A 79-year-old woman with a history of open heart surgery presented with severe aortic stenosis (AS). Computed tomography (CT) showed chronic type B aortic dissection (TBAD) between the distal aortic arch and the left common iliac artery. After careful consideration, we planned transfemoral (TF)-transcatheter aortic valve implantation (TAVI) using a 20-Fr long sheath to minimize contact with the false lumen of the aorta. TAVI was performed under general anesthesia, guided by transesophageal echocardiography (TEE). A transcatheter aortic valve was successfully implanted. TEE, immediately after valve implantation, showed no remarkable changes in the descending thoracic aorta. Repeated post-procedural CT examinations showed no obvious changes in the aorta. The patient was stable without sequelae at the 12-month follow-up. This case demonstrates that TF-TAVI using a long sheath under TEE guidance can be a treatment option for patients with severe AS and chronic TBAD.

EP Rounds

Introduction: Early recurrence of atrial tachyarrhythmias (ERAT) cause various symptoms and predict worse outcomes after pulmonary vein isolation (PVI). This study aimed to clarify whether ablation index (AI) guided PVI, which is a novel technology of radiofrequency ablation, could reduce ERAT as compared to conventional contact force (CF) guided PVI. Methods: Consecutive AF patients who underwent initial PVI from September 2014 to August 2019 were enrolled. We divided the patients into two groups: patients who underwent AI-guided PVI (AI group) and those who underwent CF-guided PVI (CF group). Using propensity score matching (PSM), we adjusted for the patient backgrounds. We compared the incidence of ERAT and late reconnection rate of isolated PVs during second session between the two groups. ERAT was defined as any atrial tachyarrhythmias ≥30 seconds during a 90-day blanking period. Results: A total of 697 patients (paroxysmal 51%) were enrolled. After the PSM, both groups included 229 patients. The incidence of ERAT was significantly lower in AI group than CF group (21.5% vs. 36.1%, P<0.001). The rate of PV reconnection was lower in AI group than CF group (45.8% vs. 71.4%, P=0.028). Multivariate analysis demonstrated that AI-guided PVI was independently correlated with the incidence of ERAT (OR=0.415, 95%CI=0.269-0.639, P<0.001). Conclusion: AI-guided PVI can reduce ERAT as compared to conventional CF-guided PVI.

Background Previous reports demonstrated that the early recurrence of atrial fibrillation (ERAF) after pulmonary vein isolation (PVI) was associated with the inflammatory process. The neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) have been proposed as indicators of a systemic inflammatory response. However the relationship between NLR/PLR and clinical outcomes after PVI remains unclear. Methods and Results We enrolled 633 consecutive atrial fibrillation (AF) patients who underwent PVI from September 2014 to June 2018. The NLR and PLR in peripheral blood leukocytes 1 day before and 36-48 hours after PVI were measured. We compared the NLR and PLR changes in each parameter (ΔNLR and ΔPLR) between a late recurrence of AF group after the PVI (LRAF, during 1 year after PVI) and the no-LRAF group. We also evaluated the relationship between the ΔNLR /ΔPLR and pulmonary vein (PV) reconnections in repeated ablation procedures. The LRAF patients consisted of 151 patients (23.9%). The ΔNLR and ΔPLR were significantly higher in the LRAF group than no-LRAF group (p=0.021, p=0.011). The ΔNLR in the initial ablation sessions was significantly higher in patients with right PVs reconnections than in those without in the repeat ablation sessions (0.914±1.199 vs 2.316±3.615, p=0.032). Conclusion The NLR and PLR changes were associated with an LRAF. A higher NLR change in the initial ablation session was associated with a right PV reconnection in the repeat ablation session.