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Objectives: We evaluated the predictors of recurrent restenosis and the impact of lesion length and vessel size on outcomes in patients treated with routine sirolimus-eluting stent (SES) implantation for in-stent restenosis (ISA) of bare-metal stent (BMS). Methods: In this study, 250 consecutive patients with 275 lesions after SES implantation for ISA of BMS were enrolled. Follow-up angiogram was obtained in 239 patients with 258 lesions eight months after implantation (follow-up rate: 95.6%). We compared characteristics of patients and lesions between the two groups (the recurrent restenosis group and the no-restenosis group). Results: Recurrent restenosis was angiographically documented in 43 lesions (16.7%). Recurrent restenosis was found in 30.4% with small vessel lesions (reference diameter of less than 2.5 mm, 92 lesions) and 23% with the diffuse type lesions (106 Iesions(. Seventy-two per cent of patients had a focal pattern of recurrent restenosis. Previously recurrent ISA lesions (odds ratio (OR) 1.94, 95% confidence interval (Cl( 0.94 to 4.06, p = 0.05(, reference diameter of less than 2.5 mm (OR 2.41, CI 1.05 to 5.41, p = 0.03(, diffuse type restenosis (OR 4.48, Cl 2.12 to 9.94, p = 0.0001( and dialysis patients (OR 4.72, Cl 1.42 to 15.7, p = 0.01( were independent predictors of recurrent restenosis. Conclusions: Small vessels, diffuse type restenosis and dialysis patients were still the predictors of recurrent restenosis in patients treated with SES for ISA of BMS. [ABSTRACT FROM AUTHOR]

Currently, no consensus has been established on the most effective antithrombotic therapy to prevent thromboembolic and bleeding events in patients undergoing percutaneous left atrial appendage closure (LAAC) with preprocedural thromboembolic or bleeding events under oral anticoagulation (OAC) therapy. We retrospectively investigated the incidence of device-related thrombosis (DRT), thromboembolic events, and bleeding events in patients who underwent LAAC from September 2019 to October 2022. After categorizing patients into three groups based on preprocedural thromboembolic or bleeding events under OAC therapy, we compared the incidence of DRT and prognosis according to the postprocedural antithrombotic therapy. In patients who received the conventional antithrombotic therapy (OAC with and without single antiplatelet therapy for 45 days after LAAC and dual-antiplatelet therapy from 45 days to 6 months followed by single antiplatelet therapy), preprocedural thromboembolic events despite OAC were independently associated with DRT or postprocedural thromboembolic events at the 3 year follow-up (hazard ratio [HR] 4.55; 95% confidence interval [CI] 1.32-15.6; P = 0.016), whereas preprocedural bleeding events were independently associated with postprocedural bleeding events (HR 8.01, 95% CI 1.45-58.3; P = 0.036). Continuation of OAC for 12 months among patients who developed preprocedural thromboembolic events during OAC significantly decreased the incidence of DRT or postoperative thromboembolic events (P = 0.002) with no increase in the bleeding events (P = 0.522). Preprocedural thromboembolic and bleeding events can predict adverse events after LAAC with the conventional antiplatelet-based antithrombotic therapy. Patients who develop thromboembolic events under continuous OAC may benefit from continuous OAC for 1 year after LAAC., Competing Interests: Declarations Conflict of interest The authors declare that there are no conflicts of interest., (© 2024. Springer Nature Japan KK, part of Springer Nature.)

Background: Patients with atrial fibrillation and malignant left atrial appendage (LAA) may benefit from LAA closure (LAAC); however, evidence is limited., Objective: The purpose of this study was to determine management strategies and clinical outcomes in patients with atrial fibrillation and malignant LAA., Methods: Malignant LAA was defined as a history of ischemic stroke and/or evidence of LAA thrombus despite continuous oral anticoagulation (OAC) therapy (continuous for ≥3 weeks). We studied 80 patients with malignant LAA treated with LAAC. We compared these patients first against 44 patients with malignant LAA treated with OAC alone and second against 114 patients without malignant LAA who were treated with LAAC for conventional indications., Results: Among patients with malignant LAA (first comparison), those treated with LAAC had a higher 1-year cumulative incidence rate of ischemic stroke than did patients treated with OAC alone (6.3% vs 5.3%; log-rank, P = .09) whereas the difference in stroke risk while receiving OAC was comparable (2.7% vs 5.3%; log-rank, P = .84). Furthermore, all disabling stroke events in patients with malignant LAA treated with LAAC occurred only while not receiving OAC. Among patients treated with LAAC (second comparison), those with malignant LAA had a higher 1-year cumulative incidence rate of ischemic stroke (and ischemic stroke due to device-related thrombosis) than did those without malignant LAA (6.3% vs 2.2%; log-rank, P = .009 and 2.2% vs 0%; log-rank, P = .04, respectively). However, these differences in stroke risk were no longer significant while receiving OAC (2.7% vs 1.0%; log-rank, P = .11)., Conclusion: Combination performing LAAC and continuation of OAC may be options to prevent ischemic stroke in patients with high thromboembolic risk and malignant LAA., Competing Interests: Disclosures Drs Chatani and Kubo are clinical proctors for Boston Scientific and have received honoraria from Boston Scientific. All other authors declare no conflicts of interest., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Aims: Atrial fibrillation (AF) is frequently associated with heart failure with preserved ejection fraction (HFpEF), but the diagnosis and prediction of the outcomes of HFpEF are difficult. Notably, the Heart Failure Association of the European Society of Cardiology proposed the use of the HFA-PEFF score in the diagnosis of HFpEF. This study aimed to assess the prognostic value of the pre- and post-procedural HFA-PEFF scores in patients with preserved ejection fraction (EF) after catheter ablation (CA) for AF. The primary endpoint was a composite of cardiac hospitalization for cardiovascular events and all-cause mortality. The secondary endpoint was AF recurrence., Methods and Results: Overall, 354 patients with AF and preserved EF who underwent CA as well as blood tests and transthoracic echocardiography 2 weeks before and 6 months after CA from January 2018 to December 2019 were retrospectively enrolled in the study. In the 354 participants, univariate analysis showed that the post-procedural HFA-PEFF score was associated with a 3-year risk of the primary endpoint (hazard ratio [HR] = 3.73; 95% confidence interval [CI] = 2.07-6.73; P < 0.001), whereas the pre-procedural HFA-PEFF score was not (HR = 1.24, 95% CI = 0.82-1.86, P = 0.307). Further, the association between the post-procedural HFA-PEFF score and primary endpoint was not modified even after including other relevant variables into the score. Similar to the primary endpoint, the post-procedural HFA-PEFF score was associated with the 3-year risk of AF recurrence (P < 0.001)., Conclusions: In patients with preserved EF undergoing AF ablation, the HFA-PEFF score at 6 months after CA was associated with the primary endpoint and AF recurrence at the 3-year follow-up., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: The HFA-PEFF score comprising echocardiographic and laboratory data is designed to diagnose heart failure with preserved ejection fraction and holds prognostic value in patients who underwent catheter ablation for atrial fibrillation (AF). However, the incorporation of many variables into this score limits its practical use., Objective: We aimed to develop and to validate a simplified score (AF-HFA-PEFF score) focusing on AF-related parameters to predict cardiovascular events and AF recurrence., Methods: We retrospectively enrolled 354 patients with preserved ejection fraction who underwent AF ablation. Using Cox regression hazard ratios from the HFA-PEFF score variables, we generated a risk score from a random 50% of patients and validated it with the other half., Results: Univariate analysis revealed that postprocedural E/e', tricuspid regurgitation peak gradient, left atrial volume index, and brain natriuretic peptide levels were associated with 3-year cardiovascular events or AF recurrence. We developed the AF-HFA-PEFF score incorporating these factors. In the derivation group, C statistics for cardiovascular events were 0.72 for the AF-HFA-PEFF score and 0.74 for the original HFA-PEFF score and 0.71 and 0.69 for AF recurrence, respectively. Validation demonstrated that patients with an AF-HFA-PEFF score <4 had a 3-year cardiovascular event risk of 1.4% vs 9.4% for scores ≥4 (P < .001). For AF recurrence, these figures were 9.7% and 65.6%, respectively (P < .001)., Conclusion: The AF-HFA-PEFF score is simpler than the HFA-PEFF score and is equally associated with 3-year cardiovascular events and AF recurrence., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Recently, conduction system pacing has been performed in patients with impaired cardiac function. We report a case in which a DF4 implantable cardioverter defibrillator lead was screwed directly into the left bundle branch area with the support of a steerable delivery sheath., (© 2024 Wiley Periodicals LLC.)

The subcutaneous implantable cardioverter defibrillator (S-ICD) is often used in young patients such as arrhythmogenic right ventricular cardiomyopathy (ARVC) and Brugada syndrome due to long-term lead durability issues. Although S-ICD lead dislodgement is rare, we encountered such an incident in a young ARVC patient during the chronic phase following the two-incision technique. Remote monitoring system is useful for early diagnosis of electrode movement (Graphical abstract image). When S-ICD lead dislodgement occurs in active young patients, lead revision using the three-incision technique may be an option., (© 2024 Wiley Periodicals LLC.)

Background: The introduction of the Perclose vascular closure device (VCD) for atrial fibrillation (AF) ablation procedures in Japan is expected to facilitate early ambulation., Methods and Results: The study population comprised 554 patients undergoing AF ablation, of whom 377 successfully underwent Perclose VCD deployment at the end of the procedure. At 4 h after the procedure, 94% (353/377 patients) achieved early hemostasis and 57% (213/377 patients) achieved early ambulation. Notably, 0.5% (2/377 patients) developed acute deep vein thrombosis., Conclusions: The Perclose VCD demonstrated promising efficacy in achieving early hemostasis, potentially facilitating early ambulation and discharge in appropriate patients., Competing Interests: All authors have no conflicts of interest to disclose., (Copyright © 2024, THE JAPANESE CIRCULATION SOCIETY.)

Background: Patients with nonvalvular atrial fibrillation (AF) not suitable for long-term anticoagulant therapy undergo percutaneous left atrial appendage closure (LAAC) using the WATCHMAN device. The safety and efficacy of WATCHMAN-FLX (WM-FLX) compared with WATCHMAN-2.5 (WM-2.5), particularly in Asian populations, is unknown., Methods: We evaluated the background, procedure, and clinical outcomes of 199 patients who underwent LAAC between September 2019 and December 2022 and compared WM-2.5 (72 patients) with WM-FLX (127 patients)., Results: The mean age was 76 years, with 128 men, and 100 had nonparoxysmal AF (non-PAF). The mean CHA 2 DS 2 -VASc, and HAS-BLED were 5.1, and 3.2 points, respectively. WM-FLX group demonstrated a shorter procedure time than WM-2.5 group (50 vs. 42 min, p = 0.001). The WM-FLX group demonstrated no procedural-related acute cardiac tamponade, which was significantly low (5.6% vs. 0%, p = 0.02), and a significantly higher rate of complete seal at 45-day (63% vs. 80%, p = 0.04). WM-FLX group had a significantly higher cumulative 1-year incidence of device-related thrombosis (DRT) than WM-2.5 group (3.4% vs. 7.0%, Log-rank p = 0.01). Univariate analysis identified two DRT risk factors in the WM-FLX group: non-PAF (odds ratio [OR] 7.72; 95% confidence interval [CI] 1.20-48.7; p = 0.04), and 35-mm device (OR 5.13; 95% CI 1.31-19.8; p = 0.02)., Conclusions: WM-FLX significantly improved the procedural quality and safety of LAAC. However, DRT remains an important issue even in the novel LAAC device, being a hazard for patients with high DRT risk, such as having non-PAF and using 35-mm devices., (© 2024 Wiley Periodicals LLC.)

Background: Cardiac resynchronization therapy (CRT) with biventricular pacing is a well-established therapy. Left bundle branch area pacing (LBBAP) is a safe technique providing physiological pacing, and LBBAP-optimized CRT (LOT-CRT) has been shown to provide better electrical resynchronization than traditional CRT. However, there are few reports on shock lead placement in the left bundle branch area (LBBA) during CRT-defibrillator (CRT-D) implantation., Case Summary: A 76-year-old woman with heart failure from dilated cardiomyopathy presented with left bundle branch block pattern (QRS duration, 160 ms). Left ventricular ejection fraction was 21%. Cardiac resynchronization therapy-defibrillator implantation was performed due to worsening symptoms. By reshaping the Agilis HisPro catheter and adding a septal curve, the shock lead was placed deep into the ventricular septum, narrowing QRS duration to 114 ms. Left ventricular activation time was 84 ms. A defibrillation threshold test confirmed successful treatment without adverse events. At 6-month follow-up, left ventricular ejection fraction improved from 21 to 63%, with the patient's condition improving from New York Heart Association class III to class I., Discussion: It was reported that QRS narrowing in CRT was related to long-term mortality, and LOT-CRT further decreased QRS duration as compared with LBBP only or biventricular pacing and increased the response rate. Combining LBBAP with coronary sinus pacing can potentially achieve superior electrical resynchronization. Lack of a suitable tool for direct shock lead placement in LBBA necessitated additional LBBAP lead in conventional LOT-CRT. Our successful LOT-CRT-D procedure with minimal number of leads through Agilis HisPro catheter reshaping enabled direct LBBA shock lead placement., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)