Publications by authors named "Kenichiro Yamagata"

48 Publications

Complications Associated With Catheter Ablation in Patients With Atrial Fibrillation: A Report From the JROAD-DPC Study.

J Am Heart Assoc 2021 Jun 27;10(11):e019701. Epub 2021 May 27.

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

Background Aging is one of the major concerns and determinants of the indications for catheter ablation (CA) for atrial fibrillation. This study aimed to assess the safety of CA in older patients with atrial fibrillation undergoing CA. Methods and Results The JROAD-DPC (Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination) is a nationwide claims database using data from the Japanese Diagnosis Procedure Combination/Per Diem Payment System. Among 6 632 484 records found between April 2012 and March 2018 from 1058 hospitals, 135 299 patients with atrial fibrillation (aged 65±10 years, 38 952 women) who underwent CA in 456 hospitals were studied and divided into the following age groups: <60, 60 to 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, and ≥85 years. The overall in-hospital complication rate was 3.4% (cardiac tamponade 1.2%), and in-hospital mortality was 0.04%. Older patients had a higher prevalence of women, lower body mass index, and a higher burden of comorbidities such as hypertension, and all of those characteristics were predictors for complications in multivariate analysis. A multivariate adjusted odds ratio revealed that increased age was independently and significantly associated with overall complications (60-64 years, 1.19; 65-69 years, 1.29; 70-74 years, 1.57; 75-79 years, 1.63; 80-84 years, 1.90; and ≥85 years, 2.86; the reference was <60 years). Conclusions The nationwide JROAD-DPC database demonstrated that the frequency of complications following CA in patients with atrial fibrillation increased according to age.
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http://dx.doi.org/10.1161/JAHA.120.019701DOI Listing
June 2021

Zero-fluoro atrial flutter ablation in a pregnant woman with a pacemaker.

BMJ Case Rep 2021 Mar 17;14(3). Epub 2021 Mar 17.

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

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http://dx.doi.org/10.1136/bcr-2020-240671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978093PMC
March 2021

Repeated loss of consciousness as the first symptom of recurrence of head and neck malignancy: a case report.

Eur Heart J Case Rep 2021 Jan 4;5(1):ytaa430. Epub 2021 Jan 4.

Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan.

Background: Head and neck malignancies rarely cause reflex syncope. Three mechanistic patterns of reflex syncope are known in such patients: carotid sinus syndrome, glossopharyngeal neuralgia syndrome, and parapharyngeal space lesions syncope syndrome. There are few reports describing parapharyngeal space lesions syncope syndrome.

Case Summary: A 61-year-old man with a history of head and neck cancer underwent left lingual resection and left anterior cervical lymph node dissection followed by chemoradiotherapy. Two months later, he experienced his first syncope and was admitted to our hospital for further investigation. During the first few days in the hospital, he experienced loss of consciousness. Carotid artery massage and cervical rotation-extension examinations revealed no abnormalities, and glossopharyngeal neuralgia was not observed. Cervical computed tomography showed recurrence of tongue cancer infiltrating the para-nasopharyngeal space. Consequently, the patient had sinus pause during the loss of consciousness; hence, we suspected parapharyngeal space lesions syncope syndrome. Pacemaker implantation was considered but could not be performed as the patient passed away because of the original malignancy.

Discussion: Parapharyngeal space tumours are often characterized by the absence of subjective symptoms, although symptoms such as neck swelling and discomfort in the throat have been reported. Parapharyngeal space lesions syncope syndrome is caused by tumour invasion into the parapharyngeal space, and there is no known trigger for syncope. Our case is unique because the patient's first symptom of recurrence of tongue cancer infiltrating the para-nasopharyngeal space was repeated loss of consciousness.
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http://dx.doi.org/10.1093/ehjcr/ytaa430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898574PMC
January 2021

An anatomical approach to determine the location of the sinoatrial node during catheter ablation.

J Cardiovasc Electrophysiol 2021 May 4;32(5):1320-1327. Epub 2021 Mar 4.

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

Introduction: The sinoatrial node (SAN) should be identified before superior vena cava (SVC) isolation to avoid SAN injury. However, its location cannot be identified without restoring sinus rhythm. This study evaluated the usefulness of the anatomically defined SAN by comparing it with the electrically confirmed SAN (e-SAN) to predict the top-most position of e-SAN and thus establish a safe and more efficient anatomical reference for SVC isolation than the previously reported reference of the right superior pulmonary vein (RSPV) roof.

Methods And Results: The e-SAN was identified as the earliest activation site in the electroanatomical map obtained during sinus rhythm. The anatomically defined SAN, the cranial edge of the crista terminalis (CT) visualized with intracardiac echocardiography (CT top), and the RSPV roof, which was obtained from the overlaid electroanatomical image of SVC and RSPV, were tagged on one map. The distance from the e-SAN to each reference was measured. Among 77 patients, the height of the e-SAN from the CT top was a median (interquartile range) of -2.0 (-8.0 to 4.0) mm. The e-SAN existed from 10 mm above the CT top or lower in 74 (96%) patients and from the RSPV roof or below in 73 (95%) patients. The reference of 10 mm above the CT top is more proximal to the right atrium than the RSPV roof and can provide longer isolatable SVC sleeves (30.0 [20.0-35.0] vs. 24.0 [18.0-30.0] mm, p < .001). The e-SAN tended to be found above the CT top when the heart rate during mapping was faster (adjusted odds ratio [95% confidence interval] per 10-bpm increase: 1.71 [1.20-2.43], p < .01).

Conclusion: The CT top is useful for predicting the upper limit of the e-SAN and can provide a better reference for SVC isolation than the RSPV roof.
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http://dx.doi.org/10.1111/jce.14961DOI Listing
May 2021

Relationship between electrical gaps after Maze procedure and atrial tachyarrhythmias and ablation outcomes after cardiac surgery and concomitant Maze procedure.

Heart Vessels 2021 May 13;36(5):675-685. Epub 2021 Feb 13.

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

Atrial tachycardia (AT) and atrial fibrillation (AF) commonly occur after cardiac surgeries (CSs). This study investigated the mechanisms and long-term outcomes of AT and AF ablation after various Maze procedures, particularly whether atrial tachyarrhythmias after the Maze procedure occur due to gaps in the Maze lines. We analyzed 37 consecutive cases with atrial tachyarrhythmias after the Maze procedures and concomitant CSs between 2007 and 2019. Fifty-nine atrial tachyarrhythmias were induced in 37 consecutive cases, and 49 of those atrial tachyarrhythmias were mappable ATs. Forty ATs were related to the Maze procedures in the 49 mappable ATs (81.6%). All 37 consecutive cases had residual electrical conductions (gaps) in the Maze lines (88 gaps; 2.4 ± 1.2 gaps/patient). Forty of 88 gaps (45.5%) were associated with gap-related ATs. The common ATs in this study were 1. peri-mitral atrial flutter due to gaps at pulmonary vein isolation (PVI) line to mitral valve annulus (MVA) (20 cases), and 2. peri-tricuspid atrial flutter due to gaps at right atrial incision to the tricuspid valve annulus (TVA) (10 cases). Forty-seven of 49 ATs (95.9%) were successfully ablated at the first session, and there were no complications. The mean follow-up period after ablation was 3.6 ± 3.2 (median, 2.1; interquartile range, 0.89-6.84) years. The Kaplan-Meier analysis of freedom from recurrent atrial tachyarrhythmias after Maze procedure was 82.7% at 1-year follow-up and 75.5% at 4-year follow-up after a single procedure. Reentry was the main mechanism of ATs after Maze procedures and concomitant CSs, and ATs were largely related to the gaps on the Maze lines between the PVI line and the MVA or those on the lines between right atrial incision to the TVA. Long-term follow-up data suggest that catheter ablation of atrial tachyarrhythmias after various Maze procedures is effective and safe.
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http://dx.doi.org/10.1007/s00380-020-01737-3DOI Listing
May 2021

Coughing as a potentially effective induction method of atrial tachycardia: a case report.

Eur Heart J Case Rep 2020 Dec 29;4(6):1-5. Epub 2020 Nov 29.

Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, 564-8565 Osaka, Japan.

Background : Cough-induced atrial tachycardia (AT) is extremely rare and its electrical origin remains largely unknown. Atrial tachycardias triggered by pharyngeal stimulation, such as swallowing or speech, appears to be more common and the majority of them originate from the superior vena cava or right superior pulmonary vein (PV). Only one case of swallow-triggered AT with right inferior pulmonary vein (RIPV) origin has been reported to date.

Case Summary : We present a case of a 41-year-old man with recurring episodes of AT in the daytime. He underwent electrophysiology study without sedation. Atrial tachycardia was not observed when the patient entered the examination room and could not be induced with conventional induction procedures. By having the patient cough periodically on purpose, transient AT with P-wave morphology similar to the clinical AT was consistently induced. Activation mapping of the AT revealed a centrifugal pattern with the earliest activity localized inside the RIPV. After successful radiofrequency isolation of the right PV, AT was no longer inducible.

Discussion : In the rare case of cough-induced AT originating from the RIPV, the proximity of the inferior right ganglionated plexi (GP) suggests the role of GP in triggering tachycardia. This is the first report that demonstrates voluntary cough was used to induce AT. In such cases that induction of AT is difficult using conventional methods, having the patient cough may be an effective induction method that is easy to attempt.
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http://dx.doi.org/10.1093/ehjcr/ytaa459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793191PMC
December 2020

High-risk atrioventricular block in Brugada syndrome patients with a history of syncope.

J Cardiovasc Electrophysiol 2021 Mar 19;32(3):772-781. Epub 2021 Jan 19.

Department of Cardiovascular Medicine, Division of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, Osaka, Japan.

Background: Determining the etiology of syncope is challenging in Brugada syndrome (BrS) patients. Implantable cardioverter defibrillator placement is recommended in BrS patients who are presumed to have arrhythmic syncope. However, arrhythmic syncope in BrS patients can occur in the setting of atrioventricular block (AVB), which should be managed by cardiac pacing. The clinical characteristics of BrS patients with high-risk AVB remain unknown.

Methods: This study included 223 BrS patients with a history of syncope from two centers. The clinical characteristics of patients with high-risk AVB (Mobitz type II second-degree AVB, high-degree AVB, or third-degree AVB) were investigated.

Results: During the 99 ± 78 months of follow-up, we identified six BrS patients (2.7%) with high-risk AVB. Three of the six patients (50%) with AVB presented with syncope associated with prodromes or specific triggers. Four patients (67%) were found to have paroxysmal third-degree AVB during the initial evaluation for BrS and syncope, while two patients developed third-degree AVB during the follow-up period. The incidence of first-degree AVB was significantly higher in AVB patients than in non-AVB patients (83% vs. 15%; p = .0005). There was no significant difference in the incidence of ventricular fibrillation between AVB and non-AVB patients (AVB [17%], non-AVB [12%]; p = .56).

Conclusion: High-risk AVB can occur in BrS patients with various clinical presentations. Although rare, the incidence is worth considering, especially in BrS patients with first-degree AVB.
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http://dx.doi.org/10.1111/jce.14876DOI Listing
March 2021

Unusual Overlapping Cardiac Sarcoidosis and Long-QT Type 3 Induced Ventricular Fibrillation.

Intern Med 2021 1;60(1):85-89. Epub 2021 Jan 1.

Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan.

A 54-year-old woman had been resuscitated after ventricular fibrillation and her electrocardiogram showed a QT prolongation (QTc=510 ms), and genetic screening revealed a missense variant, R1644C, in the SCN5A gene. She was therefore diagnosed with congenital long-QT syndrome (LQTS) type 3. However, the patient had left ventricular dysfunction, and based on the findings of cardiac magnetic resonance imaging, positron emission tomography and pathological examinations, she was diagnosed with cardiac sarcoidosis. Although both are rare diseases, their overlapping presence in this case may have led to an increased cardiovascular risk compared with either alone. Thus, not only genetic but comprehensive clinical examinations are important for making a correct diagnosis.
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http://dx.doi.org/10.2169/internalmedicine.5018-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835453PMC
April 2021

A case of macroreentrant atrial tachycardia between a persistent left superior vena cava and the left atrium with a decremental property.

HeartRhythm Case Rep 2020 Nov 17;6(11):836-840. Epub 2020 Aug 17.

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

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http://dx.doi.org/10.1016/j.hrcr.2020.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653479PMC
November 2020

Novel Non-Invasive Index for Prediction of Responders in Cardiac Resynchronization Therapy Using High-Resolution Magnetocardiography.

Circ J 2020 11 7;84(12):2166-2174. Epub 2020 Nov 7.

Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.

Background: Approximately one-third of patients with advanced heart failure (HF) do not respond to cardiac resynchronization therapy (CRT). We investigated whether the left ventricular (LV) conduction pattern on magnetocardiography (MCG) can predict CRT responders.Methods and Results:This retrospective study enrolled 56 patients with advanced HF (mean [±SD] LV ejection fraction [LVEF] 23±8%; QRS duration 145±19 ms) and MCG recorded before CRT. MCG-QRS current arrow maps were classified as multidirectional (MDC; n=28) or unidirectional (UDC; n=28) conduction based on a change of either ≥35° or <35°, respectively, in the direction of the maximal current arrow after the QRS peak. Baseline New York Heart Association functional class and LVEF were comparable between the 2 groups, but QRS duration was longer and the presence of complete left bundle branch block and LV dyssynchrony was higher in the UDC than MDC group. Six months after CRT, 30 patients were defined as responders, with significantly more in the UDC than MDC group (89% vs. 14%, respectively; P<0.001). Over a 5-year follow-up, Kaplan-Meyer analysis showed that adverse cardiac events (death or implantation of an LV assist device) were less frequently observed in the UDC than MDC group (6/28 vs. 15/28, respectively; P=0.027). Multivariate analysis revealed that UDC on MCG was the most significant predictor of CRT response (odds ratio 69.8; 95% confidence interval 13.14-669.32; P<0.001).

Conclusions: Preoperative non-invasive MCG may predict the CRT response and long-term outcome after CRT.
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http://dx.doi.org/10.1253/circj.CJ-20-0325DOI Listing
November 2020

Subcutaneous and transvenous implantable cardioverter defibrillator in high-risk long-QT syndrome type 3 associated with Val411Met mutation in SCN5A.

J Cardiol Cases 2020 Nov 11;22(5):238-241. Epub 2020 Aug 11.

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

Congenital long-QT syndrome type 3 (LQT3) with -V411M mutation has been reported as a malignant case of LQT3 with highest risk for sudden cardiac death (SCD). Here, we present two cases of LQT3 with -V411M who had been implanted with subcutaneous (S-) or transvenous (TV-) implantable cardioverter defibrillators (ICD). Case 1, a 2-year-old boy, although he had no symptoms, was diagnosed as having LQT3 (V411M-) due to family history. The QTc interval was still longer than 500 ms during follow-up even under oral mexiletine. Case 2 (his aunt) diagnosed as LQT3 suffered from syncope caused by ventricular fibrillation at 35-years-old despite taking mexiletine. Furthermore, case 1's father and half-brother, both had the V411M mutation with LQT3, had suddenly died. Thus, case 1 was recommended S-ICD when he was 15-years-old for primary prevention of SCD but not necessary for pacing therapy, while, case 2 had been implanted TV-ICD for secondary prevention of SCD. They had no event after ICD implantation, however, case 2 had to have added an extra ICD-lead due to lead failure when she was 44-years-old. The S-ICD may be a potent therapeutic option for high-risk LQTS when patients are younger and do not need pacing therapy. < In congenital long-QT syndrome (LQTS) type 3, some of the first events are lethal, particularly, LQT3 with V411M- mutation is the highest risk for sudden cardiac death (SCD). Which implantable cardioverter defibrillator (ICD), transvenous (TV-ICD) or subcutaneous (S-ICD) is better for primary prevention of SCD in LQTS is still controversial. The S-ICD rather than TV-ICD may have a potent benefit for high-risk LQTS when patients are younger and do not need pacing therapy.>.
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http://dx.doi.org/10.1016/j.jccase.2020.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588482PMC
November 2020

Improved Risk Stratification of Patients With Brugada Syndrome by the New Japanese Circulation Society Guideline - A Multicenter Validation Study.

Circ J 2020 11 17;84(12):2158-2165. Epub 2020 Oct 17.

Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.

Background: The new guideline (NG) published by the Japanese Circulation Society (JCS) places emphasis on previous arrhythmic syncope and inducibility of ventricular fibrillation (VF) by ≤2 extrastimuli during programmed electrical stimulation (PES) for deciding the indication of an implantable cardioverter-defibrillator in patients with Brugada syndrome (BrS). This study evaluated the usefulness of the NG and compared it with the former guideline (FG) for risk stratification of patients with BrS.Methods and Results:This was a multicenter (7 Japanese hospitals) retrospective study involving 234 patients with BrS who underwent PES at baseline (226 males; mean age at diagnosis: 44.9±13.4 years). At diagnosis, 46 patients (20%) had previous VF, 100 patients (43%) had previous syncope, and 88 patients (37%) were asymptomatic. We evaluated the difference in the incidence of VF in each indication according to the new and FGs. During the follow-up period (mean: 6.9±5.2 years), the incidence of VF was higher in patients with Class IIa indication according to the NG (NG: 16/45 patients [35.6%] vs. FG: 16/104 patients [15.4%]), while the incidence of VF in patients with other than class I or IIa indication was similarly low in both guidelines (NG: 2/143 patients [1.4%] vs. FG: 2/84 patients [2.4%]).

Conclusions: This study validated the usefulness of the NG for risk stratification of BrS patients.
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http://dx.doi.org/10.1253/circj.CJ-19-0910DOI Listing
November 2020

Systematic Evaluation of Variant Using ACMG/AMP Guidelines and Risk Stratification in Long QT Syndrome Type 1.

Circ Genom Precis Med 2020 Sep 16. Epub 2020 Sep 16.

Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Japan.

- Mutation/variant-site specific risk stratification in long-QT syndrome type 1 (LQT1) has been well investigated, but it is still challenging to adapt current enormous genomic information to clinical aspects caused by each mutation/variant. We assessed a novel variant-specific risk stratification in LQT1 patients. - We classified a pathogenicity of 141 variants among 927 LQT1 patients (536 probands) based on the American College of Medical Genetics and Genomics (ACMG) and Association for Molecular Pathology (AMP) guidelines and evaluated whether the ACMG/AMP-based classification was associated with arrhythmic risk in LQT1 patients. - Among 141 variants, 61 (43.3%), 55 (39.0%), and 25 (17.7%) variants were classified into pathogenic (P), likely pathogenic (LP), and variant of unknown significance (VUS), respectively. Multivariable analysis showed that proband (HR = 2.53; 95%CI = 1.94-3.32; p <0.0001), longer QTc (≥500ms) (HR = 1.44; 95%CI = 1.13-1.83; p = 0.004), variants at membrane spanning (MS) (vs. those at N/C terminus) (HR = 1.42; 95%CI = 1.08-1.88; p = 0.01), C-loop (vs. N/C terminus) (HR = 1.52; 95%CI = 1.06-2.16; p = 0.02), and P variants [(vs. LP) (HR = 1.72; 95%CI = 1.32-2.26; p <0.0001), (vs. VUS) (HR = 1.81; 95%CI = 1.15-2.99; p = 0.009)] were significantly associated with syncopal events. The ACMG/AMP-based evaluation was useful for risk stratification not only in family members but also in probands. A clinical score (0~4) based on proband, QTc (≥500ms), variant location (MS or C-loop) and P variant by ACMG/AMP guidelines allowed identification of patients more likely to have arrhythmic events. - Comprehensive evaluation of clinical findings and pathogenicity of variants based on the ACMG/AMP-based evaluation may stratify arrhythmic risk of congenital long-QT syndrome type 1.
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http://dx.doi.org/10.1161/CIRCGEN.120.002926DOI Listing
September 2020

Enhancing rare variant interpretation in inherited arrhythmias through quantitative analysis of consortium disease cohorts and population controls.

Genet Med 2021 01 7;23(1):47-58. Epub 2020 Sep 7.

Member of the European Reference Network for rare, low prevalence and/or complex diseases of the heart: ERN GUARD-Heart, Amsterdam, Netherlands.

Purpose: Stringent variant interpretation guidelines can lead to high rates of variants of uncertain significance (VUS) for genetically heterogeneous disease like long QT syndrome (LQTS) and Brugada syndrome (BrS). Quantitative and disease-specific customization of American College of Medical Genetics and Genomics/Association for Molecular Pathology (ACMG/AMP) guidelines can address this false negative rate.

Methods: We compared rare variant frequencies from 1847 LQTS (KCNQ1/KCNH2/SCN5A) and 3335 BrS (SCN5A) cases from the International LQTS/BrS Genetics Consortia to population-specific gnomAD data and developed disease-specific criteria for ACMG/AMP evidence classes-rarity (PM2/BS1 rules) and case enrichment of individual (PS4) and domain-specific (PM1) variants.

Results: Rare SCN5A variant prevalence differed between European (20.8%) and Japanese (8.9%) BrS patients (p = 5.7 × 10) and diagnosis with spontaneous (28.7%) versus induced (15.8%) Brugada type 1 electrocardiogram (ECG) (p = 1.3 × 10). Ion channel transmembrane regions and specific N-terminus (KCNH2) and C-terminus (KCNQ1/KCNH2) domains were characterized by high enrichment of case variants and >95% probability of pathogenicity. Applying the customized rules, 17.4% of European BrS and 74.8% of European LQTS cases had (likely) pathogenic variants, compared with estimated diagnostic yields (case excess over gnomAD) of 19.2%/82.1%, reducing VUS prevalence to close to background rare variant frequency.

Conclusion: Large case-control data sets enable quantitative implementation of ACMG/AMP guidelines and increased sensitivity for inherited arrhythmia genetic testing.
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http://dx.doi.org/10.1038/s41436-020-00946-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790744PMC
January 2021

Intra-day change in occurrence of out-of-hospital ventricular fibrillation in Japan: The JCS-ReSS study.

Int J Cardiol 2020 Nov 20;318:54-60. Epub 2020 Jun 20.

National Cerebral and Cardiovascular Center, Suita, Japan.

Background: Real-world evidence of out-of-hospital ventricular fibrillation (VF), especially regarding intra-day change, remains unclear. We aimed to investigate that age- and gender-dependent difference of intra-day change of VF occurrence.

Method: We enrolled 71,692 patients (males: 56,419 [78.7%], females: 15,273 [21.3%]) in whom cardiac VF had been documented from the 2005-2015 All-Japan Utstein Registry data. Subjects were divided into four groups: group-I (<18 years old), group-II (18-39), group-III (40-69), and group-IV (≥70). Among four groups in each of male and female, we compared the intra-day change of VF occurrence, and evaluated the risk factors of the unfavorable neurologic outcomes at 1 month after VF.

Results: Regardless of age, the incidence of VF was significantly greater in male than in female subjects. In male subjects, VF in group-I, III and IV occurred higher at daytime, however, group-II had no intra-day difference because group-II had a higher VF events at midnight~ early morning compared with other aged groups (Poisson regression analysis, p = .03). While in female, each group showed similar intra-day pattern of VF occurrence. Logistic regression analysis revealed that some of the clinical parameters such as time periods from call receipt to first shock and the presence of bystander cardiopulmonary resuscitation were important for risk of 30-day neurologically unfavorable outcomes.

Conclusions: The intra-day change of VF occurrence was age-dependently different in males but not in females, suggesting age- and gender-dependent differences in underlying cardiac diseases. These might affect the significant difference in unfavorable neurologic outcome.
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http://dx.doi.org/10.1016/j.ijcard.2020.06.014DOI Listing
November 2020

Clinical impact of left ventricular paced conduction disturbance in cardiac resynchronization therapy.

Heart Rhythm 2020 11 26;17(11):1870-1877. Epub 2020 May 26.

Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.

Background: Myocardial scarring is associated with nonresponse to cardiac resynchronization therapy (CRT) and conduction delay. Little is known about the significance and cause of left ventricular (LV) paced conduction disturbance (LPCD).

Objective: The purpose of this study was to investigate the clinical impact of paced interlead electrical delay and the difference in each conduction time from LV pace to right ventricular (RV) sense (LVp-RVs) and from RV pace to LV sense (RVp-LVs) [(LVp-RVs) - (RVp-LVs)], in CRT.

Methods: Among 137 patients who underwent CRT implantation, LVp-RVs and RVp-LVs were measured intraoperatively. The relationships between [(LVp-RVs) - (RVp-LVs)] and perfusion defects on myocardial perfusion single photon emission computed tomography (SPECT) imaging or [(LVp-RVs) - (RVp-LVs)] and clinical outcomes were assessed.

Results: After CRT implantation, 81 patients (59%) responded to CRT. [(LVp-RVs) - (RVp-LVs)] was significantly longer in nonresponders than in responders (9.7 ± 47.3 ms vs -4.5 ± 33.2 ms; P = .041). Patients with LPCD [(LVp-RVs) > (RVp-LVs)] had higher perfusion defects in the anterolateral region (2.7 ± 2.7 vs 1.1 ± 1.6; P = .0015) on SPECT. Multivariate analysis showed that LPCD was the independent predictor of nonresponse to CRT (odds ratio 0.40; 95% confidence interval [CI] 0.17-0.90; P = .026). During median follow-up of 2.3 years (interquartile range 1.3-5.5), LPCD was the independent predictor of cardiac death and/or heart failure hospitalization in multivariate analysis (hazard ratio 2.04; 95% CI 1.19-3.55; P = .010).

Conclusion: LPCD could predict nonresponse to CRT and poor outcome. Further intervention, such as adjustment of pacing timing or multipoint/site pacing, may be needed in such patients.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.031DOI Listing
November 2020

Efficacy and safety of new-generation atrial antitachycardia pacing for atrial tachyarrhythmias in patients implanted with cardiac resynchronization therapy devices.

J Cardiol 2020 05 29;75(5):559-566. Epub 2019 Oct 29.

Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.

Background: Atrial tachyarrhythmias (ATAs) have a significant negative impact on the prognosis of patients implanted with cardiac resynchronization therapy (CRT) devices. New-generation atrial antitachycardia pacing (Reactive ATP, Medtronic Inc., Minneapolis, MN, USA) is effective in managing ATAs in patients implanted with pacemakers. The purpose of this study was to evaluate the efficacy and safety of Reactive ATP in patients implanted with CRT devices.

Methods: This was a single-center retrospective study involving 72 CRT patients with a history of ATAs [44 patients with a device capable of Reactive ATP (ATP group) and 28 patients with a device without ATP function (Control group)]. The atrial fibrillation (AF) burden, the biventricular pacing rate, and clinical outcomes were compared between the two groups.

Results: At baseline, there was no significant difference in the AF burden and biventricular pacing rate between the ATP and Control groups. During the 832±489 days of the follow-up period, 23 of the 44 patients (52%) received a total of 2862 ATP deliveries and the median ATP success rate was 23.6% (interquartile range: 12.5-50.0%) in the ATP group. The AF burden was significantly decreased only in the ATP group 6 months after ATP was programmed (from 6.1±18.2% to 2.0±5.4%, p=0.0083) and maintained low throughout the follow-up period. Moreover, there were no Reactive ATP-related complications observed. Patients in the ATP group showed a significantly lower incidence of heart failure (HF) hospitalization (log-rank, p=0.041) and ventricular arrhythmias (log-rank, p=0.039) than those reported in the Control group.

Conclusions: Reactive ATP successfully and safely reduced AF burden, and was associated with a lower incidence of HF hospitalization in patients implanted with CRT devices.
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http://dx.doi.org/10.1016/j.jjcc.2019.10.001DOI Listing
May 2020

Efficacy of a Device-Based Continuous Optimization Algorithm for Patients With Cardiac Resynchronization Therapy.

Circ J 2019 12 26;84(1):18-25. Epub 2019 Oct 26.

Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.

Background: Cardiac resynchronization therapy (CRT) is less effective in patients with mildly wide QRS or non-left bundle branch block (non-LBBB). A new algorithm of every minute's optimization (adaptive CRT: aCRT algorithm) is effective in patients with CRT devices. This study investigated the clinical effect of the aCRT algorithm, especially in mildly wide QRS (120≤QRS<150 ms) or non-LBBB patients receiving CRT.Methods and Results:This study included 104 CRT patients (48 patients using the aCRT algorithm [adaptive group] and 56 patients not using the aCRT algorithm [non-adaptive group]). The primary endpoint was a composite clinical outcome of cardiac death and/or heart failure (HF) hospitalization. During a median follow-up of 700 days (interquartile range 362-1,173 days), aCRT reduced the risk of the clinical outcome, even in patients with mildly wide QRS or non-LBBB (log-rank P=0.0030 and P=0.0077, respectively) by Kaplan-Meier analysis. Use of the aCRT algorithm was an independent predictor of clinical outcomes in the multivariate analysis (hazard ratio (HR) 0.28, 95% confidence interval (CI): 0.096-0.78, P=0.015), the same as in patients with mildly wide QRS (HR 0.12, 95% CI: 0.006-0.69, P=0.015).

Conclusions: The new aCRT algorithm was useful and significantly reduced the risk of the clinical outcome, even in patients with mildly wide QRS.
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http://dx.doi.org/10.1253/circj.CJ-19-0691DOI Listing
December 2019

Comparing the catheter delivery system and the stylet delivery system for ventricular lead placement in pacemaker implantation-The CATS delivery system randomized controlled trial.

J Arrhythm 2019 Jun 29;35(3):524-527. Epub 2019 Mar 29.

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

Background: Right ventricular lead placement is one of the fundamental procedures during pacemaker implantation through the subclavian vein. Currently, there are two techniques to deliver the lead to the right ventricle: the catheter and stylet delivery systems. Surgeons, especially trainees in the early stage of training, are known to face difficulty while delivering the lead to the right ventricle. The objective of this study is to investigate and compare the two techniques of lead delivery by trainees in patients who are scheduled to undergo pacemaker implantation.

Methods: This is a prospective, single-center, randomized controlled clinical trial. One-hundred patients who were scheduled to undergo pacemaker implantation with a right ventricular lead will be randomized such that the pacemaker can be implanted via either the catheter delivery system or the stylet delivery system at a 1:1 ratio. The primary endpoint is the total number of attempts needed to place the lead in the ideal position. Secondary endpoints are the efficacy and safety of the implantation procedure. All implantation procedures will be performed by trainees under the supervision of expert cardiologists.

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

Conclusion: This will be the first clinical trial to compare the efficacy and safety of the catheter delivery system and the stylet delivery system during the implantation of the ventricular lead in pacemaker implantation. Our findings are expected to improve the lead implantation procedure by providing information about which delivery system to choose in which situation.
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http://dx.doi.org/10.1002/joa3.12179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595325PMC
June 2019

Clinical Differences in Japanese Patients Between Brugada Syndrome and Arrhythmogenic Right Ventricular Cardiomyopathy With Long-Term Follow-Up.

Am J Cardiol 2019 09 12;124(5):715-722. Epub 2019 Jun 12.

Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.

Some Brugada syndrome (BrS) patients have been suspected of being in the initial state of arrhythmogenic right ventricular cardiomyopathy (ARVC). This study aimed to clarify the electrocardiographic (ECG) and clinical differences between BrS and ARVC in long-term follow-up (mean 11.9 ± 6.3 years). A total of 50 BrS and 65 ARVC patients with fatal ventricular tachyarrhythmia (VTA) were evaluated according to the revised Task Force Criteria for ARVC. Based on the current diagnostic criteria concerning electrocardiographic, repolarization abnormality was positive in 2.0% and 2.6% of BrS patients at baseline and follow-up, and depolarization abnormality was positive in 6.0% and 12.8% of BrS patients at baseline and follow-up, respectively. At baseline, none of the BrS patients were definitively diagnosed with ARVC. Considering patients' lives since birth, Kaplan-Meier analysis revealed that age at first VTA attack showed the same tendency between the groups (BrS: mean 42.2 ± 12.5 years old vs ARVC: mean 44.8 ± 13.7 years old, log-rank p = 0.123). Moreover, the incidence of VTA recurrence was similar between the groups during follow-up (log-rank p = 0.906). Incidence of sustained monomorphic ventricular tachycardia was significantly higher in ARVC than in BrS whereas the opposite was true for ventricular fibrillation (log-rank p <0.001 and p <0.001, respectively). None of the diagnoses of BrS patients were changed to ARVC during follow-up. During long-term follow-up, although age at first VTA attack and VTA recurrence were similar, BrS consistently exhibited features that differed from those of ARVC.
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http://dx.doi.org/10.1016/j.amjcard.2019.05.067DOI Listing
September 2019

Feasibility of late gadolinium enhancement magnetic resonance imaging to detect ablation lesion gaps in patients undergoing cryoballoon ablation of paroxysmal atrial fibrillation.

J Arrhythm 2019 Apr 7;35(2):190-196. Epub 2019 Mar 7.

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

Background: Although late gadolinium enhancement magnetic resonance imaging (LGE-MRI) allows the identification of lesions and gaps after a cryothermal balloon (CB) ablation of paroxysmal atrial fibrillation (PAF), the accuracy has not yet been well established.

Methods: The subjects consisted of 10 consecutive patients who underwent a second ablation procedure among our cohort of 80 patients who underwent LGE-MRI after the CB ablation of PAF. LGE-MRI scar regions were compared with electroanatomical mapping during the second procedure. In the analysis, the unilateral pulmonary vein (PV) antrum was divided into 7 regions.

Results: The gap characterization analysis was performed in 140 regions around 40 PVs in total. There were 16 LGE-MRI gaps around 11 PVs (mean 1.6 ± 1.4 gaps/patient) in 7 patients and 14 electrical gaps around 10 PVs in 8 patients (mean 1.4 ± 1.1 gaps/patient). The locations of 13 electrical gaps were well matched to that on the LGE-MRI, whereas the remaining 1 electrical gap had not been predicted on the LGE-MRI. Compared to the electrical gaps in the second procedure, the sensitivity and specificity of the LGE-MRI gaps were 93% (13 LGE-MRI gaps of 14 electrical gaps) and 98% (123 LGE-MRI scars out of 126 electrical scars), respectively.

Conclusion: LGE-MRI can accurately localize the lesion gaps after CB ablation of PAF.
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http://dx.doi.org/10.1002/joa3.12161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457386PMC
April 2019

Association of Genetic and Clinical Aspects of Congenital Long QT Syndrome With Life-Threatening Arrhythmias in Japanese Patients.

JAMA Cardiol 2019 03;4(3):246-254

Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama, Japan.

Importance: Long QT syndrome (LQTS) is caused by several ion channel genes, yet risk of arrhythmic events is not determined solely by the responsible gene pathogenic variants. Female sex after adolescence is associated with a higher risk of arrhythmic events in individuals with congenital LQTS, but the association between sex and genotype-based risk of LQTS is still unclear.

Objective: To examine the association between sex and location of the LQTS-related pathogenic variant as it pertains to the risk of life-threatening arrhythmias.

Design, Setting, And Participants: This retrospective observational study enrolled 1124 genotype-positive patients from 11 Japanese institutions from March 1, 2006, to February 28, 2013. Patients had LQTS type 1 (LQT1), type 2 (LQT2), and type 3 (LQT3) (616 probands and 508 family members), with KCNQ1 (n = 521), KCNH2 (n = 487) and SCN5A (n = 116) genes. Clinical characteristics such as age at the time of diagnosis, sex, family history, cardiac events, and several electrocardiographic measures were collected. Statistical analysis was conducted from January 18 to October 10, 2018.

Main Outcomes And Measures: Sex difference in the genotype-specific risk of congenital LQTS.

Results: Among the 1124 patients (663 females and 461 males; mean [SD] age, 20 [15] years) no sex difference was observed in risk for arrhythmic events among those younger than 15 years; in contrast, female sex was associated with a higher risk for LQT1 and LQT2 among those older than 15 years. In patients with LQT1, the pathogenic variant of the membrane-spanning site was associated with higher risk of arrhythmic events than was the pathogenic variant of the C-terminus of KCNQ1 (HR, 1.60; 95% CI, 1.19-2.17; P = .002), although this site-specific difference in the incidence of arrhythmic events was observed in female patients only. In patients with LQT2, those with S5-pore-S6 pathogenic variants in KCNH2 had a higher risk of arrhythmic events than did those with others (HR, 1.88; 95% CI, 1.44-2.44; P < .001). This site-specific difference in incidence, however, was observed in both sexes. Regardless of the QTc interval, however, female sex itself was associated with a significantly higher risk of arrhythmic events in patients with LQT2 after puberty (106 of 192 [55.2%] vs 19 of 94 [20.2%]; P < .001). In patients with LQT3, pathogenic variants in the S5-pore-S6 segment of the Nav1.5 channel were associated with lethal arrhythmic events compared with others (HR, 4.2; 95% CI, 2.09-8.36; P < .001), but no sex difference was seen.

Conclusions And Relevance: In this retrospective analysis, pathogenic variants in the pore areas of the channels were associated with higher risk of arrhythmic events than were other variants in each genotype, while sex-associated differences were observed in patients with LQT1 and LQT2 but not in those with LQT3. The findings of this study suggest that risk for cardiac events in LQTS varies according to genotype, variant site, age, and sex.
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http://dx.doi.org/10.1001/jamacardio.2018.4925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439560PMC
March 2019

Multicenter Study of the Validity of Additional Freeze Cycles for Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation: The AD-Balloon Study.

Circ Arrhythm Electrophysiol 2019 01;12(1):e006989

Department of Cardiovascular Medicine (K.M., T.M., K.N., N.K., T.K., M.W., K.Y., K.I., Y.Y.I., S.N., T.N., T.A., C.I., T.N., S.Y., K.F.K.), National Cerebral and Cardiovascular Center, Suita, Japan.

Background: Pulmonary vein isolation (PVI) is a cornerstone of catheter ablation in patients with paroxysmal atrial fibrillation, and balloon-based ablation has been recently performed worldwide. The second-generation cryoballoon (CB2) ablation has proven to be highly effective in achieving freedom from paroxysmal atrial fibrillation. However, there are some debatable questions, including the ideal number of freeze cycles.

Methods: The AD-Balloon study (Multicenter Study of the Validity of Additional Freeze Cycles for Cryoballoon Ablation) was designed as a prospective, multicenter, and randomized clinical trial for investigation of the optimal strategy of freeze cycles for the CB2 ablation. One hundred and ten consecutive patients (aged 64±11 years) were randomly assigned to 2 groups after achieving a PVI by the CB2 ablation: 3-minute freeze cycles were added to each pulmonary vein (AD group: n=55) or not (non-AD group: n=55). Delayed-enhancement magnetic resonance imaging was also performed 1 to 2 months after the PVI to assess the ablation lesions.

Results: The patient characteristics did not differ between the 2 groups. A complete PVI was achieved in all patients. The total number of freeze cycles and durations for all pulmonary veins were significantly shorter in the non-AD group than in the AD group (5.7±1.6 versus 9.1±1.6 cycles, P<0.0001, and 932±244 versus 1483±252 seconds, P<0.0001). The cumulative freedom from any atrial tachyarrhythmia at 1 year was 87.3% in the AD group and 89.1% in the non-AD group (log-rank test P=0.78). There was no significant difference in the frequency of gaps on the PVI lines in the delayed-enhancement magnetic resonance imaging (46% in the AD group versus 36% in the non-AD group; P=0.38).

Conclusions: No benefit was found in the patients receiving additional 3-minute freeze cycles after the complete PVI with the CB2 ablation, suggesting that an insurance freeze after achieving a PVI with the CB2 may be unnecessary and time consuming.
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http://dx.doi.org/10.1161/CIRCEP.118.006989DOI Listing
January 2019

Low-Voltage Type 1 ECG Is Associated With Fatal Ventricular Tachyarrhythmia in Brugada Syndrome.

J Am Heart Assoc 2018 11;7(21):e009713

1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.

Background Epicardial mapping can reveal low-voltage areas on the right ventricular outflow tract in patients with Brugada syndrome with several ventricular fibrillation ( VF ) episodes. A type 1 ECG is associated with an abnormal electrogram on right ventricular outflow tract epicardium. This study investigated the clinical significance of the amplitude of type 1 ECGs in patients with Brugada syndrome. Methods and Results In 209 patients with Brugada syndrome with a spontaneous type 1 ECG (26 resuscitated from VF , 54 with syncope, and 129 asymptomatic), the amplitude of the ECG in leads exhibiting type 1 was measured among V1 to V3 leads positioned in the standard and upper 1 and 2 intercostal spaces. The number of ECG leads exhibiting type 1 did not differ among groups. The averaged amplitude of type 1 ECG was, however, significantly smaller in the group resuscitated from VF than in the asymptomatic group ( P<0.05). Moreover, the minimum amplitude of type 1 ECG was significantly smaller in the group resuscitated from VF than in the group with syncope and the asymptomatic group ( P<0.05 and P<0.01, respectively). During follow-up (56±48 months), VF occurred in 29 patients. Kaplan-Meier analysis revealed that patients with the minimum amplitude of type 1 ECG lower than or at the median value had a higher incidence of VF (log-rank test, P<0.01). In multivariate analysis, syncope, past VF episode, and minimum amplitude of type 1 ECG ≤0.8 mV were independent predictors of VF events during follow-up. Conclusions Low-voltage type 1 ECG is highly and independently related to fatal ventricular tachyarrhythmia in patients with Brugada syndrome.
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http://dx.doi.org/10.1161/JAHA.118.009713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404198PMC
November 2018

Performance of an atrial fibrillation detection algorithm using continuous pulse wave monitoring.

Ann Noninvasive Electrocardiol 2019 03 2;24(2):e12615. Epub 2018 Nov 2.

Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.

Background: Detecting asymptomatic and undiagnosed atrial fibrillation (AF) is increasingly important. Recently, we developed a wristwatch-based pulse wave monitor (PWM; Seiko Epson, Japan) capable of long-term recording, with an automatic diagnosis algorithm that uses frequency-based pulse wave analysis. The aim of this study was to evaluate the validity of continuous pulse wave monitoring for detection of AF.

Methods: During the electrophysiological study (EPS) in patients with AF, simultaneous pulse wave monitoring and Holter electrocardiograms (ECG) were recorded (n = 136, mean age 62.7 ± 10.9 years). The diagnostic accuracy of the PWM for AF was compared to the Holter ECG diagnosis. Standard performance metrics (sensitivity [Se], specificity [Sp], positive predictive value [PPV], and negative predictive value [NPV]) were calculated. The duration-based measurements were based on the diagnosis concordance ratios for the duration of time between diagnosis detected by the PWM and true diagnosis by the Holter ECG (AF or not AF). The episode-based performance metrics were based on the proportion of episodes appropriately detected with the PWM relative to episodes determined by the Holter ECG.

Results: The total recording time was 1,542,770 s (AF: 270,945 s). A high diagnostic Sp (patient average: 96.4%, cumulative: 97.7%) and NPV (patient average: 95.1%, cumulative: 96.8%) were obtained in the duration-based results. In the episode-based metrics, all indices significantly improved with longer AF episode durations.

Conclusions: Continuous pulse wave monitoring can provide accurate and dependable information to aid in AF diagnosis. A high validity in confirming freedom from AF was shown by a high NPV.
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http://dx.doi.org/10.1111/anec.12615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931792PMC
March 2019

Effect of Sympatholytic Therapy on Circadian Cardiac Autonomic Activity in Non-Diabetic Chronic Kidney Disease.

Int Heart J 2018 Nov 25;59(6):1352-1358. Epub 2018 Oct 25.

Department of Cardiovascular Medicine, The University of Tokyo Hospital.

Although beta-blockade itself is not a first choice for chronic kidney disease (CKD) patients, alpha-beta-blockers (ABB) do improve their prognoses. This study's aim was to evaluate the effect of beta-selective-blockers (BSB) and ABB on circadian cardiac autonomic activity in CKD patients.The study consisted of 496 non-diabetic individuals who underwent 24-hour Holter monitoring (149 CKD patients and 347 controls without CKD). Using heart rate variability analysis, we evaluated the proportion of NN50 and the high-frequency component (reflecting parasympathetic activity), and low- to high-frequency ratio (reflecting sympathovagal balance). These indices were evaluated by regression analysis incorporating gender, age, related comorbidities, and medications. BSB increased vagal activity only in the day-time and not the night-time in controls. In CKD patients, BSB was significantly related to higher vagal activity throughout the day and with lower sympathovagal balance at night. The night sympathovagal balance of CKD patients taking ABB was significantly higher than that of CKD patients taking BSB, which was the only significant difference between the effects of BSB and ABB.The sympatholytic therapy effect is different depending on CKD presence and whether patients are treated with BSB or ABB. In CKD patients without severe heart failure, BSB could be associated with higher parasympathetic activity and lower sympathovagal balance compared to ABB.
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http://dx.doi.org/10.1536/ihj.17-561DOI Listing
November 2018

Successful elimination of recurrent ventricular tachycardia by epicardial ablation over coronary artery supplying postinfarction aneurysm.

HeartRhythm Case Rep 2018 Apr 12;4(4):131-134. Epub 2018 Jan 12.

Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic.

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http://dx.doi.org/10.1016/j.hrcr.2017.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944047PMC
April 2018

Response by Yamagata et al to Letter Regarding Article, "Genotype-Phenotype Correlation of Mutation for the Clinical and Electrocardiographic Characteristics of Probands With Brugada Syndrome: A Japanese Multicenter Registry".

Circulation 2017 12;136(23):2289-2290

Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (K.Y., T.A., W.S.). Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan (W.S.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.117.030845DOI Listing
December 2017

Ultrasound-guided versus conventional femoral venipuncture for catheter ablation of atrial fibrillation: a multicentre randomized efficacy and safety trial (ULTRA-FAST trial).

Europace 2018 07;20(7):1107-1114

Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Vídenská 1958/9, Prague 4, Czech Republic.

Aims: Complications of catheter ablation for atrial fibrillation (AF) are frequently related to vascular access. We hypothesized that ultrasound-guided (USG) venipuncture may facilitate the procedure and reduce complication rates.

Methods And Results: We conducted a multicentre, randomized trial in patients undergoing catheter ablation for AF on uninterrupted anticoagulation therapy. The study enrolled consecutive 320 patients (age: 63 ± 8 years; male: 62%) and were randomized to USG or conventional venipuncture in 1:1 fashion. It was prematurely terminated due to substantially lower-than-expected complication rates, which doubled the population size needed to maintain statistical power. While the complication rates did not differ between two study arms (0.6% vs. 1.9%, P = 0.62), intra-procedural outcome measures were in favour of the USG approach (puncture time, 288 vs. 369 s, P < 0.001; first pass success, 74% vs. 20%, P < 0.001; extra puncture attempts 0.5 vs. 2.1, P < 0.001; inadvertent arterial puncture 0.07 vs. 0.25, P < 0.001; unsuccessful cannulation 0.6% vs. 14%, P < 0.001). Though these measures varied between trainees (49% of procedures) and expert operators, between-arm differences (except for unsuccessful cannulation) were comparably significant in favour of USG approach for both subgroups.

Conclusions: Ultrasound-guided puncture of femoral veins was associated with preferable intra-procedural outcomes, though the major complication rates were not reduced. Both trainees and expert operators benefited from the USG strategy. (www.clinicaltrials.gov ID: NCT02834221).
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http://dx.doi.org/10.1093/europace/eux175DOI Listing
July 2018