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Right bundle branch block (RBBB) is one of the most frequent alterations of the electrocardiogram. Several studies have shown that RBBB is a risk factor of cardiovascular diseases. However, the clinical outcomes after pulmonary vein isolation (PVI) in patients with RBBB remain unclear. We enrolled consecutive atrial fibrillation (AF) patients who underwent PVI from the Osaka Rosai Atrial Fibrillation (ORAF) registry. We excluded patients with other wide QRS morphologies (left bundle branch block, ventricular pacing, and unclassified intraventricular conduction disturbances) and divided them into 2 groups: RBBB (QRS duration ≥120msec) and No-RBBB (QRS duration <120) groups. We compared the incidence of late recurrence of AF and/or atrial tachycardia (AT) (LRAF) between the 2 groups using a propensity score-matched analysis and evaluated the risk of LRAF using Cox regression model. We finally analyzed 671 consecutive AF patients. The RBBB group consisted of 50 patients (7.5%) and the No-RBBB group of 621 patients. Median follow-up duration was 734 [496, 1,049] days. Hypertension and diabetes mellitus were significantly higher in RBBB group than No-RBBB group. Among the 46 matched patients pairs, Kaplan-Meier analysis demonstrated that RBBB group had a significantly greater risk of LRAF than the No-RBBB group (p = 0.046). The Cox regression model revealed significantly higher risks of LRAF (HR, 2.30; 95% CI, 1.00 to 5.33; p=0.044) in RBBB group compared with No-RBBB group. Non-PV AF triggers were significantly higher in RBBB group than No-RBBB group (p = 0.048). In conclusion, RBBB can be an important predictor of LRAF after PVI.

Percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) undergoing hemodialysis (HD) remains challenging, with limited long-term outcome data. We investigated the long-term prognosis of ACS due to de novo coronary artery lesions and stent thrombosis (ST) in patients with and without HD. We analyzed 187 patients with ACS from the Osaka Cardiovascular Conference Long ST registry, a retrospective, multicenter registry of definite ST, and 1,856 patients with ACS due to de novo coronary artery lesions at Kansai Rosai Hospital. Patients were grouped by HD status and ACS etiology ( de novo - and ST-ACS). The primary outcome was the 6-year incidence of major adverse cardiac events (MACE) defined as a composite of cardiac death, non-fatal myocardial infarction, target vessel revascularization, and subsequent ST. The 6-year MACE rate was highest in ST-ACS with HD, followed by de novo -ACS with HD, ST-ACS without HD, and de novo -ACS without HD (82.1 vs. 62.5 vs. 38.3 vs. 24.2%, respectively, p  < 0.001). Multivariate analysis identified HD (hazard ratio [HR]: 2.50, 95% confidence interval [CI]: 1.89–3.32, p  < 0.001) and ST-ACS (HR: 1.69, 95% CI: 1.17–2.45, p  = 0.006) as independent MACE predictors. The long-term prognoses following ACS are unfavorable in patients on HD, particularly those with ST-ACS.

Contemporary debulking devices such as rotational or orbital atherectomy can modify severe calcified lesions before stent implantation. Actually, we occasionally experience stent underexpansion without debulking devices in not severe but moderate calcified lesions although we expect good stent expansion. We aimed to investigate useful calcium parameters correlated with stent expansion in moderate calcified lesions. We enrolled 50 consecutive moderate calcified lesions in 47 patients who underwent optical coherence tomography (OCT) guided percutaneous coronary intervention (PCI) between January 2017 and March 2019. The exclusion criteria were the lesions without any calcium and treated with rotational or orbital atherectomy. We compared stent sizing, length, post balloon sizing, post balloon pressure, mean reference area, pre-procedure area stenosis and various calcium parameters including calcium arc, maximum calcium thickness, depth, longitudinal length in pre-PCI OCT with post-PCI stent expansion by simple and multiple regression analysis. Maximum calcium thickness was an independent predictor for stent expansion, while the other calcium parameters were not associated. The optimal thresholds of maximum calcium thickness for predicting acceptable stent expansion defined by 80% was 880 µm (area under curve: 0.73). Maximum calcium thickness < 880 µm is a useful predictor for acceptable stent expansion in moderate calcified lesions.

The aim of this study was to investigate the impact of a new optical coherence tomography (OCT)-derived volumetric method for stent expansion (new-OCT method) to predict the target lesion revascularization (TLR) and compare the expansion findings between this new method and the conventional method because, in the real world, there are few clinical data on the new-OCT-method for stent expansion. One hundred forty lesions in 135 patients who underwent OCT-guided percutaneous coronary intervention were enrolled. We compared the new-OCT-method and conventional method to predict the TLR at 1 year. A total of 7 lesions (5.0% of treated lesions) in 6 patients experienced TLR during 1 year of follow up. The minimum expansion index (MEI) using the new-OCT method was significantly lower in the TLR group than non-TLR (60.0% vs. 77.0%; p < 0.001) while the conventional method for assessing stent expansion did not show a statistically significant difference between the two groups (71.3% and 79.7%; p = 0.118). The univariate analysis showed that the stent length, minimum stent area, minimum lumen area, MEI, and renal insufficiency/failure, were significant predictors of a 1-year TLR. The multivariate model identified the stent length, MEI, and renal insufficiency/failure as the independent predictors of TLR and the value of the MEI was the only predictor in the OCT findings. The new OCT-derived volumetric method for stent expansion is superior to the conventional method for predicting the TLR at 1 year. The MEI may be the most practical and efficient way to estimate stent under-expansion.

Persistent sciatic artery (PSA) is a rare vascular anomaly that can cause acute limb ischaemia (ALI) due to peripheral thromboembolism following aneurysm formation, and surgical repair or exclusion with or without femoropopliteal bypass is the standard treatment for these symptomatic cases of PSA. Here, we report a case of a 70-year-old man with right PSA aneurysm who suffered from recurrent ALI despite the history of right femoropopliteal bypass at the age of 58 for occlusion of right PSA and graft (femoropopliteal bypass graft)-to-tibial bypass at the age of 68 for occlusion of right posterior tibial artery. We performed a catheter angiographic examination using an intravascular ultrasound and performed an endovascular therapy (EVT) for the purpose of jailing the internal iliac artery. This is a rare case of PSA aneurysm presenting with recurrent ALI after femoropopliteal bypass successfully treated with EVT.

•Holter ECG was useful to predict the recurrence of AF after catheter ablation.•Small prematurity index of APCs has a great significance.•APCs burden may be associated with VLRAF. This study aimed to evaluate the predictors of very late recurrence of atrial fibrillation (VLRAF) after an initial AF catheter ablation (CA) by analyzing the follow-up Holter electrocardiogram. We retrospectively studied patients (n = 253, mean age: 66 years, woman: 30%, paroxysmal AF: 73%) without recurrence of AF within 12 months and the use of antiarrhythmic drugs. In the Holter electrocardiogram analysis, the atrial premature complexes (APCs) burden, the profile of the APCs run and prematurity index of the APCs were evaluated. Fifty-one patients (20%) had VLRAF during the follow-up period (mean follow up: 46 months). Patients with VLRAF had a significantly greater APCs burden (0.318% [0.084 to 1.405] vs 0.132% [0.051 to 0.461], p = 0.022), longer number of APCs run (5 [3 to 11] vs 4 [0 to 7], p = 0.019), and shorter minimum prematurity index of the APCs (47 ± 7 vs 51 ± 6, p = 0.001) than those without VLRAF. The optimal cutoff value for the APCs burden, maximum number of APCs run, and minimum prematurity index of the APCs to predict VLRAF was 0.159%, 10, and 48%, respectively. The minimum prematurity index of the APCs (≤48%) was significantly associated with VLRAF in the multivariate analysis. In conclusion, the minimum prematurity index of the APCs (≤48%) at 12 months after CA was shown to be an independent predictor of VLRAF in patients without antiarrhythmic drugs. Although the index is a very simple parameter automatically calculated by analysis software, it can be an important index for following patients after CA over the long-term.

•Predictors of atrial fibrillation (AF) recurrences were evaluated based on postprocedural parameters.•Postprocedural parameters are useful to predict recurrence of AF.•Early recurrence of AFwas associated with recurrence of AF.•Follow-up Holter electrocardiogram is effective to predict recurrence of AF.•n-PReDCt score can accurately predict outcome after catheter ablation. Various predictors of atrial fibrillation (AF) recurrence have been shown based on the baseline characteristics before catheter ablation (CA). This study aimed to develop a novel scoring system for predicting very late recurrences of AF (VLRAFs) after an initial CA, taking the postprocedural clinical data into account and reassessing VLRAFs in 12-month patients’ condition using previously known preprocedural predictors of AF recurrences. We retrospectively studied 327 patients who underwent an initial CA with freedom from AF for over 12 months. We elucidated the predictors of VLRAFs and created a new score to predict VLRAFs in the discovery AF cohort (n = 181). Thereafter, we investigated whether the new scoring system could accurately predict VLRAFs in the validation AF cohort (n = 146). In the discovery AF cohort, VLRAFs were observed in 53 patients (29%) during the follow-up period (mean follow-up duration: 55 months). The univariate and multivariate Cox proportional-hazards model demonstrated that non-pulmonary vein foci, early recurrences of AF (ERAFs), atrial premature contraction (APC) burden ≥ 142/24 hours, and minimum prematurity index of the APCs ≤ 48% were associated with VLRAFs after CA. We created a new scoring system to predict VLRAFs, the n-PReDCt score (non-pulmonary vein: 1 point, early recurrences of AFs (Recurrences of AF in early phase after CA): 1 point, APC burden ≥ 142/24 hours: 1 point, and minimum prematurity index (= Coupling interval) of the APCs of ≤ 48%: 1 point). The n-PReDCt score was significantly associated with VLRAFs by a Kaplan-Meier analysis in the discovery AF and validation AF cohorts (p < 0.0001 and p < 0.0001, respectively).

•When we use a conventional algorithm for estimating left ventricular filling pressures recommended by the American Society of Echocardiography and the European Association of Cardiovascular Imaging, 2% to 10% patients are classed as “indeterminate,” and the algorithm cannot be used in patients with atrial fibrillation.•High left ventricular filling pressure assessed by echocardiography using our proposed algorithm was an independent predictor of poor clinical outcomes in patients with heart failure with preserved ejection fraction .•The same results were seen in patients with atrial fibrillation and patients originally assigned to the “indeterminate” group using the conventional algorithm. The American Society of Echocardiography and/or the European Association of Cardiovascular Imaging recommend a conventional algorithm for estimating left ventricular (LV) filling pressure in heart failure. However, several patients are classed as “indeterminate” due to their LV filling pressures being impossible to calculate. We investigated whether our new echocardiographic algorithm can predict clinical outcomes in patients with heart failure with preserved ejection fraction (HFpEF). We enrolled 754 consecutive patients from the PURSUIT-HFpEF registry. We used the new algorithm to divide them into 2 groups; a normal LV filling pressure group (N group) and a high LV filling pressure group (H group). The H group consisted of 342 patients. Over a mean follow-up of 342 days, 185 patients reached the primary composite end point (157 readmissions for worsening heart failure and 43 cardiovascular deaths). In a multivariable Cox analysis, being in the H group was significantly associated with an increased rate of cardiac events compared with the N group (hazard ratio: 1.71; 95% confidence interval: 1.17 to 2.50, p = 0.006). There were 56 patients (7%) who were assigned to “indeterminate” with the conventional algorithm. Using the new algorithm, we reclassified 16 patients (29%) into the H group and 40 patients (71%) into the N group. The Kaplan-Meier curves showed the reclassified H group had a significantly higher incidence of cardiac events than those assigned to the N group (p < 0.01). In conclusion, the present study demonstrated LV filling pressure assessed by our algorithm can predict clinical outcomes in patients with HFpEF.

The comparison of bioabsorbable-polymer and durable-polymer stents has continued to be debated, and there is ongoing concern regarding vascular healing and late stent thrombosis. This study compared the vascular healing at 8-month follow-up by optical coherence tomography (OCT) between 4 different kinds of new generation drug-eluting stents (DESs). We enrolled 112 patients (112 de novo lesions) who underwent OCT guided percutaneous coronary intervention with 4 kinds of new generation DESs including bioabsorbable-polymer everolimus-eluting stents (BP-EESs), bioabsorbable-polymer sirolimus-eluting stents (BP-SESs), durable-polymer everolimus-eluting stents (DP-EESs), and durable-polymer zotarolimus-eluting stents (DP-ZESs) and an 8-month follow-up angiogram and OCT were performed between July 2016 and April 2018. We divided them into two groups, namely BP and DP groups. We compared the OCT parameters including the percentage of uncovered struts, malapposed struts and the mean neointimal hyperplasia (NIH) thickness between the two groups. BP group consisted of 51 lesions (BP-EESs were used in 27, BP-SESs in 24 lesions) and DP group consisted of 61 lesions (DP-EESs were used in 35 and DP-ZESs in 26 lesions). The percentage of uncovered struts and malapposed struts were significantly lower (7.2 ± 8.9 vs. 15.0 ± 17.1%, p = 0.01, 0.9 ± 1.7 vs. 2.7 ± 5.2%, p = 0.03) and the mean NIH thickness was significantly thicker in BP group than DP group (112 ± 54 vs. 83 ± 31 µm, p < 0.01). The present OCT study demonstrated that uncovered struts and malapposed struts were less common with bioabsorbable-polymer stents than with durable-polymer stents.

PurposeEarly recurrence of atrial tachyarrhythmias (ERAT) cause various symptoms and predict worse outcomes after pulmonary vein isolation (PVI). This study aimed to clarify whether ablation index (AI)–guided PVI, which is a novel technology of radiofrequency ablation, could reduce ERAT as compared to conventional contact force (CF)–guided PVI.MethodsConsecutive atrial fibrillation (AF) patients who underwent initial PVI from September 2014 to August 2019 were enrolled. We divided the patients into two groups: patients who underwent AI-guided PVI (AI group) and those who underwent CF-guided PVI (CF group). Using propensity score matching (PSM), we adjusted for the patient backgrounds. We compared the incidence of ERAT and late reconnection rate of isolated pulmonary veins (PVs) during second session between the two groups. ERAT was defined as any atrial tachyarrhythmias ≥ 30 s during a 90-day blanking period.ResultsA total of 697 AF patients (paroxysmal 51%) were enrolled. After the PSM, both groups included 229 patients. The incidence of ERAT was significantly lower in the AI group than that in the CF group (21.5% vs. 36.1%, P < 0.001). Total 118 patients (25.7%) experienced late recurrence of atrial tachyarrhythmias (LRAT) after blanking period. LRAT free survival rate was significantly higher in patients without ERAT than those with ERAT (88.1% vs. 42.0%, P < 0.001). The rate of PV reconnection was lower in the AI group than that in the CF group (45.8% vs. 71.4%, P = 0.028). Multivariate analysis demonstrated that AI-guided PVI was independently correlated with ERAT (OR = 0.415, 95%CI = 0.269–0.639, P < 0.001).ConclusionsAI-guided PVI can reduce ERAT as compared to conventional CF-guided PVI.