Prevalence and characteristics of atrioventricular nodal reentrant tachycardia with a bystander concealed nodoventricular/nodofascicular pathway.

BACKGROUND: The concealed nodoventricular/nodofascicular (NV/NF) pathway is mostly a bystander, retrograde bypass tract connecting right ventricle/right bundle branch (RBB) and slow pathway (SP), which is observed in patients with atrioventricular nodal reentrant tachycardia (AVNRT). However, its prevalence and characteristics in response to pacing maneuvers have not been fully evaluated. OBJECTIVE: This study investigated the prevalence and characteristics of AVNRT with a bystander NV/NF-pathway. METHODS: We retrospectively reviewed 153 consecutive patients undergoing catheter ablation of AVNRT. Excluding 52 patients with inadequate electrophysiological data, 101 patients composed the study population. RESULTS: Three patients (3.0%) had bystander concealed NV/NF-pathways, all of which were connected to the SP. The tachycardia was typical SP/fast pathway (FP) AVNRT in two patients and atypical FP/SP AVNRT in one patient. In all cases, His-refractory ventricular extra stimuli (VESs) reset the AVNRTs with delay through the NV/NF-pathways. Ventricular overdrive pacing (VOP) in the early-phase also reset the AVNRT with delay. Earlier VESs and middle-phase of VOP did not reset the tachycardia, and further earlier VESs and late-phase of VOP reset the tachycardia with advance through the RBB-His conduction. CONCLUSION: A bystander NV/NF-pathway was not rare in patients with AVNRT. The VESs and VOP for the AVNRTs with the bystander NV/NF-pathways were characterized by the two-phase resetting phenomenon: initial transient resetting with delay through the NV/NF-pathway, and late resetting with advance through the RBB-His conduction.

A case of a systemic cancer-associated thrombosis successfully treated with multi-disciplinary treatment including anticoagulation therapy and anticancer drug therapy.

Background: Cancer-associated thrombosis (CAT) is one of the major complications during the treatment course of cancer, which often challenges clinicians in daily clinical practice despite anticoagulation therapy. Case summary: A 57-year-old man with a history of a liver transplantation was diagnosed with post-transplant lymphoproliferative disorders. He developed severe systemic thromboses including a massive pulmonary embolism and was treated with anticoagulation therapy including a factor Xa inhibitor. However, the systemic thromboses worsened despite the anticoagulation therapy. During the acute treatment course of the thromboses, we administered anticancer drug therapy in hopes of an improvement in the activity of the cancer status leading to a favourable effect on the thrombosis status. Multi-disciplinary treatment including anticoagulation therapy and anticancer drug therapy successfully improved the systemic thrombosis. Discussion: Anticoagulation therapy is a standard treatment for CAT; however, some cases of CAT do not successfully improve despite anticoagulation therapy, partly due to a highly active cancer status. Anticancer drug therapy might increase the risk of a thrombosis, whereas it could improve the activity of the cancer status leading to a decreased risk of a thrombosis. A multi-disciplinary therapy might be a reasonable option especially for CAT with a highly active cancer status.

Impact of catheter ablation on functional tricuspid regurgitation in patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) plays the main role in atrial functional tricuspid regurgitation (TR). However, the effectiveness of catheter ablation (CA) for atrial functional TR together with the mechanisms of improvement of atrial functional TR have not been fully evaluated. METHODS: We retrospectively investigated consecutive 2685 patients with AF who received CA from February 2004 to December 2019 in Kyoto University Hospital, Kyoto, Japan. The current study population consisted of 2331 patients with available transthoracic echocardiographic (TTE) data before CA (2110 patients without significant TR and 221 patients with significant TR). Among the 221 patients with significant TR, there were 64 patients with functional TR and follow-up TTE at 6-18 months after CA for AF, in whom we compared echocardiographic parameters from baseline to follow-up. RESULTS: Patients with significant TR were older, and more often women, and had more persistent AF than those without significant TR. Among the 64 patients with functional TR, TR severity and TR jet area significantly improved at follow-up (TR jet area: 5.8 [4.0-7.6] cm2 to 2.1 [1.1-3.1] cm2, P < 0.001). Moreover, mitral regurgitation jet area, left atrial area, mitral valve diameter, right ventricular end-diastolic area, right atrial area, and tricuspid valve diameter decreased at follow-up. CONCLUSIONS: TR severity and jet area improved after CA in patients with AF and significant TR. The improvement of TR might be associated with reverse remodeling of the right heart.

Periprocedural management and clinical outcomes of invasive procedures after venous thromboembolism: from the COMMAND VTE registry.

Anticoagulation therapy is prescribed for the prevention of recurrence in patients with venous thromboembolism, which could be temporarily interrupted during invasive procedures. The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE in Japan between January 2010 and August 2014. We identified patients who underwent invasive procedures during the entire follow-up period and evaluated periprocedural managements and clinical outcomes at 30 days after invasive procedures. During a median follow-up period of 1213 (IQR: 847-1764) days, 518 patients underwent invasive procedures with the cumulative incidences of 5.8% at 3 months, 11.1% at 1 year, and 24.0% at 5 years. Among 382 patients in high bleeding-risk category of invasive procedures, anticoagulation therapy had been discontinued already in 62 patients (16%) and interrupted temporarily in 288 patients (75%) during the invasive procedures with bridging anticoagulation therapy with heparin in 214 patients (56%). Among 80 patients in low bleeding-risk category, anticoagulation therapy had been already discontinued in 15 patients (19%) and interrupted temporarily in 31 patients (39%) during invasive procedure with bridging anticoagulation therapy with heparin in 17 patients (21%). At 30 days after the invasive procedures, 14 patients (2.7%) experienced recurrent VTE, while 28 patients (5.4%) had major bleeding. This study elucidated the real-world features of peri-procedural management and prognosis in patients with VTE who underwent invasive procedures during follow-up in the large multicenter VTE registry. The 30-day incidence rates of recurrent VTE and major bleeding events were 2.7% and 5.4%.