine the natural history of symptomatic AS, patients who had aortic valve replacement were censored at the time of surgery. Results: The best cutoff value of APSR was 0.76. APSR ≥ 0.76 was observed in 108 patients with symptomatic AS (48%). The prevalence was not different among the four AS subgroups. During a median follow-up period of 5.7 months, 47 patients had cardiac events. Cox proportional hazards analysis revealed that neither APSR nor APSR ≥ 0.76 was significantly associated with future cardiac events. Conclusions: Apical sparing was frequently observed in patients with symptomatic AS, and it was not a useful predictor of future adverse outcomes. Our results suggest that the underlying cause of apical sparing in AS may not be related to the presence of ATTR-CA.

Local impedance measurements during contact force-guided cavotricuspid isthmus ablation for predicting an effective radiofrequency ablation.

Background: An ablation catheter capable of contact force (CF) and local impedance (LI) monitoring (IntellaNav StablePoint, Boston Scientific) has been recently launched. We evaluated the relationship between the CF and LI values during radiofrequency catheter ablation (RFCA) along the cavotricuspid isthmus (CTI). Methods: Fifty consecutive subjects who underwent a CTI-RFCA using IntellaNav StablePoint catheters were retrospectively studied. The initial CF and LI at the start of the RF applications and mean CF and minimum LI during the RF applications were measured. The absolute and percentage LI drops were calculated as the difference between the initial and minimum LIs and 100 × absolute LI drop/initial LI, respectively. Results: We analyzed 602 first-pass RF applications. A weak correlation was observed between the initial CF and LI (r = 0.13) and between the mean CF and LI drops (r = 0.22). The initial LI and absolute and percentage LI drops were greater at effective ablation sites than ineffective ablation sites (median, 151 vs. 138 Ω, 22 vs. 14 Ω, and 14.4% vs. 9.9%; p < .001), but the initial and mean CF did not differ. At optimal cutoffs of 21 Ω and 10.8% for the absolute and percentage LI drops according to the receiver-operating characteristic analysis, the sensitivity, and specificity for predicting an effective ablation were 57.4% and 88.9% and 80.0%, and 61.1%, respectively. Conclusions: The effective sites during the CF-guided CTI-RFCA had greater initial LI and LI drops than the ineffective sites. Absolute and percentage LI drops of 21 Ω and 10.8% may be appropriate targets for an effective ablation.

Symptomatic and asymptomatic intracerebral hemorrhages detected by magnetic resonance imaging after catheter ablation of atrial fibrillation.

PURPOSE: Symptomatic intracerebral hemorrhages (ICHs) are a rare complication after atrial fibrillation (AF) catheter ablation, while the incidence of asymptomatic ICHs detected by magnetic resonance (MR) imaging remains unclear. This study aimed to investigate the incidence, characteristics, and predictors of new-onset ICHs on MR imaging after AF ablation. METHODS: We retrospectively studied 1257 consecutive AF ablation procedures in 1201 patients who underwent MR imaging on the day after the procedure. Repeat MR imaging within 3 months post-ablation was available in 352 procedures. RESULTS: Old ICHs on the initial MR imaging were observed in 28 procedures (2.2%). Post-ablation new ICHs were observed in 14 procedures (4.0%), including one symptomatic (0.3%) and 13 (3.7%) asymptomatic ICHs. One patient had a new ICH on the initial MR imaging, while the remaining 13 had such on the repeat MR imaging. A univariate analysis revealed that a previous ischemic stroke or transient ischemic attack (TIA) and the CHA2DS2-VASc score were positive predictors of new ICHs (odds ratios, 5.502 and 1.435; P = 0.004 and 0.044). The lesion diameter did not significantly differ between the old and new ICHs (median, 6.1 mm vs. 8.0 mm, P = 0.281), while the predominant location differed (lobar areas, 22.6% vs. 53.3%; cerebellum, 22.6% vs. 20.0%; others, 54.8% vs. 26.7%; P = 0.026). CONCLUSIONS: A few asymptomatic ICHs may occur after AF ablation. Most of the post-ablation new ICHs occurred a few days or later after the procedure. A previous ischemic stroke/TIA and the CHA2DS2-VASc score may be risk factors for post-ablation ICHs.

Prevalence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during local impedance-guided extensive pulmonary vein isolation of atrial fibrillation with high-resolution mapping.

INTRODUCTION: Local impedance (LI) drops during radiofrequency ablation can predict lesion formation. Some conduction gaps during pulmonary vein isolation (PVI) can be associated with nonendocardial connections. This study aimed to investigate the incidence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during an LI-guided PVI. METHODS AND RESULTS: We prospectively enrolled 157 consecutive patients undergoing an initial LI-guided extensive PVI of atrial fibrillation (AF). After the first-pass encirclement, the residual conduction gaps and reconnected gaps were mapped using Rhythmia (Boston Scientific) and a mini-basket catheter. Right and left PV (RPV/LPV) gaps were observed in 22.3% and 18.5% of the patients, respectively: 27 endocardial and 49 nonendocardial gaps. The carina regions were common sites for the gaps (51 carina-related vs. 25 noncarina-related). The carina-related gaps consisted of more nonendocardial gaps than endocardial gaps (RPVs: 90.0% vs. 10.0%, p = .001; LPVs: 76.2% vs. 23.8%, p < .001). A univariate analysis revealed that paroxysmal AF and the left atrial (LA) volume index for RPV endocardial gaps (odds ratio [OR]: 8.640 and 0.946; p = .043 and 0.009), minor right inferior PV diameter for RPV nonendocardial gaps (OR: 1.165; p = .028), and major left inferior PV diameter for LPV endocardial gaps (OR: 1.233; p = .028) were significant predictors. CONCLUSIONS: During the LI-guided PVI, approximately two-thirds of the conduction gaps were nonendocardial. The carina regions had more conduction gaps than noncarina regions, which was due to the presence of nonendocardial connections. Paroxysmal AF, a lower LA volume index, and larger inferior PV diameters may increase the risk of conduction gaps.

The prevalence and characteristics of candidates for percutaneous left atrial appendage occlusion using a WATCHMAN device among patients who underwent atrial fibrillation ablation in a Japanese population.

BACKGROUND: Percutaneous left atrial appendage occlusion (LAAO) using a WATCHMAN device could be a treatment option for patients with non-valvular atrial fibrillation (AF) with thromboembolic and bleeding risk. We sought to determine the prevalence and characteristics of patients with AF ablation who are potential candidates for WATCHMAN implantation in a Japanese population. METHODS: We enrolled 2443 consecutive patients who had previously undergone AF ablation and transesophageal echocardiography (TEE). We assessed their clinical characteristics and measured their LAA orifice diameter and depth retrospectively using the obtained TEE images. We defined patients who met both anatomical criteria (LAA orifice max diameter: 17-31 mm and LAA max depth > LAA orifice max diameter) and clinical criteria (CHA2DS2-VASc score ≥ 2 and HAS-BLED score ≥ 3) as LAAO candidates. RESULTS: Among the 2443 enrolled patients, 361 (15%) met the clinical criteria, and 1928 (79%) met the anatomical criteria. Thus 12% (293/2443) of the total patient group met the criteria of LAAO candidates. LAAO candidates showed larger left atrial (LA) volume (77.6 ± 30.1 vs. 67.7 ± 29.1 mL, P < 0.001), larger LAA orifice diameter (22.5 ± 3.2 vs. 22.0 ± 4.3 mm, P = 0.026), and larger LAA depth (28.9 ± 4.6 vs. 27.0 ± 4.8 mm, P < 0.001). LAAO candidates made up only 23% of patients with CHA2DS2-VASc score ≥ 2 (N = 1295), whereas 78% of patients with a HAS-BLED score ≥ 3 (N = 378) were LAAO candidates. CONCLUSION: Twelve percent of patients who underwent AF ablation were potential candidates for LAAO using a WATCHMAN device in this Japanese population. It is imperative to evaluate bleeding risk when considering the indications for LAAO.

Extensive Bioactivity of Astaxanthin from Haematococcus pluvialis in Human.

Astaxanthin is known as a "marine carotenoid" and occurs in a wide variety of living organisms such as salmon, shrimp, crab, and red snapper. Astaxanthin antioxidant activity has been reported to be more than 100 times greater than that of vitamin E against lipid peroxidation and approximately 550 times more potent than that of vitamin E for singlet oxygen quenching. Astaxanthin doesn't exhibit any pro-oxidant nature and its main site of action is on/in the cell membrane. To date, extensive important benefits suggested for human health include anti-inflammation, immunomodulation, anti-stress, LDL cholesterol oxidation suppression, enhanced skin health, improved semen quality, attenuation of common fatigue including eye fatigue, increased sports performance and endurance, limiting exercised-induced muscle damage, and the suppression of the development of lifestyle-related diseases such as obesity, atherosclerosis, diabetes, hyperlipidemia, and hypertension. Recently, there has been an explosive increase worldwide in both the research and demand for natural astaxanthin mainly extracted from the microalgae, Haematococcus pluvialis, in human health applications. Japanese clinicians are especially using the natural astaxanthin as add-on supplementation for patients who are unsatisfied with conventional medications or cannot take other medications due to serious symptoms. For example, in heart failure or overactive bladder patients, astaxanthin treatment enhances patient's daily activity levels and QOL. Other ongoing clinical trials and case studies are examining chronic diseases such as non-alcoholic steatohepatitis, diabetes, diabetic nephropathy, and CVD, as well as infertility, atopic dermatitis, androgenetic alopecia, ulcerative colitis, and sarcopenia. In the near future, astaxanthin may secure a firm and signature position as medical food.

Efficacy of Add-on Therapy with Carvedilol and the Direct Renin Inhibitor Aliskiren for Improving Cardiac Sympathetic Nerve Activity, Cardiac Function, Symptoms, Exercise Capacity and Brain Natriuretic Peptide in Patients with Dilated Cardiomyopathy.

Purpose/Method: Aliskiren is a direct renin inhibitor that has been reported to be effective for CHF, but the usefulness of combined therapy with carvedilol and aliskiren has not been reported. Forty-four patients with dilated cardiomyopathy (DCM) were randomized into a group receiving add-on therapy with carvedilol plus aliskiren and another group receiving carvedilol alone for 6 months. Nuclear imagings with 123I-Metaiodobenzylguanidine (MIBG) and 99mTc-Sestamibi were performed. Exercise capacity using a specific activity scale (SAS) and the New York Heart Association (NYHA) class were evaluated. Cardiac sympathetic nerve activity was evaluated by 123I-MIBG imaging, with the delayed heart-to-mediastinum activity ratio (H/M), delayed total defect score (TDS), and washout rate (WR). Results: Combined add-on therapy with carvedilol and aliskiren improved several parameters much more than carvedilol alone (p<0.05) with respect to TDS, ejection fraction (EF), NYHA, SAS on 6 months and the changes in TDS, EF, end-diastolic volume and brain natriuretic peptide (BNP). Conclusion: Add-on therapy with carvedilol and aliskiren is more effective than carvedilol alone for improving cardiac sympathetic nerve activity, cardiac function, symptoms, exercise capacity, and brain natriuretic peptide in patients with DCM.

Effect of preventing air intrusion on silent strokes during atrial fibrillation ablation using a mini-basket catheter.

BACKGROUND: Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS: We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS: SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005, <.001, and .012). On the follow-up MR imaging, 83.5% of the SCEs in group SP and 87.7% in group CP disappeared (P = .398). CONCLUSIONS: Strict prevention of LA air intrusion may have no additional effect for reducing the incidence of SCEs after local impedance-guided AF ablation using a mini-basket catheter. An older age, non-paroxysmal AF, and high-power RF applications may increase the risk of SCEs.

Incidence and characteristics of silent cerebral embolisms after radiofrequency-based atrial fibrillation ablation: A propensity score-matched analysis between different mapping catheters and indices for guiding ablation.

INTRODUCTION: The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS: Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537). CONCLUSIONS: Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.

The possibility that long-term isometric handgrip exercise contributes to left atrial enlargement in patients with hypertension.

Hypertension guidelines recommend isometric handgrip exercise (IHG) as a non-pharmacological treatment. The aim of this study was to investigate whether IHG is safe for hypertensive patients. The participants were mostly middle-aged to elderly patients with hypertension. Participants wore a pedometer for 4 weeks and were then divided into two groups: Those who had taken at least 7000 steps per day were placed in an IHG-only group (n = 11), and those who took fewer steps were placed in an IHG + walking group (n = 4). Both groups then performed IHG for 12 weeks. No significant blood pressure reduction occurred from before to after intervention in either group. In the IHG-only group, brain natriuretic peptide (BNP) was significantly higher and left atrial (LA) volume (24.6 ± 9.1 to 36.4 ± 17.9 mL, P = .007) was significantly larger after intervention than before. Long-term IHG may induce both LA enlargement and increased BNP in hypertensive patients.

Optimal local impedance drops for an effective radiofrequency ablation during cavo-tricuspid isthmus ablation.

PURPOSE: A novel ablation catheter capable of local impedance (LI) monitoring (IntellaNav MiFi OI, Boston Scientific) has been recently introduced to clinical practice. We aimed to determine the optimal LI drops for an effective radiofrequency ablation during cavo-tricuspid isthmus (CTI) ablation. METHODS: This retrospective observational study enrolled 50 consecutive patients (68 ± 9 years; 34 males) who underwent a CTI ablation using the IntellaNav MiFi OI catheter, guided by Rhythmia. The LI at the start of radiofrequency applications (initial LI) and minimum LI during radiofrequency applications were evaluated. The absolute and percentage LI drops were defined as the difference between the initial and minimum LIs and 100× absolute LI drop/initial LI, respectively. RESULTS: A total of 518 radiofrequency applications were analyzed. The absolute and percentage LI drops were significantly greater at effective ablation sites than ineffective sites (median, 15 ohms vs 8 ohms, P < .0001; median, 14.7% vs 8.3%, P < .0001). A receiver-operating characteristic analysis demonstrated that at optimal cutoffs of 12 ohms and 11.6% for the absolute and percentage LI drops, the sensitivity and specificity for predicting the effectiveness of the ablation were 66.5% and 88.2%, and 65.1% and 88.2%, respectively. Finally, bidirectional conduction block along the CTI was achieved in all patients. CONCLUSIONS: During the LI-guided CTI ablation, the effective RF ablation sites exhibited significantly greater absolute and percentage LI drops than the ineffective RF ablation sites. Absolute and percentage LI drops of 12 ohms and 11.6% may be suitable targets for effective ablation.

Impact of the type of electroanatomic mapping system on the incidence of cerebral embolism after radiofrequency catheter ablation of left atrial tachycardias.

BACKGROUND: Left atrial tachycardias (ATs) often occur after left atrial ablation. The incidence of symptomatic and silent cerebral embolism after radiofrequency catheter ablation of left ATs and the impact of the type of 3-dimensional electroanatomic mapping (3D-EAM) system on the incidence of cerebral embolism remain unclear. OBJECTIVES: This study aimed to investigate the incidence of cerebral embolism after a 3D-EAM system-guided left AT ablation procedure and compare that between the different 3D-EAM systems. METHODS: We prospectively enrolled 59 patients who underwent left AT ablation and brain magnetic resonance imaging after the procedure: 30 were guided by the Rhythmia system (Boston Scientific, Marlborough, MA) and 29 by the CARTO system (Biosense Webster, Diamond Bar, CA) (groups R and C, respectively). RESULTS: One transient ischemic attack occurred in group R, and no symptomatic embolism occurred in group C. Silent cerebral ischemic lesions (SCILs) were observed in 35 patients (59.3%), and group R had a significantly higher incidence of SCILs than did group C (86.2% vs 33.3%; P < .001). In multivariate analysis, group R and left atrial linear ablation were independent positive predictors of SCILs (odds ratio 12.822 and 8.668; P = .001 and P = .005). The incidence of bleeding complications was comparable between groups R and C (0% vs 3.3%; P = .508). CONCLUSION: Group R exhibited a higher incidence of postablation cerebral embolism than did group C. The use of the high-resolution 3D-EAM system with a mini-basket catheter to guide radiofrequency ablation of left atrial macroreentrant tachycardias may markedly increase the risk of silent cerebral embolism. The present results require further validation in a randomized study.

Ventilatory Efficacy After Transcatheter Aortic Valve Replacement Predicts Mortality and Heart Failure Events in Elderly Patients.

BACKGROUND: We aimed to clarify the predictors of death or heart failure (HF) in elderly patients who undergo transcatheter aortic valve replacement (TAVR).Methods and Results:We prospectively enrolled 83 patients (age, 83±5 years) who underwent transthoracic echocardiography (TTE) and cardiopulmonary exercise testing (CPET) with impedance cardiography post-TAVR. We investigated the association of TTE and CPET parameters with death and the combined outcome of death and HF hospitalization. Over a follow-up of 19±9 months, peak oxygen uptake (V̇O2) was not associated with death or the combined outcome. The minimum ratio of minute ventilation (V̇E) to carbon dioxide production (V̇CO2) and the V̇E vs. V̇CO2slope were higher in patients with the combined outcome. After adjusting for age, sex, Society of Thoracic Surgeons score and peak V̇O2, ventilatory efficacy parameters remained independent predictors of the combined outcome (minimum V̇E/V̇O2: hazard ratio, 1.108; 95% confidence interval, 1.010-1.215; P=0.031; V̇E vs. V̇CO2slope: hazard ratio, 1.035; 95% confidence interval, 1.001-1.071; P=0.044), and had a greater area under the receiver-operating characteristic curve. The V̇E vs. V̇CO2slope ≥34.6 was associated with higher rates of the combined outcome, as well as lower cardiac output at peak work rate during CPET. CONCLUSIONS: In elderly patients, lower ventilatory efficacy post-TAVR is a predictor of death and HF hospitalization, reflecting lower cardiac output at peak exercise.

Effect of Left Ventricular Reverse Remodeling on Long-term Outcomes After Aortic Valve Replacement.

There have been few studies with a large number of patients on the effect of left ventricular (LV) reverse remodeling and long-term outcomes after aortic valve replacement (AVR). This study aimed to investigate long-term outcomes and the prognostic impact of follow-up echocardiographic parameters after AVR. We evaluated 456 consecutive patients from a retrospective multicenter registry in Japan (J-PROVE-Retro) who underwent AVR for aortic valve diseases (predominantly aortic stenosis [AS]; 326 patients and aortic regurgitation [AR]; 130 patients). Preoperative and follow-up echocardiography at 1 year after AVR was evaluated. The primary outcome measure was a composite of cardiac death or hospitalization due to heart failure. The median follow-up period was 9.2 years in AS group and 9.7 years in AR group. The freedom rate from the primary outcome was 92% at 5 years and 79% at 10 years in AS, and 97% at 5 years, and 93% at 10 years in AR. LV end-diastolic and end-systolic diameters, and the LV mass index decreased and LV ejection fraction increased after AVR in both AS and AR, and LV mass index was normalized in more than half of the patients. In the Cox proportional hazard model, echocardiographic parameters at 1 year after AVR were more strongly related to long-term outcomes than preoperative echocardiographic parameters. In conclusion, echocardiographic parameters at 1 year after AVR are more important as predictors of long-term outcomes than preoperative parameters in both AS and AR. More attention should be paid on early postoperative remodeling for long-term follow-up of patients after AVR.

Symptomatic paradoxical low gradient severe aortic stenosis: A possible link to heart failure with preserved ejection fraction.

BACKGROUND: There is an ongoing debate regarding optimal management of patients with paradoxical low gradient severe aortic stenosis (PLG-SAS). We hypothesized that the presence of symptoms is closely associated with future adverse outcome. We aimed to determine the relation between symptoms and outcome in patients with PLG-SAS. METHODS: We prospectively enrolled 222 patients with PLG-SAS. Left ventricular (LV) volumes, mass, and strain were measured by three-dimensional echocardiography. The primary end-point was cardiac events including cardiac death, ventricular fibrillation, and heart failure leading to hospitalization. RESULTS: There were 65 cases of symptomatic PLG-SAS and 157 cases of asymptomatic PLG-SAS. Patients with symptomatic PLG-SAS received beta-blockers, angiotensin blockers, and diuretics more frequently and showed higher levels of B-type natriuretic peptide than patients with asymptomatic PLG-SAS. Although LV chamber parameters were not different, patients with symptomatic PLG-SAS had significantly higher E-wave velocity and E/A ratio than patients with asymptomatic PLG-SAS. During the median follow-up of 18 months, 20 patients reached the primary end-point. Patients with symptomatic PLG-SAS had significantly worse prognosis than patients with asymptomatic PLG-SAS. A similar trend was observed while comparing with the propensity-score-matched cohort after adjusting for age, sex, stroke volume index, and severity of AS. CONCLUSIONS: Symptomatic PLG-SAS is associated with poorer prognosis even after adjusting for flow status and severity of AS. Therefore, presence of symptoms is not always related to the severity of AS itself but might be related to the underlying comorbidities. Our results suggest a possible link between PLG-SAS and heart failure with preserved ejection fraction in some symptomatic patients.