Publications by authors named "Kanae Hasegawa"

90 Publications

Association between Changes in the Systolic Blood Pressure from Evening to the Next Morning and Night Glucose Variability in Heart Disease Patients.

Intern Med 2021 Jun 5. Epub 2021 Jun 5.

Department of cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Japan.

Aims To assess the impact of glycemic variability on blood pressure in hospitalized patients with cardiac disease. Methods In 40 patients with cardiovascular disease, the glucose levels were monitored by flash continuous glucose monitoring (FGM; Free-Style Libre™ or Free-Style Libre Pro; Abbott, Witney, Oxfordshire, UK) and self-monitoring blood glucose (SMBG) for 14 days. Blood pressure measurements were performed twice daily (morning and evening) at the same time as the glucose level measurement using SMBG. Results The detection rate of hypoglycemia using the FGM method was significantly higher than that with the 5-point SMBG method (77.5% vs. 5.0%, P<0.001). Changes in the systolic blood pressure from evening to the next morning (morning - evening [ME] difference) were significantly correlated with night glucose variability (r=0.63, P<0.001). A multiple regression analysis showed that night glucose variability using FGM was more closely correlated with the ME difference (r=0.62 [95% confidence interval, 0.019-0.051]; P<0.001) than with the age, body mass index, or smoking history. Night glucose variability was also more closely associated with the ME difference in patients with unstable angina pectoris (UAP) than in those with acute myocardial infarction (AMI) or heart failure (HF) (r=0.83, P=0.058). Conclusion Night glucose variability is associated with the ME blood pressure difference, and FGM is more accurate than the 5-point SMBG approach for detecting such variability.
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http://dx.doi.org/10.2169/internalmedicine.6784-20DOI Listing
June 2021

Ultra-high resolution mapping of reverse typical atrial flutter: electrophysiological properties of a right atrial posterior wall and interatrial septum activation pattern.

J Interv Card Electrophysiol 2021 May 8. Epub 2021 May 8.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.

Purpose: We aimed to elucidate the right atrial posterior wall (RAPW) and interatrial septum (IAS) conduction pattern during reverse typical atrial flutter (clockwise AFL: CW-AFL).

Methods: This study included 30 patients who underwent catheter ablation of CW-AFL (n = 11) and counter-clockwise AFL (CCW-AFL; n = 19) using an ultra-high resolution mapping system. RAPW transverse conduction block was evaluated by the conduction pattern on propagation maps and double potentials separated by an isoelectric line. The degree of blockade was evaluated by the %blockade, which was calculated by the length of the blocked area divided by the RAPW length. IAS activation patterns were also investigated dependent on the propagation map.

Results: The average %blockade of the RAPW was significantly smaller in patients with CW-AFL than those with CCW-AFL (25 [3-74]% vs. 67 [57-75]%, p < 0.05). CW-AFL patients exhibited 3 different RAPW conduction patterns: (1) a complete blockade pattern (3 patients), (2) moderate (> 25% blockade) blockade pattern (2 patients), and (3) little (< 25% blockade) blockade pattern (6 patients). In contrast, the little blockade pattern was not observed in CCW-AFL patients. Of 11 CW-AFL patients, 4, including all patients with an RAPW complete blockade pattern, had an IAS activation from the wavefront from the anterior tricuspid annulus (TA), and 6 had an IAS activation from the wavefronts from both the anterior TA and RAPW. One patient had IAS activation dominantly from the wavefront from the RAPW.

Conclusions: RAPW transverse conduction blockade during CW-AFL was less frequent than during CCW-AFL, which possibly caused various IAS activation patterns.
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http://dx.doi.org/10.1007/s10840-021-01003-0DOI Listing
May 2021

DDD mode-switching and loss of atrioventricular synchrony evokes heart failure: A rare but possible trigger of pacing-induced cardiomyopathy.

J Cardiol Cases 2021 Apr 21;23(4):158-162. Epub 2020 Nov 21.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Japan.

Pacing-induced cardiomyopathy (PICM), defined as left ventricular dysfunction, occurs in the setting of chronic, high burden right ventricular pacing. We describe an unusual case of PICM. A 64-year-old man underwent a medical check-up and was diagnosed with complete atrioventricular block (AVB) with regular and slow ventricular contractions at 38 beats/min (bpm). The patient underwent a pacemaker implantation with a dual-chamber pacing (DDD) pacemaker. This patient had no symptoms or signs of PICM during complete AVB or the period after undergoing dual-chamber pacing. However, PICM developed within a short time after the onset of atrial flutter (AFL). During AFL, the automatic mode switch of the DDD pacemaker to the DDIR mode worked normally, and the ventricles were paced with a stable and regular rate (60 bpm). Despite the administration of ß-blockers and diuretics, his symptoms and status did not improve. After the elimination of the AFL and restoration of AV synchrony with a DDD mode by catheter ablation, the deteriorated condition rapidly improved. In this patient, the coexistence of the loss of AV synchrony and high burden RV pacing during AFL might have caused this unusual PICM. Learning objective: Even when patients have no symptoms or signs of pacing-induced cardiomyopathy (PICM) during complete atrioventricular block or the period after undergoing dual-chamber pacing, automatic mode-switching to the DDI mode during atrial tachyarrhythmias could rapidly cause PICM. PICM could occur with a much more rapid time course than the historical model of PICM where cardiomyopathy may take several years to develop. Much attention should be paid during the follow-up to patients receiving DDD pacemakers to avoid any unusual PICM as in this case.
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http://dx.doi.org/10.1016/j.jccase.2020.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020067PMC
April 2021

Cardiac rehabilitation after catheter ablation of atrial fibrillation in patients with left ventricular dysfunction.

Heart Vessels 2021 Apr 3. Epub 2021 Apr 3.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.

Few studies have examined the efficacy and safety of cardiac rehabilitation in patients with atrial fibrillation (AF) who underwent AF ablation. We explored the feasibility of additional cardiac rehabilitation after AF ablation in patients with a reduced left ventricular ejection fraction (LVEF). Fifty-four patients with heart failure (HF) and a reduced LVEF (HFrEF) (LVEF < 50%; 67.1 ± 11.6 years; 43 men) who underwent initial AF ablation procedures were included. Fourteen (25.9%) patients underwent cardiac rehabilitation (rehabilitation-group) and the remaining 40 (74.1%) did not (non-rehabilitation-group) after the procedure. The rehabilitation-group patients were relatively older, more likely female (p = 0.024), and had more likely a history of an HF hospitalization (p < 0.01) and cardiac device implantation (p = 0.041). The baseline LVEF was significantly lower (p = 0.043) and brain natriuretic peptide (BNP) (p < 0.01) and C-reactive protein (CRP) (p < 0.01) values were significantly higher in the rehabilitation-group. The 6-min walk distance significantly improved after 21.4 ± 11.5 days of cardiac rehabilitation during hospitalization (226.1 ± 155.9 vs. 398.1 ± 77.5 m, p = 0.016) without any adverse events. During an 18.9 ± 6.3 month follow-up period, the freedom from AF recurrence (p = 0.52) and re-hospitalizations due to HF (p = 0.63) were similar between the 2 groups. No death or strokes were observed. During the follow-up period, the LVEF significantly improved similarly in both groups, and the change in the BNP and CRP values significantly decreased in the rehabilitation-group. Despite the rehabilitation-group patients having a more severe HF status, the clinical outcomes and AF freedom were similar between the 2 groups, suggesting the favorable impact of cardiac rehabilitation after AF ablation in HFrEF patients.
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http://dx.doi.org/10.1007/s00380-021-01829-8DOI Listing
April 2021

Superior vena cava isolation using a novel ablation catheter incorporating local impedance monitoring.

J Interv Card Electrophysiol 2021 Mar 23. Epub 2021 Mar 23.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.

Background: A novel technology able to measure the local impedance (LI) during radiofrequency ablation has become available for clinical use. We investigated the change in the LI characteristics during superior vena cava isolations (SVCIs) using a novel catheter equipped with mini-electrodes.

Methods: Twenty paroxysmal atrial fibrillation patients (68 ± 9 years; 14 males) underwent an SVCI by targeting breakthroughs. Subsequently, dormant conduction provoked by adenosine triphosphate (ATP) was evaluated.

Results: Electrical SVCIs were successfully achieved in all with 7.2 ± 3.0 radiofrequency applications (RFA) without any complications. The procedure and fluoroscopic times were 13.1 ± 8.1 and 2.8 ± 2.3 min. No ablation was required at the anteroseptal SVC in 19 (95.0%) patients. The baseline LI and generator impedance (GI) were 125 ± 23 and 105 ± 14Ω. LI drops during RFA were significantly greater than GI drops (17 ± 12 vs. 4 ± 4Ω, p < 0.001). The correlation between the LI drops and GI drops was relatively high (R = 0.69, p < 0.001). LI drops were highest at the septal SVC and lowest at the lateral followed by antero-lateral SVC. The baseline electrogram amplitude between the mini-electrodes and tip-ring electrodes was 1.2 ± 1.4 and 0.8 ± 0.6 mV. The mini-electrode amplitude is more sharply attenuated with a greater magnitude than the tip-ring amplitude (p < 0.001). ATP-provoked dormant conduction was exposed in 10/17 (58.8%) patients and antero-lateral SVC gap locations in 7. Antero-lateral SVC LI drops were similar between patients with and without dormancy.

Conclusions: The LI drop magnitude during RFA significantly differed among the SVC segments. Antero-lateral SVC ATP-provoked dormant conduction was often exposed, and additional applications are recommended following the isolation for a robust SVCI.
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http://dx.doi.org/10.1007/s10840-021-00980-6DOI Listing
March 2021

The mechanisms of left septal and anterior wall reentrant atrial tachycardias analyzed with ultrahigh resolution mapping: The role of functional block in the circuit.

J Cardiovasc Electrophysiol 2021 May 17;32(5):1305-1319. Epub 2021 Mar 17.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Background: Low voltage areas (LVAs) are most commonly observed on the left atrial (LA) septal/anterior wall.

Objective: We explored the mechanisms of LA septal/anterior wall reentrant tachycardias (LASARTs) using ultrahigh resolution mapping.

Methods: This study included seven consecutive LASARTs in six patients (75 [62.2-82.8] years, 4 women) who underwent atrial tachycardia (AT) mapping and ablation using Rhythmia systems.

Results: The AT cycle length was 266 (239-321) ms. During ATs, 11.0 (9.0-12.9) cm of LVAs were identified in all, and 0.8 (0.7-1.7) cm of dense scar was identified in four patients. Five ATs rotated around dense scar, while two rotated around functional linear block, which was confirmed during atrial pacing after AT termination. The AT circuit length was 8.7 ± 2.1 cm with a conduction velocity of 30.4 ± 3.7 cm/s. A median of 3.0 (2.0-4.0) slow conduction areas per circuit were identified, and 17/23 (73.9%) areas were present in LVAs, while they were at the border of the LVA and normal voltage areas in the remaining 6/23 (26.1%). Global activation histograms facilitated the identification of the critical isthmus in all. Tailor-made ablation at critical isthmuses successfully eliminated all ATs. However, one patient with AT related to functional linear block experienced recurrent AT related to dense scar, which progressed after the procedure. During a mean 14 ± 13 month follow-up after the last procedure, no patients experienced recurrent ATs without any complications.

Conclusion: LASARTs consist of not only fixed conduction blocks but also functional conduction blocks. Ultrahigh resolution mapping is highly useful to decide the optimal tailor-made ablation strategy based on the mechanisms.
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http://dx.doi.org/10.1111/jce.14983DOI Listing
May 2021

Impact of Medical Castration on Malignant Arrhythmias in Patients With Prostate Cancer.

J Am Heart Assoc 2021 Feb 18;10(5):e017267. Epub 2021 Feb 18.

Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan.

Background Medical castration, gonadotropin-releasing hormone agonists, and antiandrogens have been widely applied as a treatment for prostate cancer. Sex steroid hormones influence cardiac ion channels. However, few studies have examined the proarrhythmic properties of medical castration. Methods and Results This study included 149 patients who underwent medical castration using gonadotropin-releasing hormones with/without antiandrogen for prostate cancer. The changes in the ECG findings during the therapy and associations of the electrocardiographic findings with malignant arrhythmias were studied. The QT and corrected QT (QTc) intervals prolonged during the therapy compared with baseline (QT, 394±32 to 406±39 ms [<0.001]; QTc, 416±27 to 439±31 ms [<0.001]). The QTc interval was prolonged in 119 (79.9%) patients during the therapy compared with baseline. In 2 (1.3%) patients who had no structural heart disease, torsade de pointes (TdP) and ventricular fibrillation (VF) occurred ≥6 months after starting the therapy. In patients with TdP/VF, the increase in the QTc interval from the pretreatment value was >80 ms. However, in patients without TdP/VF, the prevalence of an increase in the QTc interval from the pretreatment value of >50 ms was 11%, and an increase in the QTc interval from the pretreatment value >80 ms was found in only 4 (3%) patients. Conclusions Medical castration prolongs the QT/QTc intervals in most patients with prostate cancer, and it could cause TdP/VFs even in patients with no risk of QT prolongation before the therapy. An increase in the QTc interval from the pretreatment value >50 ms might become a predictor of TdP/VF. Much attention should be paid to the QTc interval throughout all periods of medical castration to prevent malignant arrhythmias.
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http://dx.doi.org/10.1161/JAHA.120.017267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174268PMC
February 2021

The advantages and disadvantages of the novel fourth-generation cryoballoon as compared to the second-generation cryoballoon in the current short freeze strategy.

J Interv Card Electrophysiol 2021 Feb 11. Epub 2021 Feb 11.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.

Background: The novel fourth-generation cryoballoon (4-CB) is characterized by a shorter-tip that potentially facilitates better time-to-isolation (TTI) monitoring. We sought to clarify the advantages and disadvantages of the 4-CB compared to the second-generation cryoballoon (2-CB) in pulmonary vein isolation (PVI).

Methods: Forty-one and 49 consecutive atrial fibrillation patients underwent 2-CB and 4th-CB PVIs using 28-mm balloons and short freeze strategies. When effective freezing was not obtained, the CB was switched to the other CB.

Results: The rate of successful PVIs was significantly higher for 2-CBs than 4-CBs (162/162[100%] vs. 178/193[92.2%] PVs, p < 0.0001). The difference was significant for lower PVs, especially right inferior PVs (RIPVs)(p = 0.005). In a total of 15 PVs in 11 patients, 4-CBs were switched to 2-CBs, and 14/15(93.3%) PVs were successfully isolated. The balloon temperature tended to reach -55℃ more frequently with 2-CBs than 4-CBs during RIPV ablations (15/41[36.6%] vs. 12/49[24.5%], p = 0.21). The TTI monitoring capability was significantly higher with 4-CBs than 2-CBs (131/188[69.7%] vs. 83/160[51.9%] PVs, p = 0.0007). The difference was significant for right superior and left inferior PVs, but not for left superior PVs. Even if PVs requiring crossover were excluded, the total freeze duration (715±152 vs. 755±215 seconds, p = 0.31) tended to be shorter for 2-CBs than 4-CBs. The incidence of phrenic nerve injury was similar for 2-CB and 4th-CB ablation (0/41 vs. 2/49, p = 0.12) CONCLUSIONS: The 4-CB's shorter balloon tip enabled a significantly higher capability of TTI monitoring; however, it resulted in significantly lower rates of successful PVIs than the 2-CB, especially for the RIPVs.
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http://dx.doi.org/10.1007/s10840-021-00957-5DOI Listing
February 2021

Discrepancy between CARTO and Rhythmia maps for defining the left atrial low-voltage areas in atrial fibrillation ablation.

Heart Vessels 2021 Jul 28;36(7):1027-1034. Epub 2021 Jan 28.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki, Eiheiji-cho, yoshida-gun, Fukui, 910-1193, Japan.

Reported mapping procedures of left atrial (LA) low-voltage areas (LVAs) vary widely. This study aimed to compare the PentaRay/CARTO3 (PentaRay map) and Orion™/Rhythmia™ (Orion map) systems for LA voltage mapping. This study included 15 patients who underwent successful pulmonary vein isolation (PVI) for atrial fibrillation. After PVI, PentaRay and Orion maps created for all patients were compared. LVAs were defined as sites with ≥ 3 adjacent low-voltage points < 0.5 mV. LVAs were indicated in 8 (53%) among 15 patients, and the average values of the measured LVAs was comparable between the systems (PentaRay map = 5.4 ± 8.7 cm; Orion map = 4.3 ± 6.4 cm, p = 0.69). However, in 2 of 8 patients with LVAs, the Orion map indicated LVAs at the septum and posterolateral sites of the LA, respectively, whereas the PentaRay map indicated no LVAs. In those patients, sharp electrograms of > 0.5 mV were properly recorded at the septum and posterolateral sites during appropriate beats in the PentaRay map. The PentaRay map had a shorter procedure time than the Orion map (12 ± 3 min vs. 23 ± 8 min, respectively; p < 0.01). Our study results showed a discrepancy in the LVA evaluation between the PentaRay and Orion maps. In 2 of 15 patients, the Orion map indicated LVAs at the sites where > 0.5-mV electrograms were properly recorded in the PentaRay map.
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http://dx.doi.org/10.1007/s00380-021-01773-7DOI Listing
July 2021

Ultrahigh resolution electroanatomical mapping of the transverse conduction of the right atrial posterior wall in cases with and without typical atrial flutter.

J Cardiovasc Electrophysiol 2021 Feb 29;32(2):297-304. Epub 2020 Dec 29.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Introduction: The right atrial posterior wall (RAPW) is known to form a conduction barrier during typical atrial flutter (AFL). We evaluated the transverse conduction properties of RAPW in patients with and without typical AFL using an ultrahigh resolution electroanatomical mapping system.

Methods And Results: This study included 41 patients who underwent catheter ablation of AF, typical or atypical AFL, in whom we performed RAPW mapping with an ultrahigh resolution mapping system during typical AFL and coronary sinus ostial pacing with three different pacing cycle lengths (PCLs) (1) PCL1: PCL within 40 ms of the AFL cycle length in patients with typical AFL or 250-300 ms for those without, (2) PCL2: 400 ms, (3) PCL3: PCL just faster than the sinus rate. Local RAPW conduction block was evaluated by propagation mapping and local double potentials separated by an isoelectric line. The functional block was defined as areas blocked during shorter PCLs but conductive during longer PCLs. The degree of blockade was calculated by dividing the blocked length by RAPW length (%blockade). Only two patients demonstrated a fixed complete RAPW block (100%, %blockade). Thirty-one patients demonstrated a partial block of RAPW, and the %blockade during PCL1-3 was 49.4 ± 19.8%, 39.5 ± 19.2%, and 35.0 ± 22.9% in this group, respectively. Functional block areas were frequently observed above the fixed block area adjacent to the RA-inferior vena cava junction. Transverse conduction block was more frequently observed in patients with typical AFL at any longitudinal level of RAPW.

Conclusion: RAPW transverse conduction block is lower-side dominant and greater in patients with typical AFL than those without.
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http://dx.doi.org/10.1111/jce.14850DOI Listing
February 2021

Early repolarization in the inferolateral leads predicts the presence of vasospastic angina: a novel predictor in patients with resting angina.

Coron Artery Dis 2021 Jun;32(4):309-316

Department of Cardiovascular Medicine, University of Fukui, Shimoaizuki, Matsuoka, Eiheiji-cho, Fukui, Japan.

Background: An association between early repolarization and ventricular fibrillation has recently been reported in patients with vasospastic angina (VSA). However, no studies have clarified whether the presence of early repolarization can predict VSA.

Methods: Participants comprised 286 patients (136 males) with clinically suspected VSA who underwent intracoronary provocation tests using acetylcholine or ergonovine. Patients were divided into a VSA group [n = 94, positive provocation test as induction of coronary arterial spasm (>90% stenosis)] and a non-VSA group (n = 192). Detailed early repolarization data were compared between groups.

Results: The VSA group showed a higher frequency of smokers (28.7%) than the non-VSA group (17.2%; P = 0.02). On baseline 12-lead ECG, early repolarization (defined as a J-point elevation ≥0.1 mV from baseline in both or either of inferolateral leads) was found in 39 patients (inferior leads, n = 27; inferolateral leads, n = 12). Early repolarization was found more frequently in the VSA group (28.7%) than in the non-VSA group (6.2%, P < 0.01). Multivariate analysis revealed early repolarization as an independent predictor of VSA (odds ratio, 5.22; 95% confidence interval, 2.41-11.2; P < 0.01). Early repolarization pattern features including inferior lead, higher amplitude, notched type and horizontal/descending ST segments were associated with increased risk of VSA.

Conclusion: In patients with resting chest pain, early repolarization was a predictor of VSA that could be particularly related to the inferior lead, higher amplitude, notched type and horizontal/descending ST segment.
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http://dx.doi.org/10.1097/MCA.0000000000000983DOI Listing
June 2021

Ultra-high resolution mapping and ablation of accessory pathway conduction.

J Interv Card Electrophysiol 2020 Oct 24. Epub 2020 Oct 24.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.

Background: Detailed mapping studies of accessory pathway (AP) conduction have not been previously performed using ultra-high resolution mapping systems. We sought to evaluate the clinical utility of ultra-high resolution mapping systems and the novel "Lumipoint" algorithm in AP ablation.

Methods: This study included 17 patients who underwent AP mapping using minielectrode basket catheters and Rhythmia systems. Ablation was performed with 4-mm irrigated-tip catheters.

Results: Antegrade and retrograde AP conduction was observed in 6 and 16 patients. Atrial activation map was obtained during orthodromic tachycardia and ventricular pacing in 13 (76.5%) and 14 (82.3%) patients, and the earliest activation area was identical. Ventricular activation maps were created during atrial pacing in 3 patients. All maps showed focal activation patterns on global activation histograms, and the valley on the histogram highlighted the earliest activation area. "Complex activation" features further highlighted limited areas with continuous electrical activity during the time period in the majority. APs were located at the mitral and tricuspid annuli in 15 and 2 patients, and all were successfully eliminated with 3.4 ± 0.6 s applications. No patients had recurrences during a median follow-up of 15 [10.5-22.5] months. At successful ablation sites, the local atrial and ventricular electrogram amplitudes and ratio tended to be greater, and fusion or continuous electrical activity between the atrial and ventricular components was more frequently observed on the minielectrode than ablation catheter (17/17 vs. 12/17, p = 0.005).

Conclusions: Ultra-high resolution activation mapping and a novel algorithm facilitated the AP localization. The local electrogram characteristics differed between the minielectrode and ablation catheters.
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http://dx.doi.org/10.1007/s10840-020-00900-0DOI Listing
October 2020

A case of outflow tract premature ventricular contractions with very distant exit sites suspected to have a single origin.

J Electrocardiol 2020 Nov - Dec;63:41-45. Epub 2020 Oct 8.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Outflow tract premature ventricular contractions sometimes demonstrate multiple exit sites in the right and left outflow tracts with preferential pathways. Here we present a case of outflow tract premature ventricular contractions, which were eliminated by ablation from the right ventricular outflow tract accompanied by additional ablation from the very distant endocardial left ventricular outflow tract. The findings during the ablation indicated there was a single origin with multiple exit sites rather than multiple origins for each QRS morphology. This case illustrates that the preferential pathways can demonstrate very distant multiple exit sites.
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http://dx.doi.org/10.1016/j.jelectrocard.2020.09.015DOI Listing
October 2020

Mapping and ablation of clinical spontaneous perimitral atrial tachycardias using an ultra-high-resolution mapping system.

Heart Rhythm 2021 Feb 30;18(2):189-198. Epub 2020 Sep 30.

Department of Cardiovascular Medicine, University of Fukui, Fukui, Japan.

Background: Perimitral atrial tachycardias (PMATs) are common atrial tachycardias (ATs), yet their mechanisms vary.

Objective: The purpose of this study was to characterize clinical spontaneous PMATs using an ultra-high-resolution (UHR) mapping system.

Methods: The study included 32 consecutive PMATs in 31 patients who had undergone AT mapping/ablation using a UHR mapping system.

Results: Six, 10, 11, and 5 PMATs occurred in cardiac intervention-naïve (group A), post-lateral/posterior mitral isthmus linear ablation (group B), post-atrial fibrillation ablation without mitral isthmus linear ablation (group C), and post-cardiac surgery (group D) patients, respectively. Group A patients tended to be older, more likely were female, and had sinus node or atrioventricular conduction disturbances more frequently. A 12-lead synchronous isoelectric interval was observed in 15 PMATs (46.9%). Coronary sinus activation was proximal to distal or distal to proximal except in 3 PMATs with straight patterns due to epicardial gaps. Left atrial anterior/septal wall (LAASW) low-voltage areas were smallest in group B. Slow conduction areas (SCAs) were identified in 26 PMATs (81.2%) and were located on the LAASW in all group A and group D patients. Conduction velocity in the SCAs was slowest in group B. In group B, all PMATs were terminated by single applications, and the gaps were located epicardially in 5 of 10 (50%). Anterior (n = 23) or lateral/posterior (n = 9) mitral isthmus linear block was successfully created without any complications in all. Twenty-five concomitant ATs among 18 patients (58.1%) also were eliminated. During a median of 20.0 (11.0-40.0) months of follow-up, 28 patients (90.3%) were free from any atrial tachyarrhythmias.

Conclusion: An UHR mapping-guided approach with identification of the individual tachycardia mechanism should be the preferred strategy given the distinct and complex arrhythmia mechanisms.
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http://dx.doi.org/10.1016/j.hrthm.2020.09.016DOI Listing
February 2021

Effects of PCSK9 Inhibitor on Favorable Limb Outcomes in Patients with Chronic Limb-Threatening Ischemia.

J Atheroscler Thromb 2020 Sep 25. Epub 2020 Sep 25.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui.

Aim: The aim of this study was to examine the effects of evolocumab on favorable limb events in patients with chronic limb-threatening ischemia (CLTI).

Methods: A single-center, prospective observational study was performed on 30 patients with CLTI. The subjects were divided into 2 groups based on evolocumab administration: evolocumab-treated (E) group (n=14) and evolocumab non-treated (non-E) group (n=16). The primary outcome was 12-month freedom from major amputation. The secondary outcomes were 12-month amputation-free survival (AFS), overall survival (OS), and wound-free limb salvage. The mean follow-up period was 18±11 months.

Results: No significant difference was detected between the two groups for the 12-month freedom from major amputation (log-rank p=0.15), while the 12-month AFS rate was significantly higher in the E group than that in the non-E group (log-rank p=0.02). The 12-month OS rate in the E group was shown a tendency for improvement, as compared with that in the non-E group (log-rank p=0.056). Evolocumab administration was not associated with a significant change in freedom from major amputation (HR, 0.23, 95% CI, 0.03-2.07, p=0.19). However, evolocumab administration was related to a tendency for improvement of AFS and OS (HR, 0.13, 95% CI, 0.02-1.06, p=0.056; HR, 0.16, 95% CI, 0.02-1.37, p=0.09, respectively). Moreover, The E group had a higher proportion of wound-free limb salvage at 12 months (92% vs. 42%, p=0.03).

Conclusion: Evolocumab administration was associated with a better AFS outcome in patients with CLTI. Long-term administration of evolocumab over 12 months contributed to improving proportion of wound-free limb salvage.
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http://dx.doi.org/10.5551/jat.57653DOI Listing
September 2020

Clinically Manifesting Air Embolisms in Cryoballoon Ablation: Can Novel Water Buckets Reduce the Risk?

JACC Clin Electrophysiol 2020 09;6(9):1067-1072

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Air embolisms can lead to lethal results; however, few reports have systemically investigated this issue. Of 348 consecutive patients with atrial fibrillation who underwent cryoballoon ablation, procedures were performed conventionally in 251 patients. In the remaining 97 patients, a water bucket was used while inserting the cryoballoon into the sheath. A total of 10 coronary air embolisms with ST-segment elevation in the inferior leads were observed among 9 (2.6%) patients. Multiple air bubbles were identified in 2 patients on emergent coronary angiography. All recovered under conservative treatment without any sequela. The incidence decreased when using the water bucket (1 of 97 [1.03%] vs. 8 of 251 [3.2%], p = 0.454).
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http://dx.doi.org/10.1016/j.jacep.2020.07.012DOI Listing
September 2020

Phrenic nerve stimulation during right ventricular outflow tract pacing: A rare but possible complication.

J Cardiovasc Electrophysiol 2020 12 29;31(12):3330-3333. Epub 2020 Sep 29.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Phrenic nerve stimulation (PNS) caused by a right ventricular (RV) lead is an uncommon complication of pacemaker implantations. We demonstrated a case of left PNS caused by an RV lead placed in the RV outflow tract (RVOT). The PNS was dependent on ventricular capture. This case highlighted a risk of PNS even during RVOT pacing.
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http://dx.doi.org/10.1111/jce.14760DOI Listing
December 2020

Idiopathic right ventricular arrhythmias requiring additional ablation from the left-sided outflow tract: ECG characteristics and efficacy of an anatomical approach.

J Cardiovasc Electrophysiol 2020 10 16;31(10):2653-2664. Epub 2020 Jul 16.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Fukui, Japan.

Introduction: Despite the characteristic electrocardiogram (ECG) findings of early activation during ventricular tachyarrhythmias (VAs) and/or excellent pacemapping in the right ventricular outflow tract (RVOT), some VAs may require additional, left-sided ablation for a cure.

Methods And Results: This study included five patients with idiopathic VAs whose QRS morphologies were highly suggestive of an RVOT origin. The ECG characteristics and intracardiac electrocardiograms during catheter ablation were assessed. In all patients, the clinical VAs had an LBBB QRS morphology and inferior axis with a precordial R/S transition through leads V3-V5, and negative components in lead I. The earliest activation during the VAs (local electrogram-QRS interval = -34 ± 6.8 ms) and excellent pacemapping were obtained at the posterior portion of the RVOT just beneath the pulmonary valve. However, ablation at those sites failed, and the QRS morphology of the VAs changed. During left-sided OT mapping, the earliest activation was found at sites just contralateral to the initially ablated sites of the RVOT (junction of the left and right coronary cusps = 2, left coronary cusp = 3). In spite of the late activation time and poor pacemapping scores, catheter ablation at those sites cured the VAs. Those successful sites were also near the transitional zone from the great cardiac vein to the anterior interventricular vein (GCV-AIV).

Conclusions: Some VAs, highly suggestive of having RVOT origins, require catheter ablation in the left-sided OT near the initially ablated RVOT site. Those VAs have the same ECG characteristics and might have intramural origins in the superobasal LV surrounded by the RVOT, LVOT, and GCV-AIV.
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http://dx.doi.org/10.1111/jce.14658DOI Listing
October 2020

A multicenter study comparing the outcome of catheter ablation of atrial fibrillation between cryoballoon and radiofrequency ablation in patients with heart failure (CRABL-HF): Study design.

J Arrhythm 2020 Jun 15;36(3):449-455. Epub 2020 Mar 15.

Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.

Background: Catheter ablation of atrial fibrillation (AF) is increasingly performed worldwide in patients with heart failure (HF). However, it has been recently emphasized that AF ablation in patients with HF is associated with increased risks of procedure-related complications and mortality. There are little data about the differences in the efficacy and safety between cryoballoon (CB) and radiofrequency (RF) ablation of AF in patients with HF.

Methods: The CRABL-HF study is designed as a prospective, multicenter, open-label, controlled, and randomized clinical trial comparing the efficacy and safety of AF ablation between CB and RF ablation in patients with HF (LVEF ≤40%) (UMIN Clinical Trials Registry UMIN000032433). The CRABL-HF study will consist of 110 patients at multicenter in Japan. The patients will be registered and randomly assigned to either the CB ablation or RF ablation group with a 1:1 allocation. The primary endpoint of this study is the occurrence of atrial tachyarrhythmias (ATs) at 1 year with a blanking period of 90 days after ablation. Key secondary endpoints are the success rate of the pulmonary vein isolation, total procedural time, left atrial dwelling time, total fluoroscopy time, radiation exposure, complication rate, composite of all-cause mortality or HF hospitalizations, cardiovascular events, change in left ventricular ejection fraction, and change in quality of life.

Results: The results of this study are currently under investigation.

Conclusion: The CRABL-HF study is being conducted to compare the efficacy and safety of catheter ablation of AF between CB and RF ablation in patients with HF.
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http://dx.doi.org/10.1002/joa3.12322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279987PMC
June 2020

Transethnic Genome-Wide Association Study Provides Insights in the Genetic Architecture and Heritability of Long QT Syndrome.

Circulation 2020 Jul 20;142(4):324-338. Epub 2020 May 20.

Masonic Medical Research Institute, Utica, NY (R.P.).

Background: Long QT syndrome (LQTS) is a rare genetic disorder and a major preventable cause of sudden cardiac death in the young. A causal rare genetic variant with large effect size is identified in up to 80% of probands (genotype positive) and cascade family screening shows incomplete penetrance of genetic variants. Furthermore, a proportion of cases meeting diagnostic criteria for LQTS remain genetically elusive despite genetic testing of established genes (genotype negative). These observations raise the possibility that common genetic variants with small effect size contribute to the clinical picture of LQTS. This study aimed to characterize and quantify the contribution of common genetic variation to LQTS disease susceptibility.

Methods: We conducted genome-wide association studies followed by transethnic meta-analysis in 1656 unrelated patients with LQTS of European or Japanese ancestry and 9890 controls to identify susceptibility single nucleotide polymorphisms. We estimated the common variant heritability of LQTS and tested the genetic correlation between LQTS susceptibility and other cardiac traits. Furthermore, we tested the aggregate effect of the 68 single nucleotide polymorphisms previously associated with the QT-interval in the general population using a polygenic risk score.

Results: Genome-wide association analysis identified 3 loci associated with LQTS at genome-wide statistical significance (<5×10) near , , and , and 1 missense variant in (p.Asp85Asn) at the suggestive threshold (<10). Heritability analyses showed that ≈15% of variance in overall LQTS susceptibility was attributable to common genetic variation ( 0.148; standard error 0.019). LQTS susceptibility showed a strong genome-wide genetic correlation with the QT-interval in the general population (r=0.40; =3.2×10). The polygenic risk score comprising common variants previously associated with the QT-interval in the general population was greater in LQTS cases compared with controls (<10-13), and it is notable that, among patients with LQTS, this polygenic risk score was greater in patients who were genotype negative compared with those who were genotype positive (<0.005).

Conclusions: This work establishes an important role for common genetic variation in susceptibility to LQTS. We demonstrate overlap between genetic control of the QT-interval in the general population and genetic factors contributing to LQTS susceptibility. Using polygenic risk score analyses aggregating common genetic variants that modulate the QT-interval in the general population, we provide evidence for a polygenic architecture in genotype negative LQTS.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.045956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382531PMC
July 2020

Author's reply: Spontaneous narrow QRS complex tachycardia with ventriculoatrial dissociation.

J Cardiovasc Electrophysiol 2020 06 15;31(6):1565. Epub 2020 Apr 15.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

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http://dx.doi.org/10.1111/jce.14466DOI Listing
June 2020

Narrow QRS complex tachycardia with fluctuation in the morphology.

J Cardiovasc Electrophysiol 2020 Jun 17;31(6):1547-1549. Epub 2020 Apr 17.

Department of Cardiovascular Medicine, Faculty of Medical Science, University of Fukui, Fukui, Japan.

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http://dx.doi.org/10.1111/jce.14472DOI Listing
June 2020

Femoral vascular complications after catheter ablation in the current era: The utility of computed tomography imaging.

J Cardiovasc Electrophysiol 2020 06 13;31(6):1385-1393. Epub 2020 Apr 13.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Background: Few studies have examined the characteristics of catheter ablation vascular complications, and recently physicians increasingly use computed tomography angiography (CTA) for diagnosing.

Objective: We sought to investigate the incidence of femoral vascular complications in catheter ablation and factors associated with complications in the current era.

Methods: This single-center observational study consisted of 311 consecutive (atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia, and ventricular arrhythmias in 222 [71.4%], 7 [2.3%], 43 [13.8%], and 39 [12.5%]) patients who underwent catheter ablation. The detailed patient data and clinical outcomes were obtained from the medical records.

Results: Emergent CTA was performed in a total of 8 (2.6%) patients at a median of 4.5 (2.0-12.5) days postprocedure, and the precise diagnosis was obtained in all. Among them, pseudoaneurysms, arteriovenous fistulae (AVF), and actively bleeding hematomas were identified in two, one, and one patient, respectively, and all required readmissions after discharge. AVF was diagnosed by a Doppler ultrasound examination in another patient. In total, 5 (1.6%) patients exhibited major femoral vascular complications including two pseudoaneurysms, two AVFs, and one active bleeding hematoma. The pseudoaneurysms and AVFs were successfully eliminated by direct compression, and extravasation from the femoral circumflex artery required coil embolization. Antiplatelet therapy and the use of larger arterial sheaths (≥7-Fr) increased the major femoral arterial complications, but atrial fibrillation ablation under uninterrupted anticoagulation therapy or the use of larger venous sheaths did not.

Conclusion: Vascular complications are still not negligible procedure-related complications during catheter ablation in the current era. CTA provides a rapid and precise diagnosis for optimal treatment strategies.
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http://dx.doi.org/10.1111/jce.14468DOI Listing
June 2020

Preprocedural Troponin T Levels Predict the Improvement in the Left Ventricular Ejection Fraction After Catheter Ablation of Atrial Fibrillation/Flutter.

J Am Heart Assoc 2020 04 23;9(7):e015126. Epub 2020 Mar 23.

Department of Cardiovascular Medicine Faculty of Medical Sciences University of Fukui Japan.

Background Left ventricular (LV) systolic dysfunction is reversible in some patients once the arrhythmia is controlled. However, identifying this arrhythmia-induced cardiomyopathy among patients with LV systolic dysfunction is challenging. We explored the factors predicting the reversibility of the LV ejection fraction (LVEF) after catheter ablation of atrial fibrillation and/or atrial flutter in patients with LV systolic dysfunction. Methods and Results Forty patients with a reduced LVEF (LVEF <50%; 66.2±10.7 years; 32 men) who underwent atrial fibrillation/atrial flutter ablation were included. Transthoracic echocardiography was performed before and during the early (<4 days) and late phases (>3 months) after the ablation. Responders were defined as having a normalized LVEF (≥50%) during the late phase after the ablation. The LVEF improved from 39.8±8.8 to 50.9±10.9% at 1.2±0.6 days after the procedure, and to 56.2±12.2% at 9.6±8.0 months after the procedure (both for <0.001). Thirty (75.0%) patients were responders. The preprocedural echocardiographic parameters were comparable between the responders and nonresponders. In the multivariate analysis, the preprocedural high-sensitivity troponin T was the only independent predictor of the recovery of the LV dysfunction during the late phase after ablation (odds ratio, 1.17; 95% CI, 1.06-1.33; =0.001), and a level of ≤12 pg/mL predicted recovery of the LV dysfunction with a high accuracy (sensitivity, 90.0%; specificity, 76.7%; positive predictive value, 56.3%; and negative predictive value, 95.8%). Conclusions Preprocedural high-sensitivity troponin T levels might be a simple and useful parameter for predicting the reversibility of the LV systolic dysfunction after atrial fibrillation/atrial flutter ablation in patients with a reduced LVEF.
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http://dx.doi.org/10.1161/JAHA.119.015126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428643PMC
April 2020

Spontaneous narrow QRS complex tachycardia with ventriculoatrial dissociation.

J Cardiovasc Electrophysiol 2020 04 17;31(4):988-990. Epub 2020 Mar 17.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

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http://dx.doi.org/10.1111/jce.14442DOI Listing
April 2020

Long time-to-isolation during fourth-generation cryoballoon ablation of the right superior pulmonary vein. What should we do next?

Pacing Clin Electrophysiol 2020 04 3;43(4):423-426. Epub 2020 Apr 3.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

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http://dx.doi.org/10.1111/pace.13897DOI Listing
April 2020

Cryothermal atrial linear ablation in patients with atrial fibrillation: An insight from the comparison with radiofrequency atrial linear ablation.

J Cardiovasc Electrophysiol 2020 05 9;31(5):1075-1082. Epub 2020 Mar 9.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Background: Atrial linear lesions are generally created with radiofrequency energy. We sought to evaluate the feasibility of cryothermal atrial linear ablation.

Methods And Results: Twenty-one atrial fibrillation (AF) patients underwent linear ablation on the left atrial (LA) roof, mitral isthmus (MI), and cavotricuspid isthmus (CTI) with 8-mm-tip cryocatheters following pulmonary vein isolation. The data were compared with those of 31 patients undergoing linear ablation with irrigated-tip radiofrequency catheters. Conduction block was successfully created in 18 of 20 (90%), 9 of 21 (43%), and 20 of 20 (100%) on the LA roof, MI, and CTI by endocardial cryoablation alone with 19.0 (12.0-24.0), 30.0 (23.0-34.0), and 14.0 (14.0-16.0) minute cryo applications, respectively. The presence of either an interposed circumflex artery or pouch at the MI was significantly associated with failed MI block (P = .04). Conduction block was created in 25 of 31 (83.9%), 27 of 31 (87.1%), and 30 of 31 (96.8%) on the roof, MI, and CTI, respectively, by radiofrequency ablation. During the 17.5 (13.0-31.7) months of follow-up, freedom from AF/atrial tachycardia (AT) was significantly higher in the cryo group (P = .05); especially, recurrent AT was more frequent in the RF group (8/31 vs 1/21; P = .03). Conduction block across the roof, MI, and CTI was durable in 6 of 12 (50.0%), 4 of 12 (33.3%), and 9 of 12 (75.0%) patients during second procedures. All nine patients (except one) with recurrent ATs had at least one roof or MI conduction resumption.

Conclusions: Cryoablation is effective for creating a roof and CTI linear block, however, creating MI block by endocardial ablation alone was often challenging. Conduction resumption of LA linear block is common and recurrent arrhythmias, especially iatrogenic ATs, are more frequently observed after radiofrequency linear ablation.
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http://dx.doi.org/10.1111/jce.14420DOI Listing
May 2020

Sequential organ failure assessment score on admission predicts long-term mortality in acute heart failure patients.

ESC Heart Fail 2020 02 6;7(1):244-252. Epub 2020 Jan 6.

Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.

Aims: The sequential organ failure assessment (SOFA) score has been a widely used predictor of outcomes in the intensive care unit, whereas short-term and long-term survivals of heart failure (HF) patients are predicted by the American Heart Association Get With the Guidelines-Heart Failure (GWTG-HF) risk score. The purpose of present study was to examine whether the SOFA score on admission is more useful for predicting long-term mortality in acute HF patients than the GWTG-HF risk score.

Methods And Results: A total of 269 patients (mean age, 78.5 ± 10.9 years; all-cause mortality, 53.9%) seen in a single facility from January 2007 to December 2016 were enrolled retrospectively. They were followed up for a mean of 32.1 ± 22.3 months. All-cause death was associated with higher SOFA and GWTG-HF risk scores. However, no significant difference was observed in the area under the curve value between the scores. Kaplan-Meier survival analysis indicated that higher SOFA scores (P < 0.001) and GWTG-HF risk scores (P < 0.001) were related to increased probabilities of all-cause death. On multivariate Cox proportional hazard model analysis, the SOFA score (P < 0.001) and GWTG-HF (P < 0.001) score were independent predictors of all-cause death. Incorporating the SOFA score into the GWTG-HF risk score yielded a significant net reclassification improvement and integrated discrimination improvement. On decision curve analysis, the net benefit of the SOFA score model when compared with the reference model was greater across the range of threshold probabilities.

Conclusions: In acute HF patients, long-term all-cause mortality can be predicted by the SOFA score. Discriminative performance metrics, such as net reclassification improvement, integrated discrimination improvement, and decision curve analysis, for predicting mortality were improved when the SOFA score was incorporated.
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http://dx.doi.org/10.1002/ehf2.12563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083430PMC
February 2020