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Objectives The NIPPON (Nobori Dual Antiplatelet Therapy as Appropriate Duration) study was a multicenter randomized investigation of the noninferiority of short-term versus long-term dual antiplatelet therapy (DAPT) in patients with implantation of the Nobori drug-eluting stent (DES) (Terumo, Tokyo, Japan), which has a biodegradable abluminal coating. Background The optimum duration of DAPT for patients with a biodegradable polymer-coated DES is unclear. Methods The subjects were 3,773 patients with stable or acute coronary syndromes undergoing Nobori stent implantation. They were randomized 1:1 to receive DAPT for 6 or 18 months. The primary endpoint was net adverse clinical and cerebrovascular events (NACCE) (all-cause mortality, myocardial infarction, stroke, and major bleeding) from 6 to 18 months after stenting. Intention-to-treat analysis was performed in 3,307 patients who were followed for at least 6 months. Results NACCE occurred in 34 patients (2.1%) receiving short-term DAPT and 24 patients (1.5%) receiving long-term DAPT (difference 0.6%, 95% confidence interval [CI]: 1.5 to 0.3). Because the lower limit of the 95% CI was inside the specified margin of −2%, noninferiority of short-term DAPT was confirmed. Mortality was 1.0% with short-term DAPT versus 0.4% with long-term DAPT, whereas myocardial infarction was 0.2% versus 0.1%, and major bleeding was 0.7% versus 0.7%, respectively. The estimated probability of NACCE was lower in the long-term DAPT group (hazard ratio: 1.44, 95% CI: 0.86 to 2.43). Conclusions Six months of DAPT was not inferior to 18 months of DAPT following implantation of a DES with a biodegradable abluminal coating. However, this result needs to be interpreted with caution given the open-label design and wide noninferiority margin of the present study. (Nobori Dual Antiplatelet Therapy as Appropriate Duration [NIPPON]; NCT01514227)

Objectives The purpose of this study was to evaluate long-term clinical impact of routine follow-up coronary angiography (FUCAG) after percutaneous coronary intervention (PCI) in daily clinical practice in Japan. Background The long-term clinical impact of routine FUCAG after PCI in real-world clinical practice has not been evaluated adequately. Methods In this prospective, multicenter, open-label, randomized trial, patients who underwent successful PCI were randomly assigned to routine angiographic follow-up (AF) group, in which patients were to receive FUCAG at 8 to 12 months after PCI, or clinical follow-up alone (CF) group. The primary endpoint was defined as a composite of death, myocardial infarction, stroke, emergency hospitalization for acute coronary syndrome, or hospitalization for heart failure over a minimum of 1.5 years follow-up. Results Between May 2010 and July 2014, 700 patients were enrolled in the trial among 22 participating centers and were randomly assigned to the AF group (n = 349) or the CF group (n = 351). During a median of 4.6 years of follow-up (interquartile range [IQR]: 3.1 to 5.2 years), the cumulative 5-year incidence of the primary endpoint was 22.4% in the AF group and 24.7% in the CF group (hazard ratio: 0.94; 95% confidence interval: 0.67 to 1.31; p = 0.70). Any coronary revascularization within the first year was more frequently performed in AF group than in CF group (12.8% vs. 3.8%; log-rank p Conclusions No clinical benefits were observed for routine FUCAG after PCI and early coronary revascularization rates were increased within routine FUCAG strategy in the current trial. (Randomized Evaluation of Routine Follow-up Coronary Angiography After Percutaneous Coronary Intervention Trial [ReACT]; NCT01123291)

Background Point-by-point catheter ablation is an established treatment for drug-refractory paroxysmal atrial fibrillation (PAF). However, it is time consuming, requires excellent technique to achieve complete pulmonary vein (PV) isolation, and is associated with severe complications. Objectives The purpose of this study was to evaluate the safety and effectiveness of a HotBalloon ablation (HBA) compared with antiarrhythmic drug therapy (ADT) for the treatment of PAF. Methods A prospective multicenter randomized controlled study was conducted in Japan. Patients with symptomatic PAF refractory to antiarrhythmic drugs (Class I to IV) were randomized to HBA or ADT at a 2:1 ratio and assessed for effectiveness in a comparable 9-month follow-up period. Results A total of 100 patients in the HBA group and 43 patients in the ADT group received treatment at 17 sites. HBA procedure produced acute complete PV isolation in 98.0% (392 of 400) of the PVs and in 93.0% (93 of 100) of patients in the HBA group. The chronic success rates after the 9-month effective evaluation period were 59.0% in the HBA group (n = 100) and 4.7% in the ADT group (n = 43; p 70%) and transient phrenic nerve injury were 5.2% and 3.7%, respectively. The mean fluoroscopy time was 49.4 ± 26.6 min (n = 134), and the mean procedure duration was 113.9 ± 31.9 min (n = 133). Conclusions This study demonstrates the superiority of HBA compared with ADT for treatment of patients with PAF, and a favorable safety profile.

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.

Aims A worldwide survey reported that the success rate of atrial fibrillation (AF) ablation was higher in high-volume centers compared with low-volume centers. We tested whether the procedure volume of each operator was associated with the outcome of AF ablation in high-volume centres. Methods and results We studied 471 patients with paroxysmal AF who underwent pulmonary vein (PV) isolation for the first time in three cardiovascular centers where the annual AF ablation volume was >100 procedures. We classified a total of 10 primary operators according to their operation volume on the basis of ACC/AHA/ACP CLINICAL COMPETENCE STATEMENT; high-volume operator (≥50 cases/year, N = 3) or low-volume operator (

Background In myocardial ischemia–reperfusion injuries, the involvement of the Na + /H + exchanger (NHE) is considered to be one of the pathogenic mechanisms following reperfusion. TY-51924 is a novel hydrophilic NHE inhibitor with a lower risk of central neurotoxicity than previous NHE inhibitors. This open-label, dose-escalating study was undertaken to investigate the safety, efficacy, and pharmacokinetics of TY-51924 in patients with ST-elevation myocardial infarction (STEMI). Methods Consent was obtained from a total of 30 patients with first anterior STEMI. After 12 patients were determined to be ineligible, the remaining 18 patients, each of whom was undergoing primary percutaneous coronary intervention (pPCI), received TY-51924 intravenously up to 10, 20, or 30 mg/kg as the low-, medium-, or high-dose groups, respectively ( n = 6 in each group). The primary endpoints were safety (up to 7 days) and plasma drug concentration. The myocardial salvage index (MSI) was measured by 201 Tl/ 123 I-beta-methyl- p -iodophenyl pentadecanoic acid single photon emission computed tomography (SPECT) 3–5 days after pPCI. Results No side effects were observed. Plasma drug concentrations increased dose-dependently, and were subsequently eliminated rapidly. MSIs were 0.118, 0.335, and 0.192 in the low-, medium-, and high-dose groups, respectively. In additional analysis, the combined MSIs in the medium- and high-dose groups were significantly higher than those in the low-dose group, in patients with a longer time from symptom onset to reperfusion ( p = 0.0247). Conclusions No side effects were observed even at the highest dose with this novel hydrophilic NHE inhibitor. Therefore, TY-51924 is thought to be safe in patients with STEMI, even at the highest dose. Potential cardioprotective effects of intravenous TY-51924 might be expected based on the results obtained for the MSIs using SPECT at 20–30 mg/kg. However, further large-scale, double-blind, placebo-controlled clinical studies are required to confirm the efficacy and safety implied in the current study.

This study is a prospective multicenter study designed to investigate the effects of lipid-lowering therapy with pitavastatin on atherosclerotic plaque in patients with coronary heart disease, and to determine which factor is more closely associated with plaque regression. Participants (n = 63) were treated with pitavastatin for 12 months, and the carotid intima-media thickness (IMT) was measured by ultrasound before and after treatment. Mean IMT slightly but significantly decreased (from 0.99 ± 0.33 to 0.94 ± 0.28 mm for overall, P = 0.01) regardless of the presence of pretreatment with other statins. There were no significant relations with hs-CRP, malondialdehyde-LDL, LDL cholesterol, and smaller LDL cholesterol levels despite their decrease by pitavastatin. Decreases in mean IMT were observed significantly more frequently in subjects with high on-treatment HDL cholesterol levels than with low HDL cholesterol levels (P = 0.017). The change in mean IMT tended to be inversely correlated with increments in HDL cholesterol and apolipoprotein A-I. The IMT regression was more often observed in the absence of diabetes and metabolic syndrome. In conclusion, we demonstrated that treatment with pitavastatin attenuated atherosclerotic plaque. This effect was associated with the level of HDL cholesterol, and was stronger in the absence of diabetes and metabolic syndrome in our ischemic heart disease patients.

Some patients with persistent atrial fibrillation (AF) acquire long-term freedom from AF by pulmonary vein (PV) isolation alone. The aim of the present study was to evaluate the characteristics of their atrial substrate.We studied 20 patients with persistent AF to examine the distribution of fractionated atrial potentials (FAP) and that of the anatomic sites of ganglionated plexi (GPs) with vagal reflexes elicited by high frequency stimulation (HFS) with the use of the CARTO system before and after the PV isolation.Both the %FAP area defined as a proportion of the FAP area to the total left atrial area (34.3 ± 10.3 to 21.5 ± 10.2%; P0.0001) and number of GP sites with vagal reflexes (4.0 [3.0, 5.0] to 2.0 [1.0, 2.8]; P0.0001) were markedly decreased after the PV isolation. Seven (35%) patients had AF recurrences, and they had a greater %FAP area after the PV isolation than those without (32.8 [22.1, 37.3] versus 13.8 [10.9, 19.9]%; P = 0.0049). A %FAP area after the PV isolation of20% was significantly associated with an AF recurrence (odds ratio 20.0, 95% confidence interval 2.26470.34; P = 0.018). No significant difference was found between the patients with and without AF recurrence in the reduction rate of anatomic sites of GPs with a vagal reflex induced by the HFS.A more marked reduction in the FAP area by the PV isolation was significantly associated with a better outcome in patients with persistent AF.

Aims Procedural sedation by non-anaesthesiologists with GABAergic anaesthetics has the potential risk of fatal respiratory depression. Dexmedetomidine works its sedative action via α2-adrenergic receptors, and is less associated with respiratory depression. We tested the usability of dexmedetomidine as a procedural sedative during ablation of atrial fibrillation (AF). Methods and results Consecutive patients were randomized to be treated with dexmedetomidine ( n = 43) or thiamylal ( n = 44) as sedatives during AF ablation. Apnoeic and body movement events were monitored using a novel portable respiratory monitor, the SD-101, during the procedure. Although the majority of the patients receiving dexmedetomidine required rescue sedations with thiamylal, the respiratory disturbance index (RDI) defined as the total number of sleep-disordered breathing events divided by the recording time (10.4 ± 5.1 vs. 18.2 ± 8.1 events/h; P < 0.0001) and movement index defined as the number of body movement events per hour (7.6 ± 6.1 vs. 11.0 ± 5.5 events/h; P = 0.0098) were both significantly lower in the dexmedetomidine arm than in the thiamylal arm. A multivariate linear regression analysis including potential factors revealed that dexmedetomidine vs. thiamylal was solely and independently associated with the RDI ( β = −0.62; P = 0.0031). The occurrence of hypotension [9 (21%) vs. 4 (9%); P = 0.14] and bradycardia [4 (9%) vs. 4 (9%); P = 1.0] were similar in the patients with dexmedetomidine and thiamylal. Conclusion Procedural sedation with dexmedetomidine may assure safety and patient immobility during AF ablation, and therefore may be a potential alternative for that with GABAergic anaesthetics.

Background— Myocardial infarction (MI) is a leading cause of death worldwide. Given that a family history is an independent risk factor for coronary artery disease, genetic variants are thought to contribute directly to the development of this condition. The identification of susceptibility genes for coronary artery disease or MI may thus help to identify high-risk individuals and offer the opportunity for disease prevention. Methods and Results— We designed a 5-step protocol, consisting of a genome-wide linkage study followed by association analysis, to identify novel genetic variants that confer susceptibility to coronary artery disease or MI. A genome-wide affected sib-pair linkage study with 221 Japanese families with coronary artery disease yielded a statistically significant logarithm of the odds score of 3.44 for chromosome 2p13 and MI. Further association analysis implicated Alström syndrome 1 gene ( ALMS1 ) as a candidate gene within the linkage region. Validation association analysis revealed that representative single-nucleotide polymorphisms of the ALMS1 promoter region were significantly associated with early-onset MI in both Japanese and Korean populations. Moreover, direct sequencing of the ALMS1 coding region identified a glutamic acid repeat polymorphism in exon 1, which was subsequently found to be associated with early-onset MI. Conclusions— The glutamic acid repeat polymorphism of ALMS1 identified in the present study may provide insight into the pathogenesis of early-onset MI.

Two new oral anticoagulants, rivaroxaban and dabigatran, with no need for anticoagulation monitoring, are available for patients with atrial fibrillation (AF). We aimed to compare their anticoagulant effects and safety when used during the AF ablation periprocedural period. Patients undergoing AF ablation were randomly assigned to receive rivaroxaban 15 mg once daily (N = 30) or dabigatran 110 mg twice daily (N = 30). Rivaroxaban was withheld on the morning of the day before the ablation, and dabigatran was discontinued from the evening of the day before the procedure. Both anticoagulants were then resumed after haemostasis of the access site. D-dimer levels were measured just before the ablation, at the end of the ablation, and at 24 h and 48 h after the procedure. The baseline D-dimer levels were identical in both groups. However, D-dimer levels increased more markedly following the ablation procedure in patients receiving rivaroxaban than in those receiving dabigatran (mean ± standard deviation from 0.62 ± 0.16 to 1.09 ± 0.38 μg/mL vs from 0.59 ± 0.08 to 0.75 ± 0.17 μg/mL; p

Background Sleep-disordered breathing (SDB) frequently is induced by sedation during ablation of atrial fibrillation (AF). We tested whether or not sedative-induced SDB is associated with clinical sleep apnea syndrome (SAS). Methods We examined SDB observed during intra-ablation sedation with a novel portable respiratory monitor (PM), SD-101, in 140 patients undergoing AF ablation without any known SAS. A sleep study was repeated the next night of the ablation with the simultaneous use of the SD-101 and type 3 PM, APNOMONITOR V. Results The respiratory disturbance index (RDI) during sedation (20.0±7.8events/h) was significantly correlated with the RDI measured by the SD-101 during the night (15.8±13.7events/h; r =0.50) and the RDI assessed by the APNOMONITOR V during the night (12.7±12.3events/h; r =0.55). An excellent agreement was found between the RDIs simultaneously measured with the 2 PMs (intraclass correlation coefficient, 0.84), especially for an RDI of ⩾30events/h ( κ statistic value, 0.82). The area under the receiver-operating characteristic curve for the RDI with the use of the SD-101 during sedation to identify the patients with an RDI of ⩾30events/h by both PMs during the night was 0.92. A left atrial diameter of >40mm (odds ratio [OR], 4.10) and an RDI during sedation of >20events/h (OR, 17.75) were independently associated with having an RDI of ⩾30events/h with both PMs during the night. Conclusions Frequent episodes of sedative-induced SDB may have a diagnostic value for SAS in patients with AF.

Although several predictors of an electrical storm (ES) are indicated in patients with idiopathic dilated cardiomyopathy (IDCM), whether the severity of the myocardial tissue damage (SMTD) evaluated by myocardial perfusion SPECT (MPS) has an association with an ES remains unclear. The purpose of this study was to elucidate the clinical significance of SMTD for the prediction of ES in IDCM patients with an ICD. Thirty-seven (27 men, mean age 58 ± 15 years) IDCM patients receiving ICD implantations for secondary prevention with preoperative MPS were enrolled in this study. The medical history, physical and laboratory findings, electrocardiograms, echocardiograms and MPS findings were evaluated. The SMTD was assessed by the summed scores of 17 segments using a 4-point system (0, normal ~3, severe defect). During a mean follow-up of 43.9 ± 30.7 months, an ES developed in 12/37 (32.4 %) patients. The SMTD score predicted an ES with a 92 % sensitivity and 56 % specificity, at a cut-off score of 10. In addition, a multivariate analysis showed that the SMTD score remained an independent predictor of an ES (HR 1.09/score 1 increase, 95 % CI 1.01–1.19, p = 0.02). The SMTD score was significantly associated with three indices of late potentials on the signal-averaged electrocardiograms, and was significantly higher in patients with positive late potentials (p = 0.0006). SMTD score assessed by MPS has a strong correlation to the late potentials and higher SMTD score may increase the risk of ES among patients with IDCM and an ICD.

Objective: Sirolimus-eluting stent (SES) has shown a significant efficacy in reducing restenosis after percutaneous coronary interventions. However, an increase in total number of SES use along with targeting more complex lesions generated a large number of SES restenosis. This study aimed to investigate the clinical and angiographic outcomes of different revascularization strategies for SES restenosis. Methods and Results: A total of 176 lesions in 149 patients were included in the study. Fifteen patients underwent coronary artery bypass graft surgery (CABG group) and the remaining patients were treated with percutaneous coronary intervention (PCI). Stent reimplantation was performed in 88 patients (Stent group), whereas 46 patients received balloon therapy (Balloon group). Among 176 lesions, major cardiac adverse event (MACE) occurred in 41 lesions (23.3%) during a median follow-up of 310 days (interquartile range: 146–517 days). The Kaplan–Meier method with a log-rank test revealed no significant difference in MACE rates between the three groups (6%, 25%, 26%, p = 0.13; CABG group, Stent group, Balloon group, respectively). However, when the Balloon group and Stent group were combined together as a PCI group, PCI group had a significantly higher rate of MACE compared with the CABG group (p = 0.04). In addition, angiographic restenosis was significantly less prevalent in the CABG group when compared with the other two groups (8%, 57%, 46%, p = 0.006; CABG group, Stent group, Balloon group, respectively). Conclusions: CABG surgery for patients with SES restenosis is associated with the better clinical outcomes as well as better angiographic outcomes when compared with that of PCI. doi: 10.1111/jocs.12056 (J Card Surg 2013;28:97–101)

Point-by-point catheter ablation is an established treatment for drug-refractory paroxysmal atrial fibrillation (PAF). However, it is time consuming, requires excellent technique to achieve complete pulmonary vein (PV) isolation, and is associated with severe complications.The purpose of this study was to evaluate the safety and effectiveness of a HotBalloon ablation (HBA) compared with antiarrhythmic drug therapy (ADT) for the treatment of PAF.A prospective multicenter randomized controlled study was conducted in Japan. Patients with symptomatic PAF refractory to antiarrhythmic drugs (Class I to IV) were randomized to HBA or ADT at a 2:1 ratio and assessed for effectiveness in a comparable 9-month follow-up period.A total of 100 patients in the HBA group and 43 patients in the ADT group received treatment at 17 sites. HBA procedure produced acute complete PV isolation in 98.0% (392 of 400) of the PVs and in 93.0% (93 of 100) of patients in the HBA group. The chronic success rates after the 9-month effective evaluation period were 59.0% in the HBA group (n = 100) and 4.7% in the ADT group (n = 43; p 0.001). The incidence of major complications was 11.2% (15 of 134 patients). The incidences of PV stenosis (70%) and transient phrenic nerve injury were 5.2% and 3.7%, respectively. The mean fluoroscopy time was 49.4 ± 26.6 min (n = 134), and the mean procedure duration was 113.9 ± 31.9 min (n = 133).This study demonstrates the superiority of HBA compared with ADT for treatment of patients with PAF, and a favorable safety profile.

Aims Sarcoidosis with cardiac involvement is a rare pathological condition, and therefore cardiac resynchronization therapy (CRT) for patients with cardiac sarcoidosis is even further rare. We aimed to clarify the clinical features of patients with cardiac sarcoidosis who received CRT. Methods and results We retrospectively reviewed the clinical data on CRT at three cardiovascular centres to detect cardiac sarcoidosis patients. We identified 18 (8.9%) patients with cardiac sarcoidosis who met the inclusion criteria out of 202 with systolic heart failure who received CRT based on the guidelines. The majority of the patients were female [15 (83.3%)] and underwent an upgrade from a pacemaker or implantable cardioverter defibrillator [13 (72.2%)]. We found 1 (5.6%) cardiovascular death during the follow-up period (mean ± SD, 4.7 ± 3.0 years). Seven (38.9%) patients had a composite outcome of cardiovascular death or hospitalization from worsening heart failure within 5 years after the CRT. Twelve (66.7%) patients had a history of sustained ventricular arrhythmias or those occurring after the CRT. Among the overall patients, no significant improvement was found in either the end-systolic volume or left ventricular ejection fraction (LVEF) 6 months after the CRT. A worsening LVEF was, however, more likely to be seen in 5 (27.8%) patients with ventricular arrhythmias after the CRT than in those without (P = 0.04). An improved clinical composite score was seen in 10 (55.6%) patients. Conclusions Cardiac sarcoidosis patients receiving CRT may have poor LV reverse remodelling and a high incidence of ventricular arrhythmias.

Background We aimed to evaluate the feasibility of an oral direct thrombin inhibitor, dabigatran, as a periprocedural anticoagulant for use with ablation of atrial fibrillation (AF). Methods Consecutive patients scheduled to undergo an AF ablation were randomly assigned to receive dabigatran (n = 45) or warfarin (n = 45) to compare their clinical feasibility. Both of those oral anticoagulants were discontinued the day before the ablation and were resumed after confirming hemostasis of the venipuncture site. A bridging therapy with heparin was not used in either of the patient groups. Results Dabigatran was switched to warfarin before the ablation because of dyspepsia in three patients. An occurrence of rebleeding from the venipuncture site was less common in dabigatran-allocated patients than in warfarin-allocated patients (20% vs 44%; P = 0.013). The reduction in the D-dimer level after the initiation of oral anticoagulants was greater in the dabigatran-allocated patients than in the warfarin-allocated patients. The time from the initiation of the anticoagulants to the ablation was significantly shorter in the dabigatran-allocated patients than in the warfarin-allocated patients (43 ± 7 vs 63 ± 13 days; P < 0.0001). There was only one fatal periprocedural complication in a patient receiving warfarin, who had a mesenteric arterial thrombosis after the ablation. Conclusions An anticoagulation strategy with dabigatran may surpass that with warfarin in reducing both the periprocedural risk of minor bleeding and a hypercoagulable state, and the time to ablation in patients undergoing ablation of AF.

High-frequency stimulation (HFS) of the atria induces atrial fibrillation (AF) when applied during sinus rhythm and elicits a parasympathetic response when delivered at sites where ganglionated plexi (GPs) are located. However, little is known about its impact after an electrophysiological study.To evaluate the impact of HFS on the short-term and long-term outcomes after the ablation of persistent AF.Thirty consecutive patients with persistent or long-standing persistent AF were randomly assigned to either receive HFS of the left atrium (n = 15) or not (n = 15) during their electrophysiological studies. Patients receiving HFS were examined to determine whether or not a vagal response was elicited by the HFS at sites where GPs were located before and after conventional pulmonary vein isolation without any ablation targeting the GPs. Patients not receiving the HFS underwent the ablation procedure alone. The rate of recurrence of AF within 3 months of the procedure (early recurrence [ER]) and the frequency of that occurring after that period (late recurrence) were compared between the patient groups.The incidence of ER occurred more frequently in patients with HFS than in those without (80% vs 40%; P = .015), whereas the occurrence of late recurrence was similar between the 2 groups (27% vs 33%; P = .73). In the HFS group, the number of GPs decreased from 3.4 ± 1.1 to 1.5 ± 0.8 after the pulmonary vein isolation (P.0001), and the decrease was smaller in the patients experiencing ER than in those without.HFS increases the incidence of ER in patients with persistent AF despite a partial GP modification resulting from the pulmonary vein isolation.

AF Ablation in HD Patients. Introduction: It is not common for patients on chronic hemodialysis (HD) to undergo catheter ablation of atrial fibrillation (AF). We aimed to show the outcomes of AF ablation in the HD patients. Methods and Results: Thirty HD patients who underwent pulmonary vein (PV) isolation for drug refractory paroxysmal AF were retrospectively studied, and their AF recurrence free rate and frequency of periprocedural complications were compared to 60 age- and gender-matched control patients not requiring HD. A nonirrigated ablation catheter was used in both patient groups. During a mean follow-up period of 821 ± 218 days, 16 (54%) of the HD patients remained free from AF recurrence without any antiarrhythmic agents versus 47 (78%) of the control patients with an initial ablation (P = 0.013). A second ablation procedure was performed in 12 patients with an AF recurrence, and consequently 20 (67%) of the HD patients were in sinus rhythm compared to 53 (88%) of the controls during a follow-up duration of 747 ± 221 after the last ablation (P = 0.012). Bleeding from the venipuncture site requiring a prolonged hospital stay was identified in 2 HD patients and 1 control subject, while no life-threatening complications were observed in either patient group. Conclusion: Although the success rate of the PV isolation in HD patients was far from satisfactory, it may be considered as one of the therapeutic options for them. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1289-1294, December 2012)

Introduction: The purpose of this study was to investigate whether the effects of renin–angiotensin system inhibitors (RASIs) after encircling ipsilateral pulmonary veins isolation (EIPVsI) for atrial fibrillation (AF) differed between patients with non-dilated and dilated left atria. Materials and methods: We retrospectively studied 292 consecutive patients (mean age=61±11 years, 75% males) who underwent successful EIPVsI for paroxysmal or persistent AF. RASIs’ effects were compared between the patients with a non-dilated left atrium of

Background: The TAXUS Japan Postmarket Surveillance Study (TAXUS-PMS) enrolled patients receiving percutaneous coronary intervention in real-world clinical practice. This analysis focuses on outcomes in the overall patient population and in a subgroup of diabetic patients. Methods and Results: Between July 2007 and December 2008, 2,132 patients (with 2,504 lesions) were consecutively enrolled at 56 sites in Japan. One-year outcomes were analyzed. The prevalence of patients with diabetes was 44% (21% of diabetics were insulin-treated) and 5.5% of patients were receiving ongoing hemodialysis. The majority of patients received paclitaxel-eluting stents (PES) for `off-label' indications (68.2%). The rate of major adverse cardiovascular events (cardiac death, myocardial infarction, and target vessel revascularization (TVR)) at 1 year was 8.2%, driven mainly by TVR (6.9%). No differences in TVR, late loss or restenosis rates were found between diabetic and non-diabetic patients; outcomes in insulin- compared with oral hypoglycemic-treated diabetic patients, were similar. Multiple stent implantation and ostial lesion location were independent predictors for both major adverse cardiac events (MACE) and target lesion revascularization (TLR). Hemodialysis was an independent predictor for MACE but not TLR whereas in-stent restenosis was an independent predictor for TLR. Conclusions: TAXUS-PMS demonstrated a consistent, positive effect of PES in complex clinical cases. PES diminished the increased risk of clinical restenosis in diabetic patients, leading to a similar low risk of cardiac events in diabetic and non-diabetic patients. (Circ J 2011; 75: 2573-2580)

Background Cardiac resynchronization therapy (CRT) has been reported to improve cardiac performance. However, CRT in patients with advanced heart failure is not always accompanied by an improvement in survival rates. We investigated the association between hemodynamic studies and long-term prognosis after CRT. Methods A total of 68 consecutive patients receiving CRT devices due to advanced heart failure were assessed by hemodynamic study and long-term outcome after implantation of the device. Hemodynamic parameters were measured both with the CRT on and off. Results Patients demonstrated significant improvement in the maximum first derivative of left ventricular (LV) pressure (LV dP/dtmax) and QRS duration after periods with the CRT on. During the follow-up period of 34.9 ± 17.6 months, basal LV dP/dtmax and isovolemic LV pressure half-time (T1/2), but not percent change in LV dP/dtmax, were independent predictors of cardiac mortality or hospitalization due to heart failure after multivariate Cox regression analysis. The Kaplan-Meier survival analysis revealed that patients in the lowest basal LV dP/dtmax tertile or the longest basal T1/2 tertile exhibited a significantly higher cardiac-caused mortality or heart failure hospitalization. Conclusions Lower LV dP/dtmax or longer T1/2 independently predicts cardiac mortality or heart failure hospitalization in patients receiving CRT. The assessment of the basal LV dP/dtmax and T1/2 could provide useful information in long-term prognosis after CRT. Copyright © 2010 Wiley Periodicals, Inc. This work was supported by grant from the Grant-in-Aid for Young Scientists, the Nakashima Foundation, and the Kowa Life Science Foundation to RS. Hirohiko Suzuki, MD and Masayuki Shimano, MD equally contributed to the work.

Introduction:An additional approach may be essential to reduce recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI). We examined the efficacy of renin-angiotensin system blockers (RAS-B) in suppressing AF recurrences after PVI. Methods and Results:We retrospectively studied 264 consecutive patients (195 male, median age: 63 years) who underwent successful PVI of paroxysmal (n = 94) or persistent AF (n = 170). RAS-B treatment was performed in 145 patients (angiotensin-converting enzyme inhibitors; n = 13, angiotensin receptor blockers; n = 129, both; n = 3). Echocardiography was performed before and 3 months after the ablation to examine the occurrence of left atrial structural reverse remodeling (LA-RR). After a median follow-up of 195 (interquartile range: 95–316) days, AF recurred in 51 (19.3%) patients. A Cox regression analysis revealed that AF recurrence was significantly lower in the patients with RAS-B than in those without (hazard ratio [HR] = 0.41 [95% confidence interval (CI): 0.23–0.71], P = 0.002). After a multivariate adjustment for potential confounders, the use of RAS-B (HR = 0.39 [95% CI: 0.19–0.77], P = 0.007) and type of AF (HR = 0.30 [95% CI: 0.13–0.66], P = 0.003) were the independent predictors for AF recurrence during the entire follow-up. Although effect of RAS-B was not significant during the early follow-up ( 3 months) (HR = 0.21 [95% CI: 0.08–0.53], P = 0.001). There were no significant differences in LA-RR occurrence regarding RAS-B medication. The use of RAS-B was an independent predictor of late AF recurrences irrespective of an early LA-RR occurrence. Conclusions:Treatment with RAS-B significantly reduced the AF recurrence after PVI. This benefit became more prominent 3 months after the PVI. (PACE 2011; 34:296–303)

A 62 year-old female hemodialysis patient underwent parathyroidectomy to treat secondary hyperparathyroidism. On the preoperative assessment, the plasma levels of parathyroid hormone (PTH) and B-type natriuretic peptide (BNP) were elevated. Echocardiography showed reduced left ventricular (LV) contraction. Myocardial iodine-123-15-(p-iodophenyl)-3-(R,S) methylpentadecanoic acid (123I-BMIPP) scintigraphy showed moderately reduced tracer uptake in the postero-inferior area on single-photon emission computed tomography and decreased washout on the planar images. After parathyroidectomy, the plasma levels of PTH and BNP decreased, followed by improvement in LV contraction. Myocardial 123I-BMIPP scintigraphy revealed that the washout on planar images had increased, which suggests that myocardial 123I-BMIPP scintigraphy is useful for estimating the effect of parathyroidectomy on cardiac function. (Circ J 2009; 73: 1956-1960)

Objective: Little is known about the clinical features in patients with cardiac sarcoidosis who receive cardiac resynchronization therapy (CRT). We aimed to clarify the clinical response to CRT in patients with cardiac sarcoidosis. Methods: We compared the clinical data on CRT between heart failure patients with cardiac sarcoidosis and those with other etiologies at 3 cardiovascular centers. The primary endpoint was composite outcome of cardiovascular death or hospitalization from worsening heart failure within 5 years after the CRT. Results: The patients with cardiac sarcoidosis (N=18) were more likely than those without cardiac sarcoidosis (N=141) to be female (83.3% vs. 22.7%; P Conclusions: Outcomes after the CRT may be acceptable in patients with cardiac sarcoidosis. A poor left ventricular reverse remodeling and higher occurrence of ventricular arrhythmias may characterize them.

Background In patients with ST-elevation acute myocardial infarction (STEMI), reperfusion therapy limits infarct size, but can directly evoke myocardial reperfusion injury. Activation of the Na+/H+ exchanger (NHE) plays an important role in reperfusion injury. TY-51924, a novel NHE inhibitor, significantly reduced infarct size in animal studies and was well tolerated in early-phase clinical trials. This study aim was to evaluate the efficacy and safety of TY-51924 in patients with STEMI. Methods In this multicenter, randomized, double-blind, placebo-controlled Phase II trial, 105 patients with first anterior STEMI undergoing primary percutaneous coronary intervention (pPCI) were randomly assigned to receive an intravenous infusion of either TY-51924 or placebo. Primary endpoints were myocardial salvage index (MSI) as determined by single photon emission computed tomography (SPECT) 3–5 days after pPCI and safety up to 7 days. Results Baseline characteristics were similar in the two groups. MSI 3–5 days after pPCI (0.200 vs. 0.290, p = 0.56), 3 months after pPCI (0.470 vs. 0.500, p = 0.76), and the incidences of side effects did not differ between the two groups as a whole. However, on post hoc analysis of 52 patients with a large area at risk (AAR) (≥38%) and no antegrade coronary flow, MSI by SPECT at 3 months after pPCI was significantly higher in TY-51924 group (0.450 vs. 0.320, p = 0.03). TY-51924 did not adversely influence hemodynamics. Conclusions TY-51924 did not improve MSI or increase side effects as a whole. However, TY-51924 is potentially cardioprotective in the presence of a large AAR and no antegrade coronary flow.

The purpose of this study was to understand the trajectory of prehospital delay in patients with acute myocardial infarction (AMI) in the Japanese health care system, which offers patients a choice between seeking treatment in a neighborhood clinic/small hospital (clinic group) or a large hospital with comprehensive cardiac services, including a cardiac catheterization laboratory (hospital group).In this cross sectional study, 155 consecutive patients admitted with AMI to one of 5 urban hospitals in Japan were interviewed within 7 days after admission.The median total prehospital delay time in the clinic group (n=84) was significantly longer than the hospital group (n=71) (6 h and 48 min vs 2 h and 9 min, p.001). Patients with severe chest pain were significantly less likely to seek treatment at a clinic/small hospital than at a large hospital compared to patients with mild or moderate symptoms (OR 0.85, 95% CI: 0.75, 0.97). Patients who did not interpret their symptoms as cardiac in origin were significantly more likely to seek treatment at a clinic/small hospital than at a large hospital compared to patients who interpreted their symptoms as cardiac in origin (OR 3.32, 95% CI: 1.56, 7.10). After controlling for demographic and medical history, patients in the clinic group were 3.69 times (95% CI: 1.28, 10.66) less likely to receive any reperfusion therapy compared to patients in the hospital group.Findings support the need for public education in Japan that focuses on the appropriate response to AMI symptoms. Moreover, regional AMI networks need to be instituted to provide for early transfer for PCI from clinic/small hospitals to tertiary centers.

Background: The time interval from symptom onset to hospital arrival can guide the decision to start reperfusion for patients with acute myocardial infarction (AMI). Aims: The aims of the study were 1) to examine the consistency and agreement of prehospital delay time between medical record review and structured patient interview and 2) to identify whether symptom severity is an independent predictor of differences in reported prehospital delay between these two data sources. Methods: In this cross-sectional study, a convenience sample of 155 patients with AMI in Japan was recruited. The time and date of symptom onset were obtained from medical record review and a structured patient interview. The interviewer asked about severity of symptoms, using a scale on 0 to 10 scale, with 0 being “no symptom” and 10 being “the most severe symptoms imaginable”. Results: The prehospital delay time from the medical record was significantly shorter than from the structured interview. Perfect agreement of reported prehospital delay time between two data sources was found in 46% of patients. Patients with symptom severity scores of greater than 8 on a 10-point scale were 2.2 times (95% CI: Odds Ratio 1.1 to 5.1) more likely to report different symptom onset time. Conclusions: Prehospital delay time documented in the medical record was shorter than that identified from a structured interview. In addition, the discrepancy between the two data sources may be larger in those patients with severe AMI symptoms.

Objectives The purpose of this study was to evaluate whether an angiotensin II receptor blocker, candesartan cilexetil, reduced neointima formation after coronary stent implantation by way of serial intravascular ultrasound analysis. Background Previous experimental studies have suggested that angiotensin II receptor blocker reduced neointima formation after vascular injury. However, it is unclear whether candesartan cilexetil has a similar effect on human coronary artery. Methods We recruited 50 consecutive patients with stable angina pectoris and 60 stenotic lesions. Patients were prospectively randomized into 2 groups: (1) 25 patients with 31 lesions received candesartan cilexetil (4-12 mg/d), and (2) 25 patients with 29 lesions did not receive the drug. Follow-up intravascular ultrasound was performed 6 m after the stent implantation. Cross-sectional images were obtained at 1-mm intervals within the stent, and the stent volume (SV), lumen volume (LV), and neointima volume (NV = SV − LV) were calculated using Simpson's rule. The percentage neointima volume obstruction (%NV) was calculated as NV/SV × 100. Results Clinical and angiographic backgrounds were comparable between the 2 groups. At follow-up, the candesartan group had smaller SV and larger LV (SV, 156.3 ± 53.7 vs 165.4 ± 61.8 mm 3 , ns; LV, 122.2 ± 49.0 vs 113.1 ± 45.5 mm 3 , ns), and significantly smaller NV and significantly smaller %NV than the control group (NV, 34.2 ± 16.6 vs 52.3 ± 32.6 mm 3 , P P Conclusions Candesartan treatment decreases neointima formation and hence may reduce in-stent restenosis.

It is unclear whether 123I-labelled β-methyl iodophenyl pentadecanoic acid (123I-BMIPP) myocardial scintigraphy adds further predictive value for future cardiac events compared with the variables obtained during cardiac catheterisation in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI). We therefore investigated whether 123I-BMIPP imaging in patients with AMI treated by primary PCI was useful in predicting future cardiac events. One hundred and fifty-nine patients with AMI who were treated with primary PCI and underwent left ventriculography (LVG) on admission underwent 201Tl and 123I-BMIPP myocardial scintigraphy. Scintigrams were visually classified, and the total defect score (TDS) was calculated. Major adverse cardiac events (MACE) were defined as cardiac death including sudden death, congestive heart failure and recurrence of acute coronary syndrome. Patients were followed up for a mean of 34.5 months (12–63 months). Twenty-six patients had MACE. Kaplan-Meier analysis indicated that patients with the top 50% of 123I-BMIPP TDSs had a significantly higher rate of MACE (P=0.007). Patients with mismatch between 201Tl and 123I-BMIPP images also had significantly more MACE (P=0.02). In the prediction of MACE, the global chi-square value was 5.2 (P=0.001) based on LVEF (

Objective The purpose of this study was to describe causal attribution of acute myocardial infarction (AMI) in Japanese patients. Design A cross-sectional study design was used. Setting The setting for this study was 5 hospitals in urban areas in Japan. Sample A convenience sample of 155 patients admitted with AMI was used. Measures Causal attribution was assessed by a semi-structured interview. Known risk factors were assessed by medical record review and patient interview. Results Twenty-two different primary causes for AMI were identified. Patients most commonly cited smoking, stress, and diet as risk factors. Except for smoking, Japanese patients did not identify their cardiac risk factors as a cause of their AMI. Controlling for sociodemographic characteristics, patients with a recorded history of coronary heart disease were significantly less likely to attribute their cardiac risk factors to their AMI (P Conclusions Effective education and counseling of patients after an AMI must be coupled with their view of what factors put them at risk for future AMIs.

Although epidemiologic studies have suggested that several genetic variants increase the risk of myocardial infarction, large-scale association studies that examine many polymorphisms simultaneously are required to allow reliable prediction of the genetic risk of myocardial infarction.We used a fluorescence- or colorimetry-based allele-specific DNA-primer-probe assay system to determine the genotypes of 112 polymorphisms of 71 candidate genes in 2819 unrelated Japanese patients with myocardial infarction (2003 men and 816 women) and 2242 unrelated Japanese controls (1306 men and 936 women).In an initial screening of the 112 polymorphisms for an association with myocardial infarction in 909 subjects, 19 polymorphisms were selected in men and 18 in women by means of logistic-regression analysis, after adjustment for age, body-mass index, and the prevalence of smoking, hypertension, diabetes mellitus, hypercholesterolemia, and hyperuricemia. In a large-scale study involving the selected polymorphisms and the remaining 4152 subjects, similar logistic-regression analysis revealed that the risk of myocardial infarction was significantly associated with the C1019T polymorphism in the connexin 37 gene (P0.001) in men and the 4G-668/5G polymorphism in the plasminogen-activator inhibitor type 1 gene (P0.001) and the 5A-1171/6A polymorphism in the stromelysin-1 gene (P0.001) in women.Determination of the genotypes of the connexin 37, plasminogen-activator inhibitor type 1, and stromelysin-1 genes may prove reliable in predicting the genetic risk of myocardial infarction and might thus contribute to the primary prevention of this condition.

Cardiac Memory Modifies Repolarization Dispersion.Introduction: Transient T wave changes after cessation of preexcitation have been attributed to cardiac memory. However, there have been no reports on the effects of long-term cardiac memory on repolarization dispersion before and after catheter ablation in patients with Wolff-Parkinson-White (WPW) syndrome. Methods and Results: We investigated 47 patients with an accessory pathway (AP; 24 manifest left-sided, 14 manifest right-sided, and 9 concealed left-sided). Repolarization dispersion was analyzed by two methods, recovery time (RT) dispersion and newly proposed T wave width (WT), from 87-lead body surface maps before, 1 day after, and 7 days after catheter ablation. RT dispersion and WT were significantly correlated before, 1 day after, and 7 days after catheter ablation (r = 0.78). In patients with preexcitation, RT dispersion and WT increased significantly (P < 0.05) 1 day after catheter ablation (178 ± 32 msec and 172 ± 30 msec) compared with those before (154 ± 24 msec and 156 ± 18 msec) and 7 days after catheter ablation (147 ± 19 msec and 156 ± 16 msec), respectively. However, there were no significant changes in RT dispersion and WT before and after catheter ablation in concealed WPW syndrome. Conclusion: The findings suggest that the abrupt changes in activation sequence increase repolarization dispersion in the presence of previous cardiac memory, and that the dispersion decreases days or weeks after alteration of activation sequence by catheter ablation, with development of new cardiac memory in patients with manifest WPW syndrome.

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.

The pathogenesis of unstable angina pectoris (UAP) following percutaneous transluminal coronary angioplasty (PTCA) or directional coronary atherectomy (DCA) has not been adequately investigated, so the present study aimed to determine whether thrombi are present in restenotic lesions. The study group comprised 14 patients (16 arterial branches) with angina pectoris in whom either PTCA or DCA was performed and who had developed UAP associated with restenosis, and who then underwent DCA of the restenosed lesion (R-UAP group). The control groups comprised individuals with UAP undergoing DCA with no prior history of PTCA or DCA (P-UAP group; n=29, 29 branches), patients with acute myocardial infarction (AMI group; n=34, 34 branches), and patients with stable angina pectoris (SAP group; n=31, 33 branches). The presence of thrombi was determined by light microscopy of histologic specimens. Thrombus was present in only 1 of the 16 (6.3%) branches in the R-UAP group, 21 of the 29 (72.4%) branches in the P-UAP group, and in 25 of the 34 (73.5%) in the AMI group. In the SAP group, it was detected in only 2 of the 33 (7.1%) branches. The incidence of thrombus was significantly lower in the R-UAP group than in the P-UAP group. In conclusion, the role of thrombus is limited in causing post-interventional UAP at restenosed sites. (Jpn Circ J 2001; 65: 505 - 508)

OBJECTIVESWe examined whether preinterventional arterial remodeling influenced the interventional results after stenting.BACKGROUNDArterial remodeling is seen in atherosclerotic lesions, and it may play an important role in the early stage of atherosclerosis.METHODSWe examined 113 lesions that underwent elective stenting using tubular slotted stents under intravascular ultrasound guidance. The lesions were divided into three groups—adequate, intermediate and inadequate remodeling group—according to preinterventional arterial remodeling. The patients were subjected to coronary angiography and intravascular ultrasound evaluation on average 6.4 months after stenting.RESULTSAt baseline and immediately after stenting, there were no differences in quantitative angiographic analysis among remodeling groups. However, the plaque cross-sectional area (CSA) in the minimal lumen CSA at preintervention and intimal hyperplasia CSA at follow-up were significantly larger in the adequate remodeling group than in the inadequate remodeling group. The restenosis rate of stenting for the lesions with inadequate arterial remodeling was very low (9.4%). A significant positive correlation was found between preinterventional plaque CSA and intimal hyperplasia CSA at follow-up (r = 0.47, p < 0.0001). Moreover, remodeling index significantly correlated with relative intimal hyperplasia CSA (r = 0.28, p < 0.01).CONCLUSIONSPreinterventional arterial remodeling influenced the development of intimal hyperplasia after stenting.

BACKGROUND The relationship between pulmonary vein (PV) potential (PVP) disappearance patterns during encircling ipsilateral pulmonary vein isolation (EIPVI) of atrial fibrillation (AF), and outcome was examined. METHODS AND RESULTS A total of 352 consecutive AF patients (age, 61±12 years; 269 men, 76.4%; paroxysmal AF, n=239; persistent AF, n=73; and long-standing persistent AF, n=40) who underwent initial AF ablation were studied. After EIPVI with a double Lasso technique, pacing was performed from the PV carina to confirm isolation of the carina. PVP disappearance patterns were classified into 3 types: A, both superior and inferior PVP disappeared simultaneously; B, superior and inferior PVP disappeared separately; and C, additional RF applications were required inside the encircling lesions to eliminate the PVP after creating anatomical encircling lesions. The relationship between these patterns and outcome was examined. Six groups were defined according to the combination of right and left ipsilateral PVP disappearance patterns. The incidence of A-A, A-B, B-B, A-C, B-C, and C-C was 7.1%, 14.2%, 16.2%, 15.3%, 27.3%, and 19.9%, respectively. AF recurrence-free rate at 2 years for these 6 groups was 96%, 81%, 78%, 64%, 64%, and 59%, respectively (P

A difference in the lesion formation between open irrigated-tip (OITC) and non-irrigated 4-mm-tip catheters (NITC) may result in a difference in the dimension of the pulmonary vein (PV) ostia after PV isolation of atrial fibrillation (AF). This study evaluated the difference using intracardiac echocardiography (ICE) before and immediately after an extensive encircling PV isolation (EPVI) with an OITC and with an NITC. We studied 100 consecutive patients (OITC group, 54; NITC group, 46) who received EPVI. Changes in the vessel, lumen, and wall thickness areas of the PVs were evaluated at the PV ostia by ICE. There were no significant differences in the baseline characteristics and acute success rate of the EPVI between the OITC and NITC groups. The energy delivered to achieve EPVI was higher in the OITC group than that in the NITC group (34,967 ± 13,222 J vs. 28,300 ± 10,614 J; p = 0.01). After the ablation, the reduction in the vessel and lumen cross-sectional areas was significantly smaller in the OITC group than that in the NITC group (−9.05 ± 28.4 % vs. −21.2 ± 28.8 %, p

Radiofrequency catheter ablation guided by pace-mapping techniques has proven effective in eliminating idiopathic ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT). A method for rapidly identifying the origin of VT from 12-lead electrocardiogram (ECG) findings would be helpful for the catheter ablation procedure. The purpose of this study is to precisely localize the origin of idiopathic VT from the RVOT by a 12-lead ECG from a study of multipoint pace mapping. In one patient with premature ventricular complex (PVC) and 3 with VT, a "basket" catheter was deployed in the RVOT for bipolar pacing from 56 sites in the endocardium of RVOT. Under fluoroscopy the pacing sites were classified into the septum and free wall. We investigated the QRS morphology in leads, I, II, and III; the depth of the QS wave in leads aVR and aVL; and the height of the initial r wave in leads V1 and V2. Pacing was captured in 30-47 of 56 sites (54%-84%). As the pacing sites changed from the anterior to posterior of the septum, the QS notch (-) type in lead I shifted through rs to R, while a shift from R type to rR' or Rr' was noted in leads II and III. As the pacing sites changed from the anterior to posterior of the free wall, lead I showed a shift from the QS notch (+) type to R, while a shift from rR' to Rr' (or rR' unchanged) was found in leads II and III. The depth of the QS wave in leads aVR and aVL showed a tendency for aVR to be deeper than aVL toward the posterolateral attachment of both the septum and free wall, whereas aVL tended to be deeper than aVR toward the anterior attachment. The initial r waves in V1 and V2 became greater as the pacing site was positioned at a higher or more posterior location. These findings may provide more precise and clinically useful diagnostic information on the site of the origin of idiopathic VT originating from the RVOT by a 12-lead ECG.

The association of an insertion/deletion (I/D) polymorphism in the angiotensin converting enzyme (ACE) gene or the serum activity of ACE with coronary artery disease (CAD) was investigated in Japanese men and women. The ACE genotype of 947 CAD subjects who underwent coronary angiography and of 893 control subjects was determined by polymerase chain reaction analysis. No association of the DD genotype or the D allele with CAD was observed in men or women. In a low risk group (defined by a body mass index below the median value and the absence of a history of hypertension, diabetes mellitus, and hypercholesterolemia), there was also no association between the ACE gene polymorphism and CAD. No significant difference in serum ACE activity was detected between CAD subjects and controls of all genotypes or of the same genotype, whereas a significant association was apparent between serum ACE activity and ACE genotype for both CAD subjects and controls among both men and women. These results indicate that the ACE I/D polymorphism and genotype associated variation in serum ACE activity are not risk factors for CAD in Japanese men or women.

In Japan the majority of sarcoidosis-related deaths are due to cardiac sarcoidosis. One of the most common electrocardiographic abnormalities in patients with this disease is atrioventricular block. This study surveyed the incidence of cardiac sarcoidosis in Japanese patients (40 men and 49 women; mean age, 69.1 years) with high-degree atrioventricular block who were admitted to the hospital to receive a permanent pacemaker. We excluded cases in which sarcoidosis had been diagnosed from the involvement of other organs. Patients with the characteristic signs of sarcoidosis underwent echocardiography, radionuclide imaging, and biopsy. Ten cases (11.2%) of cardiac sarcoidosis were diagnosed, most frequently in women aged 40 to 69 years (8 of 25, 32%). Thus the possibility of cardiac sarcoidosis should be carefully considered in middle-aged or elderly Japanese women who show high-degree atrioventricular block.

The relationship of an insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene to left-ventricular hypertrophy in individuals with essential hypertension (EH) was investigated in a large population of Japanese men and women. The ACE genotype of 762 subjects with EH (425 men and 337 women) and 1,157 healthy controls (604 men and 553 women) was determined by polymerase chain reaction analysis. The distribution of ACE genotypes did not differ significantly between patients with EH and control in both men and women. For women with EH, the DD genotype was positively associated with the thickness of the interventricular septum and inversely associated with the left ventricular end-diastolic dimension, both determined by echocardiography. In contrast, the DD genotype was not associated with any echocardiographic parameter in men with EH. These results indicate that the DD genotype is a risk factor for left-ventricular hypertrophy in Japanese women with EH, but not for Japanese men.

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.

We aimed to examine what becomes of the coagulable state when warfarin is interrupted in patients undergoing ablation of atrial fibrillation (AF). We studied 62 patients with a CHADS2 score of 0 or 1 who underwent ablation for paroxysmal AF. Warfarin was discontinued the day before the ablation without heparin-bridging, and intravenous heparin was administered during the procedure in a conventional manner, and warfarin was then resumed after achieving hemostasis of the access site. The international normalized ratio (INR) values or D-dimer levels were measured at five different time points during the periprocedural period, and the periprocedural hemorrhagic and thromboembolic complications were assessed. The INR value constantly decreased after withdrawal of warfarin, and did not recover to the level before its discontinuation at the time of hospital discharge despite a short interruption of warfarin (mean ± SD, 1.75 ± 0.52 to 1.41 ± 0.27, p < 0.0001). However, the D-dimer level continued to increase over a period of 48 h after the ablation in spite of the administration of a sufficient amount of heparin during the procedure and a quick resumption of warfarin (mean ± SD, 0.57 ± 0.19 to 0.85 ± 0.36 μg/mL, p < 0.0001). The INR value measured just before the ablation had a significant inverse correlation to the D-dimer levels assessed just before (r = −0.304), immediately after (r = −0.440), 24 h after (r = −0.442) and 48 h after the ablation (r = −0.463). In conclusion, the risk of hyper-coagulability may increase during the early postprocedural period of AF ablation in patients who were inappropriately anticoagulated with warfarin.

Sirolimus-eluting stent (SES) has shown a significant efficacy in reducing restenosis after percutaneous coronary interventions. However, an increase in total number of SES use along with targeting more complex lesions generated a large number of SES restenosis. This study aimed to investigate the clinical and angiographic outcomes of different revascularization strategies for SES restenosis.A total of 176 lesions in 149 patients were included in the study. Fifteen patients underwent coronary artery bypass graft surgery (CABG group) and the remaining patients were treated with percutaneous coronary intervention (PCI). Stent reimplantation was performed in 88 patients (Stent group), whereas 46 patients received balloon therapy (Balloon group). Among 176 lesions, major cardiac adverse event (MACE) occurred in 41 lesions (23.3%) during a median follow-up of 310 days (interquartile range: 146-517 days). The Kaplan-Meier method with a log-rank test revealed no significant difference in MACE rates between the three groups (6%, 25%, 26%, p = 0.13; CABG group, Stent group, Balloon group, respectively). However, when the Balloon group and Stent group were combined together as a PCI group, PCI group had a significantly higher rate of MACE compared with the CABG group (p = 0.04). In addition, angiographic restenosis was significantly less prevalent in the CABG group when compared with the other two groups (8%, 57%, 46%, p = 0.006; CABG group, Stent group, Balloon group, respectively).CABG surgery for patients with SES restenosis is associated with the better clinical outcomes as well as better angiographic outcomes when compared with that of PCI.

OBJECTIVES Recurrent in-stent restenosis remains an important clinical issue after a percutaneous coronary intervention even after treatment with a sirolimus-eluting stent (SES) especially in patients with chronic kidney disease. We evaluated the impact of renal insufficiency on the clinical and angiographic outcomes after treatment for SES restenosis. METHODS AND RESULTS A total of 74 patients with 76 lesions underwent subsequent revascularization with a drug-eluting stent for SES restenosis. Patients were classified into three groups: group 1 included 29 patients with an estimated glomerular filtration rate more than 60 ml/min/1.73 m(2); group 2 included 27 patients with lower estimated glomerular filtration rate (

To address safety concerns with first-generation drug-eluting stents (DESs), the everolimus-eluting stent (EES) has been developed as a second-generation DES. The study aim was to: (1) demonstrate that use of the EES in Japanese patients is non-inferior to use of the paclitaxel-eluting stent (PES) in US patients; and (2) compare vessel response to the EES in Japanese vs US patients.The SPIRIT III Japan Registry, a prospective single-arm multicenter study was a part of the SPIRIT III global clinical program using harmonization by doing. The primary endpoint was in-segment late loss at 8 months, compared to US PES.A total of 88 subjects were enrolled in the Japan EES group. Angiographic in-segment late loss was significantly less in Japan EES vs US PES (0.15 ± 0.34 mm vs 0.28 ± 0.48 mm, respectively; P=.0185; Pnon-inferio r.0001), while target vessel failure (TVF; 8.0% vs 9.9%) and major adverse cardiac events (MACE) at 9 months (5.7% vs 8.8%) were not significantly different between the 2 groups. No differences were observed between Japan and US EES populations in terms of late loss, TVF, or MACE. Neointimal volume and postprocedural incomplete stent apposition rate were lower in Japan EES vs US EES/PES.The SPIRIT III Japan Registry met the primary endpoint of lower late loss in the Japan EES group vs the US PES group, with comparable results for EES between the Japanese and US patients.