Successful endovascular therapy for recurrent acute limb ischaemia due to persistent sciatic artery aneurysm after femoropopliteal bypass

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.

Impact of Baseline Right Bundle Branch Block on Outcomes After Pulmonary Vein Isolation in Patients With Atrial Fibrillation

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.

Predictors of improvement of left ventricular systolic function after catheter ablation of persistent atrial fibrillation in patients with heart failure with reduced ejection fraction

Although several studies have suggested that catheter ablation (CA) of atrial fibrillation (AF) can improve left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF), the predictor of improvement of LVEF is unclear. A total of 401 patients with persistent AF underwent an initial CA between September 2014 and October 2019 in our hospital. Among them, we analyzed consecutive patients with moderately or severely reduced LVEF (< 50%) measured by transthoracic echocardiography (TTE) within 2 months before CA and underwent follow-up TTE during sinus rhythm at 6 months or more after CA. These patients were categorized into two groups: improve group (I group) with the absolute improvement of LVEF ≥ 10% at follow-up TTE, and non- improve group (NI group) with the absolute improvement of LVEF < 10% at follow-up TTE. We compared patient characteristics, ablation procedures, and clinical outcomes between the two groups. 81 patients were analyzed, and I group consisted of 48 patients (59%). In the univariate analysis, absence of ischemic cardiomyopathy, left ventricular end-diastolic diameter (LVEDD), and absence of recurrence of AF between 3 and 6 months after CA were associated with improvement of LVEF. A receiver operating characteristics analysis determined the suitable cut-off value for LVEDD was 53 mm (sensitivity: 62.2%, specificity: 86.2%, area under curve: 0.762). A multivariate analysis showed that LVEDD < 53 mm was independently associated with improvement of LVEF (odds ratio 2.58, 95% confidence interval 1.29-6.12; P = 0.021). In conclusion, LVEDD < 53 mm might be an independent predictor of improvement of LVEF after CA of persistent AF in HFrEF patients.

Alternative Echocardiographic Algorithm for Left Ventricular Filling Pressure in Patients With Heart Failure With Preserved Ejection Fraction

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.

Impact of readmissions on octogenarians with heart failure with preserved ejection fraction: PURSUIT-HFpEF registry

Aims

Heart failure (HF) readmissions with preserved ejection fraction (HFpEF) are increasing in the elderly, which is a major socioeconomic problem. We investigated the clinical impact of HF readmissions (HFR) on octogenarians with HFpEF.

Methods and results

We enrolled consecutive octogenarians (≥80 years old) from June 2016 to February 2020 in PURSUIT‐HFpEF registry. We divided them into HFR group readmitted for HF during the follow‐up period and non‐HF readmission (non‐HFR) group. We evaluated the impact of HFR on all‐cause mortality, cardiac death, and quality of life (QOL). Additionally, we evaluated the factors at discharge correlated with HFR. HFR group comprised 116 patients (21.4%). Among all‐cause deaths, 40 patients suffered cardiac deaths (48.2%). The Kaplan–Meier analysis revealed a similar prognosis between HFR and non‐HFR groups as well as similar incidences of HF deaths. The QOL scores had significantly deteriorated by 1 year later in the HFR group (0.71 ± 0.19 vs. 0.59 ± 0.21, P < 0.001), while it was similar at 1 year in the non‐HFR group. In the multivariate analysis, diabetes mellitus (DM) (P = 0.019), N‐terminal pro‐B‐type natriuretic peptide (NT‐pro BNP) levels ≥ 1611 pg/mL (P < 0.001), and serum albumin level ≤ 3.7 g/dL (P = 0.011) were useful markers for HFR in octogenarians.

Conclusions

In octogenarians with HFpEF, HF readmission was not directly correlated with the prognosis but was well correlated with the QOL. Close follow‐up is essential to decrease HFR of octogenarians with HFpEF with DM, high NT‐pro BNP (≥1611 pg/mL) and low albumin (≤3.7 g/dL) levels at discharge.

Implantation of three transcatheter aortic valves for embolization of two valves caused by under-expansion: a case report

Background

Transcatheter aortic valve embolization is one of the serious complications of transcatheter aortic valve implantation (TAVI). We present a case of TAVI that needed implantation of three transcatheter aortic valves owing to the embolization of two self-expandable valves (SEVs).

Case summary

An 88-year-old woman underwent TAVI using a 26-mm SEV. After valve deployment, the SEV embolized to the ascending aorta during the removal of the delivery system (DS) of the SEV (DS-SEV) from the SEV. An additional SEV was implanted, which also embolized upwards. Multi-directional fluoroscopy revealed extreme under-expansion of the second SEV, which caused valve embolization due to catching of the DS-SEVs in the SEVs. Finally, a 23-mm balloon-expandable valve was successfully implanted, which was also under expanded on fluoroscopic assessment. The patient was stable without sequelae at the 1-month follow-up.

Discussion

Pre-procedurally predicting SEV under-expansions was difficult because pre-procedural computed tomography revealed no massive calcification on the aortic valve, and fluoroscopy indicated adequate expansion of the SEVs at the angle where the valves were deployed. We verified the possibility of catching of a DS-SEV in an under-expanded SEV in an in vitro test, which showed that the DS-SEV was caught in the extremely under-expanded SEV. Furthermore, balloon dilation might release the catch of the DS-SEV by changing the DS-SEV position. Therefore, we recommend performing multi-directional fluoroscopy to evaluate SEV expansion before DS-SEV removal from an SEV. Furthermore, if catching of a DS-SEV occurs, balloon dilation might be useful for releasing the catch and safely removing the DS-SEV.

Comparison of coronary angioscopic findings 8 months after stent implantation between two kinds of biodegradable polymer-coated and one durable polymer-coated drug-eluting stent

BACKGROUND

The difference of chronic neointimal conditions of biodegradable polymer-coated and durable polymer-coated drug-eluting stent have not been well investigated.

OBJECTIVE

We aimed to compare the angioscopic findings among SYNERGY biodegradable polymer-coated everolimus-eluting stent (BP-EES), ULTIMASTER biodegradable polymer-coated sirolimus-eluting stent (BP-SES), and XIENCE Alpine durable polymer-coated everolimus-eluting stent (DP-EES) 8 months after stent implantation.

METHODS

Patients who underwent implantation of BP-EES (n = 30), BP-SES (n = 26), or DP-EES (n = 21) in Osaka Rosai Hospital from December 2015 to April 2017 were retrospectively enrolled. Coronary angioscopic evaluation including dominant grade of neointimal coverage (NIC) over the stent, maximum yellow plaque grade, and existence of red thrombi were performed 8 months after stent implantation. The incidence of major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, and target vessel revascularization were assessed 1 year after coronary angioscopic evaluation among the three groups.

RESULTS

The patient and lesion characteristics were similar among the three groups. Dominant grade of NIC and maximum yellow plaque grade were not significantly different among BP-EES, BP-SES, and DP-EES groups [mean ± SD, 1.50 ± 0.73, 1.58 ± 0.64, and 1.33 ± 0.48 (P = 0.38) and 0.83 ± 0.59, 0.81 ± 0.75, and 0.95 ± 0.38 (P = 0.68), respectively]. The existence of red thrombi was similar among the three groups [20, 12, and 19% (P = 0.67)]. There was no significant difference in the MACE 1 year after coronary angioscopic evaluation among the three groups [0, 8, and 0% (P = 0.13)].

CONCLUSIONS

Coronary angioscopic findings revealed that BP-EES, BP-SES, and DP-EES produced similar favorable NIC 8 months after stent implantation.

Novel Score to Predict Very Late Recurrences After Catheter Ablation of Atrial Fibrillation

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).

Serial angioscopy during treatments for ProGlide-related femoral occlusion following transcatheter aortic valve implantation

Vascular complications associated with vascular closure device use is uncommon; however, it sometimes occurs in transfemoral transcatheter aortic valve implantation (TF-TAVI). We present a case of ProGlide (Abbott Vascular, Santa Clara, CA, USA)-related right femoral occlusion following TF-TAVI. An 83-year-old woman, who underwent TF-TAVI using double ProGlide pre-closure technique, presented with right claudication three days after TAVI. Computed tomography showed femoral occlusion of the puncture site. Recanalization without pressure gradient between the proximal and distal sites of the lesion was achieved by balloon angioplasty (BA) with a 4.0 mm balloon; however, early re-occlusion of the lesion occurred the next day after BA. Repeated BA was performed for the re-occlusion site 30 days after TAVI because of persistent claudication. Serial angioscopic images of the lesion revealed that the intima, which was injured at the first BA, had healed at the second BA, indicating that BA with larger balloons could be safely performed. We performed BA with a 6.0-mm balloon without stent implantation. The patency of the lesion was maintained during the 6-month follow-up period. The serial angioscopic findings, which revealed the healing process of the intima injury, were useful in determining a suitable endovascular therapy strategy for ProGlide-related occlusion. <Learning objective: ProGlide-related femoral occlusion can occur in arteries without stenosis, calcification, and vessel branching, suggesting that ProGlide should be carefully used with echo-guidance to avoid the occlusion of a puncture site. If endovascular therapy is performed for the lesion to avoid surgical repair, sufficient expansion is required to maintain patency. Angioscopy may be useful for determining a suitable endovascular therapy strategy for the lesion by evaluating the properties of the intima.>.

Atrial fibrillation type modulates the clinical predictive value of neutrophil-to-lymphocyte ratio for atrial fibrillation recurrence after catheter ablation

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been proposed as an indicator of a systemic inflammatory response. There are baseline differences in the inflammation status between paroxysmal atrial fibrillation (PAF) and persistent AF (PerAF). The NLR changes and late recurrences of AF (LRAF) after ablation depending on the AF type remain unknown.

METHODS

Consecutive AF patients undergoing pulmonary vein isolation (PVI) by radiofrequency catheter ablation were enrolled from September 2014 to June 2018. The peripheral blood leukocyte NLR 1 day before and 36-48 h after PVI were measured. First, the relationship between NLR changes after to before ablation (ΔNLR) and ERAFs/LRAFs in PAF and PerAF patients were investigated to exclude the baseline inflammation status and evaluate catheter ablation induced inflammation. Second, the clinical impact of the NLR for predicting LRAFs was evaluated.

RESULTS

There hundred sixty-nine PAF and 264 PerAF patients from Osaka Rosai AF registry were enrolled. The ratio of ERAFs/LRAFs in PAF and PerAF patients were 26.8%/22.5% and 39.4%/29.9%, respectively. In PAF and PerAF patients, the ΔNLR was significantly higher with ERAF than no-ERAF (p = 0.022 and p = 0.010, respectively). In PAF patients, the ΔNLR was significantly higher with LRAF than no-LRAF (p = 0.017), while with PerAF, the ΔNLR did not significantly differ between LRAFs and no-LRAFs. In PAF, the ΔNLR was independently and significantly associated with LRAFs after PVI (p = 0.029).

CONCLUSION

The ΔNLR was significantly higher only in PAF patients with LRAFs than no-LRAFs, but not in PerAF patients. The ΔNLR was useful for predicting LRAFs after PVI in PAF patients.

Electrophysiological identification of superior vena cava: Novel insight into slow conduction or conduction block

INTRODUCTION

It has not been clarified how to identify the electrophysiological junction between right atrium (RA) and superior vena cava (SVC). The aim of this study was to identify the electrophysiological RA-SVC junction according to slow conduction or conduction bock and to examine the electrophysiological SVC isolation procedure.

METHODS

Seventy-three consecutive atrial fibrillation patients who underwent SVC mapping using a CARTO 3 system were enrolled in this study. Slow conduction or conduction block between the RA and SVC was identified by adjusting the lower threshold criteria of the early meets late function and was described as a white line. The SVC isolation was performed along the white line and with pacing maneuvers to confirm direct SVC capture.

RESULTS

Activation mapping (1296 ± 631 points) was obtained in 66 patients (90%) in 4.6 ± 1.8 min. Slow conduction or conduction block was observed in all patients. The threshold for detecting slow conduction or conduction block was 24 ± 8 ms. The location of the electrophysiological RA-SVC junction was higher in the anterior portion (anterior-septal, anterior, and anterior-lateral) than in the posterior portion (posterior-septal, posterior, and posterior-lateral) (-2.3 ± 6.2 mm vs. 7.1 ± 6.3 mm, p < .001). The SVC isolation at the electrophysiological RA-SVC junction was successful in all patients without any injury to the sinus node function. Asymptomatic phrenic nerve injury was observed in three patients (4.5%).

CONCLUSION

In all patients, the electrophysiological RA-SVC junction determined by slow conduction or conduction block was identified and the electrophysiological SVC isolation was performed successfully and safely.

Difference of vascular healing between bioabsorbable-polymer and durable-polymer new generation drug-eluting stents: an optical coherence tomographic analysis

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.

Negative impact of ultra-thin strut on neointimal coverage condition within one year after implantation as compared to thin sturt in biogradable-polymer sirorimus eluting stents

Background

BIOSCIENCE randomized trial which compared biodegradable-polymer sirolimus-eluting stents with ultra-thin (60μm) strut (ultra-thin BP-SES) and durable-polymer everolimus-eluting stents with thin (81μm) strut (thin DP-EES) have reported that definite stent thrombosis within 1 year had more frequently occurred in ultra-thin BP-SES (0.9%) than in thin DP-EES group (0.4%) although it was not statistically significant. It suggests that neointimal coverage after stent implantation within 1 year might be different between ultra-thin BP-SES and thin DP-EES. Recently, two types of biogradable-polymer sirorimus eluting stents, thin (80μm) strut type (thin BP-SES) and ultra-thin (60μm) strut type (ultra-thin BP-SES), can be available in clinical settings.

Purpose

We compared neointimal coverage conditions between ultra-thin BP-SES and thin BP-SES by optical coherence tomography (OCT).

Methods

Consecutive Forty-six patients who underwent 21 ultra-thin BP-SESs or 25 thin BP-SESs implantation were enrolled. We compared incidences of acute coronary syndrome, type B2/C lesion, atherectomy device use, stent size, stent length, maximum inflation pressure, and 8-month follow-up OCT parameters including proportions of uncovered struts (%Uncovered), malapposed struts, (%Mallaposed) and mean neointimal hyperplasia thickness (mean NHT) between the two groups.

Results

%Uncovered and %malapposed were significantly higher and mean NHT was significantly lower in ultra-thin BP-SES than in thin BP-SES (Table). The other parameters were similar between the two groups.

Conclusion

Ultra-thin BP-SES showed worse neointimal coverage as compared to thin BP-SES within 1 year after stent implantation, which may increase stent thrombosis.

Funding Acknowledgement

Type of funding source: None

Real-world clinical impact of external elastic lamina-based stent sizing criteria using optical coherence tomography

Introduction

ILUMIEN III trial has reported that non-inferiority of optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) to intravascular ultrasound-guided PCI for postprocedural minimum stent area. In the trial, external elastic lamina (EEL)-based stent sizing criteria was introduced, however OCT has limitations including incomplete visualization of EEL in severale lesions.

Purpose

The aim of the study is to investigate real-world clinical impact of EEL-based stent sizing criteria.

Methods

The study included consecutive patients who underwent OCT-guided percutaneous coronary intervention (PCI) for de novo lesions in our institution between September 2016 and April 2018. EEL visibility, mean EEL diameter, mean lumen diameter and plaque morphology were assessed at proximal and distal references. The plaque morphology at references was categorized according to its most prevalent component as follows: normal, fibrous plaque, lipid plaque, and calcified plaque. Both references were divided into 3 groups according to visibility of EEL.

Results

Among 205 lesions, 31 lesions had artifacts at references (16 proximal and 17 distal references). EEL visibility was summarized in a table. Out of 174 lesions with both analyzable references, 111 lesions (63.8%) had &gt;180-degree EEL visibility at both references. Proportion of plaque morphology were significantly different among 3 groups at proximal and distal references as shown in a figure.

Conclusions

EEL-based stent sizing criteria was usable for 63.8% of all the lesions. Vessel size and plaque morphology were significantly associated with EEL visibility.

Proportion of plaque morphology

Funding Acknowledgement

Type of funding source: None

Difference of myocardial injury, inflammation and early recurrence after pulmonary vein isolation among laser balloon ablation, radiofrequency catheter ablation and cryoballoon ablation

Background

Pulmonary vein isolation (PVI) has become well-established as the main therapy for patients with drug-refractory paroxysmal atrial fibrillation (PAF) and various isolation methods including radiofrequency ablation (RFA), cryoballoon ablation (CBA) and laser balloon ablation (LBA) were available. Pathological findings in each ablation methods such as myocardial injury and inflammation are thought to be different. High sensitive cardiac troponin I (hs-TnI), subunit of cardiac troponin complex, is a sensitive and specific marker of myocardium injury. High-sensitive C-reactive protein (hs-CRP) is a biomarker of inflammation and is elevated following cardiomyocyte necrosis. Relationship between myocardial injury and inflammation after ablation using RFA, CBA and LBA and early recurrence of atrial fibrillation (ERAF) remains unclear.

Methods

We enrolled consecutive PAF patients from Osaka Rosai Atrial Fibrillation (ORAF) registry who underwent PVI from January 2019 to October 2019. We compared the clinical characteristics including age, gender, hypertension, diabetes mellitus, history of heart failure, CHADS2Vasc score, renal function, serum BNP level and echocardiographic parameters including left ventricular dimensions, left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) between RFA, CBA and LBA groups. We investigated the difference of relationship between myocardial injury marker (hs-TnI), inflammation markers (white blood cell change (DWBC) from post to pre PVI, neutrophil-to-lymphocyte ratio change (DNLR) from after to before PVI and hs-CRP) at 36–48 hours after PVI and ERAF (&lt;3 months after PVI) between each group.

Results

We enrolled 187 consecutive PAF patients who underwent PVI. RFA, CBA and LBA groups comprised 108, 57 and 22 patients, respectively. There were no significant differences of age, gender, hypertension, diabetes mellitus, history of heart failure, CHADS2Vasc score, renal function, serum BNP level and echocardiographic parameters between each group. Serum hs-TnI in RFA group and LBA group were significantly lower than in CBA group (2.643 ng/ml vs 5.240ng/ml, 1.344 ng/ml vs 5.240 ng/ml, p&lt;0.001, p=0.002, respectively, Figure). DWBC was significantly higher in LBA group than CBA group (1157.3/μl vs 418.4/μl, p=0.045). DNLR did not differ between each group. Hs-CRP in RFA group and LBA group were significantly higher than in CBA group (1.881 mg/dl vs 1.186 mg/dl, 2.173 mg/dl vs 1.186 mg/dl, p=0.010, p=0.003, respectively, Figure). Incidence of ERAF was significantly higher in LBA group than RFA group (36.4% vs 16.7%, p=0.035). Incidence of ERAF tended to be higher in LBA group than CBA group (36.4% vs 19.3%, p=0.112).

Conclusion

LBA may cause less myocardial injury than RFA and CBA, on the contrary LBA may cause more inflammation than CBA. Incidence of ERAF in LBA was highest between each procedure.

Inflammation markers and ERAF

Funding Acknowledgement

Type of funding source: None

Outcome of contact force-guided radiofrequency catheter ablation or second generation cryoballoon ablation for paroxysmal atrial fibrillation: propensity score matched analysis

Background

Little has been reported on the outcome of contact force (CF)-guided radiofrequency catheter ablation (RFCA) and second generation cryoballoon ablation (CBA).

Purpose

The purpose of this study was to compare the outcome of CF-guided RFCA and second generation CBA for paroxysmal atrial fibrillation (PAF).

Methods

We enrolled the consecutive 364 patients with PAF who underwent initial ablation between September 2014 and July 2018 in our hospital. We compared the late recurrence of atrial tachyarrhythmia more than three months after ablation between RFCA group and CBA group. All RFCA procedures were performed using CF-sensing catheter and all CBA procedures were performed using second generation CB.

Results

There were significant differences in background characteristics: chronic kidney disease, serum brain natriuretic peptide level, and left ventricular ejection fraction. After propensity score matched analysis (Table), atrial tachyarrhythmia free survival was significantly higher in CBA group than in RFCA group (Figure).

Conclusions

Second generation CBA showed a significantly lower late recurrence rate compared to CF-guided RFCA.

Kaplan-Meier Curve

Funding Acknowledgement

Type of funding source: None

Not only power and energy but also balloon size is correlated with lesion formation in laser ablation model in vitro study

Background

Power and total energy were known to correlate with lesion formation during laser balloon ablation for atrial fibrillation. However, it is unclear whether balloon size can influence lesion formation. The aim of this study was to evaluate the impact of balloon size on lesion formation during laser balloon procedure in vitro model.

Methods

Laser energy was applied to chicken muscles using first generation laser balloon. Laser ablation was performed with different 2 balloon size (18mm and 32mm) using 2 different power settings (12W/20sec and 8.5W/20sec). Forty lesions were evaluated for each setting. We compared maximum lesion width, maximum lesion depth, depth at maximum width and endocardial lesion width between 18mm and 32mm balloon groups at 12W/20sec and 8.5W/20sec, respectively.

Results

At 8.5W/20sec, inadequate lesion formation to assess lesion size was observed in 1/40 lesion of 18mm balloon group and in 5/40 lesions of 32mm balloon group. Thus, at 8.5W/20sec 18 mm balloon group consisted of 39 lesions and 32 mm balloon group consisted of 35 lesions. At 12W/20sec 18 mm balloon group consisted of 40 lesions and 32 mm balloon group consisted of 40 lesions. At both power settings, maximum lesion depth was larger in 18mm balloon than in 32mm balloon group. At 12W/20sec setting, maximum lesion width and endocardial width were larger in 32mm balloon group than in 18mm balloon group. At 12W/20sec setting, depth at maximum width was smaller in 32mm balloon group than in 18mm balloon group. Lesion morphologies were summarized in a figure.

Conclusion

Balloon size could affect lesion formation during laser balloon ablation in addition to laser power and energy. Laser ablation lesion were wider but shallower in 32mm balloon group compared with in 18mm balloon group.

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and outcomes after pulmonary vein isolation in atrial fibrillation patients with complete right bundle branch block

Background

Complete right bundle branch block (CRBBB) is one of the most frequent alterations of the electrocardiogram (ECG). Several studies have shown that CRBBB was a risk factor for cardiovascular diseases and the appearance of CRBBB in patients hospitalized for exacerbated heart failure (HF) was associated with a worse prognosis. Various alternations of ECG such as early repolarization pattern and intraventricular conduction disturbance were associated with high recurrence ratio of atrial fibrillation (AF) after pulmonary vein isolation (PVI). However clinical outcome after PVI in patients with CRBBB remains unclear.

Methods

We enrolled consecutive AF patients who underwent PVI from September 2014 to November 2018 rom Osaka Rosai Atrial Fibrillation (ORAF) registry. We excluded patients with other wide QRS (left bundle branch block, ventricular pacing and unclassified intraventricular conduction disturbance) and divided into 2 groups; CRBBB (QRS duration ≥120msec) group and no-CRBBB (QRS duration &lt;120) group. We compared the clinical characteristics including age, gender, hypertension, diabetes mellitus, history of heart failure, history of stroke, CHADS2Vasc score, paroxysmal AF (PAF), renal function, plasma brain natriuretic peptide (BNP) level and echocardiographic parameters including left ventricular end-diastolic diameter (LVDd), left ventricular end-systolic diameter (LVDs), left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) between the 2 groups. We also compared the incidence of late recurrence of AF/atrial tachycardia (AT) between the 2 groups. We investigated whether CRBBB was an independent predictor of late recurrence of AF/AT after PVI by multivariate Cox analysis.

Results

We enrolled 736 consecutive AF patients who underwent PVI. CRBBB patients comprised 55 patients (7.5%). There were no significant differences of age, gender, hypertension, diabetes mellitus, history of heart failure, history of stroke, CHADS2Vasc score, PAF, renal function, plasma BNP level and echocardiographic parameters (LVDd, LVDs, LVEF and LAD) between the 2 groups. Incidence of AF/AT recurrence after PVI was significantly higher in CRBBB group than no-CRBBB group (Figure). CRBBB was an independently and significantly associated with late recurrence of AF/AT after PVI by multivariate Cox analysis (hazard ratio: 1.923, 95% CI: 1.190–2.961, p=0.009) in addition to female (p&lt;0.001), no-PAF (p=0.005) and left atrial diameter (p=0.042).

Conclusion

CRBBB may be a strong predictor of AF/AT late recurrence after PVI.

AF/Ar recurrence after PVI

Funding Acknowledgement

Type of funding source: None

Clinical outcome of non-use of touch-up focal ablation catheters strategy during cryoballoon atrial fibrillation ablation

Background

It has been reported that frequent use of touch-up focal ablation catheters was related to worse outcomes after cryoballoon (CB) atrial fibrillation (AF) ablation. It is unknown whether non-use of touch-up focal ablation catheters strategy affects the outcome of AF ablation. Therefore, this study aimed to assess whether non-use of touch-up focal ablation catheters strategy improve clinical outcome after AF ablation using CB.

Methods

A total of 151 consecutive patients who received CB ablation from February 2017 to August 2019 were enrolled. Non-use of a touch-up focal ablation catheters strategy was started from February 2018. Patients were divided into 2 groups according to the type of strategy. In the non-touch-up group, pulmonary veins were isolated without touch-up focal ablation catheters as much as possible and in conventional group, touch-up focal ablation catheters were used as required. The 1-year atrial tachyarrhythmia free survival without class 1 or 3 antiarrhythmic drugs after a 90-day blanking period was assessed between the 2 groups.

Results

The conventional group consisted of 76 patients and the non-touch-up group consisted of 75 patients. Baseline characteristics were comparable between 2 groups. Touch-up focal ablation catheters were used more in the conventional group (11 patients, 14%) than non-touch-up group (0 patients, 0%) (p&lt;0.001). Pulmonary isolation was achieved in all patients of both groups. Atrial tachyarrhythmia recurrence occurred more frequently in the non-touch-up group (15/75 patients, 20%) than conventional group (7/76 patients, 9%) (p=0.045).

Conclusion

Non-use of a touch-up focal ablation catheters strategy may be related to worse outcome after CB AF ablation.

Funding Acknowledgement

Type of funding source: None

Ablation index guide pulmonary vein isolation can reduce early recurrence of atrial fibrillation: a propensity score-matched analysis

Background

Ablation index (AI) is a novel marker of ablation lesion quality for radiofrequency ablation (RFA). It has been reported that AI guided pulmonary vein isolation (PVI) reduced pulmonary vein reconnection and late recurrence of atrial fibrillation (AF). However, little is known about the impact of AI guided PVI on early recurrence of AF (ERAF).

Purpose

The aim of this study is to clarify whether AI guided PVI can reduce ERAF.

Methods

From September 2014 to August 2019, consecutive AF patients who underwent 1st session PVI were enrolled. We compared prevalence of ERAF between AI guided PVI group (AI group) and conventional contact force guided PVI group (CF group) using propensity score-matched analysis, which adjusted patient backgrounds (age, sex, and body mass index (BMI)), type of AF, the history of heart failure, hypertension, diabetes and stroke, laboratory findings including estimated glomerular filtration rate (eGFR) and b-type natriuretic peptide (BNP), and echocardiographic parameters including left ventricular ejection fraction (LVEF) and left atrial diameter.

Results

Total 711 patients were enrolled. AI group comprised 233 patients and CF group comprised 233 patients. Prevalence of ERAF were significantly lower in AI group than in CF group significantly (21.5% vs 36.1%, p=0.001, Table).

Conclusions

AI guided PVI can reduce ERAF as compared to conventional method.

Funding Acknowledgement

Type of funding source: None