Efficacy and feasibility of cryoballoon ablation for atrial fibrillation in patients with heart failure: A large-scale multicenter study

INTRODUCTION

Data are limited regarding outcomes of cryoballoon ablation for atrial fibrillation (AF) in patients with heart failure (HF). This large-scale multicenter study aimed to evaluate the prognosis of patients with HF after cryoballoon ablation for AF.

METHODS

Among 3655 patients undergoing cryoballoon ablation at 17 institutions, 549 patients (15%) (391 with paroxysmal AF and 158 with persistent AF) diagnosed with HF preoperatively were analyzed. Clinical endpoints were recurrence, mortality, and HF hospitalization after ablation.

RESULTS

Most patients had a preserved left ventricular ejection fraction (LVEF) ≥ 50%. During a mean follow-up period of 25.7 months, recurrence, all-cause death, and HF hospitalization occurred in 29%, 4.0%, and 4.8%, respectively. Cardiac function on echocardiography and B-type natriuretic peptide (BNP) levels significantly improved postoperatively, and the effect was more pronounced in the nonrecurrence group. Major complications occurred in 33 patients (6.0%), but most complications were phrenic nerve palsy (3.6%). Although death and HF hospitalization occurred more frequently in patients with LVEF ≤ 40% (n = 73) and New York Heart Association (NYHA) class III-IV (n = 19) than other subgroups, the BNP levels, and LVEF significantly improved after ablation in all LVEF and NYHA class subgroups. High BNP levels, NHYA class, CHADS₂ score, and structural heart disease, but not postablation recurrence, independently predicted death, and HF hospitalization on multivariate analysis. The patients with tachycardia-induced cardiomyopathy had better recovery of BNP levels and LVEF after ablation than those with structural heart disease.

CONCLUSIONS

Cryoballoon ablation for AF in HF patients is feasible and leads to significantly improved cardiac function.

Motion of left atrial appendage as a determinant of thrombus formation in patients with a low CHADS2 score receiving warfarin for persistent nonvalvular atrial fibrillation

BACKGROUND

The aim of this study was to define the independent determinants of left atrial appendage (LAA) thrombus among various echocardiographic parameters measured by Velocity Vector Imaging (VVI) in patients with nonvalvular atrial fibrillation (AF) receiving warfarin, particularly in patients with a low CHADS2 score.

METHODS

LAA emptying fraction (EF) and LAA peak longitudinal strain were measured by VVI using transesophageal echocardiography in 260 consecutive patients with nonvalvular persistent AF receiving warfarin. The patients were divided into two groups according to the presence (n=43) or absence (n=217) of LAA thrombus. Moreover, the patients within each group were further divided into subgroups according to a CHADS2 score ≤1.

RESULTS

Multivariate logistic regression analysis showed that LAAEF was an independent determinant of LAA thrombus in the subgroup of 140 with a low CHADS2 score. Receiver operating characteristics curve analysis showed that an LAAEF of 21% was the optimal cutoff value for predicting LAA thrombus.

CONCLUSIONS

LAA thrombus formation depended on LAA contractility. AF patients with reduced LAA contractile fraction (LAAEF ≤21%) require strong anticoagulant therapy to avoid thromboembolic events regardless of a low CHADS2 score (≤1).

Effects of pitavastatin on cardiac structure and function and on prevention of atrial fibrillation in elderly hypertensive patients: a prospective study of 2-years' follow-up

BACKGROUND

The aim of this prospective study was to determine whether statin therapy (pitavastatin) has a beneficial effect on the prevention of new-onset atrial fibrillation (AF) in elderly patients with hypertension (HTN) and to evaluate the relationships among statin treatment, the development of AF, and left atrial (LA) and ventricular (LV) structure and function.

METHODS AND RESULTS

We enrolled eligible elderly patients (≥65 years old) with HTN and LV hypertrophy until the number of patients reached 110 in both groups. The 110 patients with HTN who needed statin therapy (HTN with statin group) were started on pitavastatin (1-2 mg/day), and both groups continued with appropriate medication for HTN. LV and LA structure and function were examined by conventional and speckle-tracking echocardiography at baseline and after 1 year. LA volume and function in the HTN with statin group improved more than in the HTN without statin group. There was a significant difference in survival free of new-onset AF in the patients with and without statin therapy during the 2-year follow-up (hazard ratio: 0.32, P=0.027).

CONCLUSIONS

Pitavastatin had a beneficial effect on LV diastolic function and LA structure and function in elderly patients with HTN. Pitavastatin treatment may be associated with a lower incidence of new-onset AF.

Career choice and attitudes towards dental education amongst dental students in Japan and Sweden

The purpose of this study was to identify and compare the perspectives of dental students towards their career choice and dental education in Japan and Sweden. One hundred and fourteen dental students from the Nippon Dental University, Japan and 43 dental students from the Karolinska Institutet, Sweden participated in this study. Information was derived from a self-answered questionnaire consisting of five items for career choice and six items for dental education. Chi-square test and Wilcoxon signed-rank test were used for comparison. Significant differences were detected for 10 questionnaire items between the two countries. Regarding motivation towards the career choice, 44% of Swedish students indicated interpersonal motives related to helping other people, whereas 32% of Japanese students indicated expectations of their family in the dental profession. As future career options, 64% of Japanese and 47% of Swedish students planned to work as general dentists. More Swedish students (37%) preferred specialisation than Japanese students (17%). Nearly three-quarters of the Swedish students were satisfied with the teaching faculty of their school, whilst only 32% of the Japanese students indicated content. The perspectives of dental students were different in Japan and Sweden. This study provides a description of the perspectives of Japanese and Swedish dental students and enables better understanding of career decision and dental curriculum issues.

Prevention of no-reflow/slow-flow phenomenon during rotational atherectomy--a prospective randomized study comparing intracoronary continuous infusion of verapamil and nicorandil

BACKGROUND

The potential exists for microcirculatory impairment during rotational coronary atherectomy (RA) due to embolization of plaque debris, platelet aggregation, or vasospasm. This prospective randomized pilot study aimed to confirm favorable effects of nicorandil during RA compared with verapamil.

METHODS

We randomly assigned 200 patients with 219 coronary lesions planned to undergo RA with intracoronary infusion of nicorandil cocktail (100 patients, 109 lesions), which contained nicorandil 24 mg, nitroglycerin 5 mg, and heparin 10,000 U in 1000 mL saline, or verapamil cocktail (100 patients, 110 lesions), which contained verapamil 10 mg instead of nicorandil. Drug cocktails were infused through a 4F Teflon sheath of the rotablator system during RA. The primary end point was incidence of no-reflow/slow-flow phenomenon; secondary end points were those of continuous ST elevation, Q-wave myocardial infarction (MI), and non-Q-wave MI.

RESULTS

Group baseline and coronary angiographic characteristics were similar. Rotational atherectomy was performed successfully, and no patients died or required emergency coronary artery bypass grafting. Incidence of no-reflow/slow-flow phenomenon was significantly lower in the nicorandil group (nicorandil 5/109 lesions, verapamil 13/110 lesions, P < .005). Incidences of persistent ST-segment elevation and non-Q-wave MI were significantly lower in the nicorandil group (ST-segment elevation: nicorandil 3/100 patients, verapamil 10/100 patients, P < .05; non-Q-wave MI: nicorandil 2/100, verapamil 9/100 patients, P < .05). One patient each in the 2 groups experienced Q-wave MI.

CONCLUSION

Our findings suggest that continuous intracoronary infusion of nicorandil during RA prevents acute periprocedural complications. Nicorandil should be used as adjunctive treatment during RA.

Occupational scleroderma. A 17-year follow-up study

Two patients with a scleroderma-like disorder induced by epoxy resins were reported from the Department of Dermatology, Gunma University School of Medicine, Japan in 1980. Here, we describe the clinical and laboratory characteristics of these patients after 17 years' follow-up from 1976 to 1993. Their systemic manifestations and indurated sclerotic skin changes disappeared within 5 years. No internal organ involvement has developed during the period of follow-up. On routine laboratory tests, no abnormalities have been found in the peripheral blood or in the blood chemistry or serology. Histological examination revealed atrophy of the dermis and restoration of the normal pattern of fine collagen bundles, when compared with the previous skin biopsy specimens. This scleroderma-like disorder induced by epoxy resins is considered to be different from systemic sclerosis: it has an acute onset and a fairly good prognosis, and does not show involvement of the internal organs.

A scleroderma-like variant of recessive dystrophic epidermolysis bullosa?

We report a 17-year-old Japanese girl with typical clinical features of recessive dystrophic epidermolysis bullosa (RDEB). She had initially been diagnosed as suffering from systemic sclerosis because her skin became sclerotic at the age of 21 months, and there was no apparent blister formation. She subsequently developed severe dystrophic skin changes. However, there was histological evidence of subepidermal cleavage, diminished basement membrane zone immunohistochemical reactivity to anti-type VII collagen monoclonal antibody, and markedly decreased numbers of anchoring fibrils on electron microscopy. Although both the clinical and laboratory findings support a diagnosis of RDEB, we cannot exclude the possibility that our patient might represent a new clinical entity.