Pulmonary vein (PV) isolation is an established treatment strategy for paroxysmal atrial fibrillation (PAF). However, the recurrence rate of PAF is 8% to 37%, despite repeated procedures, and the ...catheter ablation strategy for PAF with non-PV foci is unclear.
The purpose of this study was to assess the PAF ablation strategy for non-PV foci.
The study included 304 consecutive patients undergoing PAF ablation (209 males, age 63.0 ± 10.4 years) divided into 3 groups: group 1 (245 patients) with no inducible non-PV foci; group 2 (34 patients) with atrial fibrillation (AF) originating from non-PV foci and all the foci successfully ablated; and group 3 (25 patients) with AF originating from non-PV triggers, but without all foci being ablated or with persistently inducible AF.
Mean follow-up period was 26.9 ± 11.8 months, and AF recurrence rates since the last procedure were 9.8%, 8.8%, and 68.0% in groups 1, 2, and 3, respectively. There was no statistically significant difference in recurrence rate between groups 1 and 2 (P = .89); however, there were statistically significant differences between groups 3 and 1 (P <.0001) and groups 3 and 2 (P <.0001). The patients in group 2 had an AF-free outcome to equivalent to those who had PV foci in group 1 (P = .83).
Success rates can be improved for PAF ablation if non-PV foci are detected and eliminated.
Abstract Background Lead extraction using laser sheaths is performed mainly for cardiac implantable electronic device (CIED) infections. However, there are few reports concerning the management of ...CIED infections in Japan. Methods and results Lead extraction procedures were performed in 183 patients targeting 450 leads (atrial leads: 170, ventricular: 181, implantable cardioverter-defibrillators (ICDs): 79, and coronary sinus: 20). One hundred twenty patients (65.6%) presented with pocket infections without the presentation of an endovascular infection. Blood cultures were positive at least once in 63 patients (34.4%). Complete procedure success was achieved for 437 leads (97.1%) while partial removal occurred in nine, and failure in four leads. Major complications directly related to the procedure occurred in five patients (2.7%). Two of the four patients with a cardiac tamponade required a surgical repair. All patients received intravenous antibiotics, at least, one week after the procedure. Pocket or systemic infections were successfully controlled in 181 patients (98.9%). Coagulase-negative staphylococci (30.1%) and Staphylococcus aureus (37.1%) were the most common causes of CIED infections. Conclusion The current status of CIED infections in Japan seems to be similar to that previously reported from foreign countries. The optimal treatment of CIED infections involves the complete explantation of all hardware, followed by antibiotic therapy.
Abstract Background Data regarding long-term mortality and factors influencing appropriate therapies in Japanese patients with implantable cardioverter defibrillators (ICD), who satisfy the ...Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) criteria for primary prevention, remain scarce. Methods A total of 118 consecutive patients who underwent ICD implantation without any prior ventricular arrhythmic event, from January 2000 to December 2012, were enrolled based on the MADIT II criteria: left ventricular ejection fraction (LVEF) of ≤30% with ischemic heart disease and at least 4 weeks after a myocardial infarction. We investigated the mortality and factors influencing appropriate ICD therapies in this population. Results The mean age was 69±10 years, and the mean LVEF was 25.1±4.5%. During the median follow up of 1406 days, the mortality rate was 20%, and the incidence of appropriate ICD therapy was 37% at 3 years. Multivariate analysis by using Cox regression model showed that left ventricular diastolic diameter ≥60 mm (hazard ratio HR, 2.31; 95% confidence interval CI, 1.07–5.38; P =0.033) and the presence of non-sustained ventricular tachycardia (NSVT) before implantation (HR, 2.26; 95% CI, 1.17-4.39; P =0.015) were independent predictors of appropriate ICD therapy. Conclusions The mortality and incidence of appropriate ICD therapy were 20% and 37%, respectively, at 3 years in Japanese patients who met the MADIT II criteria during ICD implantation for primary prevention of sudden cardiac death. The presence of NSVT and dilated left ventricle independently predicted the incidence of appropriate ICD therapy after implantation.
Abstract Background Catheter ablation can reduce episodes of ventricular tachycardia (VT) after myocardial infarction (MI). However, the optimal endpoint of the ablation procedure remains unclear. ...Methods Fifty-one consecutive patients who received catheter ablation for VT after MI were included. The procedures targeted the isthmus of all the induced, sustained VTs. When the patients with induced VTs were hemodynamically stable, radiofrequency energy was delivered at the mid-diastolic potential recording site during VT. When the patients with VTs were hemodynamically unstable, the critical channel was identified at the delayed potential recording site, showing a good pace map, with a long stimulus-QRS interval. We delivered radiofrequency energy along the identified isthmus and across the exit of the circuit. Results At the end of the procedure, all VTs became non-inducible in 30 patients (59%) and some VTs were inducible in 21 patients (41%). During a mean of 40±29 months of follow-up, no VT or ventricular fibrillation recurred in 24 patients (80%) in the non-inducible group and in 12 patients (57%) in the inducible group, respectively ( P =0.03). The identification of the channel during VT mapping tended to associate with no recurrence, although the difference was not statistically significant ( P =0.2). Fourteen patients (27%) died during the follow-up period, mostly due to non-cardiac causes. Conclusions The catheter ablation targeting the isthmus of prior-MIVT and non-inducibility at the end of the procedure can provide a satisfactory follow-up result.
Abstract Background Catheter ablation of ventricular tachycardia (VT) is feasible. However, the long-term outcomes for different underlying diseases have not been well defined. Methods Eighty-eight ...consecutive patients who underwent catheter ablation of VT using a three-dimensional mapping system were analyzed. The primary endpoint was any VT or ventricular fibrillation (VF) recurrence. Secondary endpoints were a composite of death or any VT/VF recurrence. Underlying heart diseases were remote myocardial infarction (remote MI) in 51 patients and non-ischemic cardiomyopathy in 37 (arrhythmogenic right ventricular cardiomyopathy ARVC in 18 patients, and dilated cardiomyopathy NIDCM in 19). Results Acute success was achieved in 82 of 88 (93%) patients. During a follow-up period of 39.2±4.6 months, VT recurred in 26 of 87 (30%), and VT/VF recurrence or death occurred in 39 of 87 (45%) patients. ARVC had better outcomes than NIDCM for the primary ( p <0.05) and secondary endpoints ( p <0.05). Remote MI-VT revealed a midrange outcome. Conclusions The long-term outcomes after catheter ablation of VT varied according to the underlying heart disease. ARVC-VT ablation was associated with better long-term prognosis than NIDCM. Remote MI-VT demonstrated a midrange outcome.
We evaluated the current results and the predictors of in-hospital complications for a pericardiectomy procedure for constrictive pericarditis in Japan.
A total of 346 patients who underwent isolated ...pericardiectomy for constrictive pericarditis nationwide between 2008 and 2012 were identified from the Japan Adult Cardiovascular Surgery Database.
The patients were a mean age of 65.7 ± 11.7 years. The operative approach was through a median sternotomy in 90% of the patients. Cardiopulmonary bypass was used in 28.9%. The operative mortality rate was 10.0%, and the composite operative mortality or major morbidity (stroke, reoperation for bleeding, need for mechanical ventilation for more than 24 hours postoperatively due to respiratory failure, renal failure with newly required dialysis or mediastinitis) was 15.0%. Logistic regression analysis revealed that the predictive factors for composite operative mortality or major morbidity were preoperative chronic lung disease (odds ratio OR, 4.75; p < 0.001), New York Heart Association functional class IV (OR, 3.85; p < 0.001), previous cardiac operation (OR, 2.68; p = .006), preoperative renal failure (OR, 2.62; p = .014), and cardiopulmonary bypass during the operation (OR, 2.46; p = .015). The frequency of using cardiopulmonary bypass was 2.9% in the patients treated through a left thoracotomy approach vs 31.8% in the patients treated through a median sternotomy approach (p < 0.0001).
Pericardiectomy is associated with high morbidity and mortality rates. Careful consideration should be given to these risk factors in the process of patient selection and perioperative management.
Introduction:. Patients with pulmonary tuberculosis (TB) sometimes show persistent severe inflammation for more than 1 month, even if TB treatment is effective. Although this inflammation can be ...improved through continuous antituberculous therapy, the risk factors for persistent inflammation remain unclear. Therefore, we sought to study the characteristics of patients with persistent severe inflammation. Materials and methods:. We retrospectively analyzed 147 hospitalized adult patients with C-reactive protein (CRP) levels of 5 mg/dL or more on admission to Fukujuji Hospital from April 2019 to March 2021. The patients were divided into 2 groups: 40 patients (27.2%) had CRP levels of 5 mg/dL or more at 4 weeks after admission (persistent inflammation group), and 107 patients (72.8%) had CRP levels that fell below 5 mg/dL within 4 weeks of admission (improved inflammation group). Results:. The median CRP level on admission in the persistent inflammation group was 10.8 mg/dL (interquartile range 9.1–14.5), which was higher than that in the improved inflammation group (median 8.2 mg/dL 6.5–12.1, P = .002). Patients in the persistent inflammation group had a higher prevalence of large cavities, defined as cavities ≥4 cm in diameter, on chest computed tomography (CT) (n = 20 50.0% vs n = 12 11.2%, P < .001). Discussion and conclusions:. This study showed that 27.2% of patients who had high or moderate inflammation on admission did not achieve low CRP levels within 4 weeks after admission. Risk factors for persistent severe inflammation in patients with TB were presence of a large cavity (cavity diameter ≥4 cm) on chest CT and a high CRP level on admission. Therefore, in a patient with a large cavity on chest CT and/or CRP ≥9.0 mg/dL on admission, long-term inflammation may occur despite antituberculous therapy if other diseases are ruled out.
Abstract Background The causative organism in cardiovascular implantable electronic device (CIED) infection is usually diagnosed with the cultures from blood, removed leads, and/or infected pocket ...material. The cultured organism, however, is sometimes different among these samples. Methods Two hundred sixty patients with CIED infection, who underwent lead extraction between April 2005 and December 2014, were analyzed. More than two blood culture sets, all the extracted leads, and swab culture of the pocket were sent to the laboratory for culture. Among the patients all of whose microbiological examinations were available, we analyzed the causative organism defined as the species detected in at least two different sites. Results All the culture results were available in the 208 patients, showing 69 systemic infections (including 30 cases of infectious endocarditis) and 139 local infections. Blood culture, lead culture, and swab culture were positive in 57 (27%), 169 (81%), and 152 (73%), respectively. Staphylococcus aureus 37% including methicillin-resistant S. aureus (MRSA) (12%) and coagulase-negative staphylococci (CoNS, 36%) were the most common causative organism, followed by non-staphylococci (23%), and poly-microbial infection (4%). The detection of S. aureus from pocket or removed leads rendered higher predictive value of a causative organism than that of CoNS. The detection of Gram-negative bacteria, fungi, and mycobacteria indicated that it was most likely a causative organism. Gram-positive bacteria excluding Staphylococcus , such as Corynebacterium spp., tended to coexist as a benign organism. Conclusions The causative organism is mostly S. aureus and CoNS. Detection of S. aureus or Gram-negative bacteria means that it is more likely a causative organism.
Thoracic aortic operations still remain associated with substantial risks of death and neurologic injury. This study investigated the impact of surgical stroke on the early and late outcomes, ...focusing on the physical status and quality of life (QOL).
From 1986 to 2008, 500 patients (aged 63 ± 13 years) underwent open thoracic aortic repair for root and ascending (31%), arch (39%), extended arch (10%), and descending and thoracoabdominal (19%) aneurysms. Brain protection consisted of retrograde cerebral perfusion (52%), antegrade cerebral perfusion (29%), and simple deep hypothermic circulatory arrest (19%). Surgical stroke was defined as a neurologic deficit persisting more than 72 hours after the operation. QOL was assessed with the Short-Form 36 Health Survey Questionnaire 5.9 ± 4.2 years after the operation.
Stroke occurred in 10.3% of patients. Hospital mortality was 21% in the stroke group and 2.7% in the nonstroke group (p < 0.001). At hospital discharge, 76% of survivors in the stroke group had permanent neurologic deficits (PNDs), with sustained tracheostomy in 39%, tube feeding in 46%, and gastrostomy in 14%, and 89% required transfer to other facilities. PND was an independent risk factor for late death (hazard ratio, 2.29; 95% confidence interval, 1.04 to 4.62; p = 0.041) in a multivariate analysis. The physical component of the QOL score was worse in the PND group (51% vs 100%; p = 0.039), whereas the mental component was similar in both groups (14% vs 14%).
Surgical stroke is associated with high hospital mortality and PNDs that decrease late survival and the physical component score of the QOL survey.
Objectives Surgical papillary muscle (PM) imbrication has been reported to be effective to relieve leaflet tethering in patients with functional mitral regurgitation (FMR). However, the mechanism ...that contributes to improvement of FMR by shortening the interpapillary muscle distance (IPMD) has not been well investigated. The purpose of the present study was to investigate whether IPMD can affect MR severity independently of PM tethering distance in patients with left ventricular dysfunction (LVD) using multislice computed tomography. Methods We analyzed volumetric multislice computed tomography images of mitral apparatus in 83 patients with LVD (ejection fraction <50%): 37 patients with FMR and 46 patients without FMR. By using the original software, we assessed the 3-dimensional geometry of mitral apparatus including IPMD, tethering distances, and mitral tenting volume at end-systole. The severity of FMR was assessed using vena contracta (VC) width by 2-dimensional echocardiography. Results Posterior and anterior tethering distance and IPMD were increased significantly in patients with FMR than in those without FMR. Patients with IPMD in the highest tertile had a significantly higher degrees of MR (mean ± standard error VC width, 4.5 ± 0.3 mm) compared with patients in the lowest and the middle tertiles, adjusting for PM tethering distance (mean ± standard error VC width, 3.0 ± 0.4 and 2.9 ± 0.3 mm; P < .001, respectively). Multivariate analysis showed that anteroposterior annular diameter and IPMD were the strongest determinants of FMR severity and mitral tenting volume. Conclusions IPMD, which affects leaflet tethering independently of PM tethering distance, was the major determinant of mitral tenting volume and FMR severity in patients with LVD.
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