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Little has been reported on the predictors of maintenance of sinus rhythm (SR) after radiofrequency catheter ablation (RFCA) for long-standing persistent atrial fibrillation (AF). We enrolled 151 patients with long-standing persistent AF (defined as AF lasting more than 12 months) who underwent an initial RFCA between October 2014 and December 2020 in our hospital. These patients were categorized into 2 groups on the basis of the absence and presence of the late recurrence (LR, defined as a recurrence of atrial tachyarrhythmia between 3 and 12 months after RFCA): SR group and LR group. The SR group comprised 92 patients (61%). In the univariate analysis, there were significant differences in gender and preprocedural average heart rate (HR) between the 2 groups (p = 0.042 and p = 0.042, respectively). A receiver operating characteristics analysis revealed that a cut-off value of preprocedural average HR to predict the maintenance of SR was 85 beats/min (sensitivity: 37%, specificity: 85%, area under curve: 0.58). A multivariate analysis showed that preprocedural average HR ≥85 beats/min was independently associated with the maintenance of SR after RFCA (odds ratio 3.30, 95% confidence interval 1.47 to 8.04, p = 0.003). In conclusion, a relatively high preprocedural average HR might be a prognostic factor of maintenance of SR after RFCA for long-standing persistent AF.

Abstract Background Ventricular arrhythmias are a significant cause of morbidity and mortality in patients with ischaemic heart disease. When pharmacologic therapies, catheter ablation (CA), and implantable cardioverter defibrillator (ICD) are ineffective, stellate ganglion blockade (SGB), sympathectomy, and renal sympathetic denervation are considered. However, they are invasive for patients with high bleeding risk. We present a case of successfully recovering from haemodynamically unstable ventricular tachycardia (VT) storm with stellate ganglion phototherapy (SGP) in a non-invasive manner. Case summary A 73-year-old male presented to the emergency department with chief complaint of general malaise, resulting from VT storm associated with ischaemic cardiomyopathy. He had a history of CA and implantation of ICD. Despite multiple electrical cardioversions, pharmacologic therapies, and deep sedation with mechanical circulatory support (MCS), VT storm was not controlled. Thereafter, we irradiated the patient’s neck with SGP to inhibit sympathetic neurological activity, which suppressed VT storm and dramatically improved his haemodynamic status. Discussion It has been reported that SGP is an alternative to SGB for refractory VT storm. Stellate ganglion phototherapy was easy and non-invasive to perform because we just irradiated the patient’s neck with the near-infrared light for 5 min per day. If conventional therapies are ineffective in suppressing VT storm, SGP may be considered as a next step, especially for patients with high bleeding risk. However, since the effect of a single SGP lasts only 1–2 days, it should be performed as a bridge therapy to CA or sympathectomy. Stellate ganglion phototherapy may be effective in suppressing VT storm that requires MCS devices.

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.

Abstract Background Coronary artery rupture is a rare but fatal complication of percutaneous coronary intervention (PCI). The mortality rate reaches 19% in patients with the Ellis type III classification. The predictors of coronary artery rupture were reported in previous studies. However, there are few reports showing the risk factors of this threatening complication in terms of intravascular image such as optical coherence tomography and intravascular ultrasound (IVUS). Case summary We report the case of three patients with coronary artery rupture, who underwent IVUS-guided PCI for severe calcified lesions. All three patients developed the Ellis grade III rupture, which was successfully managed with the use of a perfusion balloon and covered stents. In these patients, the common characteristics were observed in pre-procedural IVUS images. Specifically, a C-type CAlcified and residual Thin plaque sign (C-CAT sign) was seen in all three patients. Discussion These patient cases provide an insight into the coronary artery rupture in severe calcified lesions. The C-CAT sign in the pre-IVUS image may predict coronary artery rupture. If we obtain such a unique IVUS image before intervention, we have to consider using a smaller balloon size, for example a half size down, judging from the vessel diameter of the reference site or using ablation devices such as orbital atherectomy and rotational atherectomy to prevent coronary artery rupture. Conclusion The C-CAT sign may predict coronary artery perforation in severe calcified lesions during PCI, although larger registries of such intracoronary pre-perforation imaging are required in order to correlate different signs with outcomes.

The role of sigmoid septum (SS) observed using preprocedural transthoracic echocardiography (TTE) in patients undergoing transcatheter aortic valve implantation (TAVI) remains unknown. This study aimed to compare clinical outcomes of TAVI using the current-generation transcatheter heart valves in patients with and without SS. We divided 140 consecutive patients, excluding four patients who underwent pacemaker implantation before TAVI, into two groups (those with and without SS) and compared the periprocedural outcomes, including new pacemaker implantation, within 30 days post-TAVI. Thirty-five patients (25%; 32 female patients) had SS before TAVI. The body surface area and aortic annulus area measured using computed tomography were significantly smaller in patients with SS than in those without SS (1.40 m2 vs. 1.48 m2, P = 0.03; and 372 mm2 vs. 409 mm2, P < 0.01; respectively). Device success was achieved in all patients with SS. Postprocedural TTE on 30 days post-TAVI showed no significant differences in the valvular hemodynamics between patients with and without SS. No severe prosthesis-patient mismatch was noted on TTE, although the transcatheter heart valve size tended to be smaller in patients with SS. Within 30 days of the TAVI, three (8.6%) and eight (7.6%) patients with and without SS, respectively, had new pacemaker implantation (P = 0.86). The presence of SS was not associated with periprocedural outcomes following TAVI in patients without pre-existing pacemakers. No specific assessment or treatment strategy is required for the TAVI in patients with SS using the current-generation devices.

Abstract Background Papillary muscle rupture (PMR) is a catastrophic complication of acute myocardial infarction. However, the best timing and modality of circulatory support for surgery are unknown. Case Summary A 75-year-old man presented to the emergency room in our hospital for worsening shortness of breath accompanied by chest pain. Transthoracic echocardiograph showed severe mitral regurgitation (MR) with a flail posterior mitral valve leaflet, and coronary angiography demonstrated distal right coronary artery occlusion. We diagnosed as cardiogenic shock due to subacute myocardial infarction and ischaemic PMR. An Impella CP (Abiomed, Danvers, MA, USA) was introduced to improve haemodynamics. Despite the grade of MR was still severe, the mean blood pressure and pulmonary artery pressure improved 4 h after an Impella CP support. At day 8, the patient underwent elective mitral valve replacement with single coronary artery bypass grafting. Discussion PMR is a rare but lethal complication of acute myocardial infarction. Expeditious surgical treatment offers the optimal chance of survival, but the post-operative mortality or morbidity is very high. Therefore, preoperative stabilization can be closely correlated with outcomes in these patients. It was reported that directly unloading the left ventricle by an Impella decreased wall stress, external work, and myocardial oxygen consumption. Therefore, an Impella can be the most suitable mechanical circulatory support for PMR. In conclusion, Impella CP alone can become one of the suitable bridges to surgery in the patients with PMR.

Left atrial tachycardia (AT) is often observed in patients who have undergone atrial fibrillation (AF) ablation. 1 The main mechanisms of the ATs are macroreentry, such as peri-mitral flutter and roof-dependent AT. 2 The use of ultra-high-density mapping with multielectrode catheters enables to delineate the ATs rapidly and precisely. 3 However, due to the scar and low-voltage area (LVA), it can often be difficult to identify the circuit of AT exactly. Postpacing interval (PPI) at the LA septum near mitral valve was equal to the TCL with orthodromic capture of all atrial potentials (Figure 3(B)), while PPI at the right atrium and proximal coronary sinus was greater than TCL by +266 ms and + 132 ms, respectively. [...]LAT map at pacing rate lower than heart rate during AT allows for relatively more local potentials to be annotated on the 3D map (Figure 4(B)). [...]in AT cases whose LAT maps are difficult to interpret, isochronal map at a pacing rate lower than the heart rate during AT may provide useful information to identify the termination site of AT.

The detailed electrophysiological characteristics of atrial fibrillation (AF) initiating non-pulmonary vein (PV) triggers excluding origins from the superior vena cava (SVC) and left atrial posterior wall (LAPW) (Non-PV-SVC-LAPW triggers) remain unclear. This study aimed to clarify the detailed electrophysiological characteristics of non-PV-SVC-LAPW triggers. Among 446 AF ablation procedures at 2 institutions, patients with reproducible AF initiating non-PV-SVC-LAPW triggers were retrospectively enrolled. The trigger origin was mapped using the self-reference mapping technique. The following electrophysiological parameters were evaluated: the voltage during sinus rhythm and at the onset of AF at the earliest activation site, coupling interval of the trigger between the prior sinus rhythm and AF trigger, and voltage change ratio defined as the trigger voltage at the onset of AF divided by the sinus voltage. Detailed electrophysiological data were obtained at 28 triggers in 21 patients. The median trigger voltage at the onset of AF was 0.16mV and median trigger coupling interval 182msec. Normal sinus voltages (≧0.5mV) were observed at 16 triggers and low voltages (<0.5mV) at 12 triggers. The voltage change ratio was significantly lower for the normal sinus voltage than low sinus voltage (0.20 vs. 0.60, p = 0.002). The trigger coupling intervals were comparable between the normal sinus voltage and low sinus voltage (170ms vs. 185ms, p = 0.353). The trigger voltage at the onset of AF was low, regardless of whether the sinus voltage of the trigger was preserved or low.

Identifying patients who would benefit from extensive catheter ablation along with pulmonary vein isolation (PVI) among those with persistent atrial fibrillation (AF) has been a subject of controversy. The objective of this study was to apply uplift modeling, a machine learning method for analyzing individual causal effect, to identify such patients in the EARNEST-PVI trial, a randomized trial in patients with persistent AF. We developed 16 uplift models using different machine learning algorithms, and determined that the best performing model was adaptive boosting using Qini coefficients. The optimal uplift score threshold was 0.0124. Among patients with an uplift score ≥ 0.0124, those who underwent extensive catheter ablation (PVI-plus) showed a significantly lower recurrence rate of AF compared to those who received only PVI (PVI-alone) (HR 0.40; 95% CI 0.19–0.84; P -value = 0.015). In contrast, among patients with an uplift score < 0.0124, recurrence of AF did not significantly differ between PVI-plus and PVI-alone (HR 1.17; 95% CI 0.57–2.39; P -value = 0.661). By employing uplift modeling, we could effectively identify a subset of patients with persistent AF who would benefit from PVI-plus. This model could be valuable in stratifying patients with persistent AF who need extensive catheter ablation before the procedure.

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.