Kyouichi Kaneko

Association Between Left and Right Atrial Remodeling With Atrial Fibrillation Recurrence After Pulmonary Vein Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation A Pilot Study

Background— Left atrial (LA) remodeling is a factor in atrial fibrillation (AF) recurrence after pulmonary vein catheter ablation (CA), but right atrium (RA) remodeling has not been investigated for possible associations to AF recurrence. Methods and Results— Using 64-slice multidetector computed tomography, RA and LA volumes were measured 3-dimensionally before CA in 65 patients with initially proven idiopathic paroxysmal AF (mean age, 60±10 years, 81.5% men). The CA procedure was guided by CARTO Merge atrial electroanatomic mapping. Sixteen patients (24.6%) had AF recurrence within the 6-month period after the CA. The recurrence was associated with a large RA volume [odds ratio, 1.04; 95% confidence interval (CI), 1.02 to 1.07, P<0.0001], a large LA volume with 1.04 [95% CI, 1.01 to 1.06, P=0.002], and low LA mean voltage with 1.03 [95% CI, 1.01 to 1.05, P=0.002]. After adjustment for potential confounding variables, RA and LA volumes remained predictive of AF recurrence. Large atrial volumes (mL) (RA ≥87 or LA ≥99) predicted AF recurrence (sensitivity of RA volume: 81.3% in 13 of 16 patients with AF recurrence; specificity: 75.5% in 37 of 49 patients without AF recurrence; sensitivity of LA volume: 81.3% in 13 of 16 patients with AF recurrence; specificity: 69.4% in 34 of 49 patients without AF recurrence), and the combined estimate of both atrial volumes was incremental and additive prognostic power (sensitivity: 75% in 12 of 16 patients with AF recurrence; specificity: 93.9% in 46 of 49 patients without AF recurrence). Conclusions— Both LA and RA remodeling are equally associated with post-CA AF recurrence.

The Significance of Cardiac Sympathetic Nervous System Abnormality in the Long-Term Prognosis of Patients with a History of Ventricular Tachyarrhythmia

Severe left ventricular dysfunction or cardiac sympathetic nervous system (SNS) abnormality predicts cardiac death in various heart diseases, including arrhythmogenic disorders. However, it is not clear whether SNS abnormality predicts sudden cardiac death during long-term follow-up in patients with a history of ventricular tachyarrhythmia. We hypothesized that SNS abnormality would be associated with recurrent ventricular arrhythmic events. Methods: 123I-metaiodobenzylguanidine (MIBG) scintigraphy was performed on 86 patients (mean age ± SD, 46 ± 19 y, 65.1% men) with a history of ventricular tachycardia or fibrillation. 123I-MIBG (111 MBq) was intravenously administered under resting conditions, and planar images were obtained 15 min and 4 h later (anterior view for 6 min; 512 × 512 matrices; zoom ratio, 1.0). SNS activity was assessed using the heart-to-mediastinum ratio on delayed imaging. Results: During about 11 y of follow-up (mean ± SD, 5.2 ± 3.7 y), 3 patients (3.5%) had sudden cardiac death and 21 patients (24.4%) had sustained ventricular tachyarrhythmic events. SNS abnormality, defined as a heart-to-mediastinum ratio of less than 2.8, and left ventricular dysfunction, defined as a left ventricular ejection fraction of less than 50%, were associated with sudden cardiac death or recurrent ventricular tachyarrhythmic events (18/40 patients [45%] with SNS abnormality, vs. 6/46 patients [13%] without, P = 0.004; 9/15 patients [60%] with left ventricular dysfunction, vs. 15/71 patients [21.1%] without, P = 0.008). After adjustment for potential confounding variables such as age, sex, coronary risk factors, medication use, history of structural heart disease, and left ventricular function, SNS abnormality was a powerful predictor of recurrent arrhythmic events, with a hazard ratio of 3.6 [95% confidence interval, 1.4–9.2, P = 0.007]). Further, SNS abnormality had incremental and additive prognostic power in combination with left ventricular dysfunction, with an adjusted hazard ratio of 4.4 [95% confidence interval, 1.9–9.9, P < 0.0001]). Conclusion: SNS abnormality predicted recurrent ventricular tachyarrhythmic events during long-term follow-up. 123I-MIBG scintigraphic evaluations for SNS abnormality may be an option for screening patients at high risk for sudden cardiac death.

Iodine-123 mIBG Imaging for Predicting the Development of Atrial Fibrillation

OBJECTIVES we investigated whether cardiac sympathetic nervous system (SNS) activity measured by iodine-123 meta-iodobenzylguanidine ((123)I-mIBG) imaging would be associated with both the occurrence of heart failure (HF) and the transit to permanent atrial fibrillation (AF) in patients with paroxysmal AF. BACKGROUND atrial fibrillation occurs suddenly and transiently and can persist, and results in the occurrence of HF. An important feature of AF and HF is their propensity to coexist not only because they share antecedent risk factors, but also because the one may directly predispose the heart to the other. However, a useful modality for predicting the occurrences of both those has not been established in patients with paroxysmal AF. METHODS the (123)I-mIBG scintigraphy was performed to evaluate cardiac SNS activity presented as the heart/mediastinum ratio in 98 consecutive patients (age 66 ± 13 years, 63.3% male) with idiopathic paroxysmal AF and preserved left ventricular ejection fraction (≥ 50%). RESULTS during 4 ± 3.6 years of follow-up, the transit to permanent AF was associated with the occurrence of HF (34.3% in 12 of 35 patients with permanent AF vs. 6.3% in 4 of 63 patients without, p < 0.0001). Lower heart/mediastinum ratio and lower left ventricular ejection fraction were the independent predictors of the transit to permanent AF with adjusted hazard ratios of 3.44 (95% confidence interval [CI]: 1.9 to 6.2, p < 0.0001) and 1.04 (95% CI: 1.01 to 1.08, p = 0.014). Further, these factors and higher plasma brain natriuretic peptide concentration were the independent predictors of the occurrence of HF with permanent AF, with adjusted hazard ratios of 5.08 (95% CI: 1.5 to 17.5, p = 0.011), 1.11 (95% CI: 1.03 to 1.19, p = 0.004), and 1.004 (95% CI: 1.001 to 1.008, p = 0.014). CONCLUSIONS cardiac SNS abnormality was associated with the occurrence of both HF and permanent AF in paroxysmal AF patients, and (123)I-mIBG imaging may be a useful modality for predicting the development of AF.

Impact of depression on masked hypertension and variability in home blood pressure in treated hypertensive patients.

This study was conducted to determine the effects of depression and/or insomnia on masked hypertension (MHT) compared with other types of HT and on variability in home-measured blood pressure (HBP) and clinic BP (CBP). Three hundred and twenty-eight hypertensives (132 women) aged 68±10 years were classified into four BP types: controlled HT (CHT), white-coat HT, MHT and sustained HT (SHT), based on CBP (140/90 mm Hg) and morning HBP (135/85 mm Hg) measurements. A score of ⩾16 on the Center for Epidemiologic Studies Depression Scale (CES-D) was defined as depression. The mean values and s.d. of BP were calculated from measurements taken during the 14 consecutive days just before the CES-D evaluation. Compared with the CHT group, the risk of depression was 2.77-fold higher in the SHT group and even higher in the MHT group (7.02-fold). The association between depression and MHT was augmented in the presence of insomnia and was somewhat stronger in women. A HBP variability index defined as s.d./mean BPs in both morning and night time was significantly higher in MHT than in the other BP types, whereas that of CBP was not. Both morning and night-time HBP variability were significantly higher in depressive patients than in non-depressives. These suggest that depression is associated with MHT and that increases both morning and night-time HBP variability but not CBP variability. Physicians should be mindful of mental stresses such as depression in their hypertensive patients when forming strategies to control BP over the diurnal cycle.

Reversible T‐Wave Inversions and Neurogenic Myocardial Stunning in a Patient with Recurrent Stress‐Induced Cardiomyopathy

A 72‐year‐old female was diagnosed as a stress‐induced cardiomyopathy from apical ballooning pattern of left ventricular dysfunction without coronary artery stenosis after the mental stress. ECG showed the transient T‐wave inversions after the ST‐segment elevations. By the mental stress after 1 year, she showed a transient dysfunction with similar ECG changes again. T‐wave inversions recovered earlier, and cardiac sympathetic dysfunction showed a lighter response corresponding to the less severe dysfunction than those after the first onset. Wellens’ ECG pattern was associated with the degree of neurogenic myocardial stunning with sympathetic hyperinnervation caused by mental stress.

Five-year follow-up of a giant coronary aneurysm using virtual coronary angioscopy.

Yasushi Akutsu, Youichi Kobayashi, Takehiko Sambe, Toshikazu Kurihara, Kyouichi Kaneko, Yusuke Kodama, Hui-Ling Li, Jumpei Suyama, Yuji Hamazaki, Junya Iwasaki, Takehiko Gokan, Kazuo Itabashi, Katsuji Oguchi, Naoki Uchida and Shinichi Kobayashi, Department of Internal Medicine (Cardiology), Clinical Research Institute for Clinical Pharmacology & Therapeutics, Showa University Karasuyama Hospital, Department of Medicine, Division of Cardiology, Departments of Pediatrics, Radiology and Pharmacology, Showa University School of Medicine, Tokyo, Japan

Pulmonary Vein Obstruction After Catheter Ablation Following Atrial Fibrillation

The patient was 68-year-old man with highly symptomatic paroxysmal atrial fibrillation. Transoesophageal echocardiography was performed to confirm no left atrial embolism, and contrast-enhanced 64-row multidetector computed tomography (MDCT) was performed to clarify the anatomic forms and routes of pulmonary veins (PV) before ablation (Figure 1A). The circumferential ablation procedure was performed using electroanatomical mapping (Figure 1B). Radiofrequency catheter energy was delivered with a closed irrigation cool-tip ablation catheter. The patient was kept on oral anticoagulation with a controlled international normalized ratio between 2 and …

Sympathetic dysfunction of systemic right ventricle in congenitally corrected transposition of the great arteries

We evaluate the systemic right ventricle (SRV) failure of congenitally corrected transposition of the great arteries using the scintigraphic studies in a case with 32-year-old male who improved the heart failure by the use of beta-adrenergic blockers. The myocardial perfusion sympathetic nervous system activity mismatch with preserved coronary flow and wall thickness indicates a distinctive feature as SRV cardiomyopathy, suggesting the importance of recovery of SRV sympathetic dysfunction for improving the prognosis.

Dataset of calcified plaque condition in the stenotic coronary artery lesion obtained using multidetector computed tomography to indicate the addition of rotational atherectomy during percutaneous coronary intervention.

Our data shows the regional coronary artery calcium scores (lesion CAC) on multidetector computed tomography (MDCT) and the cross-section imaging on MDCT angiography (CTA) in the target lesion of the patients with stable angina pectoris who were scheduled for percutaneous coronary intervention (PCI). CAC and CTA data were measured using a 128-slice scanner (Somatom Definition AS+; Siemens Medical Solutions, Forchheim, Germany) before PCI. CAC was measured in a non-contrast-enhanced scan and was quantified using the Calcium Score module of SYNAPSE VINCENT software (Fujifilm Co. Tokyo, Japan) and expressed in Agatston units. CTA were then continued with a contrast-enhanced ECG gating to measure the severity of the calcified plaque condition. We present that both CAC and CTA data are used as a benchmark to consider the addition of rotational atherectomy during PCI to severely calcified plaque lesions.

Thallium-201 and I-123 beta-methyl iodophenyl-pentadecanoic acid dual isotope single photon emission computed tomography for evaluating reperfusion injury after successful reperfusion therapy.

We report a reperfusion injury after rotational coronary atherectomy (RA) in a 66-year-old man with coronary artery disease. Submaximal exercise with thallium-201 single photon emission computed tomography (SPECT) imaging before reperfusion showed partially reversible perfusion defects in the apex and reversible perfusion defects in the anteroseptal area. Thallium-201 and I-123 beta-methyl iodophenyl-pentadecanoic acid (BMIPP) dual isotope SPECT was performed 5 days before and 1 hour after RA, and 1 month after RA. SPECT images at 1 hour after recovery of no reflow phenomenon after RA revealed enlargement of the defect sizes on thallium-201 and BMIPP uptakes in the anteroseptal area including the apex compared with those before RA. The defect size of thallium-201 uptake was progressively improved on 5 hour delayed redistribution imaging and 1 month after reperfusion compared with that of BMIPP uptake. In conclusion, the changes for the worse of thallium-201 uptake and fatty acid metabolism immediately after the no reflow phenomenon may indicate an injured membrane integrity with altered myocardial metabolism rather than myocardial ischemia. Thallium-201 and I-123 BMIPP dual isotope SPECT is useful for evaluating reperfusion injury after successful reperfusion therapy in a patient with acute coronary syndrome.