Scholarly article on topic 'ABSTRACT Poster Presentation'

ABSTRACT Poster Presentation Academic research paper on "Clinical medicine"

Share paper
Academic journal
Journal of Arrhythmia
OECD Field of science

Academic research paper on topic "ABSTRACT Poster Presentation"



Voltage mapping of left atrium in patients with fixed atrial fibrillation

Sou Takenaka, Tetsuro Takase, Takahiro Gunji, Naoki Sato, Hiroyuki Ozaki, Mitsuchika Nakamura, Masato Otsuka, Yukio Tsurumi

Department of Cardiology, Yokohama General Hospital, Yokohama, Japan

Background & Objectives: Atrial fibrillation (AF) is can make the structural change in left atrium (LA). Persistent AF often accompanies organized atrial reentrant tachycardia or flutter. The additional line(s) after the pulmonary vein isolation (PVI) could prevent the recurrence of fixed AF. We evaluated the degree of LA damage and the left atrial (LA) roof linear ablation.

Methods & Results: After the pulmonary vein isolation, we obtained the high-density three-dimensional (3D) voltage mapping (Ensite® Velocity) of the LA in 11 patients with fixed AF, and determined the areas of low voltage. We defined the total area of LA pulled to PV and mitral annulus areas. A threshold of 0.5mV was used to define low voltage, and the areas of low voltage were defined as LA damaged area. LA roof linear ablation was performed with guidance of 3D electroanatomical mapping.Total area of LA was 116 ± 23 cm2 and LA damaged area was 52 ± 32 cm2 (43 ± 24 %). The recurrence rate of AF 12 months after RF catheter ablation was 27% (3/11 patients).

Conclusions: The damage of LA was progressing in patients with fixed AF. The LA roof linear ablation as well as PVI provides a significant improvement of sinus rhythm maintenance rate in fixed AF.

Prolonged PR interval is associated with advanced electroanatomical remodeling of left atrium and predicts the clinical outcome after catheter ablation of atrial fibrillation

Junbeom Park, Tae-Hoon Kim, Ki-Woon Kang, Jin-Kyu Park, Nam Kyun Kim, Jae-Sun Uhm, Jong-Youn Kim, Boyoung Joung, Moon-Hyoung Lee, Hui-Nam Pak

Yonsei University Health system, Seoul, Republic of Korea

Background: Electrocardiographic (ECG) finding reflects the cardiac remodeling and prognosis of heart disease. We hypothesized that PR interval is associated with electroanatomical remodeling of left atrium (LA) and predicts the clinical outcome of radiofreuquency catheter ablation (RFCA) for atrial fibrillation (AF).

Methods: We included 652 patients with AF (78.1% male, 57.9±11.2 year old, 70.4% paroxysmal AF) who underwent RFCA. PR interval at sinus rhythm before procedure was compared with and LA volume (CT), endocardial voltage (NavX), or clinical outcome, based on median value.


1. In patients with PR190ms were older (p<0.001), more likely to have persistent AF (p<0.001), or hypertension (p=0.005), and greater body mass index (p=0.019) or CHADS2 score (p=0.010) than those with <190ms.

2. The patients with PR190ms had greaterLA dimension (Echo; p<0.001), LA volume index (CT; p<0.001), or E/Em (p=0.004), and lower LA voltage (p<0.001) than those with short PR. PR interval has weak correlations with LA volume index (CT; r=0.276, p<0.001) and LA voltage (r=-0.166, p<0.001).

3. Prolonged PR interval was linearly correlated with long durations of P wave in lead II (r=0.462, p<0.001) or negative P terminal force in V1 (r=0.313, p<0.001), and high amplitude of negative P terminal force in V1 (r=0.164, p<0.001).

4. During 13.7±7.8 month of follow-up, PR>190ms was independently associated with clinical recurrence of AF (HR=4.76, 95% CI 2.442-9.276, p<0.001).

Conclusion: Prolonged PR interval is closely associated with advanced remodeling of LA, and has a predictive value for worse clinical outcome after catheter ablation for AF.

Keywords: Atrial fibrillation, Electrocardiography, PR interval, Recurrence, Remodeling



The impact of heterogeneous pulmonary vein anatomy in catheter ablation of atrial fibrillation

Chen Wei-Ta1,2, ChangShih-lin23, Lin Yenn-Jiang23, Lo Li-Wei-3, Chen Yi-Jen1", Chen Shih-Ann

1Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University; Division of Cardiology and Cardiovascular Research Center, Taipei Veterans General Hospital, Taipei, Taiwan. Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan

Background and Objectives: Recurrence rate after radiofrequency ablation of atrial fibrillation (AF) was still high. Computerized tomography or magnetic resonance imaging of left atrium and pulmonary veins were often performed before ablation. Using the morphological evaluation, we present the novel parameters to predict recurrence

Methods: From January 2011 to January 2012, 119 patients who received first radiofrequency ablation of AF (86 paroxysmal and 33 non-paroxysmal AF) were enrolled with mean follow-up of 19 months. All patients received computerized tomography of left atrium and pulmonary veins before ablation. The roof line distance, the left atrial diameter and the angle of the main trunk of the bilateral superior pulmonary veins were measured. The roof line distance / left atrial diameter ratio was calculated. Underlying parameters were also collected. The end point was recurrence after ablation.

Results: Patients with recurrence of AF had a shorter roof line distance, smaller roof line distance / left atrial diameter ratio, longer left atrial diameter, larger angle of the left superior pulmonary vein, and lower voltage amplitude compared with those without recurrence. The results were similar in either paroxysmal or non-paroxysmal AF patients. Multivariant analysis showed that the roof line distance / left atrial diameter ratio had the most predictive value with the cut-off level of 0.32, 92.6% sensitivity rate and 95.7% specificity rate (The area under the receiver operating characteristics curve was 0.97). The other independent risk factors for recurrence of AF include roof line distance and angle of the left superior pulmonary vein.

Conclusion: Roof line distance / left atrial diameter ratio, roof line distance and the angle of the left superior pulmonary vein are the novel parameters to predict AF recurrence after ablation.

Table 1. Basic characteristics and morphological findings

Patients Patients P

with recurrence without recurrence value

number 27 92

Age, mean±SD, y 54.1±7.4 53.4±11.6 0.77

BMI, meaniSD 25.4±3.0 25.1±3.4 0.63

Male gender, n(%) 22(81.5) 58(63) 0.07

Smoking, n(%) 9(33.3) 26(28.3) 0.64

Alcoholism, n(%) 2(7.4) 13(14.1) 0.52

Hypertension, n(%) 12(44.4) 55(59.8) 0.19

Stroke, n(%) 1(3.7) 2(2.2) 0.54

CHADS2, mean±SD, point 0.6±0.7 0.8±0.9 0.16

CHA2DS2-VSC, mean±SD, point 1.4±0.9 1.5±0.9 0.61

Triglyceride, mean±SD, mg/dL 104.4±70.4 87.0±50.4 0.29

Total cholesterol, mean±SD, mg/dL 188.0±34.0 175.5±32.7 0.19

HDL, mean±SD, mg/dL 50.7±13.3 48.9±14.7 0.68

LDL, mean±SD, mg/dL 122.4±35.6 111.2±27.4 0.21

Uric acid, mean±SD, mg/dL 5.8±1.4 5.6±1.9 0.65

ALT, meaniSD, U/L 34.9±24.1 31.2±15.1 0.51

Creatinine, mean±SD, mg/dL 1.0±0.2 1.2±1.7 0.67

LAD by ultrasound, mean±SD, mm 41.7±6.6 37.7±6.1 <0.01

EF, mean±SD, % 58.4±8.8 59.6±6.4 0.46

Voltage, mean±SD, mV 1.2±0.6 1.6±0.6 0.01

Roof line distance, mean±SD, mm 15.0±2.3 21.9±5.7 <0.005

Roof line distance/LAD, mean±SD 0.27±0.05 0.44±0.07 <0.005

LAD by CT, mean±SD, mm 55.9±10.9 50.1±8.0 <0.005

RSPV angle 141.7±3.6 140.9±3.5 0.35

LSPV angle 50.7±8.5 39.1±6.0 <0.005

ALT, Alanine Aminotransferase; BMI, body mass index; CT, computerized tomography; EF, ejection fraction; HDL, high-density lipoprotein; LAD, left atrial diameter; LDL, low-density lipoprotein; LSPV, left superior pulmonary vein; RSPV, right superior pulmonary vein

Figure 1.

The example of measurement of roof line distance, LA diameter, angle of LSPV and RSPV. (A) example of recurrent case (B) example of non-recurrent case

LA, left atrium; LSPV, left superior pulmonary vein; RSPV, right superior pulmonary vein

Clinical utility of adding ablation of localized complex fractionated electrograms after a stepwise linear ablation in persistent atrial fibrillation

Yuichi Hori, Shiro Nakahara, Akiko Okano, Sayuki Kobayashi, Yoshihiko Sakai, Kan Takayanagi

Department oof Cardiology, Dokkyo Medical University Koshigaya Hospital,Saitama, Japan

Background: Linear left atrial (LA) ablation in persistent atrial fibrillation (PsAF) patients results in eliminating most complex fractionated electrogram (CFE) sites. However, the clinical efficacy ofadditional localized CFE ablation is inconclusive.

Methods: Eighty-consecutive PsAF patients underwent construction of CFE and dominant frequency (DF) maps, and stepwise linear ablation followed by either additional localized CFE ablation (40 patients) or not (40 patients) detected by an automatic algorithm.

Results: Correlating the continuous CFE (con-CFE) burden (<50ms) with the LA volume index (LAVI) demonstrated an inverse relationship (P<0.0001). A significant reduction in the con-CFE burden after linear ablation (69% vs. 21%; P<0.0001) was confirmed, and localized CFEs were observed with a significant predilection for the anterior (30%), posterior (30%), and inferior LA regions (38%). Comparing the localized CFEs with higher-frequency sources, 57% of localized CFEs involved con-CFE sites, and 59% ofthose overlapped with high-DF sites (>8Hz). Additional localized CFE targeted ablation further decreased the DF within the CS (6.0±0.8 to 5.7±0.7Hz; P=0.0013). After 13±6 months of follow-up, a trend toward a better clinical outcome in patients receiving additional localized CFEs ablation was observed, but was not statistically significant. A multivariate analysis showed a single procedure success could be predicted by both a smaller LAVI and additional localized con-CFE site ablation.

Conclusions: The presence of localized con-CFEs with a predilection for particular LA regions after linear ablation could provide the optimal sites for selective substrate modification. However, the distribution of these ideal targets might be influenced by atrial structural and functional remodeling.


Impact of left atrial appendage ridge ablation on the complex fractionated electrograms within the coronary sinus in persistent atrial fibrillation

Naofumi Tsukada, Shiro Nakahara, Yuichi Hori, Yasuo Okumura, Noritaka Toratani, Yoshihiko Sakai, Kan Takayanagi

Department oof Cardiology, Dokkyo Medical University Koshigaya Hospital,Saitama, Japan

Background: The left atrial appendage (LAA) is a possible key contributor to the maintenance of persistent atrial fibrillation (PsAF). The effect of LAA ostial ablation on global left atrial higher-frequency sources remains unclear.

Methods and Results: Complex fractionated electrograms (CFEs) and dominant frequency (DF) maps acquired with a NavX system in 58 PsAF patients were examined before and after LAA posterior ridge ablation, which followed a stepwise linear ablation. High-density left atrial mapping identified continuous CFE sites in 50% and high-DFs (>8Hz) in 53% of patients at the LAA posterior ridge. In 44 patients that AF persisted despite PVI and linear ablation, LAA ablation significantly increasedthe mean CFE cycle length from 98±29ms to 108±30ms (P<0.0001) and decreased DF from 6.1±0.8Hz to 5.9±0.8Hz (P<0.005) within the CS. A multivariate analysis showed single procedure failures could be predicted by the LA volume index and absence of continuous CFEs at the LAA posterior ridge. The percent decrease in the global LA DF after LAA ablation was significantly lower in the patients with than in those without an enlarged LA (>90mL/ m2) (median 0% vs. 4.8%; P<0.01), and significantly lower in the patients with than in those withoutthe absence ofcontinuous CFEs in the LAA posterior ridge region (median 0.6% vs. 4.8%; P<0.05).

Conclusions: These findings suggested that an approach incorporating an LAA posterior ridge ablation was effective in modifying high-frequency sources in the global LA in PsAF patients, but a lesser effect was documented in patients with electroanatomical remodeling of the LA.



Pulmonary vein isolation extremely attenuate the amplitude of pulmonary vein potential in the second session

S Kaneko, M Shinoda, R Kubota, T Ohashi Y Mizutani, Y Murase, T Haga, H Kanayama, T Murohara

Toyota Kosei Hospital, Japan

Purpose: The purpose of this study is to examine the amplitude of the pulmonary vein (PV) potential after extensive encircling of ipsilateral pulmonary vein isolation (EEPVI) for atrial fibrillation (AF).

Methods: We examined the amplitude of 4 PV ostium potential during PV pacing and compared the highest amplitude of the first session after EEPVI with the highest amplitude at the beginning of the second session.

Results: EEPVI for 247 consecutive patients was performed from March, 2011, to April, 2013. Sixty one patients underwent re-ablation for recurrence AF, and 214 PVs were examined. Left ejection fraction was 63.7 ± 8.9 % (left atrial dimension: 42.9 ± 5.2mm, hypertension: 64.5%, hypertrophic cardiomyopathy: 16.7%). Second sessions were performed at 310&amp;amp;amp;a mp;amp;plusmn;336 days from first sessions.

The PVs were dividedinto a no-conduction (NC, n=108) andare-conduction (RC, n=106) group.

The highest amplitude of the PV potential decreased considerably from 0.36 ± 0.23 mV to 0.05 ± 0.14 mV in the NC (p<0.0001). Comparatively, the amplitude of the RC was almost equal between first (0.48 ±0.26 mV) and second (0.45 ± 0.28 mV) sessions (p=0.15). In the NC, six PVs indicated comparatively identical voltage between the two sessions resultant from automatic ectopic beats in PVs.

Conclusions: This study indicates that a lack of electrical signals from the atrium weakens the PV muscle, similar to that experienced with lack of exercise and skeletal muscle, while PV firing keeps PV potential. Long term EEPVI entraps PVs in only the vein without arrhythmic origin. It is considered that EEPVI over a long period abolishes AF recurrence from PVs.

Predictor of atrial fibrillation inducibility after pulmonary vein isolation assessed by speckle tracking echocardiography in patients with persistent atrial fibrillation

T. Hirose, M. Kawasaki, R. Tanaka, S. Warita, R. Matsuok

Gifu Prefectural General Medical Center, Japan

Introduction: The ablation strategies for persistent atrial fibrillation (AF) is not enough established. We assessed the hypothesis that global remodeling of left atrium (LA) may be responsible for recurrence of AF after extended pulmonary vein isolation (EPVI). The aim of this study was to discriminate persistent AF patients with LA global remodeling.

Methods: Consequent 33 patients with persistent AF were enrolled. LA emptying function (EF) as global function, peak strain and strain rate (SR) as regional function and LA volume (LAV) were measured before ablation procedure using speckle tracking echocardiography (STE). Cardioversion was performed before or during ablation procedure to maintain sinus rhythm, and AF inducibility was tested by atrial pacing within coronary sinus stimulator just after EPVI. The stimulation protocol consisted of 2 attempts at atrial pacing at the shortest cycle length resulting 1:1 atrial capture for >15 seconds. AF was considered inducible only if its duration was >5 minutes. Patients were divided into 2 groups according to the induction test: inducible group (n=20, age 58±11), and non-inducible group (n=13, age 58±11).

Results: In some STE indices, LAV (minimum) increased, and LAEF and LAEF / min. LAV x 100 were reduced in inducible group (68.8±23.0 vs. 49.8±17.7ml, 31.5±9.2 vs. 42.2±7.7% and 41±9 vs. 94±54, p<0.05, respectively). Using cutoffof47 of LAEF / LAV (minimum) x 100, the sensitivity and specificity was 100 and 80%, AUC was 0.95.

Conclusion: In persistent AF, we could discriminate patients with LA global remodeling by assessment ofvolume and function using STE.



Identifying spiral waves in physiological systems: an objective assessment of wave type

D Chapman, P Sanders, P Kuklik

Adelaide University, Australia

Background & Objectives: Spiral waves are hypothesised to be one mechanism underlying persistent atrial fibrillation (AF); however, their clinical localization has been difficult. While activation mapping has been the cornerstone for the successful ablation of many cardiac arrhythmias, significant challenges exist for activation mapping during complex arrhythmia like AF. This abstract describes a method for objectively assessing a spiral wave using the principles of activation mapping.

Methods: Four previously described activation sequences seen in AF were modeled using FitzHugh-Nagumo methods in custom software; spiral, ectopic foci, multiple waves and passive activation. Activation maps were exported in 50x50 matrices of x,y location and local activation time for each type. Distance from the position of earliest activation was calculated for each of the 2500 simulated electrode locations. Distance vs Activation Time (DAT) plots were created for each map. The best second order quadratic curve was fitted to the DAT maps. The curves were analysed for unique signatures to discriminate activation sequence.

Results: Curve agoodness of fita was calculated through regression analysis on DAT plots. r2 was high for spiral (0.83) and ectopic foci (0.89) and low for multiple (0.08) and planar activity (0.35). Spiral and Ectopic DAT plot curves yielded distinct curvature signatures of-4.05m-1 and ectopy 0.4m-1 respectively.

Conclusion: DAT plots are able to discriminate spiral waves and ectopic foci from multiple collisions and planar activity in simulated physiology.

Utility of an oesophageal temperature probe for geometry creation

C Hayes, S Fletcher Cooper, B Pardoe, KRajappan, T Be

John Radcliffe Hospital, United Kingdom

Introduction: Ablation of atrial fibrillation is frequently aided by electro anatomical mapping systems. One system in common use is EnSite NavX™ (St. Jude Medical, Inc., Minneapolis MN).

This relies on tranthorasic impedance using external patches and an internal catheter as a reference.

The model created is dependent on stability of the reference catheter.

We report on the use of an Oesophageal temperature probe as such a reference catheter and its stability.

Methods: 21 consecutive ablations for atrial fibrillation, both paroxysmal and persistent were carried out. catheters were positioned in the left atrium then the oesophageal temperature probe was positioned. Once in position we used the fluoroscopy equipment to create still images in LAO 30 and RAO 30.

The position ofthe temperature probe to a fixed point on the spine was measured.

The ablation was then performed at the operators discretion. This was always a wide area cirmcuferential ablation of the veins, but variously included ablation of complex fractionated electrograms and linear lesions. On occasion cardioversion was necessary.

At the end of the case the position of the temperature probe was again measured in LAO and RAO projections.

Results: The movement ofthe temperature probe was minimal. Mean displacement was 3.38mm vertically (range 0-14.85) and 2.38 horizontally (range 0-19.14). The largest displacements occurred post cardioversion.

There were no cases where the geometry had to be reset due to catheter shift

Conclusion: An oesophageal temperature probe can be successfully used as a stable reference for geometry.


The progression of trigger from non-pulmonary vein foci was the cause of the difficulty of ablation for very long-standing atrial fibrillation


Cardiovascular Center, Japan

Background: Catheter ablation (CA) of very long-standing persistent atrial fibrillation (VLS-AF; AF persisting >3 years) is difficult, because ofthe advanced AF substrate in atria. We assessed the possibility that the progression of AF trigger was also its cause.

Methods: Consecutive 263 patients underwent CA to persistent AF (PeAF) were investigated. Patients were divided into VLS-AF group (n=72) and others (PeAF group; n=191) based on the period AF persisted. Cardioversion were performed before procedure to determine the presence or absence of IRAF-Triggers, defined as premature atrial contraction initiating AF recurrence within 90 seconds after restoration of sinus rhythm (SR) reproducibly. We repeated cardioversion to distinguish IRAF-Triggers from pulmonary vein (PV) and those from non-PV (Non-PV IRAF-Triggers). We performed average 1.3 &plusmn; 0.5 sessions of CA, followed them for 20 ± 11 months and checked the AF recurrence based on ECG at the last hospital visit.

Result: Successful ablation of AF-Triggers were highly associated with success in maintenance of sinus rhythm (OR=16.3, p<0.0001). Non-PV AF-Triggers was observed in 23 patients (9%). All AF-Triggers ablated unsuccessfully were Non-PV AF-Triggers (16/16 patients, 100%) and their ablation were succeeded only in 30% (7/23) of patients. The prevalence of Non-AF AF-Trigger was significantly higher in VLS-AF group than PeAF group (15% vs. 6%, p=0.02). As a result, AF recurrence rate was significantly higher in VLS-AF group than in PeAF group (22% vs. 6%, p<0.018).

Conclusion: The progression of AF trigger from Non-PV foci was also the cause ofthe difficulty of CA for VLS-AF.


Predictors of echocardiographic left atrial reverse remodeling after catheter ablation for chronic atrial fibrillation

Marina Okada, Takehiro Kimura, Yoshiki Katsumata, Takahiko Nishiyama, Nobuhiro Nishiyama, Kotaro Fukumoto, Yoshiyasu Aizawa, Yoko Tanimoto, Seiji Takatsuki, Keiichi Fukuda

Department of Cardiology, University of KEIO, Japan

Background: It is known that ablation of atrial fibrillation(AF) results in a reverse remodeling of the left atrium(LA). The purpose of this study was to evaluate the impact of ablation on volume of LA, and to find predictors for LA reverse remodeling.

Methods: 88 patients with persistant AF undergoing ablations(1.4±0.7 sessions)were studied. LA volumes were assessed with echocardiography at baseline and after a mean of 24 ± 19months of follow-up. The study population was divided according to LA reverse remodeling. Responders were defined as patients who exhibited reduction in maximum LA volume at long-term follow-up.

Results: The LA size of patients who were sinus rhythm at follow-up was significantly smaller than patients with AF rhythm (3.8±0.5vs4.3±0.8cm,p=0.039).65 patients (73%) were classified as responders, whereas 23 patients (27%) were nonresponders. At baseline, LA size was significantly larger in the responders as compared with the nonresponders (4.3±0.6%vs.3.9±0.4%;p=0.001), and was significantly smaller at follow up (3.8±0.6%vs.4.1±0.5%; p=0.019). Although there were no significant differences in the number of ablations, plasma concentrations ofthe BNP, CHADS2 score, recurrence of AF, with or without CFAE ablation and past history of congestive heart failure, there were significant differences in the number of patients with hypertension (29.2%vs.52%; odds ratio2.641,p=0.048), and deceleration time ofthe transmitral flow (171.0±40.6vs.204.5±59.3cm/sec, p=0.010).

Conclusion: In the present study, 73% ofthe patients exhibited LA reverse remodeling after ablation for AF. Our findings suggest that hypertension and diastolic dysfunction could be involved in LA reverse remodeling.


New appearance of non-pulmonary vein triggers initiating atrial fibrillation in patients with durable pulmonary vein disconnection: lessons from repeat procedure

Takekuni Hayashi

Saitama Medical Center, Jichi Medical University, Japan

Background: Pulmonary vein isolation (PVI) is established strategy for paroxysmal atrial fibrillation (AF). However, it often requires multiple procedures since the incidence of recurrence was up-to 50% ofpatients at 5-year follow-up after single procedure.

Objective: The purpose of the present study was to evaluate repeated procedure irrespective with or without atrial tachyarrhythmia (ATa) recurrence.

Methods and Results: We investigated 46 consecutive patients with 182 PVs who underwent PVI of paroxysmal AF. All patients underwent repeat procedure after 6 months. ATa recurrence was present in 15 (33%) between sessions. At repeated procedure, 71 (39%) reconnected PVs were observed in 35 (76%) patients. The number of reconnected PV was more commonly observed in patients with ATarecurrence thanwithout ATa recurrence (2.3±1.0vs.1.2±1.1, P = 0.004). Non-PV triggers initiating AF was observed in 15 (33%) patients (4 [9%]; initial procedure, 11 [24%]; repeated procedure). During repeated procedure, non-PV triggers initiating AF was observed in 6 (55%) patients with durable PV disconnection and in 5 (14%) patients with reconnected PV (P = 0.013). Multivariate analysis showed durable PV disconnection was independent predictor of new appearance of non-PV triggers initiating AF (P = 0.011). During the median follow-up period of 367 days after repeated procedure, 40 (87%) of 46 patients were free from ATa without blanking period.

Conclusions: New appearance ofnon-PV foci initiating AF was prevalent in patients with durable PV disconnection. The present study may indicate PV disconnection is necessary but not sufficient improving outcomes.


Impact of low-dose dipyridamole injection on adenosine test after pulmonary vein isolation

S. Miyazaki, H. Taniguchi, T. Uchiyama S. Kusa, H. Nakamu

Tsuchiura Kyodo Hospital, Japan

Background: Dipyridamole increases the levels of extracellular adenosine. The study investigates the impact of low-dose intravenous dipyridamole on adenosine test after pulmonary vein isolation (PVI).

Methods and Results: This prospective study included 12 paroxysmal atrial fibrillation (AF) patients (61±12 years; 9 men), who underwent PVI at the first procedure. Transient PV reconnection was provoked by adenosine test in 4/48 (8.3%) PVs. In 44 PVs without reconnection intravenous infusion of low-dose (10 mg) dipyridamole preceded the adenosine test. Among 4 PVs with transient reconnection, it was eliminated by RF application(s) until no dormant conduction was exposed by adenosine test(s) in 2. Then, dipyridamole potentiated adenosine test was undertaken to provoke dormant conduction (Group-1). In the remaining 2 PVs, dipyridamole potentiated adenosine test was followed by RF elimination of conduction gap and repeat adenosine test to confirm complete elimination (Group-2).Low-dose dipyridamole prolonged the duration of adenosine induced AV block without vasodilatatory hypotension. There was no evidence of reconnection in 44 PVs without dormant conduction and in group-1, wherein transient reconnection was eliminated by 6.5±3.5 RF applications in 12.5±0.7 minutes and adenosine injected 4 times. In group-2, dipyridamole plus adenosine test revealed the same dormant conduction which persisted longer than during adenosine alone. It was eliminated by single RF application in 3.0± 0.6 minutes and adenosine injected once.

Conclusions: Low-dose dipyridamole safely prolongs the electrophysiological effects of adenosine test without provoking additional PV reconnection. This allows sustained visualization and facilitates complete RF elimination of the electrical conduction gap.



Study on ablation therapy in primary prevention of cerebral infarction

Kenichi Hiroshima, Masahiko Goya,Kentarou Hayashi,Yuu Makihara,M

cardiorogy, Japan

Now stroke isn't just as a cause of death in an aging society, but also take more medical costs and reduce quality of life. Especially cerebral infarction caused by atrial fibrillation is rising and is becoming more severe rather than other type of cerebral infraction. Now some large scale studies reported that warfarin and new oral anticoagulants are useful to prevent cerebral infarction for atrial fibrillation, but more over 1%/year of patients under these drugs were occurred stroke and anticoagulant hemorrhagic complication. If catheter ablation can prevent atrial fibrillation, we may reduce stroke and hemorrhagic complication by stopping the anticoagulant therapy for low CHADS2 groups. This time we investigated whether catheter ablation reduce stroke and hemorrhagic complication to looking back the patients over 65 years old who under went catheter ablation from 2004 to 2011 at Kokura Memorial Hospital. The number of patients following over 6 months are 281,190 men ,206 paroximal atrial fibrillation, mean age is 69.8 ±4.4, mean CHADS2 is 0.94, mean follow up period is 40.1months. 1st ablation success rate is 64.4% and finally 89.3% of patients are free from af. Anticoagulant drug are discontinued as possible as we can for low CHADS2 group .In this period, only one patient occurred TIA and no patient occurred sever hemorrhagic complication. Ablation is useful to prevent cerebral infarction and stopping unwanted anticoagulant reduce bleeding complication.

The Association of von Willebrand Factor with Left Atrium Remodeling in Patients with Atrial Fibrillation

Dae In Lee1, Jae Joong Lee1, Rho Seung Young1, Yae Min Park, Jin-Keun Jang1, Whan Cheol Park,Jong-Il Choi, Hong-Eui Lim5, Sang-Weon Park, Young-Hoon Kim

Department of Cardiology, Korea University Anam Hospital, Seoul, Korea; Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea; Jeju Halla General Hospital, Jeju, Korea; Hanyang University Guri Hospital Gyeongi, Korea; Korea Univeristy Guro Hosptial, Seoul, Korea

Background and Objectives: The correlation of von Willebrand factor (vWF) with atrial fibrillation (AF) has been demonstrated. However, the precise mechanism for the increased vWF in patients with AF is not clarified. This study investigated the association among vWF, clinical and echocardiography characteristics in patients with AF.

Methods: A total of 55 patients (40 male; 55±11 years old; 27 persistent AF) were analyzed. One day before catheter ablation, vWF antigen was evaluated by enzyme-linked immunoassay kits.

Results: The level ofvWF washigher in persistent AFthanthat in paroxysmal AF [149.1±.41.0(%) VS 115.7±39.8, p=0.003]. There was no significant difference of mean ofvWF according to risk factors of AF including hypertension, diabetes, CHADS2 and CHA2DS2VASc scores. Using simple linear regression analysis, vWF was directly correlated with LA size (R=0.382, P=0.004) and left atria appendage (LAA) velocity (R= -0.320, P=0.017). Multiple linear regression analysis demonstrated the association between the vWF and LA size (R=0.382, p=0.004).

Conclusion: vWF was significantly higher in persistent AF than that in paroxysmal AF. Patients with a high level of vWF were directly associated with LA size and LAA velocity. Further study to assess the relationship of vWF with LA substrates and long-term outcome of catheter ablation is warranted.

Keywords: von Willebrand factor, endothelial dysfunction, atrial fibrillation



The Delay of Electrical Potential in Left Atrial Appendage after Stepwise Ablation in Patients with Persistent Atrial Fibrillation Is Independently Related to Low Recurrence Rate of Atrial Tachyarrhythmias

Dae In Lee1, Jae Joong Lee1, Rho Seung Young1, Yae Min Park2, Jin-Keun Jang1, Whan Cheol Park, Jong-Il Choii, Hong-Eui Lim5, Sang-Weon Park, Young-Hoon Kim1

Department of Cardiology, Korea University Anam Hospital Seoul, Korea; Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea; .Jeju Halla General Hospital, Jeju, Korea; Hanyang University Guri Hospital Gyeongi, Korea; Korea Univeristy Guro Hosptial, Seoul, Korea

Introduction: Previous studies demonstrated that complete block of anterior line resulted in significantly delayed activation of the lateral left atrium (LA) and left atrial appendage (LAA). However the clinical outcome of delay of electrical potential LAA (LAA delay) is not known. This study investigated the relation of the LAA delay with clinical outcome in patients with persistent atrial fibrillation (PeAF).

Methods: 102 patients [12 females; 55.9± 10.1 years; 92 patients with LPAF] were analyzed. Patients underwent pulmonary vein isolation and complex fractionated atrial electrograms (CFAE)-guided anterior linear ablation. After restoring sinus rhythm, we evaluated LAA delay which was defined as either LAA potential followed the initiation of P-wave by > 110 ms or bidirectional block by differential pacing.

Results: In 44 patients of 102 patients (43%), LAA delay was achieved by CFAE-guided anterior line ablation. The recurrence rate of ATs in patients without LAA delay were higher than that with LAA delay [31 patients of fifty eight (53.4%) VS 13 patients of forty four (29.0%), P=0.026]. Multivariate cox regression analysis showed LAA delay (Hazard ratio: 0.46; P=0.046; Confidence intervals: 0.23-0.89), LA size (Hazard ratio: 1.07; P=0.034; Confidence intervals: 1.006-1.14) and diabetes (Hazardratio: 3.37; P=0.015; Confidence intervals: 1.27-8.95) were independently related to low recurrence rate of ATs after catheter ablation. No thromboembolic event was documented in patients with LAA delay during follow up.

Conclusion: LAA delay resulted from CFAE-guided anterior linear ablation led lower ATs recurrence after catheter ablation in patients with PeAF. LAA delay did not complicate with thromboembolic event during follow up

Keywords: anterior line, catheter ablation, atrial fibrillation

Long-term changes of heart rate variability after radiofrequency catheter ablation of atrial fibrillation: 1 year follow-up study in irrigation tip catheter era

Ki-Woon Kang, Jae Sun Uhm, Boyoung Joung, Moon-Hyung Lee1, Hui-Nam Pak

Yonsei University Health System, Seoul, Republic of Korea Eulji University Hospital Daejeon, Republic of Korea

Background: It has been known that radiofrequency catheter ablation (RFCA) ofatrial fibrillation (AF) changes cardiac autonomic nerve activity, but its long-term effect has not yet been evaluated in the open irrigation tip catheter (OITC) era.

Objectives: We hypothesized that post-RFCA changes of heart rate variability (HRV) are associated with clinical recurrence of AF and maintained over 1 year after OITC ablation.

Methods: We analyzed HRVs of pre-RFCA (HRVpre), post-RFCA 3rd month (HRV3™) and lyear (HRV:yr) with 24-hour Holter after sorting out arrhythmic events in 144 patients (70% male, 57±10 years old, 83% paroxysmal AF) who underwentRFCA with OITC.

Results: After RFCA with OITC, the increase of mean heart rate and reductions of HF or LF/HF were significant in HRV3mo (p<0.001) and maintained in HRV^ (p<0.01). During 20±8 months follow-up, 33 out of 144 patients (23%) showed clinical recurrence of AF. In contrast to the significant reduction ofHRV3m0 and lyrparameters in non-recurrence group, the patients with clinical recurrence did not show the reductions of HF in HRV3mo (p=0.05) and HR-V^ (p=0.189). In the Cox regression analysis, ALF/HF>0.26 in HRV^ was significantly associated with clinical recurrence of AF (HR 2.52, 95% CI 1.19-5.32, p=0.015).

Conclusions: In contrast to the previous reports about long-term HRV recovery after AF ablation with conventional catheter, RFCA-induced change of cardiac autonomic nervous activity maintained for 1-year in the OITC era. ALF/HF>0.26 at HRV3mo was independently associated with clinical recurrence of AF after RFCA.

Keywords: Atrial fibrillation, Heart rate variability, Catheter ablation, Irrigation tip catheter



Gene and protein expression of transient receptor potential channel in atrium from patients with atrial fibrillation

Feng Cao, Congxin Huang, Zhe Li, Wenmao Ding, Bin Zeng, Qingyan Zhao, Bo Yang

Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China

Background & Objectives: Studies have shown that TPRC channels are involved in the development of cardiomyotrophy, heart failure and cardiac arrhythmia. This study aimed to observe the expression of gene and protein of transient receptor potential channel (TRPC1) in human atrial myocytes of the patients with atrial fibrillation (AF) and to reveal the role of the exression underlying channel remodeling in chronic AF.

Methods: Thirty-seven patients with cardiac valve disease were divided into chronic atrial fibrillation (CAF) group (n=15), paroxysmal atrial fibrillation (PAF) group (n=9) and sinus rhythm (SR) group (n=13). Right atrial appendages were obtained in three groups underwent cardiac valve replacement surgery. The mRNA expression of TRPC1 in atrial myocytes was detected with reverse transcription polymerase chain reaction (RT-PCR), the protein expression of TRPC1 was measured with Western Blot.

Results: The mRNA and the protein expression level of TRPC1 were both significantly higher in CAF group than in SR and PAF group (P < 0. 01). Compared with SR group, The mRNA and the protein expression level ofTRPCl in PAF group were increased, but no significant difference was found. The mRNA and the protein expression level of TRPC1 were positively correlated with left atrial diameter and AF duration.

Conclusion; The changes ofmRNAandthe protein expression level of TRPC1 maybe associated with the incidence and continuance of atrial fibrillation.

Keywords: atrial fibrillation; transient receptor potential channel

The Impact of Low Voltage Area and Gross Area of Left Atrium on the Prognosis after Ablative Therapy in Patients with Atrial Fibrillation

Yoon-Jung Choi, Jeong-Hwan Cho, Chan-Hee Lee, Hyun-WookLee, Sang-Hee Lee, UngKim, Jong-Seon Park, Dong-Gu Shin, Young-Jo Kim

Department of cardiology, Yeungnam University Medical Center, South Korea

Background & Objectives: We sought to evaluate the relationship of the low voltage area (LVA) on voltage map (VM) and the gross area of left atrium (LA) on computed tomography (CT) and the recurrence rate in patients who underwent ablative therapy ofatrial fibrillation (AF).

Methods: From January 2010 to January 2012, we enrolled 38 eligible patients who underwent catheter ablation for AF. CT scan was conducted and VM of LA was performed before ablation. The study population was categorized by the size of low voltage area (into 2 groups by median value of 73.15 mm2), and the gross area of LA (into 2 groups by median value of 205.4 mm2). Clinical follow up was performed at 1, 3, 6, and 12-month.

Results: The higher rate of recurrence during blanking period was observed only in patients with the larger LVA (72.2% vs. 21.1%, p=0.003). However, the recurrence rate after blanking period was different according to LA diameter, CHADS2-VASc score, and hypertension. In adjusted model using continuous value of 2 parameters, only the LVA value [odds ratio, 1.06; 95% CI, 1.02 to 1.1; p=0.004] was risk factor for the recurrence during blanking period. For the recurrence after blanking period, alcohol consumption and the gross area of LA [Hazard ratio, 1.04; 95% CI, 1.02 to 1.07; p=0.001] were remained as risk factors.

Conclusions: The LVA and the gross area of LA were significant prognostic factors but the role of 2 parameters appeared to be different according to the time of recurrence.

Keywords: atrial fibrillation, ablative therapy



Successful radiofrequency catheter ablation in a child with paroxysmal atrial fibrillation due to left atrial tachycardia and atrial flutter

Ami Cho, Naokata Sumitomo, Akiko Komori, Hiromi Okuma, Yuriko Abe, Junji Fukuhara, Takahiro Nakamura, Rie Ichikawa, Masaharu Matsumura, Hiroshi Kamiyama, Mamoru Ayusawa, Shori Takahashi

Nihon University School of Medicine, Japan

Background: Atrial fibrillation (AF) without any heart disease in children is extremely rare arrhythmia. Here we report a child with paroxysmal atrial fibrillation due to left atrial tachycardia and atrial flutter.

Case Report: A 14 year-old boy was referred to our hospital for treatment of arrhythmia. He was first noted arrhythmia by electrocardiogram (ECG) before operation for allergic rhinitis. He has no family history of arrhythmia and no cardiac anomaly was found by echocardiogram. Irregular AF was noted on ECG. We decided to perform radiofrequency catheter ablation (RFA) to control this AF. During electrophysiological study, atrial flutter (AFL) (cycle length: 140 to 160 ms) was induced by rapid atrial pacing (SS140msec) under use of isoproterenol. AFL was successfully terminated by linear RFA from tricuspid annulus to inferior vena cava. No other tachycardia was initiated after AFL ablation, however 4 months later tachycardia was recurred. This tachycardia was spontaneously initiated with a cycle length of 226 ms. The earliest activation was recorded from posterior wall of the left atrium between right superior and inferior pulmonary vein. This atrial tachycardia was successfully terminated by point ablation of the earliest activation site. We followed him for 5 years without any recurrence of tachycardia.

Conclusion: Irregular AF electrocardiogram in this patient was probably recorded by combined occurrence of AFL and atrial tachycardia from left atrium. Precise mapping during AF may be significant to avoid unnecessary RFA lesions.

P Wave Morphology as an Independent Predictive Value for Recurrence of Atrial Tachyarrhythmias after Ablation of Paroxysmal Atrial Fibrillation

Jae Joong Lee, Dae In Lee' Rho Seung Young1, Yae Min Park, Jin-Keun Jang1, Whan Cheol Parkk, Jong-Il Choi, Hong-Eui Lim5, Sang-Weon Park1, Young-Hoon Kim1

Department of Cardiology, Korea University Anam Hospital, Seoul, Korea; Department of Cardiology, Gachon University Gil Medical Center Incheon, Korea; Jeju Halla General Hospital, Jeju, Korea; Hanyang University Guri Hospital, Gyeongi, Korea; Korea Univeristy Guro Hosptial, Seoul, Korea

Background & Objectives: This study was conducted to investigate that P wave morphology characterized by amplitude and duration after ablation of AF is a useful predictor of recurrence of AF after catheter ablation.

Method: 101 (76 male) patients with paroxysmal AF were included. Standard 12-lead ECGs was performed in all patients before and within 1-2 days after ablation. The amplitude(PA1) and duration(PD1) of P wave before and after(PA2, PD2) ablation were measured with a caliper and the difference between the two were defined as APA and APD. Recurrence was defined as any atrial tachyarrhythmias occurring after 3 months.

Results: During the follow-up of 31.4 ± 3 months, 24% showed recurrence of ATs. PA1, PA2, and APA did not show significant difference between the recurrence group and the non-recurrence group. But in recurrence group, PD1 (105.3 ± 14.1 vs 114.9 ± 14.9ms, P=0.006) was significantly shorter and PD2 (103.7 ± 17.4 vs 89.9 ± 13.0ms, P=0.001) was significantly longer than those without recurrence. APD (1.6 ± 10.4 vs 24.9 ± 11.8ms, P=0.001) was significantly shorter in the recurrence group. Multivariate cox regression analysis showed PA2 (hazard ratio: 2.906; P=0.044; confidence interval: 1.0.28-8.214), PD1 (hazard ratio: 0.961; P=0.019; confidence interval: 0.9290.993), PD2 (hazard ratio: 1.053; P=0.001; confidence interval: 1.029-1.078), APD (hazard ratio: 0.923; P=0.001; confidence interval: 0.903-0.945) were independently relatedto recurrence of ATs after ablation of paroxysmal AF.

Conclusion: P wave duration before and after ablation, andAPD, tiny amplitude of P wave after ablation were independent risk factors for predicting recurrence after ablation of paroxysmal AF.



Left Atrium and Left Atrial Appendage Function: relation with CHADS2 score and clinical outcome

H-C Park, HS Lee, KJKo, DILee, YM Park, JM Shim, J-E

Hanyang University Guri Hospital, South Korea

Background: Background: Left atrial (LA) or LA appendage (LAA) thrombogenic milieu (spontaneous echo contrast, sludge, and thrombus) which was determined by transesophageal echocardiography was definitely related with stroke event. The aim of this study was to find the correlation between multiple clinical parameters including LA and LAA function which were assessed by ejection fraction in LA angiogram and CHADS2 score and clinical outcome after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF).

Methods: This study comprised 176 paroxysmal AF patients (137 men, 54.1 ± 11.5 years old) who underwent LA angiogram and RFCA. We calculated LA and LAA ejection fractions (EFs) which images were obtained in LA angiogram and clinical parameters including CHADS2 score. We also compared these parameters for AF recurrence after RFCA. Of these patients, 17 (9.7%) had a history of stroke/TIA (transient ischemic attack).

Results: The mean follow up duration and CHAS2 score were 34.3 ± 12.8 months and 0.82 ± 0.98. The proportion of oral anti-coagulants use was 35.8% (63 out of 176) and the mean international normalized ratio in these patients was 2.52 ± 0.68. Among the clinical parameters, the LAEF and LA size were correlated with CHADS2 score (p= 0.019, p= 0.028 respectively). The body surface area was also correlated with CHADS2 score (p< 0.001). The others including LAA EF, LV EF, LA volume, LAA volume and AF duration were not. The age, CHADS2 score, LA volume, LAA volume, LV EF, and the LA EF were not significantly different between AF recurrence and non-recurrence groups. In the Cox regression analysis for AF recurrence, anti-arrhythmic drug medication use, the LAA EF, and AF duration were the significant predictors of AF recurrence after RF catheter ablation. (p< 0.001, p= 0.008, p= 0.013 respectively).

Conclusions: The LA EF and LA size were correlated with CHADS2 score in paroxysmal AF patients. However, LAAEF andAF duration were the predictors of AF recurrence.

Keywords: CHADS2 score, atrial fibrillation (AF), ejection fraction (EF)

The difference in autonomic nervous activity between paroxysmal and persistent atrial fibrillation and its change after radiofrequency catheter ablation

Y. Nakazawa, K. Yoshida, K. Ogata, T. Inaba, T. Miyashita, K.Aonuma

University of Tsukuba, Japan

Background & Objectives: Autonomic nervous activity plays an important role in the occurrence and maintenance of atrial fibrillation. The difference in autonomic nervous activity between paroxysmal and persistent AF has not been elucidated.

Methods: The subjects consisted of 120 patients with paroxysmal AF (n=97) or persistent AF (n=23). Patients with structural heart disease were excluded from the study. Magnetocardiogram (MCG) was undergone 1-day before (baseline), 1-day, 8 weeks, and 24 weeks after ablation to analyze the heart rate variability (HRV).

Results: At baseline, low/high frequency component (LF/HF) reflecting sympathetic activity and heart rate in persistent AF group were lower than that in paroxysmal AF group (LF/HF = 0.692 ±0.360 vs. 2.543 ± 2.133, P = 0.026, HR = 53 ± 7 vs. 61 ± 10 /min, P = 0.048). High-frequency power (HF) reflecting parasympathetic nervous activity in persistent AF group was higher than that in paroxysmal AF group (67.73 ± 55.10 vs. 35.60 ± 34.90 ms2, P = 0.027). HF was dramatically decreased 1-day after ablation in both groups and the difference in HF between paroxysmal AF and persistent AF groups became non-significant at any follow up points. LF/HF was significantly decreased 1-day after ablation in paroxysmal AF and this decrease persisted throughout the follow up, whereas LF/HF tended to increase until 8 weeks after ablation in persistent AF group.

Conclusions: Parasympathetic nervous activity in persistent AF group was higher than that in paroxysmal AF group at baseline. Autonomic nervous activity was dramatically influenced in both groups after radiofrequency catheter ablation.



Prolonged Ablation Duration for Persistent Atrial Fibrillation: Always Bad?

Jaemin Shim, Dae In Lee, Yae Min Park, Whan Cheol Park, Jin-Keun Jang, Jong-Il Choi, SangWon Park, Young-Hoon Kim

Korea University Anam Hospital, Seoul, Korea

Background: Extensive and prolonged radiofrequency catheter ablation (RFCA) procedures are not uncommon in persistent atrial fibrillation (PeAF). It has been reported that long duration of ablation is associated with worse clinical outcome. This study evaluated clinical outcome and predictors of recurrence in patients who underwent prolonged RFCA for PeAF.

Methods: Since January 2008, a total of 57 consecutive patients (mean age 57±9 years, 84% male) with drug-refractory PeAF who underwent RFCA using a stepwise approach (including pulmonary vein isolation, biatrial ablation of complex fractionated electrograms and linear lesions) with prolonged ablation duration (> 200 minutes) were included. We analyzed the clinical characteristics and predictors of arrhythmia recurrence.


1. During 23±18 months of follow-up, clinical recurrence after 3 months of blanking period occurred in 31 patients (54.4%). Redo ablation was performed in 12 patients (12%) and freedom from any atrial arrhythmias after repeated ablation procedures was reached in 61.4% of patients.

2. In terms of complications, groin hematomas and pericardial tamponades which were managed successfully by pericardial drainage occurred in 2 (3.5%) and 4 (7%) patients, respectively. One patient (1.8%) had sinus node dysfunction unmasked after cardioversion and required pacemaker implantation. No stroke occurred.

3. When we compared clinical characteristics between patients with and without recurrence, there were no significant differences in age, gender, CHADS2 score, AF duration, left atrium size, ablation duration, and mode of termination during the procedure (all p>0.05).

4. In a Cox regression analysis, diabetes was an independent risk factor for recurrence of AF after RFCA (OR 3.712, CI 1.064-12.951, p=0.040).

Conclusions: Prolonged ablation for PeAF is acceptably safe and effective. Diabetes was an independent predictor of worse clinical outcomes in patients with long duration of RFCA.

Keywords: prolonged ablation duration, atrial fibrillation, catheter ablation

The Characteristics of the Patients who Implanted Permanent Pacemaker after Atrial Fibrillation Ablation

Yung-Lung Chen

Division of Cardiology, South Korea

Introduction: Symptomatic sinus node dysfunction (SND) or atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation was rarely complicated after atrial fibrillation (AF) ablation. This study aimed to analyze the underlying etiology and ablation lesion set in patients required PPM implantation after AF ablation.

Methods: Among 1428 patients underwent AF ablation between October 2002 and August 2012, total 13 patients (0.9%) received PPM implantation. The patients&rsquo; characteristics and procedural factors related to PPM implantation were analyzed.

Results: Among the 13 patients (M:F = 7:6, mean age: 58 ± 11 years), eight (62%) patients had paroxysmal AF and 5 patients (38%) had persistent AF. The median time interval from AF ablation to PPM implantation was 16 days (range: 3-570 days). SND was accompaniedwith AF as a clinical tachycardia-bradycardia syndrome in 4 patients prior to AF ablation. In these 4 patients, symptomatic sinus arrest was followed by recurrent AF during follow up. Two patients received His bundle ablation to control ventricular rate. In other 7 patients without PPM indication before ablation, SND and complete AVB were newly developed in 3 and 4 patients. Those 2 patients with sinus pause more than 3 seconds all received superficial vena cava (SVC) isolation , and those 4 patients with complete AVB all received high septal ablation.

Conclusions: Underlying SND accompanied with AF, SVC isolation and extensive ablation lesions at the high septum were attributable to significant bradycardia requiring PPM implantation after AF ablation.


Safety of Catheter Ablation for Atrial Fibrillation in Nonagenarians

L. Bing Liem

El Camino Hospital, United States of America

Background and Objectives: Catheter ablation for atrial fibrillation (AF) has become a common practice as its efficacy over safety profile has improved over the past decade. However, there remains a concern in performing the procedure in the elderly due to reported increased in procedural complications. Previous studies have shown that patients over the age of 75 years have a significantly higher risk for stroke and other major complications as compared to those younger. Many centers, however, have performed AF ablations in people up to age 85 years old but there has been few reports safety in patients over 90 years old.

Methods: We performed AF ablations in four patients over 90 years old (ages 90-92; 1 male and 3 females) with recurrent persistent AF. All patients were otherwise healthy and lead an active life. All desired arrhythmia cure with the hope of attaining better quality of life (QOL). One patient was still engaged in long-distance bicycle tours around the world and desired to be off anticoagulation. Three of four patients underwent a second session of ablation before achieving long-term (over a year) cure, the fourth (who also had recurrence) decided to have rate control with atrioventricular junction (AVJ) ablation as she already had a pacemaker in-situ.

Results: All patients underwent their ablation(s) without major or any cardiovascular complications. The one male patient with a history of prostate hypertrophy had recurrent urinary retention requiring urologic consultation. Three patients were cured and one decided to have rate control with AVJ ablation.

Conclusions: AF ablation is safe in nonagenarians who are otherwise healthy and arrhythmia cure leads to improved QOL.


The Affect of Anatomical Pulmonary Vein Variation for Atrial Fibrillation Ablation and its Clinical Outcome in Patients with Atrial Fibrillation.

Y. Nagamoto, T Tsuchiya, T Yamaguchi, K Miyamoto, T Matsuu

Saga Prefectural Hospital Koseikan, Japan

Background & Objectives: It is known there is a variation of pulmonary vein (PV) anatomy. This study aimed to evaluate the affect of anatomical PV variation on the procedure of atrial fibrillation (AF) ablation and its clinical outcome.

Methods: Sixty-six patients undergoing pulmonary vein antrum isolation (PVAI), and if necessary, substrate ablation and/or cavotricuspid-isthmus linear ablation were analyzed. All patients were classified into 2 groups according to anatomical PV variation; normal PV (Group 1), right middle PV branch or left PV common trunk (Group 2). Left atrium (LA) and PV volumes were calculated using NavX software with the pre-acquired computed tomography. In addition to this, AF type, the parameters during AF ablation procedure such as total radiofrequency energy, procedure and fluoroscopy time, and the number of non PV atrial foci inducing AF, and the rate of AF/atrial tachycardia recurrence during follow-up period were compared between 2 groups.

Results: AF type, procedure and fluoroscopy time, the number ofnon PV foci, LA and PV volume were similar between 2 groups, however radiofrequency energy for right PVAI is more needed (p<0.05) and the rate of AF/atrial tachycardia recurrence during a period of 18.4 ± 6.8 months tended to be higher in Group 2(p = 0.16)

Conclusion: In patients with anatomical PV variation who undergo AF ablation, total radiofrequency energy is more needed for right PVAI, which might result in a worse clinical outcome tendency.


Superior Outcome of Hybrid Procedure as Compared to Catheter Ablation for Atrial Fibrillation

L. Bing Liem, Gan H. Dunnington

El Camino Hospital, United States oof America

Background and Objectives: Curative procedure(s) for atrial fibrillation (AF) has been the desired therapeutic modality by patients and is becoming a mainline form of treatment even for persistent and longstanding persistent AF. Both surgical and catheter-based methods are being pursued. The recent advancement in minimally-invasive approach utilizing video-assisted thoracoscopic surgery (VATS) for a Maze procedure has gained advancement as, under an experienced surgeon, achieves high efficacy of cure rates when coupled with endocardial ablation for completion of ablation lines not feasible from epicardial approach. Initial reports from centers performing this hybrid procedure have been promising.

Methods: We report comparative procedural data and arrhythmia outcome in patients undergoing the hybrid procedure (19 patients) to those with catheter-based approach ( 32 patients) from the same institution over the same period of time (04/2011-12/2012). The hybrid procedure was performed in a staged fashion, whereby the catheter ablation was conducted 2-3 days after the surgery.

Results: Procedural safety was similar in the two methods. There were no major procedural complications from either approach. One patient with the VATS Maze procedure had respiratory distress from a mucous plug. Hospitalization was longer in those undergoing the hybrid procedure (4.5 days) versus catheter approach (1.1.days). Cure rate (after 8.2 months) was significantly higher from the hybrid procedure (89%) as compared to catheter-based approach (82% for paroxysmal AF and 78% for persistent AF; with some patients having to have two sessions of ablation).

Conclusion: Hybrid procedure with VATS Maze followed by catheter based is safe and highly effective in patients with paroxysmal, persistent or longstanding persistent AF.


The predictor of early recurrence of atrial fibrillation after pulmonary vein isolation

Ken-ichi Yokoyama, Keiichi Inada

Jikei University School of Medicine, Japan

Background and Objectives: It has been already known that early recurrence of atrial fibrillation(ERAF) is not rare after pulmonary vein isolation (PVI) and is associated with AF recurrence during a long-term follow-up. However, the predictor of ERAF itself has not been well determined in patients with paroxysmal atrial fibrillation (AF).

Methods: A total of 426 patients with paroxysmal AF who underwent the single PVI targeting all four PVs was included. No atrial substrate ablation was performed in any patients. ERAF was defined as AF appearance within the first 5 days after PVI procedure. We compared clinical characteristics and ablation results between patients with and without ERAF.

Results: All PVs were successfully isolated. ERAF was observed in 139 patients (32.6%). On univariate analysis, age was higher (57.5±2.7 vs. 54.6±1.3 year of age, p<0.01), dimension of left atrium was larger (38.6±1.0 vs. 37.1±0.6mm, p<0.01) in patients with ERAF compared to those without. Interestingly, ERAF was less frequently observed in patients who underwent ablation by using irrigated catheter than those who did not (70/243(28.8%)vs 69/183(37.7%),respectively ,p<0.05). Multivariate analysis demonstrated that older age (p=0.02; odds ratio=1.03; 95% CI 1.004 to 1.046), enlarged left atrium (p=0.02; odds ratio=1.05; 95% CI 1.008 to 1.093) and use ofnon-irrigated catheter predict ERAF (p=0.02; odds ratio=1.67; 95% CI 1.089 to 2.550).

Conclusion: Older age and larger left atrium can predict ERAF following the single PVI. Use of irrigated catheter might be reasonable to reduce AF appearance in acute phase following ablation procedure



AF surveillance post AF ablation using implantable cardiac monitor

JH Ip, X Yan, D Grimes, K Jager, D Gandhi

Sparrow Hospital System, United State oof America

Pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF), however, there is no consensus on the definition for success or follow-up strategies.Existing data are limited to intermittent Holter or trans-telephonic monitoring with reliance of patients symptoms.

Objectives: We sought to determine the outcomes of AF ablation and post-ablation AF surveillance with a leadless implantable cardiac monitor (ICM).

Methods: Sixty-five patients with drug refractory AF underwent pulmonary vein isolation. An ICM was implanted subcutaneously post-ablation to assess AF recurrence. AF recurrence was defined as > 1 AF episode with a duration of > 30 S. The device-stored data was downloaded weekly over the internet and will transimtted events were reviewed.

Results: A total of 2105 AF automatic and patient activated AF episodes were analysed over a follow-up of 18 +/- 4 months. Of these episodes, 63% were asymptomatic. Furthermore, only 49% ofthe patient-activated episodes were AF. AF recurrence was highest in the first 4 weeks and substantially decreased 6 months post-ablation. The overall freedom from AF recurrence at the end of follow-up was 54%. When 48 h Holter recordings were compared with the device stored episodes, the sensitivity ofthe device to detect AF was 95% and the specificity was 62%.

Conclusion: The ICM provides an objective measure of AF ablation success and provides excellent sensivity in AF detection. A significant percentage of AF episodes post-ablation are aymptomatic.

Intracardiac echocardiography in steerable sheath: noble tool for safe transseptal intervention

Shinji Ishimaru, Risa Kakinoki, Mariko Kawasaki, Masaki Tabata, Motohito Tadokoro*, Shunsuke Kitani, Teppei Sugaya1, Kuniharu Nishimura1, Tadashi Igarashi, Hiroaki Okabayashh, Jungo Furuya1, Yasumi Igarashi1, Keiichi Igarashi1

Internal Medicine of Cardiology, Cardiovascular Center, Hokkaido Social Insurance Hospital Department of Medical Engineering, Hokkaido Social Insurance Hospital

Background: Transseptal left heart catheterization plays an important role in both coronary intervention and electrophysiology. Although transseptal catheterization is a safe procedure generally, several complications were reported such as accidental aortic puncture and cardiac tamponade following atrial or ventricular perforation. The rate of complications is not so high. But once the complication happens, it will be sometimes lethal without proper treatment. Intracardiac echocardiography (ICE) guided approach is regarded as safe and reliable. But the operator might not gain good septal wall image using ICE in pre-shaped sheath or straight sheath. The steerable sheath bending any angle as you like, might give the operator a good image of septal wall in atrial septal puncture.

Objectives: To evaluate the safety and efficacy of ICE in steerable sheath (AGILISTM; St. Jude Medical Inc, St. Paul, MN) in transseptal intervention.

Method: In transseptal catheterization, such as ablation of atrial fibrillation (AF), left-sided accessory pathway (lt. AP), and atrial tachycardia (AT) originating in left atrium, we used ICE in AGILISTM form Mar.2011 to Feb. 2013. Consecutive 64 patients (AF n=52, lt. AP n=8, AT n=4) underwent transseptal catheterization. Mean left atrial diameter evaluated by echocardiogram in parasternal long axis was 43.3 mm in AF, 36.9 mm in lt. AP, and 35.2 mm in AT.

Result: No failure was found in atrial septal puncture with ICE in AGILISTM. And there is no complication along with this procedure.

Conclusion: Using ICE in steerable sheath is safe and reliable tool in atrial septal puncture.



Echoguided venopuncture: safe and reliable method in patient with anticoagulation

Shinji Ishimaru1, Risa Kakinok1, Mariko Kawasaki, Masak Tabata, Motohito Tadokoro1, Shunsuke Kitani, Teppei Sugaya1, Kuniharu Nishimura1, Tadashi Igarashi, Hiroak Okabayash1, Jungo Furuya1, Yasumi Igarashi1, Keiichi Igarashi1

Internal Medicine of Cardiology, Cardiovascular Center, Hokkaido Social Insurance Hospital Department of Medical Engineering, Hokkaido Social Insurance Hospital

Background: Venopuncture is an essential procedure in medical front. Although venopuncture is a safe procedure generally, several complications might occur such as hematoma, veno-arterial anastomosis and hemorrhage which is needed catheter intervention to stop bleeding. The cause of those complications is not for venous, but for misdirected arterial puncture. So the operator must pay attention not to puncture artery especially in patients under anticoagulation. In ablation of atrial fibrillation (AF), patients usually take anticoagulant and continue it before, during, and after operation. There is a risk of bleeding by arterial puncture in blind procedure especially under unticoagulation. Echoguided approach can make it possible to puncture target vein under direct visual guidance by echogram and might reduce vascular complications.

Objective: To evaluate the safeness and reliability for echoguided venopuncture in patients under anticoagulation in AF ablation.

Method: From Mar. 2011 to Feb. 2013, we had consecutive 58 patients who underwent AF ablation. All of them took anticoagulant. 25 took warfarin, 24 dabigatran, and 1 rivaloxaban. Six in 58 patients took antiplatelet therapy along with anticoagulant and three in six took dual antiplatelet therapy. Total venopuncture were 217 times. Jugular vein punctures were 55 and femoral vein 162. All of the puncture procedures were done by echoguidance.

Result: There was no complication along with puncture procedure, such as hematoma, veno-arterial anastomosis,or hemorrhage needed intervention during and after AF ablation.

Conclusion: Echoguided approach is simple procedure and safe and reliable method of venopuncture especially in ablation of atrial fibrillation under anticoagulation therapy.

Evaluation of electrophysiological and antiarrhythmic effects of niferidile, investigational potassium channel blocker, in patients with supraventricular tachycardia

N.Yu. Mironov, S.P. Golitsyn, S.F. Sokolov, E.B. Maykov, N.B. Shlevkov, Yu.A. Yuricheva, Yu.V. Mareev, L.V. Rosenstraukh, E.I. Chazov

Russian cardiology research complex, Russia

Background: Niferidile (Nf) is an investigational potassium channel blocker. Greater affinity of Nf to atrial myocardium predispose to high efficacy in supraventricular arrhythmias and low risk of ventricular proarrhythmia.

Aim: Assessment of electrophysiologic and antiarrhytmic effects of Nf in patients with paroxysmal supraventricular tachycardia (PSVT).

Methods: Effects ofNf (20micrograms/kg intravenously) were studied in 30 patients (18 males) with PSVT by electrophysiological study. All patients signed the consent form before inclusion.

Results: Nf terminated PSVT in 16 of 21 patients (76%) and prevented reinduction in 20 of 26 patients (77%).

Nf prolonged sinus cycle length (by 5.1%), did not alter sinus node recovery time and corrected sinus node recovery time and decreased sinoatrial conduction time (by 6.7%). Nf increased ERP of right atrium (by 21.9%), left atrium (by 20.9%), right ventricle (by 11.4%) and accessory pathways (anterogradely by 21.5%; retrogradely by 34.4%).

Nf increased ERP of AV node (by 21.6%), relative (by 36.8%) and functional (by 35%) refractory periods of His-Purkinje system. Nf did not increase PQ, AH and HV intervals. In patients with WPW syndrome modest increase in P-Delta interval (by 6%) was observed.

Nfprolonged QT (by 22.6%) andQTc(by20.9%) intervals. In 1 of30patients (3.3%) shortrun of polymorphic ventricular tachycardia (13 complexes) was registered.

Conclusion: Nfdemonstratedhigh antiarrhythmic efficacy andgood safetyprofile in patients with PSVT. Prolongation ofERP is the main electrophysiologic effect ofNf.


Omega-3 polyunsaturated fatty acids may decrease the incidence of clinical postoperative atrial fibrillation

Xue-Yuan Guo, Cai-Hua Sang, Chen-Xi Jiang, Ri-Bo Tang, De-Yong Long, Rong-Hui Yu, Man Ning, Rong Bai, Xin Du, Jian-Zeng Dong, Chang-Sheng Ma

Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, 100029, China

Background and Objectives: The effects of omega-3 fatty acids (PUFA) on the preventionof postoperative atrial fibrillation (POAF) were discrepant from current studies. The aim of this meta-analysis was to ascertain the protective role ofPUFA on POAF.

Methods: Studies were identified through PubMed, CENTRAL, EMBASE, reviews and reference lists of relevant papers. The odds ratio (OR) was calculated for POAF. Statistical analysis were performed with Review Manager 5.0 (The Cochrane Collaboration, Copenhagen, Denmark).

Results: 8 randomized controlled trials with 2687 patients were included in the analysis. The use ofPUFA did not significantly reduce the incidence of POAF compared with the control (OR:0.76; 95%CI: 0.57-1.03; P=0.08; I2=52%). However, PUFAreducedthe incidence ofclinical POAF that lasted >5 minorrequiredinterventionby 16%(OR:0.84; 95%CI: 0.71-0.99;P=0.04; I2=45%).

Conclusions: PUFA can not decrease the incidence of POAF, but appears to be effective in the prevention of clinical POAF. Studies about PUFA on the prevention of POAF may be still worthwhile to be conducted in the future.


CHADS2 and CHA2DS2-VASc Scores in the prediction of mortalities in patients without atrial fibrillation after acute myocardial infarction (from the KAMIR)

Jin Hee Choi1, Jun Kim1, Sang Hyun Lee1, Min Ku Chun1, Jeong Su Kim1, Yong-Hyun Park1, June Hong Kim1, Kook Jin Chun1

Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea

Background & Objectives: The CHADS2 and CHA2DS2-VASc scores are simple and validated stroke risk stratification schemes for patients with nonvalvular atrial fibrillation (AF). The CHADS2 and CHA2DS2-VASc components, such as heart failure, hypertension, and diabetes mellitus, are risk factors for stoke, cardiovascular events and mortality. However, the value of those scoring system in the risk stratification of patients without AF presenting with acute myocardial infarction (AMI) has not yet been specifically investigated. This study aimed to evaluate whether the CHADS2 and CHA2DS2-VASc scores can be predictors of mortality in patients after AMI.

Methods: Of 14,885 patients enrolled from 2005 to 2008 in the Korea Acute Myocardial Infarction Registry (KAMIR), 12,178 patients without AF were analyzed. The main clinical outcomes were all-cause and cardiac death.

Results: Patients with higher CHADS2 and CHA2DS2-VASc scores were older and had decreased eGFR. All-cause and cardiac death were higher in patients with CHADS2 score > 2 and CHA2DS2-VASc score > 3 (Figure). On Cox proportional hazards analysis, higher CHADS2 and CHA2DS2-VASc scores independently predicted all-cause (harzard ratio [HR] 2.1, 95% confidence interval [CI]=1.621-2.594, p<0.001; and HR 3.5, 95% CI=2.592-4.856, p<0.001, respectively) and cardiac death (HR 2.0, 95% CI =1.488-2.684, p<0.001; and HR 3.8, 95% CI=2.465-5.708, p<0.001, respectively). Additionally, decreased eGFR (<60ml/min/1.73m2) and female gender were independent predictors for all-cause and cardiac death.

Conclusion: The CHADS2 and CHA2DS2-VASc scores are useful predictors ofmortality after AMI.

Figure. Kaplan-Meier survival curves for all-cause (A, B) and cardiac death (C, D) by CHADS2 and CHA2DS2-VASc scores

0 200 400 600 0 200 400 600

Days after follow-up Days alter follow-up


In hospital registry of atrial fibrillation and multivariant analysis

B Vijaya Chaitanya, B Vinodkumar ,S Thanikachalam

Sri Ramachandra University, India

Aim: To study the role of risk factors in the genesis of atrial fibrillation and its association with valvular and non valvular heart diseases and incidence of complications.

Methods & Results: In a large single centre study, 1506 hospitalized patients with ECG-documented AF between Jan 2007 to 31 st dec 2012 were enrolled. The clinical type of AF was grouped as chronic( n-614), paroxysmal (n-586) and first detected (n-306). Classified them into valvular(30.6%) and non valvular(69.33%). Among valvular 70.33% are of rheumatic in nature. Among the non valvular causes large number of patients had hypertension (59.8%).11.2% had lone AF.6.9% had thromboembolic complications. Heart failure was noted in 27%. Antithrombotic measures for stroke prevention was given to 41.2% of eligible patients, among them antiplatelets (73.5%) are preferred. No direct relation between LA size and LVEDD and LV mass index was noted, but LA enlargement more than 4.0 cm seen in 78.6% patients.

Conclusion: Rheumatic valvular heart disease is still a considerable burden in developing world. Systemic hypertension is becoming a prevalent, anti-thrombotic measures are still inadequate. LA size can be a single most reliable indicator.



Are Asian patients more susceptible to intracranial bleeding of new oral anticoagulants for stroke prevention in atrial fibrillation? Insights from a meta-analysis of randomized controlled trials

Joey S.W. Kwong, Yat-Yin Lam, Bryan P. Yan, Cheuk-Man Yu

The Chinese University ofHong Kong, Hong Kong

Background & Objectives: Asian patients with atrial fibrillation (AF) are more susceptible to warfarin-related intracranial bleeding. Whether this phenomenon is consistent with the new oral anticoagulants (NOACs) remains unknown. We aimed to systematically review the safety and efficacy ofNOACs for stroke prevention in Asian patients with AF.

Methods: MEDLINE, EMBASE and CENTRAL were searched in May 2013 for eligible randomized controlled trials (RCTs). Primary outcomes were intracranial bleeding, major and clinically relevant non-major (CRNM) bleeding, and gastrointestinal (GI) bleeding. Secondary outcomes were all-cause mortality, stroke and systemic embolism, ischemic stroke and hemorrhagic stroke. A Mantel-Haenszel random-effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs).

Results: We included four Asian-only RCTs (n=2649) and one subanalysis of Japanese participants ofthe global RE-LY study (n=326). No significant differences were observed in intracranial bleeding (RR 0.53, 95% CI 0.22-1.31, P=0.17), major and CRNM bleeding (RR 1.06, 95% CI 0.81-1.38, P=0.69), or GI bleeding (RR 0.61, 95% CI 0.27-1.39, P=0.24). NOACs were associated with a significantly lower rate of stroke and systemic embolism (RR 0.45, 95% CI 0.24-0.83, P=0.01) and ischemic stroke (RR 0.41, 95% CI 0.19-0.86, P=0.02), with no effects in hemorrhagic stroke (RR 0.56, 95% CI 0.17-1.89, P=0.35) or all-cause mortality (RR 0.99, 95% CI 0.29-3.36, P=0.98).

Conclusions: NOACs are more effective than warfarin in reducing stroke and systemic embolism in Asian patients with AF, with comparable bleeding profiles. Further research may be useful to establish Asian-specific clinical guidelines on the use ofNOACs in AF.

Safety and efficacy of short-time compression with a kaolin filled pad after catheter ablation of atrial fibrillation

Y Matsudo, Y Hama, T Kuwahara, H Fujimaki, S Tokimasa B

Kimitsu Chuo Hospital, Japan

Background: The administration of anti-coagulants during atrial fibrillation (AF) ablation may require a long period of manual compression to insure hemostasis at femoral puncture sites. A newly developed hemostatic pad filled with kaolin causes blood to clot quickly. This study prospectively assessed the safety and efficacy of a 5 minute compression with a kaolin-filled pad after catheter ablation of AF.

Methods: A total of 328 procedures were performed in 300 patients (72% male, mean age 66.5 ± 10.5 years). The patients were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation (Dabigatran group, n=80) and those undergoing ablation on dose-adjusted warfarin (Warfarin group, n=248). Dabigatran was held 24-30 h pre-procedure and restarted 4-6 h after the procedure. Warfarin was continued through the procedure. The standard right femoral access employed a 5 French sheath in the right femoral artery and 3 sheaths (8.5 French, and two 8 French) in the right femoral vein. All patients received compression with the kaolin-filled pad upon sheath removal.

Results: The mean activated clotting time at the time of sheath removal was 325±64 seconds. The total procedural time was 169±56 minutes. Hemostasis was achieved with only 5 minutes of manual compression in 96.3% (316/328) ofthe procedures. Rebleeding or groin hematomas were less frequent in the Dabigatran group than in the Warfarin group (0% vs. 4.8%, P=0.04) No device-related complications, or deep vein thromboses occurred.

Conclusion: A kaolin filled pad yielded prompt and safe hemostasis. Femoral complications were infrequent in the Dabigatran group.



Clinical usefulness of the blood bepridil concentration measurement and validity of the dose adjustment by creatinine crearance in atrial fibrillation patients

Shunichiro Hondo, Daisuke Kito, Shintaro Matuura , Hideki Tokuhisa, Kanako Yamamoto, Wataru Omi, Takahiro Saeki, Hideo Nagai, Satoru Sakagami

National Hospital Organization Kanazawa Medical Center, Japan

Background & Objectives: Bepridil is an antiarrhythmic drug blocking potassium channel mainly, and has been used to treat refractory atrial fibrillation (AF) in Japan. But it is somewhat difficult drug to use because of its nonlinear effect to ECG parameters and clinical effectiveness depends on its use duration. Blood concentration (BC) of the drug can be a useful indicator for the adjustment ofthe dose.

Methods: We evaluated bepridil BC in 101 AF patients (male 59, mean age 70yrs) who had taken it more than one month. We investigated the relationship between the BC and various clinical parameters.

Results: The drug dose was 125±40mg/day and the BC was 590±460ng/ml. The BC have a correlation with dose or body weight (Dose: r = 0.506, p<0.001, Body weight: r = 0.568,p<0.001) ,but creatinine clearance(Ccr) was closely correlated to blood concentration (r = 0.745,p<0.001). So the adequate dose can be estimated by Ccr. BC was tend to be higher in patients with QTc prolongation than those with QTc normal (QTc prolongation : 810±623 ng/ml vs QTc normal : 503±344ng/ml, p<0.05). In some patients with low BC patients, AF termination achieved by increased the dose. In the patients with high BC, the dose decreased even the QTc were within normal range. Tdp has not been observed in any cases.

Conclusions: The bepridil BC measurement is effective clinically in AF patients. And dose adjustment by Ccr is thought as a valid method.

Time in therapeutic range during warfarin therapy in Korean patients with non-valvular atrial fibrillation and its clinical implications

MH Bae, JH Kim, SY Jang, SH Park, JH Lee, DH Yang, HS Park, Y CHo, SC Chae

Kyungpook National University Hospital, South Korea

Background & Objectives: Warfarin therapy for prevention of stroke or systemic embolization in patients with atrial fibrillation (AF) is essential. We investigated time in therapeutic range (TTR) and its clinical implications in Korean patients with non-valvular AF.

Methods: We enrolled 465 AF patients (mean age 66±10; 323 men) taking warfarin for a¥2 years and calculated the percentages of the total time within the preset therapeutic range (International normalizedratio ofprothrombin time [PT-INR] between 2.0 and3.0) over the entire period.

Results: Mean follow-up period was 921±191 days. TTR was 45±19% and time below and over TTR was 44±21% and 11±10%, respectively. Follow-up interval of PT-INR showed negative correlation with TTR (r=-0.109, P=0.009). However, age and CHA2DS2-VASc were not correlated with TTR. Also sex, warfarin dose, and antiplatelet co-administration did not affect TTR. During follow-up periods, there were 12 strokes, 4 systemic embolisms and 27 major bleedings including 4 intracranial hemorrhages. However, there was no significant difference in TTR according to the presence or absence of stroke/systemic embolism or major bleeding.

Conclusion: TTR during warfarin therapy in Korean patients with non-valvular AF was low. However annual stroke rate was acceptable.



Incidence of new onset atrial fibrillation in patients with permanent pacemakers and the relation to the pacing mode

Sarmad Said, Chad Cooper, Haider Alkhateeb, Suchet

Texas Tech Health Science Center, United States oof America

Introduction: Atrial fibrillation is a relatively common arrhythmia that occasionally may be seen in patients with permanent pacemakers. The aim of this study is to assess the incidence of new onset AF in patients with permanent pacemakers and compare the difference in incidence between single and dual chamber mode of pacing.

Materials and Methods: We conducted a retrospective medical chart review of a consecutive series of 104 patients with either a permanent pacemaker or Implantable Cardioverter Defibrillator (ICD) with documented follow up between 2002 and 2012. Three patients were excluded due to unavailable data. For each subject, we documented the pacing mode used along with the device manufacturer, clinical, angiographic and echocardiographic variables and whether or not AF had occurred. Categorical variables were compared using Fisher's exact test.

Results: The average age of the patient population was 68 years. Of the studied population, 51% of the patients were male and 49% were females. Average time period that the patient had the pacemaker was 6 years and 3 months. New onset AF occurred in 45.2% patients. Ofthese patients, 46.8% were eventually paced in the VVIR mode and 53.2% were paced in the DDD mode. However this didnotprove to be significant. 54.8% ofthe total number ofpatients didnot develop AF with 96.5% ofthese patients being paced in non VVI mode (91.2% DDD, 5.25% AAI). Only 3.5% were paced in a VVImode. This difference was statistically significant (p 0.0001).

Conclusions: Incidence of atrial fibrillation appears to be less in patients whose pacemakers are programmed in a Non-VVI mode.

Atrial fibrillation reduces the functional REServe of the heart by a fifth

NT Lewis, KA Gilbert, W McDonald, AJ Hogarth, LB Tan, MH Tayebjee

Leeds Teaching Hospitals NHS Trust & University oof Leeds. U.K.

Background & Objectives: It is well known that compared to sinus rhythm (SR), Atrial Fibrillation (AF) is associated with increased mortality and morbidity. Furthermore, patients may experience adverse effects from drug treatment that may negate the beneficial effects of maintaining SR. What is still unknown is in what ways and by how much overall cardiac function is impaired when the atrial kick in SR is lost. We therefore wished to test the hypothesis that cardiac pumping capability diminishes with AF.

Methods: Twelve unselected ambulatory patients with symptomatic persistent AF underwent maximal symptom limited treadmill cardiopulmonary exercise tests (CPET), using a CO2 non-rebreathe technique, to determine peak circulatory haemodynamics, before and after DCV. Cardiac pumping capability: Cardiac power output (CPO)= Cardiac output (CO) x Mean arterial pressure (MAP).

Results: 10:2 Male: Female, Mean age 58±14 years. Aetiology: IHD (17%), HTN (25%), LV dysfunction (42%), Valve disease (25%), lone AF (25%), Obesity (25%). No patients hadprevious catheter ablation and all medications remained unchanged during the tests. All patients reported improvement in symptoms following restoration of sinus rhythm (SR). Haemodynamic changes shown in Table 1.

Table 1: Observed Haemodynamic changes before and post cardioversion

Variable AF Pre DCV Mean±SD SR Post DCV Mean±SD p Value

Exercise duration (s) 538±226 643±169 0.045

Peak VO2 (l.min-1) 2.25±0.95 2.62±1.05 0.002

Rest HR (mins-1) 83±20 67±20 0.016

Peak HR (mins-1) 163±42 128±18 0.03

Peak SV (mls) 99.5±20.4 145.4±38 <0.0001

Peak CO (l.min-1) 16.2±5.0 18.9±5.8 <0.0001

Peak MAP (mm Hg) 106.0±8.6 112.2±9.2 0.038

Peak CPO (Watts) 3.85±1.3 4.68±1.5 <0.0001

HR: Heart rate; SV: Stroke Volume; VO2: O2 consumption.

Conclusion: Our data shows that atrial contraction contributes to a fifth ofthe hearts pumping capacity. Re-establishing SR appears to restore both the pressure and flow generating capacity of the heart at significantly lower peakheartrates. This also supports the position ofon going needto try and maintain sinus rhythm in patients post successful DCV.



Left atrial thrombi is associated with left atrial appendage flow velocity rather than left atrial diameter in patients with atrial tachyarrhythmia

Hideyuki Kishima, Takanao Mine, Takeshi Kodani, Tohru Masuyama

Hyogo College of Medicine, Japan

Apixaban versus warfarin in patients with atrial fibrillation and valvular heart disease: findings from the ARISTOTLE study

A. Avezum 1 RD. Lopes 2, PJ. Schulte 2, F. Lanas 3, M. Hanna 4, P. Pais 5, C. Erol6, R. Diaz 7 CB.

Granger 2, JH. Alexander 2

Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil

Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA

University oof La Frontera, Temuco, Chile

Bristol-Myers Squibb, Princeton, NJ, USA

St. John's Medical College, Bangalore, India

Ankara University, Ankara, Turkey

Estudios Cardiologicos Latinoamerica ECLA, Rosario, Argentina

Background and Objectives: Apixaban is indicated for the prevention of stroke and systemic embolism (SE) in patients with non-valvular atrial fibrillation (AF). In this context, valvular refers to clinically significant mitral stenosis (MS) and not to other valvular heart disease (VHD). Little is known about the efficacy and safety of apixaban in AF and VHD (AF-VHD) patients.

Methods: We used data from 18,197 AF patients with > 1 risk factor for stroke in ARISTOTLE with VHD information. Patients with clinically significant MS and mechanical heart valves were ineligible. Of these, 4808 (26.4%) had VHD defined by any history of at least moderate mitral regurgitation MS, aortic regurgitation, aortic stenosis, tricuspid regurgitation, or valve surgery. We compared the effect of apixaban versus warfarin on rates of stroke or SE and major bleeding in patients with and without VHD using Cox proportional hazards modeling.

Results: VHD patients were older, had more prior MI and bleeding, higher mean CHADS2 scores, and less hypertension and diabetes than patients without VHD. VHD patients had higher rates of stroke or SE and bleeding than patients without VHD. The benefits of apixaban versus warfarin in reducing stroke and SE (interaction p=0.38), causing less major bleeding (interaction p=0.23), and decreasing death (interaction p=0.10) were consistent irrespective of VHD presence.

Conclusions: AF-VHD patients are at high risk for thromboembolic events and bleeding. Apixaban was similarly efficacious and safe in AF patients with and without VHD. Additional research is needed on the efficacy andsafety ofapixaban in AF-VHD patients.



Apixaban reduces hospitalization in patients with atrial fibrillation: an analysis of the effect of apixaban therapy on resource use in the apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation trial

Patricia A. Cowper, Wenqin Pan, Kevin Anstrom, Judith Stafford Renato Lopes, Linda DavidsonRay, Lars Wallentin, Hemant Phatak, Jack Ansell, Paul Dorian, Steen Husted, John McMurray, P. Gabriel Steg, John Alexander, Christopher Granger, Daniel Mark

Duke Clinical Research Institute, Durham, NC, USA

Background and Objectives: In the ARISTOTLE trial, apixaban (versus warfarin) significantly reduced stroke or systemic embolism, death and major bleeding in 18,201 patients with atrial fibrillation (AF) and at least one additional risk factor after a median follow-up of 1.8 years. Using data from ARISTOTLE, we assessed the effect of apixaban versus warfarin on medical resource use.

Methods: Dates of all hospitalizations, length of stay and dates of procedures were obtained from ARISTOTLE case report forms. Hospitalizations were classified as cardiovascular or non-cardiovascular based on event, procedure and adverse event data. Hospitalization frequency was estimated using Bang-Tsiatis methods, and compared between treatment groups in the overall population, andin the U.S. cohort. Cumulative length ofstaywas also examined.

Results: Overall, 26.5% (n=4,831) of patients were hospitalized an average of 1.5 times during the study, with patients receiving apixaban experiencing a significant reduction in all-cause hospitalization compared to those treated with warfarin (p=0.04). Most of this difference was attributable to cardiovascular hospitalizations (p=0.02). While the number of hospitalizations per patient was similar between treatment groups, cumulative length of stay was shorter with apixaban (p=0.05). In the U.S. cohort, the number of hospitalizations per patient was lower with apixaban (p=0.05), accompaniedby anon-significant reduction in cumulative length ofstay.

Conclusions: In ARISTOTLE, apixaban was associated with small but significant reductions in the likelihood of hospitalization in AF patients. For every 1,000 patients treated with apixaban instead of warfarin, 13 patients avoided hospitalization an average of 1.5 times during the study.

Apixaban is efficacious and safe in patients with atrial fibrillation using concomitant amiodarone: insights from the ARISTOTLE trial

Greg C. Flaker, Stefan Hohnloser, Daniel Wojdyla, Elaine Hylek, Renee Sullivan, Renato Lopes, Sana Al-Khatib, Christopher Granger, David Garcia

University oof Missouri, Columbia, MO, USA

Background: Compared with warfarin, apixaban has been shown to reduce stroke, systemic embolism, mortality and major bleeding. Amiodarone may lead to poor INR control and excess embolic and bleeding events when used with warfarin. Interactions between apixaban and amiodarone on clinical outcomes have not been explored.

Methods: The Apixaban for Reduction In Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial included 18,201 patients randomizedto apixaban 5 mgtwice daily or warfarin (target INR 2 3). This analysis explores outcomes in patients on and off amiodarone. Endpoints were summarized using rates per 100 patient years of follow-up. The Cox regression model was used to derive hazard ratios comparing apixaban versus warfarin and test the interaction between randomized treatment and amiodarone.

Results: From the overall population, 2,051 (11%) patients received amiodarone at randomization including 1,009 patients assigned to apixaban and 1,042 assigned to warfarin. Patients on amiodarone were younger (median 68 versus 70 years) and had lower CHADS2 score (mean 2.0 versus 2.1). Patients assigned to warfarin who were on amiodarone had a lower mean time in therapeutic range (TTR) when compared with those who were not on amiodarone (56.5% versus 63%, p < 0.0001). Outcomes are shown inthe table.

Conclusions: Despite a lower TTR with warfarin and amiodarone, the efficacy and safety of apixaban versus warfarin is consistent in patients with or without concomitant amiodarone therapy.



Efficacy and safety of apixaban compared with warfarin according to age for stroke prevention in atrial fibrillation

Sigrun Halvorsen1, Dan Atar1, Hongqiu Yang 2, Christopher B Granger 3 Michael Hanna 4, Raffaele de Caterina , Cetin Erol , David Garcia , Claes Held , Steen Husted , Peltr Jansky , Withold Ruzyllo11, Elaine M Hylek11 , Renato D Lopes 3, Lars Wallentin 8

1Department of Cardiology, Oslo University Hospital, Oslo, Norway; 2Duke Clinical Research Institue, Duke University Medical Center, Durham, NC, USA; Duke University Medical Center Durham, NC, USA; Bristol-Myers Squibb, Princeton, NJ, USA; G. d'Annunzio Universita - Chieti and Fondazione Toscana G. Monasterio, Pisa, Italy; Faculty of Medicine, Ankara University, Ankara, Turkey; University of New Mexico, Alberquerque, NM, USA; Department of Medical Sciences and Uppsala Clinical Research Center Uppsala University, Uppsala, Sweden; 9Aarhus University Hospital, Aarhus, Denmark; 10Charles University Prague, Czech Republic; 11National Institute of Cardiology, Warsaw, Poland; Boston University School of Medicine, Boston, MA, USA

Background and Objectives: The risk of stroke in patients with atrial fibrillation (AF) increases with age. Apixaban, a novel oral anticoagulant, was compared with warfarin in the ARISTOTLE trial and reduced the rate of stroke, death and bleeding. The aim of the present analysis was to evaluate these outcomes as well as specified secondary endpoints in relation to age.

Methods: The design and major results of the ARISTOTLE trial have been published previously. In this subgroup analysis, we estimated event rates and used Cox models to compare outcomes in patients according to age.

Results: Ofthe trial population (n = 18201), 5471(30%) were < 65 years, 7052 (39%) were 65 to < 75 years, and 5678 (31%) were 75 years. The rates of both cardiovascular events and bleeding were higher in the older age group. Apixaban was more effective than warfarin in preventing stroke or systemic embolism and reducing mortality, irrespective of age. Apixaban was associated with less major bleeding, less total bleeding and less ICH across all age groups. These results were consistent after multivariate adjustment. No significant interaction with apixaban dose was found with respect to stroke or major bleeding.

Conclusion: The effects of apixaban versus warfarin were consistent in patients with AF regardless of age. Owing to the higher risk of these outcomes in patients at older age, the absolute benefits of apixaban were greater in the older patient group.

Efficacy and safety of low dose amiodarone for preventing recurrence of persistent atrial fibrillation after direct current cardioversion

Satoshi Kawada, Atsuyuki Watanabe

Fukuyama City Hospital, Japan

Background: In Japanese, it has been reported that low dose Amiodarone (AMD) would be effective in patients with persistent atrial fibrillation (PEF). But little is known about efficacy of low dose AMD for the treatment ofPEF after direct current cardioversion (DCC).

Methods: We studied 37 consecutive patients with PEF(mean age 67.9±7.2 y.o, LVEF 60.6 ±11.1%, BNP 197.9 ±135 pg/ml, duration of AF 255±277 days) who underwent DCC between May 2011 and April 2013 in our hospital. We divided them into two groups; 29 patients were assigned to AMD (50mg/day) and 9 patients to Propafenone (300mg/day).

Results: Compared with Propafenone group, AMD group had higher CHA2DS2 vasc score (2.57±1.31 vs 1.66±1.00 P=0.04) and BNP (215±148 vs 143± 56 P=0.04). But no significant differences were found in other clinical parameters , and mean or maximal energy of shocks required between two groups.

After a 30-day follow up, there was no significant difference in freedom from AF between AMD group and Propafenone group (13/27 48.1% vs 3/9 33.3% P=0.35). And log-rank test showed no significant difference between two groups (P=0.34 follow up 24M). Drug inducedhypothyroidism and KL6 elevation requiring the discontinuation of drug occurred in three patients and there was no case of fatal adverse events. Low dose AMD proved non-inferiority to Propafenone restoring sinus rhythm in patients with PEF after DCC and can be safely used.

Conclusion: Low doe AMD would be safe and effective for preventing recurrence of AF in patients with PEF.



Short stature and ischemic stroke in patients with nonvalvular atrial fibrillation: new insight into the old observation

Jeonggeun Moon,1 Hye-Jeong Lee,2 Young Jin Kim,2 Jaemin Shim,3 Jong-Youn Kim,3 Hui-Nam Pak,3 Moon-Hyoung Lee,3 Boyoung Joung,3

Cardiology Division, Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Republic of Korea; Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea; Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea

Backgrounds: Atrial fibrillation (AF) still serves as a major predisposing condition of ischemic stroke of which impact on mortality and morbidity is substantial. For decades, there have been repeated epidemiologic observations regarding the inverse relationship between stature and cardiovascular (CV) diseases including stroke. This study investigated whether patient's height is associated with remodeling of the heart and ischemic stroke in nonvalvular AF.

Methods: Between 2008 and 2012, a total of 558 AF patients were enrolled. Echocardiography and computed tomography were performed to evaluate cardiac structure and function. Characteristics were compared between the patients with and without ischemic stroke.

Results: (1) AF patients with ischemic stroke are significantly shorter than without stroke (164±8, vs. 169±8 cm, p<0.001); (2) short stature was an independent predictor of stroke (OR 0.93, 95% CI 0.91-0.95, p<0.001); (3) stature and E/E' were inversely correlated in patients with AF (P -0.21, p<0.001). Height showed significant inverse correlation with E/E' independently, even after other variables, including age, sex and body weight, were adjusted; (4) LA and LAA volumes do not depend entirely on stature, whereas left ventricular size increases according to height of the patients with AF.

Conclusions: Short stature might be related with diastolic dysfunction and stroke. Although height is not a modifiable risk factor of ischemic stroke, these findings suggest that height affects diastolic function in AF; hence more impaired diastolic function in shorter patients with AF might play a pathophyhsiological role in ischemic stroke occurrence.

The role of renin-angiotensin system gene on the atrial flutter/fibrillation in patients after transcatheter closure of atrial septal defect

Shuenn-Nan Chiu, Mei-Hwan Wu, Chia-Ti Tsai, Jou-Kou Wang

National Taiwan University Hospital, Taiwan

Background: Atrial flutter/fibrillation (AF/Af) is a common late complication after atrial septal defect (ASD) occluder implantation. Renin-angiotensin system (RAS) genetic polymorphisms may be associated with AF/Af.

Methods and Results: From 1998 to 2010, all patients older than 18 years who received ASD occluder implantation in our hospital were enrolled. Previously identified polymorphisms on the AGT gene, the A1166C polymorphism on the angiotensin II type I receptor gene, and I/D patterns on the angiotensin-converting enzyme gene were checked using direct sequencing.

A total of 517 patients (M/F 127/390) were enrolled. The occluder deployment mean age was 41.5±14.5 years, and the mean size of the occluder used was 25.6±7.3 mm. For cardiac catheterization data, the mean Qp/Qs ratio was 2.9±1.1, and the mean pulmonary artery pressure was 19.8±8.4 mmHg. Before occluder deployment, 4.4% of patients had persistent AF/Af, and 3.3% of patients had paroxysmal AF/Af. After a follow-up of 1894 patient-years, 3.6% had persistent AF/Af, and 1.8% of patients had paroxysmal AF/Af. The greatest risk factors of AF/Af genesis included age, occluder size, the presence of multiple ASD and fenestrated occluder use (P <.001, <.001, .029, and .04, respectively). Preoperative AF/Af is the most important factor in determining AF/Af resolution and progression after an intervention. The RAS gene polymorphism had no association with AF/Af genesis, progression, or resolution after intervention.

Conclusions: AF/Af is common after ASD occluder implantation, and predisposed by older age, larger and multiple ASDs, and significant pulmonary hypertension. RAS gene polymorphisms had no association with AF/Af in ASD patients.



The association of intra-atrial coagulation factor IX and new-onset atrial fibrillation after cardiac surgery

Ching-Hui Weng, Hu Yu-Feng, Lin Yenn-Jiang, Chang Shih-Lin, Lo Li-Wei, Wen-Chin Tsai, Tzu-Fan Chao, Chung Fa-Po, Liao Jo-Nan, Chen Shih-Ann

Taipei Veterans General Hospital, Taiwan

Introduction: The interaction between atrial fibrillation (AF) and coagulation activity is far from clear.

Methods: The intra-atrial blood samples both from left and right atrium were obtained during cardiac surgery before heparinization, and the activities of coagulation factors (II, VII, VIII, IX, and X) were evaluated in 27 patients. New-onset AF was followed until three months after the surgery. The patients receiving warfarin were excluded.

Results: The age of study population was 64.7±14.5 years old (21 males). Cardiac surgeries included valvular replacement (n=13), coronary artery bypass surgery (n=13), and myxoma (n=1). There were 18.5% patients with diabetes mellitus, 51.9% hypertension, 22.2% hyperlipidemia, 3.7% chronic obstructive lung disease, and 7.4% stroke. None of coagulation factors was associated with new-onset AF except factor IX in the left atrium. Higher levels of factor IX activities (more than 83%) in the left atrium was associated with higher incidence of new-onset AF after cardiac surgery during the follow-up of three months (Figure, log-rank, p=0.01), which remains significant after adjusted for baseline characteristics.

Conclusions: The baseline intra-atrial coagulation activities were associated with new-onset of AF after cardiac surgery.

Feasibility of a novel ejection index derived from blood pressure in detecting atrial fibrillation - a pilot study

Chao-Shun, Chan1,2, Eric Chong1,3, Yenn-Jiang Lin1,3, Shih-Lin Chang1,3, Li-Wei Lo1,3, Yu-Feng

Hu '3, Tze-Fan Chao1,3, Fa-Po ChungJonan LiaoShih-Ann Chen1^

Division of Cardiology, Taipei Veterans General Hospital; Division of Cardiology, Taipei Medical University Hospital, Taipei, Taiwan; Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan

Introduction: Previous study investigated the relationship ofQT/RR interval in ECG during sinus rhythm (SR) and atrial fibrillation (AF). Using multiple linear regression analysis, the slope ofQT/ RR was lower than that during SR. The purpose of this study was to extrapolate the association between BP waveform and ECG rhythm using a novel ejection index which was defined as the ratio ofpressure ejection interval / pulse interval (PP / RR interval in ECG).

Methods: A prospective pilot study was conducted in a cardiac center. Five patients with AF undergoing ablation were enrolled. Real time intra-aortic root BP was recorded using pigtail catheter during AF and sinus rhythm in each patient. Forty episodes of aortic BP signals during both SR and AF were analyzed per patient. An average of 10 beats were used for each episode.

Results: During AF, patient's pressure ejection interval was significantly shorter than that during SR (p<0.001). (table 1). From the analysis of ejection index, majority of the patients demonstrated significant difference between AF and SR. (table 2). The ejection index was significantly higher during AF than SR (p<0.001).

Conclusion: We investigated a novel method of differentiating AF and SR using ejection index derived from blood pressure measurement. The ejection index was significantly higher during AF. Our pilot study finding could provide foundation for further research in detecting AF using BP based algorithms.

Table 1. Pulse pressure during AF and sinus rhythm

Pulse pressure (pp) AF SNR P

pi 0.302±0.009 0.357±0.002 0.0018

P2 0.232±0.004 0.284±0.003 <0.001

P3 0.222±0.012 0.343±0.001 <0.001

P4 0.252±0.006 0.3114±0.002 <0.001

P5 0.258±0.004 0.285±0.001 <0.001

Table 2. Ejection fraction during AF and sinus rhythm

Ejection index AF SNR P

P1 0.399±0.218 0.299±0.003 0.0018

P2 0.406±0.013 0.40±0.009 0.2582

P3 0.482±0.058 0.34±0.007 0.0168

P4 0.509±0.06 0.397±0.004 0.0324

P5 0.516±0.014 0.339±0.011 <0.001

Total 0.463±0.0615 0.355±0.04 <0.001



Comparison of pulse amplitudeand time interval irregularity index in differentiation of atrial fibrillation and sinus rhythm - a pilot study

Po-Ching Chi12, Eric Chong1J, Yenn-JiangLin1J, Shih-Lin Chang13, Li-Wei Lo1-3, Yu-Feng HuJ, Tze-Fan ChaoShih-Ann Chen1

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Mackay Memorial Hospital, Taipei, Taiwan, Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University

Background and Objectives: Special algorithm and index have been designed using BP to detect AF. Time interval irregularity index (T Index) is calculated as the ratio of standard deviation of total pulse time intervals / mean of total time intervals. However, limitation of the T index includes difficulty in predicting the etiology of arrhythmia. The purpose of our study was to investigate a new index using pulse pressure amplitude for AF detection and to compare it with the T index.

Methods: Based on the T index algorithm, pulse pressure amplitude index (A index) was defined as the ratio of standard deviation of total pulse amplitudes / mean of total pulse amplitudes.Five patients were enrolled prospectively during AF ablation. Central aortic BPand ECG were recorded during AF and sinus rhythm (SR) via pigtail catheter. Continuous intracardiac BP signalswere recorded and divided into multiple episodes of 10 beats. A and T index were calculated and compared.

Results: The sensitivity and specificity of T index were 80%. One patient was falsely being labeled AF during actual SR as a result of ventricular ectopic (PVC). Tindex showed wider range of distribution(0.1074~0.3544) with overlapping of values during AF and SR, therefore it would be harder to define an optimal cut off point. In contrast, the A index showed narrower range of distribution (0.01~0.025) and had no overlapping of value during AF and SR. If applying 0.9 as cut off point, it could differentiate AF from SR without mistaking the PVC case. During AF, the A index ranged between 0.095~0.28, which was more closely distributed than T index.

Conclusion: Base on the comparison, although both indexes can be applied for AF detection, there was limitation in using T index alone due to false positive results from non-AF type of arrhythmias. The A index may have an added role in improving the diagnostic specificity and accuracy of AF.

Lenient vs. strict rate control in patients with atrial fibrillation and left ventricular hypertrophy

Peeyush M. Grover1, Ghanshyambhai T. Savani1, Neeraj Shah2, Nileshkumar J. Patel2, Ankit Chothanii, Kathan Mehta4, Vikas Singh1, Abhishek Deshmukh5, Ankit Rathod, Apurva O. Badheka1, Raul D. Mitram1, Juan F. Viles-Gonzalez

University o;f Miami Miller School of Medicine, Miami, FL, USA; Staten Island University Hospital Staten Island, NY, USA; Medstar Washington Hospital Center, Washington, DC, USA; Drexel University School oof Public Health, Philadelphia, PA, USA; University of Arkansas, Little Rock, AR, USA; Cedar Sinai Medical Center, Los Angeles, CA, USA

Background and Objectives: Although prospective studies have demonstrated that "lenient" rate control is not inferior to "strict" rate-control in patients with AF. Role of strictvs. lenient rate control in patients with AF and associated left ventricular hypertrophy (LVH) in unclear.

Methods: We identified366 patients with echocardiography data on left ventricular mass (LVM) enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial (rate-control arm).Patients had AF both at the baseline and 2-month visits, available resting Heart Rate (Hr) data at both visits, without pacemaker insertion prior to randomization.LVH was defined as increased LVM, stratified by American Society of Echocardiography (ASE) criteria. The primary endpoint was all-cause mortality (ACM), secondary endpoint was cardiovascular hospitalization (CVH). Patients were stratified as strict rate control group (n=105) and the remainder (n=261) in the lenient rate control group.Adequate controlat 2 months was defined as resting Hr <80 and post-exercise Hr<110 bpm after 6 min of exercise.

Results: The mean follow-up time was 32.8 months.LVH was not a significant predictor of ACM in either the lenient (HR 1.14; p=0.7) or strict rate control groups (HR 4.8; p=0.1). LVH was a significant predictor of CVH in the lenient rate control group (HR 1.72; p=0.03), but not in the strict rate control group (HR 0.86; p=0.76).

Conclusion: In patients with AF and LVH, strict rate control may be associated with better outcomesthan lenient rate control. Future prospective studies are needed to better delineate this relationship.



SCN5A mutations associated with familial atrial fibrillation without structural heart diseases

Takeru Makiyama, Kenichi Sasaki, Yimin Wuriyanghai, Suguru Nishiuchi, Mamoru Hayano, Yuta Yamamoto, Tsukasa Kamakura, Jiarong Chen, Aya Umehara, Satoshi Shizuta, Takeshi Kimura, Seiko Ohno, Hideki Ito, Minoru Horie Kyoto University Graduate School of Medicine, Japan

Background and Objectives: SCN5A mutations are associated with a variety of inherited arrhythmias, and the variants of ion channels have been identified in patients with famial atrial fibrillation (AF) by the past genetic analyses. However, the relationship between SCN5A mutations and familial Atrial Fibrillation is not clearly known.

Methods: We screened the susceptible genes encoding cardiac ion channels in the 33 patients with familial AF of our cohort.

Results: We identified the susceptible genetic mutations in the 5 familial AF patients. 2 patients carried SCN5A mutations, and 3 others carried the mutations ofthe potassium channels. We previously reported a case ofthe SCN5A mutation carrier (M1875T). In the present study, we identified another novel SCN5A mutation, T977I, in the 48-year-old proband who underwent radiofrequency catheter ablation for drug-refractory AF. He was diagnosed with AF at age 41 years, which later progressed to drug-refractory AF. Three family members, along with the proband, presented with AF. Further genetic screening revealed the same mutation in the affected individuals. Although the proband carried the SCN5A mutation, his electrocardiogram revealed no ST elevation like Brugada syndrome, nor abnormality of the QT interval, and his left ventricular systolic function was normal.

Conclusion: We identified a novel SCN5A mutation in the familial AF patient without structural heart diseases. Further studies are needed to elucidate the relationship between SCN5A mutations and the pathogenesis of AF.

The role of macrophage migration inhibitory factor in the regulation of connexin 43 in atrial myocytes

Fang Rao, Chun-Yu Deng1,2,3, Yu-Mei Xue12 Qian-Huang Zhang1', Su-Juan KuangQiu-Xiong Lin1A3, Zhi-Xin Shan1123, Jie-Ning Zhu1123, Xi-Yong Yu12 Shu-Lin Wu1,2

department oof ' Cardiology, Guangdong Cardiovascular Institute, 96 Dongchuan Road, Guangzhou 510080, PR China

2Guangdong General Hospital, Guangzhou 510080, PR China Guangdong Academy oof Medical Sciences, Guangzhou 510080, PR China

Introduction: Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Recent findings have demonstrated a mechanistic link between inflammatory and the development of AF. Macrophage migration inhibitory factor (MIF), a pleiotropic cytokine, controls the inflammatory 'set point' by regulating the release of other pro-inflammatory cytokines. Recent studies have revealed that Connexin 43 (Cx 43) not only is involved in the electrical conductivity between the cells, but also forms a complex with PKP2 and Na+ channel to affect the sodium current. The purpose ofthis study is to observe the role ofMIF in the expression of Cx43, and the role of Cx43 in the regulation of calcium channel current in atrial myocytes.

Methods: Cx 43 expression in human atrial tissues and HL-1 cells were determined by Western blot and Real time PCR. Whole-cell voltage-clamp recordings and Real time PCR were used to study the regulation and expression of ICa,L and ICa,T in HL-1 cells before and after Cx 43 siRNA knocking down.

Results: Expression levels of Cx 43 mRNA and protein are significantly reduced while MIF expression levels were increased in patients with AF. In HL-1 cells, the depression of Cx 43 expression levels induced by rMIF was prevented by ERK 1/2 inhibitor U0126, but not Src inhibitor Genistein and PP1. Both ICa,L and ICa,T are reduced after Cx 43 siRNA knocking down, probably by down-regulation of L type calcium channel 1C subunit and T type calcium channel 1G subunit.

Conclusion: These results implicate MIF in the pathological mechanism of AF, probably by decreasing Cx43 expression through the activation of ERK1/2 kinases in atrial myocytes. And ICa,L and ICa,T are regulated directly by Cx43, implicate involvement of Cx 43 in the electrical remodeling.

Keywords: Macrophage migration inhibitory factor; Atrial fibrillation; HL-1 cells; L-type calcium channel; T-type calcium channel; Connexin 43


Clinical outcomes of cardiac resynchronization therapy in patients with atrial fibrillation: a single center study including 111 patients with 3 years' median follow-up

Hideya Suehiro, Kazumasa Adachi, Yasutaka Hirayama, Takeshi Matsuura, Tomomi Akita, Yukinori Katou, Kenzo Uzu, Hiroki Takada, Kohei Kamemura, Akira Matsuura, Masahito Kawata, Susumu Sakamoto

Division of Cardiology, Akashi Medical Center, Japan

Background & Objectives: The clinical effect of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with atrial fibrillation (Af) is not determined yet. The purpose of this study is to evaluate the long term clinical outcomes between patients with or without Af received CRT.

Methods: The study retrospectively analysed 111 consecutive patients who underwent CRT implantation during 2004-2011.

Results: We detected Afin 60patients (54%) at implant or during follow-up period, and compared clinical outcomes (hospitalization for HF, death) between sinus group and Af group. The baseline clinical characteristics were well matched. The mean follow-up time was 36&amp;amp;plusmn;23 months. 30 (53.6%) patients in Af group were hospitalized for HF and 13 (36.0%) in sinus group. Survival salvage analysis showed that cumulative hazards of hospitalization for HF were significantly higher in Af group(long-rankP=0.035). Cox analysis showed Af was an independent positive factor ofhospitalization (HR:2.36, 95%CI:1.034-2.919, P=0.037). However there were not significant difference in mortarity between Af group and sinus group (41.7% vs 29.4%, longrank P=0.170). 24 (40%) patients with Af underwent atrioventricular (AV) node ablation. The hospitalization rate ofthese patients was 61.5% as compared to 63.0% in Af patinets who did not undergo AV-node ablation (P=0.820) and the mortality was 42.7% as compared to 42.7% (P=0.585).

Conclusion: The presence of Af was associated with an increased risk of hospitalization for HF in patients who underwent CRT implantation.


Effect of respiration on catheter-tissue contact force during pulmonary vein isolation for atrial fibrillation

Saurabh Kumar,1'2 Joseph B. Morton,1,2 Justin M.S. Lee,1 Michael C.G. Wong,1,2 Karen Halloran,1 Steven J. Spence, Peter M. Kistler, ' Jonathan M. Kalman ,

Department of Cardiology & Department of Medicine, The Royal Melbourne Hospital & University of Melbourne, Victoria; Department of Cardiology, Alfred Hospital & Baker IDI, Melbourne, Australia

Background & Objectives: Catheter-tissue contact is important for effective lesion creation. We assessed the effect of respiration on contact force during pulmonary vein isolation (PVI) for AF.

Methods: PVI was performed in 12 patients under general anesthesia with a total of 964 lesions delivered during ventilation (30 s) alternating with lesions during apnea (30 s) at an anatomically adjacent location at the PV antra. Contact force (CF) data consisting of average force (Fav), forcetime integral (FTI), force variability index (FvJ were measured in a region specific manner using a novel force-sensing ablation catheter. Operators were blinded to CF data.

Results: Fav and FTI were significantly higher with apnea compared to ventilation in all PV segments (P < .05). This was due to drop in CF associated with each respiratory swing, resulting in greater Fv^- (P < .05) in ventilation. Low FTI lesions (<500g) correlated with longer ablation time to achieve left (r2=0.65, P = .009) and right PVI (r2=0.41, P = .05). Sites of acute PV reconnection were associated with lower Fav and FTI compared to non-reconnected sites (P < .001). At sites of acute PV reconnection, the more index lesions were delivered in ventilation than in apnea (79% vs. 21%, P< .001).

Conclusions: During PVI, catheter-tissue CF is critically influenced by respiration; greater CF is seen with ablation during apnea. Poor contact results in longer ablation time for PVI and acute PV reconnection. Apnea associated increase in CF may translate to a reduction in acute PV reconnection.

Catheter-tissue contact force determines atrial electrogram characteristics before and after ablation in patients with atrial fibrillation

Saurabh Kumar,1,2 Joseph B. Morton/'2 Martin Chan, Justin M.S. Lee,1 Matias Yudi,1 Michael C.G. Wongg,1^ Karen Halloran, Steven J. Spence, Peter M. Kistler,1- Jonathan M. Kaiman1

Department of Cardiology & Department of Medicine, The Royal Melbourne Hospital & University of Melbourne, Victoria; Department of Cardiology, Alfred Hospital & Baker IDI, Melbourne, Australia

Background & Objectives: Catheter-tissue contact force (CF) is critical for effective lesion formation. We examined the relationship between CF and atrial electrogram (EGM) characteristics before and lesion efficacy after AF ablation in humans.

Methods: 334 lesions in 11 patients undergoing AF ablation using a novel CF-sensing catheter were assessed for bipolar EGM peak-to-peak amplitude, width and morphology before and after ablation. Lesion efficacy was defined based on previously established EGM criteria: (i) complete abolition of positive deflection when pre-ablation QR present; (ii) >75% attenuation ofthe positive deflection when pre-ablation QRS present; and (iii) complete elimination of R' when pre-ablation RSR' present. CF was correlated with EGM amplitude pre-ablation. Force-time integral (FTI) during ablation was correlated with markers of lesion efficacy. Operators were blinded to CF data.

Results: Pre-ablation CF positively correlated with EGM amplitude (r=.22) and inversely with EGM width (r=.14]. Higher FTI correlated with greater EGM amplitude reduction (r=.65]. FTI positively correlated with lesion efficacy (r=.65). 100% of lesions with FTI >1000g*s were effective, whereas only 20% of lesions <500g*s were effective on EGM criteria. FTI >405 g*s had sensitivity, specificity, positive and negative predictive values of 85%, 91%, 89% and 87% respectively for an effective lesion.

Conclusion: This study defines the CF necessary to create effective lesions based on previously validated EGM attenuation criteria. For each CF range, there was considerable overlap in pre-ablation EGM amplitude and width. This information has important implications for ablation efficacy during PVI.



Marked growth of catheter ablation procedures for atrial fibrillation over the past decade: a nationwide study with implications for health care policy, infrastructure and spending

Saurabh Kumar,1,2 Tomos E. Walters,1'2 Graham Hepworth,3 Karen Hattoran, Peter M. Kistler,1'24 Christopher X Wong, Prashanthan Sanders, Jonathan M. Kalman ,

Department of Cardiology & Department of Medicine, The Royal Melbourne Hospital & University of Melbourne; Department of Mathetmatics & Statistics, University of Melbourne, Parkville; Department of Cardiology, Alfred Hospital & Baker IDI, Melbourne, Australia; Centre for Heart Rhythm Disorders, University oof Adelaide and the Royal Adelaide Hospital, Adelaide, Australia

Background & Objectives: Catheter ablation is a class I indication for treatment of drug refractory AF. Little is known of national trends in numbers of AF ablation procedures. We examined nationwide temporal trends in the provision of catheter based AF ablation over the past decade.

Methods: We performed a review of the numbers of catheter based AF ablations from 2000/1 to 2009/10 from three sources: the Australian Institute of Health, Welfare and Aging (AIHW), Medicare Australia database (MA), and local records at a high volume tertiary referral center (TR) for AF ablation. For comparison, we also examined nationwide trends in all cardiovascular procedures and percutaneous coronary interventions (PCIs).

Results: Catheter-based AF ablation showed a 30.9%, 23.2% and 39.8%/year population-adjusted increment over 10 years from the AIHW, MA and TR sources respectively (P<0.001 for all). In contrast, there was a 5.1%/year population-adjusted increment in PCIs over 10 years from both, the AIHW and MA sources (P<0.001). This was similar to the growth rate of all cardiovascular procedures (AIHW: 5.1% vs. 3.8%/year, P=0.27). Growth of AF ablations was significantlyhigher than PCIs (P<0.001 for AIHW and MA sources) and all cardiovascular procedures (AIHW: 30.9% vs. 3.8%/year, P<0.001).

Conclusions: AF ablation procedures have had a marked growth exceeding the growth of PCIs and of all cardiovascular procedures over the past decade. Given the increasing epidemic of AF, this data has critical implications for health policy assessing the adequacy of expenditure, infrastructure, training and funding for AF ablation services.

Usefulness of activated partial thromboplastin time check in clinical use of dabigatran for patients with atrial fibrillation

H. Tasaka, K. Kadota, S. Fujii, K. Mitsudo

Kurashiki Central Hospital, Japan

Background: Clinical efficacy and safety of dabigatran use for patients with atrial fibrillation using activated partial thromboplastin time (APTT) check in the real world remain unclear.

Methods: A total of 466 patients, who had been given dabigatran (298 men, mean age: 70.9 ± 11.5 years), were enrolled from April 2011 to June 2012. In this study, 275 patients were followed for more than three months (mean follow-up period: 330 ± 146 days) by our medical records and questionnaires to referred medical institutions. We evaluated the efficacy by incidences of stroke and systemic embolism and safety by incidences ofmajor and minor bleeding events.

Results: The doses ofdabigatran were 300 mg (22.5%), 220 mg (74.5%), and 150 mg (3.0%). Stroke and systemic embolism occurred in 6 patients (2.2%). Bleeding events occurred in 26 patients (9.5%), 5 of those had major bleeding events (4 gastrointestinal, 1 intracranial). Comparing the bleeding group with the nonbleeding group, the mean age was significantly higher (74.8 ± 9.3 vs. 69.1 ± 10.9; p<0.05) and APTT was significantly higher (63.0 ± 17.5 vs. 54.4 ± 10.8; p<0.01). Comparing the APTT >70 group (26 patients) with the APTT<70 group (228 patients), the bleeding event rate was significantly higher (26.9% vs. 8.3%; p=0.003).

Conclusion: In the clinical use of dabigatran, the bleeding event rate was significantly high in elderly patients and patients with prolonged APTT >70. APTT can be useful as a new value to predict bleeding events.



Integrated chronic care management in patients with atrial fibrillation: a (cost-) effective treatment strategy

JML Hendriks1,2, HJGM Crijns1, HJM Vrijhoef3

Maastricht University Medical Centre, Department of Cardiology, Maastricht, The Netherlands Maastricht University Medical Centre, Department Health Services Research: Care And Public Health

Research Institute (CAPHRI), Maastricht, The Netherlands

National University of Singapore, Saw Swee Hock School of Public Health, Singapore

Background and Objectives: Integrated chronic care management is a necessary, systemic approach to face future capacity problems and high healthcare costs in patients with chronic disease, like atrial fibrillation (AF). Such approach in AF is not available yet. Therefore a nurse-led, guideline-based, software supported AF outpatient service was developed.

Methods: A randomised controlled trial, including a cost-effectiveness analysis was conducted. In total, 712 patients were randomly assigned to the AF-Clinic or usual care group. In the AF-Clinic patients underwent protocolized clinical testing, were seen by a nurse specialist, supervised by a cardiologist. In the usual care patients were treated by a cardiologist in the regular outpatient setting. The primary endpoint was a composite of cardiovascular death and hospitalization. A cost per life year and a cost per Quality Adjusted Life Year (QALY) analysis were performed.

Results: At baseline, mean age was 67±13, and 418 pts (59%) were male. Underlying diseases: hypertension 380 pts (53%), heart failure 50 pts (7%), coronary artery disease 71 pts (10%), stroke 89 pts (13%).

At follow-up, 51 pts (14.3%) had reached their primary endpoint in the AF-Clinic group versus 74 pts (20.8%) in the usual care group; (HR 0.65, 95% confidence interval (CI) 0.45-0.93). Cardiovascular hospitalization occurred in 48 (13.5%) versus 68 pts (19.1%) (HR 0.66, CI 0.460.96) and death in 4 (1.1%) versus 14 pts (3.9 %), respectively (hR 0.28, CI 0.09 0.85). The AF-Clinic contributed to 0.009 QALY gains with a reduced cost of € 1109 per patient and 0.02 life years gain with a reduced cost of € 735 per patient. The program is considered dominant.

Conclusion: The AF-Clinic is superior to usual care in terms ofmajor clinical events. Moreover, this approach is cost-saving and therefore a cost-effective management strategy for patients with AF. ( NCT00753259).

The atrial fibrillation registry in China: baseline characteristics and patient management

Han Zhang, Yan-min Yan, Jun Zhu, Shao Xinhui, Wang Juan, Tian Li, Huang Bi

Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy oof Medical Sciences and Peking Union Medical College, Beijing, China

Background: To describe patient characteristics, risk factors, comorbidities, management strategy, and control of Chinese atrial fibrillation (AF) patients in the emergency department (ED) daily practice.

Methods: We conducted a prospective, observational registry of patients with AF/flutter in China. Participants were enrolled in the ED. Baseline characteristics were collected and follow-up was planned at 1 year.

Results: Of the 2016 Chinese patients from 19 sites, 54.8% were women. 618 (30.7%) had paroxysmal, 452 (22.4%) had persistent, and 945 (46.9%) had permanent AF. The most common comorbidity was hypertension (55.5%), followed by coronary artery disease (41.8%), heart failure (37.4%) and current smoking (21.5%). The prevalence of comorbidities, such as heart failure valvular heart disease, and history of stroke or transient ischemic attack, increased as AF progressed, as well as the mean CHADS2 score. In patients with non-valvular AF, 110 (12.7%) of those with CHADS2>2 were prescribed with oral anticoagulants (OACs), while 119 (15.6%) of those with CHADS2 2received. In324patientswithvalvular AFqualifiedforOACs, 134(41.4%) actually used. INR value was within the target INR range (2.0-3.0) only in 96 patients (26.4%). About one sixth of patients received >1 antiarrhythmic agents (AADs), while rate-control agents were usedmore frequently (68.4%). 78.3% ofpersistent and97.7% ofpermanent AFpatients were still in AF/flutter when left ED.

Conclusions: The risk profile of Chinese patients was different from previous studies in other countries, and the use of oral anticoagulants was inadequately deviate from current guidelines.

Keywords: Atrial fibrillation, risk factor, comorbidity, CHADS2 score, anticoagulation, antiarrhythmic agents.


Patients with atrial fibrillation and other primary diagnosis in the emergency department: baseline characteristics and outcomes

Han Zhang, Yan-min Yang, Jun Zhu, Shao Xinhui, Wang Juan, Tian Li, Huang Bi

Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

Background: Atrial fibrillation (AF) is common in the emergency department (ED), however, patients with AF sometimes visit ED because of other primary reason. There are no data on the characteristics and outcomes of ED patients with atrial fibrillation who have other primary ED diagnoses.

Methods: In this prospective observational multicentre registry study, all AF cases were confirmed by the electrocardiograms (ECGs) in the ED from November 2008 to October 2011 in China. Repeat ED visits were excluded. By pulling all patient charts, we separated patients with a primary diagnosis of atrial fibrillation from those with other primary ED diagnoses, using the EPs' first diagnosis written on the ED chart. Patients demographics, medical history, type of AF, treatment, and outcome of emergency room visit were collected at baseline by the treating physicians using a standardized questionnaire. The main outcome measure was all-cause mortality at 1 year post-ED visit. As a secondary analysis, logistic regression was used to compare 1 year mortality of these patients to those with primary ED diagnoses ofatrial fibrillation seen during the same time period.

Results: During the study period, 2016 Chinese patients visited the ED, AF was the primary reason only in 825 patients (40.9%), while AF was the secondary diagnosis in the remaining patients. Patients with secondary AF diagnosis were older (69.8±13.1 vs 66.6±13.3) and thinner (BMI, 23.2±3.6 vs 24.0±3.5), while systolic blood pressure (SBP) was higher (133.8±24.7 vs 129.0±21.3) and heart rate was lower (97.4±27.1 vs 107.9±31.3). Permanent AF was more frequent (61.2% vs 26.3%) inpatients with secondary AF diagnosis andtheywere less likely to be paroxysmal AF (21.1% vs 44.5%). Meanwhile, the prevalence of risk factors and comorbidities, such as heart failure (49.1% vs 20.5%), coronary artery disease (46.6% vs 35.0%), stroke/TIA (11.7% vs 17.6%), valvular heart disease (19.6% vs 12.5%), and diabetes mellitus (17.2% vs 13.0%) was higher. Similarly, there was an increase in CHADS2 [cardiac failure, hypertension, age, diabetes, stroke (doubled)] score (2.1±1.4 vs 1.4±1.3), but there was no difference in antithrombotic therapy between two groups. The most common primary ED diagnoses were congestive heart failure (30.3%), respiratory diseases (7.7%), stroke/TIA (7.6%), dyspnea (7.1%), fever (7.0%), palpitation (6.0%), coronary artery disease (6.0%), dizzy (5.7%), and chest pain not yet diagnosed (5.0%). 1-year mortality were 7.8% and 18.3%, respectively. In the adjusted analysis, an alternative primary ED diagnosis was associated with an increased risk of death (hazard ratio [OR] = 1.84; 95% CI, 1.38-2.46, p <0.001).

Conclusions: Patients seen in the ED with atrial fibrillation and different primary ED diagnoses are older and have more comorbitieshigher than patients with primary ED diagnoses of atrial fibrillation. 1-year mortality was also higher in paitents with secondary AF diagnosis. Future studies of atrial fibrillation in the ED should distinguish between these two populations and the potential contribution of atrial fibrillation to mortality in the setting of other primary ED diagnoses.

Keywords: Atrial fibrillation; Primary diagnosis; Secondary diagonisis.

Table 1. Baseline characteristics between patients with secondary AF diagnosis and primary AF diagnosis

Characteristic Primary AF Diagnosis Secondary AF Diagnosis P value

N=825 (%) N=1190 (%)

Age, yrs, mean (SD) 66.6 (13.3) 69.8 (13.1) 0.000

Female, % 448 (54.3) 656 (55.1) 0.715

SBP,mmHg, mean (SD) 129.0 (21.3) 133.8 (24.7) 0.000

HR, bpm, mean (SD) 107.9 (31.3) 97.4 (27.1) 0.000

BMI, kg/m2, mean (SD) 24.0 (3.5) 23.2 (3.6) 0.000

Types of AF, %

Paroxysmal AF 367 (44.5) 251 (21.1) 0.000

Persistent AF 241 (29.2) 211 (17.7)

Permanent AF 217 (26.3) 728 (61.2)

Previous Medical History, %

Myocardial Infarction 34 (4.1) 114 (9.6) 0.000

Coronary heart disease 289 (35.0) 554 (46.6) 0.000

Congenital heart disease 11 (1.3) 32 (2.7) 0.038

Heart failure 169 (20.5) 584 (49.1) 0.000

Rheumatic Heart Disease 100 (12.1) 218 (18.3) 0.000

Valvular Heart Disease 103 (12.5) 233 (19.6) 0.000

Permanent Pacemaker 27 (3.3) 37 (3.1) 0.837

Recent Cardiac surgery 2 (0.2) 6 (0.5) 0.484

Hypertension 462 (56.0) 656 (55.1) 0.698

LVH by ECG or echo 100 (12.1) 229 (19.3) 0.000

Stroke/TIA 111 (13.5) 268 (22.5) 0.000

Sleep apnea 26 (3.2) 44 (3.7) 0.51

Smoking 169 (20.5) 264 (22.2) 0.361

LV systolic dysfunction 89 (10.8) 296 (24.9) 0.000

Dementia/cognitive defects 8 (10) 36 (3.0) 0.002

Pericarditis 0 (0.0) 8 (0.7) 0.024

Emphysema/COPD 60 (7.3) 176 (14.8) 0.000

Diabetes Mellitus 107 (13.0) 205 (17.2) 0.009

Hyperthyroidism 34 (4.1) 32 (2.7) 0.076

Major Bleeding 12 (1.5) 36 (3.0) 0.023

Table 2. The primary reason of patients with AF and other primary ED diagnosis

Other primary diagnosis N (%)

Heart failure 360 (30.3)

Respiratory diseases 92 (7.7)

Stroke/TIA 90 (7.6)

Dyspnea 84 (7.1)

Fever 83 (7.0)

Palpitation 83 (7.0)

Coronary artery disease 71 (6.0)

Dizzy 69 (5.7)

Chest pain 59 (5.0)

Hypertension 28 (2.4)

Infection 21 (1.8)

Table 3. Adverse events in patients with secondary AF diagnosis and primary AF diagnosis

Primary AF Secondary AF Adverse events Diagnosis Diagnosis P value _N=819 (%) N=1172 (%)_

Death 64 (7.8) 215 (18.3) 0.000

Stroke 48 (5.9) 98 (8.4) 0.035

Non-CNS systemic embolism 5 (0.6) 10 (0.9) 0.538

Major Bleeding 8 (10) 18 (1.5) 0.280

Sig. Exp(B) 95.0% CI for Exp(B)

Age .000 1.066 1.053 1.079

BMI .000 .930 .898 .962

SBP .018 .994 .989 .999

CAD .031 .761 .593 .976

DM .033 1.388 1.028 1.875

HF .000 1.691 1.323 2.161

Reason .000 1.840 1.378 2.459


Digoxin and mortality in patients with atrial fibrillation

Han Zhang, Yan-min Yang, Jun Zhu, Shao Xinhui, Wang Juan, Tian Li, Huang Bi

Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

Background: Digoxin is frequently used for rate control in paroxysmal, persistent and permanent atrial fibrillation (AF). The relationship of digoxin and mortality was so different in recent studies, and it remains unclear how digoxin affected mortality. The objective of this study was to determine the relationship between digoxin and mortality in patients with AF.

Methods: In this prospective observational multicentre registry study, all AF cases were confirmed by the electrocardiograms (ECGs) in the ED from November 2008 to October 2011 in China. Patients demographics, medical history, type of AF, treatment, and outcome of emergency room visit were collected at baseline by the treating physicians using a standardized questionnaire. The main outcome measure was all-cause mortality at 1 year post-ED visit.

Results: The association between digoxin and mortality was assessed in 2016 Chinese patients with AF enrolled in emergency department (ED) using multivariate Cox proportional hazards models. Of those, 722 received digoxin as initial therapy and 1291 received no digoxin at baseline. Propensity scores for digoxin use were estimated for each of these 2016 patients and used to assemble a cohort of 359 pairs of patients receiving and not receiving digoxin, who were balanced on 49 baseline characteristics. Among pre-match patients, digoxin was associated with an increase in all-cause mortality (16.6% vs 12.6%, P=0.014). However, this association became nonsignificant after multivariable adjustment (HR: 1.03; 95% CI: 0.66-1.61; P=0.911) and adjustment for propensity scores (HR, 0.97; 95% CI: 0.63-1.50; P=0.892). All-cause mortality occurred in 15.2% and 14.7% ofmatchedpatients receiving andnotreceiving digoxin, respectively (HR: 1.21; 95% CI: 0.68 2.13; P=0.519).

Conclusion: There was no significant increase in all-cause mortality in AF patients with digoxin as baseline initial therapy.



Is the CHADS2 score predicts prognosis in atrial fibrillation patients concomitant with valvular atrial fibrillation

Han Zhang, Yan-min Yang, Jun Zhu, Shao Xinhui, Wang Juan, Tian Li, Huang Bi

Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy oof Medical Sciences and Peking Union Medical College, Beijing, China

Background: We sought to evaluate the prognostic performance of the CHADS2 score for prediction of death and major adverse events (MAEs) in patients with atrial fibrillation (AF) and valve heart disease (VHD).

Methods: In China AF registry, we enrolled 2016 patients with AF, 336 of whom were concomitant with VHD. We calculated the CHADS2 scores (congestive heart failure, hypertension, age>75, diabetes mellitus (1 point each), and prior stroke or transient ischemic attack (TIA) (2 points) ). All patients were followed by 1 year. The primary outcome was death from any reason. The second outcome was the composite adverse events of death, stroke, and non-CNS systemic embolism.

Results: Of 336 patients with valvular atrial fibrillation (VAF), the mean CHADS2 score was 1.5±1.2, which was lower than that in patients with non-valvular atrial fibrillation (NVAF). Compared to patients with low (0-1) CHADS2 scores, those with intermediate (2-3) and high (4,5, and 6) CHADS2 scores had an increased rate of death (14.1%, 13.1%, and 23.8%, respectively; P = 0.375), but not of MAEs (18.8%, 17.2%, and 33.3%, respectively; P = 0.247). The KaplanMeier analysis did not reveal a tendency of higher CHADS2 score toword death (Figure 1a; logranktest, P = 0.459), orMAEs (Figure 1b; log-ranktest, P = 0.356). However, after adjustment for reason for Emergency Department (ED) visit, type of AF, tobacco use, and antithrombotic therapy, the CHADS2 score was not an independent risk factor of death (P =0.692) or MAEs (P =0.507) in VAF patients.

Conclusion: In patients with VAF, the CHADS2 score is not related to death or MAEs. Keywords: the CHADS2 score; valvular atrial fibrillation; death; major adverse events (MAEs).

Effects of pericardial fat on P wave duration

Shih-Jie Jhuo, Kun-Tai Lee

Kaohsiung Medical University Hospital, Taiwan

Background and Objectives: The amount of pericardial fat is associated with the occurrence of atrial fibrillation (AF). The purposes of this study was to determine effects of pericardial fat on P wave duration in ECG.

Methods: 30 patients (20 males, mean age: 45±10 years) were enrolled. P waves duration and P wave dispersion were measured by computer caliber in each leads. The amount of fat around the right atrium (RA), left atrium (LA) and both atria were measured by 640-slice of computer tomography.

Results: The mean values of P wave duration were 100±20 ms in lead I, 112±11 ms in lead II, 98±19 ms in lead III, 109±7 ms in lead aVR, 76±28 ms in lead aVL, 107±16 ms in lead aVF, 93 ±19 ms in lead V1, 76±40 ms in lead V2, 90±34 ms in lead V3, 107±11 ms in lead V4, 113±13 ms in lead V5, and 110±20 ms in lead V6, respectively. The mean value of P wave duration dispersion was 43±15 ms. The mean volume of fat around the RA, LA and both atria were 31±52, 16±5 and 47±54, respectively. The P wave duration in lead II was correlated with the amount of fat around the LA (R=-0.67;P=0.038) and the duration of P wave in lead III were correlated with the amount of fat around both atria (R=-0.63; P=0.049). The P wave dispersion was not significantly correlated with the amount of fat around atria.

Conclusions: The P wave duration was correlated with the amount of fat tissue around the atria which may contribute mechanism of arrhythmogenesis by pericardial fat.



CHADS2 score predicted new-onset dementia in the absence of atrial fibrillation: a nationwide cohort study

Min-Tsun Liao1; Lian-Yu Lin2; Chia-Ti Tsai; Jiunn-Lee Lin2

1 Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan

2Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan

Background: Atrial fibrillation (AF) is associated with increased risk of dementia. CHADS2 scores were reported to be important risk factors for the development of AF. The goal of this study sought to evaluate whether the CHADS2 scores could predict the incidence of new-onset dementia in the absent of AF.

Methods: A total of 460,844 patients in the absence of AF who had no history of dementia and were above 20 years old were enrolled from National Health Insurance Research Database of Taiwan from January 1, 1997 to January 1, 1998. The CHADS2 scores were calculated for every patient. Finally, 279,574 (score 0), 102,232 (score 1), 48,447 (score 2), 17,493 (score 3), 10,414 (score 4), 2,440 (score 5) and 244 (score 6) patients were studied and followed for the development of dementia.

Results: During a mean follow-up of 10.9±0.7 years, there were 7,356 (1.6%) patients occurring new-onset dementia. The incidence of new-onset dementia was 1.46 per 1000 patient-year. The Kaplan-Meier curve also demonstrated that CHADS2 scores were associated with the incidence of new-onset dementia inpatients without AF (log rankP < 0.001). (Figure 1) After an adjustment for the gender and comorbidities, cox-regression analysis showed that the hazard ratio of CHADS2 scores were 3.962, 7.026, 11.316, 12.819, 16.248, 20.707 (score 0 vs 1, 2, 3, 4, 5 and 6; all P < 0.001).

Conclusion: The CHADS2 scores predicted new-onset dementia and were useful in risk stratification ofnew-onset dementia.

Kaplan-Meier Curve

0«) 200 4.00 6.00 8.00 10.00 12.00 Yuri

Randomized comparison of intravenous sedatives during catheter ablation of atrial fibrillation; interim result of DDR (deep sedation with dexmedetomidine and remifentanil) trial: interim result of ongoing prospective study

Sung-Hwan Kim, Bo-KyungKim, Young WoongHa, Jeong-WookPark

Seoul St. Mary Hospital, South Korea

Background: Recently, dexmedetomidine and remifentanil were used for sedation of non-intubated patients during surgery or other medical procedures. The feasibility and safety of sedation with these drugs were investigated in patients undergoing catheter ablation of atrial fibrillation (AF).

Methods: Fifteen patients were randomized to study group (continuous infusion of dexmedetomidine and remifentanil) or control group (intermittent infusion of midazolam and fentanyl). Heart rate (HR), invasive arterial blood pressure, oxygen saturation and intervening procedure due to awakening were monitored. Non-invasive positive pressure ventilation was applied in all patients.

Results: Regarding to baseline characteristics, there was no significant difference of age (64±14 vs. 57±10 years, P=0.27), systolic (143±19 vs. 136±18 mmHg, P=0.46) and diastolic blood pressure (87±15 vs. 82±7 mmHg, P=0.44), and baseline HR (71±19 vs. 78±14 beats per minute, P=0.50) between study and control group. During procedure, the frequencies of low oxygen saturation (< 90%), hypotension (systolic blood pressure < 90 mmHg), bradycardia (heart rate < 50 bpm), and intervening procedure due to awakening were summarized (Table).

Conclusions: Although this is the interim result of ongoing study, combined use of novel drugs (dexmedetomidine and remifentanil) may reduce intervening procedure due to awakening, resulting in safer catheter ablation of AF.

Midazolam Dexmedetomidine + fentanyl + remifentanil P _(n=7)_(n=8)_

O2 saturation < 90% 0(0.0%) 1(12.5%) 0.53

SBP < 90 mmHg 4(57.1%) 3(37.5%) 0.41

HR < 50 bpm 0(0.0%) 0(0.0%)

Intervening procedure due to awakening

4(57.1%) 0(0.0%)



Randomized Comparison of Continuous and Intermittent Heparin Infusion during Catheter Ablation of Atrial Fibrillation; Interim Results of ongoing COHERE (Continuous HEparin infusion REferring to ablation of atrial fibrillation) trial

Sung-Hwan Kim, Bo-KyungKim, Young WoongHa, Jeong-WookPark

Seoul St. Mary Hospital, South Korea

Background: We hypothesized that continuous heparin infusion would be favorable for maintenace ofheparin concentration during catheter ablation ofatrial fibrillation (AF).

Methods: Ninety-five patietns undergoing AF ablation were consecutively enrolled and randomized to intermittent or continuous heparin infusion. A 100 u/kg bolus of heparin was injected just after femoral artery puncture. The dose ofheparin was determined to maintain optimal activated clotting time (ACT) (300~400 sec), which were checked every 30 minute during procedure. The primary endpoint was the frequency of the maintence of optimal ACT.

Results: There was no significant difference of age (years, 60.6±10.9 vs. 58.6±13.4, P=0.42), sex (male, 30/48 vs. 34/47, P=0.31), body surface area (m2, 1.72±0.19 vs. 1.79±0.20, P=0.09) and baseline INR (1.95±0.53 vs. 1.86±0.43, P=0.37) between intermittent and continuous group. The results of heparin and ACT were summarized (Table).

Conclusions: During catheter ablation of AF, continuous heparin infusion was useful to maintain optimal ACT range with small amount ofheparin and small ACT fluctuations.

Intermittent infusion Continuous infusion



Loading dose of heparin (u) Heparin infusion time (hr) Total dose of heparin (u) Average of ACT (sec.) Standard deviation of ACT (sec.) The frequency within optimal ACT _(300~400 sec)_


2.4±0.6 13442±3879 379±76 65±35



2.3±0.5 11783±3625 349±65 44±24

129/219 (58.9%)

0.19 0.57 0.03 <0.01 <0.01

The Institut Jantung Negara (the national heart institute of Malaysia) left atrial appendage occluder registry

Zulkeflee M, LP. Segundo, Ma SK, Surinder K, Azlan H, Suhaini K, Lim BC, R, Rebo, Devanthiran PS, Zunida A, Tay GS, Noor Asyikin S and Razali O

Department of Cardiology, Institut Jantung Negara, Kuala Lumpur, Malaysia

Background: The left atrial appendage (LAA) occluder device has been used in numerous centers to prevent embolic events in patients with non-valvular atrial fibrillation who are not eligible for life-long anticoagulation, with varying success and efficacy rates.

Objective: To report a single center experience in implantation of left atrial appendage occluder device

Methodology: From July 22, 2010 to December 31, 2012, a total of 52 patients with non-valvular atrial fibrillation and CHA2DS2VASc score of at least 2 have been selected in Institut Jantung Negara (IJN) to receive LAA occluder based on the following criteria: prior bleeding (32.7%), patient compliance factors (19.2%), erratic INR (25.0%), and high risk of bleeding (23.1%). Implantation ofthe LAA occluder was done under general anaesthesia using fluoroscopy and TEE guidance. Patients were followed up with TEE after 45 days to assess complete endothelialization to allow stopping oral anticoagulation. Routine clinical follow up was done in all patients from 45 days to 18 months.

Results: Mean age was 65.5 years, males (62.7%), and mean CHA2DS2VASc score of 4.1. Most patients received Warfarin (54.9%) pre-implantation, followed by Dabigatran (27.4%), combination of Aspirin and Clopidogrel (13.7%), Fondaparinux (2%) and with no anticoagulant (2%).

Majority ofthe patients were implanted with LAA occluder size 24mm (32.7%) and 27mm (28.8%). Acute success, defined by position, compression, stability, and seal assessed via TEE, was 100%.

At 45 days, TEE showed no thrombus, no leakage and good stability in 42 out of 45 (93.3%) patients. Of the 44 patients previously on anticoagulation, 39 patients were shifted to dual antiplatelet (88.6%).

At 6 months follow up, TEE showed no thrombus, no leakage and good stability in 14 out of 17 (82.4%) patients. All of the patients have been off oral anticoagulation. No patient had stroke, embolism nor cardiovascular death.

Conclusion: The LAA occluder device is a relatively safe and effective therapy in preventing embolic events among AF patients who are not eligible to receive life-long anticoagulation.



Incidence and characteristics of patients unsuitable for dabigatran in clinical practice - a report from the STACIN registry

Hitoshi Minamiguchi1, Yuji Okuyama1,2, Tetsuo Minamino1, Shozo Konishi1, Masaharu Masuda1, Masafumi Kitakaze, Yukihiro Koretsune, Yasunaga Hiyoshi, Takahisa Yamada, Shinji Hasegawa7, Shinsuke Nanto1

Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka University, Suita, Japan

Department of Advanced Cardiovascular Therapeutics, Osaka University Graduate School oof Medicine, Suita, Japan

Department of Cardiovascular Medicine, National Cerebral Cardiovascular Center, Suita, Japan Institute for Clinical Research, Osaka National Hospital Osaka, Japan Department of Internal Medicine, Tokyo Metropolitan Ebara Hospital, Tokyo, Japan 6 Division of Cardiology, Osaka General Medical Center, Osaka, Japan Department of Cardiology, Osaka Kosei Nenkin Hospital, Osaka, Japan

Background: Dabigatran, which is a new oral direct thrombin inhibitor, is safe and effective for preventing stroke in patients with atrial fibrillation. However, dosage of dabigatran depends on specific patient characteristics such as renal function. We investigated the incidence and characteristics of patients unsuitable for dabigatran in clinical practice.

Methods: In STACIN registry that was amulticenter atrial fibrillation registry, 516 patients (71±9 years, 364 males) with CHADS2 score 1 were analyzed. Patients unsuitable for dabigatran was defined as those having more than 2 factors (creatinine clearance 50ml/min, age 70 years, administration of P-glycoprotein inhibitors such as verapamil and amiodarone). We evaluated the distribution of patients unsuitable for dabigatran in CHADS2 score.

Results: 179 patients (35%) were unsuitable for dabigatran in terms of fulfillment of more than 2 factors. Distribution ofthese patients were as follows: 40 of 153 patients (26%) with a CHADS2 score=1, 56 of 166 patients (34%) with a CHADS2 score =2, 47 of 97 patients (48%) with a CHADS2 score =3, and 36 of 80 patients (45%) with a CHADS2 score 4. Patients who were not suitable for dabigatran had higher CHADS2 score than those who were suitable (2.5±1.2 vs. 2.0±1.2, p<0.0001).

Conclusions: Incidence of patients unsuitable for dabigatran was not rare in clinical practice. Warfarin and other new anticoagulant dugs may be better choice for preventing stroke especially in patients with higher CHADS2 score.

Reduced ventricular response rate variability was associated with high risk clinical conditions in patients with persistent atrial fibrillation

Jumsuk Ko, Namho Kim, Seungnam Shin, Youngcheol Kim

Wonkwang University School of Medicine And Hospital, South Korea

Introduction: It has been known that reduced heart rate variability during sinus rhythm was associated with adverse clinical outcomes of structural heart disease. But there was debate on predictive value ofventricular response rate variability in patients with persistent atrial fibrillation. We aimed to identify clinical implication of ventricular response rate variability in persistent atrial fibrillation.

Methods: We analyzed49 patients(male 57.1%, mean age 67.1±11.5) withnon-valvularpersistent atrial fibrillation. Variability ofventricular response rate was estimatedby the SD ofthe mean R-R interval (SDNN) and the SD ofthe 5-min mean R-R interval (SDANN). Correlations between variability parameters and various clinical factors including stroke, CHAD score, laboratory data and echocardiography data were assessed.

Results: The patients with reduced ventricular response rate variability showed significant higher serum BNP level (588.5±746.4 vs 237.5±138.8, p<0.05) and higher incidence of CVA ( 35.3% vs 6.7%, p<0.05). And serum BNP level was negatively correlated with SDNN/SDNN (p<0.05). There was no other significant difference between two groups.

Conclusion: The data in this study suggested that reduced ventricular response rate variability have prognostic value in persistent atrial fibrillation.



Clinical association of atrial fibrillation and cognitive impairment

Zhong Guoqiang, Li Jinyi

Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Institute of Cardiology, Nanning 530021, China

Objective: To study the clinical association ofatrial fibrillation and cognitive impairment.

Methods: Combined with the foreign latest clinical results and evidence-based systematic reviews of of atrial fibrillation and cognitive impairment to review the clinical association ofatrial fibrillation and cognitive impairment.


(1) In clinical studies, van Deelen found in the elderly patients with atrial fibrillation, MiniMental State examination (MMSE) score < 23 independently associated with anticoagulant therapy of poorly controlled INR, which suggested that the cognitive impairment in elderly patients with atrial fibrillation may lead to the oral anticoagulation therapy of poorly controlled INR. Wozakowska-Kapion found about 43% of patients with atrial fibrillation have cognitive impairment, atrial fibrillation and limited activities of daily living were the independent factors for cognitive impairment. Bellomo found that 31% of patients with atrial fibrillation have the risk of cognitive impairment, and 15% patients have the risk of depression. Ball found that 65% ofpatients with atrial fibrillation have mild cognitive impairment, and the influenc factors including the low education level, high CHA2DS2-VASc score and digoxin used history. Datas of ONTARGET and TRANSCEND trials shows, irregular heartbeat (such as atrial fibrillation) are effective predictors of cognitive impairment and loss of self-care ability in older people with cardiovascular disease. Atrial fibrillation increased cognitive impairment and dementia.

(2) In the research of systematic review and meta-analysis, Kwok showed in patients with stroke history, atrial fibrillation was closely related to dementia incidence. Eggermont found that atrial fibrillation could lead to cognitive inflexibility such as reduced abstract reasoning, visual and verbal memory deficits, and executive function deficits. A new systematic review at 2013 showed even in the absence of stroke, atrial fibrillation was the significantly risk of decreased cognitive factors.

Conclusion: Atrial fibrillation and cognitive impairment has clinical relevance, but the mechanisms underlying the association between atrial fibrillation and cognitive impairment is unknown. More well-designed longitudinal studies may reveal the potential mechanism of atrial fibrillation and cognitive impairment.

Keywords: Atrial fibrillation; Cognitive impairment; Clinical association

Omega-3 fatty acid attenuated vulnerability of atrial fibrillation in left arial pressure overload rat model

Jumsuk Ko, Namho Kim, Seungnam Shin, Yongcheol Kim

Wonkwang University School of Medicine and Hospital, South Korea

Introduction: N-3 polyunsaturated fatty acids (n-3 PUFAs) exert antiarrhythmic effects and reduce sudden cardiac death. However, their role in the prevention of atrial fibrillation remains controversial. We aimed to evaluate the effect ofn-3 PUFAs on vulnerability ofatrial fibrillation in left arial pressure overload rat model.

Methods: Male Sprague-Dawley rats (n=15) were equally divided into three groups : sharm operation group, TAC (transaortic constriction surgery) with conventional rat chow group and TAC with daily oral Omega-3 fatty acid (300 mg/kg) group. We estimated remodeling of left atrium and left ventricle by 2D echocardiography at 5 weeks after operation. Test for inducibility of atrial fibrillation was performed by transesophageal pacing. And fibrosis of left atrium was assessed by MCP-1 expression in left atrial tissue.

Results: LV wall thickness, LA diameter and heart weight/body weigh index was significant higher in control and omega-3 fatty acid group compared with sharm operation group. Inducibility of atrial fibrillation was significantly lower in omega-3 fatty acid group compared with control group. And omega-3 fatty acid group showed significantly lower tissue MCP-1 expression.

Conclusion: The data in this study suggested that omega-3 fatty acid attenuated vulnerability of atrial fibrillation by ameliorating fibrosis of left atrium in pressure overload rat model.



Identification of left atrial thrombus after 3-week anticoagulation prior to elective cardioversion in high risk patients with persistent atrial fibrillation

Youngjin Cho,1 Myung-Jin Cha, 1 Eue-Keun Choi, Il-Young Oh,2 Seil Oh1

Department of Internal medicine, Seoul National University Hospital, South Korea Department of Internal medicine, Seoul National University Bundang Hospital, South Korea

Background & Objectives: We sought to find patients with atrial fibrillation (AF) lasting > 48 hours who are at high risk of left atrial (LA) thrombus despite 3-week anticoagulation before elective direct-current cardioversion (DCC), as recommended by the current guidelines.

Methods: Persistent AF patients scheduled for elective DCC were enrolled consecutively. Patients anti-coagulated for more than 3 weeks and who had undergone transesophageal echocardiography before DCC were included (n=237, age 63±10 years, 73 [31%] females).

Results: TEE revealed LA thrombus in 8 out of 237 patients (3.4%). Patients with LA thrombus showed higher prevalence ofvalvular AF (3/8 [37.5%] vs. 11/229 [4.8%], p=0.008), and larger LA size (55±5 vs. 50±7mm, p=0.037). The percentages of time above PT INR 2.0 during 3-weeks of anticoagulation was not significantly different between patients with and without LA thrombus (64±40 vs. 77±36%, p=0.290). There was no significant difference in mean CHADS2 (1.4±1.4 vs. 1.0±1.0, p=0.373), CHA2DS2-VASc (3.0±2.0 vs. 2.2±1.5, p=0.135), and HAS-BLED score (2.0±1.4 vs. 1.6±1.0, p=0.301). In a multivariate analysis, valvular AF (adjusted odds ratio [OR], 15.9; 95% confidence interval [CI], 2.1 - 118; p=0.007) and CHADS2 > 4 (adjusted OR, 34.7; 95% CI, 2.0 603; p=0.015) were independentpredictors ofLA thrombus in TEE.

Conclusions: Three weeks anticoagulation prior to DCC in persistent AF patients does not guarantee absence ofLA thrombus. Patients with valvular AF or those with CHADS2 > 4 are at high risk for LA thrombus and TEE may play an important role in these patients.

Measurement of arterial stiffness in patients with atrial fibrillation

Scott R Willoughby, Dennis Lau, Carlee D Schultz BHltSc (Hon), Sachin Nayyar, MD; Rajiv Mahajan, MD; Rajeev Pathak; Melissa Middledorp, Prashanthan Sanders, MBBS, PhD. Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital Adelaide, South Australia, Australia

Background & Objectives: Augmentation index (AI) measures the contribution that wave reflection makes to the arterial pressure waveform. AI is considered a surrogate marker for the stiffness of the arterial system; however its utility in atrial fibrillation is unknown. Therefore we sought to determine whether AI calculated from the fingertips (patAI) provides similar information to that ofthe aortic transformed AI in patients with atrial fibrillation.

Methods: 35 consecutive patients with paroxysmal atrial fibrillation (age 59±12) were examined during sinus rhythm. For each subject, rAI were recorded using radial applanation tonometry (SphygmoCor) and patAI using peripheral arterial tonometry (EndoPat2000). AI is the ratio first to second peaks of the central arterial waveform) and expressed as a percentage of pulse pressure. rAI data was transformed to produce a corresponding aortic AI.

Results: Overall, aortic AI (19±13%) was significantly (p<0.005) higher than patAI (9±21%) but both indices were highly correlated to each other. The R value was 0.79 (p<0.0001) and the R-squared value was 0.62 (Figure A). Bland Altman plot of the difference between the two techniques (patAI- aortic AI values) versus their mean demonstrates that patAI under-estimates augmentation index (Figure B). The bias calculated over the range of averaged concentrations was -10%. However, the bias is not constant over this range.

Conclusion: While there is a good correlation between the AI calculated from both techniques, the lack of uniform bias between the values suggests that the two techniques are not interchangeable as estimates ofarterial stiffness in patients with atrial fibrillation.

A: Correlation patAI and rAI B: Bland-Altman Plot

-20 0 20 40 60 -20 0 20 40 60

rAI (%) Average of patAI and rAI (%)



Complications associated with initiation of anticoagulation therapy using warfarin - an observational study


department of Pharmacy, Singapore General Hospital, Singapore Department of Pharmacy, National Heart Centre, Singapore Department of Hematology, Singapore General Hospital Singapore Department of Cardiology, National Heart Centre, Singapore

Background & Objectives: To report observations on management of anticoagulation therapy in patients newly initiated on warfarin in two local institutions.

Methods: All patients newly initiated on warfarin over a 6 months period were identified and followed up for six months. The average time to reach first therapeutic International Normalized Ratio (INR) (Tl) and time to reach two consecutive therapeutic INR with interval of at least 30 days (T2) was calculated. All-cause mortality, rate of hospitalization due to complications of warfarin therapy and episodes of INR > 4 within six months of follow up were recorded.

Results: A total of 321 patients were included in the study. T1 was 24.3 days (SD 38.6), with 9.3% ofpatients never reaching target. T2 was 65.l days (SD 6l.l), with 52.6% ofpatients never reaching target. The total rate of discontinuation oftherapy was 23.7% with the main reason being labile INR. All-cause mortality was 4.l%, with l.2% attributed to warfarin therapy. The total rate of re-hospitalization due to all complications of warfarin therapy was 9.0%, with 6.l% due to bleeding episodes (l.4% major bleeding; 4.7% minor bleeding). The number ofpatients with at least one incidence ofINR>4were l02 (2l.8%).

Conclusion: In our study group, an average of 60 days was required before full therapeutic effects were experienced. Patients newly initiated on warfarin were at significant risk of bleeding complications. This will also translates to considerable costs of warfarin initiation.

Correlation of CHADS2 and CHA2DS2-VASc scores with left atrial thrombus in Chinese patients with nonvalvular atrial fibrillation

YM. Xue, J. Huang, T. Liu, XH. Fang, XZ. Zhang, SL. Wu

Guangdong General Hospital, Guangdong Cardiovascular Institute, Department oof Cardiology, Guangzhou, People's Republic of China

Objective: The aims of this study were to evaluate the relationship of the CHADS2 and CHA2DS2-VASc scores with left atrial (LA) thrombus detected by transesophageal echocardiographic and to compare these two risk stratification schemes with respect to their ability to predict LA thrombus in Chinese patients with nonvalvular atrial fibrillation.

Methods: Transesophageal echocardiograms of 1544 patients (mean age 57.1±11.9 years; 32% female; 1297 paroxysmal atrial fibrillation) with nonvalvular atrial fibrillation were retrospectively reviewed for LA thrombus. The patients' CHADS2 and CHA2DS2-VASc risk scores and categories were also calculated.

Results: Transesophageal echocardiography revealed LA thrombi in 53(3.4%) patients. Using CHADS2, LA thrombus was found in 2.7% ofthe low-risk group, 4.4% ofthe intermediate-risk group and 3.7% ofthe high-risk group (P = 0.26). Using CHA2DS2-VASc, LA thrombus was found in 2.3% ofthe low-risk group, 3.9% ofthe intermediate-risk group and 3.7% ofthe high-risk group (P = 0.24). The frequency of patients with LA thrombi fell into the low intermediate-risk group classified based on the CHADS2 and CHA2DS2-VASc score were 85.0% and 56.6%, respectively. The C-statistics for predicting LA thrombi with CHADS2 and CHA2DS2-VASc were 0.55 (95% CI: 0.473-0.628) and 0.55 (95% CI: 0.477-0.623), respectively.

Conclusion: Both CHADS2 and CHA2DS2-VASc scores may have limited value for predicting LA thrombus in Chinese patients with nonvalvular atrial fibrillation. Further research is needed to examine their true predictive value.



Exogenous cell-penetrating (cp)-Gail/2 C-terminal peptide inhibits adenylate cyclase (AC)/ cAMP/ PKA pathway and reduces vagal-induced atrial fibrillation

Hua Jiang, Xianhui Zhou, Jian Zhang, Baopeng Tang, Fei Li, Haoxuan Qin, Tianyi Gan

Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830011, PR China

Background & Objectives: The parasympathetic nervous system is thought to play a critical role in the pathogenesis of atrial fibrillation (AF). The parasympathetic signalling is primarily mediated by the heterotrimeric G-protein,GaiPy, we hypothesized that targeted inhibition of Gai interactions in the posterior left atrium (PLA) would suppress vagal-induced AF.

Methods: By stimulating vagus nerve trunk and rapid right atrial pacing, we established paroxysmal atrial fibrillation model in canine. Rhodamine-labeled exogenous cp-Gai1/2 C-terminal peptide was injected in the PLA in experimental group, while in control group, saline was injected in the same location. Confocal fluorescence microscopy was used to verify the expression of cp-Gai1/2 peptide. Gai1/2 subunit mRNA and protein expression were assessed by real-time PCR and western blot, respectively. The amounts of cAMP in PLAs homogenates were assessed via competitive enzyme immunoassay.

Results: Cp-Gai1/2 peptide was confirmed existing in experimental group PLAs. There was no significant difference in the mRNA and protein expression of Gai1/2 subunit between the two groups, while cAMP levels in experimental group PLAs were found to be significantly higher than that in control group P<0.01 . Electrophysiological mapping of canine PLA, left atrial pulmonary veins (PVs), and left atrial appendage (LAA) indicated that the delivery of cp-Gai1/2 peptide prolonged effective refractory periods(ERP) and the dERP of different sites P<0.05 .

Conclusion: These results demonstrate that specific Gai C-terminal peptide can be used to achieve selective disruption of parasympathetic-mediated M2R/Gi-protein coupled signalling by the inhibition of AC/cAMP/PKApathway, thus decreases vagal-inducedAF.

Keywords: atrial fibrillation; cell-penetrating(cp)-Gai1/2 C-terminal peptide; parasympathetic nervous system

Predictors of recurrence of atrial fibrillation after direct-current cardioversion in patients with non-valvular persistent atrial fibrillation

Chang Hee Kwon, Gi-Byoung Nam, Woo Seok Lee, Yoo Ri Kim, Yong

Asan Medical Center, South Korea

Background: Direct-current cardioversion (DCCV) is an effective method of converting atrial fibrillation (AF) to sinus rhythm. However, the recurrence of AF after DCCV is relatively high. The aim of this study was to identify prognostic indicators for successful cardioversion and maintenance of sinus rhythm after DCCV in patients with non-valvular persistent AF (PeAF).

Methods: Eighty consecutive patients with PeAF for > 1 month, scheduled for DCCV, were included in this study. Clinical, laboratory, and echocardiographic characteristics were evaluated in all patients. Long-standing PeAF was defined as lasting for> 12 months.

Results: The mean age of the patients was 56 years (inter-quartile range 50, 64) and duration of AF was 34 (inter-quartile range 4, 39) months. Sinus rhythm was established in 66 (82.5%) patients. In patients (n=66) with restoration of sinus rhythm, 43 (65.2%) patients showed recurrence of AF during follow-up. Univariate Cox regression analysis revealed that long-standing PeAF was independent predictor for recurrence of AF after DCCV (hazard ratio [HR] 3.48, 95% confidence interval [CI] 1.73-7.00, p<0.001). Time-dependent receiver-operating characteristic (ROC) curve analysis showed that AF duration > 12 months (sensitivity of 72.1%, specificity of 78.3%) was the best cut-off value for predicting the recurrence of AF after DCCV (area under curve 0.790, 95% CI 0.672-0.908, p<0.001). Kaplan-Meier analysis revealed a significant difference in the rate of AF recurrence between patients according to long-standing PeAF (p<0.001) (figure).

Conclusion: In patients with PeAF, about two thirds of patients show the recurrence of AF after successful DCCV. The long-standing PeAF is only independent factor for predicting the recurrence of AF. Thus, DCCV may not be a useful method to convert AF to sinus rhythm in patients with long-standing PeAF.

Figure. Kaplan-Meier curve for rates of maintenance of sinus rhythm according to atrial fibrillation duration (persistent atrial fibrillation versus long-standing persistent atrial fibrillation).



Role of C-reactive protein level in carotid atherosclerosis in patients with atrial fibrillation and elevated

Kyoung-Im Cho, Tae-Joon Cha, Jung-Ho Heo, Hyun-Su Kim, and Jae-Woo Lee

Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, South Korea

Background: Carotid intima-media thickness (IMT) is associated with chronic inflammation, and C-reactive protein (CRP) level is elevated in patients with choric atrial fibrillation (AF). We investigated the role of CRP in the carotid atherosclerosis in patients with AF.

Methods: One hundred thirty patients (male=68) were underwent carotid ultrasonogram (US) and mean common carotid arteries (CCA) IMT, mean internal carotid arteries (ICA) IMT, and plaque score were measured. Patents were divided to 4 groups according to the presence of AF and elevated level of CRP [AF(-)CRP(-)(n=45), AF(-)CRP(+)(n=(n=45), AF(+)CRP(-)(n=37), AF(+) CRP(+)(n=13)).

Results: CCA IMT was significant higher in the AF(-)CRP(+)(0.98±0.46 mm) and AF(+) CRP(+) (0.96±0.27 mm) groups compared to AF(-) CRP(-)(0.81±0.33 mm) and AF(+) CRP(-)(0.78±0.20 mm) groups (p <0.05 by Anova). Although there was no significant difference in mean ICA IMT among the groups, plaque score was highest in AF(+) CRP(+)(3.81±3.84), followed by AF(-) CRP(+)(2.01±2.49), AF(+)CRP(-)(1.22±2.73) and AF(-)CRP(-)(0.96±2.37)(p=0.006 by Anova). Multiple regression logistic test showed that the age (OR 4.513, p<0.05,), AF(-)CRP(+)group (OR 4.685, p<0.05,) and AF(+)CRP(+) group (OR 16.61, p<0.05) were significantly related to increased CCA IMT.

Conclusions: Elevated plasma CRP concentrations may be a reliable surrogate marker for the prediction of carotid atherosclerosis in patients with AF, and this may be related to the increased risk of cerebral infarction.

Body mass index and mortality in patients with atrial fibrillation

Han Zhang, Yan-min Yang, Jun Zhu, Shao Xinhui, Wang Juan, Tian Li, Huang Bi

Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy oof Medical Sciences and Peking Union Medical College, Beijing, 100037, China

Background: Obesity is associated with the development of atrial fibrillation and may impact atrial fibrillation-related outcomes. To date, it's unclear whether body mass index (BMI) predicts death and major adverse events (MAEs) in atrial fibrillation patients.

Methods: We conducted a prospective, observational registry of patients with AF/flutter in China. Participants were enrolled in the ED. Baseline characteristics were collected and follow-up was planned at 1 year. The primary outcome was death from any cause, and the secondary outcome was major averse events (MAEs, a composite endpoint of death, stroke, non-CNS system embolism, and major bleeding).

Results: Of the 2016 subjects with atrial fibrillation, 162 (9.0%) had a body mass index (BMI) in the underweight category (BMI <18.5 kg/m2), 1224 (60.7%) were categorized as normal weight (BMI 18.5 to <25.0 kg/m2), 524 (25.7%) patients in overweight group (BMI 25.0 to <30.0kg/ m2), and 105 (4.6%) subjects met the BMI criteria for obesity (>30.0kg/m2). The rate of death and MAEs were higher in underweight (23.9% and 27.7%) and normal (15.7% and 22.7%) weight patients than overweight (8.1% and 16.1%) and obesity patients (8.6% and 20.0%). On multivariate analysis, BMI stratification was associated with 1-year all-cause mortality (P =0.008). Using underweight patients as reference, the risk of death was significantly lower in overweight (HR: 0.52; 95% CI: 0.33-0.84, P =0.007), but not in normal weight (HR: 0.91; 95% CI: 0.62-1.32, P=0.616) and obesity patients (HR: 0.57; 95% CI: 0.26-1.21, P =0.141). Continuous analyses of BMI also revealed BMI predicted 1-year mortality in patients with AF (HR: 0.94; 95% CI: 0.900.97, P <0.001). However, the HRs for MAEs were 1.07(95% CI: 0.76-1.50, P=0.69) for normal weight, 0.86 (95% CI: 0.58-1.27, P=0.438) for overweight, and 1.09 (95% CI 0.63-1.89, P=0.753) for obese. As a continuous variate, BMI was also not associated with MAEs (HR: 0.98; 95% CI: 0.95-1.01, P=0.139).

Conclusion: In patients with atrial fibrillation, lower BMI appears to be a risk factor of 1-year mortality.

Keywords: Atrial fibrillation; Body mass index; Mortality; Major adverse events



Analysis of risk factors for all cause-mortality in atrial fibrillation patients

Juan Wang, Han Zhang, Xing-hui Shao, Li Tian, Bi Huang, Yan-min Yang, Jun Zhu

Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037,China

Objective: To explore the independent risk factors associated with one-year mortality in patients with atrial fibrillation.

Methods: This study consecutively enrolled patients presenting to an emergency department with atrial fibrillation at 19 hospitals in China from 2009 to 2011.Baseline data and treatment were recorded, all patients were followed up for one year, and major cardiovascular outcomes were recorded. A total of 2016 atrial fibrillation patients were enrolled. Predictors of one year mortality were identified by univariate and multivariate Cox regression analysis using baseline, therapy variables and follow-up therapy variables.

Results: The one-year all-cause mortality was 13.8% among the 2016 atrial fibrillation patients. All the patients were divided into 2 groups: the death group (279 cases) and non-death group (1737 cases), the baseline data of the two groups were analyzed, the death group patients were older, smaller of body mass index compared to non-death group; the proportion of permanent atrial fibrillation and CHADS2 score >2 points was higher in the death group. History of heart failure, previous stroke, left ventricular systolic dysfunction, diabetes, dementia, chronic obstructive pulmonary disease were was in a higher proportion of the death group. Among the drug treatment, the usage of diuretics, digoxin and other anticoagulants (heparin, etc) was more in the death group; however, the proportion of beta blockers, angiotensin receptor blockers, aspirin, warfarin, antiarrhythmic drugs, cardioversion therapy was higher in the non-death group. The KaplanMeier survival curves showed that the mortality rate increased along with the CHADS2 score increased. Multivariarte Cox regression analysis showedthat age (HR 1.053, 95%CI 1.040-1.066), permanent atrial fibrillation (HR 1.374, 95%CI 1.003-1.883), history ofheart failure (HR 1.385, 95%CI 1.009-1.901), previous stroke (HR 1.345, 95%CI 1.009-1.795), chronic obstructive pulmonary disease (HR 1.379, 95%CI 1.030-1.848), unused angiotensin receptor blockers (HR 1.955,95%CI 1.349-2.832), aspirin unused (HR 1.770,95%CI 1.375-2.278) and warfarin unused (HR 3.262, 95%CI 1.824-5.834) were independent risk factors of one-year mortality ofatrial fibrillation patients.

Conclusion: The CHADS2 score was not only a risk factor for thrombo-embolia of atrial fibrillation patients, but in this study was also a predictor of all-cause death. Age, history of heart failure, previous stroke, COPD/emphysema history were independent risk factors of one-year all-cause mortality of atrial fibrillation patients. In drug therapy, ARB, aspirin and warfarin unused was risk factor for death at one- year of atrial fibrillation patients. The clinician should pay more attention on the the treatment and management of patients with these risk factors.

Keywords: Atrial fibrillation; Prognosis; Mortality; Risk factors

The impact of polyunsaturated fatty acid on the recurrence after ablative therapy in patients with persistent atrial fibrillation

Yoon-Jung Choi, Jeong-Hwan Cho, Chan-Hee Lee, Hyun-WookLee, Sang-Hee Lee, UngKim, Jong-Seon Park, Dong-Gu Shin, Young-Jo Kim

Department of cardiology, Yeungnam University Medical Center, South Korea

Background & Objectives: Impact ofpolyunsaturatedFatty Acid (PUFAs) on the maintenance of sinus rhythm after ablative therapy of persistent atrial fibrillation (PeAF) is not evaluated yet. The aim of this study is to access if patients treated with PUFAs had lower recurrence rates compared to an untreated population

Methods: From Jan 2009 to June 2011, fifty patients who underwent catheter ablation for PeAF were enrolled. Of the study population, 19 patients (male 18, mean age 56±7 year-old) with PUFA after ablative therapy and 31 patients (male 24, mean age 60±9 year-old) without PUFA were enrolled in group 1 and group 2, respectively. Clinical follow up was performed at 1, 3, 6, and 12-month in all patients.

Results: Baseline characteristics, initial laboratory and echocardiography findings, procedural approach, procedural complication rate were not different between 2 groups. Two patients in group 1 and 13 patients in group 2 had recurrence of AF. The recurrence rate in group 1 was significantly lower than group 2 (10.5% vs. 41.9%, p=0.026). Other prognostic factors for the recurrence were sex, hypertension, the prevalence period, and the use of beta-blocker in univariates analysis. However, a multivariates analysis by cox-regression analysis revealed that the use of PUFAs after ablation of PeAF was not significant predictors of AF recurrence [Hazard ratio (HR), 0.89; 95% Confidence interval (CI), 0.34 to 5.27; p>0.05].

Conclusion: The role ofPUFA in upstream therapy after radiofrequency ablation therapy was not clear in this study. Therefore, larger randomized studies will be needed.

Key word: Atrial Fibrillation, Polyunsaturated Fatty Acids, Catheter Ablation



Clinical profile of atrial fibrillation in a tertiary hospital in Indian subcontinent

John B, Kezia P

Department of Cardiology, Christian Medical College, Vellore, India

Background: Prevalence and clinical profile of atrial fibrillation (AF) have not been well studied in the Indian subcontinent. We sought to determine the prevalence of atrial fibrillation in a tertiary care hospital and study its association with structural heart disease.

Method: Cross sectional study was conducted among consecutive patients attending the general outpatient clinic in a tertiary care hospital in India, referred for an electrocardiogram (ECG). The co-existence of valvular heart disease, diabetes mellitus, ischemic heart disease (IHD) and hypertension were noted.

Results: Among 3566 (Mean age 48.8±13.5 years; 62.8% Male) patients who underwent standard 12 lead ECG at the clinic, 60 patients (1.68%, 95% CI 1.2 2.1) were identified to be in chronic AF. Among patients who had AF, valvular heart disease was found in 18.6%; diabetes in 5.4%; IHD in 3.6% and hypertension in 16.6%. Valvular heart disease conferred the greatest odds for AF (OR 196, 95%CI 99 386; p<0.0001) followed by IHD (OR 4.1, 95%CI 1.7 4.8; p=0.001). However, hypertension (OR 0.5, 95%CI 0.26 1.0; p=0.049) and diabetes (OR 0.6, 95% CI 0.29 1.24; p=0.2) were not significantriskfactors for the presence of AF. There were equal proportion of patients with AF aged 40-60 (OR 1.2, 95%CI 0.64 2.3; p=0.5) and >60 years (OR 1.3, 95% CI 0.63 2.9; p=0.4)

Conclusion: Atrial fibrillation is most commonly associated with valvular heart disease in tertiary hospitals in India. We cannot exclude a referral bias and hence the odds may not be generalized to the entire population.

The time course of paroxysmal atrial fibrillation and its implication: an analysis from a snapshot

Minoru Tagawa \ Yoshifusa Aizawa 2, the Niigata AF study group

Department of Cardiology, Nagaoka Chuo General Hospital Nagaoka, Japan Niigata University Graduate School of Medical and Dental Science, Niigata, Japan

Background: Paroxysmal atrial fibrillation (PAF) is the most likely to progress to persistent of permanent AF. So far, the progression rate of PAF is determined as the proportion of PAF patients who develop permanent AF over a certain period. However, the patients had different paroxysmal atrial fibrillation (PAF) duration, and the progression of PAF was rarely assessed in relation to the duration of the onset of PAF.

Methods: The present study included 186 patients with PAF who were followed by cardiologists. The patients were considered to represent a snapshot of the PAF patients with a varying duration of PAF since the first episode. The duration of PAF was defined as the time interval from the first episode of AF to the date ofthe last visit that showed sinus rhythm. AF progression was confirmed by the absence of sinus rhythm in the subsequent 2 years. The number of patients who had PAF without progression for n years or longer (>n) was plotted against the PAF duration.

Results: The time course of PAF was well fitted by an exponential curve with a time constant of -0.177 (P<0.0001), and not affected by antiarrhythmic drugs. The clinical characteristics were similar between the patients with PAF duration of >10 and <10 years.

Conclusion: A snapshot of PAF patients may enable us to estimate the progression in to chronic AF which seemed to occur in a constant manner.


Detection of an irregular vein activity using a LED and its potential for patients with atrial fibrillation

Results : Fig. 2 shows the vein image size changes according to time (duration 6 seconds). It shows that the LED provides vein activity, which can calculate the heart rate.

Jinseok Lee!, Chang Won Jeong, Jong-Hyun Ryu, Su-Chong Joo, Jum Suk Ko4, Nam-Ho Kim4, Kwon-Ha Yoon

Biomedical Engineering Department, Wonkwang University School of Medicine, 2Computer Science Department, Wonkwang University,

Imaging Science Based Lung and Bone Disease Research Center, Wonkwang University School of Medicine, Iksan, Jeonbuk, Republic of Korea,

Department of Internal Medicine, Wonkwang University School of Medicine,

Radiology Department, Wonkwang University School of Medicine, Iksan, Republic of Korea

Background and Objectives : Atrial fibrillation (AF) is common and associated with adverse health outcomes. Timely detection of AF can be challenging using traditional diagnostic tools. LED use is simple and may provide an inexpensive and user-friendly means to diagnose AF. The objective is to show the potential that a LED-based application could detect an irregular pulse from AF.

Methods : We designed and developed a LED based vein activity monitoring system shown in the top of Fig 1. A Red LED was used and shed on an arm. The bottom of Fig. 1 shows the detected vein, which is visible with darkness. A camera records the vein activity corresponding to the darkness size. To investigate the vein activity, we recorded and extracted the vein image using a camera. We further applied low pass filter with cutofffrequency of4 Hz.

Fig. 2. Vein image size changes according to time (duration 6 seconds)

Conclusions : Recently, we developed the AF detection algorithm using statistical methods (Root mean square successive difference and Shannon Entropy) based on HRV[1]. Thus, the LED based vein activity can be applied to the HRV statistical methods for AF detection. We expect that our designed system can provide simple, inexpensive and user-friendly diagnosis tool.

Acknowledgement: Research supported by a grant of the Korean Health Technology R&D Project, Ministry ofHealth & Welfare, Republic ofKorea (no. A120152).

References: [1] D. D. McManus "A novel application for the detection of an irregular pulse using an iPhone 4S in patients with atrial fibrillation," Heart Rhythm, vol. 10, no 3, 2013.

Fig. 1. (Top) LED based vein activity monitoring system; A camera records the image. (Botton) Vein (dark) is detected using the LED. The darkness is visible with an eye.



Combining aspirin and warfarin for stroke prevention in atrial fibrillation: an incidence-based population study in Taiwan

Chieh-Yu Liu1, Tze-Fan Chao2, Hui-Chun Chen1

School of Nursing, National Taipei University of Nursing and Health Sciences, Taiwan Cardiology Division, Medicine Department, Taipei Veterans General Hospital Taiwan

Background & Objectives: There are a limited number of studies investigating the effectiveness for stroke prevention of combining aspirin and warfarin. This study was aimed to investigate the effectiveness for stroke prevention of combining aspirin and warfarin by using a population-based database.

Methods: This study used the National Health Insurance claims database in Taiwan from 20082010 and adopted an incidence-based cohort study design. An incidence-based cohort of atrial fibrillation patients was identified, who had at least two outpatient visits with primary disease of atrial fibrillation (ICD-9-CM code 427.31) and did not have any confirmed stroke diagnoses (including Ischemic and hemorrhagic)in 2008. This incidence-based cohort was followed for two years (to 2010). The longitudinal data were analyzedby using general estimation equations (GEE).

Results: A total of 33,170 atrial fibrillation patients who did not have stroke in 2008 were identified. The stroke incidences of this cohort were 6.7% in 2009 and 7% in 2010. The GEE results showed that, for atrial fibrillation patients with higher CHADS2 score, who received both aspirin and warfarin had significant 16.1% reduction of risk for stroke than receiving aspirin or warfarin along (OR=0.839, p-value=0.002, 95%CI ofOR=(0.751, 0.937)).

Conclusion: Although some novel anticoagulants were proposed, for now, most of atrial fibrillation patients received aspirin or warfarin for stroke prevention. The findings of this population-based study indicated that combining use of aspirin and warfarin may help prevent stroke for atrial fibrillation patients with high CHADS2 score.

Data from the Indian Heart Rhyhtm Society Atrial Fibrillation Registry (IHRS-AF Registry)

Nair M, Vora A, Narasimhan C, Ravikishore AG, Kapoor A, Nabar A, Dwivedi SK, Lokhandwala Y, Namboodri N, Hygriv R, Saxena A, Garg S, Bardoloi N, Yadav R, Nambiar A, Pandurangi U et al for the IHRS-AF registry

Sanjay Gandhi PGIMS, India

Background: A national Atrial fibrillation Registry was conducted under the aegis of the Indian Heart Rhyhtm Society to capture epidemiological data pertaining to (a) prevalence and type of AF atthe time offirst diagnosis and (b) current followedtreatmentpractices.

Methods: A total of 1548 patients from 24 participating centers were diagnosed with AF from July 2011-August 2012. The mean age was 54.2 years (range 15-96); 51% were females. Nearly 23% patients were < 40 years, while 36% were older than 60 years. At the baseline visit, 35% and 33% respectively had persistent and permanent AF; only 19% were diagnosed to have paroxysmal AF. The commonest underlying diagnosis was rheumatic heart disease (RHD: 47.8%), while coronary artery disease, hypertension andheart failure were present in 21%, 31% and 18% respectively. The objective of initial anti-arrhythmic drug (AAD) therapy was rate control in the majority (81%); digoxin (27%) was the most commonly used drug, followed by beta-blockers (21%), calcium channel blockers (15%) and Class III AAD (12%). The CHADS2 score (in non-rheumatic patients) was > 2 in 49%, equal to 1 in 34% and < 1 in 17%. The most frequently prescribed anti-coagulant was Warfarin (36%) followed by acenocoumarin (26%). Anti-platelet drugs were prescribed in 32% patients (Aspirin: 20% and Clopidogrel: 12%).

Conclusion: In a developing country like India, RHD is still the most frequent cause of AF. Most patients have persistent/ paroxysmal AF at the time ofthe first diagnosis, prompting rate control as the commonest initial therapy.



Electrogram characteristics during atiral fibillation using cool-flex vs. 4mm bipolar electrode mapping catheter

Ra Seung Lim1, Chul Min Mun1, Hyun Soo Lee1, Jae Joong Lee1, Rho Seung Young1, Dae In Lee1, Yae Min Park, Jae Min Shim1, Jin-Keun Jang, Whan CheolPark, Jong-Il Choi, Hong-EuiLim , Sang-Weon Park, Young-Hoon Kim

Department of Cardiology, Korea University Anam Hospital, Seoul, Korea; Department of Cardiology, Gachon University Gil Medical Center Incheon, Korea; Jeju Halla General Hospital, Jeju, Korea; Hanyang University Guri Hospital, Gyeongi, Korea; Korea Univeristy Guro Hosptial , Seoul, Korea

Background and Objective: We empirically found that the electrogram property of complex fractionated atrial electrogram(CFAE) during atrial fibillation(AF) measured by non-irrigation catheter was a little different from that of Cool-flex open irrigation Catheter. We investigated the differences of the electrograms acquired by these two catheters.

Methods: After pulmonary vein isolation, the properties ofthe electrograms of 24 CFAEs in five consecutive patients(mean age:53years old, male: 4 patients, persistent AF: 5 patients) were compared between those acquired by a 4mm open-irrigation-tip catheter(Therapy Cool-Flex, ST Jude Medical, CA, USA) and non-irrigation-tip catheter(Blazer II, Boston Scientific, Costa Rica) at the site in close proximity to each other within 1mm.

Results: The mean positive amplitude by Cool-Flex was lower than that of Blazer II(0.021±0.033mV vs. 0.053±0.073mV,p=0.062), whereas the mean negative amplitude by Cool-Flex was not different from that of Blazer II(-0.043±0.12mV vs, -0.073±0.18mV, p=0.49). The range of amplitude recorded by Blazer II was significantly larger than that of Cool-Flex. Cool-Flex catheter frequently missed low amplitude ofCFAEs (threshold ofdetection >0.01mV), which was higher than that of Blazer II(<0.005mV).

Conclusions: Compared to non-irrigated 4mm bipolar catheter, a Cool-Flex catheter underdetected CFAE, especially low amplitude of electrograms during AF.

Efficacy and safety of dabigatran in the peri-procedural period of radiofrequency ablation for atrial fibrillation

Nobuaki Tanaka, Kouichi Inoue,Kouji Tanaka,Toshinari Onishi,Y

Sakutabasi Watanabe Hospital, Japan

Background: A recent large scaled randomized trial evidenced a non-inferiority of a novel anticoagulation agent, dabigatran, over warfarin in the prevention of both bleeding and thromboembolic events in patients with non-valuvular atrial fibrillation (AF). It has a rapid onset of action, a predictable anticoagulant response, and few major interactions. We aimed to evaluate the efficacy and safety of dabigatran in the peri-procedual period of radiofrequency catheter ablation (RFCA) for AF.

Method: We retrospectively studied consecutive 99 patients who received oral dabigatran, administered at a dose of 110 mg or 150 mg twice daily as anticoagulation therapy in the peri-procedural of RFCA for AF. Dabigatran was discontinued the day before RFCA and was resumed in the same day after RFCA for AF.

Result: The average age was 59±10 years. 60 patients (60%) were paroxysmal AF and 29 patients (29%) were persistent AF. No bleeding and thromboembolic events were occurred except for only one patient who suffered from transient ischemic attack one day after RFCA.

Conclusion: The anticoagulation therapy with dabigatran in the peri-procedural period of RFCA for AF was effective and safe. This observation has promise for clinical practice.


Long term results of CRT in patients with permanent atrial fibrillation and sinus rhythm

Y.V. Mareev, V.N. Shitov, T.A. Malkina, V.G.. Kiktev, N.Y. Mironov, O.V. Sapelnicov, R.S. Latipov, I.R. Gishin, S.F, M.A. Saidova, R.S. Akchurin, S.P. Golitsyn

Russian cardiology research complex, Russia

Background: Sub-analysis of RAFT trial show that use of CRT don't influence prognosis of patients with permanent atrial fibrillation (AF) unlike patients with sinus rhythm (SR). But in RAFT trial percent of biventricular (BV) pacing was controlled by telemetry of CRT. There are some data that telemetry of CRT overestimation real percent of pacing. Our hypothesis was that patients with AF and > 90% of BV pacing on 24 hours ECG would have comparable effect from CRT as patients with SR.

Methods: We used 6 minutes walk test, LVEF and functional class by NYHA. Percent of BV pacing we calculated by using 24 hours Holter monitor.

Results: We included 11 patients with permanent AF and 21 patients with SR. Groups had not differences by age, gender, etiology, NYHA and other factors. 2 of 11 patients with permanent AF had < 90% BV complexes and we send them to AV node ablation.

There was no death during first 6 months. Mean NYHA class decreased from III to II in both groups. Distance of 6-min walk test increased by107 m group AF and by 105 m in SR. LVEF increased by 7% in MA and by 6% in SR group. The difference was not significant.

Mean time of further observation was 3,5 years. There was 2 death (18%) in group of AF and 3 deaths (14%) in group ofSR. (P > 0,05)

Conclusion: CRT is effective in CHF patients with permanent AF if percent of BV pacing is more than 90% on Holter monitor.


Close monitoring of arterial blood gas analysis is of importance when intravenous propofol is used for sedation of the patients for catheter ablation of atrial fibrillation

KY Ko, HS Lee, JH Chae, JY Seong,SWPark, YH Kim

Korea University Medical Center, South Korea

Methods: 3-5 Initial mg/kg/hr IV in profofol adjusted by height, weight, sex and age, was started and followed by continuous infusion to keep motionless and painless states. In addition to monitoring oxygen saturation, blood pressure, and heart rate, ABGA was done every 30 minutes in patients with ABGA (+).

Results: 242 patients (M:192, Age=56.6±10.9, Paroxysmal AF:122) underwent CA of AF were divided into two groups (ABGA (+) vs. ABGA (-), 119 vs. 123). The incidence of respiratory acidosis (pH<7.35) and metabolic acidosis in ABGA (+) was 73 (61.3%) and 13 (5.4%), respectively. The patients in ABGA (+) were additionally managed to maintain normal arterial PH, PO2, PCO2, and HCO3 throughout procedure.

The total dose of propofol (6.14±1.23 vs 5.18±1.03 mg/kg/hr, p<0.001) during procedure was higher in ABGA (-). The time interval to deep sedation (6.24±2.68 vs. 8.09±4.42 min, p<0.001), the recovery time (31.28±12.18 vs. 38.01±19.05 min, p=0.001) of consciousness in ABGA (+) was shorter than that of ABGA (-). Procedure time of ablation in ABGA (-) was longer than that of ABGA (+). The incidence of paroxysmal hypotension defined a decrease of systolic blood pressure of >30% from baseline in ABGA (-) was significantly higher in ABGA (+) (94, 76.4% vs 58, 48.7%, p<0.001), however, the incidence of bradycardia, hypoxia and respiratory distress did not differ between two groups.

Conclusion: Sedation with propofol under close monitoring of AGBA during CA of AF had advantages, smaller total dose of propofol, shorter recovery time of consciousness, lower incidence of paroxysmal hypotension, and shorter time interval till deep sedation.

New onset atrial fibrillation in patient with pacemaker implantation for sinus node dysfunction and atrioventricular block and its effect on clinical outcome

KJ Ko, HS Lee, JH Chae, HC Park, SW Park, Y-H Kim

Korea University Medical Center, South Korea

It has been known that atrial fibrillation (AF) commonly occurs in patients with permanent pacemaker implantation (PPM). We investigated whether the patients with certain clinical and electrophysiological parameters are more vulnerable to the occurrence of AF with long-term pacing therapy for sinus node dysfunction (SND) and atrioventricular block (AVB).

Methods: 152 (M=63, 63±14 yrs, SND (n=63)) without documented AF who were implanted pacemaker were included. Atrial high rate episode (AHRE) was defined as the presence of either more than 5 min of documented AF or mode switching on the stored electrograms. The average F/ U duration was 107± 49 months. we classified to 5 groups according to long duration of AHRE.

Results: Forty-six patients (SND=21 (33.3%), AVB=25 (28.1%)) developed new onset AF during F/U (P=NS), AF was detected in 9 patients (19.9%) within 1 year after PPM (p<0.001) and 14 patients (30.4%) within 2 years (p<0.001). In patients with SND, The higher cumulative ventricular pacing (VP) is associated with a 1.059 fold increase in risk of developing AF. The longer duration of AHRE is associated to higher VP (p=0.082) and shorter AV delay. (P=0.015). Clinical evidence of thromboembolism (14.3% vs 2.4%, p=0.106) is higher in patients with AHRE (+) than AHRE (-) without statistical difference. The clinical event of cardiovascular (CV) mortality (28.6% vs 2.4%, p=0.013) and heart failure (HF, 23.8% vs 2.4%, p=0.025) were greater in AHRE (+).

Conclusion: The substantial (33.3% vs 28.1%) number ofthe patients with SND and AVB developed new onset of AF after PPM. New onset AF during F/U was associated with greater accumulated ventricular pacing and the occurrence of AF was related to higher incidence of HF and CV death. It is clinically important to identify and treat new onset of AF in patients with SND and AVB following pacemaker therapy.


Personal impedance measurement of the patient with AF in electrical cardioversion

Seung-Young Roh, Dae-In Lee, Soon-Hwa Shin, Jaemin Shim, Sang

Korea University Medical Center, South Korea

Background: Electrical cardioversion (CV) is one of safe and useful treatment for atrial fibrillation (AF). Delivered energy in CV was usually empirically decided as only type of tachyarrhythmia. This conventional method is sometimes failed and can cause electrical damage due to unnecessory shock. We measured impedance and electrical current at a moment of shock to analysis individual factor.

Method: We performed direct current CV to the persistent and chronic AF patients. Adhesive pad applied in the apicoposterior position. Initial energy was biphasic 70~100 J. If AF was sustained or recurred after shock, energy was upgraded as 30 or 50 J until 200 J. Impedance of anteroposterior direction of human thorax and electrical current was measured by HeartStart® defibrillator(Philips, inc).

Result: A total 260 case of CV was performed to 212 persistent of chronic AF patients. The average of human thoracic impedance was 63±11 Q and current at success was 23±6 mA. Success rate was 93% in persistent AF, 88% in chronic AF. Used final energy at success time was impacted by human impedance (p=0.04, multiple regression analysis, B=-0.704) and left atrial volume (p=0.012 B=2.808). Impedance was related with body mass index (BMI) (p=0.05, correlation analysis). Impedance showed a declined tendency as shock was repeated due to inflammation. Impedance and electrical current, all echocardiography index was not significantly different in success and fail group.

Conclusion: It is important to decide effective delivered energy to avoid repeated shock and electrical damage. It will be helpful to consider individual difference like impedance and BMI.



Effects of proangiotensin-12 on atrial electronic remodeling in a canine atrial rapid stimulation model

Xudong Xie, Liangrong Zheng

The First Affiliated Hospital, Medical School of Zhejiang University, China

Background: Activation of the RAS in atrial tissue is associated with the episodes of atrial fibrillation (AF). Proangiotensin-12 (proang-12), a newly isolated angiotensin peptide, is cleaved from angiotensinogen by chymase and assumed to function as a non-renin dependent component of the tissue RAS.

Aim: To investigate the contribution of chymase-mediated angiotensina ii (ANG II) from proangiotensin(1-12) to atrial electrical remodeling.

Methods and Results: Twenty-four canine rapid atrial pacing (RAP) models were assigned to four groups (n=6): sham, pacing, pacing+perindopril and pacing+chymostatin (chymase inhibitor). Both drugs were given orally two weeks prior to RAP. Programmed stimulation was performed at baseline and after 6-h RAP, including effective refractory period (ERP) and window of vulnerability (WOV) forAF. RAP significantly induced shortening of ERP and increase of WOV (both p<0.05). These changes were suppressed by pretreatment with chymostatin (both p<0.01), butnot by perindopril. There were marked elevations of ANG II andproang-12 in atrial tissue after 6-h RAP (both p<0.05), whereas the plasma Ang I and ANG II levels did not alter significantly. Compared with paced group, the up-regulation of tissue ANG II was greatly decreased in pacing + chymostatin group ( p<0.01), but without an obvious reduction in pacing+perindopril group. No significant difference was observed in tissue concentratons of proang-12 between pacing+ chymostatin and pacing+ perindopril group.

Conclusions: RAP-induced atrial electronical remodeling was attenuated by chymostatin, but not by ACEI. These findings support the notion that chymase-dependent ANG II from proang-12 may have more pivotal role in AF inducibility.

Ahmed, Saleh

Prince Sultan Cadiac Center, Saudi Arabia

Background: Rotational angiography is one of the latest angiographicmodalitiestomap thecoronary venoustree anatomy. It provides a significantreduction in both contrast agent usage and radiation dose(up to 30%), withoutcompromising theclinical utility of images.Hence,the presentstudywasconducted to describe a newtechniqueto minimizethe amount ofcontrast media used during cardiac resynchronization therapy (CRT) implantation.

Method: The SL3 sheathwasinserted into theright atriumvia thefemoral vein followed bywithdrawal of the dilator.Thetip of thesheathwasmanipulated to the vicinity of thecoronary sinus (CS) ostium (OS).The CS wasentered using a deflated balloon catheter.Thesheath was then advanced gently beyond theCSOS.Occlusive venographywas performed using 5-8 ml ofcontrast media in a rotational view starting from 45° LAO to 0° AP while holding theinflated balloon for a few seconds.

Result. Data from 30 consecutive patients who underwent CRT implantation were analyzed. Thefeasibility ofrotational angiography,while occluding theCSwith a specialized long, preshaped sheath and using an ordinary

cath-lab imagingmachine,wassupported by thecorrectly delineatedCS anatomy of all patients without any complications and death related to the placement of the CS catheters or sheaths.The mean contrast dose

used fortheentire procedurein all patients undergoingCRTwas 14.76 ±6.8ml.

Conclusion: Useofrotational CSocclusive venography; utilizing an ordinary cath-labX-raymachine; minimizes the use of contrastmedia during CRT; implantation without compromising; the visualized anatomy



The HAS-BLED score is an independent predictor of symptomatic intracranial haemorrhage following haemorrhagic transformation of acute ischemic stroke in non-anticoagulated patients with or without atrial fibrillation

Tatjana S. Potpara1'2, Dijana Djikic3, Marija M. Polovina, Zoran Marcetic, Vladan Peric, Gregory Y.H. Lip.

Faculty of Medicine, Belgrade University, Serbia. Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia, University Clinic Center Pristina Gracanica, City Hospital Centre for Cardiovascular Sciences, Birmingham, United Kingdom

Purpose: We investigated predictive value of the HAS-BLED score for the occurrence of symptomatic intracranial hemorrhage (sICH) following haemorrhagic transformation of an acute ischemic stroke (IS).

Methods: Consecutive IS patients presenting within the first 12 hours from symptom onset were included and none underwent thrombolysis (unavailable in our hospital); sICH was defined as a CT-documented haemorrhage related to deterioration in the patient's neurological condition within the first 7 days ofIS.

Results: Of 273 acute IS patients (mean age 70.4±9.1 years, 152 males [55.7%]), 44 (16.1%) experienced a sICH, (16 of them [36.4%] died subsequently, during the index hospitalization); sICH patients were older and more frequently had prior stroke, atrial fibrillation, heart failure, chronic kidney or liver disease, enlarged left atrium, reduced left ventricular systolic function and higher NYHA class, compared with non-sICH patients (all p<0.05), and there was no significant difference in the prior aspirin use.

sICH patients had lower creatinine clearance, and higher fibrinogen, D-dimer, troponin and C-reactive protein levels (all p<0.001) as well as higher mean CHADS2 (3.05±1.28 vs. 1.77±0.1), CHA2DS2-VASc (5.23±1.55 vs. 3.52±1.60) andHAS-BLED (3.68±0.77 vs. 2.29±0.99) scores [all p<0.001]. All three scores had a significant predictive value for sICH (c-statistic of0.78 [0.70-0.85], 0.78 [0.71-0.84] and 0.86 [0.81-0.90], respectively, all p<0.001.

On multivariable analysis only atrial fibrillation and the HAS-BLED were significantly related to sICH (OR 20.8, 95%CI,5.9-73.5 and5.1, 95%CI,2.8-9.3, respectively, both p<0.001).

Conclusions: The HASBLED score is an independent predictor ofclinically relevant hemorrhagic transformation of an acute IS.

An initiative to minimize amount of contrast media utilizing a novel rotational coronary sinus occlusive venography technique with ordinary cath-lab x-ray machine during CRT implantation

Ahmed Saleh

Prince Sultan Cadiac Center, Saudi Arabia

Background: Rotational angiography is one of the latest angiographicmodalitiestomap thecoronary venoustree anatomy. It provides a significantreduction in both contrast agent usage and radiation dose(up to 30%), without compromising theclinical utility of images. Hence, the present study was conducted to describe a new techniqueto minimizethe amount of contrast media used during cardiac resynchronization therapy (CRT) implantation.

Method: The SL3 sheath was inserted into theright atrium via the femoral vein followed by withdrawal of the dilator. The tip of the sheath was manipulated to the vicinity of thecoronary sinus (CS) ostium (OS). The CS was entered using a deflated balloon catheter. The sheath was then advanced gently beyond the CSOS. Occlusive venography was performed using 5-8 ml ofcontrast media in a rotational view starting from 45° LAO to 0° AP while holding theinflated balloon for a few seconds.

Result: Data from 30 consecutive patients who underwent CRT implantation were analyzed. The feasibility of rotational angiography, while occluding the CS with a specialized long, preshaped sheath and using an ordinary cath-lab imaging machine, was supported by the correctly delineated CS anatomy of all patients without any complications and death related to the placement of the CS catheters or sheaths. The mean contrast dose used fortheentire procedurein all patients under going CRT was 14.76 ±6.8ml.

Conclusion: Use of rotational CS occlusive venography utilizing an ordinary cath-labX-raymachine minimizesthe use of contrast media during CRT implantation without compromising the visualized anatomy.


Left atrial appendage closure followed by six weeks antithrombotic therapy - a prospective single center experience

KR Julian Chun, Stefano Bordignon, Verena Urban, Laura Perrotta, Daniela Dugo, Alexander Furnkranz, Bernd Nowak, Boris Schmidt

CCB Frankfurt, Germany

Background: Currently, two different LAA closure systems are available for stroke prevention in patients (pts) with non-valvular atrial fibrillation (NVAF) but lacking comparative data.

Objective: To prospectively compare procedural data and patient outcome for two contemporary LAA closure systems followed by six weeks dual platelet inhibition.

Methods: Consecutive NVAF patients, high risk for stroke and either contraindication or not willing to accept long term oral anticoagulation (OAC) were prospectively enrolled. Watchman&trade;, Boston Scientific (group A) or Amplatzer Cardiac Plug&trade; St. Jude Medical devices (group B) were implanted. All patients received dual antiplatelet therapy (aspirin/ clopidogrel) or OAC for 6 weeks. After repeat TEE, switch to stand alone ASA was performed.

Results: 80 pts were prospectively enrolled. There was no statistical difference in patient characteristics between group A (n=40) and B (n=40): CHA2DS2VASC: 4.2±1.5 vs. 4.4±1.8, HASBLED: 3.3±1.1 vs. 3.0±1.1, respectively. Acute LAA occlusion was achieved in 78/80 (98%) pts (group A: 38/40, 95%, group B: 40/40, 100%), respectively. Procedure- and fluoroscopy-time were not different between both groups. Major procedural complications included air embolism and one delayed tamponade in each group. At 6 weeks F/U one device dislodgment was observed (group B) and four device related thrombi detected (group A: n=3, group B n=1). Switch to ASA alone was enabled in 95% ofpatients after 6 weeks. During a median follow up of314 days (Q1-Q3 233-489 days) no systemic embolism occurred but 3 patients died (heart failure: n=2, bleeding: n=1).

Conclusions: Implantation of both LAA closure devices can be performed with high success rates in high-risk patients. Postprocedural 6 weeks antithrombotic therapy followed by ASA appears to be a viable option.


Optimal strategy for restoration and maintenance of sinus rhythm in patients with rheumatic mitral stenosis and atrial fibrillation. a prospective randomized study

Krishnan A Reghuram, Narayanan Namboodiri, Harikrishnan S, Anees Thajudeen, Bijulal K Sasidharan, Sanjay Ganapati, SP Abhilash, Shunmuga sundaram, VK Ajitkumar, Jaganmohan A Tharakan

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Background: The optimal strategy for restoration and maintenance of sinus rhythm in patient with severe mitral stenosis (MS) undergoing balloon mitral valvotomy (BMV) is not defined. We hypothesized that preloading with amiodarone would improve the chances of restoration and long-term maintenance of sinus rhythm in this subgroup.

Materials and Methods: 270 patients who underwent BMV during the periodbetween November 2010 and March 2012 were screened and 42 patients with persistent/permanent AF were included in this study. These patients were prospectively randomized into 2 groups (Group A and B) based on the strategies for restoration and maintenance of SR. Patients in Group A underwent DC cardioversion alone within 24 hours of BMV, and in Group B, patients were subjected to cardioversion after being given intravenous infusion of amiodarone 1000mg over 24 hours. The patients in this group were continued on oral amiodarone 200mg/day for 3 months.

Results: In Group A, ofthe 20 patients, 17(85%) patients were successfully cardioverted whereas in Group B, out of 20 patients, 16 (80%) attained sinus rhythm. The immediate recurrence rate of atrial fibrillation (AF) (i.e., within 24 hours) was 17% (3/17) in Group A, whereas there was no immediate recurrence of AF in group B. At 1 month, only 9 /20 (45%) patients in group A had maintained sinus rhythm. Over a 6- month follow up, 2 more patients had recurrence of AF. Of the 15 patients who have completed follow up of 12 months, 4 (26.6%) were in sinus rhythm. The recurrence rate was slower in group B. At 1 month, 12/20(60%) had maintained sinus rhythm, and 10 (50%) at 3 months. After discontinuing amiodarone at the end of 3 months, as per protocol, there was an increase in recurrence rate with only 4/13(30.1%) maintaining sinus rhythm at 1 year.

Conclusion: This study showed that adjuvant amiodarone therapy when added to DC cardioversion in rheumatic MS patients after BMV reduced the risk of immediate and early recurrence of AF. However, an adjuvant short-term (3 months) amiodarone therapy does not contribute to higher rates of maintenance of sinus rhythm at one year follow up.



Femoral extraction and focused force venoplasty: an alternative to protectoral extraction for venous access

S Worley, M Bernabei

The Heart and Vascular Institute of Lancaster General Hospital, United States oof America

Background and Objectives: Although femoral extraction of chronic leads is less likely to displace the remaining leads femoral approach is not used for venous access because the residual fibrous tissue makes it difficult to advance a sheath. We present our results with femoral extraction and venoplasty for venous access.

Methods: In twelve patients with subclavian occlusion the IS-1 connector was removed and a .014 inch wire advanced into the stylet lumen ofthe lead. Using a needles eye snare the lead was extracted pulling wire into the right atrium where it was exchanged for a .035 inch extra stiff wire and the fibrous tissue dilated an ultra-noncompliant 6 mm x 4 cm balloon (rated burst pressure 30 atmospheres). If the sheath did not advance easily the dilating force was enhanced by adding a second extra stiff wire and inflating the balloon against the second wire (focused force venoplasty).

Results: In all cases, including 3 with superior vena cava occlusion, venous access was successful and lead(s) were placed. However in all cases the fibrous tissue surrounding the extracted lead required focused force venoplasty to allow easy passage of a sheath. None of the retained functional leads were displaced by extraction or damaged by venoplasty

Conclusions: Femoral extraction of chronic leads followed by venoplasty can be used to provide access for the addition of new leads without displacing or damaging the existing leads. However, the fibrous tissue left after femoral extraction requires high pressure balloons and focused force venoplasty.

Preliminary diagnosis of asymptomatic atrial tachyarrhythmia using pacemakers is not a risk for stroke

T.Mine, H.Kishima, T.Kodani, T.Masuyama

Hyogo College of Medicine, Japan

Current pacemaker technology has evolved and most pacemakers have functions capable of automatic episode recording. Asymptomatic atrial tachyarrhythmia (AAT) is frequently detected during routine pacemaker follow up. We aimed to clarify whether monitoring for AAT using a pacemaker is a risk for stroke or death. Methods: We studied 175 patients (94 females, 75+/-11 yrs) with dual-chamber pacemakers implanted for sinus node dysfunction (SND) or atrioventricular block (AVB) but without any history of symptomatic atrial tachyarrhythmia. AAT was evaluated for 6 months after pacemaker implantation and detected in 74 patients (42%). Pacemakers were able to detect atrial high rate episodes (AHREs) when the atrial rate was >180bpm, with AAT defined as AHRE s for >1 minute. Results: AAT occurs more frequently in patients with SND (53%) than in those with AVB (34%) (p=0.02). Twenty-nine patients (39%) with AAT were undergoing anticoagulant therapy (4 patients treated for mechanical valve replacement, 2 with deep vein thrombosis and 23 with incidental atrial fibrillation). There were no differences in age, sex, clinical, echocardiography variables or CHADS2 scores in patients with or without AAT. During the follow-up period (32+/-14 months), no patient suffered stroke and 3 patients with AAT died (N.S.). Conclusion: The incidence of stroke is low in patients with asymptomatic atrial tachyarrhythmia detected by routine pacemakers. Preliminary diagnosis of asymptomatic atrial tachyarrhythmia using pacemakers may not be a risk for stroke or death.



Real necessity of magnetic resonance imaging examinations after permanent pacemaker implantation

Akira Taruya, Atsushi Tanaka, Tetsuya Iwaguro, Satoshi Ueno

Social Insurance Kinan Hospital, Japan

Background: The usage of magnetic resonance imaging (MRI) is restricted for patients who are implanted a permanent pacemaker. While several manufactures announce to launch pacing systems for MRI use, no actual data is available for the prevalence of MRI-required events after pacemaker implantation. The aim of this study was to investigate the prevalence ofthe MRI-required event after PM implantation.

Methods: Permanent pacemaker implantation was performed for 244 patients between January 2000 and September 2012. All patients were received regular follow-up at the outpatient clinic of Social Insurance Kinan hospital. We excluded a patient for move, and 3 for non-cardiac death from the original population. Ultimately, we analyzed 240 patients for this study. The patients were divided into two groups (a event group and a non-event group) depending on the MRI-required event.

Results: The MRI-required events were observed in 40 (17%) patients during the mean observational period of 38 months. Intracranial disease was in 17 (43%) patients, upper canal disease in 5 (13%) patients, lower canal disease in 11 (28%) patients, heart disease in 5 (13%) patient, pelvic area disease in 1 (3%) patient, and abdominal disease in 1 (3%) patient. There were no differences in patient's characteristics between the two groups. Multivariable logistic analysis also revealed that no specific clinical characteristic was associated with the MRI-required event.

Conclusions: The MRI-required event cumulatively increases at the rate of 5.3%/year after permanent pacemaker implantation. No specific predictive factor was found for the future MRI-examination necessity. Our results suggest that MRI-conditional pacemaker should be considered for all patients who need pacemaker therapy.

The type of sinus node dysfunction might predict the atrial remodeling and the outcome after catheter ablation of atrial fibrillation

Boyoung Joung1, Jae-Sun Uhm1, Jung-Hoon Sung2, Jong-Youn Kim1, Hui-Nam Pak1, Moon-Hyoung Lee1

Division oof Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul; and Division oof Cardiology, Department of Internal Medicine, Bundang CHA Medical Center, CHA University, Seongnam, Korea

Background & Objectives: The electrical and structural remodeling of atrium, and the response to radiofrequency ablation (RFA) of atrial fibrillation (AF) might be different according to the type ofsinus node dysfunction (SND).

Methods: Consecutive enrolled 293 AF patients (245 males, mean 57±11 years), who had undergone RFA, were sub-grouped as follows; Group 1 (patients without SND, n=241), group 2 (AF patients mainly sinus bradycardia, n=22), group 3 (AF patients with tachybradycardia, n=30).

Results: Compared with group 1, group 2 had decreased left atrial conduction velocity (0.87±0.20, vs. 1.01±0.20 m/s, p=0.006). For group 1, 2 and 3, LA size was 42±6 mm, 47±6 mm and 39±6 mm, respectively. LA size was larger in group 2 than group 1 (p<0.001) and 3 (p<0.001). Group 2 had increased sinoatrial conduction time (249±193, vs. 145±72 ms, p<0.001) and corrected SN recovery time (914±1047, vs. 360±184 ms, p<0.001) than group 1. However, group 3 showed no difference with group 1. During the follow up period of 20±10 months, sinus rhythm was maintained in 72%, 36%, and 83% in group 1, 2 and 3 without antiarrhythmic drug. Group 2 had lower sinus rhythm maintenance rate than group 1 (p=0.001) and 3 (p=0.01).

Conclusion: While AF patients with sinus bradycardia were related with severe structural and electrical remodeling of atrium, and poor outcome after RFA of AF, those with tachybradicardia were not. These results suggest that the pattern of SND might reflect the degree of atrial remodeling and predict the outcome after RFA of AF.


The relationship between acute changes in the pacing threshold after screw-in and the pacing impedance before screw-in in the active-fixation leads

Hideyuk Hasebe, Daisuke Yamada, Masashi Osugi, Nobuhiro Matsuyama, Minoru Yamada

Division of Arrhythmia and Cardiology, Shizuoka Saiseikai General Hospital, Japan

Background & Objectives: The pacing threshold and impedance of active-fixation leads change rapidly after screw-in, and predicting the changes before screw-in is difficult. We evaluated the relationship between pacing threshold and impedance before and after screw-in.

Methods: We studied 22 patients without left ventricular systolic dysfunction who underwent implantation with active-fixation leads (TendrillTM 2088TC, St. Jude Medical) in preparation for placement of a new dual-chamber pacemaker. Pacing threshold and impedance were measured before screw-in, immediately, and 5 and 10 minutes after screw-in, and at the end of the operation.

Results: Mean pacing threshold and impedance decreased markedly when comparing before screw-in to immediately after screw-in. After screw-in, the pacing threshold decreased slightly with time, and the pacing impedance changed only minimally (threshold: 2.1± 1.5, 1.2 ± 0.5, 1.0 ± 0.4, 0.9 ± 0.4, 0.7 ± 0.4 mV/0.40 ms; impedance: 1,804 ± 524, 612 ± 108, 596 ± 106, 589 ± 91, 586 ± 117 Q at each time point, respectively). There was a positive correlation between pacing threshold change ratio (pacing threshold before screw-in / that at the end of operation) and pacing impedance (R = 0.73, P < 0.001). This correlation was stronger in the ventricle (R = 0.82) than in the atrium (R = 0.45)

Conclusion: The pacing impedance before screw-in is a useful parameter for predicting change in pacing threshold. The strength of the relationship between the pacing impedance before screw-in and the pacing threshold change ratio differed between the atrium and the ventricle.


The experience of automatic pacemaker data entry system "trophy" from the programmer to an electronic medical record

Y. Kosakai

Senri Central Hospital, Japan

Background: The pacemaker data which is read by programmer is generally printed on paper. Recently, it becomes common practice for hospital to record the medical data in electromagnetic media. However, it is the actual situation that doctors and other staff save their data on paper. This practice requires time and labor of physicians. And it is expected the good system. "Trophy" was developed by Aso, Iizuka Hospital and Simono Software Ltd.

Objectives and Methods: The object of this study was to confirm whether this system could save time and labor with 20 patients with pacemaker made by Medtronic and SJM Company. Using USB memory, their data are transferred from a programmer to the computer.

Results: As for data, e.g. mode, rate output, lead impedances, battery voltage and so on was also transferred into the computer automatically. These data could be plotted by this software to drawn into graphs chronologically. The longevity of the battery could be foreseen by observing the graphs drawn by the software. In addition, both of lead impedances and those changes were could be easily observed and shown on the graphs.

Conclusion: We confirmed that this software can contribute to analysis of the data for diagnosis and treatment of the pacemaker implanted patients. Now, we can transfer the data of pacemakers made by only two of Medtronic and SJM pacemaker automatically. However, it is anticipated that this software will be applicable to other manufacturers such as Boston Scientific, ERA and Biotronic within a half of year.


Usefulness of measurement of current of injury during screw-in lead implantation into right ventricular septum

Daisuke Fujibayashi1, Norishige Morita1, Akira Ueno1, Takayuki Iida1, Masashi Kaneko1, Tadashi Hashida2, Yoshiaki Deguchi2, Yoshinori Kobayashi1

Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan. Division of Cardiology, Department of Medicine, Tokai University Hospital, Kanagawa, Japan.

Backgrounds: During implantation of screw-in lead of cardiac implantable device(CID) into right ventricle(RV), electrophysiologic evidences based on which the lead could be properly fixed has been remain understood. Some literatures have reported usefulness of current of injury(COI) measured by uni-polar electrogram from tip-electrode during implantation into RV apex, but that during implantation into RV septum remains unknown.

Method: This study consisted of 35 RV screw-in lead implantations in 32 pts. COI was measured as voltage difference between the baseline and maximum elevated point of ST-segment of unipolar electrogram ofthe tip before and after fixing ofRV lead.

Results: The lead implantation into RV septum was properly achieved in all the implantations in regard to RV EGM amplitude and pacing output threshold enable to capture RV. Seven implantations needed to change the implantation sites because of high pacing threshold and/or acute dislodgement. COI before fixation did not differ between successful implantations without need of change of sites (Group-S) and such failed implantation as described above (Group-F) (10.8±4.8 vs. 11.4±6.2mV NS). After fixation with screw-in COI was significantly higher in Group S than in Group F (15.7±7.1 vs. 8.9±8.2mVP 0.05). Actual change and rate of change of COI between before and after fixation were significantly greater in Group-S than Group-F (4.8±4.8 vs. -2.51±10.7mV P=0.01, 0.56±0.6 vs. -0.07±0.54 P=0.01).

Conclusion: This study may suggest that evaluation of COI during lead implantation of CID into RV septum leads to aid in judgment of proper fixation of the lead.


The long-term result of the single lead VDD pacemaker in the patient with atrioventricular block:a comparison of VDD and DDD pacemaker

C.Miyasaka, S.Hari, M.Tsuji, Y.Nishimura, S.Asano, D.Mori, M.Asaki, Y.Iwanami, N.Kikuchi, T.Kogure, M.Kanisawa, K.Nagata, H.Tanaka, T.Ueda, K. Futagawa

Tokyo Metropolitan Tama Medical Center Japan

Background and Objectives: VDD pacing is the optimal pacing mode for patients with AV block but without sinus node dysfunction. However, VDD mode is being used much less than expected. Methods: We evaluated the retrospective data of 261 patients with symptomatic AV block who received a VDD or DDD pacemaker at our center between 2000 and 2012. The patients were analyzed with respect to the following variables: postoperative p wave amplitude, incidence of atrial tachyarrhythmias, mode survival rate, and complications.

Results: The mean follow-up period was 64.2±48.0 months in the VDD group and 37.8±26.7 months in the DDD group. The implantation P wave was lower with VDD patients compared to DDD patients (1.7±1.3 vs 2.6±1.6 mV, p<0.001), but remained stable in both groups during the long-term follow-up. During the follow-up period, fifteen VDD patients lost their original VDD mode and were programmed to VVI pacing (undersensing, 4; chronic AF/AT, 4; sick sinus syndrome, 1), while six DDD patients had the same results (chronic AF/AT,6). One VDD patient and three DDD patients developed a pacemaker infection. Among the other cases, two VDD patients and one DDD patient experienced a lead fracture, and three DDD patients experienced a lead dislodgment.

Conclusion: Reprogramming of the VDD system is done infrequently and is usually prompted by atrial arrhythmias or failure of atrial sensing. If an adequate atrial rate can be verified, VDD becomes a valid alternative to DDD pacing and survives well over the long term.



Incidence of pacing-induced myocardial perfusion defect

Hisaharu Ohe, Haruhiko Abe

University of Occupational and Environmental Health, Japan

Background and Objectives: Effects ofventricular pacing on myocardial perfusion in paced patients has been obscured. The objective was to test the hypothesis that the incidence of pacing-induced myocardial perfusion defect at different ventricular pacing sites on thallium (Tl)-scintigraphy in paced patients with implantable cardiac devices.

Methods: 24 patients (mean 73.3+/-9.1 years, 12 males), in whom 13 patients had implanted pacemaker for complete atrioventricular block associated with cumulative % ofventricular pacing (cum%Vp) > 90% and 11 patients had CRT for chronic heart failure associated with cum%Vp > 90%, were investigated by using Tl-scintigraphy. In a total of 35 ventricular pacing leads, ventricular lead was placed at right ventricular (RV) apical site in 11, at RV septum site in 13, at posterobasal or lateral site of left ventricle (LV) in 11 patients, respectively.

Results: Myocardial perfusion defect at pacing site were observed in 9 of 11 (82%) at RV apical site, in 12 of 13 (92%) at RV septum site and in 6 of 11 (54%) at LV site, respectively. There was a significant higher incidence of myocardial perfusion defects in RV pacing site than those in LV pacing site (P=0.03).

Conclusions: In paced patients associated with cum%Vp > 90%, presence of pacing-induced myocardial perfusion defect is a common finding. However, the incidence was different at ventricular pacing sites and was higher in RV pacing site than in LV pacing site.

Evaluation of the ventricular intrinsic preference and ventricular autocapture features in pacemaker patients: results of the VALIDATE study

Rakesh Yadav, Aparna Jaswal, Sharada Kalavakolanu, Prakash Kamath, Shirish MS. Hiremath, Dhiman Kahali, Naresh K. Sood, Anil Mishra, Jitendra S. Makkar, Upender Kaul

All India Institute oof Medical Sciences (New Delhi), Escorts Heart Institute and Research Centre (New Delhi), Care Hospital Nampally (Hyderabad), Amrita Institute oof Medical Sciences and Research Centre (Kochi), Ruby Hall Clinic (Pune), B. M. Birla Heart Research Centre (Kolkata), Hero DMC Heart Institute (Ludhiana), B. M. Birla Heart Research Centre (Kolkata), Fortis Escorts Hospital (Jaipur), Fortis Fit. LT. Rajan Dhall Hospital (New Delhi)

Background & Objective: The objective of VALIDATE study is to test the hypothesis that Ventricular Intrinsic Preference (VIP) and Ventricular Autocapture (VAC) features provide improved right ventricular (RV) pacing management and reduce long-term incidence of unnecessary RV pacing in patients with compromised or intact AV conduction.

Methods: VALIDATE is a prospective, randomized, single-blinded, multicenter study. Patients implanted with dual chamber pacemakers were enrolled within 15 days and within 45 days were classified to either AVI arm (intact AV conduction, defined by AV/PV delay < 210 ms) or AVC arm (compromised AV conduction, defined by AV/PV delay >210 ms). In each group, patients were randomized 1:1 to have VIP + VAC OFF (Control group) or VIP + VAC ON (Treatment group). Device-based %RV pacing (%RVP) and cardiovascular adverse events were monitored over 12 months.

Results: A total of 80 patients from 10 centers in India were enrolled, and 71 completed follow-up (Death: 4, Lost: 4, Withdrawal: 1). The ON groups of both study arms exhibited significant reduction in %RVP at 12 months post-implant: AVC arm OFF n=20, 97.4±3.7% vs. ON n=23, 39.0±41.9%, p=0.0004; AVI arm OFF n=13, 68.2±39.2% vs. ON n=14, 15.2±25.5%, p=0.0067. A total of 5 cardiovascular adverse events occurred during the study period, 4 (16%) patients from AVC ON group and 1 (6%) patient from AVI ON group (p=0.11 and p=0.99 respectively, statistically insignificant). There were no device-related adverse events reported during study period.

Conclusion: Validate study shows that VIP & VAC features significantly reduce %RV pacing in patients with compromised and intact AV conduction.



Screening of sleep disordered breathing with thoracic impedance in patients with cardiac pacemaker implantation

K Fujiwara, A Iwasa K Abe, E Nakagami

New Tokyo Hospital, Japan

Background & Objectives: Previous reports have shown the high prevalence of sleep disordered breathing (SDB) in patients with cardiac pacemaker implantation. Minute ventilation sensor with thoracic impedance which functions as a heart rate response sensor has a potential to detect SDB. Thus, we investigated the usefulness of this device function to evaluate SDB.

Methods: 27 patients (10 male, 76 ± 6 years old) who had cardiac pacemaker (SORIN REPLY) implanted were enrolled in this study. All patients underwent Epworth Sleepiness Scale (ESS) assessment and sleep study with portable monitor. SDB was defined as 3% oxygen desaturation index (ODI) 10 events/h in this study. The number of respiratory cycle 10 sec (NRC10) was counted with thoracic impedance and was compared with 3%ODI. Furthermore, the ability of the NRC10to identify SDB was analyzedbyreceiver operating characteristics (ROC) analysis.

Results: 9 patients (33%) had SDB. Mean ESS score was in the normal range(3.8 ±3.3) and there was only one patient who had an abnormal score (ESS>11). NRC was well correlated with 3%ODI (r=0.741, p<0.001). The ROC for NRC10 showed an area under the curve of0.71. When a cutoff NRC10value was 88.5, NRC10 predicted SDB with a sensitivity of67% and a specificity of89%.

Conclusions: Minute ventilation sensor with thoracic impedance showed good correlation with portable SDB monitor. This function might be useful to detect SDB in patients with pacemaker implantation.

Pacemaker implantation in dextrocardia

So Yui Chi, Kwok Miu Fong Jennifer

Hong Kong Heart Rhythm Centre, Hong Kong

Aim: Pacemaker Implantation of Dextrocardiac patient

Background: There were few documentations of pacemaker implantation in Dextrocardiac patient. Therefore, we report a case of dual chambers pacemaker implantation ( DDDR MRI compatible) in a middle aged lady.

Methods: A lady aged 58 years old had known dextrocardia. Holter was done and showed that she had intermittent high grade heart block. CT coronary angiogram showed minor CAD only. She complained of chronotropic incompetence on exercise.

We performed a dual chamber pacemaker implantation through right sided axillary veins double puncture. A right arm veinogram was performed before the implantation. The vessels run in normal contour. RV leads screwed to RVOT region. Then, RA leads was tined to RAA.

Results: The whole procedure lasted around 2.5 hours. Flouroscopy time was around 45 minutes. Sensing for A was 3.4 mV and for V was 5 mV. Capture threshold was 0.5v/0.4 ms for A and 0.75/0.4 ms for V. All threshold and impedance were satisfactory.

Conclusion: Difficulties lie in the mirror image of RAO /LAO views. We must tune to this mirror image views during implantation. However, we can finish with the implantation within a standard time showing that pre-operative planning was important.



The risk for newly occurrence of atrial fibrillation in pacemaker patients with atrioventricular block

Katsuhide Hayashi, Haruhiko Abe, Taichi Watabe, Hisaharu Ohe, Ritsuko Kohno, Yasushi Oginosawa

University of Occupational and Environmental Health, Japan, Japan

Background and Objective: Although it is well known that increase of cumulative % of ventricular pacing (cum%Vp) is associated with the occurrence of atrial fibrillation (AF) in sinus node diseases, it has been obscure in atrioventricular (AV) block patients. We investigated to test the hypothesis that there has an association between cum%Vp and newly occurrence of AF in AV block patients.

Methods: A total of 93 AV block patients, who had implanted dual-chamber pacemakers and had no histories and detections of AF (> 6 min durations at a rate of >190 bpm) following 3 months of pacemaker implantation, was followed every 6 months for a mean of 3.3+/-1.7 years. Clinical characteristics, associated diseases, use of drugs, cum%Ap and cum%Vp, and time to first episode of AF occurrence were investigated.

Results: Newly developed AF was observed in 19of93 (20%) patients andtime to first episode of AF was mean 1.8+/-1.3 years. The cum%Vp in AF group showed a significant higher than that in non-AF group (89+/-27% in AF vs. 68+/-39% in non-AF, P=0.028), though the cum%Ap showed similar. Multivariable regression analysis showed that the higher cum%Vp (HR 7.7; 95%CI 1.481.9, P=0.017) and presence of left ventricular hypertrophy (LVH) on echocardiography (HR 5.0; 95%CI 1.0-26.9, P=0.046) were both independent predictor for the risk of newly occurrence of AF.

Conclusions: Increase of cum%Vp and presence ofLVH had significantly associated with the risk of newly occurrence of AF in pacemaker patients with AV block.

Comparison of outcomes of permanent pacemaker insertion using right ventricular apex versus right ventricular outflow tract septal pacing: a single center retrospective study

Ritche O. Go, Marcellus Francis Ramirez

Section of Cardiology, University oof Santo Tomas, Manila, Philippines

Background: The right ventricular apex (RVA) has traditionally been preferred for the insertion of permanent cardiac pacemaker leads because of vast experience with their use, their ease of implantation, and the stability of passive fixation. However, numerous studies have revealed that prolonged pacing using the RVA site can lead to deleterious effect overtime and the RVOTS has been suggested as an alternative pacing site.

Objective: To compare the clinical profiles and effects of Permanent Pacemaker Insertion on Left Ventricular dysfunction, Regional Wall motion abnormalities, development of atrial fibrillation and heart failureon patients using Right Ventricular Apical (RVA) and Right Ventricular Outflow Tract Septal (RVOTS) pacing sites at the UST Hospital.

Methodology: Records of 75 patients who underwent PPI using RVA and RVOT as pacing sites in UST Hospital from 2007 - 2011 were retrieved and analyzed for the presence of Left ventricular dysfunction, regional wall motion abnormalities, atrial fibrillation, mitral regurgitation, and heart failure.

Results: 47 patients underwent PPI using RVAwhile 28patients had PPI using RVOTS. 2 cases of intraprocedural complications were noted in the RVA group and 1 in the RVOTS. 5 RVA subjects developed Atrial fibrillationand 4 for the RVOTS group on subsequent pacemaker analysis (p>.05). The study showed that in RVA pacing,there was a mean decrease in ejection fraction of 4.8% compared to 0.79% for the RVOTS group (p>0.05). 1 from each group developed regional wall motion abnormalities (p>0.05). On follow up consult, 15% ofthe RVA subjects developed heart failure symptoms compared to11% for the RVOTS pacing group (p>0.05).

Conclusion: The study failed to show any association with pacing sites to the following parameters: decrease in Ejection fraction, development of wall motion abnormalities, development of Atrial fibrillation, and heart failure. Although RVOT pacing may provide better hemodynamic outcome and showed cardiovascular benefits in previous studies, the possibility ofthe RVOTS being a better alternative to RVA was not established through the results in this study. Nevertheless, further studies are recommended.


Evolution mechanical dilator sheath as a first choice for transvenous lead extraction

Rana Costa, Patrick Lahoud, Marwan Refaat, Maurice Khoury, Bernard Abi-Saleh

American University of Beirut Medical Center, Beirut, Lebanon

Background: The Evolution mechanical dilator sheath (Cook Medical) uses a rotational mechanism and a bladed tip to overcome fibrosis around Cardiac Implantable Electronic Device (CIED) leads.

Objective: The purpose of this study was to report the success ofthe Evolution system used as a first line tool.

Methods: Between July 2011 (our first use of Evolution) and March 2013, the Evolution sheath was used for extraction of CIED leads in 12 patients (28 leads). Success and complications were defined according to the Heart Rhythm Society expert consensus document on lead extraction.

Results: Indications for extraction were infection in 10 patients and lead malfunction in 1 patient and subclavian vein stenosis in 1 patient. Mean implantation time was 72 months (range 12-96 months). Ofthe 28 leads, 10 (35.7%) were atrial and 18 (64.2%) were ventricular. Seven (25%) ICD leads and 21 (75%) pacemaker leads were extracted. Evolution was used as first choice in all patients, with 100% clinical success. Complete procedural success was achieved in 11 patients; in 1 patient, the distal electrode with the distal end of the RV coil was retained. This patient on follow up was cured from her bacteremia and was able to undergo reimplantation of a new CRT-D system. Ofthe 12 patients, a right-sided approach was used in two (8.3%).

Conclusion: Our data suggest that the Evolution mechanical dilator sheath is a useful and safe tool to be used as first line tool for transvenous lead extraction.

Baseline Characteristics

Male Age

Coronary Artery Disease Coronary Artery Bypass Graft Congestive Heart Failure Diabetes mellitus II Hypertension Lead Age (months)

Extracted Leads (Total=28; Total pts=12)

By Type

Defibrillator lead Pacemaker lead By Location Atrial Ventricular By Approach Left-sided Right-sided By Indication Pocket infection/erosion Lead fracture Subclavian vein stenosis By Brand St. Jude Medtronic Biotronik Ela

Boston Scientific

68.25 (± 10.34)

72 (± 29.4)

4 2 2 2 1

83.3 16.6

84 8.3 8.3

33 16.6 16.6 16.6



Foreign body retrieval from coronary sinus during CRT implantation

S. Sathish, S.Jayaprakash, S.Sathish, G.Somasheka

Sri Jayadeva Institute of Cardiovascular Sciences and Research Centre, India

Our patient aged 55yrs,DCMP,NYHA III heart failure on optimal medical treatment,ECG-LBBB,QRS duration-160msec was taken for CRT implantation(Medtronic,Syncra). After CS Cannulation with standard curve Worly safe sheath,9Fr,ballon occlusion venogram showed good sized postero-lateral vein.The vein was wired with 0.014 soft floppy wire(BMW high torque wire) and 5fr dual canted lead(4296) could not be tracked,hence switched over to 4fr straight tined fixation lead(4396),unable to track.We tried Buddy wire technique for support and straightening the vein,but unsuccessful.Reviewing the angio showed sharp bend at the origin of vein,hence decided to use subselection lead delivery catheter,Attain command(6248).The tip of subselection catheter broke and was freely floating in coronary sinus.

We started off with retrieving the foreign body as done in coronary intervention.First we tried with snaring device,but were unable to open the loop,as the coronar sinus is small to accommodate the loop hence we switched to next method of using the bioptome forceps and grasping foreign body, but unsuccessful on trying multiple times.We than tried with passing two PTCA wires across the foreign body,one wire through lumen and other outside,and get the hard end of wire at foreign body and tried to entangle foreign body by continuosly rotating the wires against each other.We had difficulty in passing the wire through the lumen,hence this method abandoned.

The consequences of leaving the foreign body were migration to Right ventricle causing ectopics,embolisation into pulmonary circulation and getting organised with no consequences.In this process as the last ditch effort we tried aspiration of foreign body with the same worly sheath and were successful

Real-world, long-term comparison of titanium nitride coating versus non-coating platinum stimulating electrodes

Il-Young Oh, Youngjin Cho, Myung-Jin Cha, Eue-Keun Choi, Seil Oh

Seoul National University College of Medicine, South Korea

Background & Objectives: Stimulating electrode materials must be capable of supplying high-density electrical charge to effectively activate neural tissue. Platinum is the most commonly used material for neural stimulation. One other material, titanium nitride (TiN), has been considered and widely used. This study directly compared the long-term status of two pacing leads which used different electrode materials: platinum with TiN coating and platinum without coating.

Methods: Patients (n=127) underwent permanent pacemaker and received regular follow-up for more than 3 years were enrolled. Ninety-one patients were implanted with TiN-coated lead and 36 patients were implanted with non-coated lead. Pacemaker interrogation performed at 3-4 years after implantation was analyzed and the change of ventricular lead profile (voltage of R wave, impedance, and threshold) was compared in two groups.

Results: The mean follow-up duration was 4.1 years. During this follow-up period, no lead malfunction developed in both groups except one lead fracture in non-coated lead. The mean change of lead impedance was significantly higher in TiN-coated lead group than in non-coated lead group (-292±325 vs. 3±142 ohms, p<0.0001). However, no differences were observed between TIN-coated lead and non-coated lead in respect to measured R wave (-0.9±9.6 vs. -2.4±8.3 mV, p=0.42) and threshold (0.3±0.4 vs. 0.4±0.3 V, p=0.27).

Conclusion: Safe and efficient pacing were achieved with both leads. The TiN-coating lead may preserve energy-consuming by decreasing pacing impedance.



Transvenous pacemaker in a patient of bioprosthetic tricuspid valve following surgical excision of tricuspid valve vegetations

R Manoj kumar, K Naveen krishna, R Vadi velu, B Mukul

Postgraduate institute of medical education and research, India

Background & Objectives: Patients with tricuspid biological valves for whom recordings of atrioventricular block indicated the requirement of pacemaker implantation. We have used a minimally invasive approach of right ventricular lead placement and effective stimulation for a patient with a prosthetic tricuspid valve.

Methods: 26 year old male with history of Intravenous drug abuse presented to our hospital with high grade fever and right heart failure. Echocardiography revealed 1 cm vegetation on tricuspid valve with severe tricuspid regurgitation. He underwent excision of the tricuspid valve and replacement with a #29 mm bioprosthetic valve (model #6900P, Edward life sciences, Perimount plus pericardial bioprosthesis). Postoperative day 4, he had developed dizziness with heart rate of 35 beats per minute with high degree atrioventricular block. Patient was on an anticoagulant therapy with warfarin, and then changed to a regimen of heparin. After three days and to avoid a new thoracotomy, a screwing endocardial lead placed through the tricuspid prosthesis with minimal manipulation for right ventricular pacing. The stimulation threshold there was 0.7 V at 0.5 ms, the impedance was 700 ohms, and the R wave amplitude was 14mV. Another lead was placed in right atrium with the stimulation threshold was 0.6 V. The electrocardiogram showed normal ventricular pacing; the leads were connected to a Dual chamber rate adaptive pacemaker (SENSIA SED R01, Medtronic). After a week an x-ray revealed that the lead position remained stable. Echocardiography showed a trivial tricuspid regurgitation.

Conclusion: Screwing tip lead and minimal manipulation of endocardial pacing lead while positioning prevents damage to the bioprosthetic tricuspid valve.

Corrected QT interval of paced-QRS complex as a risk factor for new-onset heart failure after permanent pacemaker implantation

Eun jeong Cho, Seung-Jung Park, Sung Ho Lee, Young Keun On

Samsung Medical Center, South Korea

Background: Long-standing right ventricular (RV) pacing creates abnormal left ventricular contraction and reduced pump function in selected patients. However, risk factors that increases heart failure (HF) after permanent pacemaker (PPM) implantation still remains unclear.

Objective: We investigate whether repolarization parameters of paced-QRS complex are associated with new-onset HF after PPM implantation.

Methods: In 493 consecutive patients with normal left ventricular ejection fraction (LVEF<50%) patients undergoing PPM implantation, clinical, laboratory, echocardiographic variables, and electrocardiographic parameters were analyzed. We defined new-onset HF as the development of significant LV systolic dysfunction on follow-up echocardiography (LVEF<40%).

Results: During the follow-up period (78±51months), new-onset HF was found in 35 of the 493 patients (7.1%). Baseline LV end-systolic dimension (LVESD), Paced-QRS duration (p-QRSd), paced-corrected QT interval (p-QTc), cumulative percentage of ventricular pacing (cum% VP), and proportion of atrioventricular block were greater in the new-onset HF group than the non-HF group. However, pacing mode and lead location showed no difference between the two groups. In multivariate analysis, p-QTc (P=0.035), Cum% VP (P=0.040), LVESD (P=0.029) were independently associated with new-onset HF after PPM implantation. The greater the p-QTc (as quartiles), the higher the rate of new-onset HF (P for trend=0.003). Additionally, the new-onset HF group showed a significantly higher mortality rate than the non-HF group (P=0.006).

Conclusions: Paced-QTc interval along with ventricular pacing percentage and baseline LVESD was independently associated with new-onset HF after PPM implantation. Close flow-up might be needed especially in patients with longer paced-QTc interval after PPM implantation.


ci CvfUvJKfi waft ^^jipgffletfta raaiifty) ^^m LJ I LJ


Lack of atrial contraction as a predictor for permanent pacemaker implantation after the Cryo-Maze procedure combined with valve surgery

Seung-Jung Park, Eun Jeong Cho, Sung Ho Lee, Young Keun On, Ju

Samsung Medical Center, South Korea

Background: The lack of atrial contraction (AC) after the Maze procedure is reported to cause subsequent annulus dilatation and an increase in embolic stroke.

Objective: To evaluate whether the lack of AC could increase the risk of permanent pacemaker (PPM) implantation in patients undergoing the Maze and valve surgery.

Methods: Recovery of AC was assessed using Doppler echocardiographic measurement of the transmitral A-wave velocity at baseline, immediate (<2weeks), early (4.6±3.8months), and late (3.5±1.1years) postoperative stages in 376 consecutive patients who underwent cryo-Maze and combined valve surgery.

Results: During a median follow-up of 53 months, 10 patients (8 female, 61±13years) underwent PPM implantation; 7 for sinus node dysfunction (pauses, 9.6±2.4sec), 1 for marked sinus bradycardia, and 2 for advanced/complete atrioventricular block. Median (interquartile range) time to the PPM implantation was 13.8 (0.5-68.2) months. Patients with PPM implantation showed a more frequent lack of AC versus those without PPM implantation in the early stage (P=0.005). Multivariate analysis revealed that the lack of AC in the early stage was identified as an independent predictor for PPM implantation (odds ratio 5.62, 95% confidence interval 1.06 to 30.0, P=0.039).

Conclusions: The lack of atrial contraction might aggravate dysfunction of cardiac conduction system in patients undergoing the Maze and valve surgery. Therefore, close follow-up might be needed when the atrial contraction is not recovered during the follow-up.


Wrap sleeve method: a novel suture sleeve fixation method after lead implantation by cephalic vein cut-down

T. Nishida, A. Takitsume, M. Fujii, T. Kanki, M. Watanabe

Nara Medical University, Japan

Background: Cephalic vein cut-down is a well-established approach for inserting implantable leads. In some cases, however, the sizes of cephalic vein are too small to insert the suture sleeves (SS) into the vein, especially using large-diameter leads such as defibrillator leads. We introduced a novel SS fixation method applicable regardless ofvein size.

Methods: Before lead insertion, SS were demounted from leads and cut spirally. After lead implantation, we wrapped the prepared SS around the lead together with the vein. From October 2012 to January 2013, we applied this method (wrap sleeve method) for 10 leads (5 pacing and 5 defibrillator leads). We assessed the efficacy of this method by comparing the total procedure time and acute complications with the standard SS fixation in preceding implantations (23 pacing leads and 6 defibrillator leads).

Results: After tying threads around the wrapping SS, all leads were fixated and there were no bleeding from the vein. Total procedure time was 102 &plusmn; 37 minutes in the wrap sleeve group and 111 &plusmn; 32 minutes in the standard fixation group (P = 0.28). No major complications were noted in the wrap sleeve group except for one hematoma not relevant to the lead fixation in a patient receiving anticoagulation therapy. In standard fixation group, eight SS could not be inserted to the vein, and there were one hematoma and one lead dislodgement.

Conclusion: Wrap sleeve method is applicable regardless ofvein size, and assure the lead fixation and local hemostasis.


Assessment of developing heart failure after pacemaker implantation by means of thoracic impedance and cytokines

Y. Ajiro, K. Shimiza, S. Morita, R. Henmi, H. Hattori

National Hospital Organization Yokohama Medical Center Japan

Purpose: To assess the development of heart failure after brady-pacemaker implantation by measureing ofthoracic impedance (Optivol, Japan Medtoronic Co.) and cytokines

Methods: The patients who were implanted the devices with Optivol function at Yokohama Medical Center between May 2010 through April 2011 were enrolled. Optivol fluid index and cytokines were measured at around three months and at 12 months after the implantion. It was confirmed that any imflammation related with the operation was not exist at the timing ofcytokine measurement.

Results: Among 24 patients who were enrolled to this study, 2 patients with ventricular pacing ratio more than 40% experienced heart failure worsening and modification of medication for heart falilure. ©Optivol fluid index was elevated in those patiets. Cytokines were assessed 10 patients among enrolled 24 patients. Interestingly, coenzyme Q10, protective biomarker for oxidative stress, was significantly reduced at 1 year afeter the implantation comparing with those at 3 months (573.4±57.8 vs. 728.7±40.6, p=0.032). MMP3 (85.6±10.7 vs. 73.4±10.2, p=0.15) and TGF-beta1 (1.44±0.21 vs. 1.72±0.07, p=0.042), the maker for imflammation and fibrosis, were elevated at 1 year after implation, whereas TNF-alfa and urine 8OHdG were not changed significantly.

Conclusions: It is suggested that the patients who was undergone the pacemaker implantation, the protection from the oxidative stress and silent remodeling was implied. It should be check the heart failure states for those patients, and Optivol function might help early detection for such patinets.


Where to pace in RV for pacemaker dependent or frequent need of ventricular pacing

Ramdeo Yadave

Batra Hospital, India

Principle: Pacing at the attachment of Moderator band in the septum captures the myocardium and Purkinje fibres more earlier than at the RVOT or Apex of RV. Since the Moderator band attaches at the lower third or at the junction of lower third and mid third of RV septum . Pacing at this site showed narrowest QRS duration.

Study: I have implanted around 95 pacemaker over four year period where RV pacing is required by putting screwing lead at the lower third or mid septum and found a QRS duration of 110 msec to 130 msec in majority of patient . There were 50 males and 45 females. Age range was from 5 year to 84 years old. Fourty four patient requiring pacing for Brady arrhythmia and 51 patient for either CRT-P or CRT-D and 10 patient for ICD.

Twenty four patient were of CHB and 20 patient for SSS. Single chamber pacemaker implanted in 10 patients and dual chamber in 34 patients. Fifty one patient required devices for heart failure and for VT. In all patients successful devices were implanted . There was one patient who developed capture failure within 24 hrs and lead needed repositioned . Those on brady arrhythmia requiring frequentventricularpacing none ofthem developedLV systolic dysfunction on 1-4 years ofFU.

Conclusion: Where ever frequent RV pacing is needed it should be paced at the lower or mid septum near attachment of Moderator band to get narrowest QRS instead of RVOT or Apex of RV



A rare complication with pacemakers- 'lead tip fracture'

R Manoj kumar, K Naveen krishna, R Vadi velu, B Mukul

Postgraduate institute of medical education and research, India

Background & Objectives: The incidence of lead fractures in pacemakers is less common (1%-4%). Most fractures occur in the area just lateral to the subclavian venous entry site as a result of compression of the lead between the clavicle and the first rib or entrapment of the lead by soft tissue in the costoclavicular space. In our case it was spontaneous fracture at the lead tip which was very rare occurrence.

Methods: 35 year old male who had single chamber ventricular rate adaptive pacemaker for symptomatic junctional bradycardia 10 years back. Now he presented with episodes of dizziness after mild exertion. Electrocardiogram showed junctional rhythm at rate of 55 beats per minute. Pacemaker interrogation showed high ventricular threshold of 4.5 v and impedance of 2000 ohms with battery showing end of life status. Xray chest showed lead fracture at tip of lead. He was taken for lead extraction (TENDRIL SDx DP 168922) and the distal tip left behind. New lead was inserted with threshold 1.25V, at 7.5 mV sense and impedance of 536 ohms. The new lead was attached to the battery Verity ADx XL SC that was placed in the sub pectoral pocket.

Conclusion: Lead tip fracture is a very rare occurrence. First to report from India, needs to be evaluated thoroughly for the cause of lead fracture. Treatment is lead extraction and new pacemaker insertion.

Predictors of development of new-onset heart failure in patients underwent permanent cardiac pacemaker implantation: the QRS vector amplitude involves

Jianfeng, Xu

Zhongshan Hospital, Fudan University, China

Background and Objective: The clinical predictors of the development of new-onset heart failure (HF) in patients underwent permanent pacing remained unclear. Base on the previous report that the QRS vector exhibited a strong correlation with mechanical cardiac dyssynchrony, we aimed to examine the relationship between the QRS vector and the incidence of new-onset heart failure in those patients over long-term follow-up.

Methods: We retrospectively enrolled, at two study centers, all patients with three-degree atrioventricular block who underwent dual-chamber pacemaker implantation in which ventricular lead was routinely implanted in the right apex. Patients, companied with a bundle-branch block, a serious burden of tachy-arrhythmia, left ventricular ejection fraction (LVEF) <35% or a prior diagnosis of HF were excluded. 230 patients were consecutively enrolled with an examination of vectorcardiography when ventricles were paced. The diagnosis of HF was based on the presenting symptoms, clinical findings, and appropriate investigations, in accordance with the guidelines. The maximal QRS vector amplitude increase (MVAI) was defined as the vector difference ofthe projection on vertical coordinates ofthe maximal QRS vector between LV pacing and intrinsic conduction.

Results: During a follow-up of (62±18) months, 196 patients were ultimately finished investigation, bearing a burden of more than 95% ventricular pacing. 17 (8.67%) subjects reached the endpoint of HF diagnosis. On multivariate analysis, age ( 75 years) (HR, 3.23; 95% CI, 1.5 6.4; P=0.027), LVEF ( 50%) (HR, 4.82; 95% CI, 1.8 10.5; P=0.021) and MVAI ( 2.5mV) (HR, 3.51; 95% CI, 1.3 5.9; P=0.031) were confirmedas independentpredictors ofnew-onsetHF, while the duration of QRS (>120ms) were not evidenced to be the reliable predictors. There was a statistical correlation between MVAI ( 2.5mV) and new-onset HF incidence (median r=0.83; IR, 0.73 0.88; P=0.031). Furthermore, patients with MVAI more than 2.5mV exhibited significantly higher rates of HF (log-rank test, P=0.036).

Conclusions: 8.67% ofpatients, in those with a standard indication for permanent cardiac pacemaker implantation, developed new-onset HF over long-term follow-up, which could be predicted by a pacing MVAI more than 2.5mV, suggesting that the QRS vector amplitude might be a practical parameter for individual treatment optimization.



Long-term outcome of right ventricular septal versus apical pacing on left ventricular dysfunction patients with high degree heart block

WUDongyan, Lu Fengmin, Sun Jianmei, Li Qiong, Fu Naikuan, Chen Yongli, Ma Wei, Xujing

Department of Cardiology, Tianjin Chest Hospital, Tianjin, 300051, China

Backgroud and Objective: Right ventricular septal(RVS) pacing has been advocated as an alternative to right ventricular apical(RVA) pacing to avoid long-term detrimental effects.But its longterm impact on heart function remains controversial. A prospective study attempt to access whether long-term RVS pacing is superior to RVA pacing in high heart block patient with left ventricular dysfunction.

Methods: Fifty-nine patients (33 with RVS pacing, and 26 with RVA pacing) were recruited, whose left ventricular eject fraction(LVEF) were between 35% and 50%. Their ventricular pacing percent were more than 80%. Ultrasonic-cardiogram(UCG) confirmed a septal lead position in all patients in the RVS pacing group. 1 week and 6 months following implantation, we measured LVEF, and left ventricular dyssynchrony (by tissue Doppler imaging) and inter-ventricular mechanic delay(IVMD).

Result: During the long term follow-up(averaged 48.9±5.6 months), in RVA pacing group, there were 3 patients died, 5 patients upgrade to cardiac resynchronization therapy, 7 patients hospitalization because of heart failure. In RVS pacing group, there were only 4 patient hospitalization because of heart failure and 1 patient died. The cardiovascular fatal event-free rates had significantly difference (P 0.01) and differences ofIVMDwere observedbetween groups.

Conclusion: Compared with RVA pacing, RVS pacing confirmed by UCG could improve the outcome of high degree heart block with left ventricular dysfunction. The latter were associated with better inter-ventricular contraction synchrony.

Late recurrence of persistent third degree atrioventricular block after implantation of permanent pacemaker

Ling Sun, Yu Zhang, Yanyi Zhang, Baopeng Tang

Cardiology Department, The First Hospital Affiliated oof Xinjiang Medical University, China

Objective: To determine the changes of atrioventricular conduction in patients with persistent third degree atrioventricular block (p °AVB) after implantation ofa permanent pacemaker, and to explore its causes.

Methods: This retrospective analysis was conducted from data gathered between January 2004 and December 2011. All of patients had symptomatic bradycardia, and complied with the class I indications of permanent pacemaker implantation. No evidence of intrinsic atrioventricular conduction was found.

Results: Three hundred and ninety-three patients with p °AVB were implanted permanent pacemaker in 8 years. Patients were followed up from 1 to 107 months, and 6 patients were lost. The pacemaker implanted in 46 patients could not calculate the ratio ofventricular pacing (VP%). The data of 341 patients were included analysis. Three hundreds patients whose VP% maintained more than 90% in the follow-up was no atrioventricular conduction recurrence group (NAVCR). The other 41 patients was atrioventricular conduction recurrence group (AVCR), whose VP% maintained less than 90% in the follow-up, and the intrinsic atrioventricular conduction was recorded inthe electrogram. The width ofQRS in AVCRwas less thanthat inNAVCR P=0.044 . The width of QRS that less than 120ms was the predictor which recurrence of atrioventricular conduction [OR 0.091 95%CI0.020 0.422 P=0.002].

Conclusion: The study showed about 12% patients with p IIIoAVB had late recurrence of atrioventricular conduction. The width of QRS that less than 120ms maybe the predictor which recurrence of atrioventricular conduction.

6№APHRS w-K&ri n I D CARDIORHYTHM / l ,1

Cl CVfUvJKfl Wflft & AUÊPteacMTW SprficMn ^^m LJ I LJ


Capturing the His-Purkinje system is not possible from right ventricular apical and non-apical pacing sites

Benjamin J. Pang, Saurabh Kumar, Mark A. Tacey, Harry G. Mond

The Department of Cardiology, Royal Melbourne Hospital, Parkville The Department of Medicine, University of Melbourne, Victoria, Australia

Background & Objectives: Direct His bundle capture may allow physiological activation of the heart and negate the adverse electrical dyssynchrony induced by right ventricular (RV) apical pacing. Our aim was to investigate if direct His bundle pacing was possible from conventional RV pacing sites.

Methods: Consecutive patients undergoing elective pacemaker implantation were paced in random order from the RV outflow tract, middle RV and RV apex using active fixation pacing leads. Pacing was performed at threshold and at increasing voltages of 2.5, 5, 7.5 and 10 volts (V). QRS width and morphology on 12-lead electrocardiograph (ECG) were compared in sinus and paced rhythm at the different voltages at each location.

Results: Twelve patients underwent a total of 2,160 QRS measurements. Progressive increases in voltage did not change QRS morphology or duration regardless of site of pacing (RV outflow tract, middle RV and RV apex) in any ofthe 12 ECG leads. In addition, apart from at threshold between the RV outflow tract and RV apex, there was no statistically significant difference in QRS duration between the three pacing sites.

Conclusion: In patients with a baseline normal QRS duration, none of the three conventional RV pacing sites produced significant QRS narrowing and thus capture ofthe His-Purkinje system. Furthermore, based on paced QRS duration as an indirect surrogate of electrical LV dyssynchrony, there was no clear advantage of one pacing site over another.

Pacing lead posiltion Threshold 2.5V 5V 7.5V 10V

RVOT 141.8 ± 4.1» 147.3 ± 4.2 147.4 ± 4.2 150.0 ± 4.2 144.9 ± 4.5

Middle RV 144.7 ± 4.5 149.2 ± 5.8 146.3 ± 5.8 144.0 ± 5.9 141.0 ± 6.0

RVA 155.7 ± 4.6 158.8 ± 5.0 158.3 ± 4.8 158.0 ± 5.2 153.4 ± 4.5

* statistically significant (p = 0.034) difference between RVOT and RVA.


The proximity of implanted pacemaker and implantable cardioverter-defibrillator leads to coronary arteries as assessed by cardiac computer tomography

Benjamin J. Pang, Subodh B. Joshi, Elaine H. Lui, Mark A. Tacey, Jeff Alison, Sujith K. Seneviratne, James D. Cameron, Harry G. Mond

Monash Cardiovascular Research Centre, MonashHEART, The Department of Cardiology, Royal Melbourne Hospital, Parkville, The Department of Medicine, University of Melbourne, Victoria, Australia

Background & Objectives: Screw-in pacemaker and implantable cardioverter-defibrillator (ICD) leads pose a potential threat to adjacent coronary arteries. Our aim was to assess the proximity of right atrial (RA) and right ventricular (RV) pacemaker and ICD leads to the major coronary anatomy using cardiac computer tomography (CCT).

Methods: Images from a CCT scanner were retrospectively analysed to assess the spatial relationship ofRAandRV pacemaker and ICD lead tips to the major coronary anatomy.

Results: Fifty RV leads and 35 RA leads were assessed. Leads in the short axis RV antero-septal junction position (20 of 52) were in close proximity (median 4.7 mm) to, and orientated towards the overlying left anterior descending coronary artery. RA leads in the anterior (26 of 35) and lateral (7 of 35) walls of the RA appendage were not close to (16.9 ± 7.7 mm and 18.9 ± 12.4 mm respectively) and directed away from the right coronary artery. However a RA lead adjacent to superior border of the tricuspid valve was 4.3 mm from the right coronary artery and a RA lead on the medial wall of the RA appendage was 1.6 mm away from the aorta. A RV pacemaker lead in the lateral wall ofthe RV adjacent to the tricuspid valve was 3.4 mm away from the right coronary artery.

Conclusions: At particular RA and RV sites, pacemaker and ICD screw-in leads are in close proximity and pose a potential threat to the aorta, left anterior descending and right coronary artery.


Pacing and implantable cardioverter-defbrillator lead perforation as assessed by cardiac computer tomography: appearances and clinical correlates

Benjamin J. Pang, Elaine H. Lui, Subodh B. Joshi, Mark A. Tacey, Jeff Alison, Sujith K. Seneviratne, James D. Cameron, Harry G. Mond

Monash Cardiovascular Research Centre, MonashHEART, The Department of Cardiology, Royal Melbourne Hospital, Parkville, The Department of Medicine, University of Melbourne, Victoria, Australia

Background & Objectives: Pacemaker and implantable cardiac defibrillator (ICD) leads can perforate through the myocardium both acutely and chronically. Our aim was to assess the degree of perforation of right atrial (RA) and right ventricular (RV) pacemaker and implantable cardiac defibrillator (ICD) leads based on their location in the right heart using cardiac computer tomography (CCT).

Methods: Images from a 320 slice CCT scanner were retrospectively independently analysed by two reviewers for lead position, pericardial effusion and perforation. Perforation results were correlated with pacing sensing, impedance and threshold measurements.

Results: 52 patients had RV leads and 35 had RA leads. Five of 17 RV apical, one of 35 RV non-apical and none of the 35 RA leads perforated through the myocardium on CCT imaging criteria. Two perforated leads (5 and 15 mm from the outer edge of the myocardium), had pericardial effusions and changes in pacing parameters and required RV lead repositioning. In contrast, there were four apparent "partial perforations" (that had protruded only an average 1.5 ± 0.5 mm from the outer edge of the myocardium) that did not require repositioning. These had the appearance of perforation on CCT, however were not associated with pericardial effusions or significant changes in RV pacing lead sensing, impedance and threshold measurements.

Conclusions: CCT scanning with multiplanar reformatting is useful for screening for cardiac perforation. The clinical significance and natural history of apparent "partially perforated" pacing and ICD leads on CCT is uncertain. However extraction of asymptomatic, functioning leads does not appear necessary.


A cardiac computer tomography assessment of conventional fluoroscopic and ECG criteria for RV septal pacemaker lead placement

Benjamin J. Pang, Subodh B. Joshi, Elaine H. Lui, Mark A. Tacey, Jeff Alison, Sujith K. Seneviratne , James D. Cameron, Harry G. Mond

Monash Cardiovascular Research Centre, MonashHEART, The Department of Cardiology, Royal Melbourne Hospital, Parkville, The Department of Medicine, University of Melbourne, Victoria, Australia

Background & Objectives: Pacing the RV septum instead of the RV apex may decrease the risk of pacing induced heart failure, atrial fibrillation and increased mortality. A lack of benefit shown from clinical trials may be due to a failure to locate the lead on the true RV septum. Our aim was to validate conventional fluoroscopic and ECG criteria for describing pacemaker and implantable cardioverter-defibrillator RV "septal" lead position using cardiac computer tomography (CCT).

Methods: CCT images of RV pacemaker leads implanted using conventional ECG and fluoroscopic criteria were retrospectively analysed. Traditional fluoroscopic projections (posterior-anterior, 40o left anterior oblique (LAO), 40o right anterior oblique (RAO) and left lateral) were reviewed to develop a schema to implant RV leads in the true RV septum.

Results: Only 16% (9 of 56) of presumed "septal" RV leads using conventional fluoroscopic criteria were on the true septum. There was only fair to moderate agreement for ECG critieria with CCT. A schema was developed to define septal position in the RAO view.

Conclusion: Using conventional fluoroscopic criteria, only a minority ofRV leads were implanted on the RV septum. Instead, aiming for the middle ofthe cardiac silhouette in the RAO fluoroscopic view, confirming rightward orientation in the LAO view and having a paced QRS duration < 140 msec may allow the implanting cardiologist a simple, more accurate method to achieve true RV septal lead positioning



Related risk factors and treatment experience in cardiovascular implantable electronic device infection

Danhong Fang, Gaojun Wu, Haiying Li, Jie Lin, Weijian Huang

The First Affiliated Hospital of Wenzhou Medical University, China

Background: Cardiovascular implantable electronic device (CIED) infection is a major complication of the implantation of a pacemaker and defibrillator. The purpose of this study was to analyze retrospectively the CIED infection related risk factors and treatment experience in our heart center.

Methods: Twelve years (2000-2012) of cases of CIED infection were analysed retrospectively. The clinical presentation, base characteristics and management strategies of these patients were analysed.

Results: 2000-2012 year, 1817 cases (male: female = 1.4:1) were implanted cardiac electronic device (permanent pacemakers, cardiac resynchronization therapy or implantable cardioverter defibrillator) in our heart center. Of 16 patients (12 males, male: female = 3:1; aged 64 ± 11 years) occurred CIED infection, the incidence was 0.88%. The average onset time was 25 ± 16 months after pacemaker implantation. Fifteen (93.75%) cases were identified as pacemaker pocket infection. Eight cases (50%) was implanted ICD / CRT-D. The body mass index(BMI) of non-diabetic male CIED infection patients was 20.65 ± 2.72, significantly lower than all of non CIED infection male patients (BMI = 23.50 ± 2.93 ;P = 0.011). Nine cases were treatedwith pacemaker pocket debridement and povidone-iodine immersion disinfection, and then resetted the original pacemaker between the pectoralis major and pectoralis minor muscle, but 4 cases succeeded. The remaining 11 cases were cured by removing the original pacemaker or and the leads. The average hospital stay was 41 ± 18 days; mean follow-up was 4.9 ± 2.6 years.

Conclusion: The incidence of CIED infection in our heart center was 0.88%. It remains a rare but potentially very serious complication of device implantation. Patients with large volume CIED ( such as ICD /CRT-D), male patients especially lower BMI males patients were more susceptible to CIED infection. Pacemaker pocket debridement and povidone-iodine immersion disinfection, removing the pacemaker or and the electrode leads, was the key to cure CIED infection.

Keywords: Cardiovascular implantable electronic device; infection; body mass index

ATAF burden in pacemaker patients with algorithms for the reduction of ventricular pacing in the COMPARE study QM Tao, LR Zheng, SL Chen, KP Chen, FR Shen, SL Wu, J

The First Affiliated Hospital, Zhejiang University School of Medicine, China

Background: Right ventricular pacing (VP) has been recognized to associate with risks for heart failure and atrial fibrillation (ATAF) in sinus node dysfunction patients. The correlation between VP reduction and ATAF burden has not been well elucidated in pacemaker patients.

Methods: The randomized parallel prospective COMPARE study in 29 centers in China enrolled patients indicated for dual-chamber pacemaker excluding those with persistent 3o AV block. Patients were randomized in two groups based on two algorithms for VP reduction: the MVP group (MVP: managed ventricular pacing algorithm) or the Search AV+ algorithm (SAV+) group. The follow up was conducted at 1, 6, and 12 month post-implant. Percent VP over all beats at follow-ups and ATAF burden were evaluated using device diagnostic data.

Results: A total of385 patients were enrolled inthe COMPARE study. Basedonthe VP percentage represented by 4 quartiles with each quartile having similar number, there is a trend of VP percent and ATAF burden (a significant difference (P<0.03) between quartile 1 with lower VP percent vs. each of other three quartiles with higher VP percent). There was no significant difference in ATAF burden between the MVP group and the SAV+ group at 12-month follow-up (P=0.94) while MVP had a lower percent VP (median 0.4%) than SAV+ (median 3%, P<0.0001 vs. MVP).

Conclusion: There is a trend of the correlation between percent VP and ATAF burden in pacemaker patients. The MVP algorithm may yield a lower VP percent than the search AV+ algorithm.



To assess the long term effects of RV apical pacing on left ventricular function in patients with normal baseline left ventricular function

J V Balasubramaniyan, Sriram Rajagopal, G Lakshmi ,P V Thanuja ,R

Sri Ramachandra medical University, India Aim:

1) Assess the long term effects of RV Apical Pacing on Left Ventricular function in patients with normal baseline Left Ventricular Function.

2) To determine changes in LV dimensions , if any , following RV apical pacing.

3) Determine correlation , if any , between various attributes such as age, sex , etc on the outcome of RV apical pacing.

Materials And Methods: Retrospective study to assess the long term effects of RV apical pacing on LV Function ; 51 patients on RV apical pacing randomly selected from among the patients registered , Chennai formed the material for the study.

Inclusion Criteria: Patients on either a single or double chamber pacemaker for more than or equal to five years on >/= 90% ventricular pacing ;Normal baseline LV function at the time of pacemaker implantation

Exclusion Criteria: Structural heart disease ; Coronary heart disease ;Atrial Fibrillation ; Cardiac surgery in past ;Malignancy

LV function was assessed by 2 dimensional echocardiography at the time of pacemaker implantation and during follow up .Pacemaker was interrogated and those patients with a ventricular pacing of more than 90 % from the time of implantation were only included .Echocardiography assessment of LV function and LV dimensions and severity of mitral regurgitation at the time of pacemaker implantation and subsequent follow up was done for all patients. Statistical analysis was carried out using Student "t" test. Results :

1. Complete Heart Block was the commonest (74.5%) indication for pacemaker implantation in the study population.

2. Although DDD, DDDR, VDD, VVI were various pacing modes employed, VVI was the commonest amounting to 52.94% followedby VDD in 31.3%.

3. There was a significant change in Left Ventricular ESD and EDD before and after pacing reflecting a change in LV dimensions following RV apical pacing (>90%) for the above mentioned indications.

4. However comparison of Left Ventricular EF in the Study population before and after pacing did not show a statistically significant variation.

5. It was also noted that age group of the study population and sex did not affect the ESD and EDD significantly.

6. The functional class (NYHA) of the study population also did not change significantly in the follow up period.

Conclusion : Not all patients who receive RV apical pacing will experience adverse effects. The amount of LV dyssynchrony depends on LV function at baseline and accompanying conduction disease at baseline. Though changes in LV dimensions were noted, LV dysfunction was not a significant companion ofRV apical pacing.

Enrhythm pacemaker longevity post software upgrade: a single centre experience

Murniwati Binte RAHMAT, Joyce Wei Ying ANG, Su Yi HO, Hui Min CHONG, Shufen LIANG, Chien Fern Lim, Paul Chun Yih LIM, Eric Tieng Siang LIM, Kah Leng HO, Boon Yew TAN, Wee Siong TEO, Chi Keong CHING

Department oof Cardiology, National Heart Centre Singapore, Singapore

Introduction and Background: Medtronic EnRhythm pacemakers were released commercially in 2005, followed by the MRI conditional version (EnRhythm MRI) in 2007. In 2010, a software update was released to address premature ERI notification issues and the ERI threshold was changed from 2.59V to 2.81V, with consecutive daily measurements when voltage dropped to <2.81V. The update would reduce the longevity of the devices by 10-15% to an estimated 8.5 to 10.5years with 0.4ms, 6o per minute and 100% pacing.

We aim to review the longevity ofEnRhythmn pacemakers post software update.

Methods: We conducted a retrospective case series analysis of all patients implanted with Medtronic Enrhythm and EnRhythm MRI pacemakers at our centre from 2005 who had undergone the software upgrade, with attention focused on patients with EnRhythmn pacemakers that had reached ERI requiring generator replacements. Device characteristics (battery impedence, voltage and longevity) were analysed.

Results: 83 EnRhythm/Enrhythm MRI pacemakers were implanted at our centre, and none of the patients have had EnRhythmn pacemakers implanted for longer than 8.5 years as yet. 12 pacemakers (14.5%) had reachedERI were replaced. Among patients who requiredpulse generator changes, the mean longevity of the EnRhythm pacemakers was 6.2 years and median was 5.9 years.

Conclusion: EnRthythmn pacemakers post software update may have longevity shorter than the expected 8.5-10.5 years. Actual device longevity needs to be further studied.


ci CvfUviKfi waft & AUÊPteacMTW fsxmtí&i SprficMn ^^m LJ I LJ



Correlation analysis of risk factors of shoulder pain after artificial cardiac pacemaker implantation

LI Ji-wen, JIANG Ping, LI Zhen, HANG Hong-wei SU Xi

Department of Cardiology, Asia heart Hospital, Wuhan 432000, China

Objective: To investigate the risk factors of shoulder pain after artificial cardiac pacemaker implantation.

Methods: Correlation analysis of risk factors were carried out to assess the clinical events in 3 months follow-up period in 146 patients with implantation of permanent pacemaker, including 56 patients with shoulder pain (A group), compared with 114 patients without shoulder pain (B group).

Results: In A group, the ratio of shoulder pain history(15.6% vs 8.2%, p<0.05)was higher than B group.The logistic regression on multiple factors analysis showed that the advanced age, the extended operation time, and the prolonged upper limb immobilization time were related to the occurrence of shoulder pain after artificial cardiac pacemaker implantation(r=0.926, 1.252, 3.128, all P<0.05).

Conclusions: A history of shoulder pain, advanced age, surgical time, and upper limb immobilization time are risk factors of shoulder pain after permanent pacemaker implantation.

Keywords: cardiac pacemaker implantation; shoulder pain; risk factors

Alternatives for pacemaker rate sensor optimization: can the outcome be comparable with conventional exercise test method?

YWLeung, CS Yue, KF Leung, WYM Mak, SW Wong, KS Chow, SK Tang

United Christian Hospital, Hong Kong

Background and Objective: Pacemaker rate sensor optimization is crucial for those with chronotropic incompetence (CI), and the prevalence increases with time after implantation.

Exercise test for sensor optimization is effective but was generally underutilized for limited clinic time and resources.

We have investigated alternatives that may best fit Hong Kong clinic setting also patient outcome.

Method: Twenty ambulatory pacemaker patients with symptoms of exercise intolerance were recruited in an eighteen months pilot program, with rate sensor optimization conducted in our Cardiac Nurse Pacemaker clinic using three different methods: 1) conventional exercise test; 2) hall walk test; 3) adjust by experience and review every 1-2 months.

Results: The outcomes were measured with average heart rate (HR) histogram; exercise tolerance (floor and stairs) and quality of life (QoL) questionnaire.

All measured parameters shown similar improvements in group one (n=2) and group two (n=6) during one and four months follow-up. One in each groups (n=2) could even resumed their jobs.

There are only 50% of cases in group three with improvement in average HR histogram, although 67% (n=8) with improvement in exercise capacity. Furthermore, repeated clinic follow-up and readjustment are required.

Conclusion: Hall walk rate sensor optimization shows improvement in both exercise capacity and QoL. And the result is comparable with conventional method but more time-saving and cost effective.

CI increases with time after implantation, more attention is merits when we encounter ambulatory patient who is pacing-dependent, with monotonic HR profile and impaired exercise capacity.


Our strategy to prevebt device infection

Takayuki Uchida, Takashi Matsumoto, Takaki Tsutsumi, Yoko Fuku

Iizuka hospital, Japan

In our hospital, cardiovascular surgeons have performed all device operation for 25 years. Recently, some cardiologists joined our team Our strategy to prevent periooperative device infection is as follows;1. to keep bioclean level of cath labo same as cardiovascular surgery operation room, 2.strict education system of operative technique (especially of sterilization and sheets setting), 3. preoperative bacteria culture examination of nasal cavity and selection of proper antibiotics. 4. make device pocket as deep as possible(at least, under the fascia of greater pectoral muscle). 5.make device pocket enough large to reduce skin tension. We performed total 1199 device operation during ten years(2003/1/1-2013/5/31). During ten years, we had two perioperative device infection cases . 80years old female and 78 years old male. Incidence of perioperative infection was 0.0016%(2/1199). Cultured bactria;, MSSE;1, MSSA;1, Device ICD(dual chamber):1, DDD pacemeker1, Device poceket location;1(ICD) under pectoris major, 1:under fascia ofpectoris major. Riskofinfection;steroidusage for dermatosis for both cases.

We think most important points to prevent device infection are to recognize device implantation as surgey, and to learn correct surgical skills (especially about sterilization, sheets setting and pocket preparation).



Atrial lead location plays an important role to avoid unnecessary ventricular pacing during both atrial pacing and atrial sensing

C Suga, Y Sugawara, T Hayashi, T Mitsuhashi S Momomu

Jichi Medical University Saitama Medical Center, Japan

Introduction: It is important to avoid unnecessary ventricular pacing (VP) to prevent adverse cardiac events in pacemaker recipients. However, right atrial (RA) pacing sometimes causes PQ interval prolongation leading to increase of VP frequency. The purpose of this study was to determine if there was any favorable RA lead location to avoid VP.

Methods: This study included 18 patients with sinus rhythm and spontaneous atrio-ventricular conduction, and undergoing pacemaker implantation or electrophysiological study (11males, age 62+/-18.5years). Ventricular lead was placed in right ventricular (RV) apex or septum, and RA lead was placed in RA appendage (RAA), high RA septum (HAS) and low RA septum (LAS) in series. The following parameters were obtained from ECG and compared according to 3 atrial lead locations: P width, interval from atrial pacing (AP) spike to QRS (AP-QRS), and the shortest AV delay which enables avoidance of VP (Non-VP AVD) during AP, interval from onset of P wave to local A wave (P-AS), interval from local A wave to QRS (AS-QRS) and Non-VP AVD during atrial sensing (AS).

Results: During AP, P width (112.8+/-26.8:103.8+/-19.8:88.8+/-26.5[ms], p<0.05), AP-QRS (186.1+/-42.6:170.5+/-36.2:146.4+/-33.9[ms], p<0.05) and Non-VP AVD (231.7+/-47.4:209.4+/-48.9:190.6+/-52.5[ms], p<0.05) were shortest during LAS pacing. During AS, LAS lead location resulted in the longest P-AS (5.6+/-18.9:7.1+/-18:28.6+/-32.9[ms], p<0.05), the shortest AS-QRS (163.7+/-23.2:164.2+/-24.7:144.1+/-30[ms], p<0.05) and the shortest Non-VP AVD (180.6+/-31.9:188.9+/-37.7:157.2+/-32.7[ms], p<0.05). Non-VP AVD correlated with AP-QRS (r=0.92, p<0.0001) and AS-QRS (r=0.73, p<0.0001).

Conclusions: LAS lead location resulted in shortest Non-VP AVD due to shortening of atrio-ventricular conduction during AP, and due to prolongation of the interval from onset of atrial activation to atrial sensing during AS. LAS atrial lead positioning seems to be most favorable to avoid unnecessary ventricular pacing under the presence of spontaneous atrio-ventricular conduction.


Unusual ratchet syndrome: spontaneous lead retraction after a generator exchange

Satoshi Higuchi, Koichiro Ejima, Tetsuyuki Manaka, Ken Kato, Kentaro Yoshida, Toshiaki Nuki, Bun Yashiro, Morio Shoda, Nobuhisa Hagiwara

Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan

"Ratchet syndrome" is a rare complication involving a lead dislodgement and retraction mechanism by a ratchet-like mechanism. The majority of these occur within a couple of weeks after surgery. We report a case with "ratchet syndrome" occurred after a generator exchange. A 72-year-old female with idiopathic dilated cardiomyopathy underwent a cardiac resynchronization therapy defibrillator implantation 5 years ago. She underwent a generator exchange for battery depletion with a full pocket capsulectomy 4 months previously. An aggressive capsulectomy with an adhesiotomy of the connective tissue around the leads was performed. She was doing well after the operation under continuous biventricular pacing, but during the last 2 weeks her condition worsened. Her chest X-ray demonstrated a displacement of the LV lead, while the RA and RV leads remained in place. The loss of capture during LV pacing caused a subacute exacerbation of her heart failure. Upon opening the submuscular pocket, the tissue surrounding the suture sleeve was loose, and backward tension on the lead could easily withdraw the lead out of the vasculature, and forward advancement of the lead most likely caused the flexible lead to buckle in the pocket rather than advance back into the vasculature.

In this case, an aggressive adhesiotomy of the connective tissue around the leads might have weaken the tightening of the fixation sleeve suture, enabled to create a new friction leading to pull on the lead, and finally led to retract the lead by a ratchet-like movement through the suture sleeve.

Termination of persistent atrial fibrillation refractory to pulmonary vein isolation using very low-dose ibutilide and individualized atrial ablation

Xian-dong Yin, Ying Tian, Xu Zhou, Liang Shi, Zhen-yu Jiao, Jun Mao, Juan Zhang, Xin-chun Yang, Xing-peng Liu

Cardiology Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China

Introduction: Atrial fibrillation (AF) usually remains after pulmonary vein isolation (PVI) in patients with persistent AF(PsAF). We hypothesized that very low-dose ibutilide combined with individualized atrial ablation can facilitate AF termination in these patients.

Methods: Sixty consecutive patients (43 males; age, 60±12 years, LA:48±4mm) with PsAF were prospectively included. The initial AFCL of PVs and left atrial appendage(LAA) was recorded, and then the AFCL of LAA After circumferential PVI and 5,10,15,20,25,30mins after 0.25 mg ibutilide injection were recorded. 0.25 mg ibutilide was injected intravenously over 3 minutes in patients with ongoing AF. According to the response to ibutilide, individualized ablation was performed with an endpoint of restoration of sinus rhythm (SR).

Results: All patients remained in AF after PVI. After ibutilide administration, AF converted to SR in 1 patient (no further ablation) and organized to atrial tachycardia (AT) in 8 patients, including 6 typical atrial flutter (AFL) and 2 with perimitral AFL. In the remaining 19 (68%) patients refractory to ibutilide, AF converted to SR in 2 patients and changed to AT in 11 patients (8 typical AFL and 3 perimitral AFL) during the subsequent ablation targeting the complex fractionated atrial electrogram (CFAE). All ATs converted to SR by corresponding linear ablation. Totally, restoration of SR was achieved in 22 (78.6%) patients via this individualized ablation strategy. In the remaining 6 patients, SR was restored by cardioversion after extensive CFAE and linear ablation. AF free rate at 12 months follow-up after single procedure was 80% (48/60). One patient who developed acute heart failure was treated with diuretics and recovered soon after without long-term sequelae. No ibutilide related complications occurred.

Conclusions: In the majority of patients with persistent AF, AF can be terminated by very low-dose ibutilide combined with individualized atrial ablation. Although the initial outcome is promising, the long-term efficacy ofthis ablation strategy needs further evaluation.

Figurel. The Protocol andthe flow chart ofablation procedure for PsAF with low dose ibutilide. The endpoint was SR restoration, if linear ablation was performed, the bidirectional conduction block should be achieved. PsAF: persistent atrial fibrillation; CPVI: circumferential pulmonary vein isolation;AF: atrial fibrillation; SR: sinus rhythm; AT: atrial tachycardia; CFAE: complex fractionated atrial electrogram; CV: cardioversion.


Unusual presentation of subclavian crush syndrome

HC Yuen, NY Chan, CC Choy, CL Lau, YK Lo, PS Chu, HF Chow, PT Tsui, NS Mok Princess Margaret Hospital, Hong Kong

Background and Objectives: Subclavian crush syndrome is a rare but potentially serious complication in pacemaker implantation. We encountered an unusual presentation of subclavian crush syndrome that has not been reported in the literature. Our case might help cardiologists to better understand the different presentations of subclavian crush syndrome.

Case Summary: Our case was a 78-year-old gentleman who presented with heart block and syncope in April 2011. Pacemaker (DDDR) was implanted over left subclavian vein with RV lead screwed at RV septum and RA lead screwed at RA appendage. During follow-up in early August 2011, RV lead pacing threshold was elevated. Another follow-up in late August 2011, RA lead pacing and sensing threshold was also found to be suboptimal. CXR showed no displacement of leads. He was scheduled for lead replacement. During lead replacement, both leads couldn't be unscrewed. Careful inspection at the subclavian entry site through XR showed crushing of both leads. We did an experiment off-table by clamping an screwed-out lead at the proximal part with a forcep to see if it could be unscrewed or not. It proved that subclavian crush could probably cause failure in unscrewing of a screw-in lead. We didn't perform lead extraction because of failure in unscrewing. A new pacemaker system was then implanted over right axillary vein.

Conclusion: Subclavian crush syndrome could cause failure in unscrewing of a screw-in lead. It might affect lead replacement or extraction during subclavian crush syndrome.


Aconitine induced bidirectional ventricular tachycardia successfully supported by ECMO

HC Yuen, NY Chan, CC Choy, CL Lau, YK Lo, PS Chu, HF Chow, PT Tsui, NS Mok

Princess Margaret Hospital, Hong Kong

Background and Objectives: Aconitine is notoriously known as a poison causing ventricular arrhythmia. In case of aconitine induced ventricular tachycardia, the underlying cause of venticular arrhythmia at presentation is usually not known and the best treatment strategy is not certain. Our case illustrated a specific form of ventricular arrhythmia which was bidirectional ventricular tachycardia for aconitine poisoning and the successful haemodynamic support by ECMO during the critical period.

Case Summary: Our case was a 62-year-old gentleman who presented with chest discomfort and palpitation in January 2013. ECG showed bidirectional ventricular tachycardia. His ventricular arrhythmia became incessant and he was haemodynamically unstable. He failed to respond to multiple defibrillation and intravenous amiodarone. Urgent coronary angiogram was normal and ECMO was inserted for haemodynamic support. His ventricular arrhythmia subsided the next day and ECMO was weaned off few days later. Cardiac MRI was normal. Urine toxicology showed aconitine. On detailed questioning, patient had taken some herbal medication before admission. Option of adrenaline provocation test was offered to rule out catecholaminergic polymorphic ventricular tachycardia but patient refused. He had no more ventricular arrhythmia during follow-up 5 months after discharge.

Conclusion: Aconitine poisoning could present with bidirectional ventricular tachycardia. One of the crucial management in the initial critical period would be haemodynamic support. We reported a case of aconitine induced bidirectional ventricular tachycardia successfully supported by ECMO.


ICD lead fracture caused by subclavian venoplasty during CRT upgrade

HC Yuen, NY Chan, CC Choy, CL Lau, YK Lo, PS Chu, HF Chow, PT Tsui, NS Mok

Princess Margaret Hospital, Hong Kong

Background and Objectives: The number of CRT upgrade is increasing worldwide. Subclavian venoplasty is one of the solution if subclavian vein stenosis is found during CRT upgrade. We encountered a case of possible ICD lead fracture after subclavian venoplasty for subclavian vein stenosis during CRT upgrade.

Case Summary: Our case was a 70-year-old gentleman who underwent dual chamber ICD implantation in left pectoral region for dilated cardiomyopathy with LVEF 40% and ventricular tachycardia in 2006. He presented with heart failure in 2010 and echocardiogram showed LVEF of 35%. ICD interrogation showed 90% ventricular pacing. CRT upgrade was performed and venogram showed significant left subclavian vein stenosis. Subclavian venoplasty was done and LV lead was successfully implanted over posterolateral branch of coronary sinus. However, he had multiple inappropriate ICD shock 4 months later. ICD interrogation showed very high RV ICD lead impedance indicating lead fracture. RV ICD lead fracture was likely due to previous subclavian venoplasty. A new ICD lead had to be reinserted.

Conclusion: Subclavian venoplasty is a potential cause of lead fracture. As the number of CRT upgrade and subclavian venoplasty for subclavian vein stenosis is increasing, the drawback of possible lead fracture needs to be considered when subclavian venoplasty is needed during CRT upgrade.



The effect of the initial ratio of left atrial appendage cycle length (LAACL) / pulmonary vein cycle length (PVCL) on the AF termination in persistent atrial fibrillation (PsAF) catheter ablation

Xian-dong Yin, Ying Tian, Xu Zhou, Liang Shi, Zhen-yu Jiao, Xiao-qing Liu, Xin-chun Yang, Xing-peng Liu

Cardiology Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China

Background and Objective: The substrates for sustained atrial fibrillation (AF) in different patients with persist AF (PsAF) may be different, so the different patients with PsAF may need different substrate modification strategy. We hypothesize that the initial ratio of left atrial appendage cycle length (LAACL) /pulmonary vein cycle length (PVCL) may represent a marker of substrate for sustained AF.

Methods: Sixty consecutive patients (43 males; age, 60±12 years, LA: 48±4mm) with PsAF were prospectively included. The initial PVCL and LAACL were measured with LASSO( the shortest PVCL was adopted) . Then the ablation protocol(showed in figure 1) was performed, firstly circumferential pulmonary vein antrum ablation (CPVA) followed by 0.25 mg ibutilide administration intravenously in patients with ongoing AF after pulmonary vein isolation(PVI). According to the response to ibutilide, corresponding ablation was performed to restore sinus rhythm (SR). The primary endpoint was AF termination including AF converted to ATs or restoration of SR.

Results: All patients were indivded into 2 groups according to the initial ratio of LAACL/PVCL. Group A included the patients with ratio >1, and group B included the patients with ratio < 1, There are 37 and 23 patients with the ratio of LAACL/PVCL>1 and < 1 respectively, and the rate of AF termination during the procedure were 86% and 30% (P < 0.05). Multiple factors regression analysis showed the duration of AF and the Initial ratio of LAACL/PVCL >1 were independent predictors for AF termination during procedure.

Conclusions: Patients with Initial ratio of LAACL/PVCL >1 had higher rate of AF termination during procedure than the patients with ratio < 1 , the ratio >1 may represent the atrial substrate for sustained AF is relative mild.

Figurel. The Protocol and the flow chart of ablation procedure for PsAF with low dose ibutilide. The endpoint was SR restoration, if linear ablation was performed, the bidirectional conduction block should be achieved. PsAF: persistent atrial fibrillation ; CPVI: circumferential pulmonary vein isolation;AF: atrial fibrillation; SR: sinus rhythm; AT: atrial tachycardia; CFAE: complex fractionated atrial electrogram ; CV: cardioversion.

Utility of unipolar electrogram morphologies in the pulmonary vein isolation with radiofrequency ablation

Xiao-Qing Liu, Xian-Dong Yin, Ying Tian, Xu Zhou, Liang Shi, Kui Chen, Zhen-Ming Jiang, Xin Fu, Xing-Peng Liu, Xin-Chun Yang

Department oof Cardiology, Center for Atrial Fibrillation, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China

Background and Objective: RS morphology of the unipolar electrogram is associated with propagation of the wave front through the exploring electrode, whereas positive uniphasic (R) unipolar electrograms are characteristic of the end of activation. The study is to investigate the feasibility and efficacy of the utility of unipolar electrogram morphologies in the pulmonary vein isolation (PVI) with radiofrequency ablation(RFA) .

Methods: Consecutive patients with paroxysmal atrial fibrillation were prospectively enrolled and randomly divided into group A and group B undergoing RFA of circumferential PV antrum ablation. Group A underwent traditional ablation based on the amplitude reduction of bipolar electrogram, the ablation endpoint of each point is at least 50% amplitude reduction. In group B, only the points with RS or rS unipolar electrogram morphology were ablated, and the endpoint of each point was loss of negative components and development of an R or RR' pattern(changed from RS, rS, to R or RR') of the unipolar electrogram(showed in figure 1). The procedure endpoint was PVI, if necessary, the additional ablation was performed to achieve PVI.

Results: Each group included twenty patients respectively, with mean age 62±8 years and 30 (75%) male. PVI was achieved in all patients. The radiofrequency duration in group B was shorter than in the group A (38.4±8.8 vs 24.7±3.5 minutes, p < 0.01). The mean RF duration of each points were 39.4±8.6 and 22.1±3.7 seconds in group A and B (P < 0.01). The mean follow-up was 10±5 months. Documented atrial fibrillation recurred in 5 patient in group A and 3 patients in group B(P=0.74).

Conclusions: Utility of real time unipolar electrogram morphologies to guide the pulmonary vein isolation with RF ablation is feasibility and safe, can reduce the ablation requirements than traditional approach significantly and facilitate the procedure ofPVI.

Key words: unipolar electrogram; pulmonary vein isolation; .radiofrequency ablation

Figure 1. The utility of unipolar electrogram to guide the pulmonary vein ablation. The unipolar electrogram of the first two beat at MAP1 is RS. with the RFA, The unipolar electrogram of the last three beat at MAP1 loss the negative components and changed to RR', the point's ablation endpoint is achieved.



To identify the recurrence patients with persistent atrial fibrillation after catheter ablation: value of a pre-procedural ibutilide test

Ying Tian, Xiandong Yin, Liang Shi, Xu Zhou, Xiaoqing Liu, Xinchun Yang, Xingpeng Liu

Beijing Chaoyang Hospital, China

Introduction: High recurrence is the major limitation of current catheter ablation techniques in treating patients with persistent atrial fibrillation (AF). This study aimed to identify patients who will be refractory to catheter ablation treatment of persistent AF using an ibutilide provocative test pre-procedurally.

Methods: Sixty consecutive patients (43 men, aged 60±12 years; median AF duration: 2.5 years) who underwent index catheter ablation for persistent AF were enrolled in this prospective study. Two days before ablation, surface ECG AF cycle length (AFCL) was measured in lead V1 every 5 min until 30 min during administration of low-dose ibutilide (0.25 mg over 3 min). After circumferential pulmonary vein isolation, complex fractionated atrial electrograms ablation guided by intra-procedural administration of the same dose of ibutilide was performed. The ablation endpoint was AF termination.

Results: During the pre-procedural ibutilide test, the maximal surface ECG AFCL prolongation was 46±14 ms. Prolongation of surface ECG AFCL was strongly correlated with AFCL recorded in the left atrial appendage during the administration of ibutilide intra-procedurally. Persistent AF termination was achieved in 44 (73%) patients in whom prolongation of surface ECG AFCL during the pre-procedural ibutilide test was significantly longer than that in those who did not attain this endpoint (48±13 ms versus 40±15 ms, P<0.05). After a mean follow-up of 11±5 months, 13 (21.7%) patients suffered from recurrent atrial tachyarrhythmias (ablation non-responders). Prolongation of surface ECG AFCL of ablation non-responders was significantly shorter than ablation responders (38±13 ms vs 48±13 ms, P<0.05). By multivariate analysis, prolongation of surface ECG AFCL less than 30 ms during the pre-procedural ibutilide test was the only independent predictor of ablation non-responders (0R=10.232, 95% CI=1.770-59.133; P=0.009).

Conclusion: The pre-procedural ibutilide test is a simple, non-invasive and objective method for identifying non-responders of catheter ablation treatment in patients with persistent AF.

A novel approach to ablate paroxysmal atrial fibrillation refractory to pulmonary vein isolation: value of low dose ibutilide

TIAN Ying, YIN Xiandong, SHI Liang, ZHOU Xu, LIU Xiaoqing, YANG Xinchun, LIU Xingpeng

Beijing Chaoyang Hospital, China

Introduction: During catheter ablation for paroxysmal atrial fibrillation (AF), one cumbersome situation is AF ongoing in spite of the fact that pulmonary veins (PV) have been isolated. We hypothesize that the majority of such AF episodes may be driven by some critical sites beyond PVs, and thus can be terminated by limited lesions. The goal of this study is to investigate the feasibility of ablating paroxysmal AF episodes refractory to PV isolation by administration of low dose ibutilide.

Methods: Ten consecutive patients (4 men, age 62±11 years) with paroxysmal AF who met the following criteria were included: (1)PV isolation was done during AF; (2)sustained AF lasted more than 10 minutes after PV isolation; and (3)the electric activity of superior vena cava is constantly slower than the right atrial appendage. Two 3-dimensional electro-anatomical maps of left atrium (LA) were created and complex fractionated atrial electrograms (CFAE) were tagged on it before and after administration of ibutilide (0.25 mg, over 3 minutes). Only CFAEs on the second map were ablated.

Results: Of the 10 patients, sustained AF after PV isolation was terminated by 0.25mg ibutilide in 2. In the remaining 8 patients, administration of low dose ibutilide significant increased the AF cycle length in the LA appendage (Baseline: 185±45 ms, 10 minutes later: 265 ±50 ms, P=0.0014) and decreased the CFAE areas on the LA map (3.9±2.0 versus 1.8±0.6, P=0.0052). In one patient, another 0.25mg ibutilide was injected again because of the concern of pro-arrhythmic effect of aggressive ablation (>10 CFAE areas on the second LA map in this patient). After 4±3 applications of radiofrequency ablation, sustained AF was terminated in all 8 patients. The termination sites included LA anterior wall (n=3), septum (n=2), roof (n=1) and base of LA appendage (n=2). All but 1 patient were free from atrial tachyarrhythmias without antiarrhythmic drugs after a mean follow-up of 12±5 months.

Conclusion: Using low dose of ibutilide, the sustained AF refractory to PV isolation can be terminated by limited ablation lesions in patients with paroxysmal AF.



The effects of cilostazol on the ion channels in rat right ventricular myocyte HE Rong, LI Guang-ping, Wu Ying-le Li, Jian Cheng, Li-jun

Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin 3002}}, China

Objective: This study aims to observe the effects of Cilostazol on the transient outward potassium current and L-Type Calcium Channels in rat right ventricular myocyte, explore the mechanism of ion channels that ciolstazol inhibit ventricular arrhythmias in BrS

Methods: Single myocytes were isolated from right ventricular of adult rat with collagenase II. Ito and ICa,L in cell of right ventricular were recoreded by whole-cell patch clamp technique. This experiment were divided into two parts, (1) acute pharmacological expriment means the perfusion expriment, there are four groups, Cilostazole 1, 2, 5, 50^mol/L groups. The differentce about current density of Ito was recoreded between before and after drug perfusion in each group, and the differentce about change of current density of Ito also was observed among four groups. (2) chronic pharmacological expriment means oral medication expriment invided two groups: control group(CON group) and exprimental group(CILO group), The differentce about current density of ICa,L was recoreded between the two groups.


1. The result of perfusion expriment (1) In Cilostazole 1, 2, 5, 50^mol/L each group, current density of Ito after cilostazol perfusion is lower than before, and here were significant statistical differences when the self-command voltage +60 mV ( all P < 0.05), the current density of Ito in ecah group were: (20.82±7.42) vs(7.48±2.56) pA/pF;(18.64±7.89) vs (7.63±1.78) pA/pF;(18.87±5.05) vs(7.19±1.79);(21.45±2.54) vs(6.96±2.31) pA/pF; (2) in each command voltage, this study compared the reduction rate of current density of Ito among four different concentrations of cilostazol perfusate, and found there was no significant changes among four groups without statistical significance(P>0.05), in addition, reduction rate of current density of Ito are all about 60% among four groups in +60 mV.

2. The result of oral medication expriment : the current density of ICa,L in CON group is sightly higer than CILO group in +60 mV without statistical significance, (-6.24±2.65) pA/pF vs (5.17±1.61) pA/pF(P>0.05).

Conclusion: 1. Ito was significantly inhited when Cilostazole 1^mol/L, Cilostazole 2^mol/L, Cilostazole 5pmol/L, Cilostazole 50^mol/L directly acted on the rat right ventricular cells, there was no difference in the degree ofdecline ofIto from Cilostazole 1pmol/L to Cilostazole 50pmol/L; It is the "all or non"direct effect of ion channel that cilostazol inhibites Ito. 2. oral cilostazol had no effect for ICa,L in the rat right ventricular cells.

Keywords: Cilostazole; right ventricular cell; transient outward potassium current; L-type calcium current

MS Wek

Objectives: To study the relationship between red cell distribution width (RDW) ,direct-bilirubin(D-BIL) andparoxysmal atrial fibrillation (AF) in patients with hypertension.

Method: Eighty patients, who were hospitalized in Second Hospital of Tianjin Medical University from October 2011 to April 2012,were enrolled in this study. The patients were divided into two groups, AF group and control group, according to the history of AF. The baseline clinical data were collected including age, sex, combined cardiovascular diseases, laboratory results and echocardiography findings. The multi-variable logistic regression model was established to identify the potential risk factors for paroxysmal AF.


• The level ofRDW, D-BIL, UA and left atrial diameter (LAD) was significantly higher (p<0.05) in patients with AF than those in control group.

• Taking the variables which is statistically significant between atrial fibrillation group and the control group into the multivariate Logistic regression. Logistic regression analysis showed D-BIL and LAD were the independent risk factors for the development of paroxysmal AF. The value ofOR ofD-BILwas 2.171 (95%CI: 1.082-4.354,p=0.029)

• Taking the values of D-BIL and LAD in atrial fibrillation group into ROC curve analysis. The area under the ROC curve of D-BIL was 0.660(p<0.05, 95%CI:0.539-0.781),we could indicate the occurrence of atrial fibrillation when the value of D-BIL>2.35mmol/L; The area under the ROC curve of LAD was 0.802 (P<0.01,95%CI: 0.695-0.909) ,we could indicate the occurrence ofatrial fibrillation when the value ofLAD>36.685mm.

Conclusion: The higher level of D-BIL may relate to the development of paroxysmal AF in hypertensive patients.

Keywords: Atrial fibrillation; Red cell distribution width; Direct-bilirubin; Hypertension



Pulmonic valve endocarditis with an underlying ventricular septal defect a report on three cases at the philippine general hospital

JA Aherrera, MJ Reyes, G Floro, E Timbol, JM Zapanta, L Blanquisco, K Tumabiene, FE Punzalan

Philippine General Hospital, Phillipines

Synopsis: Pulmonic valve endocarditis (PVE) is considered a rare disease, noted in 1.5 to 2.0% of all cases of infective endocarditis with fewer than 90 cases reported. Its occurrence warrants investigation of possible risk factors that would predispose an individual to such a right sided event, such as an underlying congenital heart disease with a left-to-right shunt. We present three cases of pulmonic valve endocarditis with an underlying ventricular septal defect (VSD) encountered at the Philippine General Hospital.

Clinical Presentation: We report three cases seen (two males and one female) who each sought consult due to prolonged fever and heart failure symptoms, particularly right sided manifestations such as facial edema and ascites. Fulfilling the duke's criteria for a definite endocarditis, the assessment for the three cases was a pulmonic valve subacute endocarditis with an underlying ventricular septal defect. Two of the three cases also developed renal failure from endocarditis-associated glomerulonephritis.

Significance and Recommendations: This case series documents three rare cases of pulmonic valve endocarditis complicating a ventricular septal defect. Basic knowledge of the epidemiology of infective endocarditis is always helpful in reaching its proper diagnosis and treatment. We emphasize the need to consider a congenital heart disease as a predisposing risk factor in patients presenting with PVE despite negative initial imaging, as evident in one of the cases presented. Suspicion of an infective endocarditis should be made whenever there is a worsening of heart failure (particularly right sided in the case of pulmonic valve endocarditis) in a patient with an underlying predisposition, such as a congenital heart defect.

Recurrent transient ischemic attacks in a female with an atrial septal aneurysm and an atrial septal defect: a case report

JA Aherrera, J Adviento, JLavente, A Magpali, JD Magno, R Jara

Philippine General Hospital, Phillipines

The prevalence of atrial septal aneurysm (ASA) is 2.2%, occurring at a mean age of 65 years. Most ASAs are clinically silent, however, potential clinical consequences include cardiogenic embolism and arrhythmias. We present a case of an atrial septal aneurysm with an atrial septal defect, manifesting as recurrent transient ischemic attacks. Transesophageal Echocardiography documented an atrial septal defect with an atrial septal aneurysm (Olivares-Reyes type 1R). We managed our patient with medical therapy, utilizing dual antiplatelets, showing significant resolution of symptoms.



Cardiac tamponade as a rare manifestation of systemic lupus erythematosus a report on three cases in the Philippine General Hospital

JA Aherrera, BH Manapat-Reyes, E Salido, L Lantion-Ang, FE Punzalan

Philippine General Hospital, Phillipines

Synopsis: Cardiac tamponade among systemic lupus erythematosus (SLE) patients is an unusual event. The pericardial effusion may be a consequence of uremia, infections in the pericardium, or the lupus pericarditis itself. We present three atypical cases of cardiac tamponade from pericarditis of connective tissue disease, both of which were treated successfully with drainage and immunosuppressants. Due to the rarity of this combination, management was a challenge.

Clinical Presentation: Three patients (all female) each sought consult for dyspnea associated with typical manifestations of connective tissue disease such as arthritis, characteristic rashes, serositis, typical laboratory features, and a positive ANA and/or anti-dsDNA. The first two cases fulfilled the criteria for SLE, while the third fulfilled the criteria for SLE-dermatomyositis overlap syndrome. Echocardiography revealed massive pericardial effusion in tamponade physiology.

Diagnosis: Cardiac tamponade from serositis due to connective tissue disease [SLE (case 1 and 2) or SLE-dermatomyositis overlap (case 3)].

Three cases of cardiac tamponade as a manifestation of connective tissue disease were presented. Literature underlines the rarity of this condition anytime during the course of SLE. Despite this, SLE should be considered as one of the differentials of cardiac tamponade, especially in patients who manifest with multi-systemic findings. Likewise, massive pericardial effusion should be considered in patients with a connective tissue disease presenting with subtle evidence of pericardial involvement. It requires timely identification and treatment with high dose steroids, after other causes such as infections have been excluded. Immediate drainage through pericardiocentesis or pericardiostomy in combination with immunosuppressants may be life-saving.

The case presentation of concealed WPW with the pseudo myocardial infarction (MI)

Nongnooch, Kongkiat

Advocate Illinois Masonic Medical Center United States of America

29 year-old male with past medical history of hypertension and hyperlipidemia was found cardiac arrest in the golf field. He was found pulseless with the ventricular fibrillation on the EKG monitor. At emergency room ,he was shocked 6 times and given 6 doses of epinephrine. Initial Lab was unremarkable .Echocardiogram showed EF45% with no vulvular abnormalities or pericardial effusion. He regained his consciousness with the sinus tachycardia without any conduction pathway abnormalities from the EKG . Given the unclear etiology of ventricular fibrillation, subsequently the electrophysiology testing (EP study ) was performed .The EP study showed the left lateral accessory pathway compatible with the Wolff Parkinson White syndrome (WPW).He was successfully ablated with RFA (radiofrequency ablation )without complication.

The sudden cardiac arrest is the rare presentation of the WPW syndrome which can be found approximately 1%. In this patient, the initial EKG didn't impressively show the delta wave. The concealed WPW was the term described when there was the only retrograde pathway conduction without anterograde accessory pathway . The electrophysiology testing (EPS) is the good method for both diagnostic and therapeutic purposes in suspected patients with unclear etiology of cardiac arrest. And EPS with ablation is now the definitive treatment for the symptomatic tachycardia condition .



Supraventricular tachycardia with hydrops in a 20-year old primigravid

A.L. Fernandez

Chong Hua Hospital, Phillipines

Background: Fetal supraventricular tachycardia is rare that when complicated with hydrops increases fetal mortality.

Objective: To present a case of fetal supraventricular tachycardia with hydrops

Case: A 20-years old female, primigravid at 30 weeks age of gestation with stable vital signs was referred to our institution on the third day due to fast fetal heart rate. Fetal cardiogram showed short VA interval with 1:1 AV conduction at 220 bpm. Fetal biophysical profile showed pleural effusion. Maternal baseline was normal. The mother was then given loading dose of Digoxin 0.25 mg IVTT q 6 hours for 4 doses and maintained at a dose of 0.25 mg orally once daily. However after 24 hours fetal heart rate was still at a rate of 210-220 bpm. She was then started with Flecainide 50 mg orally two times daily which was gradually increased to 100 mg twice daily. Fetal heart rate converted to sinus on the eight day of treatment with no maternal complications.

Discussion: Fetal SVT is one of the most complicated forms of fetal tachycardia. It is diagnosed through echocardiogram showing short VA interval with 1:1 atrioventricular conduction. Presence of fetal hydrops is associated with mortality rate of 35% compared with 0-4% in nonhydrops fetuses. Risks of fetal hydrops with SVT presents at a younger gestational age, incessant, enduring. The first choice of management is transplacental transfer with digoxin and flecainide as commonly used antiarrhythmics.

Third degree atrioventricular block and pericarditis complicating hyperthyroidism and persistent left superior vena cava

M Vicente, JMercado, JA Aherrera, M San Juan, P Nacpil, R Jara

Philippine General Hospital, Phillipines

Synopsis: The coexistence of heart blocks and pericarditis with hyperthyroidism is unusual. We report a case of a patient harboring these abnormalities with incidental finding of persistent left superior vena cava.

Case: A 20 year old, previously diagnosed hyperthyroid female patients was admitted due to shortness of breath and vomiting. She complained of two-week history of flue like symptoms, watery stools, and palpitations prior to admission. She was noted to be bradycardic upon admission with ECG findings consistent with pericarditis with third degree atrioventricular block. Thyroid function tests were consistent with hyperthyroidism. Pericardial effusion was seen on echocardiography. Contrast echocardiogram was also done which confirmed persistent left superior vena cava as a cause of coronary sinus dilatation. The patient underwent temporary transvenous pacemaker insertion which relieved her symptoms. She was given antithyroid medications, aspirin, colchicine, and enalapril. After eight days, the transvenous pacemaker was removed due to resolution of heart block and improvement in patient's symptoms. She was eventually discharged hemodynamically stable and symptom free.

Significance: In patients presenting with heart blocks and pericarditis, thyrotoxicosis should also be recognized as a likely etiology. Hyperthyroid patients should therefore be observed for these life threatening conditions



Evaluation of an algorism for identification of the origin of atrial tachycardia by the detailed analysis of P wave

Mitsumi Yamashita

Yokohama City Bay Red Cross Hospital, Japan

Background: Catheter ablation of atrial tachycardia (AT) is effective and have high long-term success. The efficacy of AT ablation might be due to the analysis of AT origins. Aim of this study was to investigate accuracy in terms of identifying AT origin with P-wave algorism(P-Alg).

Methods: 43 patients (29 men, 60&amp;plusmn;17 years) were included in this study. P wave morphology during ATs was analyzed with P-Alg, and its accuracy in terms of identifying AT origin was assessed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value in predicting AT origin were provided.

Results: AT origin for these 43 ATs were as follows; superior vena cave (SVC, n=6), crista terminalis (CT, n=8), tricuspid annulus (TA, n=7), coronary sinus ostium (CSos, n=7), perinodal (n=6), right septum (RS, n=2), right atrial appendage (n=1), right pulmonary vein(RPV, n=2), and left atrium(n=4), and all these were ascertained by successful ablation. True AT origins could be found in 24 of 43 (56%), and suspected AT origins were incorrect according to P-Alg in 19 out of 43 (44%). P-Alg demonstrated good sensitivity/specificity for CT(88/80%), TA(100/83%), CSos (86/94%) and RPV(100/73%), while it showed poor sensitivity and PPV for perinodal and RS (25 and 50%, respectively). AT from SVC was excluded from P-Alg study.

Conclusions: P-Alg was suitable for distinguishing AT origin from CT, TA, CSos and RPV origin. However it had limitations to identify AT origin from atrium septum and SVC.

A case of catecholaminergic polymorphic ventricular tachycardia with de novo mutation in ryanodine receptor 2 misdiagnosed as epilepsy

Xin Liu \ Juxiang Li 1 Jinzhu Hu 1 Yang Shen 1 Wenfeng He 2, Qinmei Xiong1, Qing Cao 12, Kui Hong '

Cardiovascular department, the Second Affiliated Hospital of Nanchang University, Nanchang of Jiangxi, 330006, China

The Key Laboratory oof Molecular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang oof Jiangxi, 330006, China

Background & Objectives: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited rhythm disorder characterized by excise- and stress-induced syncope or sudden death. We describe a case of syncope following physical activities or emotional stress misdiagnosed as epilepsy.

Methods: Symptoms and signs of the patient were collected. Electrocardiogram, cardiac imaging examinations and other assistant investigations were analyzed. Additionally, the genetic testing was performed.

Results: An 11-year-old boy presented with syncope accompanied with paroxysmal convulsion after excise or frightened since age 3. Each episode of syncope lasted from seconds to minutes, and always recoveried spontaneously. He was diagnosed with epilepsy and underwent a relevant surgery in 2011. Oxcarbazepine and magnesium valproate were orally given since then. However, syncope still occurred and the boy was referred to our cardiovascular department. Excise induced bidirectional ventricular premature ectopics and torsades de pointes were both recorded by treadmill exercise testing and holter monitoring while heart structure was normal in cardiac magnetic resonance and echocardiography. Genetic screening revealed a heterozygous missense mutation (c.7202G>A) in exon 47 of ryanodine receptor 2 gene (RYR2) and resulted in the amino acid substitution R2401H. Syncope did not recur after administration oforal p blocker.

Conclusion: The outcome of clinical examination, especially genetic testing and effective p blocker response help we make a definitive diagnosis of CPVT. It is highlight the significance of cardiac factor for syncope that worth noting for physicians outside cardiologist.



Arrhythmogenic right ventricular tachycardia with total AV block manifestation

Utami A.D., Achmad C.

Padjajaran University, Bandung, Indonesia

A 16 year-old boy presented to our hospital after a period time of weakness without any history of syncope nor near syncope. He reported a family history of sudden death. ECG showed total AV (atrioventricular) block. The laboratory revealed within normal limit but from echocardiogram showed dilated RA, dilated RV and deep trabeculated RV. The patient performed CT Cardiac Imaging that revealed a dilated right ventricle with deep trabeculation, scalopping and fatty infiltration at myocardium. The diagnosis of Arrhythmogenic Right Ventricular Dysplasia with TAVB manifestation was confirmed. Arrhythmogenic Right Ventricular Dysplasia is characterized by fibrofatty replacement of the right ventricular myocardium leading to hypokinetic regions of the heart. This condition can cause malignant arrhythmias, usually with VT/VF manifestation and rarely with total AV block. The authors report a case of total atrioventricular block in ARVD patient. Early detection and appropriate placement of Implantable Cardioverter Defibrillators in high risk patients with Arrhythmogenic Right Ventricular Dysplasia must be done to reduces the incidence of sudden cardiac death. In our case we performed permanent pacemaker implantation to treat the heart block due to financial problem.

Interpulmonary vein electrical connection and pulmonary vein tachycardia in a patient with paroxysmal atrial fibrillation: the important role of pulmonary vein carina

Eiji Sato1'2, Tetsuo Yagi, Akio Namekawa1, Akihiko Ishida1, Yoshiaki Mibiki', Yoshihiro Yamashina', Hirokazu Sato1, Manjirou Sakuramoto1 , Takashi Nakagawa, Jyuri Komatsu, Tomoyuki Yambe

}Division of Cardiology, Sendai City Hospital, Sendai, Japan

Department of Medical Engineering and Cardiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan

We report the case of a 66-year-old man with paroxysmal atrial fibrillation who underwent encircling ipsilateral pulmonary vein isolation (EIPVI) while in arrhythmia. During EIPVI, the left inferior pulmonary vein (LIPV) tachycardia (cycle length, 110 ms), that is, organized electrical activity within the LIPV, was initiated. Meanwhile, the left superior pulmonary vein (LSPV) showed fibrillation conducting to the atria. After the radiofrequency catheter ablation (RFCA) at the posterior wall of the left pulmonary vein carina, fibrillation in the LSPV was converted to organized electrical activity with a cycle length of 220 ms (LSPV tachycardia), suggesting a conduction ratio of 2:1 from the LIPV to the LSPV. Moreover, as the LSPV tachycardia conducted to the left atrium with a ratio of 2:1, atrial tachycardia (cycle length, 440 ms) was observed on an electrocardiogram. After RFCA at the posterior wall of the left PV carina, both the LSPV tachycardia and the atrial tachycardia terminated; however, the LIPV tachycardia continued, indicating disconnection between the inter-PV connections. The LIPV tachycardia was terminated by applying RFCA at the posterior wall of the LIPV carina. This case illustrates the important role of the PV carina that leads to inter-PV electrical connection and arrhythmogenicity of PV tachycardia.



Transeptal, transmitral left ventricular lead positioning during CRT device implantation is safe

ArefArjomandd, Arieh Kieren2,Vince Paul, Tim Gattorna1

Royal Perth Hospital; Sir Charles Gairdner Hospital, Perth, Western Australia, Australia

Background/Objectives: During CRT device implantation it is not always possible to position the LV lead in a satisfactory position. Transeptal, transmitral, endocardial LV lead positioning is an established alternative to surgical intervention. We report on our initial experience .

Methods: In five patients (4 male, mean age 64) conventional coronary sinus LV lead positioning had failed because of CS anomalies in 2, unsatisfactory threshold in 2 and no suitable branch in1. In 4/5 patients there was a preexisting indication for anticoagulation.

A femoral transeptal puncture was undertaken and used to guide a guiding sheath from the Coronary Sinus into the left atrium and through to the LV.

Successful transeptal LV lead positioning was achieved in all patients. Mean procedure time was 1.6 hours. All patients had LV lead positioned successfully on the lateral wall with threshold below 1V, sensing >10mv and no phrenic stimulation. 4/5 patients were discharged the following day. In one patient acute lead displacement and tamponade occurred. This patients underwent successful re-positioning of lead 2 days later.

Results: During a mean follow up of 11 months (range 2-17) the LV lead has functioned well in all patients with threshold below 1V. 4 patients have responded well clinically with one to be assessed. All remain on formal anticoagulation.

Conclusion: Transeptal, transmitral LV lead placement is technically feasible and straightforward procedure which provides a stable functioning position independent of CS anatomy. There are additional theoretical advantages for this approach which is a preferred alternative to surgical intervention.

Clinical effects of chemical ablation for the vein of Marshall in terms of pulmonary vein isolation in patients with atrial fibrillation

Tomoaki Hasegawa

Yokohama City Bay Red Cross Hospital, Japan

Background: Ethanol infusion (EI) into the vein of Marshall (VOM) has been performed mainly to construct bidirectional conduction block at the Mitral isthmus (MI) in patients with atrial fibrillation (AF). In addition, EI into VOM can be expected to perform electrical isolation of pulmonary vein (PVI).

Methods: Total of 93 study patients ( male; 65, average age; 65 ± 11 years) and 57 control patients were involved in this study. Multi-electrode circular catheters (LASSO) were inserted into left superior and inferior PV. EI into VOM could be successfully performed in 75 out of 93 patients (81%), and time-course change of status of PVI was investigated with LASSO. Then, adjunctive PVI was performed with radiofrequency energy (RF) catheter ablation (CA) in cases of incomplete PVI only by EI into VOM. Parameters regarding RF-CA were compared between EI-VOM and control group.

Results: Left superior PVI in 2, left inferior PVI in 7 occurred only by EI into VOM. Total of RF application time for the completion of PVI was significantly lower in EI-VOM than control patients (28 ± 9 v.s. 35 ± 11, P=0.03).

Conclusions: EI into VOM itself contributes to PVI to a great extent. Significant reduction of RF application at endocardium can be expected only by EI into VOM, which leads to a safer PVI procedure.


Successful catheter ablation against purkinje related reentrant ventricular tachycardia associated with myotonic dystrophy - a case report

M. Kaneda, T. Hirose, S. Warita, R. Matsuoka, M. Ishiguro, H. Yagasaki, H. Miwa, F. Tokoro, S. Abe, Y. Goto, T. Yoshizane, T. Fuji, T. Kato, T. Kojima, M. Iwama, M. Kawade, K. Ono, S. Tanihata, M. Arai, T. Noda, S. Watanabe

Department of Cardiology, Gifu Prefectural Genaral Medical Center Gifu city, Gifu, Japan

Present illness: The patient was 41-year-old man with myotonic dystrophy. He had implanted a implantable cardioverter defibrillator(ICD) because of pulseless ventricular tachycardia(VT). He was preferred to the our emergency room with a chief complaint of feeling ICD shock. The electrocardiogram(ECG) on admission revealed a wide QRS complex tachycardia with heart rate of 158 bpm, right bundle-branch block morphology with superior axis.

Electrophysiologic study and interventional treatment: In electrophysiologic study, atrium-His(AH) interval was 135 msec and His-ventricle(HV) interval was 110 msec, and monomorphic VT was induced easily by a single programmed stimulus from the right ventricular apex (at a coupling interval of 320 msec). Using anatomical-electro-mapping system, the earliest myocardial activation site during VT was observed at the infroapical septum, where was the end of left posterior fascicule. In this site, the local Purkinje potential was observed and preceded the initial deflection of QRS on ECG by 30 msec during VT, and the recording demonstrated fused Purkinje potential during sinus rhythm. A distinct His deflection was recorded during VT with an HV interval that was shorter than that during sinus rhythm. Entrainment of VT was possible. Radio frequent current delivered to this site could suppress the VT. After ablation, clinical VT was never induced by any programmed stimulus, and AH interval and HV interval were not prolonged. The VT has not been recorded in ICD analysis after ablation.

We reported the case of successful catheter ablation against Prukinje related reentrant VT associated with myotonic dystrophy.


Successful radiofrequency catheter ablation for atrial tachycardia with specific activation mapping in a limited area after sequential linear defragmentation approach

Jin Iwasawa, Shigeki Kusa, Hitoshi Hachiya, Noboru Ichihara, Takamitsu Takagi, Akio Kuroi, Hiroaki Nakamura, Shinsuke Miyazaki, Hiroshi Taniguchi, Yoshito Iesaka

Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan

We present a 67-year-old man who underwent radiofrequency catheter ablation (RFCA) for atrial tachycardia (AT). The patient underwent extensive encircling pulmonary vein isolation and sequential linear defragmentation approach for chronic atrial fibrillation 2 year before this session. The AT cycle length was 250 ms. The P waves were too low amplitude to describe the polarity in all leads. AT continued inside the area enclosed by a roof line, a mitral isthmus block line, and a left atrial (LA) anterior line during ablation at the LA anterior wall in the electro-anatomical mapping (CARTO), though 12-lead ECG showed sinus rhythm. We performed activation mapping in the enclosed area and the AT was diagnosed as a focal AT originating from the anterior left atrial appendage (LAA). However we did not perform RFCA at this site in order to avoid LAA electrical isolation. A few minutes later, the AT recurred because of reconduction through the gap in the LA anterior line. At this time, as the origin of the AT had been already identified, we performed RFCA not at the gap of the LA anterior line but at the anterior LAA which was the AT origin. Finally the AT was terminated by RFCA to the site. The LAA was not isolated at sinus rhythm due to the conduction gap in the LA anterior line. We report a rare case in which we could identify the arrhythmia mechanism by performing specific activation mapping in a limited area through the CARTO system.


Ventricular tachycardia storm in left dominant arrythmogenic cardiomyopathy

Surendra K Chutani

PCH, India

Background: Arrythmogenic Cardiomyopathy (AC) is considered to be typically right sided with significant positive family history. Left dominant type is rare.

Objective: To report two cases of Left Dominant Cardiomyopathy who presented in VT Storm who were successfully ablated by radiofrequency.

Methods: Both patients were interrogated for detailed family history, clinical exam, Echocardiography, Coronary angiography and left ventriculogram for left ventricular morphology. They were taken to Electrophysiology lab for mapping of ventricular tachycardia with 3D Electronatomical mapping using St.Jude EnSite system. Radiofrequency ablation of substrate was done successfully followed by implantation of single chamber Intra cardiac defibrillator.

Results: Pt A was 44 male Construction worker with no family history of heart disease or sudden cardiac death, presented with haemodynamically significant monomorphic ventricular tachycardia. Coronary arteries were normal and left ventricular angiogram showed two aneurysms involving mid septum and left ventricular apex.LV EF was 35%. Mapping revealed mid diastolic potentials and low voltage on 3D map. Successful Radiofrequency ablation was done with non inducibility of Ventricular tachycardia.

Pt. B was 61 male with hypotensive monomorphic ventricular tachycardia with deep S waves all across precordial leads, normal Coronary arteries and LV angiogram and LVEF was 60%. Detailed 3D electro anatomical map showed low voltage scar tissue around mitral valve and was successfully ablated with RFA with no more inducible VT.

Conclusions: Left dominant Arrythmogenic cardiomyopathy is a rare condition. Genetic mutation study was not done.



A case of ventricular tachycardia originated from right purkinje system

Sung-Won Jang, Sou-Hyun Lee, Tae-SeokKim, Sung-Hwan Kim, Woo-Seung Shin, Ji-Hoon Kim, Yong-Seog Oh, Man-Young Lee, Tae-Ho Rho

The Catholic Univerisity of Korea, South Korea

Background: Ventricular tachycardia (VT) originated from the right Purkinje system is rare. We report a focal Purkinje VT arises from right ventricle (RV) and it was successfully treated by catheter ablation using radiofrequency (RF) energy.

Case: A 44-year-old male presented with palpitations and near syncope. The ECG showed wide complex tachycardia (figure 1). The tachycardia cycle length was 300ms and atrioventricular (AV) dissociation was noted. Because the patient complained moderate to severe dyspnea and blood pressure was 70/40mmHg, electrical cardioversion was applied and sinus rhythm was restored. Resting ECG showed regular sinus rhythm with heart rate of 80/min and complete right bundle branch block. The patient had been taking angiotensin receptor blocker due to hypertension. The echocardiogram and coronary angiography revealed neither structural heart disease nor significant coronary stenosis. Electrophysiologic study was performed. RV pacing did not show retrograde nodal conduction and isoproterenol use spontaneously induced VT which is similar to the clinical one. VT was also induced and terminated by ventricular burst pacing. We mapped on the septal side of RV and pacemapping was matched of 11/12. During VT, the mapping catheter demonstrated discernible Purkinje potential which preceded QRS complex about 40ms (figure 2). RF energy delivery successfully eliminated tachycardia and VT was not induced after ablation.

Conclusion: A rare presentation of idiopathic VT that arises from right Purkinje system was successfully treated by RF ablation targeting Purkinje potential. Further investigation is needed to determine the mechanism of this kind of VT.

Figure 1


Thrombus formation in the left atrial appendage during catheter ablation for persistent atrial fibrillation

Shin Kashimura, Seiji Takatsuki, Marina Okada, Kouhei Inagawa, Yoshinori Katsumata, Takahiko Nishiyama, Takehiro Kimura, Nobuhiro Nishiyama, Yuriko Satou, Koutarou Fukumoto, Yoshiyasu Aizawa, Youko Tanimoto, Koujirou Tanimoto, Keiichi Fukuda

Keio University School of Medicine, Japan

Objectives: We evaluated the usefulness of intracardiac echocardiography(ICE) for continuous monitoring of thrombus formation in the left atrium(LA) and left atrial appendage(LAA) during catheter ablation for atrial fibrillation(AF).

Methods: We performed catheter ablation for AF on two patients. Both patients received long-term sufficient anticoagulation therapy include during catheter procedure. Prior to ablation, cardiac computed tomography(CT) and transesophageal echography(TEE) was performed and they revealed no thrombi but only spontaneous echo contrast(SEC) in the LAA. ICE was located in the pulmonary artery. DC was performed to terminate AF. Catheter ablation was performed under the activated clotted time over 300 sec.


Case1: 76 year-old man with persistent AF(CHADS2=3), whose LA diameter was 4.6cm and LAA flow velocity was 7-18 cm/sec, underwent pulmonary vein isolation(PVI) followed by DC. Mitral isthmus linear ablation and cavo-tricuspid isthmus ablation were performed, and after that, ICE revealed mobile mass was formed at the tip of the LAA.

Case2: 64 year-old woman with persistent AF(CHADS2=2), whose LA diameter was 4.1cm and LAA flow velocity was 20-36 cm/sec, firstly received DC, the flow velocity of the LAA was remarkably decreased and SEC stagnated. During PVI, it became clearer, but still remained 60 minutes after DC.

Conclusion: During catheter ablation for persistent AF combined with DC, thrombus could be generated in the LA and the LAA in spite ofsufficient anticoagulation by heparin.


A case with much lower and varying basic rate induced by noncompetitive atrial pacing

Toshiya Kojima, Yasushi Imai, Katsuhito Fujiu, Kazuo Asada, Issei Komuro

The University of Tokyo, Japan

A Medtronic Protecta XT CRT-D (Medtronic Inc.) was implanted in a 70-year old male, who had cardiac sarcoidosis with extremely low cardiac function.

He had ventricular tachycardia but controlled by catheter ablation, medication and pacing. The programmed mode was DDI, lower rate was 90 ppm, paced AV delay was 150 msec and the noncompetitive atrial pacing (NCAP) function was programmed as 300 msec.

After his admission for pneumonia and heart failure, there were cycle lengths which were longer than setup one and alternately varied. We could avoid this phenomenon with AV delay of 120 msec and NCAP of 200 msec.

NCAP is an algorithm which spaces above a certain period after the detection of an atrial signal in the postventricular atrial refractory period of the pacemaker. This is to prevent atrial tachycardia and repetitive nonreentrant ventriculoatrial (VA) synchrony in the presence of retrograde VA conduction.

But in this case, NCAP algorithm induced much lower rate than programmed basic one.

This situation produced some arrhythmias and exacerbated symptoms of heart failure. So we have to pay attention to that, especially when we program high basic heart rate.



An unusual case of torsades de pointes: look before you treat!

Vivek Chaturvedi, Dhaval Shah, Annirudha Vyas, Vijay Trehan

Department of Cardiology, GB pant Hospital, New Delhi, India

Background: A 65 year old female presented with multiple syncopal episodes in the preceding 24 hours. She was a known case of hypertension and type 2 diabetes on lifestyle intervention and had an episode of self-limiting diarrhea 2 days ago. At presentation, her ECG showed torsades de pointes (TDP) that required electrical cardioversion (Figure). Her ECG subsequently showed left ventricular hypertrophy with abnormal repolarization and prolonged QTc (>600 ms) along with intermittent runs of polymorphic tachycardia. Her serum potassium and magnesium were mildly low, which were corrected. Her other metabolic parameters, echocardiogram and serum troponin did not contribute to the diagnosis. It was then noticed that the lady had a thyroid swelling which had been all along partially covered with religious cloth. While there were no symptoms of thyroid excess, a thyroid profile was ordered. Her episodes of TDP continued and she was started on lignocaine infusion. This decreased TDP somewhat but her QTc remained prolonged and she required further shocks for TDP when her infusion was discontinued after 24 hours despite all metabolic parameters being normal. Her thyroid profile now showed thyrotoxicosis. She was immediately started on neomercazole, on which she showed dramatic improvement with TDP disappearing within 24 hours. At follow up after 3 months, she was asymptomatic with normal thyroid profile and a QTc of470 ms.

Conclusion: While prolonged QTc is described with thyrotoxicosis, spontaneous TDP as in this case has been described only once. Hyperthyroidism should be considered in differential diagnosis of refractory TDP cases.

Figure 1: Evolving ECG changes of the index case. A : Torsades de pointes at presentation. B& C: ECG after cardioversion. D & E: ECG after 24 hours of xylocaine infusion. F: ECG after 3 months of antithyroid therapy.

Lone atrial fibrillation in an adolescent girl S.Y. Kwok, A.F.C. Lo, G.C.F. Mok, M.C. Yam

Department oof Paediatrics, Prince oof Wales Hospital, The Chinese University of Hong Kong, Hong

We report a 15-year-old adolescent girl with a good past health, who presented with sudden onset of palpitation and dizziness. Examination revealed fast, irregular apical beats (170 beats/ minute) with normal blood pressure. Electrocardiogram showed typical fast atrial fibrillation (AF). Transthoracic echocardiogram confirmed there was not any structural abnormality, but the cardiac function was suboptimal with biventricular hypokinesia. No intracardiac thrombus was identified. Successful synchronized cardioversion was performed without anticoagulation, and the rhythm was converted to sinus without any thromboembolic event. The girl was put on new generation anticoagulant and antiarrhythmic medication, dabigatran and dronedarone, respectively, for a short period of time, and there was no more recurrence of AF. Lone AF is rare in the paediatric population. The thromboembolic risks are exceedingly low. Therefore, aggressive rhythm control would be the approach in its management, and anticoagulation before cardioversion may not be indicated. Genetic predisposition has become a new trend in the study of young-onset lone AF. The updated evidence of managing lone AF in children and adolescents is discussed, including the use of dabigatran and dronedarone.


Case of late perforation of right ventricular caused by electrode

Zhao-guang Liang

The First Affiliated Hospital oof Harbin Medical University, China

Background & Objectives: Pacemaker and implantable cardioverter defibrillator electrode perforation is recognized as a potential complication of pacemaker or defibrillator electrode implantation. Treatment of this perforation, especially late one, has not been evaluated. The aim of this study was therefore to find and evaluate a option to deal with late perforation.

Methods: In a case of late perforation (detected more than five month after implanting dual chamber pacemaker), computed tomography (CT) showed right ventricular and pericardium perforation caused by a passive electrode. A catheter was implanated through the right subclavian vein to right ventricular for ventriculography. To avoid damage of blood vessels and other tissues caused by the electrode, it was withdrawn under X-ray visulization. Then a new electrode was implanted to replace the old one through the left subclavian vein.

Results: The results of twice right ventriculography (one is before the withdrawal and the other is after the withdrawal) demonstrate that there was no leakage of contrast medium. The new implanted electrode has been working well so far.

Conclusion: This study shows that the treatment of late perforation should include right ventriculography in order to detect pericardial effusion timely. As for the electrode,which has perforated pericardium, it should be withdrawed to avoid further damage of tissue and blood vessel.



Successful catheter ablation of para-hisian atrial tachycardia from the noncoronary cusp of aortic valve

Li Li Cheung, Gary Chin Pang Chan, Joseph Yat Sun Chan

Divison of Cardiology, Department of Medicine and Therapeutics, Prince oof Wales Hospital, the Chinese University of Hong Kong, Hong Kong

A 55-year-old woman was admitted to our hospital for evaluation of recurrent episodes of palpitation. Physical examination, blood tests and echocardiography revealed no evidence of structural heart disease. Twelve-lead ECG taken at the time of admission demonstrated a regular narrow complex tachycardia with ventricular rate 180bpm. There was no discernible P wave during the tachycardia.

The electrophysiological study was performed, three catheters were introduced to the right atrium (RA), the right ventricle(RVA), and at the HB region via the femoral veins, Also a 6F multi-polar catheter was advanced within the coronary sinus (CS) via the right internal jugular vein. A long RP tachycardia was induced. The diagnosis of focal atrial Tachycardia was confirmed with earliest atrial activation located in the His-bundle region. Detailed activation mapping was performed at both right atrium and left atrium and the earliest atrial activation site was found at the noncoronary cusp of the aortic valve.

Radiofrequency ablation using the retrograde trans-aortic approach successfully terminate the tachycardia in 4 seconds.

NCC of the aortic valve is the most posterior cusp and is close by to the penetrating His Bundle. Catheter ablation of para-hisian atrial tachycardia using this access is safe and effective.

Moxifloxacin-induced torsade de pointes, after the cardiac surgery

Fatih Ada, Fatih Ada, MehmetCahit Saricaoglu, Hus

Ankara University School Of Medicine, Turkey

Torsade de pointes (TdP) occuring due to a long QT interval is a rare but potentially fatal arrhythmia. The most common cause of drug-induced QT prolongation is inhibition of the rapidly activating component of the delayed potassium current (IKr). Fluoroquinolones are broad-spectrum antibiotics, are being used for especially hospital-acquired diseases and resistance to prior antibacterial agents. In general, fluoroquinolones are well tolerated, with most side effects being mild to moderate, but can cause serious adverse effects occasionally. Most of these side effects are associated with all types of fluoroquinolones, but certain quinolones carry risks of specific toxicity to unique organs, like moxifloxacin carries a higher risk of QTc prolongation. This takes place by blockage of the rapid component of the delayed rectifier potassium current (IKr), which regulates the outward flow of potassium from the myocyte. IKr inhibition delays repolarization by blocking the potassium in myocytes. In the presence of risk factors like female gender, organic cardiac disease, advanced age, bradycardia, long QT syndrome histories, renal and hepatic dysfunction and electrolyte abnormalities, likelihood of progressing to fatal arrhythmias, especially TdP, is dramatically increased. The patient has TdP risk factors female sex, organic cardiac disease, bradycardia. On the fifth day 400 mg/day of oral moxifloxacin admission the patient had an episode of TdP, which progressed to ventricular fibrillation and successfully defibrilated.



Cardiac tamponade complicating disseminated non-tuberculous mycobacterial infection involving the pericardium: a case report

A Manguba, A Faltado, J Aherrera, M Llanto, R Jara

Philippine General Hospital, Phillipines

The most common mycobacterial species causing infection in the Philippines is Mycobacterium tuberculosis. Non-tuberculous mycobacteria (NTM) have not been reported in Philippine literature to disseminate to the pericardium. We present a case of disseminated mycobacterial (tuberculous and non-tuberculous co-infection involving the pericardium, pleura, spleen and abdominal wall. A 37-year old female presented with dyspnea and multiple nodules within the abdominal wall. Work up lead to a diagnosis of disseminated co-infection with nontuberculous mycobacterium and M. tuberculosis involving the pericardium, pleura, spleen and abdominal wall. She had a cardiac tamponade from mycobacterial species (tuberculous and nontuberculous) with bacterial superinfection (A. baumanni, B. mallei).

This case highlights the importance of a high index of suspicion in considering nontuberculous mycobacterial species in patients who do not show improvement with the standard HRZE regimen for M. tuberculosis. Pericardial involvement and pericardial effusion in disseminated RGM infection is rare. Moreover, the course of pericardial involvement in RGM infection is unknown.

Close follow-up of patients with pericardial involvement of nontuberculous mycobacteria is recommended as the course of these patients have not yet been well-characterized due to its rarity.

A case of retained broken wire in coronary sinus during biventricular pacemaker implant

Ti-kei NG, Sum-kin LEUNG

Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong

Introduction: Failure to secure the LV lead to a site with satisfactory sensing and pacing threshold is not uncommon in biventricular pacemaker implantation. We reported a case of accidentally broken and retained guidewire in the coronary sinus during biventricular pacemaker implantation. Interestingly, the LV lead was found to have better sensing and pacing threshold after occurrence of this "complication". Will it be a potential alternate method in securing the LV lead after placement ?

Case description: A 62 years old gentleman who had DDDR pacemaker implanted for complete heart block was scheduled for a generator change due to depleted battery. Pre-Procedural echocardiogram revealed the LVEF was 30%. He has NYHA Class II symptom. Due to his pacing dependency, upgrading to biventricular pacing was decided. A Abott Whisper guidewire was steered into lateral cardiac vein after CS sheath was placed. After LV lead placement, we withdrew the Whisper wire. But it was found broken inside the LV lead. Attempt to remove the LV lead and the guidewire together failed as the broken part of the wire was kept retained in the cardiac vein. The LV lead was then advanced over the broken part of the guidewire. A site with good sensing and pacing threshold was readily obtained. The broken part of the wire was left there. Post procedure the LV lead parameters remained satisfactory, though there was pericardial effusion which was subsiding upon serial monitoring.

Discussion: Plastic-coated (hence electrically insulated) guidewire inside LV lead may aid its placement.



A closely spaced bipolar electrode to eliminate phrenic pacing: two leads in the same vein connected by an adapter

S Worley,M Bernabei, D Gohn

Lancaster Heart and Vascular Institute, United States oof America

Background & Objectives: Phrenic pacing is observed in 33%-37% of patients at the time of implant with 6.6% still reporting phrenic pacing despite repeated attempts at reprograming. A temporary pacing lead with closely spaced bipolar electrode can reduce phrenic pacing. The objective was to devise a closely spaced bipolar electrode for chronic implantation

Methods: Four patients with previously failed attempts at left ventricular (LV) lead placement due to phrenic pacing had two leads introduced into the same vein and positioned with the tips separated by approximately 2 mm. Phrenic pacing and capture thresholds were assessed in a standard manor for each convectional bipolar electrode and from the closely spaced bipolar electrode formed by selecting one tip as the cathode and the other tip as the anode. The two tip electrodes where adapted to create a single IS-1 output with the tip of one lead serving as the tip of the adapted bipolar electrode and the tip of the second serving as the ring.

Results: In all 4 patients the closely spaced bipolar electrode created by adapting the two tip electrodes reduced phrenic pacing to provide a > 5 volt safety margin between LV and phrenic pacing. The leads remained in stable position at one month with satisfactory acute and chronic thresholds.

Conclusion: Using an adapter a closely spaced bipolar electrode can be created to eliminate phrenic pacing by placing two leads in the same vein with their tips separated by 2 millimeters.

Atrial tachycardia ablation facilitated by residual ASD in a child post ASD closure

Prafithrie Avialita Shanti, Yoga Yuniadi, Dicky Hanafy, Sunu B Rahardjo, Ganesja Mulia Harimurti

Departement oof Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia

National Cardiovascular Center Harapan Kita, Jakarta, Indonesia

Atrial tachycardia post ASD closure in children is one of the rare arrhythmic complications (commonly idiopathic) which involves mechanisms of focal pacemaker activity or reentry. Mostly, elimination of this arrhythmia exhibits a high successful rate by using radiofrequency ablation applied to the left atrium. We reported the focal atrial tachycardia in a case of an eight-year-old girl was found in non-pulmonary vein (PV) confirmed by ECG algorithm. The patient has successfully undergone the conventional ablation procedure. In addition, the insertion of catheter (facilitated with residual ASD) to the left atrium via the right atrium was done without performing trans-septal approach.

Keywords: atrial tachycardia, radiorequency ablation, ASD closure, residual ASD



Congenitally corrected transposition of the great arteries in a forty-four year old male

Anthony B. King, Michelle M. Maliwat

Makati Medical Center, Phillipines

Levo-transposition of great arteries, also commonly referred to as congenitally corrected transposition of the great arteries (ccTGA), is a rare, complex form of congenital heart disease. The clinical presentation and prognosis of patients depends on the associated cardiac anomalies and development of systemic ventricular dysfunction. Patients undiagnosed until adulthood usually have no associated anomalies.

Our patient was diagnosed because of an abnormal electrocardiogram (ECG) and later on presented at emergency department because of palpitation. The ECG at emergency room is suggestive of atrial tachycardia 2:1 conduction. During his stay, noted monomorphic ventricular tachycardia of 9 complexes. The following day, repeat ECG showed sinus rhythm, first degree AV block. 2d echocardiogram showed the following: The aorta is anterior and to the left of the pulmonary artery. The right atrium enters the morphological LV, which gives rise to the pulmonary artery, and the left atrium communicates with the morphological RV, which gives rise to the aorta. The systemic ventricle has an ejection fraction of 35%. There was no stenosis or regurgitation noted.

In the absence of associated anomalies, the life expectancy of patients with unrepaired congenitally corrected transposition of the great arteries depends on the ability of the right ventricle to withstand systemic pressure.

A case of recurrent loss of consciousness, who was correctly diagnosed as having epilepsy by using implantable loop recorder

Osamu Wakisaka, Tatsuhiko Ooie, Miho Haraguchi, Shozou Yamasue, Masaya Arikawa, Naohiko Takahashi, Tetsunori Saikawa

Cardiovascular Medicine, Oita Medical Center, Oita, Japan

Department oof Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan

Yufuin Kosei Nenkin Hospital, Oita, Japan

Case: A 55-year-old man was referred to our hospital due to recurrent episodes of loss of consciousness (LOC) for 10 months.

He had already got examinations including ECG, echocardiogram, blood tests, head CT and MRI, which resulted in failure to identity the cause of LOC. In our hospital, additional examinations including head-up tilt test, electrophysiological test, carotid massage, and coronary angiography (CAG) were carried out. His CAG findings showed no organic coronary stenosis. However, a vasospastic change was provoked by the administration of ergonovine. Then, he started to take Ca-channel blocker (CCB). After the discharge, he experiencedLOC again in spite oftaking CCB. Following obtaining informed consent, we implanted an implantable loop recorder (ILR) for him. After the implantation, he experienced LOC, during which intermittent high frequency potential was recorded on ILR. Normal QRS complexes were observed when high frequency potential was not observed. During the episode, his wife recorded his behavior on her mobile phone, which demonstrated clonic seizure. The intermittent high frequency potentials were regarded as muscle twitching.

By neurologist, he was diagnosed as having epilepsy and started to take medicine. After that, his LOC disappeared.

Conclusion: Our case suggests that ILR is a useful device to identify the cause of LOC, even though it is due to epilepsy.

Category: Case reports/series