Prospective Randomized Study of the Safety and Efficacy of Interrupted Anticoagulant’s Therapy in the Perioperative Period of Catheter Ablation for Atrial Fibrillation: The SEACOAST Rhythm AF Trial

No prospective, randomized study has been conducted to date in Japan comparing the use of warfarin and rivaroxaban for preventing thrombotic and bleeding events in the perioperative period of catheter ablation （CA） for atrial fibrillation （AF）. This was a prospective, open-label randomized study assessing the safety and efficacy of warfarin and rivaroxaban in the perioperative period of CA for AF. Thrombotic events including silent cerebral lesion （SCL） detected by magnetic resonance imaging （MRI）, bleeding events, and coagulation test results were assessed in correlation with interrupted warfarin or rivaroxaban in the perioperative period of CA for AF. Finally, thirty-six patients （18 men; aged 65±9.4 years） who underwent CA for AF were prospectively enrolled. No instance of symptomatic cerebral infarction occurred, but 12 of 36 patients （33.3％） showed new SCLs during the postprocedural cerebral MRI examination （8/21 in the rivaroxaban group and 4/15 in the warfarin group; P＝0.47）. The duration of hospitalization was significantly shorter in the rivaroxaban group than in the warfarin group （6 vs. 8 days; P＝0.0135）. The incidence of minor bleeding was significantly lower in the rivaroxaban group than in the warfarin group （0％ vs. 26.6％; P＝0.078）. D-dimer concentration was significantly higher in the SCL group than in the no-SCL group （P＝0.024） under warfarin, while the values of protein S （P＝0.017） and prothrombin time （P＝0.018） were significantly lower in the SCL group than in the no-SCL group under rivaroxaban. Rivaroxaban usage in CA is safer than warfarin usage with respect to the incidence of minor bleeding. In patients receiving rivaroxaban therapy, a lower protein S level may be correlated with the incidence of SCL in CA

Characteristics of head-up tilt testing with additional adenosine compared with head-up tilt testing with isoproterenol and isosorbide dinitrate

Background: Head-up tilt (HUT) testing is used to establish the diagnosis of neurally mediated syncope (NMS). Adenosine administration during HUT testing is useful for inducing NMS. However, no comparison between adenosine HUT testing and HUT testing using other drugs has been reported. The purpose of this study was to investigate the clinical usefulness of adenosine compared with isoproterenol (ISP) and isosorbide (ISDN) during HUT testing. Methods: The subjects comprised 103 consecutive patients with unexplained syncope who underwent adenosine and isoproterenol (ISP) HUT tests following a negative response in a drug-free HUT test. Subjects were first tilted upright at an 80° angle for 30 min and shown to have a negative response in drug-free HUT test. Subsequently, a continuous bolus of 0.1- or 0.2-mg/kg adenosine was administered while the subjects remained upright and were observed for 5 min (adenosine HUT test). Next, they were tilted upright for 15 min during a continuous infusion of 0.01–0.02 mg/kg min ISP (ISP HUT test). Lastly, they were tilted upright for 15 min after 1.25-mg ISDN infusion (ISDN HUT test). Results: The diagnostic yield of the adenosine HUT test was 18.1% (18/99) and that of the ISP HUT test was 6.0% (6/99; p=N.S.). Sixty-one of 99 patients underwent ISDN HUT testing, and 17 patients had a positive response. The diagnostic yield of the adenosine HUT test was 14.7% (9/61) and that of ISDN HUT test was 27.8% (p<0.05). Five patients had positive responses in both adenosine and ISDN HUT tests. Conversely, 4 patients had a positive response in the adenosine HUT test and a negative response in the ISDN HUT test. Conclusion: The adenosine HUT test was effective in the diagnosis of NMS and is useful as the ISP HUT test for inducing NMS. The diagnostic yield of the adenosine HUT test was not higher than that of the ISDN HUT test. However, the adenosine HUT test took only a few minutes and induced NMS in some of the patients in whom NMS was not induced by the ISDN HUT test. Therefore, performing adenosine HUT testing is worthwhile