[Right Atrial Myxoma After Catheter Ablation:Report of a Case].

An 81-year-old man underwent total arch replacement for thoracic aortic aneurysm 8 years ago and catheter ablation for paroxysmal atrial fibrillation 1 year ago. Transthoracic echocardiography revealed a mass in the right atrium, and the patient was admitted for close examination and treatment. Transesophageal echocardiography revealed a 23×17 mm large well-defined mass above the cavotricuspid isthmus. Two venous drainage cannulas were inserted directly to the superior vena cava and to the inferior vena cava via the right femoral vein, in order to avoid the direct contact with the right atrium prior to institution of cardiopulmonary bypass. The right atrial tumor was found attached to the cavotricuspid isthmus, and was resected together with the right atrial wall. Pathological examination showed myxomatous tissue. Postoperative course was uneventful. He was discharged 23 days after the operation.

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.

A confluent non-enhanced dark core on serial late gadolinium enhancement imaging after a moderator band-ventricular tachycardia ablation.

A 77-year-old man underwent radiofrequency catheter ablation of incessant ventricular arrhythmias (VAs) originating from the right ventricular (RV) moderator band (MB). Activation mapping during the VAs exhibited a centrifugal pattern with the earliest activation site (EAS) on the RV septum. A local impedance (LI)-guided radiofrequency application targeting the EAS with a maximum power output of 50W successfully eliminated the VAs and resulted in an LI drop of up to 35 Ω. Late gadolinium enhancement magnetic resonance imaging (LGE-MRI) on the day after the ablation procedure demonstrated a confluent non-enhanced dark core on the RV septal portion of the MB. On the LGE-MRI two months after the procedure, the dark core region became contracted and instead the peripheral region surrounding the dark core exhibited a bright enhancement. The size of the dark core and peripheral enhanced regions on the LGE-MRI remained almost unchanged two months to two years after the procedure. He had no VA recurrences during a two-year follow-up period. Previous LGE-MRI studies reported that an ablated area within healthy ventricular myocardium exhibits a bright homogenous enhancement during the post-ablation chronic phase, while that within ventricular scar tissue exhibits a confluent non-enhanced dark core. This case suggested the presence of a dark core with a peripheral enhancement corresponding to the ablated area within the healthy myocardium of the RV-MB. LGE-MRI may be useful for accurately detecting RF ablation lesions on the RV-MB and visualizing the serial changes in the LGE-MRI characteristics from the post-ablation acute to chronic phases.

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.

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.

Correction to: Systolic modified Look-Locker inversion recovery myocardial T1 mapping improves the accuracy of T1 and extracellular volume fraction measurements of patients with high heart rate or atrial fibrillation.

The article "Systolic modified Look-Locker inversion recovery myocardial T1 mapping improves.

Systolic modified Look-Locker inversion recovery myocardial T1 mapping improves the accuracy of T1 and extracellular volume fraction measurements of patients with high heart rate or atrial fibrillation.

Image data for T1 mapping are generally acquired during mid-diastole period. However, T1 mapping tends to fail for patients with high heart rate or atrial fibrillation because of short or irregular R-R interval. Focusing on the evidence that the timing of systole is more stable than that of diastole from the R wave, we compared systolic T1 mapping with conventional diastolic T1 mapping for all participants (n = 58) by visual scoring of T1 calculation error. The systolic scores were significantly better than the diastolic scores (p < 0.05). This advantage of the systolic scores was confirmed selectively for patients with atrial fibrillation (p < 0.05, n = 19). The successful number of nonrigid image registration alignment for extracellular volume fraction (ECV) analysis also increased significantly for systolic images compared with diastolic images (p < 0.05). Thus, systolic T1 mapping improves the accuracy of T1 values and ECV analysis.

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.

Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-centre study on post-ablation thrombo-embolic and haemorrhagic events.

AIMS: This prospective, randomized, single-centre study aimed to directly compare the safety and efficacy of uninterrupted and interrupted periprocedural anticoagulation protocols with direct oral anticoagulants (DOACs) in patients undergoing catheter ablation of non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS: We randomly assigned 846 NVAF patients receiving DOACs prior to ablation to uninterruption (n = 422) or interruption (n = 424) of the DOACs on the day of the procedure. The primary endpoint was a composite of symptomatic thromboembolisms and major bleeding events within 30 days after the ablation. Secondary endpoints included symptomatic and silent thromboembolisms and major and minor bleeding events. The primary endpoint occurred in 0.7% of the uninterrupted DOAC group [1 transient ischaemic attack (TIA) and 2 major bleeding events] and 1.2% of the interrupted DOAC group (1 TIA and 4 major bleeding events) (P = 0.480). The incidence of major and minor bleeding was comparable between the two groups (0.5% vs. 0.9%, P = 0.345; 5.9% vs. 5.4%, P = 0.753). Silent cerebral ischaemic lesions (SCILs) were observed in 138 (20.9%) of the 661 patients undergoing post-ablation magnetic resonance (MR) imaging. The uninterrupted and interrupted DOAC groups revealed a similar incidence of SCILs (19.8% vs. 22.0%, P = 0.484) and percentage of SCILs with disappearance on follow-up MR imaging (77.8% vs. 82.1%, P = 0.428). CONCLUSION: Both the uninterrupted and interrupted DOAC protocols revealed a low risk of symptomatic thromboembolisms and major bleeding events and similar incidence of SCILs and minor bleeding events and may be feasible for periprocedural anticoagulation in NVAF patients undergoing catheter ablation.

Postablation cerebral embolisms in balloon-based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation.

INTRODUCTION: This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon-based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA). METHODS AND RESULTS: We enrolled 123 consecutive AF patients who underwent a balloon-based pulmonary vein isolation (PVI) and brain magnetic resonance (MR) imaging after the ablation procedure (CBA, n = 65; HBA, n = 58). The DOACs were continued in 62 patients throughout the periprocedural period and discontinued in 61 on the procedural day. Intravenous heparin was infused to maintain an activated clotting time of 300 to 400 seconds during the procedure. No symptomatic embolisms occurred in this series. Silent cerebral ischemic lesions (SCILs) were observed on MR imaging in 22 patients (17.9%), and the incidence of SCILs did not significantly differ between the CBA and HBA groups (21.5 vs 13.8%; P = 0.263). According to a multivariate logistic regression analysis, an older age was an independent positive predictor of SCILs (odds ratio, 1.062; 95% CI, 1.001-1.126; P = 0.046), but neither the balloon catheter type nor periprocedural continuation or discontinuation of the DOACs were significant predictors. The incidence of major and minor bleeding complications was comparable between the CBA and HBA groups (1.5 vs 0%, P = 0.528; 7.7 vs 5.2%, P = 0.424). CONCLUSIONS: Both CBA and HBA of AF revealed a similar incidence of postablation cerebral embolisms. Elderly patients may be at a risk of SCILs after a balloon-based PVI with periprocedural DOAC treatment.

Prevalence and Characteristics of Venous Thrombosis after Catheter Ablation of Atrial Fibrillation in Patients Receiving Periprocedural Direct Oral Anticoagulants.

BACKGROUND: Periprocedural venous thromboembolisms (VTEs) area rare occurrence but a critical complication after catheter ablation of atrial fibrillation (AF).The aim of this study was to investigate the incidence of symptomatic deep vein thromboses (DVTs) and pulmonary thromboembolisms (PTEs) in patients who underwent AF catheter ablation and received periprocedural oral anticoagulation with direct oral anticoagulants (DOACs). METHODS AND RESULTS: A total of 2,193 consecutive patients undergoing AF catheter ablation with periprocedural DOACs were retrospectively analyzed.Two patients (0.091%) experienced symptomatic DVTs after the ablation, and no patients had any PTEs. One patient was a 72-year-old female who underwent cryoballoon ablation with periprocedural apixaban at a dose of 2.5 mg twice daily. The other patient was a 74-year-old male who underwent a Hot Balloon ablation and thereafter radiofrequency catheter ablation for recurrent AF with edoxaban at30 mg once daily. Both DVT patients underwent AF ablation by the right femoral vein approach, and after discharge had right leg pain and swelling on post-procedural days 4 and 8, respectively. TheDVT was treated by increasing the dose of apixaban and changing it from 30 mg/day of edoxaban to 15-30 mg/day of rivaroxaban, and the thrombi completely disappeared in both patients without any thromboembolic and hemorrhagic complications. CONCLUSIONS: AF catheter ablation with periprocedural DOAC treatment revealed anextremely low incidence of symptomatic VTEs, which may be successfully treated by increasing the DOAC dose or changing the DOAC type.

The Right to Left Atrial Volume Ratio Predicts Outcomes after Circumferential Pulmonary Vein Isolation of Longstanding Persistent Atrial Fibrillation.

BACKGROUND: We aimed to identify the predictors of clinical outcomes after circumferential pulmonary vein isolation (CPVI) without any substrate modification for longstanding persistent atrial fibrillation (LSP-AF). METHODS: This study retrospectively analyzed 70 consecutive LSP-AF patients who underwent an initial CPVI and were followed-up for more than 1 year. The right and left atrial volumes indexed to the body surface areas (right atrial volume index [RAVI] and left atrial volume index [LAVI]) were determined by preacquired contrast-enhanced computed tomography (CT). The %RAVI/LAVI was obtained as 100 × RAVI/LAVI. RESULTS: During a median follow-up period of 15 months (interquartile range, 13-19 months), 21 patients (30%) had arrhythmia recurrences after the CPVI. Antiarrhythmic drugs were continued in 34 patients (48%). In the Cox proportional hazard model, the %RAVI/LAVI was a significant positive predictor of arrhythmia recurrences (hazard ratio, 1.048; P = 0.039). A receiver-operating characteristic analysis demonstrated that at an optimal cutoff of 100.1 for the %RAVI/LAVI, the sensitivity and specificity for predicting arrhythmia recurrences were 85.7% and 71.4%, respectively. The Kaplan-Meier analysis showed that arrhythmia recurrences were less frequent in patients with a %RAVI/LAVI of <100.1 than in those with a %RAVI/LAVI of ≥100.1 (P < 0.0001), and the arrhythmia-free survival rate at 12 months was 89.7% and 45.2%, respectively. CONCLUSIONS: The ratio of the RAVI to LAVI on CT may be a useful predictor of clinical outcomes after CPVI of LSP-AF. LSP-AF patients with a less predominant right atrial enlargement relative to the left atrial enlargement may be good candidates for successful treatment with CPVI alone as the ablation strategy for LSP-AF.

Evaluation of Simultaneous Dual-radioisotope SPECT Imaging Using (18)F-fluorodeoxyglucose and (99m)Tc-tetrofosmin.

OBJECTIVES: Use of a positron emission tomography (PET)/single-photon emission computed tomography (SPECT) system facilitates the simultaneous acquisition of images with fluorine-18 fluorodeoxyglucose ((18)F-FDG) and technetium ((99m)Tc)-tetrofosmin. However, (18)F has a short half-life, and 511 keV Compton-scattered photons are detected in the (99m)Tc energy window. Therefore, in this study, we aimed to investigate the consequences of these facts. METHODS: The crosstalk correction for images in the (99m)Tc energy window involved the dual energy window (DEW) subtraction method. In phantom studies, changes in the count of uniform parts in a phantom (due to attenuation from decay), signal detectability in the hot-rod part of the phantom, and the defect contrast ratio in a cardiac phantom were examined. RESULTS: For (18)F-FDG in the step-and-shoot mode, nearly a 9% difference was observed in the count of projection data between the start and end positions of acquisition in the uniform part of the phantom. Based on the findings, the detectability of 12 mm hot rods was relatively poor. In the continuous acquisition mode, the count difference was corrected, and detectability of the hot rods was improved. The crosstalk from (18)F to the (99m)Tc energy window was approximately 13%. In the cardiac phantom, the defect contrast in (99m)Tc images from simultaneous dual-radionuclide acquisition was improved by approximately 9% after DEW correction; the contrast after correction was similar to acquisition with (99m)Tc alone. CONCLUSION: Based on the findings, the continuous mode is useful for (18)F-FDG acquisition, and DEW crosstalk correction is necessary for (99m)Tc-tetrofosmin imaging.

[Safety of pemetrexed according to the duration of vitamin B12 and folic acid supplementation prior to the first dose of pemetrexed].

OBJECTIVE: Administration of vitamin B12 and folic acid for 7 days prior to the administration of the first dose of pemetrexed is recommended. However, vitamin supplementation rarely is initiated less than 7 days prior to the first dose of pemetrexed. Therefore, we analyzed the safety of pemetrexed with vitamin supplementation for less than 7 days prior to the first dose of pemetrexed. METHODS: Patients were classified into 2 groups according to the duration of vitamin supplementation prior to the first dose of pemetrexed: group A received vitamin supplementation for 7 days or more, and group B received vitamin supplementation for less than 7 days. We analyzed adverse effects, such as myelosuppression, rash, and diarrhea, after 1 cycle of pemetrexed therapy. RESULTS: A total of 70 patients were administered pemetrexed; 40 patients were men and 30 were women with a median age of 64.5 years(range, 43-86 years). A total of 57 patients were classified into group A and 13 into group B; 33 patients were administered pemetrexed as a first-line treatment. Neutropenia of Grade 3 or more was observed in 4/49(8.2%)patients in group A and 2/13(15.4%)patients in group B(p=0.60). There were no significant differences in the rates of occurrence of neutropenia, rash, and diarrhea. CONCLUSION: This retrospective study indicated that patients could be safely treated with pemetrexed if vitamin supplementation is initiated for less than 7 days prior to the first administration of pemetrexed. However, further studies are needed because of a lack of statistical power and adjustment for confounding factors.

[Physical improvements and rising motivation following the "school style" technique in the residents of a nursing home].

OBJECTIVES: After five years of using our unique "school style" technique, we were able to increase the number of home discharges and decrease the number of days spent in the facility. In order to identify the factors underlying these results, a survey was conducted regarding changes of the physical and cognitive function while in the facility. METHODS: The subjects included 41 patients who newly began using our facility. All subjects participated in both group and individual programs and were evaluated using the Mini Mental State Examination (MMSE), Frontal Assessment Battery at the bedside (FAB), Vitality Index and Functional Independence Measure (FIM) determined monthly starting the first day of entry into our facility. We compared the results using the Friedman test. RESULTS: The rate of participation in the group program was 81.9%. The average duration of participation in functional training as an individual program was 5.94 days, while that for Kumon learning therapy was 3.27 days. Effective improvements were noted in all four evaluation measurements: MMSE・FAB・Vitality Index・FIM. CONCLUSIONS: Improvements in the physical and cognitive function were obtained despite the status of the subjects as elderly individuals with chronic disease. Against this background, we applied interventions with rehabilitation using an intensive program for individuals and noted a pleasant experience during all activities in our unique "school style" protocol, which seeks to improve the subject's motivation. These factors are therefore important for improving the physical and cognitive function.

[A clinical case of progressive supranuclear palsy with long-term frontal presentation preceding the onset of gaze palsy].

Progressive supranuclear palsy (PSP) is a neurodegenerative disorder with diverse clinical phenotypes characterized by supranuclear gaze palsy, parkinsonism with postural instability, and frontal dementia. The early and accurate diagnosis of PSP remains difficult because of the variable combination of symptoms and frequent lack of gaze abnormalities early in the disease course. Moreover, a subset of PSP shows behavioral changes as the initial presentation, which considerably overlaps with the clinical picture of frontotemporal dementia (FTD). Thus, this subgroup possibly needs psychiatric assessments. Here, we describe a clinical case of PSP difficult to differentiate from FTD because the frontal presentation persisted without gaze palsy until the late stage of the clinical course. A 58-year-old man was admitted to our hospital for the reconsideration of a diagnosis of FTD. Disinhibited and gambling behaviors inconsistent with his previous personality first appeared at around the age of 45, with gradual progression, followed by memory deficits, executive dysfunction, and a slowing of mental processes. Recurrent sexual disinhibition led him to undergo psychiatric consultation at the age of 57. Downward gaze palsy and postural instability with recurrent falls emerged 8 months after the first psychiatric examination, and he was clinically diagnosed with PSP 13 years after the initial frontal presentation. PSP should be considered in the differential diagnosis of patients presenting with frontal lobe symptoms, even in psychiatric practice.

Predictors of asymptomatic cerebral infarction associated with radiofrequency catheter ablation for atrial fibrillation using an irrigated-tip catheter.

AIMS: Catheter ablation is a potentially curative treatment for atrial fibrillation (AF). However, complications such as ischaemic stroke are more frequent and more severe compared with ablation procedures for other arrhythmias. Irrigated-tip catheters have been reported to reduce the risk of stroke. The present study aimed to evaluate predictors of asymptomatic cerebral infarction (CI) after AF ablation using an irrigated-tip catheter. METHODS AND RESULTS: A total of 70 consecutive AF patients who underwent catheter ablation were subjected to brain magnetic resonance imaging (MRI) 1 day after the procedure. In 10 (14.3%) of 70 patients, MRI revealed acute CI, but neither symptoms nor abnormal neurological findings were present in these patients. In univariate analysis, a history of persistent AF, left atrial dimension, presence of spontaneous echo contrast (SEC), procedure duration prior to heparin injection, and electrical cardioversion during the procedure differed significantly between the two groups, those with and without CI (P = 0.02, 0.05, 0.01, 0.01, and 0.05, respectively). Multivariate logistic regression analysis identified SEC [odds ratio (OR), 9.39; 1.60-55.2; P = 0.01] and procedure duration prior to heparin injection (OR, 1.19; 1.04-1.36; P = 0.01) as predictive of acute asymptomatic CI after AF ablation. CONCLUSION: The presence of SEC and procedure duration prior to heparin injection are determinants of asymptomatic CI during AF ablation despite the use of an irrigated-tip catheter.