Some patients require radiofrequency catheter ablation (RFCA) within the coronary sinus (CS) to eliminate conduction through accessory pathways (APs). A 23-year-old man was diagnosed with atrioventricular reentrant tachycardia (AVRT) utilizing a left-sided AP as the retrograde limb and was successfully treated by RFCA within the CS. Following the RFCA, another form of narrow QRS complex tachycardia was observed, and an electrophysiology study revealed the tachycardia as reentrant atrial tachycardia (AT) involving the CS. RFCA within the CS successfully terminated the tachycardia. This is the first case of iatrogenic reentrant AT secondary to RFCA for AVRT. Learning objective Radiofrequency catheter ablation (RFCA) is the standard treatment for atrioventricular reentrant tachycardia (AVRT) caused by accessory pathways. This case highlights that patients with AVRT who have undergone extensive RF applications may develop recurrent reentrant atrial tachycardia. Operators need to be aware that extensive RF applications can generate arrhythmogenic substrates, even in patients with AVRT.

AbstractBackgroundInsertion of electrode catheters into the coronary sinus (CS) through the right internal jugular vein (RIJV) carries risks of pneumothorax and severe hematoma formation. This study was performed to compare the safety and feasibility of catheterization through the left cubital superficial vein versus the RIJV.MethodsThis prospective nonrandomized study involved consecutive patients who underwent catheter ablation from September 2021 to February 2023. Blind puncture techniques were used in the left cubital vein group; ultrasound‐guided insertion was performed in the RIJV group. The success rates of sheath insertion and CS catheterization, the procedure and fluoroscopy times of CS cannulation, and complications were compared between groups.ResultsThe left cubital vein group comprised 152 patients, and the RIJV group comprised 58 patients. The sheath insertion success rate was significantly lower in the cubital vein group than in the RIJV group (84.9% vs 100%, respectively; p = .0008). In the cubital vein group, blind puncture attempts failed in 20 patients; three patients developed guidewire‐induced venous injury. One arterial puncture occurred in the RIJV group. After successful sheath insertion, no significant differences were observed in the CS cannulation success rate (97% vs 100%, p = .55), procedure time (median [range], 93 [51–174] vs 74 [44–129] s; p = .19), or fluoroscopy time (median [range], 66 [36–134] vs 48 [30–92] s; p = .17). No serious complications requiring procedural discontinuation occurred.ConclusionThe left cubital vein approach is practical, offering a viable alternative to the RIJV approach.

Background: Advanced interatrial block (A-IAB) on electrocardiography (ECG) represents the conduction delay between the left and right atria. We investigated the association of A-IAB with left and right atrial (LA/RA) remodeling in patients with atrial fibrillation (AF).Methods: We enrolled 74 patients who underwent ECG, cardiac computed tomography (CCT), and echocardiography during sinus rhythm before catheter ablation of AF. A-IAB was defined as P-wave duration & GE;120 ms with a biphasic morphology in leads III and aVF or notched morphology in lead II. We compared the maximum and minimum LA/RA volume indices (max and min LAV/RAVI), LA/RA expansion index (LAEI/RAEI), and total, passive, and active LA/RA emptying fraction (LAEF/RAEF) between patients with and without A-IAB.Results: Of the 74 patients (mean age, 64.3 & PLUSMN; 9.6 years), 35 (47%) showed A-IAB. Patients with A-IAB had a significantly higher likelihood of hypertension and left ventricular diastolic dysfunction than those without. Patients with A-IAB had significantly larger max (69.2 [60.7-79.7]mL/m2 vs. 60.9 [50.4-68.3]mL/m2, P < 0.01) and min (44.0 [37.2-52.1]mL/m2 vs. 34.1 [29.2-43.5]mL/m2, P < 0.01) LAVI than those without. The max and min RAVI were not significantly different between groups. LAEI (55.1 [48.2-78.5]% vs. 72.1 [57.8-84.8]%, P < 0.05), total LAEF (35.5 [32.5-44.0]% vs. 41.9 [36.6-45.9]%, P < 0.05), and passive LAEF (12.2 [10.0-14.4]% vs. 15.5 [11.2-19.6]%, P < 0.05) were significantly lower in patients with A-IAB than without. Conclusions: A-IAB was associated with LA, but not RA enlargement, in patients with AF. A-IAB may indicate LA functional remodeling in the reservoir and conduit phases.

We experienced a case of lead-related SVC syndrome, which was successfully treated using unique transvenous lead extraction technique and endovascular stenting. This case also suggests that intravascular ultrasound facilitates decision-making on whether the interventionist should perform TLE alone or add stenting in case of a lead-related venous obstruction.

Objective Early recurrence (ER) after pulmonary vein isolation (PVI) for atrial fibrillation (AF) is expected to resolve within the recommended 3-month blanking period, irrespective of the ablation device used. To compare the occurrence and relationship of AF within the blanking period and subsequent late recurrence (LR) with radiofrequency (RF) and cryoballoon (CB) ablation. Methods A retrospective analysis of 294 patients (mean age=62±9, 70.0% male) undergoing PVI for drug-refractory paroxysmal AF was done. After categorizing the patients into the RF group (n=152) and the CB group (n=142), a group-wise comparison was done to investigate the impact of ER on LR throughout a 2-year follow-up. Results The groups were similar regarding the occurrence of ER (RF=22.4%, CB=24.6%, p=0.62), while LR was significantly higher in the RF group (p=0.003). ER was associated with LR in the RF group (p<0.01) but not in the CB group (p=0.08), while a significant independent association with an increased LR risk was observed [hazard ratio (HR) 6.12; 95% confidence interval (CI) 3.56-10.51, p<0.01]. RF ablation also significantly increased the risk of LR (HR=2.93; 95% CI=1.64-5.23, p<0.01). Conclusion A recurrence of atrial arrhythmia is more frequent with RF-PVI than with CB-PVI for patients with paroxysmal AF. ER and RF-ablation are strong predictors for LR after the 3-month blanking period.

A 70-year-old man was referred for evaluation and treatment of wide QRS complex tachycardia with left bundle branch block morphology. Electrocardiography showed atrial bigeminy with an alternating bundle branch block (ABBB) aberration. Atrial burst stimulation reproducibly demonstrated ABBB. What is the mechanism?

Background: Our aim was to analyze the incidence of P-wave abnormalities in embolic and non-embolic strokes, and evaluate its clinical usefulness for predicting stroke etiology.Methods: We included 376 consecutive patients hospitalized for acute ischemic stroke from January 2015 to September 2021. Among the patients in sinus rhythm at admission, 31 had ischemic stroke due to atrial fibril-lation (AF)-related embolism, 59 had embolic stroke of unknown source (ESUS), and 143 had non-embolic stroke. P-wave abnormalities were defined as 1. P-wave axis abnormality (PWAA); 2. P-wave terminal force in V1 (PTFV1) <=-4000 mu V*ms; 3. advanced inter-atrial block (A-IAB).Results: The prevalence of each type of abnormality was consistently lower in patients with non-embolic stroke than in those with AF-related embolism (AF-related vs. ESUS vs. non-embolic; PWAA, 45% vs. 20% vs. 14%; PTFV1, 36% vs. 37% vs. 15%; and A-IAB, 55% vs. 31% vs. 13%, respectively). The identification of at least one type of P-wave abnormality improved the sensitivity compared to using a single abnormality parameter (sensitivity 72%, specificity 62%), while at least two types of abnormality had low sensitivity, but high specificity (sensitivity 29%, specificity 95%). Multivariate regression analysis revealed that identification of at least one type of P-wave abnormality was independently associated with embolic stroke (odds ratio 3.11, 95%CI 1.46-6.63).Conclusions: The incidence of each type of P-wave abnormality was significantly lower in patients with non -embolic stroke. A combination of PWAA, PTFV1, and A-IAB parameters could be useful for distinguishing embolic from non-embolic stroke.

A 39-year-old woman with no structural heart disease underwent an electrophysiology study (EPS) to assess recurrent supraventricular tachycardia (SVT). The electrocardiogram did not show any preexcitation. The baseline atrio-His and His-ventricular intervals were 108 and 43 ms. Ventricular pacing demonstrated concentric, decremental ventriculoatrial (VA) conduction, and the single jump changed the earliest atrial activation site (EAAS) from the His bundle region to the proximal coronary sinus (CS) region.

A 74-year-old man was admitted for a second replacement of a transvenous implantable cardioverter-defibrillator (ICD) generator at 15 years after implantation. Postoperatively, electrocardiographic monitoring showed atrial lead malfunction. Chest X-ray revealed that the tip of the active fixation atrial lead was dislocated. We present a case of atrial lead dislodgement after a very long-term period of an ICD implantation.

Abstract Background Vascular inflammation plays a fundamental role in most vascular diseases including atherosclerosis and vasculitis syndrome, in which arterial wall vascularization (AWV) frequently develops. Visualization of AWV is informative in detecting the vascular inflammation but is challenging. A new ultrasound technique (superb micro-vascular imaging [SMI]) allows the detection of extremely low-velocity flows. We examined an availability of SMI for assessment of the instability of atherosclerotic plaques and the activity of Takayasu arteritis (TA). Methods and results The study consists of two independent and consecutive parts A and B, examined in carotid stenosis (A) and TA (B), respectively. In part A, 12 patients with symptomatic severe carotid stenosis (CS group) scheduled for carotid endarterectomy were enrolled. In six of 12 patients, preoperative ultrasonography with SMI showed intraplaque neovascularization at the plaque shoulder. Postoperatively, histopathology confirmed the neovessels at the corresponding sites of visualized AWV. SMI had a sensitivity of 67%, specificity of 90% for detection of AWV in CS group. In SMI analysis, false positive findings were caused by motion artifact and arterial wall calcification, and a false negative finding is attributed by intraplaque hemorrhage. In part B, 10 patients with TA were enrolled. All patients underwent 18F-FDG-PET/CT, and its vascular uptake were compared with AWV detected by SMI. Bilateral common carotid arteries (CCA), internal carotid arteries and common iliac arteries were examined by SMI. Active vascular 18F-FDG uptake (max SUV >2.1) were found at five sites in three patients, which were not significantly correlated with the prevalence of macaroni sign, increase in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Of note, SMI revealed AWV at five sites corresponding to uptake of 18F-FDG, with a sensitivity/specificity of 100% and 98%, positive predictive value 71%, and a negative predictive value 100%. Conclusion SMI enables visualization of AWV at vulnerable plaque in CS patients and at 18F-FDG positive sites in TA patients. SMI has potential as a modality to detect the vascular inflammation. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research, Japan

Recently, an increasing attention has been paid to foot microcirculation in critical limb ischemia (CLI). Although skin perfusion pressure (SPP) is the most frequently used marker of microcirculation, SPP is often unmeasurable at the most ischemic site in the foot. A new ultrasound technique (superb

Interventional radiology (IR) procedures tend to be complex, which delivers high radiation exposure to patient. In the present study, we measured the radiation exposure dose [Hp(3)] in the eye using a direct eye dosemeter placed next to the physician's eye during procedures. Physicians wore a direct eye dosemeter just lateral to eyes and an additional direct eye dosemeter outside the radiation protective eyeglasses close to their eyes. Additionally, a neck glass badge was worn at the neck. Although we found a positive correlation between the left neck glass badge dose [Hp(0.07)] and the left eye lens dose [Hp(3)], the value of R2 of the regression equation were 0.62 and 0.71 (outside and inside). We thought that the exact eye lens dose might not be estimated from the neck glass badge. In conclusion, a correct evaluation of the lens dose [Hp(3)] using the direct eye dosemeter is recommended for tachyarrhythmia physicians.

In a previous study, we reported on a novel (prototype) real-time patient dosimeter with non-toxic phosphor sensors. In this study, we developed new types of sensors that were smaller than in the previous prototype, and clarified the clinical feasibility of our newly proposed dosimeter. Patient dose measurements obtained with the newly proposed real-time dosimeter were compared with measurements obtained using a calibrated radiophotoluminescence glass reference dosimeter (RPLD). The reference dosimeters were set at almost the same positions as the new real-time dosimeter sensors. We found excellent correlations between the reference RPLD measurements and those obtained using our new real-time dosimeter (r2 = 0.967). However, the new type of dosimeter was found to underestimate radiation skin dose measurements when compared with an RPLD. The most probable reason for this was the size reduction in the phosphor sensor of the new type of dosimeter. We believe that, as a result of reducing the phosphor sensor size, the backscattered X-ray irradiation was underestimated. However, the new dosimeter can accurately determine the absorbed dose by correcting the measured value with calibration factors. The calibration factor for the new type dosimeter was determined (by linear regression) to be ~1.15. New real-time patient dosimeter design would be an effective tool for the real-time measurement of patient skin doses during interventional radiology treatments.

The number of implanted cardiac devices has been growing steadily over the last several years. Systems to monitor device data remotely have been introduced with the goal of reducing follow-up burden for both patients and physicians. Since the introduction of telemedicine depends greatly on the situations that are unique to each country, the acceptance of cardiac device remote monitoring in Japan was analyzed.A total of 203 patients who had previously undergone cardiac device implantation were enrolled. The subjects were provided with a CareLink Monitor that performed interrogation and transmission of device data at home, and then the physicians reviewed the data via a website at one and 3 months after baseline visits. A total of 470 transmissions were made. Questionnaires were completed by subjects and physicians to evaluate acceptance, ease of use, and satisfaction with the system. More than 87% of the subjects felt the Monitor was easy to use and nearly all of the physicians were satisfied with the system. A majority of patients felt reassured by having their devices assessed from a remote location and preferred the decreased number of clinic visits that were possible when using the Monitor. The patients spent an average of 168.2 minutes per clinic visit, whereas follow-up time was reduced to 13.0 minutes by remote monitoring. Physician consultation time was reduced by 2.7 minutes.The CareLink Network was well accepted by both the patients and physicians. Underlying issues did emerge, but once they are overcome, the system appears to have great potential to improve the quality of care given by healthcare providers.