Objective-Right ventricular regional contractility has been thought to be difficult to assess precisely. Cine magnetic resonance imaging with presaturation myocardial tagging was employed to quantitate the contraction of the right ventricular free wall and to identify normal performance compared with the left ventricle. Methods-Nine normal volunteers, aged 27-39 years, were examined in a 1 5 Tesla superconductive magnet, and short axis and four-chamber sections at the midventricular level were imaged with cine magnetic resonance sequences. Tags, applied at end diastole as two parallel black lines, intersected the mid-portion of the free wall, dividing it into upper, centre, and lower segments in the short axis section, and anterior, middle, and posterior segments in the four-chamber section. From a series of cine magnetic resonance images at 50 ms intervals over a cardiac cycle, end diastolic, and early, mid-, and end systolic images were chosen for calculation of the endocardial, epicardial, and mean percent fractional shortenings (%FS) in the six segments. Results-There was (1) a gradual increase in %FS in systole in both sections (P < 0 001, <0.005); (2) a poor transmural gradient of contractility; (3) a predominance of meridional shortening (whole length, mean end systolic %FS (SD): short axis, 17-4 (3.1)%; fourchamber, 30'1 (4.1)%; P < 0.001) in contrast to dominant circumferential shortening in the left ventricular lateral wall; (4) lower predominance of contractility in the short axis section (P < 0 001), and a middle dip of contractility in the four-chamber section (P < 0.005).Conclusions-Heterogeneity of contractility was closely correlated with the myocardial fibre architecture, and with wall stress determined by its thickness and curvature. It was proved that right ventricular regional function could be analysed non-invasively using cine magnetic resonance imaging with myocardial tagging. (Br HeartJ 1995;74:186-191) Keywords: Regional contraction; right ventricle; cine magnetic resonance imaging; presaturation tagging Although the significance of an assessment of right ventricular function is well recognised, especially for patients with congenital cardiac anomalies and with valvular heart diseases, no standard approach to this has been established because of the complex configuration and non-concentric nature of the contraction of the ventricle. Some basic indices reflecting the global function of the right ventricle, such as cavity volume and ejection fraction, can be estimated by using conventional angiocardiographyl-' or radionuclide scintigraphy,45 but the results lack accuracy and do not always reflect regional dysfunction. Right ventricular regional contractility, which may be more sensitive to maladaptation to overload, has been considered to be much more difficult to assess precisely than global function, and very few reports have appeared discussing regional contraction of the right ventricle even in experimental researches.67At the present time, we can easily depict the right ven...

Introduction: Recently, output-dependent QRS transition was reported to be required to confirm left bundle branch (LBB) capture in LBB area pacing (LBBAP) procedure. This study aimed to evaluate the achievement rate and the learning curve of LBB capture in LBBAP procedure performed with the goal of demonstrating output-dependent QRS transition, and investigate predictors of LBB capture. Methods and Results:The LBBAP procedure was performed in 126 patients with bradyarrhythmia. LBB capture was defined as a demonstration of output-dependent QRS transition. The following pacing definitions were used for evaluation: (1) LBBAP, which met the previously reported LBBAP criteria, (2) LBB pacing (LBBP), LBB capture was confirmed, and (3) available LBBP, LBB threshold was clinically usable (<3 V at 0.4 ms). The learning curve was evaluated by division into three timeperiods. The achievement rates of LBBAP, LBBP, and available LBBP were 88.1%, 41.2%, and 35.7%, respectively. The achievement rates of all three pacing definitions significantly increased with experience (p < .01), but the achievement rate of available LBBP was still 50% in the third period. As predictors of LBB capture, the interval between LBB-Purkinje potential and QRS onset ≥22 ms had high specificity of 98.3%, while R wave peak time in V6 < 68 ms had insufficient sensitivity of 79% and specificity of 68%. Conclusion:Even if LBB capture was aimed in LBBAP procedure, it was not easy to achieve, and there was a clear learning curve. Much of LBBAP may be left ventricular septal pacing that does not capture LBB.

Background:In performing left bundle branch pacing (LBBP), various QRS morphologies are observed as the lead penetrates the ventricular septum (VS). This study aimed to evaluate these characteristics and infer the mechanism underlying each QRS morphology. Methods:In 19 patients who met the strict criteria for LBB capture, we classified the QRS morphologies observed during the LBBP procedure into seven patterns, the first five of which were determined by the depth of penetration: right ventricular septal pacing (RVSP), intraventricular septal pacing (IVSP1 and IVSP2), endocardial side of left ventricular septal pacing (LVSeP), nonselective LBBP (NS-LBBP), selective LBBP (S-LBBP), and NS-LBBP with anodal capture. The parameters of the QRS morphologies in these seven patterns were evaluated.Results: Among the first five patterns, stimulus-QRSend duration (s-QRSend) was the narrowest in IVSP1 rather than in NS-LBBP, and stimulus-to-peak of R wave in V6 (s-LVAT) was significantly shortened in two steps, from RVSP to IVSP1 (96 ± 11; 82 ± 8 ms, p < .01) and from LVSeP to NS-LBBP (76 ± 7; 60 ± 4 ms, p < .01). The late-R duration in V1 was significantly prolonged in the order of LVSeP, NS-LBBP, and S-LBBP (45 ± 7; 53 ± 10; 71 ± 15 ms, respectively, p < .01).Conclusions: s-QRSend was the narrowest in IVSP1 rather than in NS-LBBP among the QRS morphologies observed during lead penetration through the VS. The prolonged late-R duration in V1 and abrupt shortening of the s-LVAT in V6 may help determine LBB capture during lead penetration. K E Y W O R D Sconduction system pacing, left bundle branch pacing, left ventricular septal pacing, paced QRS duration, paced QRS morphology, pacing-induced cardiomyopathy BACKGROUNDIn 10%−20% of patients with a high right ventricular pacing burden, left ventricular contractility decreases significantly, resulting in pacinginduced cardiomyopathy. 1,2 Recently, the effectiveness of His bundle pacing (HBP) as a type of His-Purkinje conduction system pacing has been reported. 3,4 While HBP is an effective physiological form of pac-ing, it may be limited by challenges during implantation, high thresholds, and low sensing in some patients. [5][6][7] Huang et al. 8 first described left bundle branch pacing (LBBP) as a novel pacing approach in a patient with heart failure and complete LBBB. Recently, the safety and feasibility of LBBP have been reported 9-14 along with its usefulness for CRT-adapted cases. 15,16 LBBP has gained attention as an alternative for HBP. LBBP is a pacing method that captures the left bundle branch

Atrial fibrillation (AF) is the most common arrhythmia, and the number of patients in need of treatment has been increasing [1,2]. AF is associated with increased risk of severe life-threatening complications, such as heart failure and embolism, including stroke [3,4]. As a result, AF can be the cause of not only troublesome symptoms that reduce the quality of life (QoL), activity of daily living (ADL), and exercise performance, but can also cause a life crisis [5][6][7]. Some patients suffer from disabling symptoms but others do not present with specific clinical signs, reporting such general symptoms as fatigue and dyspnea. In fact, some patients do not have any symptoms. It has been reported that persistent AF (per-AF), defined as exceeding 1 week, tends to be asymptomatic compared with paroxysmal AF [8]. Importantly, asymptomatic AF patients have a higher risk factor for complications than symptomatic patients [9]. Therefore, early detection and

BackgroundTolvaptan is a vasopressin type 2 receptor antagonist used in heart failure (HF) with refractory diuretic resistance. However, since tolvaptan is also ineffective in some HF patients with reduced ejection fraction (HFrEF), the identification of responders is important.MethodsThe study population consisted of 51 HFrEF patients who were administered tolvaptan (EF, 28 ± 7%). We defined responders as patients with a ≥50% increase in urine volume during the 24-hours after administration of tolvaptan. All patients underwent comprehensive transthoracic echocardiography before administration of tolvaptan. Patients were followed for 120 days to ascertain secondary events (cardiac death and rehospitalization for HF).ResultsMultiple regression analysis indicated that right ventricular (RV) enlargement (defined as basal RV diameter > 41 mm and midlevel RV diameter > 35 mm, according to guidelines) remained a predictor of response after adjustment for age, sex, starting dosage of tolvaptan, and estimated glomerular filtration rate (odds ratio, 4.88; 95%-confidence interval, 1.26–18.9; P < 0.05), whereas left ventricular parameters and RV dysfunction were not. Kaplan-Meier curves indicated responsiveness to tolvaptan was associated with better prognosis among the overall population (P < 0.05); similar trends were observed among patients with RV dilatation (P = 0.056).ConclusionsThese findings suggest that RV enlargement, which represents right-sided volume overload, elevated filling pressure, and diastolic dysfunction similar to that seen in constrictive pericarditis, predicts responsiveness to tolvaptan in patients with HFrEF. Moreover, administration of tolvaptan may have the potential to improve the reportedly poor prognosis for HFrEF patients with RV dilatation.

Highlights Differences in risk factors for SBI between paroxysmal and persistent AF was studied. NVAF patients (119 paroxysmal, 71 persistent) underwent brain MRI, TTE, and TEE. DM and CKD, which represents microvascular disease, predicted SBI in paroxysmal AF. There was no obvious therapeutic target for SBI after progression to persistent NVAF. Intervention for DM and CKD from paroxysmal NVAF may prevent SBI and future stroke.

Percutaneous transluminal angioplasty (PTA) of the popliteal artery and its branches was performed for relief of ischemia of the leg. Thirty-four procedures were performed in 31 patients (bilateral in 1 and repeated in 2). Angioplasty was technically successful in 29 cases (85%), with immediate clinical improvement in 26 (89%). The mean ankle-arm pressure index rose from 0.28 to 0.77. Long-term noninvasive follow-up in 23 of 26 patients with initial clinical improvement demonstrated reocclusion in 6 (2 of whom had successful redilatation) and continued patency in 13 who were followed up for 3 to 29 months (average, 11.6 mo.); the mean ankle-arm pressure index was 0.71 and the cumulative patency rate at 2 years was 57%. Six patients died, though all were asymptomatic. Since many of these procedures are performed for limb salvage in patients who would not benefit from surgery, PTA is useful in providing acute and often prolonged relief of ischaemia of the leg.

Background and Objectives This study aimed to evaluate the utility of high‐sensitive troponin T (hs‐TnT) for predicting AF recurrence and major adverse cardiovascular events (MACE) after AF ablation. Methods and Results A total of 227 consecutive patients with AF (mean age, 66 ± 10 years; persistent AF, n = 98) who underwent an initial ablation were enrolled. We measured hs‐TnT before AF ablation and divided the patients into three groups according to the hs‐TnT level: low, lesser than or equal to 0.005 µg/L (n = 54); medium, 0.006–0.013 µg/L (n = 127); and high, greater than or equal to0.014 µg/L (n = 46). We evaluated the composite endpoint of AF recurrence or MACE (including death, stroke, acute coronary syndrome, and heart failure hospitalization) after the ablation. The median hs‐TnT level was 0.008 µg/L. The values of chronic kidney disease prevalence, CHA2DS2‐VASc score, B‐type natriuretic peptide level, and left atrial diameter were the highest in the high hs‐TnT group among the three groups. During a mean follow‐up of 15 ± 8 months, AF recurrence and MACE occurred in 56 (25%) and 9 (4%) patients, respectively. The high hs‐TnT group had the highest incidence of AF recurrence and MACE among the three groups (high: 39% and 15%, medium: 22% and 2%, and low: 19% and 0%, respectively; log‐rank P < .05). In multivariate analysis, hs‐TnT greater than or equal to 0.014 µg/L and persistent AF were independent predictors of the composite endpoint. Conclusion Hs‐TnT may be a useful marker for predicting AF recurrence or MACE after AF ablation.