An 84-year-old woman with type B WPW with Ebstein anomaly was admitted with heart failure. She had rapid wide QRS tachcardia due to accessory pathway conduction associated with atrial fibrillation (AF). Since transesophageal echocardiography before catheter ablation showed a left atrial thrombus, ablation was performed using a 3D mapping system under AF. After marking the functional tricuspid anulus with intracardiac echocardiography, three dimensional intracardiac electrogram visualization (ripple map) during AF enabled clear identification of location of the accessory pathway. After ablation, there was no complication of cerebral infarction and heart failure improved.

Background: In terms of the pulmonary vein (PV), atrial fibrillation (AF) patients have a shorter effective refractory period (ERP) and a larger dispersion of the ERP than patients without AF. Although the frequency of AF from the superior vena cava (SVC) was the highest among non-PV foci, the characteristics of the ERP in the SVC (SVC-ERP) were unclear. The purpose of this study was to elucidate the relationship between SVC-ERP and the inducibility of AF after pulmonary vein isolation (PVI). Methods and Results: Consecutive 28 patients who underwent PVI were included. After successful PVI, the SVC-ERP was measured at three positions in SVC. Rapid electrical stimuli were delivered at the shortest SVC-ERP to induce AF. Patients in whom AF was induced were assigned to the SVC-induced group (SIG) and the remaining patients were the non-SVC-induced group (non-SIG). The size of the SVC sleeve was evaluated using three-dimensional electroanatomic mapping. The SIG had a significantly shorter average SVC-ERP (236.0±25.2 vs. 294.8±36.8 ms, p<0.001), while SVC-ERP dispersion was not significantly different (30.0±25.4 vs. 33.3±20.1 ms, p=0.56). Although the longer SVC diameter was significantly longer in the SIG (27.4±4.3 vs. 22.9±4.6 mm, p=0.03), the SVC-ERP was significantly associated with pacing inducibility of AF after adjustment for the longer SVC diameter (odds ratio: 0.96 [1-ms increments], p=0.01). Conclusions: The SIG had a shorter SVC-ERP, while the dispersion was not significantly different between the two groups. The SVC-ERP can be one of the mechanisms of arrhythmogenicity for AF originating from the SVC.

Introduction: An implantable cardioverter defibrillator (ICD) is the most reliable therapeutic device for preventing sudden cardiac death in patients with sustained ventricular tachycardia (VT). Regarding the effectiveness of the ICD, targeted VT is defined based on the tachyarrhythmia cycle length. However, variation of the RR interval variability of VTs does occur. A few studies reported on VT characteristics and effects of ICD therapy according to RR interval variability. This study aimed to identify the clinical characteristics of VTs and effects of ICD therapy according to RR interval variability. Methods: We analyzed 821 VT episodes in 69 of 185 patients treated with ICDs or cardiac resynchronization therapy defibrillators. VTs were classified as regular or irregular based on RR interval variability. We evaluated successful termination using anti-tachycardia pacing (ATP)/shock therapy, spontaneous termination, and acceleration between regular and irregular VTs. Reproducibility of the RR interval variability in one VT episode and within an individual with recurrent VT episodes was evaluated. Results: Regular VT was significantly more successfully terminated than irregular VT by ATP therapy. There was no significant difference in shock therapy or VT acceleration, irrespective of the variability of the VT cycle length. Spontaneous termination of VT occurred significantly more often in irregular than in regular VT. Reproducibility of RR interval variability in an episode and individual was 89% and 73%, respectively. Conclusion: ATP therapy showed greater effectiveness for regular than for irregular VT. Spontaneous termination was more common in irregular than in regular VT. RR interval variability of VTs is reproducible.

An 82-year-old woman received pacemaker implantation for sick sinus syndrome. Two days after the implantation, electrocardiography showed 2:1 atrial pacing failure, followed by bradycardia-dependent increase in the atrial pacing threshold during a pacemaker examination. However, transient 1:1 atrial pacing capture recovered by adenosine triphosphate (ATP) administration, which was performed to evaluate the bradycardia-dependent pacing failure mechanism. We considered this phenomenon to be caused by phase 4 depolarization and avoided replacing this atrial lead. Three weeks later, the atrial pacing threshold had improved. We report the potential role of phase 4 depolarization in bradycardia-dependent increase in pacing threshold by using ATP.

Introduction: To know whether cardiac pacemaker implantations improve the functional capacity (FC) and affect the prognosis. Methods and Results: We prospectively enrolled 621 de-novo pacemaker recipients (age 76±9 years, 50.7% male) between April 2015 and September 2016. The FC was assessed by the metabolic equivalents (METs) during the implantation and periodically thereafter. The patients were a priori classified into a poor FC (<2 METs, n=40 [6.4%]), moderate FC (24 METs, n=342 [55.1%]). Three months after the pacemaker implantation, poor FC or moderate FC patients improved to a good FC by 43%. The distribution of the three FCs remained at those levels by the end of the follow-up (p=0.18). During a median follow-up of 2.4 years, 71 patients (11%) had cardiovascular hospitalizations and 35 (5.6%) all-cause death. A multivariate Cox analysis revealed that a poor FC at baseline was an independent predictor of both a cardiovascular hospitalization (hazard ratio [HR] 2.494, 95% confidence interval [CI] 1.227-5.070, p=0.012) and all-cause death (HR 3.338, 95% CI 1.254-8.886, p=0.016). One year after the pacemaker implantation, the 19 patients whose poor FC improved to a good FC did not die, however, the 8 who remained with a poor FC had a high mortality rate of 37.5% (p<0.01). Conclusion: Approximately half of the poor or moderate FC patients improved to a good FC 3 months after the pacemaker implantation. The baseline FC predicted the prognosis, and patients with an improved FC after the pacemaker implantation had a better prognosis.