Satoshi Yanagisawa

Differences in activated clotting time among uninterrupted anticoagulants during the periprocedural period of atrial fibrillation ablation

BACKGROUND Close monitoring of intraoperative activated clotting time (ACT) is crucial to prevent complications during the periprocedural period of atrial fibrillation (AF) ablation. However, little is known about the ACT in patients receiving new oral anticoagulant agents (NOACs). OBJECTIVE The purpose of this study was to evaluate change in the ACT among anticoagulant agents used during the periprocedural period of AF ablation. METHODS We examined 869 consecutive patients who underwent AF ablation between April 2012 and August 2014 and received NOACs (n = 499), including dabigatran, rivaroxaban, and apixaban, or warfarin (n = 370) for uninterrupted periprocedural anticoagulation. Changes in intraprocedural ACT were investigated among the anticoagulant agents. Furthermore, the incidence of periprocedural events was estimated. RESULTS The average time in minutes required for achieving a target ACT >300 seconds was significantly longer in the dabigatran group (DG) and apixaban group (AG) than in the warfarin group (WG) and rivaroxaban group (RG) (60 and 70 minutes vs 8 and 9 minutes, respectively; P < .001). In addition, the proportion of patients who achieved the target ACT after initial heparin bolus was significantly lower in the DG and AG than in the WG and RG (36% and 26% vs 84% and 78%, respectively; P < .001). Furthermore, the incidence of periprocedural complications was equivalent among the groups. CONCLUSION The average time required to reach the target ACT was longer in the DG and AG than in the WG and RG.

Feasibility and Safety of Uninterrupted Dabigatran Therapy in Patients Undergoing Ablation for Atrial Fibrillation

OBJECTIVE Uninterrupted oral warfarin strategy has become the standard protocol to prevent complications during catheter ablation (CA) for the treatment of atrial fibrillation (AF). However, little is known about the safety and efficacy of uninterrupted dabigatran therapy in patients undergoing CA for AF. Therefore, this study investigated the safety and efficacy of uninterrupted dabigatran therapy and compared the findings with those for uninterrupted warfarin therapy. METHODS Bleeding and thromboembolic events during the periprocedural period were evaluated in 363 consecutive patients who underwent CA for AF at Nagoya University Hospital, and received uninterrupted dabigatran (n=173) or uninterrupted warfarin (n=190) for periprocedural anticoagulation. RESULTS A total of 27 (7%) patients experienced either bleeding or thromboembolic complications. Major bleeding complications occurred in 2 (1%) patients in the dabigatran group (DG) and 2 (1%) patients in the warfarin group (WG). Eight (5%) patients in the DG and 9 (5%) patients in the WG experienced groin hematoma, a type of minor bleeding complication. Meanwhile, no patient in the DG and 1 (1%) in the WG developed cerebral ischemic stroke. Overall, there was no significant difference between the groups for any category. The activated partial thromboplastin time (APTT) independently predicted periprocedural complications in the DG. CONCLUSION Uninterrupted dabigatran therapy in CA for AF thus may be a safe and effective anticoagulant therapy, and appears to be closely similar to continuous warfarin; however, it is essential to pay close attention to the APTT values when using dabigatran during CA.

The prognostic value of treadmill exercise testing in very elderly patients: heart rate recovery as a predictor of mortality in octogenarians.

AIMS Several treadmill exercise testing prognostic parameters have been identified in various populations. However, despite the widespread use of treadmill exercise testing, the prognostic value in very elderly patients has not been well characterized. The aim of this study was to assess the results of treadmill exercise testing in octogenarians, and to examine various parameters in order to identify a prognostic marker of mortality. METHODS AND RESULTS This study included 97 consecutive octogenarians (age, 81.1 ± 1.8 years; 66% male) who were referred for treadmill exercise testing. During the follow-up period (2.6 ± 1.6 years), all-cause death occurred in 20 patients (21%). Univariate Cox proportional hazard regression analysis showed that abnormal heart rate recovery (HRR) (defined as a decreased heart rate of ≤ 18 beats per minute after peak exercise) [hazard ratio (HR), 2.82; 95% confidence interval (CI), 1.06-7.47; P = 0.037] and ischaemic ST-segment change (HR, 2.56; 95% CI, 1.01-6.46; P = 0.047) were significantly associated with all-cause mortality. After adjusting for age and sex, multivariate Cox proportional hazard analysis showed that abnormal HRR was the only independent predictor of all-cause death (HR, 2.86; 95% CI, 1.01-8.11; P = 0.048). CONCLUSION Attenuated HRR is a significant prognostic marker for all-cause death among octogenarians. The results may provide helpful support for risk stratification in clinical practice.

Clinical outcomes and prognostic factor for acute heart failure in nonagenarians: impact of hypoalbuminemia on mortality.

In the current aging society, acute heart failure (AHF) is one of the leading causes of hospitalization due to the increased number of older individuals, and the prevalence of HF is increasing, raising a major public health concern in industrialized countries [1,2]. In addition, HF is one of themost important causes of death in elderly patients. The 5year-survival rate after the first admission for HF was reportedly worse than for that for cancer [3]. On the other hand, recent advances in technology and development of medical therapies have improved mortality in heart disease, and their effect include expanding an opportunity for therapy even among very elderly patients. However, the situation in very elderly population, over 90 years of age with heart disease is unclear, and few data are available on outcome and mortality in nonagenarians with HF. The aim of the present of study was to investigate the clinical features of AHF in nonagenarians, and identify prognostic factors by using routine non-invasivemethods and examinations. A retrospective observational review of 146 consecutive patients aged 90 years and older who were admitted to our institution during the period from January 2006 to December 2008 with a diagnosis of AHF was conducted. AHF was defined as new onset decompensated HF or worsening of chronic HF requiring emergency hospitalization. Patients whose course was complicated by acute coronary syndrome and severe renal failure were also included. Clinical records including medical history, co-morbidities, demographic data, and the results of examinations at the time of hospital admission, were retrospectively reviewed. Total mortality was evaluated during the follow-up period, and prognostic factors identified. The study protocol was approved by our institutional review board. Continuous variables were expressed as means±standard deviation, and categorical variables as numbers and proportions. The patients were divided into a survival group and a non-survival group, and characteristics and examination results are compared by Cox proportional hazards regression analysis. The factors with p values b0.10 in univariate analysis were entered in the multivariate Cox proportional hazards regression model to identify independent predictive factors for mortality. Based on the obtained independent predictor, a receiver operating characteristics (ROC) curve was plotted, and cut-off point for ROC curve factor was determined. The

Elevated Red Blood Cell Distribution Width Predicts Recurrence After Catheter Ablation for Atrial Fibrillation in Patients With Heart Failure – Comparison With Non-Heart Failure Patients –

BACKGROUND Elevated red blood cell distribution width (RDW) predicts poor prognosis in patients with cardiovascular diseases. However, little is known about the association between RDW and outcomes after catheter ablation of atrial fibrillation (AF). METHODSANDRESULTS A total of 757 patients who underwent radiofrequency catheter ablation of AF were divided into heart failure (HF, n=79) and non-HF (n=678) groups; RDW was assessed as a predictor after catheter ablation in each. During a 22.3-month follow-up period, the baseline RDW in the HF group was greater in the recurrence group than in the non-recurrence group (14.5±2.0% vs. 13.5±0.9%, P=0.013). In contrast, no significant difference in RDW at baseline was found in the non-HF group between the recurrence and non-recurrence groups (13.3±0.8% vs. 13.2±0.8%, P=0.332, respectively). Multivariate analysis demonstrated that RDW (hazard ratio 1.20, 95% confidence interval 1.01-1.40, P=0.034) was an independent predictor of AF recurrence in the HF group. The cut-off values of RDW for the recurrence of AF and major adverse events in the HF group were 13.9% and 14.8%, respectively. CONCLUSIONS High RDW is an independent predictor for the recurrence of AF and major adverse events in patients with HF after catheter ablation. RDW is a potential noninvasive marker in AF patients complicated with HF. (Circ J 2016; 80: 627-638).

Alogliptin, a dipeptidyl peptidase-4 inhibitor, regulates the atrial arrhythmogenic substrate in rabbits

BACKGROUND Dipeptidyl peptidase-4 (DPP-4) inhibitors were recently reported to have cardioprotective effects via amelioration of ventricular function. However, the role of DPP-4 inhibition in atrial remodeling, especially of the arrhythmogenic substrate, remains unclear. OBJECTIVE We investigated the effects of a DPP-4 inhibitor, alogliptin, on atrial fibrillation (AF) in a rabbit model of heart failure caused by ventricular tachypacing (VTP). METHODS Rabbits subjected to VTP at 380 bpm for 1 or 3 weeks, with or without alogliptin treatment, were assessed using echocardiography, electrophysiology, histology, and immunoblotting and compared with nonpaced animals. RESULTS VTP rabbits exhibited increased duration of atrial burst pacing-induced AF, whereas administration of alogliptin shortened this duration by 73%. The extent of atrial fibrosis after VTP was reduced by 39% in the alogliptin-treated group. VTP rabbits treated with alogliptin displayed a 1.6-fold increase in left atrial myocardial capillary density compared with nontreated rabbits. A 2-fold increase in endothelial nitric oxide synthase (eNOS) phosphorylation was observed in the left atrium of alogliptin-treated rabbits compared with nontreated rabbits. Moreover, a nitric oxide synthase inhibitor (N(ω)-nitro-l-arginine methyl ester) blocked the beneficial effects of alogliptin on AF duration, fibrosis, and capillary density. CONCLUSION Alogliptin shortened the duration of AF caused by VTP-induced fibrotic atrial tissue by augmenting atrial angiogenesis and activating eNOS. Our findings suggest that DPP-4 inhibitors may be useful in the prevention of heart failure-induced AF.

Impaired renal function is associated with recurrence after cryoballoon catheter ablation for paroxysmal atrial fibrillation: A potential effect of non-pulmonary vein foci

BACKGROUND Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related. The present study aimed to evaluate the association between estimated glomerular filtration rate (eGFR) and outcomes after cryoballoon catheter ablation for AF. METHODS We included a total of 110 patients (64.0±10.1 years, 64% men) with paroxysmal AF who underwent second-generation cryoballoon catheter ablation in this study. Recurrence and change in renal function after ablation were assessed by stratification of eGFR sub-groups. RESULTS During a mean follow-up period of 9 months, 20 (18%) patients had AF recurrence after the first catheter ablation procedure. Multivariate Cox regression analysis showed that eGFR [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.93-0.99, p=0.047], non-pulmonary vein (PV) ectopic beats at initial ablation (HR 2.92, 95% CI 1.03-8.27, p=0.043), and history of stroke (HR 7.47, 95% CI 2.30-24.2, p=0.001) were independent predictors of recurrence after the ablation. Among the CKD groups, recurrence was found in 7% (1/15), 12% (9/73), and 46% (10/22) of the eGFR ≥90mL/min/1.73m2, eGFR 60-89.9mL/min/1.73m2, and eGFR 30-59.9mL/min/1.73m2 groups, respectively (p=0.001). Kaplan-Meier survival curves demonstrated that patients with eGFR 30-59.9mL/min/1.73m2 had significantly worse prognosis than did the other groups (log-rank p<0.001). In addition, non-PV ectopic beats at initial ablation were detected in 7% (1/15), 14% (10/73), and 50% (11/22) of the patients among the three CKD groups, respectively (p<0.001). No patients developed contrast-induced nephropathy after the catheter ablation procedure. CONCLUSIONS Low eGFR at baseline was an independent predictor of recurrence after cryoballoon ablation for paroxysmal AF. The presence of non-PV ectopic beats was significantly increased in patients with impaired renal function, which might be associated with a poor outcome.

Comparison of medically versus surgically treated acute type a aortic dissection in patients <80 years old versus patients ≥80 years old.

Although recent progress in emergency surgery has resulted in an increase in the indication for older patients with acute type A aortic dissection (AAD), some patients remain who cannot undergo surgical treatment and little is known about the prognosis of patients with AAD who receive medical treatment, especially in elderly patients. Of the 82 patients with AAD who were admitted to our institution, 48 received medical therapy only. We retrospectively reviewed their clinical data and analyzed the prognostic value of the clinical characteristics in both younger and older patients. The in-hospital and 1-year mortality were significantly lower in the patients who underwent surgical treatment than in those who received medical treatment (6% vs 65%, p <0.001; 8% vs 73%, p <0.001, respectively). Of the patients with medical treatment, the in-hospital and 1-year mortality rate in the younger (<80 years old, n = 27) and older (≥80 years old, n = 21) groups was 70% and 80% and 57% and 65%, respectively. For the younger group, the presence of an open false lumen was significantly associated with in-hospital mortality (89% vs 50%, p = 0.044). In contrast, in the older group, a lower serum albumin level (3.4 ± 0.3 vs 4.0 ± 0.5 g/dl, p = 0.010) and the incidence of an open false lumen (83% vs 33%, p = 0.032) were significantly associated with in-hospital mortality. In conclusion, in addition to an open false lumen as a risk factor, a lower serum albumin level is an important prognostic factor in older patients with AAD.

Right ventricular outflow tract obstruction: metastatic thyroid carcinoma.

![Figure][1] [![Graphic][3] ][3] A 62-year old female dialysis patient presented with intermittent fever, dyspnea, and hoarseness (due to a diagnosed thyroid tumor). While she was treated for fever of unknown origin, transthoracic echocardiography (A) showed a solid high-echoic mass (

Poor tolerance of beta-blockers by elderly patients with heart failure

Despite the well-understood importance of beta-blocker therapy in heart failure, it is sometimes not possible to use beta-blockers in elderly patients due to poor tolerance. In this report, we describe the case of an 83-year-old patient with severe systolic heart failure complicated by aortic valve stenosis and atrial fibrillation. A simple therapeutic approach involving discontinuation of beta-blockers remarkably alleviated the symptoms such as left ventricular ejection fraction, and improved the chest radiography and laboratory findings; further, atrial fibrillation converted to sinus rhythm. It is important to carefully administer beta-blocker therapy to elderly patients with heart failure, especially after considering cardiac output.