Yoshiyasu Aizawa

Serum inflammation markers predicting successful initial catheter ablation for atrial fibrillation.

BACKGROUNDnWe investigated various serum inflammatory markers to predict ablation responders who have no atrial fibrillation (AF) relapse after the initial ablation.nnnMETHODSnForty-four consecutive AF patients (age: 59 ± 8 years, paroxysmal: 31, CHADS₂: 1.1 ± 1.1) who underwent an initial pulmonary vein isolation were investigated. Various serum inflammatory markers, such as adiponectin, ANP, BNP, 1CTP, F1+2, hs-CRP, IL-6, intact P1NP, MDA-LDL, MMP-2, TGF-β, TIMP-2, and TNF-α, were evaluated prior to ablation. AF relapse was defined as AF documented in telemonitoring electrocardiograms twice a day during 9.7 ± 2.4 months of follow-up with three months of a blanking-period.nnnRESULTSnA total of 29 patients (paroxysmal: 21) maintained sinus rhythm after the initial catheter ablation. These ablation responders had significantly lower MMP-2 (Sinus vs. Relapsed: 748 ± 132.7 vs. 841.2 ± 152.4 ng/mL, P=0.042) and TNF-α (1.1 ± 0.4 vs. 1.8 ± 1.7 pg/mL, P=0.046) levels prior to ablation. A BNP-adjusted Cox multivariate regression analysis revealed that the independent predictive factor for AF recurrence was high MMP-2 levels (>766 ng/mL) accompanied by high TNF-α levels (>1.2 pg/mL).nnnCONCLUSIONSnThe levels of MMP-2 and TNF-α might be useful for predicting initial AF catheter ablation responders.

Predictive factors of lead failure in patients implanted with cardiac devices

INTRODUCTIONnLead failures (LFs) are one of the most common complications in patients implanted with cardiovascular implantable electronic devices. LFs often cause serious secondary complications such as inappropriate ICD shocks or asystole. This study aimed to identify the clinical factors associated with the occurrence of LFs.nnnMETHODSnA total of 735 consecutive device implantations (mean age 67±15years, males 64%) performed at a single university hospital setting from 1997 to 2014 were included. The implanted devices consisted of 421 pacemakers, 250 implantable cardioverter defibrillators (ICD), 9 cardiac resynchronization therapy pacemakers (CRT-P), and 55 CRT defibrillators (CRT-D). The primary endpoint was the development of an LF.nnnRESULTSnDuring a mean duration of 5.8±4.3years, 38 LFs developed in 31 patients (mean age 56±14years). LFs included 32 ICD (7 Sprint Fidelis, 2 Riata), and 6 pacing leads. Nine patients received inappropriate ICD shocks and 1 had syncope due to an LF. All patients underwent lead reinsertions with device replacements. Eight patients required opposite site implantations due to venous occlusions. The predictive factors of LFs were the age, male sex, taller body length, ICD vs. pacemaker, lesser lead number, extra-thoracic puncture of the axillary vein vs. a cut-down of the cephalic vein, use of recalled leads and patients with idiopathic ventricular fibrillation (IVF) and Brugada syndrome (BrS).nnnCONCLUSIONnLFs occurred mainly with ICD leads. A lesser age, the puncture method, lead model, and diagnosis of IVF/BrS were associated with the development of LFs.

Operator-blinded contact force monitoring during pulmonary vein isolation using conventional and steerable sheaths☆

BACKGROUNDnWe performed contact force (CF) monitoring during pulmonary vein (PV) isolation to evaluate CF according to sheath type, catheter position, and inadequate ablation.nnnMETHODSnThirty consecutive patients (paroxysmal atrial fibrillation, 23; CHADS2 score, 0.5 ± 0.7; age, 56 ± 10 years) who underwent PV isolation using a CF-sensing catheter were included. Data for operator-blinded CF, impedance, and duration of the first touch (first round of ablation in each PV) was collected. We compared the CF, maximum CF, force-time integral, average impedance, and impedance drop (Δ impedance) between different sheaths (Swartz™ vs. Agilis™) in 12 different catheter positions, and in inadequate first touches requiring additional ablation.nnnRESULTSnA total of 1283 ablation points (Swartz™, 620 points; Agilis™, 663 points) were evaluated. The average CF was significantly higher in the Agilis™ group (17.8 ± 13.0 g) than the Swartz™ group (15.0 ± 12.4 g; P < 0.001), especially in the anterior, inferior-anterior, and inferior-posterior sections of the right PV, and the top of the roof, and calina of the left PV. The Δ impedance showed a mildly significant negative relationship with the average CF (r=-0.206; P<0.001) and with the force-time integral (r = -0.279; P < 0.001). Compared to first touches, the average CF and Δ impedance were significantly smaller in inadequate first touches in the Swartz™ group, but not in the Agilis™ group.nnnCONCLUSIONSnCF for PV isolation was significantly different depending on the position of the catheter and the type of sheath.

Visualization of the left atrial appendage by phased-array intracardiac echocardiography from the pulmonary artery in patients with atrial fibrillation

AIMSnThe left atrial appendage (LAA) represents the major source of cardiac thrombus formation in patients with atrial fibrillation (AF). Phased-array intracardiac echocardiography (ICE) has become available and frequently used during catheter ablation of AF. We attempted to study the feasibility of using ICE for the visualization and evaluation of the LAA from the pulmonary artery (PA) in patients with AF.nnnMETHODS AND RESULTSnEighty patients with AF undergoing catheter ablation (70 males, 57.5 ± 9.1 years) were included. Transoesophageal echocardiography was performed on the prior day before the catheter ablation, and ICE was performed just before the transseptal puncture during the catheter ablation. The ICE catheter was advanced up into the PA from the femoral vein, where the LAA was clearly and entirely visualized by manipulating the ICE catheter. We compared the degree of spontaneous echo contrast, and the correlation was obtained between the ICE and TEE (κ = 0.534, P < 0.001). Furthermore, the LAA flow velocity (LAA emptying and filling velocities) measured by ICE had a good correlation to that measured by TEE (R = 0.872, P < 0.01 and R = 0.753, P < 0.01, respectively). No patients developed any complications.nnnCONCLUSIONnThe utilization of ICE in the PA is feasible for the observation and evaluation of the LAA.

Risk factors for early replacement of cardiovascular implantable electronic devices

1. IntroductionCardiovascularimplantableelectronicdevices(CIEDs)improvedthesurvivaland quality-of-life in patients with variousheart rhythmdisor-ders [1].Howeverpatientswillneedfrequentdevicereplacementsdur-ing their remaining life span [2]. Battery depletion isthe most commoncause of device replacements. Device replacements increase thehealthcare cost and risk of infection or hemorrhagic complications[3–5]. The estimated battery longevities provided by manufactures arebasedoncalculatedstableidealconditionsandtheymightdifferinclin-icalpractice.Weassessedthehypothesisthattheremayexistsomeriskfactors of shortening the replacement cycle that have not been fullyclarified. The purpose of this study was to disclose the clinical factorsfor predicting frequent generator replacements.

Pericardial Endoscopy–Guided Left Atrial Appendage Ligation A Pilot Study in a Canine Model

Background—Approaches for closing the left atrial appendage (LAA) have been developed for stroke prevention. However, the prevailing maneuvers require an open-chest surgery, intravascular access, or transseptal puncture. We evaluated the feasibility and safety of pericardial endoscopy-guided LAA ligation in a canine model. Methods and Results—We used a total of 8 canines and computed tomography was performed before the procedures. After a double percutaneous pericardiocentesis, a transurethral rigid endoscope was inserted into the pericardial space. The ENDOLOOP ligature was advanced to the ostium of the LAA by counter pulling the tip of the LAA with forceps. After confirming the positioning guided by transesophageal echocardiography, the ligature was securely tightened. Acute success was evaluated by transesophageal echocardiography and chronic success was evaluated by blood testing, computed tomography, and transesophageal echocardiography. The LAA ligation was safely achieved in all canines without major complications. One month after the ligation, the ligated LAA was replaced by fibrotic tissue, and both the transesophageal echocardiography and computed tomographic images revealed no residual shunt. There was only a localized adhesion of the pericardium, where the original LAA was located, without the need for antibiotic or steroid administration. The postprocedural internal surface of the ligated LAA was smooth by virtue of intimal growth. Blood tests showed a slight elevation of the inflammatory markers, but this normalized spontaneously. Conclusions—Pericardial endoscopy-guided LAA ligation could provide an alternative, minimally invasive, and feasible solution for LAA closure that does not require vascular access or a transseptal puncture.

Thrombus formation in the left atrial appendage during catheter ablation for atrial fibrillation under sufficient heparinization.

A 76-year-old man with hypertension and congestive heart failure (CHADS2 [Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack] 1⁄4 3; CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age [ 75 y], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 y], Sex [Female] 1⁄4 4) underwent catheter ablation for 7-month persistent atrial fibrillation (AF). Intracardiac echocardiography (ICE) (Soundstar Biosense Webster, Diamond Bar, CA) advanced in the pulmonary artery (PA) through the right atrium (RA) and the right ventricle showed no thrombi in the left atrial appendage (LAA) with a flow velocity of 7-18 cm/s during AF. Both pulmonary veins were isolated circumferentially 12 hours after the last intake of dabigatran. AF was terminated by intracardiac cardioversion, followed by linear ablation at the lateral mitral isthmus to treat the induced atrial tachycardia. At the end of the session, ICE imaging revealed a solid 3 4 mm mobile mass in the tip of the LAA (Fig. 1A-C; Video 1 view video online) observed from the PA (Fig. 1D). The activated clotting time was maintained over 300 seconds throughout the procedure by intravenous administration of heparin. Before ablation, examination by cardiac computed tomography detected a remarkable incomplete enhancement in the LAA without thrombi (Fig. 1E). The left atrial size on transthoracic echocardiography was 4.6 cm, and the ostial flow velocity of the LAA measured using transesophageal echocardiography was 30-36 cm/s during AF with evidence of