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Atrial fibrillation (AF) is a common arrhythmia and gastroesophageal reflux disease (GERD) is popular in Japan. The two common diseases share several predisposing factors such as lifestyle and senescence, and inflammation and oxidative stress play an important role in their development and progression. Incidental cases of AF treated successfully by proton pump inhibitor (PPI) applied for coexisting GERD have been sporadically reported. An increasing evidence indicates that GERD induces the initiation and the perpetuation of AF. This is caused by the autonomic nerve influence, mechanical compression, and propagation of local inflammation due to proximity of left atrium (LA) and lower esophagus. Meanwhile, AF also develops GERD by mechanical and inflammatory actions of LA characterized by remodeling and inflammation. The robust association of AF with GERD is not limited to their natural interaction, i.e., pharmacological or nonpharmacological treatment of AF is reported to aggravate GERD. Many cardiac drugs (anticoagulants, calcium antagonists, and nitrates) induce esophageal mucosal damage and lower esophageal sphincter relaxation promoting acid reflux. These drugs are frequently prescribed in patients with AF for stroke prevention, rate control, and for coexisting coronary heart disease. Catheter ablation also yields both GERD and esophageal thermal injury, which is a precursor lesion of atrioesophageal fistula. The notion that AF and GERD are mutually interdependent is widely and empirically recognized. However, mechanistic link of the two common diseases and objective evaluation of PPI as an adjunctive AF treatment warrant future large‐scale prospective trials.

Acetylcholine is widely used for a diagnostic provocation test of coronary spasm in patients with vasospastic angina. Acetylcholine usually induces coronary vasodilatation mediated by muscarinic receptor activation, but sometimes it evokes vasoconstriction of coronary arteries where the endothelium is damaged. Early repolarization syndrome is characterized by a J wave observed at the end of the QRS complex in a surface electrocardiogram. The J wave is attributed to the transmural voltage gradient at the early repolarization phase across the ventricular wall, which stems mainly from prominent transient outward current in the epicardium, but not in the endocardium. Transient high-dose application of acetylcholine into the epicardial coronary arteries provides a unique opportunity to augment net outward current, selectively, in the ventricular epicardium and unmask the J wave, irrespective of the cardiac ischemia based on coronary spasm. Acetylcholine augments cardiac membrane potassium conductance by enhancing acetylcholine-activated potassium current directly and by activating adenosine triphosphate-sensitive potassium current, in addition to the reduced sodium and calcium currents in the setting of severe ischemia due to vasospasm. However, the role of acetylcholine as an arrhythmogenic probe of the J wave induction in patients with suspected early repolarization syndrome warrants future prospective study.

A 53-year-old woman reported burning pain, muscle weakness, and dysesthesia of the left arm 2 months after permanent pacemaker insertion in the ipsilateral side for the treatment of sick sinus syndrome. Complex regional pain syndrome (CRPS) induced by pacemaker implantation was diagnosed. In 2017, her pulse generator became exhausted and was exchanged carefully to avoid exacerbation of CRPS, under the application of local anesthesia and premedication. Six months later, the patient's grip strength in her left hand remained lower relative to that in her right hand. Although rare, the presence of CRPS following device implantation should be remembered. Keywords: Complex regional pain syndrome, Pain control, Permanent pacemaker implantation

A 51-year-old man with a resuscitation episode was referred to our hospital. Coronary angiography revealed a focal spasm overlapped with organic stenosis where a bare metal stent was implanted. Acetylcholine (ACh) provocation test did not induce chest pain. It revealed no discernible ST-T changes but unmasked a J wave at the end of the QRS complex, which was associated with short-coupled repetitive premature ventricular beats. A J wave reportedly appears immediately before the onset of ventricular fibrillation caused by vasospastic angina. However, a J wave observed newly after a coronary spasm provocation test using ACh without ST-T changes is informative when considering the mechanisms of the J wave.

INTRODUCTION: As indication for implantable cardioverter defibrillators (ICDs) has expanded, prophylactic implantations have increased. It has been well understood that some ICD recipients have psychological problems. Some of those problems are recognized as maladjustment syndromes. METHODS: We studied 35 ICD recipients regularly followed at outpatient department of Kyushu University Hospital in order to clarify the psychological distress and the quality of their daily lives (QOL). By using questionnaire instruments (SF-8, Beck Depression Inventory, Impact of Event Scale Revised, and State-Trait Anxiety Inventory), we studied their psychological status. RESULTS: Depression, anxiety, and post-stress syndromes existed in 45.5% of the ICD recipients and their QOL was compromised. Female ICD recipients reacted to the stress related to ICD implantation differently from male recipients. Elder ICD recipients had a different way of adjustment from the younger recipients. Various ICD related psychological problems were noted in terms of magnitude and diversity. CONCLUSION: To support ICD recipients both physically and mentally, not only the cardiologists but also specialists from other fields such as psychologists and nurse specialists are needed. Ancillary care must be provided through the support team. Cardiologists who determine whether ICD implantation is required must keep in mind potential psychological sequelae.

A 55-year-old housewife was diagnosed as polymyositis due to leg weakness, when she was 33-year-old. Polymyositis was associated with cardiomegaly and nonsustained VT. Myocarditis secondary to polymyositis was confirmed. She complained palpitation, when she was 51-year-old. Paroxysmal AF was documented. AF was eliminated by the first catheter ablation (i.e., pulmonary vein isolation). She complained exertional dyspnea due to impaired LV function caused by persistent AT last year. Secondary RF ablation was performed and AT was successfully ablated by blockline formation in the damaged right atrial anterior wall under the 3D mapping. Thereafter, frequent PVCs were recorded by Holter monitoring this year. PVCs were refractory to antiarrhythmics. Therefore, third RF ablation was conducted under the CARTO mapping. Polymorphic PVCs were originated from LV posterolateral and right ventricular inferior walls. These foci of PVCs were coincided well with the areas showing contractile abnormalities. PVCs were ablated successfully under the pace-mapping. After the third RF ablation, PVCs were remarkably decreased and LV function was gradually restored. She is well being at present under the administration of sotalol. This case is didactic in that myocarditis secondary to polymyositis demonstrates various kinds of drug-refractory tachyarrhythmias (i.e., AF, AT and VT) and RF catheter ablation is recommended in such a case.

Background: Although gastroesophageal reflux disease (GERD) causes noncardiac chest pain, systemic studies surveying the effects of common cardiac drugs on symptomatic GERD are rare. Methods: To investigate the drug-related GERD, this survey enrolled 201 consecutive outpatients (69.7±10.5 years) including those with atrial fibrillation (AF). They were assessed using the Frequency Scale for Symptoms of GERD (F-scale) to screen GERD with a cut-off value of 8.0. Clinical background was obtained from medical records. Gastric medicine was empirically administered at discretion of the attending physician. F-scale score and incidence of GERD were analyzed relating background and prescription. Results: The average F-scale score did not correlate with gender, age or underlying diseases. F-scale score was elevated significantly (p=0.006) by calcium channel blockers (CCB) in patients treated with gastric medicine, suggesting that CCB exacerbate the possibly preexisting GERD. Incidence of GERD within 2 months after starting warfarin tended to be greater than that at other durations (p=0.087). Patients showing a high score (>8.0) suggestive of GERD showed a correlation with coadministration of CCB (OR=3.19; 95%CI=1.01–10.11; p=0.049) and warfarin (OR=3.05; 95%CI=1.00–9.27; p=0.049). Conclusion: Coadministration of CCB and warfarin is common in AF. This survey demonstrates that this combination therapy is an independent risk of GERD.

Focal atrial tachycardia (AT) is sometimes associated with sick sinus syndrome. A 57-year-old female complained of palpitation, fatigue and presyncope. Ambulatory monitoring demonstrated frequent segments of AT and subsequent sinus arrests. P wave morphology of ectopic beats was similar to that of sinus rhythm. After obtaining diagnosis of bradycardia tachycardia syndrome, she underwent electrophysiologic study (EPS) and radiofrequency (RF) catheter ablation to eliminate AT. Conventional EPS could not be performed due to frequent spontaneous ectopic beats. EnSite mapping demonstrated that AT originates from posterosuperior right atrium (RA) and that local electrogram of ectopic focus precedes the onset of P wave in surface ECG by 40 msec. After EnSite-guided RF ablation to the target area, ambulatory monitoring detected no AT or sinus arrest. EPS performed one week after RF ablation showed atropine-induced partial restoration of sinus node dysfunction. Her symptoms were resolved remarkably and permanent pacemaker implantation has not been necessary to date. RF ablation guided by EnSite mapping was useful to eliminate AT arising from limited ectopic focus and this case implies existence of "pacemaker-avoidable" bradycardia tachycardia syndrome.