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Accurate noninvasive assessment of right atrial pressure (RAP) is important for volume management in patients with heart failure (HF). Transient elastography is a noninvasive and reliable method to assess liver stiffness (LS). We investigated the value of LS for evaluation of RAP in patients with HF without structural liver disease. We measured LS using transient elastography (Fibroscan) in 31 patients undergoing right-sided cardiac catheterization (test group). The relation between LS and RAP found in the test group was used to derive the best-fit model to predict RAP. The applicability of the model was then tested in a validation group of 49 additional patients. There was an excellent correlation between LS and RAP in the test group (r = 0.95, p <0.0001; RAP = −5.8 + 6.7 × ln [LS]). Natural log transformation (ln) of LS provided the regression equation to predict RAP. When the equation model derived from the test group was applied to the validation group, predicted RAP correlated excellently with actual RAP (r = 0.90, p <0.0001). The receiver operating characteristic curve analyses in the test group showed that LS favorably compared with echocardiography for detecting RAP >10 mm Hg (area under the curve 0.958 vs 0.800, respectively, p = 0.047). In the validation group, LS with a cut-off value of 10.6 kPa for identifying RAP >10 mm Hg had a higher sensitivity and accuracy (p = 0.046 and p = 0.049, respectively) than echocardiography. In conclusion, LS may offer an accurate noninvasive diagnostic method to assess RAP in patients with HF.

Aims The purpose of this study was to compare the impact of catheter ablation on cardiac structural reverse remodelling and atrial (AFMR) and ventricular (VFMR) functional mitral regurgitation (MR), and the long‐term prognosis of patients with AFMR and VFMR. Methods and results The retrospective study included persistent AF patients who had AFMR (n = 136, left atrial (LA) volume index >30 mL/m2 and left ventricular (LV) ejection fraction ≥40%) or VFMR (n = 31, LV ejection fraction <40% or LV regional asynergy) and had undergone the initial AF ablation from April 2015 to December 2019. Baseline and 6 month follow‐up echocardiography were performed to assess MR, LA, and LV sizes. MR improvement after ablation was comparable in the AFMR (64%) and VFMR groups (52%, P = 0.20). Patients with AFMR improvement showed a greater decrease in left atrial volume after ablation than those without (amount of change: −11.4 ± 15.1 vs. −2.3 ± 21.1 mL/m2, P = 0.01). Patients with VFMR improvement showed a greater increase in LV ejection fraction than those without (amount of change: 28.5 ± 13.6% vs. 9.0 ± 14.8%, P = 0.001). The composite endpoint of all‐cause death and heart failure hospitalization during the 2 year follow‐up period was more frequently observed in the VFMR than in the AFMR group (22.6% vs. 3.7%, P < 0.0001). Patients with MR improvement after catheter ablation less frequently demonstrated the composite endpoint than those without (1.9% vs. 15.6%, P < 0.0001). Conclusions Atrial functional mitral regurgitation and VFMR improvement after ablation were associated with atrial and ventricular reverse remodelling, respectively. It is possible that long‐term prognosis is better in patients with AFMR than with VFMR, and in those with MR improvement than in those without.

Although the superiority of DCBs to uncoated balloon angioplasty for the treatment of femoropopliteal (FP) lesions has been demonstrated, the association of clinical factors, including anatomical features evaluated by intravascular ultrasound (IVUS) and platelet reactivity, with the loss of patency has not been systematically studied. The current prospective, observational study enrolled 160 consecutive patients (male 67.5%, mean age 74.7 ± 9.7 years) with 213 FP lesions treated with DCBs under IVUS evaluation. The platelet reactivity was measured in P2Y12 reaction units for all of the patients at the DCB treatment. The primary end point was primary patency at 12 months, while the secondary end points were freedom from target lesion revascularization (TLR), all-cause death, major target limb amputation and bleeding events at 12 months. Mean lesion length was 11.9 ± 9.4 cm and 34 (16.0%) were chronic total occlusions (CTOs). Thirty-four (16.0%) were severely calcified lesions. Primary patency by Kaplan–Meier estimate was 79.2% at 12 months, while the 12-month freedom from TLR, all-cause death and bleeding events were observed in 89.1%, 93.4% and 97.4%, respectively. There were no major target limb amputations through 12 months. Multivariate analysis showed that subintimal angioplasty for CTO lesions was a sole risk factor for loss of 12-month primary patency, while other IVUS parameters and platelet reactivity were not.

PurposeCardiac conduction disturbance necessitating pacemaker implantation is common among elderly patients. However, patients often have comorbidities and increased frailty which may result in limited life prognosis and a high rate of procedure-related complications. We evaluated pacemaker implantation in older patients by comparing life prognosis and complication rate in patients aged ≥ and < 85 years.MethodsWe retrospectively enrolled 262 consecutive patients who underwent initial pacemaker implantation for bradycardia (age, 77 ± 10 years old; male, 132 (50%); dual chamber pacemaker, 222 (85%) patients). Acute and long-term outcomes were compared between patients aged ≥ 85 and < 85 years. Primary outcome was a composite of all-cause death and severe procedure-related complications.ResultsSeven (14%) patients aged ≥ 85 years (n = 50; 19%) were non-ambulatory. During 2-year follow-up, primary outcome (death or severe complication) occurred in 47 (18%). Freedom from primary outcome was similar between age groups (81.6% versus 80.8%; p = 0.98). Freedom from all-cause death and from severe complication in the study period were also similar (all-cause death, 91.6% versus 88.7%, p = 0.70; severe complication, 89.7% versus 91.5%, p = 0.75). On multivariate analysis, sick sinus syndrome (hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.1–6.4, p = 0.03), immunosuppressant use (HR 21 (95% CI 3.3–134), p < 0.01), and high C-reactive protein (HR 1.5 (95% CI 1.2–1.9), p < 0.01) were independent predictors of primary outcome.ConclusionsLife prognosis and severe complication rates after pacemaker implantation were similar between patients aged ≥ and < 85 years.

The major mechanism underlying the early recurrence of atrial fibrillation (AF) after ablation is mainly reconnection of the isolated pulmonary vein (PV); however, the mechanism responsible for very late recurrence (VLR) has not been fully elucidated. The purpose of the present study was to investigate the mechanism underlying VLR. The study population included 150 consecutive patients with AF who underwent a second session of catheter ablation because of recurrence. We divided them into 2 groups according to the point of initial AF recurrence: the late recurrence group (LR group, initial recurrence 3 to 12 months after ablation, n = 124) and the VLR group (initial recurrence >12 months after ablation, n = 26). We identified PVs with ectopic foci (trigger PVs) in the first procedure and checked their electrical reconnection in the second procedure. The prevalence of PV reconnection and trigger PV reconnection were significantly lower in the VLR group than in LR group (LR vs VLR, 90% vs 69% and 48% vs 27%, p = 0.007 and p = 0.045, respectively). In the VLR group, left ventricular systolic and diastolic function were significantly worse than in the LR group, and more patients in the VLR group required non-PV trigger ablation in the second session than did those in the LR group (30% vs 54%, p = 0.034). In conclusion, electrical PV reconnection contributed less to VLR than to LR. Progression of the AF substrate might be an important mechanism responsible for VLR.

Background Continuous anticoagulation based on the CHA2DS2‐VASc score is recommended to prevent embolism caused by atrial fibrillation (AF), but it does not consider AF episodes. The Apple Watch's continuous heart rhythm monitoring and fast‐acting direct oral anticoagulants (DOACs) could enable precise, episode‐tailored anticoagulation, reducing bleeding risks while preventing stroke. This study evaluates Apple Watch‐guided personalized anticoagulation therapy, adjusting DOAC usage based on real‐time AF detection. Methods This multicenter prospective single‐arm study will enroll patients who have maintained sinus rhythm post‐ablation and are on DOACs. The target enrollment is 50 patients free of AF for at least 30 days following the initiation of Apple Watch monitoring. If no AF occurs for the first 30 days of monitoring, anticoagulants will be discontinued on day 31. If AF is confirmed after day 31, DOAC administration will be resumed and continued until the end of the observation period. The primary endpoint is the reduction in the total number of days with DOACs from day 31 to day 360 compared to the conventional method of continuing anticoagulation. Secondary endpoints include all‐cause mortality, stroke, systemic thromboembolism, bleeding events, and Apple Watch malfunctions. Results Enrollment of a total of 50 patients was completed in April 2024. Follow‐up of the last enrolled patient will be completed in April 2025 and primary results are expected to be available in late 2025. Conclusions The Up to AF trial is the first trial to evaluate Apple Watch‐guided personalized anticoagulation therapy. This trial represents a potential advancement in personalized medicine for AF management. The Up to AF trial evaluates Apple Watch‐guided personalized anticoagulation therapy for atrial fibrillation (AF), adjusting DOAC use based on real‐time AF detection. In this single‐arm study, 50 post‐ablation patients are monitored, aiming to reduce DOAC days while assessing mortality, stroke, and bleeding events. Results are expected in 2025.

Purpose Epicardial adipose tissue (EAT) surrounding the left atrium has been reported to have a pro-arrhythmic influence on atrial myocardium and to play an important role in the pathophysiology of atrial fibrillation (AF). The purpose of this study was to explore whether the abundance of EAT correlates with early and late recurrences of AF after ablation. Methods We included 53 consecutive patients with drug-refractory AF scheduled for ablation. Early and late recurrences were defined as atrial tachyarrhythmias within and after 3 months following the ablation procedure, respectively. The total and left atrial EAT volumes were obtained by 320-detector-row multislice computed tomography. Results During a follow-up period of 16 ± 4 months, early and late recurrences occurred in 29 (55 %) and 12 (23 %) patients, respectively. The left atrial EAT volume was larger in patients with than without early recurrence (35.1 ± 13.1 vs. 25.0 ± 9.5 cm 3 , p  = 0.002); however, there was no difference in the total EAT volume between the two groups (98.5 ± 45.7 vs. 94.5 ± 35.2 cm 3 , p  = 0.72). A multivariate analysis revealed that a large left atrial EAT volume, persistent AF, and large left atrial volume were independent predictors of early recurrence. Conversely, there was no significant difference in left atrial (29.3 ± 14.6 vs. 29.7 ± 11.7 cm 3 , p  = 0.93) and total EAT (91.0 ± 50.1 vs. 97.9 ± 37.0 cm 3 , p  = 0.66) volumes between patients with and without late recurrence. Conclusions The abundance of left atrial EAT independently predicted early recurrence after AF ablation; on the contrary, it did not have an impact on late recurrence. Left atrial EAT may have a pro-arrhythmic influence, especially in the early post-ablation phase.

Background Although several clinical reports demonstrated a durable patency rate after a novel fluoropolymer-coated paclitaxel-eluting stent (Eluvia; Boston Scientific, Marlborough, MA, USA) placement, aneurysmal degeneration after drug-eluting stent (Eluvia) placement has raised clinical concerns. Here, we report a case with progressive aneurysm formation on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery atheromatous plaque. Case presentation A 79-year-old woman with right leg intermittent claudication at 100 m distance was referred to our hospital. Pre-procedural angiography showed long-segment severe stenosis from the middle-to-distal part of the right superficial femoral artery, and a 7 mm wide drug-eluting stent (Eluvia) was placed. However, the patient had a recurrence of intermittent claudication in the right lower extremity 25 months thereafter. Angiography revealed de novo stenosis in the distal part of the popliteal artery and proximal superficial femoral artery in-stent restenosis. Subsequently, the patient underwent endovascular therapy for these lesions. In addition, intravascular ultrasound at the time of endovascular therapy revealed femoral artery enlargement with a maximum vessel diameter of 10.0 mm at the distal edge of the stent. Intermittent claudication on the right side recurred again 50 months after drug-eluting stent (Eluvia). Angiography demonstrated de novo severe stenosis from the distal part of the superficial femoral artery to the middle part of the popliteal artery. Peri-stent contrast staining was found at the distal part of the drug-eluting stent (Eluvia) site. Intravascular ultrasound showed a further enlargement of maximum vessel diameter to 12.0 mm at the distal edge of the stent. Conclusions We report a case with progressive aneurysm degeneration on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery stenosis.

The Japanese Catheter Ablation (J‐AB) registry, started in August 2017, is a voluntary, nationwide, multicenter, prospective, observational registry performed by the Japanese Heart Rhythm Society (JHRS) in collaboration with the National Cerebral and Cardiovascular Center. From January 2022, the data registration system was changed from the Research Electronic Data Capture (REDCap) system to the Fountayn system. The purpose of this registry is to collect the details of target arrhythmias, the ablation procedures, including the type of target arrhythmias, outcomes, and acute complications in real‐world settings. During the year of 2023, we have collected a total of 102 584 procedures (mean age of 66.9 years and 65.2% male) from 549 participant hospitals. Detailed data were shown in figures and tables.

Background Repeat ablation is often required in patients with atrial fibrillation (AF) due to recurrent arrhythmias. Although pulmonary vein isolation (PVI) is the only recommended ablation technique for repeat ablation, various additional strategies are commonly used in clinical practice. The purpose of this study was to evaluate the implementation, efficacy, and safety of repeat ablation strategies in Japan. Methods This study was conducted by using the Japanese Catheter Ablation Registry (J‐AB registry). A total of 26 684 patients who underwent a second ablation procedure for AF between August 2017 and December 2020 were included and analyzed for patient characteristics, procedural characteristics, and complications. Additionally, the AF recurrence rate over a 12‐month follow‐up period was also investigated in 1508 s ablation procedures. Results In the second ablation procedure, repeat‐pulmonary vein isolation (re‐PVI) was performed for 20 938 (78%) patients and 14 552 (55%) patients underwent left atrial additional ablation. Both of re‐PVI and left atrial additional ablation were performed for 10 086 (38%) patients. As the number of left atrial additional ablations in the second ablation procedure increased, the overall complication rate also significantly increased (paroxysmal AF, p < 0.001; persistent AF, p < 0.001). The rate of freedom from AF recurrence during the follow‐up period was 87.6% for paroxysmal AF and 80.6% for persistent AF. Conclusions In the second ablation procedure performed in Japan, re‐PVI was required in 78% of patients, and both of re‐PVI and left atrial additional ablation were performed for 38% of patients. As the number of left atrial additional ablations increased, the overall complication rate also increased. Trial Registration The J‐AB registry is registered in the UMIN Clinical Trial Registry (UMIN 000028288) and ClinicalTrials.gov (NCT03729232) Patients who underwent second or later ablation procedures for AF were analyzed. In total, 41% of patients underwent re‐PVI only; conversely, both of re‐PVI and left atrial additional ablation were performed for 38% of patients. As the number of additional ablations increased, the overall complication rate also increased.