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Background: Despite the positive impact of implantable cardioverter defibrillators (ICDs) and wearable cardioverter defibrillators (WCDs) on prognosis, their implantation is often withheld especially in Japanese heart failure patients with reduced left ventricular ejection fraction (HFrEF) who have not experienced ventricular tachycardia (VT) or ventricular fibrillation (VF) for uncertain reasons. Recent advancements in heart failure (HF) medications have significantly improved the prognosis for HFrEF. Given this context, a critical reassessment of the treatment and prognosis of ICDs and WCDs is essential, as it has the potential to reshape awareness and treatment strategies for these patients., Methods: We are initiating a prospective multicenter observational study for HFrEF patients eligible for ICD in primary and secondary prevention, and WCD, regardless of device use, including all consenting patients. Study subjects are to be enrolled from 31 participant hospitals located throughout Japan from April 1, 2023, to December 31, 2024, and each will be followed up for 1 year or more. The planned sample size is 651 cases. The primary endpoint is the rate of cardiac implantable electronic device implementation. Other endpoints include the incidence of VT/VF and sudden death, all-cause mortality, and HF hospitalization, other events. We will collect clinical background information plus each patient's symptoms, Clinical Frailty Scale score, laboratory test results, echocardiographic and electrocardiographic parameters, and serial changes will also be secondary endpoints., Results: Not applicable., Conclusion: This study offers invaluable insights into understanding the role of ICD/WCD in Japanese HF patients in the new era of HF medication., Competing Interests: YOk received research funding from Bayer Healthcare and Biosense Webster, Inc, and received scholarship grant from Boston Scientific Japan, and received speaker honoraria from Daiichi‐Sankyo, Bayer Healthcare, and Bristol‐Meyers Squibb, Ono Pharmaceutical, and Medtronic Japan, and affiliated with endowed courses from Boston Scientific Japan, Japan Lifeline, Fukuda Denshi, Abbott Medical Japan, BIOTRONIK Japan, and Medtronic Japan. RKo is affiliated with an endowed division supported by BIOTRONIK Japan, Abbott Medical Japan, Japan Lifeline and Medtronic Japan. KN received research funding from Johnson & Johnson K.K. TN received lecture fees from Abbott Medical Japan, Medtronic Japan, and BIOTRONIK Japan. TKat received lecture fees from Daiichi‐Sankyo, Bristol‐Myers Squibb, Bayer Healthcare, Boston Scientific Japan, Abbott Japan, Nihon Kohden and Medtronic Japan. HF received speaker honoraria from Daiichi‐Sankyo, Bayer Yakuhin, Nippon Boehringer Ingelheim, Johnson & Johnson K.K., Abbott Medical Japan, Medtronic Japan and Japan Lifeline. SK received research funding from Johnson & Johnson K.K. SN received speaker honoraria from Bayer Healthcare, Daiichi‐Sankyo, Bristol‐Meyers Squibb and Medtronic Japan. MH received research funding from BIOTRONIK Japan, Medtronic Japan, Abbott Medical Japan, Japan Lifeline, Nihon Kohden and Boston Scientific Japan, and received speaker honoraria from Nippon Boehringer Ingelheim, Daiichi‐Sankyo, Bristol‐Meyers Squibb, Medtronic Japan, Japan Lifeline, and Abbott Medical Japan. MM received speaker honoraria from Medtronic Japan and Boston Scientific Japan. WS received grants from Daiichi Sankyo and Nippon Boehringer Ingelheim, and received remuneration for lectures, presentations, speakers bureaus, manuscript writing or educational events from Daiichi Sankyo, Nippon Boehringer Ingelheim, Bristol‐Meyers Squibb, K.K., Bayer Yakuhin, Pfizer, Ono Pharmaceutical and Medtronic Japan. KKu received speaker honoraria from Daiichi‐Sankyo, Ltd., Bayer Yakuhin, and Medtronic Japan, and received research grants from Medtronic Japan, HITACHI, and JSR. KI received speaker honoraria from Medtronic Japan and BIOTRONIK Japan. TH received speaker honoraria from Medtronic Japan, BIOTRONIK Japan and Bayer Yakuhin. IN has received speaking honoraria from Medtronic Japan. MS is affiliated with an endowed division supported by BIOTRONIK Japan, Boston Scientific Japan K.K, Medtronic Japan and Abbott Medical Japan. SHi is affiliated with an endowed division supported by BIOTRONIK Japan, Boston Scientific Japan K.K., Medtronic Japan and Abbott Medical Japan. IM received speaker honoraria from Daiichi‐Sankyo and Abbott Medical Japan. RKa received speaker honoraria from Daiichi‐Sankyo and Medtronic Japan, and received research grants from Boston Scientific Japan and Abbott Medical Japan. YIked received speaker honoraria from Bayer Yakuhin and Medtronic Japan. KKa has received research grants from Omron Healthcare Co., Ltd., A&D Co., Ltd., and Fukuda Denshi Co., Ltd. SS is affiliated with an endowed division supported by BIOTRONIK Japan, and received speaker honoraria from Medtronic Japan, Abbott Medical Japan, BIOTRONIK Japan, Boston Scientific Japan, and Japan Lifeline. YKo received speaker honoraria from Daiichi‐Sankyo, Bayer, Abbott Medical Japan, BIOTRONIK Japan, Boston Scientific Japan, Japan Lifeline, and received research funding from Daiichi‐Sankyo. KM has received honoraria for Chugai Pharmaceutical, AstraZeneca, Taiho Pharmaceutical, MSD, Kyowa Kirin, Yakult Pharmaceutical, and Boehringer Ingelheim. Other authors have no conflict of interest., (© 2024 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society.)

The gold standard for diagnosing syncope is to elucidate the symptom-electrocardiogram (ECG) correlation. The ECG recordings during syncope allow physicians to either confirm or exclude an arrhythmia as the mechanism of syncope. Many studies have investigated the use of internal loop recorder (ILR), while few studies have used external loop recorder (ELR) for patients with unexplained syncope. The aim of this review is to clarify the clinical usefulness of ILR and ELR in the diagnosis and management of patients with unexplained syncope. Many observational and four randomized control studies have shown that ILR for patients with unknown syncope is a useful tool for early diagnosis and improving diagnosis rate. ILR also provides important information on the mechanism of syncope and treatment strategy. However, there is no evidence of total mortality or quality of life improvements with ILR. The diagnostic yield of ELR in patients with syncope was similar to that with ILR within the same timeframe. Therefore, ELR could be considered for long-term ECG monitoring before a patient switches to using ILR. A systematic approach and selection of ECG monitoring tools reduces health care costs and improves the selection of patients for optimal treatment possibilities.

Background: Left atrial-esophageal fistulas (LAEFs) are serious complications with high mortality after atrial fibrillation radiofrequency ablation (AFRA). Decreasing the incidence of esophageal thermal lesions (EsoTLs) that may lead to LAEFs is important. The aim of this study was to suppress EsoTL development and determine the appropriate alarm setting for a temperature-monitoring probe by using steerable sheath (STS) methods., Methods: We enrolled 82 consecutive patients (mean, 61.9±11.7 years; 75.6% men) who underwent AFRA, including pulmonary vein isolation for symptomatic, drug-refractory atrial fibrillation with esophageal temperature monitoring by using STS between January 2011 and April 2014. All patients underwent upper gastrointestinal endoscopy (UGE) 1-3 days after AFRA. The timing of ablation discontinuation in the first 17 patients was determined by each physician during AFRA (only monitoring group, OM). In the next 65 patients, physicians were to immediately discontinue ablation when an alarm set at 39 °C went off (instruction group, INS). We compared two groups with respect to the incidence of EsoTLs., Results: Among the 82 patients, 5 (6.1%) had EsoTLs after AFRA. EsoTLs occurred in 3 of 17 patients (17.6%) and 2 of 65 patients (3.1%) in the OM and INS groups, respectively. The incidence of EsoTLs in the INS group was significantly lower than that in the OM group ( p =0.0254). EsoTL did not occur at maximal temperature less than 39 °C, measured by using esophageal temperature-monitoring probe., Conclusions: Immediate discontinuation of ablation during pulmonary vein isolation remarkably decreased the incidence of EsoTLs, even when using STS.

Background: Pulmonary vein isolation (PVI) via catheter ablation has been shown to be a highly effective treatment option for patients with symptomatic paroxysmal atrial fibrillation (AF). The recurrence of AF within 3 months after PVI is not considered to be the result of ablation procedure failure, because early recurrence of AF is not always associated with late recurrence. We examined the usefulness of an external loop recorder with an auto-trigger function (ELR-AUTO) for the detection of atrial fibrillation following PVI to characterize early recurrence and to determine the implications of AF occurrence within 3 months after PVI., Methods: Fifty-three consecutive symptomatic patients with paroxysmal AF (age 61.6±12.6 years, 77% male) who underwent PVI and were fitted with ELR-AUTO for 7±2.0 days within 3 months after PVI were enrolled in this study., Results: Of the 33 (62.2%) patients who did not have AF recurrence within 3 months after PVI, only 1 patient experienced AF recurrence at 12 months. Seven (35%) of the 20 patients who experienced AF within 3 months of PVI experienced symptomatic AF recurrence at 12 months. The sensitivity, specificity, positive predictive value, and negative predictive value of early AF recurrence for late recurrence were 87.5%, 71.1%, 35.0%, and 96.9%, respectively., Conclusions: AF recurrence measured by ELR-AUTO within 3 months after PVI can predict the late recurrence of AF. Freedom from AF in the first 3 months following ablation significantly predicts long-term AF freedom. ELR-AUTO is useful for the detection of symptomatic and asymptomatic AF.