Background:The shape of the left atrial appendage (LAA) might affect thrombus formation. The chicken wing-type LAA (CW) has been reported as unlikely to influence stroke events in atrial fibrillation (AF) patients, so we investigated whether LAA shapes could influence LAA function. Methods and Results:We studied 102 patients (64 men, age 65±9 years) who underwent transthoracic echocardiography, transesophageal echocardiography (TEE), and cardiac computed tomography prior to catheter ablation (CA) for AF. LAA morphology were classified into 2 types: (1) CW: LAA with a bend in its shape and (2) non-CW type (NCW): LAA without any bends. All patients were classified into these groups using a cutoff value of LAA flow velocity (LAAFV). Patients with LAAFV <35 cm/s were classified as the low LAAFV group (Low FV, n=37). The patients with LAAFV >35 cm/s were classified as normal LAAFV group (Normal FV, n=65). The NCW type was detected in 25/102 patients (25%). In multivariate analysis, the patients with Low FV were associated with NCW type (P=0.0429, odds ratio [OR] 9.664, 95% confidence interval [CI] 1.075-86.900) and higher B-type natriuretic peptide (BNP) (P=0.0350, OR 1.012 for each 1 pg/ml increase in BNP, 95% CI 1.001-1.022). Conclusions:The NCW-type LAA and higher BNP were associated with lower LAAFV. One reason for the frequent cardiogenic stroke in patients with the NCW-type LAA may be the lower LAAFV. (Circ J 2015; 79: 1706 -1711

Some patients experience a left atrial thrombus (LAT) in spite of taking warfarin. We aimed to clarify the characteristics of patients with LAT during warfarin administration and investigated whether the CHADS2 or CHA2DS2-VASc scores are useful predictors of LAT. We studied 230 patients (169 males, age 65 ± 10 years) who underwent transesophageal echocardiography (TEE) prior to cardioversion or catheter ablation of atrial tachyarrhythmias between 2008 and 2012. All patients were taking oral warfarin. LAT was detected in 19 patients (8.3%) using TEE. LAT was significantly associated with the presence of hypertension (P = 0.0035), prior congestive heart failure (P < 0.0001), structural heart disease (P = 0.0012), persistent arrhythmias (P < 0.0001), the absence of SR during TEE (P = 0.0070), left ventricular ejection fraction (P < 0.0001), left atrial diameter (P = 0.0015), left ventricular dimension during end diastole (P = 0.0215), left ventricular hypertrophy (LVH; P < 0.0001), and the E/e' ratio (P = 0.0074). A multivariate analysis showed that LVH (P = 0.0065, OR 5.591, 95% CI 1.618–19.316) and persistent arrhythmia (P = 0.0364, OR 12.121, 95% CI 1.171–125.451) were independently associated with LAT. Moreover, the mean CHADS2 (2.3 ± 0.9 vs. 1.4 ± 1.2) and CHA2DS2-VASc scores (3.8 ± 1.2 vs. 2.8 ± 1.7) were higher in the patients with than without LAT. However, a multivariate analysis showed that the CHADS2/CHA2DS2-VASc scores did not associate with LAT. LVH and persistent arrhythmia may be useful for predicting LAT in patients with atrial tachyarrhythmias.

BackgroundVarious difficulties can occur in patients who undergo cardiac resynchronization therapy for drug-refractory heart failure with respect to placement of the left ventricular (LV) lead, because of anatomical features, pacing thresholds, twitching, or pacing lead anchoring, possibly requiring other pacing sites. The goal of this study was to determine whether Purkinje potential (PP) pacing could provide better hemodynamics in patients with left bundle branch block and heart failure than biventricular (BiV) pacing.MethodsEleven patients with New York Heart Association functional class II or III heart failure despite optimal medical therapy were selected for this study. All patients underwent left- and right-sided cardiac catheterization for measurement of LV functional parameters in the control state during BiV and PP pacing.ResultsMaximum dP/dt increased during BiV and PP pacing when compared with control measurements. This study compared parameters measured during BiV pacing with PP pacing and non-paced beats as the control state in each patient (717±171 mmHg/s vs. 917±191 mmHg/s, p<0.05; and 921±199 mmHg/s, p<0.005); however, the difference between PP pacing and BiV pacing was not significant. There was no difference in heart rate, electrocardiographic wave complex duration, minimum dP/dt, left ventricular end-diastolic pressure, left ventricular end-systolic pressure, pulmonary capillary wedge pressure, or cardiac index when comparing BiV pacing and PP pacing to control measurements.ConclusionsThe hemodynamic outcome of PP pacing was comparable to that of BiV pacing in patients with advanced heart failure.

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Shock after DFT testing improved LV systolic and diastolic function immediately, especially in patients with preserved LV ejection fraction.

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Subclavian venous occlusion may be present before cardiac implantable electronic device placement. A history of cancer represents a risk factor subclavian venous occlusion, and patients with this risk factor should undergo subclavian venography prior to electronic device placement.

IntroductionWe sometimes encounter patients with hypertrophic obstructive cardiomyopathy (HOCM) who need administration of Na channel blockers in addition to beta-blockers. They may be administered safely in many patients, but some Na channel blockers and their metabolites have K channel blockade profiles, which could provoke QT interval prolongation in a small number of patients. We encountered a patient on hemodialysis in whom the QT intervals were prolonged by procainamide metabolite, N-acetyl procainamide (NAPA). While it is well known that NAPA is more likely to accumulate in the body than procainamide, this is the first report of long QT syndrome caused by this drug in a hemodialysis patient. We are presenting this case with literature reviews. Case reportA 65-year-old man, who was on dialysis three times a weeks due to end-stage renal failure, received surgical repair of abdominal aortic aneurysm and mitral valve plasty one year prior to this hospitalization. He had been taking 75 mg of cinacalcet, 15 mg of lansoprazole, and 100 mg of aspirin once a day.The patient had increasingly complained of breathlessness on exertion after surgery. While there was lack of evidence of hypertrophic cardiomyopathy before surgery, echocardiography showed intraventricular septum thickness of 18 mm and posterior wall thickness of 10 mm, indicating asymmetrical septal hypertrophy. There was an intracavitary pressure gradient of 62 mmHg, and left ventricular ejection fraction was 71%. Administration of beta-blocker with carvedilol was started. Its dose was titrated up A B S T R A C TA 65-year-old male on hemodialysis three times a week due to end-stage renal failure underwent cardiac surgery one year previously, and complained of breathlessness on exertion after surgery. Echocardiograms evidenced a significant obstruction in the left ventricular outflow with intraventricular pressure gradient of 62 mmHg, and the patient was started on beta-blocker. After a maximal dose of carvedilol was given, a class 1A antiarrhythmic drug of Na channel blocker, procainamide, was added because of insufficient relief of symptoms. Electrocardiogram (ECG) showed prolonged QT intervals (523 ms) on a regular visit one month after the administration of procainamide, and the dose of procainamide was decreased. On the next day, he was brought to our hospital due to cardiac pulmonary arrest. Initial rhythm was ventricular fibrillation and the corrected QT intervals (QTc) were prolonged (531 ms). Blood examination revealed that N-acetyl procainamide (NAPA), metabolite of procainamide, was significantly higher than the recommended threshold. NAPA was identified as the cause of prolonged QTc and procainamide was stopped. NAPA decreased under the recommended threshold on the seventh day and the QT intervals were normalized. This case report outlines the first case of long QT syndrome caused by NAPA in a hemodialysis patient.