Effectiveness of remote risk-based monitoring and potential benefits for combination with direct data capture.

BACKGROUND: In recent years, alternative monitoring approaches, such as risk-based and remote monitoring techniques, have been recommended instead of traditional on-site monitoring to achieve more efficient monitoring. Remote risk-based monitoring (R2BM) is a monitoring technique that combines risk-based and remote monitoring and focuses on the detection of critical data and process errors. Direct data capture (DDC), which directly collects electronic source data, can facilitate R2BM by minimizing the extent of source documents that must be reviewed and reducing the additional workload on R2BM. In this study, we evaluated the effectiveness of R2BM and the synergistic effect of combining R2BM with DDC. METHODS: R2BM was prospectively conducted with eight participants in a randomized clinical trial using a remote monitoring system that uploaded photographs of source documents to a cloud location. Critical data and processes were verified by R2BM, and later, all were confirmed by on-site monitoring to evaluate the ability of R2BM to detect critical data and process errors and the workload of uploading photographs for clinical trial staff. In addition, the reduction of the number of uploaded photographs was evaluated by assuming that the DDC was introduced for data collection. RESULTS: Of the 4645 data points, 20.9% (n = 973, 95% confidence interval = 19.8-22.2) were identified as critical. All critical data errors corresponding to 5.4% (n = 53/973, 95% confidence interval = 4.1-7.1) of the critical data and critical process errors were detectable by R2BM. The mean number of uploaded photographs and the mean time to upload them per visit per participant were 34.4 ± 11.9 and 26.5 ± 11.8 min (mean ± standard deviation), respectively. When assuming that DDC was introduced for data collection, 45.0% (95% confidence interval = 42.2-47.9) of uploaded photographs for R2BM were reduced. CONCLUSIONS: R2BM can detect 100% of the critical data and process errors without on-site monitoring. Combining R2BM with DDC reduces the workload of R2BM and further improves its efficiency.

Direct detection of dithiocarbamate fungicides by SALDI/MS using porous TiC ceramic powder as a substrate.

Dithiocarbamate fungicides (DTCs) have been widely used all over the world. Some of them show toxicities, such as growth toxicity and teratogenicity. Therefore, the analysis of DTCs in environments or crops is very significant. However, their direct and individual analysis was difficult, because most of them are metal complex compounds and have macromolecular properties and a low solubility in water or organic solvents. In the conventional analytical methods for DTCs, the total amount of DTCs was obtained by the quantification of the derivatives of the ligand or by measuring the carbon disulfide formed by the decomposition of the fungicides. Surface assisted laser desorption (SALDI)/MS can detect various compounds, such as metal complexes and macromolecules, present in a nanostructured substrate. The porous titanium carbide (TiC) ceramic powder shows adsorptive properties to various substances and can be used as a substrate for SALDI/MS. In this study, a method for the individual and direct detection of dithiocarbamate pesticides by SALDI/MS using porous TiC ceramics as a substrate has been developed. The dithiocarbamate fungicide was mixed with the porous TiC powder in a mortar, and the mixture was analyzed by SALDI/MS. The deprotonated ion of the ethylene-bis-dithiocarbamate complex, mancozeb or zineb, was detected in the negative ion mode. For the dimethyldithiocarbamate complexes, ferbam and ziram, the ion of the eliminated dithiocarbamate ligand was detected in the positive ion mode. Calibration curves by the present method for Manzeb showed good linearity by using an internal standard material. Based on these results, we concluded that this method is useful for the analysis of DTCs.

Effect of water deficit stress during fruit cultivation on the carbon stable isotopes of organic acids in Japanese apricots and liqueur prepared from these fruits.

ABSTRACTThe objective of this study was to assess the impact of water deficit stress during fruit cultivation on the δ13C values of citric acid and malic acid in Japanese apricots at different ripeness stages and their resulting liqueurs. Our experiments show that water deficit stress increases the δ13C values of citric acid and malic acid in tree-ripened fruits, counteracting the typical decrease during ripening. However, water deficit treatment has a minimal effect on the δ13C values of organic acids in green fruits. Regardless of fruit ripeness or water status, the δ13C values of organic acids in fruits are directly reflected in the resulting liqueurs. Overall, water deficit stress during fruit cultivation has the potential to promote similarity in the δ13C values of organic acids across fruits at different ripeness levels, reducing variations among liqueurs derived from fruits of varying ripeness levels.

Computational and Experimental Analyses for Pathogenicity Prediction of ACVRL1 Missense Variants in Hereditary Hemorrhagic Telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is a vascular disease caused by the defects of ALK1/ACVRL1 receptor signaling. In this study, we evaluated 25 recently identified ACVRL1 missense variants using multiple computational pathogenicity classifiers and experimentally characterized their signal transduction capacity. Three extracellular residue variants showed no detectable cell surface expression and impairment of bone morphogenetic protein 9 (BMP9) responsiveness of SMAD-dependent transcription in luciferase assays. Four variants with amino acid replacement in the motifs essential for the intracellular kinase function lost SMAD-dependent signaling. Most of other variations in the kinase domain also caused marked downregulation of signaling; however, two variants behaved as the wild-type ACVRL1 did, while computational classifiers predicted their functional abnormalities. Three-dimensional structure prediction using the ColabFold program supported the significance of the L45 loop and NANDOR domain of ACVRL1 for its association with SMAD1 and BMPR2, respectively, and the variations in these motifs resulted in the reduction of SMAD signaling. On the other hand, two of the GS domain variants maintained high signal transduction capacity, which did not accord with their computational pathogenicity prediction. These results affirm the requirement of a combinatory approach using computational and experimental analyses to accurately predict the pathogenicity of ACVRL1 missense variants in the HHT patients.

Carbon stable isotopic compositions of glucose and ethanol in sake after simultaneous saccharification and fermentation processes.

The carbon stable isotopic composition of glucose is transferred to that of ethanol during the simultaneous saccharification and fermentation processes of sake production. However, there is limited information regarding carbon isotope discrimination between the ingredient rice and the sake components. Our fermentation experiments show that the carbon stable isotopic composition of rice is intermediate between those of glucose and ethanol in sake and do not differ significantly from those of rice koji and sake lees. Carbon isotope discrimination from rice to ethanol and from glucose to ethanol is 0.9 ± 0.1‰ (mean ± standard deviation, n = 18) and 1.9 ± 0.2‰, respectively. This is approximately half of the isotope discrimination observed in grape wine due to the saccharification process during sake manufacture. Carbon isotope discrimination from ingredient rice to sake components provides valuable insights for the manufacturing process and the authentication of sake.

The effect of Aspergillus luchuensis pectin methylesterase genes pmeA and pmeB on methanol production in sweet potato shochu.

To reduce the methanol content in sweet potato shochu, we studied the pectin methylesterase genes of the shochu-koji mold Aspergillus luchuensis. We found the following three homologs of pectin methyleseterase in the genome of A. luchuensis: pmeA, pmeB, and pmeC. Using pectin as a substrate, the methanol-producing activity of the recombinant of each gene expressed in A. luchuensis was examined and found to be present in recombinant PmeA and PmeB. Additionally, small-scale fermentation of sweet potato shochu using disruptions of pmeA and pmeA-pmeB in A. luchuensis (∆pmeA and ∆pmeApmeB) resulted in significant reduction of the methanol content. Taken together, we revealed that the A. luchuensis pmeA gene was mainly involved in methanol production in sweet potato shochu.

Atlantoaxial Stabilization Using C1 Lateral Mass and C2 Pedicle/Translaminar Screw Fixation by Intraoperative C1- and C2-Direct-Captured Navigation with Preoperative Computed Tomography Images.

In C1-C2 posterior fixation, the C1 lateral mass and C2 pedicle/translaminar screw insertion under spine navigation have been used frequently. To avoid the risk of neurovascular damage in atlantoaxial stabilization, we assessed the safety and effectiveness of a preoperative computed tomography (CT) image-based navigation system with intraoperative independent C1 and C2 vertebral registration. It is ideal when a reference frame can be linked directly to the C1 posterior arch for C1-direct-captured navigation, but there is a mechanical challenge. A new spine clamp-tracker system was implemented recently, which allows reliable C1- and C2- direct-captured navigation in nine patients with traumatic C2 fractures. In this way, there was no misalignment of C1-C2 screws. C1 lateral mass screws were used except for one case, and translaminar screws were primarily used as an anchor for C2. The C1 lateral mass screw locations, which are 19 mm laterally from the C1 posterior arch's center, are taken to be constant. However, there is one unusual circumstance in which using a C1 laminar hook instead of a C1 lateral mass screw appears to be a beneficial substitute. The increase of surgical accuracy for posterior C1-C2 screw fixation without cost constraints is significantly facilitated by intraoperative C1- and C2-direct-captured navigation with preoperative computed CT images.

Presence of Disulfide-Bonded Thiols in Malt and Hops as the Precursors of Thiols in Beer.

Disulfide-bonded thiols in malt and hops were first identified as possible precursors of thiols in beer. The presence of disulfide-bonded 3-mercaptohexan-1-ol (3MH) was confirmed in malt and hops by observing an 8.9-9.9 times increase in the 3MH concentration in hopped water and unhopped wort after the reduction using tris(2-carboxyethyl)phosphine (TCEP), a reducing agent specific for disulfide bonds. The presence of disulfide-bonded 4-mercapto-4-methylpentan-2-one (4MMP) was confirmed in hops by observing 2.1 and 5.1 times increase in the 4MMP concentration after reduction in hopped water. Proteins, peptides, and amino acids having sulfhydryl groups or other thiol substances were assumed to form disulfide bonds with polyfunctional thiols in malt and hops. The release of thiols by the reduction of disulfide-bonded thiols during fermentation was first identified. A 65-82% of disulfide-bonded 3MH were reduced during fermentation, and as a result, concentrations of 3MH in hopped water and unhopped wort increased by 9.5-14.2 times during fermentation.

Isolation of Aspergillus oryzae mutants producing low levels of 2,4,6-trichloroanisole.

Musty or moldy off-odor in sake severely reduces its quality. Such off-odor is caused by 2,4,6-trichloroanisole (TCA), a compound that is produced by Aspergillus oryzae during sake production by O-methylating the precursor 2,4,6-trichlorophenol (TCP). TCP suppresses the growth of fungi, including A. oryzae, although TCA does not. Therefore, strains that are unable to convert TCP to TCA should be sensitive to TCP in the medium. Nevertheless, A. oryzae with a disrupted O-methyltransferase gene (ΔomtT) grew in a medium containing TCP. In agar medium, we observed no growth difference between the ΔomtT strain and a non-disrupted transformant; however, a significant growth delay was observed with the ΔomtT strain grown in liquid medium containing 0.5 µg/mL of TCP. This strain was more sensitive to low concentrations of TCP, suggesting that omtT contributes to the conversion (detoxification) of TCP in liquid culture. We generated A. oryzae RIB 40 mutants by ultraviolet irradiation and then cultured them in liquid medium containing TCP to obtain strains that did not produce moldy odor. The slow-growing strains were cultured in agar plates and then used to make koji with added TCP. We obtained three strains with lower TCA-producing ability and with sufficient hydrolase activities for sake brewing.

Chemometric approaches for determining the geographical origin of Japanese Chardonnay wines using oxygen stable isotope and multi-element analyses.

Determining the geographical origin of wines is a major challenge in wine authentication, but little information is available regarding non-parametric statistical approaches for wines. In this study, we collected 33 domestic Chardonnay wines vinified on a small scale from grapes cultivated in Japan, and 42 Chardonnay wines imported from 8 countries, for oxygen stable isotope and multi-element analyses. Non-metric multidimensional scaling (NMDS), kernel principal component analysis (KPCA) and principal component analysis (PCA) were applied to the oxygen stable isotopic compositions (δ18O) and the concentrations of 18 elements in the wines to compare the extractions by parametric and non-parametric methods. The non-parametric methods, NMDS and KPCA, separated domestic from imported Chardonnay wines better than the parametric method, PCA. Of 19 variables, 18 were important for geographical discrimination, with the δ18O value being the most significant in all statistic methods. Non-parametric multivariate analyses will help discriminate domestic from imported Chardonnay wines.

Prediction method for determining the carbon stable isotopic composition of berry sugars in the original must of Chardonnay wines.

The carbon stable isotopic composition, as indicated by the δ13C value, of wine ethanol is inherited from berry sugars, but little is known about the variation in sugar δ13C values of Japanese grapes relative to overseas grapes. This study found a large variation in sugar δ13C values of Chardonnay grapes grown in Japan (-27.2 ± 0.9‰, mean ± standard deviation, n = 33), with sugar δ13C values depending on the δ13C values and content of monosaccharides. After complete fermentation, the carbon isotope discrimination between berry sugars and wine ethanol was 1.5 ± 0.1‰. Ethanol δ13C values and carbon isotope discrimination enabled prediction of sugar δ13C values in the original must. Imported wines had higher sugar δ13C values than those of wines made from Japanese grapes, suggesting drier overseas viticulture conditions. The determination of sugar δ13C values in grape berries provides valuable information for viticulture and wine authentication.

Two long-term phase 3 studies of enarodustat (JTZ-951) in Japanese anemic patients with chronic kidney disease not on dialysis or on maintenance hemodialysis: SYMPHONY ND-Long and HD-Long studies.

Enarodustat (JTZ-951) is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor developed for treating anemia in chronic kidney disease. Two open-label, uncontrolled phase 3 studies evaluated the 52-week safety and efficacy of enarodustat in Japanese anemic patients with chronic kidney disease not on dialysis (n = 132) [SYMPHONY ND-Long study] or on maintenance hemodialysis (n = 136) [SYMPHONY HD-Long study]. The most frequent adverse events were viral upper respiratory tract infection (25.8%) followed by chronic kidney disease (8.3%) in the SYMPHONY ND-Long study, and viral upper respiratory tract infection (49.3%) followed by contusion (16.9%) and diarrhea (16.9%) in the SYMPHONY HD-Long study. The incidence of any adverse events did not increase over time. Mean hemoglobin levels and 95% confidence intervals were maintained within the target range (10.0-12.0 g/dl) over 52 weeks in both studies. The long-term safety and efficacy of enarodustat were confirmed in Japanese anemic patients with chronic kidney disease.

Development of Indole Alkaloid-Type Dual Immune Checkpoint Inhibitors Against CTLA-4 and PD-L1 Based on Diversity-Enhanced Extracts.

Cancer immunotherapy involves the use of the immune system for cancer treatment. Recently, immune checkpoint-blocking antibodies have become integral for the treatment of some cancers. However, small molecules exhibit advantages over monoclonal antibody drugs, such as cell penetration, long half-life, and low manufacturing costs, and the possibility of oral administration. Thus, it is imperative to develop small-molecule immune checkpoint inhibitors. Previously, we have screened a library of synthetic indole-alkaloid-type compounds, which are produced by diversity-enhanced extracts of Japanese cornelian cherry, and reported that an unnatural pentacyclic compound inhibits CTLA-4 gene expression. In this study, immune checkpoint inhibitors with increased potency were developed by introducing substituents and conversion of functional groups based on the unnatural pentacyclic compound. The developed compounds suppressed not only CTLA-4 and PD-L1 gene expression but also protein expression on the cell surface. Their efficacy was not as potent as that of the existing small-molecule immune checkpoint inhibitors, but, to the best of our knowledge, the developed compounds are the first reported dual small-molecule inhibitors of CTLA-4 and PD-L1.

Growth characteristics of Aspergillus oryzae in the presence of 2,4,6-trichlorophenol.

During the making of rice-koji for sake production, 2,4,6-trichlorophenol (TCP) is O-methylated to 2,4,6-trichloroanisole (TCA) by the koji-mold, Aspergillus oryzae, resulting in a musty/moldy off-odor, which significantly reduces the quality of sake. Thus, we aim to develop A. oryzae strains with a less-efficient ability to produce TCA. TCP is a fungicide that suppresses the growth of fungi, whereas TCA does not. The exact effects of TCP on the growth of A. oryzae are unknown. However, it is assumed that a strain with low TCP conversion ability will be sensitive to TCP concentration. In this study, we investigated the effects of the different concentrations of TCP on the growth suppression of A. oryzae. As the TCP concentration in the media increased, the growth rate, and conidia formation of A. oryzae slowed down. No growth was observed in liquid culture (for 1 day at 30°C) containing more than 30 µg/mL of TCP and in agar culture (for 7 days at 30°C) containing more than 50 µg/mL of TCP. However, A. oryzae was able to grow on alpha rice containing higher concentrations of TCP. The results in agar culture are consistent with the effects of TCP on other Aspergillus species.

Expression profiles of amylolytic genes in AmyR and CreA transcription factor deletion mutants of the black koji mold Aspergillus luchuensis.

The black koji mold, Aspergillus luchuensis, which belongs to Aspergillus section Nigri, is used for the production of traditional Japanese spirits (shochu) mainly in the southern districts of Japan. This mold is known to produce amylolytic enzymes essential for shochu production; however, mechanisms regulating amylolytic gene expression in A. luchuensis have not been studied in as much detail as those in the yellow koji mold, Aspergillus oryzae. Here, we examined the gene expression profiles of deletion mutants of transcription factors orthologous to A. oryzae AmyR and CreA in A. luchuensis. A. luchuensis produces acid-unstable (AmyA) and acid-stable (AsaA) α-amylases. AmyA production and amyA gene expression were not influenced by amyR or creA deletion, indicating that amyA was constitutively expressed. In contrast, asaA gene expression was significantly down- and upregulated upon deletion of amyR and creA, respectively. Furthermore, the glaA and agdA genes (encoding glucoamylase and α-glucosidase, respectively) showed expression profiles similar to those of asaA. Thus, genes that play pivotal roles in starch saccharification, asaA, glaA, and agdA, were found to be regulated by AmyR and CreA. Moreover, despite previous reports on AsaA being only produced in solid-state culture, deletion of the ortholog of A. oryzae flbC, which is involved in the expression of the solid-state culture-specific genes, did not affect AsaA α-amylase activity, suggesting that FlbC was not associated with asaA expression.

Construction of transcription factor gene deletion library of Aspergillus luchuensis.

We selected 96 genes of Aspergillus luchuensis for the construction of a transcription factor gene deletion library. Of these, we successfully deleted 93 genes using Agrobacterium-mediated transformation (AMT) of A. luchuensis RIB 2604 ΔligD strains. We obtained only heterokaryonic strains after deletions of adaB, anBH1, hacA, hapB, hsf1, metR, and sonC gene, and additionally, could not obtain deletion strains for genes abaA and mcmA. The deletion strains will be available through our website (https://www.nrib.go.jp).

Clinical trial monitoring effectiveness: Remote risk-based monitoring versus on-site monitoring with 100% source data verification.

BACKGROUND/AIMS: Traditional on-site monitoring of clinical trials via frequent site visits and 100% source data verification is cost-consuming, and it still cannot guarantee data quality effectively. Depending on the types and designs of clinical trials, an alternative would be combining several monitoring methods, such as risk-based monitoring and remote monitoring. However, there is insufficient evidence of its effectiveness. This research compared the effectiveness of risk-based monitoring with a remote monitoring system with that of traditional on-site monitoring. METHODS: With a cloud-based remote monitoring system called beagle View®, we created a remote risk-based monitoring methodology that focused only on critical data and processes. We selected a randomized controlled trial conducted at Tohoku University Hospital and randomly sampled 11 subjects whose case report forms had already been reviewed by data managers. Critical data and processes were verified retrospectively by remote risk-based monitoring; later, all data and processes were confirmed by on-site monitoring. We compared the ability of remote risk-based monitoring to detect critical data and process errors with that of on-site monitoring with 100% source data verification, including an examination of clinical trial staff workload and potential cost savings. RESULTS: Of the total data points (n = 5617), 19.7% (n = 1105, 95% confidence interval = 18.7-20.7) were identified as critical. The error rates of critical data detected by on-site monitoring, remote risk-based monitoring, and data review by data managers were 7.6% (n = 84, 95% CI = 6.2-9.3), 7.6% (n = 84, 95% confidence interval = 6.2-9.3), and 3.9% (n = 43, 95% confidence interval = 2.9-5.2), respectively. The total number of critical process errors detected by on-site monitoring was 14. Of these 14, 92.9% (n = 13, 95% confidence interval = 68.5-98.7) and 42.9% (n = 6, 95% confidence interval = 21.4-67.4) of critical process errors were detected by remote risk-based monitoring and data review by data managers, respectively. The mean time clinical trial staff spent dealing with remote risk-based monitoring was 9.9 ± 5.3 (mean ± SD) min per visit per subject. Our calculations show that remote risk-based monitoring saved between 9 and 41 on-site monitoring visits, corresponding to a cost of between US$13,500 and US$61,500 per trial site. CONCLUSION: Remote risk-based monitoring was able to detect critical data and process errors as well as on-site monitoring with 100% source data verification, saving travel time and monitoring costs. Remote risk-based monitoring offers an effective alternative to traditional on-site monitoring of clinical trials.

Awamori fermentation test and 1-octen-3-ol productivity analysis using fatty acid oxygenase disruptants of Aspergillus luchuensis.

1-Octen-3-ol is a major aroma component of awamori, a traditional distilled liquor produced in Okinawa Prefecture, Japan. As 1-octen-3-ol is thought to affect the sensory properties of awamori, it is important to fully characterize the compound's biosynthetic pathway and control mechanism. We previously reported that the fatty acid oxygenase ppoC (ppo: psi-produced oxygenase) of Aspergillus luchuensis is directly involved in the production of 1-octen-3-ol in rice koji (Kataoka et al., J. Biosci. Bioeng., 129, 192-198, 2020). In the present study, we constructed A. luchuensis ppoD disruptants to characterize the role of ppo genes in 1-octen-3-ol biosynthesis. A small-scale awamori fermentation test was performed using ppoA, ppoC, and ppoD single disruptants (ΔppoA, ΔppoC, and ΔppoD, respectively), along with the parent strain, ΔligD. 1-Octen-3-ol was not detected in the distillate prepared using the ΔppoC strain. We conclude that A. luchuensis ppoC is the only 1-octen-3-ol-producing factor in the awamori brewing process. Because ΔppoA and ΔppoD slightly enhanced 1-octen-3-ol productivity, these two genes may play a role in negatively controlling 1-octen-3-ol biosynthesis.

Impact of delayed ventricular wall area ratio on pathophysiology of mechanical dyssynchrony: implication from single-ventricle physiology and 0D modeling.

Electrical disparity can induce inefficient cardiac performance, representing an uncoordinated wall motion at an earlier activated ventricular wall: an early shortening followed by a systolic rebound stretch. Although regional contractility and distensibility modulate this pathological motion, the effect of a morphological factor has not been emphasized. Our strain analysis in 62 patients with single ventricle revealed that those with an activation delay in 60-70% of ventricular wall area suffered from cardiac dysfunction and mechanical discoordination along with prolonged QRS duration. A computational simulation with a two-compartment ventricular model also suggested that the ventricle with an activation delay in 70% of the total volume was most vulnerable to a large activation delay, accompanied by an uncoordinated motion at an earlier activated wall. Taken together, the ratio of the delayed ventricular wall has a significant impact on the pathophysiology due to an activation delay, potentially highlighting an indicator of cardiac dysfunction.

Etiology of atrial fibrillation in patients with complex congenital heart disease - for a better treatment strategy.

BACKGROUND: The demographics of patients with congenital heart disease (CHD) and atrial fibrillation (AF) differ significantly from the general population. The etiology and treatment strategy for AF in CHD patients have been investigated but are to date inconclusive. METHODS: To determine the etiology of AF in CHD and to seek a better treatment strategy, we retrospectively evaluated the atrial overload in 42 complex CHD cases with normal atrial arrangements and AF (age 25; range, 9-66 years) and the impact of a reduction in the atrial overload on the atrial rhythm. RESULTS: Cardiac defect diagnoses varied, with 17% of the patients having a persistent left superior vena cava (PLSVC). In regard to the volume overload, the frequencies of an overload in the right atrium (RA), left atrium (LA), or both, were 50 %, 23%, and 10%, respectively (p = 0.015). Other sustained supraventricular tachycardias were observed in 29 patients (69%) before and after the onset of AF. Among these 29 patients, 26 had intra-atrial reentrant tachycardia. Fifteen patients (36%), 10 of whom had chronic AF, died during the follow-up including 3 with arrhythmias and 10 because of heart failure. Fourteen (33%) patients had no AF at the last follow-up due to medical interventions, 8 of which underwent solely an RA-sided catheter ablation and/or surgical RA overload reduction. CONCLUSIONS: AF in complex CHD with a normal atrial arrangement correlates with a higher RA-sided overload than an LA-sided and exhibits a high incidence of PLSVCs, high comorbidity of intra-atrial reentrant tachycardias, and high mortality rate. In a substantial number of patients, RA-sided interventions were effective in controlling AF. To effectively manage AF in complex CHD it is essential to understand each individual's hemodynamics and consider hemodynamic interventions.