Feasibility, Safety, and Long-Term Outcomes of Zero-Contrast Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease.

BACKGROUND: The long-term safety and utility of intravascular ultrasound (IVUS)-guided zero-contrast percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) are unknown.Methods and Results: A total of 698 consecutive patients treated with PCI (1,061 procedures) in our center were studied. Patients with acute coronary syndrome, who are on maintenance hemodialysis, and who had a planned rotational atherectomy were excluded. Finally, they were divided into 2 groups: zero-contrast PCI (n=55, 78 procedures) and conventional PCI (n=462, 670 procedures). After propensity score matching, 50 patients were matched for each group to evaluate long-term outcomes. Primary endpoints were major adverse cardiovascular events (MACE), including all-cause death, non-fatal myocardial infarction (MI), and clinically driven target lesion revascularization. All patients in the zero-contrast PCI group had stage 3-5 CKD with an estimated glomerular filtration rate of 38.3±14.8 mL/min/1.73 m2. Zero-contrast PCI was successful in all 78 procedures without renal events such as acute kidney injury or emergent hemodialysis and procedural complications such as coronary perforation or periprocedural MI. During a follow-up period of 32 months, 7 patients died (1 cardiac, 6 non-cardiovascular), and 4 patients were introduced to renal replacement therapy. The incidence of MACE was similar between the zero-contrast and conventional PCI groups (log-rank, P=0.95). CONCLUSIONS: IVUS-guided zero-contrast PCI might be safe and feasible in patients with CKD with satisfactory acute and long-term renal and cardiovascular outcomes.

Clinical predictors for bradycardia and supraventricular tachycardia necessitating therapy in patients with unexplained syncope monitored by insertable cardiac monitor.

BACKGROUND: Insertable cardiac monitors (ICMs) improve diagnostic yield in patients with unexplained syncope. The most of cardiac syncope is arrhythmic causes include paroxysmal bradycardia and supraventricular tachycardia (SVT) in patients with unexplained syncope receiving ICM. Predictors for bradycardia and SVT that necessitate therapy in patients with unexplained syncope are not well known. HYPOTHESIS: This study aimed to investigate predictors of bradycardia and SVT necessitating therapy in patients with unexplained syncope receiving ICMs. METHODS: We retrospectively reviewed medical records of consecutive patients who received ICMs to monitor unexplained syncope. We performed Cox's stepwise logistic regression analysis to identify significant independent predictors for bradycardia and SVT. RESULTS: One hundred thirty-two patients received ICMs to monitor unexplained syncope. During the 17-month follow-up period, 19 patients (14%) needed pacemaker therapy for bradycardia; 8 patients (6%) received catheter ablation for SVT. The total estimated diagnostic rates were 34% and 48% at 1 and 2 years, respectively. Stepwise logistic regression analysis indicated that syncope during effort (odds ratio [OR] = 3.41; 95% confidence interval [CI], 1.21 to 9.6; p = .02) was an independent predictor for bradycardia. Palpitation before syncope (OR = 9.46; 95% CI, 1.78 to 50.10; p = .008) and history of atrial fibrillation (OR = 10.1; 95% CI, 1.96 to 52.45; p = .006) were identified as significant independent predictors for SVT. CONCLUSION: Syncope during effort, and palpitations or history of atrial fibrillation were independent predictors for bradycardia and for SVT. ICMs are useful devices for diagnosing unexplained syncope.

Predictors of Mortality, Rehospitalization for Syncope and Cardiovascular Events in Patients With Cardiovascular Syncope.

BACKGROUND: Predictors of poor outcomes remain unknown for cardiovascular syncope patients after discharge.Methods and Results:We reviewed the medical records of consecutive patients admitted to hospital with cardiovascular syncope. We then performed Cox stepwise logistic regression analysis to identify significant independent factors for death, rehospitalization for syncope, and cardiovascular events. The study group was 206 patients with cardiovascular syncope. Of them, bradycardia was diagnosed in 50%, tachycardia in 27%, and structural disease in 23%. During a 1-year follow-up period, 18 (8%) and 45 (23%) patients, respectively, were rehospitalized for syncope or a cardiovascular event, and 10 (4%) died. Independent predictors of cardiovascular events were systolic blood pressure <100 mmHg (odds ratio [OR] 3.25; 95%confidence interval [CI] 1.41-7.51, P=0.006) and implantation of a pacemaker (OR 0.19; 95% CI 0.05-0.51, P=0.0005) (inverse association). Drug-induced syncope (OR 4.57; 95% CI 1.54-12.8, P=0.007) was an independent risk factor for rehospitalization. Finally, a history of congestive heart failure (OR 11.0; 95% CI 2.78-54.7, P=0.0006) and systolic blood pressure <100 mmHg (OR 5.40; 95% CI 1.30-22.7, P=0.02) were identified as significant independent prognostic factors for death. CONCLUSIONS: Drug-induced syncope, hypotension, no indication for a pacemaker, and a history of congestive heart failure are risk factors post-discharge for patients with cardiovascular syncope and careful follow-up of these patients for at least 1 year is recommended.

Recurrence of atrial fibrillation within three months after pulmonary vein isolation for patients with paroxysmal atrial fibrillation: Analysis using external loop recorder with auto-trigger function.

BACKGROUND: Pulmonary vein isolation (PVI) via catheter ablation has been shown to be a highly effective treatment option for patients with symptomatic paroxysmal atrial fibrillation (AF). The recurrence of AF within 3 months after PVI is not considered to be the result of ablation procedure failure, because early recurrence of AF is not always associated with late recurrence. We examined the usefulness of an external loop recorder with an auto-trigger function (ELR-AUTO) for the detection of atrial fibrillation following PVI to characterize early recurrence and to determine the implications of AF occurrence within 3 months after PVI. METHODS: Fifty-three consecutive symptomatic patients with paroxysmal AF (age 61.6±12.6 years, 77% male) who underwent PVI and were fitted with ELR-AUTO for 7±2.0 days within 3 months after PVI were enrolled in this study. RESULTS: Of the 33 (62.2%) patients who did not have AF recurrence within 3 months after PVI, only 1 patient experienced AF recurrence at 12 months. Seven (35%) of the 20 patients who experienced AF within 3 months of PVI experienced symptomatic AF recurrence at 12 months. The sensitivity, specificity, positive predictive value, and negative predictive value of early AF recurrence for late recurrence were 87.5%, 71.1%, 35.0%, and 96.9%, respectively. CONCLUSIONS: AF recurrence measured by ELR-AUTO within 3 months after PVI can predict the late recurrence of AF. Freedom from AF in the first 3 months following ablation significantly predicts long-term AF freedom. ELR-AUTO is useful for the detection of symptomatic and asymptomatic AF.

J-Wave in Patients With Syncope.

BACKGROUND: Syncope is a common occurrence. The presence of J-wave, also known as early repolarization, on electrocardiogram is often seen in the general population, but the relationship between syncope and J-wave is unclear. METHODS AND RESULTS: After excluding 67 patients with structural heart disease from 326 with syncope, we classified 259 patients according to the presence or absence of J-wave (≥1 mm) in at least 2 inferior or lateral leads. Head-up tilt test (HUT) was performed for 30 min. If no syncope or presyncope occurred, HUT was repeated after drug loading. Before tilt, 97/259 (37%) had J-wave (57 male, 47.6±22.5 years) and 162 patients had no remarkable change (89 male, 51.1±21.2 years). HUT-positive rate was higher in patients with J-wave, compared with patients without (P<0.0001). The combination of J-wave and descending/horizontal ST segment in the inferior leads was more strongly associated with positive HUT than J-wave with ascending ST segment (odds ratio, 3.23). CONCLUSIONS: Prevalence of J-wave in the inferior or lateral leads was high in patients with syncope and was associated with HUT-induced neurally mediated reflex syncope (NMRS). Furthermore, the combination of J-wave and descending/horizontal ST segment in the inferior leads could be associated with a much higher risk of NMRS.

Single center experience in Japanese patients with syncope.

BACKGROUND AND PURPOSE: The present diagnostic method and features of syncope in Japan are unclear. Implantable loop recorder (ILR) and head-up tilt tests have recently become available for diagnosing syncope. The examination method and rates of diagnosing syncope may vary. This study aimed to clarify the present diagnostic method and features of syncope in a single Japanese medical center. METHODS AND RESULTS: We retrospectively reviewed the medical records of consecutive patients who were seen at our hospital from January 1, 2009, to December 31, 2012. A total of 547 patients (328 men, 60.4±21.5 years) with syncope were seen at our hospital. Reflex syncope was diagnosed in 29.1% of the cases, orthostatic hypotension in 11.7%, cardiac syncope in 34.0%, and unexplained syncope in 23.9% by initial and early evaluations. The number of patients with situational syncope and orthostatic hypotension that could be diagnosed in the initial evaluation of the first examination was significantly greater than that in subsequent evaluations. Forty-three percent of the unexplained syncope patients received an ILR. The consent rate for ILR implantations in the unexplained syncope patients with a suspected arrhythmia nature was 53.1%. The cumulative ILR diagnostic rates were 47% and 65% at 1 and 2 years after the ILR implantation, respectively. The estimated ILR diagnostic rates were significantly greater than that for conventional test without using an ILR. When patients with unexplained syncope could be diagnosed, the recurrent symptoms were greatly reduced. CONCLUSIONS: Syncope is induced by various causes in Japan. It is important that we understand the characteristics of each syncope cause. The consent rate for implanting an ILR in appropriate unexplained syncope patients is low. We need to educate these patients about the importance of making a diagnosis of syncope.

Type III procollagen-N-peptide as a predictor of persistent atrial fibrillation recurrence after cardioversion.

AIMS: Fibrosis and inflammation may play a significant role in the pathogenesis of atrial fibrillation (AF) recurrence. Type III procollagen-N-peptide (PIIINP) may be related to atrial fibrosis and play a role in predicting the recurrence of AF. We investigated whether PIIINP as a fibrosis marker predicts the recurrence of AF after cardioversion. METHODS AND RESULTS: Serum PIIINP, interleukin-6, high-sensitivity C-reactive protein, brain natriuretic peptide, renin and aldosterone were measured at baseline and 24 months in 88 patients (62%) with sinus rhythm (SR) maintenance and 54 patients (38%) with AF recurrence. Furthermore, the root mean square voltage in the last 20 ms (RMS20) via P-wave signal-averaged electrocardiogram (P-SAECG) was measured and the relationship between fibrosis biomarkers and RMS20 was examined. Baseline PIIINP with AF recurrence was significantly higher than for those with SR maintenance (0.664 vs. 0.581 U/mL, P = 0.001). However, there were no significant differences in other biomarkers. A logistic regression identified PIIINP (odds ratio 2.61, P = 0.008) as an independent predictor of AF recurrence. The RMS20 as measured by P-SAECG with SR maintenance and PIIINP levels <0.72 U/mL (at baseline) was significantly higher after 24 months than at baseline. Furthermore, the RMS20 with AF recurrence and PIIINP levels >0.72 U/mL (at baseline) was significantly lower after 24 months than baseline. CONCLUSIONS: Elevated baseline PIIINP concentration is an independent predictor for AF recurrence after cardioversion. Furthermore, there is a relationship between PIIINP and RMS20 and the fibrosis of AF.