Taihei Itoh

Comparison of lesion formation between contact force-guided and non-guided circumferential pulmonary vein isolation: A prospective, randomized study

BACKGROUND Contact force (CF) monitoring could be useful in accomplishing circumferential pulmonary vein (PV) isolation (CPVI) for atrial fibrillation (AF). OBJECTIVE The purpose of this study was to compare procedure parameters and outcomes between CF-guided and non-guided CPVI. METHODS Thirty-eight consecutive AF patients (mean age 60 ± 11 years, 28 paroxysmal AF) undergoing CPVI were randomized to non-CF-guided (n = 19) and CF-guided (n = 19) groups. CPVI was performed with the ThermoCool SmartTouch catheter in both groups. The end-point was bidirectional block between the left atrium (LA) and PV. In the CF group, CF was kept between 10 and 20 g during CPVI, whereas in the non-CF group, all CF information was blanked. Radiofrequency energy at 30 W in the anterior and 25 W in the posterior LA wall was applied for 20-25 seconds at each point. RESULTS CPVI was successfully accomplished without any major complications in both groups. Mean CF in the non-CF and CF groups were 5.9 ± 4.5 g and 11.1 ± 4.3 g, respectively, for left-side CPVI, and 9.8 ± 6.6 g and 12.1 ± 4.8 g, respectively, for right-side CPVI (both P <.001). The procedure and fluoroscopy times for CPVI in the non-CF and CF groups were 96 ± 39 minutes and 59 ± 16 minutes, respectively (P <.001), and 22 ± 63 seconds and 9 ± 20 seconds (P = NS), respectively. Total number of residual conduction gaps was 6.3 ± 3.0 in the non-CF group and 2.8 ± 1.9 in the CF group (P <.001). During 6-month follow-up, 84.2% of patients in the non-CF group and 94.7% in the CF group were free from any atrial tachyarrhythmias (P = .34). CONCLUSION CF-guided CPVI is effective in reducing procedure time and additional touch-up ablation and may improve long-term outcome.

Reduced residual conduction gaps and favourable outcome in contact force-guided circumferential pulmonary vein isolation

Abstract Aims Although contact force (CF)-guided circumferential pulmonary vein isolation (CPVI) for paroxysmal atrial fibrillation (PAF) is useful, AF recurrence at long-term follow-up still remains to be resolved. The purpose of this study was to assess safety and efficacy of CF-guided CPVI and to compare residual conduction gaps during CPVI and long-term outcome between the conventional (non-CF-guided) and the CF-guided CPVI. Methods and results We studied the 50 consecutive PAF patients undergoing CPVI by a ThermoCool EZ Steer catheter (conventional group, mean age 61 ± 10 years) and the other 50 consecutive PAF patients by a ThermoCool SmartTouch catheter (CF group, 65 ± 11 years). The procedure parameters and residual conduction gaps during CPVI, and long-term outcome for 12 months were compared between the two groups. Circumferential pulmonary vein isolation was successfully accomplished without any major complications in both groups. Total procedure and total fluoroscopy times were both significantly shorter in the CF group than in the conventional group (160 ± 30 vs. 245 ± 61 min, P < 0.001, and 17 ± 8 vs. 54 ± 27 min, P < 0.001, respectively). Total number of residual conduction gaps was significantly less in the CF group than in the conventional group (2.7 ± 1.7 vs. 6.3 ± 2.7, P < 0.05). The AF recurrence-free rates after CPVI during 12-month follow-up were 96% (48/50) in the CF group and 82% (41/50) in the conventional group (P = 0.02 by log rank test). Multivariate Cox regression analysis further supported this finding. Conclusion Contact force-guided CPVI is safe and more effective in reducing not only the procedure time but also the AF recurrence than the conventional CPVI, possibly due to reduced residual conduction gaps during CPVI procedure.

Overexpression of coupling factor 6 attenuates exercise-induced physiological cardiac hypertrophy by inhibiting PI3K/Akt signaling in mice.

Background: Regular exercise improves systolic cardiac dysfunction through Akt cascade-mediated physiological hypertrophy in congestive heart failure. Tissue acidosis impairs Akt cascade, and coupling factor 6 induces tissue acidosis via activation of ecto-F1Fo complex. We tested the hypothesis that coupling factor 6 attenuates physiological cardiac hypertrophy induced by exercise and its benefit in mice. Methods and results: Adult wild-type mice (n = 20) and coupling factor 6-overexpressing transgenic mice (n = 20) were divided into two groups with or without 4-week exercise consisting of 90-min swimming twice daily. Left ventricular posterior wall and interventricular septum thicknesses were increased by 0.12 ± 0.1 and 0.16 ± 0.1 mm, respectively, after 4-week swimming in wild-type mice (both P < 0.01), but unchanged in transgenic mice. Fractional shortening was increased from 37 ± 1 to 41 ± 1% after 4-week swimming in wild-type mice (P < 0.05), whereas it was unchanged in transgenic. The insulin-like growth factor 1 (IGF-1) receptor protein and its phosphorylated form in the heart were both increased by 1.83 ± 0.23 and 1.83 ± 0.09 times, respectively, after 4-week swimming in wild-type mice (both P < 0.05), but were unchanged in transgenic. Downstream phosphoinsulin receptor substrate 1, phosphoinositide 3-kinase, and phospho-Akt were increased by 2.22 ± 0.22, 1.78 ± 0.31, and 2.24 ± 0.49 times, respectively, in wild-type mice (all P < 0.05), but were unchanged in transgenic. Restoration of phospho-Akt by IGF-1 injection recovered left ventricular hypertrophy and systolic function after 4-week swimming in transgenic. Conclusion: Overexpression of coupling factor 6 attenuates exercise-induced physiological cardiac hypertrophy by downregulating Akt signaling, thereby cancelling its benefit for cardiac function in mice. Reduction in coupling factor 6 level seems to be useful for drawing the exercising effects on cardiac function.

High Correlation of Estimated Local Conduction Velocity with Natural Logarithm of Bipolar Electrogram Amplitude in the Reentry Circuit of Atrial Flutter

Low conduction velocity (CV) in the area showing low electrogram amplitude (EA) is characteristic of reentry circuit of atypical atrial flutter (AFL). The quantitative relationship between CV and EA remains unclear. We characterized AFL reentry circuit in the right atrium (RA), focusing on the relationship between local CV and bipolar EA on the circuit.

Validation of Accuracy of Three‐Dimensional Left Atrial CartoSound™ and CT Image Integration: Influence of Respiratory Phase and Cardiac Cycle

CartoSound™ (CS) module is useful in integrating 3‐dimensional (3D) left atrial (LA) image with CT image. Integration method, however, has not been established. We reported the accuracy of LA electroanatomical (EA) and CT image integration by registering LA roof (LAR) and posterior wall (LAPW).

Estrogen attenuates coupling factor 6-induced salt-sensitive hypertension and cardiac systolic dysfunction in mice

In male coupling factor 6 (CF6)-overexpressing transgenic (TG) mice, a high-salt diet induces hypertension and cardiac systolic dysfunction with excessive reactive oxygen species generation. However, the role of gender in CF6-mediated pathophysiology is unknown. We investigated the effects of ovariectomy and estrogen replacement on hypertension, cardiac dysfunction and Rac1 activity, which activates radical generation and the mineralocorticoid receptor, in female TG mice. Fifteen-week-old male and female TG and wild-type (WT) mice were fed a normal- or high-salt diet for 60 weeks. Systolic and diastolic blood pressures were higher in the TG mice fed a high-salt diet than in those fed a normal-salt diet at 20–60 weeks in males but only at 60 weeks in females. The blood pressure elevation under high-salt diet conditions was concomitant with a decrease in left ventricular fractional shortening. In the WT mice, neither blood pressure nor cardiac systolic function was influenced by a high-salt diet. In the female TG mice, bilateral ovariectomy induced hypertension with cardiac systolic dysfunction 8 weeks after the initiation of a high-salt diet. The ratios of Rac1 bound to guanosine triphosphate (Rac1-GTP) to total Rac1 in the heart and kidneys were increased in the ovariectomized TG mice, and estrogen replacement abolished the CF6-mediated pathophysiology induced under the high-salt diet conditions. The overexpression of CF6 induced salt-sensitive hypertension, complicated by systolic cardiac dysfunction, but its onset was delayed in females. Estrogen has an important role in the regulation of CF6-mediated pathophysiology, presumably via the downregulation of Rac1.

CHA2DS2-VASc and HAS-BLED scores and activated partial thromboplastin time for prediction of high plasma concentration of dabigatran at trough

INTRODUCTION Although dabigatran, an oral direct thrombin inhibitor, does not require routine monitoring, high plasma concentration of dabigatran (PDC) at trough level is shown to be a high risk for bleeding in patients with nonvalvular atrial fibrillation (NVAF). As dabigatran prolongs the activated partial thromboplastin time (APTT), we examined relationships of PDC at trough with APTT and clinical features to identify patients at high risk for major bleeding during dabigatran treatment. MATERIALS AND METHODS In the consecutive 48 patients with NVAF taking dabigatran at a daily dose of 220mg (n=32) or 300mg (n=16), we measured PDC using HEMOCLOT Thrombin Inhibitor assay and APTT ratio to control before (trough) and 2hours after taking dabigatran. RESULTS PDC was positively correlated with APTT ratio (R(2)=0.64, p<0.0001). Using this regression equation and values of median trough PDC 116 (46.7-269) ng/mL observed in patients with major bleeding in the RE-LY trial, we calculated the expected value of APTT ratio corresponding to the 10th percentile of trough PDC (46.7). It was 1.20. There was a significant increase in trough PDC with increasing CHA2DS2-VASc score (p=0.01) and with increasing HAS-BLED score (p=0.01), especially in CHA2DS2-VASc score ≥4 and in HAS-BLED score ≥3, respectively. The highest trough PDC was obtained in patient group with CHA2DS2-VASc score ≥4, HAS-BLED score ≥3, or creatinine clearance ≤80, each combined with trough APTT ratio ≥1.20. CONCLUSIONS This study provides an important clinical implication for identifying patients at high risk for major bleeding during dabigatran treatment in clinical practice.

Potential roles of the wearable cardioverter-defibrillator in acute phase care of patients at high risk of sudden cardiac death: A single-center Japanese experience

BACKGROUND The wearable cardioverter-defibrillator (WCD) has been expected to play a role as an effective bridge therapy to implantable cardioverter-defibrillator (ICD) implantation in patients at high risk of ventricular tachyarrhythmias (VA). Although WCD has been available since April 2014 in Japan, its usefulness remains unclear. METHODS AND RESULTS During the early period after hospitalization, patients at high risk of VA after excluding some elderly patients were prescribed WCD. The consecutive 50 patients with WCD use (median age 56 years, 38 for secondary prevention) were studied. We analyzed clinical efficacy and safety of WCD, and examined its potential roles. Of the 50 patients, 38 used WCD only during hospitalization. During WCD use [median 16 (IQR 8-33) days], all patients wore WCD for 98% of a day regardless of in or out-of-hospital use. Sustained VA was detected in 4 patients (8%; for primary prevention in 1) with 7 episodes, and 6 of 7 episodes required shock therapy. Of the 6 shock therapies, 4 were for sustained ventricular tachycardia with the median rate of 236beats/min (IQR 203-250), and the other 2 for ventricular fibrillation. Subsequently, only 27 patients (54%) of all underwent ICD implantation following the WCD use, because of reduced risk of VA after optimal pharmacological therapy or improvement in the left ventricular function. CONCLUSIONS The WCD use for the acute phase care of patients at high risk of VA can be safe and effective, and may be useful for evaluating indication of ICD implantation.

Usefulness of combined CARTO electroanatomical mapping and manifest entrainment in ablating adenosine triphosphate-sensitive atrial tachycardia originating from the atrioventricular node vicinity

By using a noncontact mapping system, adenosine triphosphate (ATP)‐sensitive atrial tachycardia (ATP‐AT) originating from the atrioventricular (AV) node vicinity was successfully ablated at the entrance to the slow conduction zone indicated by the manifest entrainment technique. We aimed to prospectively validate the efficacy of the combination of CARTO electroanatomical mapping and manifest entrainment in ablating this ATP‐AT.

Telediagnosis of heart failure with continuous intrathoracic impedance monitoring by Medtronic CareLink Network: Importance of the elevation pattern of OptiVol Fluid Index

The Medtronic implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy with defibrillator (CRT‐D) device is equipped with the OptiVol fluid status monitoring system, which continuously measures intrathoracic impedance and provides an early warning of thoracic fluid retention, which is indicative of decompensated heart failure (HF). The accuracy of the telediagnosis of HF with this system still remains to be elucidated.