Long-term effectiveness of right septal pacing vs. right apical pacing in patients with atrioventricular block

AbstractBackgroundLong-term right ventricular apical (RVA) pacing increases the risk of heart failure (HF) by inducing ventricular dyssynchronization. Although recent studies suggest that right ventricular septal (RVS) pacing results in improved short-term outcomes, its long-term effectiveness remains unclear.Methods and resultsThis study investigated 149 consecutive patients who underwent implantation of a dual chamber pacemaker for atrioventricular block with either RVS-pacing between July 2007 and June 2010 or RVA-pacing between January 2003 and June 2007. The endpoint was defined as death and hospitalization due to heart failure (HF). The rates of mortality and hospitalization due to HF were significantly lower in the RVS-pacing group than that in the RVA-pacing group (event free RVS: 1 year, 98% and 2 years, 98%; RVA: 1 year, 85% and 2 years, 81%; p<0.05). None of the patients died from HF in the RVS-pacing group, while 4 patients died from HF in the RVA-pacing group within 2 years after pacemaker implantation. The paced QRS interval was significantly shorter with RVS pacing than with RVA pacing at different times after pacemaker implantation (RVS: immediately 157.8±24.0ms, after 3 months 157.3±17.5ms, after 6 months 153.6±21.7ms, after 12 months 153.6±19.4ms, after 24 months 149.3±24.0ms vs. RVA: immediately 168.3±23.7ms, after 3 months 168.7±26.0ms, after 6 months 168.0±22.8ms, after 12 months 171.2±22.3ms, after 24 months 176.1±25.5ms; p<0.05).ConclusionsRVS pacing is feasible and safe with more favorable clinical benefits than RVA pacing

Right Atrial Volume Calculated by Multi-detector Computed Tomography: Useful Predictor of Atrial Fibrillation Recurrence after Pulmonary Vein Catheter Ablation

We investigated whether right atrial (RA) volume could be used to predict the recurrence of atrial fibrillation (AF) after pulmonary vein catheter ablation (CA). We evaluated 65 patients with paroxysmal AF (mean age, 60+10 years, 81.5% male) and normal volunteers (57 ± 14 years, 41.7% male). Sixty-four-slice multi-detector computed tomography was performed for left atrial (LA) and RA volume estimations before CA. The recurrence of AF was assessed for 6 months after the ablation. Both left and right atrial volumes were larger in the AF patients than the normal volunteers (LA: 99.7+33.2ml vs. 59.7+17.4ml; RA: 82.9+35.7ml vs. 43.9+12ml; P100ml) for predicting the recurrence of AF was 81.3% in 13 of 16 patients with AF recurrence, and the specificity was 69.4% in 34 of 49 patients without recurrence. The sensitivity with large RA volumes (>87ml) was 81.3% in 13 of 16 patients with AF recurrence, and the specificity was 75.5% in 37 of 49 patients without recurrence. RA volume is a useful predictor of the recurrence of AF, similar to LA volume

Effect of Implantable Cardioverter-defibrillator Therapy for Ventricular Fibrillation Patients with Out-of-hospital Cardiac Arrest

Survivors of ventricular fibrillation out-of-hospital cardiac arrest（VF-OHCA）due to potentially reversible causes such as acute coronary syndrome（ACS）, vasospastic angina and electrolyte abnormalities are considered low risk for recurrent arrhythmia. Accordingly, implantable cardioverter-defibrillator therapy is not routinely recommended in such patients. We investigated the risk of mortality and the value of ICD therapy for VF-OHCA. Among 2,248 cardiopulmonary arrest patients presenting at our hospital, we retrospectively investigated 110 patients with VF-OHCA who were admitted for treatment. We divided the patients based on ICD（n＝71） or No-ICD status（n＝39）, and on reversible cause（n＝70） or irreversible cause（n＝40）. The groups were compared for baseline characteristics, mortality and ICD therapies. Patients with a reversible cause had a significantly lower rate of ICD implantation than those with an irreversible cause（P＝0.03）. Males in the ICD group presented more frequently than those in the No-ICD group, and cardiac mortality in patients with acute coronary syndrome was significantly lower with ICD therapy than without ICD（P＝0.04）. The rate of appropriate ICD therapies with a reversible cause was 28％, and the first ICD therapy was highest within 1 year post-implantation. Patients with VF-OHCA due to a reversible cause remain at high risk of recurrent ventricular arrhythmias, suggesting that ICD implantation is a reasonable approach in such cases

Head-up Tilt Test May Be Useful for Determining Permission of Flight for Regular Passenger Aircraft Pilots with Vasovagal Syncope

To determine the permissibility of piloting an aircraft with vasovagal syncope （VVS） is a complex responsibility, because it is difficult to evaluate VVS quantitatively. There are no clear guidelines for aircraft pilots with VVS. In some facilities, Head-up Tilt Test （HUTT） is used to determine its reproducibility and treatment effect. In most cases, permission is dependent on the strict examinations by specialists and judgement of the committee established for each country. Therefore, we assessed pilots with VVS and designed an algorism of permission for piloting an aircraft. Here, we describe 7 consecutive regular passenger aircraft pilots with VVS who were restricted to fly. All patients were men and their mean age was 37 years. All pilots were permitted to fly after at least two or more tilt-tests. The observation period was two years after flight permission. None of the pilots in the present study fainted after receiving flight permission. We can make a risk stratification to determine hypotensive susceptibility by multiple tilt tests. Based on the results of multiple HUTT, we can more quantitatively make the judgement as to whether the pilot’s VVS is well managed

Epicardial Adipose Tissue in the Right Atrium Is Associated with Progression of Atrial Fibrillation and Recurrence after Pulmonary Vein Catheter Ablation in Patients with Atrial Fibrillation

An increase in epicardial adipose tissue（EAT）in the left atrium（LA）predicts the progression of atrial fibrillation（AF）and AF recurrence after pulmonary vein catheter ablation（CA）. We hypothesized that EAT in the right atrium（RA）is also associated with the progression of AF and post-CA AF recurrence. Using 128-slice multidetector computed tomography, EAT volume and atrial volume were measured 3-dimensionally before CA in 68 patients who had proven AF（paroxysmal AF, 42; persistent AF, 26; mean age, 65±11 years; 42.6％ female）with successful CA and 21 volunteers with sinus rhythm（age, 63±13 years; 52.3％ female）. In both atria, EAT and atrial volumes were largest in patients with persistent AF, followed, in order, by those with paroxysmal AF, and then healthy volunteers（P＜0.001）. Increased EAT and atrial volumes in both atria predicted persistent AF（P＜0.001）. Fifteen patients had AF recurrence（22.1％）during the 2-year period after CA. Increased EAT volume in both atria were independent predictors for AF recurrence, and a RA EAT volume≥6.2ml was an independent predictor, with a hazard ratio of 5.47（95％ confidence interval, 1.2-24.3; P=0.03）. The combination of EAT and atrial volume in both atria was a more powerful independent prognostic factor, with a hazard ratio of 4.8（95％ confidence interval, 1.7-3.7; P=0.003）, and a sensitivity of 60％ in 9 of 15 patients, and specificity of 81.1％ in 43 of 53 patients,（P=0.003）. RA EAT is associated with the progression of AF and post-CA AF recurrence

New Parameter to Predict Recurrence of Paroxysmal Atrial Fibrillation after Pulmonary Vein Isolation by the P-Wave Signal-Averaged Electrocardiogram

Noninvasive methods for predicting the recurrence of atrial fibrillation (AF) after initial pulmonary vein isolation (PVI) have not been well described. The aim of the present study was to evaluate the usefulness of the P-wave signal-averaged electrocardiogram (P-SAECG) in predicting the recurrence of AF after initial PVI. The P-SAECG was recorded before and after (within 1 week) the initial PVI session. The filtered P-wave duration (FPD) and root mean square voltage of the last 20ms of the filtered P-wave (LP20) were measured in 87 consecutive idiopathic AF patients (ejection fraction ≥50%, B-type natriuretic peptide ≤200pg/ml). During the follow-up period (12±7 months), 22 of 87 (25%) patients had recurrence of AF (11 with paroxysmal AF and 11 with persistent AF). In the group with recurrence of paroxysmal AF, the post-PVI FPD was significantly shorter and the post-PVI LP20 was significantly larger than in the non-recurrence group. Furthermore, the post-PVI LP20/FPD ratio was significantly higher in the group with paroxysmal AF recurrence than in the non-recurrence group (0.024±0.009 vs 0.015±0.007µV/ms, respectively; P0.015µV/ms than in those with a post-PVI LP20/FPD ≤0.015µV/ms. The optimal post-PVI LP20/FPD cut-off value of 0.015µV/ms had a sensitivity of 90% and a specificity of 60%. The data also suggest that the post-PVI LP20/FPD may be a new parameter for predicting successful PVI in patients with idiopathic paroxysmal AF after PVI

Simple Vestibuloplasty Using a Tube in Combination with Cortical Bone Screws Around Dental Implant

Introduction We developed a novel, reliable and easy method that retains stability of the repositioned flap and vestibular expansion. Method The conventionally elevated mucosal flap is secured to the desired depth of the vestibule by the pressure created by the polyvinyl chloride 6Fr suction catheter which is fixed to the alveolar bone with cortical bone screws passing through the inner lumen of the tube. The keratinized free flap is placed on the periosteum conventionally, and horizontal mattress suturing is performed for immobilization, with the suture running through the inner lumen of the tube transversally. Conclusion This simple method gives us great benefit on the vestibuloplasty

Left atrial appendage ligation in patients with atrial fibrillation leads to a decrease in atrial dispersion.

BackgroundLeft atrial appendage (LAA) exclusion has been performed in patients with atrial fibrillation (AF) to prevent thrombus formation and subsequent cardioembolic events. Left atrial electrical remodeling is a recognized factor in the recurrence of AF. The effects of LAA exclusion on P-wave characteristics and left atrial electrical remodeling have not been well described. The purpose of this study was to evaluate the effect of LAA ligation on P-wave morphology in patients with AF.Methods and resultsFifteen patients who were in sinus rhythm during the LAA ligation procedure were included in the study. We evaluated the P-wave characteristics, including P-wave duration, P-wave amplitude, PQ interval, and P-wave dispersion, before and after ligation. Eleven patients had paroxysmal AF and 4 patients had persistent AF (12 male patients and 3 female patients). P-wave duration immediately after ligation was significantly shorter compared with baseline in all limb leads except lead aVR (P&lt;0.05). P-wave amplitude immediately after ligation was significantly greater compared with baseline in inferior leads; however, P-wave amplitude after 1 to 3 months was significantly lower compared with immediately after ligation. PQ interval immediately after ligation was significantly shorter compared with baseline (P=0.01), and P-wave dispersion after 1 to 3 months was significantly shorter compared with baseline (P=0.02).ConclusionsLAA exclusion produces consistent P-wave changes consistent with decreased atrial mass and decreased atrial dispersion that may represent reverse electrical atrial remodeling. This is a potential mechanism to explain the role of LAA ligation in maintaining sinus rhythm in patients with AF