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The heart failure (HF) "pandemic" is an ongoing critical issue related to the aging population. Among the new heart failure medications, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to provide clinical benefit in HF patients with chronic kidney disease (CKD). However, the efficacy and safety of SGLT2i in old age patients remains uncertain.The OSHO-heart (Optimal Solution after Hospitalization in Onomichi for heart failure) is a prospective study of 213 patients aged ≥ 75 years-old hospitalized for acute decompensated HF with stage 3 to 4 CKD. The composite outcomes of HF rehospitalizations or cardiovascular death and the rate of decline in the estimated glomerular filtration rate (eGFR) were compared between the Loop (n = 76), tolvaptan (TLV) (n = 80) and SGLT2i (n = 57) groups, respectively.During follow-up (17.2 months, median), composite of HF rehospitalization or cardiovascular death events occurred in 30 (39.5%) in Loop, 19 (23.8%) in TLV and 8 (14%) in SGLT2i groups, respectively (Log-rank: P = 0.015). A multivariate analysis demonstrated that the continuation of SGLT2i (hazard ratio, 0.41; 95% CI, 0.19 to 0.78; P = 0.022) and an EF 30% (hazard ratio, 2.19; 95% CI, 1.22 to 3.92; P = 0.009) were independently associated with the composite outcome. The rate of decline in the eGFR was significantly less in TLV and SGLT2i groups than Loop group (-1.64 vs. -1.28 vs. -5.41 ml/min/1.73 mSGLT2i therapy might reduce the combined risk of HF hospitalizations or cardiac death and preserve a worsening renal function in old age patients with HF and CKD.

The BLOCK HF trial showed that heart failure patients with atrioventricular block (AVB) and left ventricular systolic dysfunction (LVSD) are considered good candidates for cardiac resynchronization therapy (CRT), even though they have a narrow QRS duration. We aimed to compare the clinical response to CRT between patients with AVB combined with LVSD and patients with pre-existing CRT indications.We compared the clinical data on CRT across the following 3 groups in 3 cardiovascular centers; heart failure patients with an LV ejection fraction (LVEF) of ≤35% who had a QRS duration of ≥120ms (standard indication, n=125), those needing an upgrade to CRT (upgrade, n=49), and patients with an LVEF of ≤50% who had advanced AVB (AVB with LVSD, n=27).The prevalence of left bundle branch block differed significantly across the groups (87.2%, 98.0% and 40.7%; P0.001). No inter-group difference was found in the percentage of patients in whom clinical composite score (CCS) assessed 6months after the CRT was improved (60.8%, 57.1% and 70.4%; P=0.67). Whereas, even among the patients with an improved CCS, a significantly smaller LV end-systolic volume reduction after the CRT was seen in the ABV with LVSD group (-35.3±34.7, -21.4±28.5 and -5.2±23.9%; P=0.001). The incidence of cardiovascular death or hospitalization from heart failure within 5years occurred with a similar frequency (44%, 55.1% and 44.4%; P=0.9).As compared to patients with preexisting CRT indications, CRT may be similarly effective for patients with AVB and LVSD, however, LV reverse remodeling may be uncommon among them.

Among heart failure patients diagnosed as having exertional oscillatory ventilation (OV), some present with OV at rest that persists during exercise, and others develop OV only after the onset of exercise during cardiopulmonary exercise (CPX) testing. We tested whether or not there was any difference in the prognostic significance between the two abnormal breathing patterns.Patients with New York Heart Association class III-heart failure were categorized into the following 3 groups according to their ventilation pattern during the CPX: patients with an OV pattern at rest that persisted for ≥60% of the exercise test at an amplitude of ≥15% of the average resting value (group 1), patients with the same abnormal ventilatory pattern as group 1 that was observed only during exercise (group 2), and patients without any OV (group 3). The patients were followed-up for at least 2 years to assess the composite outcome of cardiac death or hospitalization for worsening heart failure.The occurrence of the composite outcome differed significantly across the groups with its highest occurrence in group 1 (21/29 [72.4%], 15/38 [39.5%] and 48/167 [28.7%]; log-rank P 0.001). In multivariate hazard analyses, an N-terminal pro-brain natriuretic peptide of900 pg/mL (hazard ratio [HR] = 1.72, P = 0.04), and group 1 (HR 2.03, P = 0.02) were independently associated with the composite outcome.Checking for the resting OV prior to incremental exercise during CPX testing may be helpful in risk-stratification among subjects with advanced heart failure.

Background Inappropriate shocks resulting from atrial tachyarrhythmias are highly problematic for patients with an implantable cardioverter defibrillator (ICD). We aimed to determine the effectiveness of catheter ablation of atrial fibrillation (AF) in preventing inappropriate shocks due to rapid AF in patients diagnosed with Brugada syndrome (BS) who were implanted with an ICD. Methods We performed AF ablation in 5 BS patients with ICDs who experienced inappropriate shocks caused by rapid paroxysmal AF and in a BS patient scheduled to determine an indication of an ICD implantation who frequently experienced rapid AF. Results Although 2 patients underwent a 2nd ablation procedure because of AF recurrences, 5 of the 6 patients were finally free from AF after their last procedure during a median follow-up period of 43.2months. No further inappropriate shocks caused by rapid AF occurred after the 1st ablation session in any of the patients. A patient developed a ventricular fibrillation storm during his electrophysiological study following the ablation procedure, and then was implanted with an ICD. Conclusions AF ablation in BS patients may be reasonable to prevent inappropriate ICD shocks resulting from rapid AF. However, ventricular extrastimuli just after the ablation had better be avoided in them.

Although it is relatively rare, there are some patients with persistent or longstanding (LS) persistent atrial fibrillation (AF) who develop recurrences of AF with a paroxysmal form after pulmonary vein (PV) isolation [1]. Since there is no consensus on how to treat those patients, we tested what the results would be if they underwent a repeat ablation procedure. Consecutive patients were eligible for inclusion if they had any symptoms resulting from recurrent paroxysmal or persistent AF after PV isolation for the initial treatment of persistent or LS persistent AF, and then underwent a second ablation procedure. The types of AF were defined according to the current guidelines [2]. Written informed consent was obtained from all patients, and the study protocol was approved by the research committee of the institution. A double lasso guided extensive PV isolation with a cavotricuspid isthmus (CTI) ablation was performed in each patient as an initial ablation procedure. The details of the procedurewere described in our previous work [3]. In the second procedure, if any electrical reconnection was seen in the PVs or CTI, re-ablation was carried out in the samemanner as in the initial session. In principle, a roof line and anterior line [2] were additionally created if the patients had one or no reconnected PV. Finally, the superior vena cava was isolated circumferentially in all patients. The antiarrhythmic drugs withdrawn before the ablation were resumed the evening of the procedure in all patients. We scheduled to follow them up 3, 9, 12, and finally 24 months after the procedure to screen for any AF recurrences defined based on the current guidelines [2]. The end point was an AF recurrence occurring after the 2nd session in patients with a paroxysmal form of AF recurrence and those with a persistent form of AF recurrence after the 1st session.

article i nfo Background:Restless patientisrecalcitrant during ablation of atrial fibrillation (AF). Weaimed toassess the asso- ciation between patient movements during AF ablation and its outcome. Methods: We examined the body movement during AF ablation in 78 patients with the use of a novel portable respiratory monitor, the SD-101, which also has the ability to quantify the frequency of body movements. Results: The body movement index, defined as the number of the units of time with body movement events di- videdby therecording time(11.4 ± 6.5 events/h), wassignificantlycorrelatedwith the ablation time defined as the time from the first point of the ablation to the end of the procedure (1.2 ± 0.3 h) (r = 0.35; p = 0.0014) and a total radiofrequency energy applied (56.6 ± 17.7 kW) (r = 0.36; p = 0.0015). A multiple linear regres- sion analysis showed that non-paroxysmal AF (β = 0.25; p = 0.036) and the body movement index (β = 0.36; p = 0.0019) were independent determinants of the ablation time. The body movement index was similar in patients with and without recurrence of AF. Conclusions: Keeping patients motionless may be important to reduce the procedural duration of AF ablation. © 2013 Elsevier Ireland. Ltd All rights reserved.

ment dilemma for ED physicians; i.e. those with undifferentiated chest pain, but no ST changes on ECG or elevation in cardiac markers may be helpful. Since our study was performed, TIMI has been studied in the Asia-Pacific region as part of a 2-hour rule out protocol for adverse events following chest pain [9]. Although the ASPECT trial did not state that TIMI had not been validated in Asia at that time, our study validates the TIMI score in this context and provides further support for its findings. Since previous studies [6,7] have shown variations in the importance of different risk factors in various regions and ethnic groups, larger studies to compare the predictive value of TIMI with other risk stratification systems are required. This was a relatively small, single centre studyandpatientswerenot recruited consecutively, introducing a possibility of selection bias; however, it is unlikely that patientswere not representative of the ED patient population with undifferentiated chest pain.