Background Suppressing atrial remodeling by reducing atrial fibrillation (AF) burden during the blanking period (BP) after AF ablation may lead to subsequent suppression of AF recurrence. However, the management of early recurrences (ERs) remains controversial. Herein, we examined the impact of aggressive strategies to restore and maintain sinus rhythm following AF ablation recurrence. Methods This retrospective cohort study initially included 681 consecutive patients who underwent an initial radiofrequency catheter ablation (RFCA) for AF at two centers; 151 patients with ERs of atrial tachyarrhythmias within 3 months post-RFCA were included in the final analysis. Participants were divided into two groups based on the treatment received: Group A, aggressive strategy (n = 112, paroxysmal: 49) and Group B, conservative strategy (n = 39, paroxysmal: 14). Baseline characteristics, clinical parameters, and recurrence rates 12 months after ablation (12m) were compared between groups. Both groups were stratified by AF type and similarly assessed. Results A significant difference was observed in the 12m recurrence-free rate between the groups (Group A: 82/112 [73.2%] vs. Group B: 21/39 [53.9%]; p = 0.016). The aggressive strategy was associated with a lower risk of 12m recurrence (adjusted hazard ratio, 0.24; 95% confidence interval, 0.08-0.74; p = 0.013). Among patients with paroxysmal AF (PAF), no difference was observed (Group A: 35/49 [71.4%] vs. Group B: 9/13 [69.2%]; p = 0.887); however, in those with non-PAF, the 12m recurrence-free rate was higher in Group A than in Group B (47/63 [74.6%] vs. 12/26 [46.2%]; p = 0.004). Conclusions Aggressive strategies for ERs can reduce subsequent recurrences following AF ablation, especially in patients with non-PAF.

A 74-year-old Japanese man was admitted to our hospital for catheter ablation of paroxysmal atrial fibrillation. Transthoracic echocardiography revealed basal interventricular septal hypertrophy without apical sparing. Cardiac magnetic resonance imaging revealed late gadolinium enhancement in the hypertrophic lesions. The Kumamoto criteria was one point, and the patient had no carpal tunnel syndrome. However, technetium-99m pyrophosphate scintigraphy revealed an accumulation in the basal region of the left ventricle. A skin biopsy revealed transthyretin (TTR) amyloid deposition. A TTR gene examination revealed no variants. This case suggests that amyloid deposition in TTR may occur in the basal area of the interventricular septum.

Background:Atrial fibrillation (AF) is a common arrhythmia associated with cardiac amyloidosis (CA). Diastolic dysfunction and atrial lesions have been reported in patients with AF fibrillation. We aimed to evaluate the diastolic function and atrial lesions in patients with CA and AF. Methods and Results:We included 27 patients (mean age 72 years) with biopsy-confirmed CA. We analyzed the average E/e' as diastolic function using echocardiography and atrial late gadolinium enhancement (LGE) as an atrial lesion using cardiac magnetic resonance imaging (CMRI). We compared these parameters among 20 patients with sinus rhythm (SR) and 7 with AF. Echocardiography examination showed that average E/e' were larger in the AF group than in the SR group (average E/e': AF, 21.3 [14.5-30.3]; SR, 14.2 [10.3-16.9]; P=0.0053). CMRI demonstrated that atrial LGE was more severe in the AF group than in the SR group (AF, 7/7 [100%]; SR, 11/21 [52.4%]; P=0.00228). Univariate logistic regression analysis showed that average E/e' demonstrated significant association with AF in all patients (odds ratio 1.24; [95% confidence interval 1.03-1.51]; P=0.0251). Conclusions:AF may be associated with atrial lesions and diastolic dysfunction in patients with CA.

The importance of treating non-pulmonary vein (PV) foci is increasing with improvements in the durability of PV isolation. We describe two cases wherein non-PV foci were induced by mechanical irritation and conventional induction in the same area, which was impossible to induce after ablation, suggesting a relationship between mechanical irritation and induction of non-PV foci. In a recurrent case of non-PV foci, atrial fibrillation (AF) was induced only by mechanical irritation. No recurrence has been observed since the ablation of the area. Thus, treatment of the AF induction site with mechanical irritation could be considered an effective therapy for non-PV foci.

Background The relationship between induction and recurrence due to atrial tachycardia (AT) and left atrial (LA) matrix progression after atrial fibrillation (AF) ablation remains unclear. Methods One hundred fifty-two consecutive patients with paroxysmal and persistent AF who underwent pulmonary vein isolation (PVI) and cavo-tricuspid isthmus (CTI) ablation and achieved sinus rhythm before the procedure were classified into three groups according to the AT pattern induced after the procedure: group N (non-induced), F (focal pattern), and M (macroreentrant pattern) in 3D mapping. Results The total rate of AT induction was 19.7% (30/152) in groups F ( n = 13) and M ( n = 17). Patients in group M were older than those in groups N and F, with higher CHADS 2 /CHA 2 DS 2 -VASc values, left atrial enlargement, and low-voltage area (LVA) size of LA. The receiver operating characteristic curve determined that the cut-off LVA for macroreentrant AT induction was 8.8 cm 2 (area under the curve [AUC]: 0.86, 95% confidence interval [CI]: 0.75–0.97). The recurrence of AT at 36 months in group N was 4.1% (5/122), and at the second ablation, all patients had macroreentrant AT. Patients with AT recurrence in group N had a wide LVA at the first ablation, and the cut-off LVA for AT recurrence was 6.5 cm 2 (AUC 0.94, 95%CI 0.88–0.99). Adjusted multivariate analysis showed that only LVA size was associated with the recurrence of macroreentrant AT (odds ratio 1.21, 95%CI 1.04–1.51). Conclusions It is important to develop a therapeutic strategy based on the LVA size to suppress the recurrence of AT in these patients. Graphical abstract

A 70-year-old man was admitted to our hospital for restoration of sinus rhythm from atrial fibrillation by direct current counter shocks. On admission, he had a coronavirus disease 2019 (COVID-19) infection and syncope during bed rest. Electrocardiography revealed polymorphic ventricular tachycardia after ST-segment elevation with a normal QT interval. Coronary angiography revealed coronary vasospasm. Coronary vasospasm may be a cause of polymorphic ventricular tachycardia in COVID-19 patients.

BACKGROUND There are few data on ventricular fibrillation (VF) initiation in patients with inferolateral J waves. OBJECTIVES This multicenter study investigated the characteristics of triggers initiating spontaneous VF in inferolateral J -wave syndrome. METHODS A total of 31 patients (age 37 +/- 14 years, 24 male) with spontaneous VF episodes associated with inferolateral J waves were evaluated to determine the origin and characteristics of triggers. The J -wave pattern was recorded in inferior leads in 11 patients, lateral leads in 3, and inferolateral leads in 17. RESULTS The VF triggers (n = 37) exhibited varying QRS durations (176 +/- 21 milliseconds, range 119-219 milliseconds) and coupling intervals (339 +/- 46 milliseconds, range 250-508 milliseconds) with a right (70%) or left (30%) bundle branch block (BBB) pattern. Trigger patterns were associated with J -wave location: left BBB triggers with inferior J waves and right BBB triggers with lateral J waves. Electrophysiologic study was performed for 22 VF triggers in 19 patients. They originated from the left or right Purkinje system in 6 and from the ventricular myocardium in 10 and were undetermined in 6. Purkinje vs myocardial triggers showed distinct electrocardiographic characteristics in coupling interval and QRS-complex duration and morphology. Abnormal epicardial substrate associated with fragmented electrograms was identified in 9 patients, with triggers originating from the same region in 7 patients. Catheter ablation resulted in VF suppression in 15 patients (79%). CONCLUSIONS VF initiation in inferolateral J -wave syndrome is associated with significant individual heterogeneity in trigger characteristics. Myocardial triggers have electrocardiographic features distinct from Purkinje triggers, and their origin often colocalizes with an abnormal epicardial substrate. (J Am Coll Cardiol EP 2024;10:1-12) (c) 2024 by the American College of Cardiology Foundation.

BACKGROUND:Coronary artery spasms (CASs), which can cause angina attacks and sudden death, have been recently reported during catheter ablation. The aim of the present study was to report the incidence, characteristics, and prognosis of CASs related to atrial fibrillation (AF) ablation procedures. METHODS AND RESULTS:The AF ablation records of 22,232 patients treated in 15 Japanese hospitals were reviewed. CASs associated with AF ablation occurred in 42 of 22,232 patients (0.19%). CASs occurred during ablation energy applications in 21 patients (50%). CASs also occurred before ablation in 9 patients (21%) and after ablation in 12 patients (29%). The initial change in the electrocardiogram was ST-segment elevation in the inferior leads in 33 patients (79%). Emergency coronary angiography revealed coronary artery stenosis and occlusions, which were relieved by nitrate administration. No air bubbles were observed. A comparison of the incidence of CASs during pulmonary vein isolation between the different ablation energy sources revealed a significantly higher incidence with cryoballoon ablation (11/3,288; 0.34%) than with radiofrequency catheter, hot balloon, or laser balloon ablation (8/18,596 [0.04%], 0/237 [0%], and 0/111 [0%], respectively; P<0.001). CASs most often occurred during ablation of the left superior pulmonary vein. All patients recovered without sequelae. CONCLUSIONS:CASs related to AF ablation are rare, but should be considered as a dangerous complication that can occur anytime during the periprocedural period.

A 15 year-old-Japanese girl was admitted to our ward because of syncope. Electrocardiography (ECG) demonstrated sinus bradycardia with heart rate of 52/min. Holter ECG showed no arrhythmia related to syncope. Coronary enhanced computed tomography and cardiac magnetic resonance imaging showed no abnormal findings. Head-up tilt test revealed syncope with sinus arrest. 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy revealed focally decreased uptake on the anterior wall of the left ventricle but generally maintained uptake of MIBG. Finally, she was diagnosed with cardioinhibitory vasovagal syncope (CIVS). Sympathetic nerve abnormalities seemed to be related to CIVS in this patient.

Asian patients with nonvalvular atrial fibrillation (NVAF) have a higher risk of stroke and systemic embolism than non-Asians, but experience more frequent major bleeding on oral anticoagulation (OAC), including intracranial hemorrhage. Although Asians constituted only a minority of patients in

Key Teaching Points•Atrial standstill is a rare clinical condition characterized by absence of electrical and mechanical atrial activity, and the spatial distribution of atrial lesion can be diffuse or partial.•In atrial standstill when pacemaker implantations are thought to be necessary, evaluation by electrophysiological study should be considered before implantation.•Atrial standstill is a progressive disease; therefore, atrial pacing failure might occur. Patients implanted with a pacemaker should be followed up carefully. •Atrial standstill is a rare clinical condition characterized by absence of electrical and mechanical atrial activity, and the spatial distribution of atrial lesion can be diffuse or partial.•In atrial standstill when pacemaker implantations are thought to be necessary, evaluation by electrophysiological study should be considered before implantation.•Atrial standstill is a progressive disease; therefore, atrial pacing failure might occur. Patients implanted with a pacemaker should be followed up carefully.

BACKGROUND:A free-floating ball thrombus in the left atrium is a rare clinical condition. However, the diagnosis of this condition has been facilitated by the advent and development of echocardiography and multi-detector row computed tomography (MDCT) and several cases have been reported. CASE REPORT:We report a case of a 75-year-old woman who had recurrent giant spherical thrombi in the left atrium. She was diagnosed with chronic atrial fibrillation at 52 years of age. A pacemaker implantation was performed at 54 years of age because of a complete atrioventricular block; and mitral valve replacement was performed for severe mitral regurgitation at 62 years of age. She had a history of cerebral infarction and she was under treatment for chronic heart failure. Despite intensive anticoagulant therapy, she developed ball thrombi in the left atrium three times in six months. During hospitalization for acute myocardial infarction treated with percutaneous catheter intervention, transthoracic echocardiography and computed tomography (CT) revealed a free-floating giant spherical thrombus in the left atrium. She was treated with intensive anticoagulation therapy and the left atrial ball thrombus disappeared; however, two ball thrombi in the left atrium and left atrial appendage recurred after three months. Surgical removal of the thrombi and closure of the left atrial appendage were performed. Unfortunately, a ball thrombus in the left atrium recurred again after a further three months. CONCLUSIONS:The present case highlights the difficulty of treating refractory thrombi in the left atrium.

Objective Karoshi, which is the Japanese term for death from over-work, is usually the extreme result of cardiovascular diseases, and occupational stress plays a pivotal role in the pathogenesis. Depression is closely associated with atherosclerotic cardiovascular disease. The present study was undertaken to examine the relationship between occupational stress and depression.Methods We enrolled 231 consecutive outpatients with lifestyle-related diseases such as diabetes, hyperlipidemia and hypertension were enrolled. Occupational stress was measured by qualitative constructs assessing job control, job demands, and worksite social support using a job content questionnaire (JCQ). The job strain index measured by the ratio of job demands to job control was used as an indicator of the occupational stress. Depression was evaluated by the Self-rating Depression Scale (SDS).Results A univariate linear regression analysis showed the SDS scores to be positively correlated with job demands and the job strain index and negatively correlated with job control and worksite social support. Multiple regression analyses to predict the SDS scores demonstrated that job demands were positively associated with SDS scores and job control and worksite social support were negatively associated with SDS scores after controlling for other variables. The job strain index was positively related to SDS scores.Conclusion Occupational stress expressed as the job strain index was strongly associated with depression. By simultaneously using the SDS and JCQ, the health conditions of patients could be classified based on occupational stress and mental stress, and this classification could help to promote a healthy work environment and guide individual workers.

Objective: LOX-Index is a novel biomarker for cardiovascular disease (CVD) and is calculated by multiplying LOX-1 ligands containing apolipoprotein B (LAB) and soluble LOX-1 (sLOX-1). The Framingham risk score (FRS) is a common clinical tool for risk assessment of coronary artery disease. Mental stress can also be an important risk factor for CVD. The purpose of this study was to examine the relationship between LOX-Index and FRS or mental stress.Methods: LOX-Index was measured in 453 subjects including 150 consecutive outpatients with lifestyle-related diseases such as diabetes, hyperlipidemia, and hypertension and 303 healthy volunteers. Mental stress was evaluated by the Self-Rating Depression Scale (SDS).Results: LOX-Index was significantly related with the 10-years risk of FRS. Multiple regression analysis demonstrated that LAB was closely associated with the smoking status, low-density lipoprotein (LDL), and high-density lipoprotein (HDL). There were no significant associations between LOX-Index and the SDS scores; however, by simultaneously using LOX-Index and SDS, the subjects could be classified in terms of oxidative stress and mental stress.Conclusions: LOX-Index appears to be a comprehensive marker that could evaluate the status of multiple CVD risk factors. The classification with LOX-Index and SDS could contribute to the risk assessment for CVD. (C) 2016 The Authors. Published by Elsevier Ireland Ltd.

AIMS:Left bundle branch block (LBBB) induces mechanical dyssynchrony, thereby compromising the coronary circulation in non-ischaemic cardiomyopathy. We sought to examine the effects of cardiac resynchronization therapy (CRT) on coronary flow dynamics and left ventricular (LV) function.METHODS AND RESULTS:Twenty-two patients with non-ischaemic cardiomyopathy (New York Heart Association class, III or IV; LV ejection fraction, ≤35%; QRS duration, ≥130 ms) were enrolled. One week after implantation of the CRT device, coronary flow velocity and pressure in the left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCx) were measured invasively, before and after inducing hyperemia by adenosine triphosphate administration, with two programming modes: sequential atrial and biventricular pacing (BiV) and atrial pacing in patients with LBBB or sequential atrial and right ventricular pacing in patients with complete atrioventricular block (Control). We assessed hyperemic microvascular resistance (HMR, mean distal pressure divided by hyperemic average peak velocity) and the relationship between the change in HMR and mid-term LV reverse remodelling. Hyperemic microvascular resistance was lower during BiV than during Control (LAD: 1.76 ± 0.47 vs. 1.54 ± 0.45, P < 0.001; LCx: 1.92 ± 0.42 vs. 1.73 ± 0.31, P = 0.003). The CRT-induced change in HMR of the LCx correlated with the percentage change in LV ejection fraction (R = -0.598, P = 0.011) and LV end-systolic volume (R = 0.609, P = 0.010) before and 6 months after CRT.CONCLUSION:Cardiac resynchronization therapy improves coronary flow circulation by reducing microvascular resistance, which might be associated with LV reverse remodelling.

Patient: Male, 76Final Diagnosis: Rheumatic valvular heart diseaseSymptoms: Breathlessness and leg edemaMedication: -Clinical Procedure: Medical treatment for heart failureSpecialty: CardiologyObjective: Rare diseaseBackground: Complete calcification of the left atrium (LA) is called "coconut atrium", which decreases the compliance of LA, leading to the elevation of LA pressure that is transmitted to the right-side of the heart. The pathogenesis of LA calcification in patients with rheumatic heart disease is unknown; however, possible mechanisms include chronic strain force in the atrial wall and inflammation. We report here a patient with long-standing rheumatic valvular heart disease with coconut atrium.Case Report: A 76-year-old man presented with breathlessness and leg edema due to right-sided heart failure. He was diagnosed with rheumatic fever at 8 years of age. Mitral commissurotomy and the mitral and aortic valve replacement were previously performed to treat mitral and aortic valvular stenosis. The profile view of the chest X-ray indicated a diffuse calcified outline of the LA wall. A transthoracic echocardiogram revealed pulmonary hypertension and dilatation of both atria. Moreover, computed tomography showed nearly circumferential calcification of the LA wall. Despite intense medical treatment, he succumbed to heart failure. An autopsy demonstrated that the LA was markedly dilated, its wall was calcified, and its appearance was similar to the surface of an atherosclerotic aorta. Microscopic examination revealed intensive calcification in the endocardium. Minimal accumulation of inflammatory cells was noted. Although slight fibrosis was observed, the cardiac musculature was preserved.Conclusions: To the best of our knowledge, this is the first report that identifies the histological changes of LA calcification associated with long-standing rheumatic valvular heart disease.

Background: Outcomes related to prophylactic catheter ablation (PCA) for ventricular tachycardia (VT) before implantable cardioverter-defibrillator (ICD) implantation in non-ischemic cardiomyopathy (NICM) are not well characterized. We assessed the efficacy of single endocardial PCA in NICM patients. Methods: We retrospectively analyzed 101 consecutive NICM patients with sustained VT. We compared clinical outcomes of patients who underwent PCA (ABL group) with those who did not (No ABL group). Successful PCA was defined as no inducible clinical VT. We also compared the clinical outcomes of patients with successful PCA (PCA success group) with those of the No ABL group. Endpoints were appropriate ICD therapy (shock and anti-tachycardia pacing) and the occurrence of electrical storm (ES). Results: PCA was performed in 42 patients, and it succeeded in 20. The time to ES occurrence was significantly longer in the ABL group than in the No ABL group (p=0.04). The time to first appropriate ICD therapy and ES occurrence were significantly longer in the PCA success group than in the No ABL group (p=0.02 and p<0.01, respectively). Conclusion: Single endocardial PCA can decrease ES occurrence in NICM patients. However, high rates of VT recurrence and low success rates are issues to be resolved; therefore, the efficacy of single endocardial PCA is currently limited.