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.
Diffuse alveolar hemorrhaging (DAH) due to oral anticoagulation (OAC) is a life-threatening condition that leads to severe respiratory failure. There is a clinical dilemma in that OAC-induced DAH ...often forces the discontinuation of OAC therapy and the administration of high-dose corticosteroids, which increases the risk of stroke and cardiovascular events. We herein report the first case of OAC-induced DAH and atrial fibrillation (AF) in a patient who completely discontinued OAC therapy and high-dose corticosteroids after experiencing percutaneous left atrial appendage (LAA) occlusion. This case suggests that percutaneous LAA closure may aid in the management of OAC-induced DAH and AF.
Background
The role of nonpulmonary vein (PV) triggers ablation in persistent atrial fibrillation (PEAF) was suggested but it is still under debate.
Objectives
We aimed to assess the effectiveness of ...non‐PV trigger‐targeted ablation for patients with PEAF.
Methods
Consecutive patients with PEAF undergoing catheter ablation (CA) between January 2015 and April 2017 were enrolled. Isoproterenol plus adenosine challenge was performed to provoke non‐PV triggers. Non‐PV triggers were defined as the trigger beats inducing AF (non‐PV AF triggers) and/or frequent premature contractions (non‐PV PACs) from other than PVs. Three groups were defined: Group 1 (n = 186) without non‐PV triggers; Group 2 (n = 65) with non‐PV triggers that could be completely eliminated with CA; Group 3 (n = 49) with non‐PV triggers still inducible after CA. The primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence.
Results
A total of 300 patients (230 males, age 64 ± 10) were enrolled. The mean follow‐up period was 27 ± 10 months. Freedom from ATa recurrence at 1 and 2 years were significantly lower in Group 3 compared to the other two groups (Group 1; 74.7%, 67.2% vs. Group 2; 75.8%, 68.3% vs. Group 3: 52.1%, 38.6%, p = .0005), irrespective of the type of non‐PV triggers (non‐PV AF triggers vs. non‐PV PACs). On multivariate analysis, unsuccessful elimination of non‐PV triggers was an independent predictor for ATa recurrence (hazard ratio = 1.80, 95% confidence interval = 1.07–2.95, p = .026).
Conclusion
Successful non‐PV triggers elimination can improve the ATa recurrence rate in PEAF ablation. ATa recurrence rate is higher, if non‐PV AF triggers or even non‐PV PACs remain in patients with PEAF.
Background: Left atrial appendage closure (LAAC) usually requires contrast medium during the procedure. However, patients with chronic kidney disease (CKD) are at high risk of developing contrast ...nephropathy. This study aimed to assess the safety and feasibility of zero-contrast LAAC in patients with CKD.Methods and Results: Zero-contrast LAAC was attempted in 15 patients with CKD Stages 3b-5 who were not on hemodialysis. All procedures were performed successfully, without any periprocedural complications. At the 45-day follow-up, no device-related complications or acute kidney disease were observed.Conclusions: The strategy of zero-contrast LAAC in patients with CKD can be an acceptable option.
•The left atrial appendage closure (LAAC) has recently been introduced in Japan.•The real-world data on LAAC in Japanese patients are scarce.•The initial experience showed a high success rate but ...high post-procedural bleeding.•The optimal antithrombotic regimens considering each background are warranted.
The left atrial appendage closure (LAAC) device for patients with nonvalvular atrial fibrillation (NVAF) has recently been introduced in Japan. However, clinical data of Japanese patients are insufficient.
In this single-center study, 55 consecutive patients (mean age, 74 years) who received LAAC therapy from September 2019 to December 2020 were analyzed. The WATCHMAN implant procedure (Boston Scientific, St. Paul, MN, USA) was performed under transesophageal echocardiography and general anesthesia for all cases.
The baseline CHA2DS2-VASc score was 4.6 ± 1.4, and the baseline HAS-BLED score was 3.8 ± 0.9. All procedures (98.2%) were successful, except for one, and no procedure-related complications were observed. After the procedures, various antithrombotic regimens were employed according to the bleeding risk of each patient; warfarin was used in 27 patients (49%), direct oral anticoagulants (DOACs) were used in 22 patients (40%), and dual antiplatelet therapy (DAPT) was employed in 6 patients. During a mean follow-up of 360 days, three cases of device-related thrombus (DRT) were detected. One DRT case was related to ischemic stroke. Nine patients had major bleeding during follow-up: two patients received DOACs, six patients received DAPT, and one patient received aspirin.
In this initial Japanese experience, LAAC therapy for high bleeding risk patients with NVAF seems feasible. Optimal antithrombotic regimens are warranted for better clinical outcomes.
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His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) emerge as better alternatives to right ventricular apical pacing (RVAP) in patients with bradycardia requiring permanent cardiac ...pacing. We aimed to compare the clinical outcomes of LBBAP, HBP, and RVAP in Japanese patients with bradycardia.
A total of 424 patients who underwent successful pacemaker implantation (HBP,
= 53; LBBAP,
= 75; and RVAP,
= 296) were retrospectively enrolled in this study. The primary study endpoint was the cumulative incidence of heart failure hospitalization (HFH) during the follow-up.
The success rate for implantation was higher in the LBBAP group than in the HBP group (94.9% and 81.5%, respectively). Capture threshold increase >1V during the follow-up occurred in the HBP and RVAP groups (9.4% and 5.1%, respectively), while it did not in the LBBAP group. The cumulative incidence of HFH was significantly lower in the LBBAP group than the RVAP (adjusted hazard ratio, 0.12 95% confidence interval: 0.02-0.86;
= .034); it did not differ between the HBP and RVAP groups (adjusted hazard ratio, 0.48 95% confidence interval: 0.17-1.34;
= .16). Advanced age, mean percent right ventricular pacing (per 10% increase), left ventricular ejection fraction <50%, and RVAP were associated with HFH.
Compared to RVAP and HBP, LBBAP appeared more feasible and effective in patients with bradycardia requiring permanent cardiac pacing.
Background
The incidence, predictors, and clinical impact of lead break during transvenous lead extraction (TLE) were previously unknown.
Methods
We included consecutive patients who underwent TLE ...between September 2013 and July 2019 at our institute. Lead break during removal was defined as lead stretching and becoming misshapen, as assessed by fluoroscopy.
Results
A total of 246 patients underwent TLE for 501 leads. At a patient level, complete success was achieved in 226 patients (91.9%). At a lead level, 481 leads (96.0%) were completely removed and 101 leads (20.1%) were broken during the procedure. Of 392 identified pacemaker leads, 71 (18.3%) were broken during the TLE procedure. A multivariable analysis confirmed high lead age (odds ratio OR 1.12, 95% confidence interval (CI) 1.07‐1.17; P < .001), passive leads (OR 2.29 95% CI 1.09‐4.80; P = .028), coradial leads (OR 3.45 95% CI 1.72‐6.92; P < .001), and insulators made of nonpolyurethane (OR 2.38 95% CI 1.03‐5.26; P = .04) as predictors of lead break. Broken leads needed longer procedure times and were associated with a higher rate of cardiac tamponade.
Conclusions
Lead age, coradial bipolar leads, passive leads, and leads without polyurethane insulation were predictors of lead break and could increase the difficulty of lead extraction.
The extraction of cardiac implantable electronic device leads due to infections, malfunctions, and recalls is common, and can lead to complications such as lead break resulting in incomplete lead removal and cardiac tamponade. We found that older lead age, co‐radial leads, passive leads, and non‐polyurethane leads were independent predictors of lead break during extraction. These findings will guide clinicians to make appropriate choices of procedure and take greater care when these risk factors are present.
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.
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