Introduction The presence of an epicardial connection (EC) decreases the success rate of pulmonary vein isolation (PVI); however, the effect of designing isolation lines has not been evaluated. We sought to clarify the effects of designing an anterior line for right‐sided PVI considering the presence and location of the EC. Methods Seventy‐four consecutive patients who underwent initial catheter ablation for atrial fibrillation were retrospectively included in this study. The presence of the EC was determined by the left atrial (LA) activation map during right atrial pacing, and patients were divided into EC‐positive (n = 23, 31%) and EC‐negative (n = 51, 69%) groups. EC‐positive patients were further subdivided based on the EC location: on‐the‐line group, (EC on the PVI line, n = 11); inside‐line group (EC on the pulmonary vein [PV] side, n = 10); and outside‐line group (EC on the LA side, n = 2). The PVI parameters were compared among the three groups. Results The success rates of the first‐pass isolation were comparable between the EC‐negative and EC‐positive groups (70.6% vs. 60.9%, ns), but the success rate was significantly higher in the on‐the‐line group than in the inside‐line group (91% vs. 20%, p = 0.002). First‐pass isolation was successful in both patients in the outside‐line group. Additional carina ablation was required only in the inside‐line group. Conclusions The association between the EC site and the right‐sided PV anterior isolation line affected the success rate of first‐pass isolation. For successful right‐sided PVI, it is important to consider the EC site when designing the PVI line.

Background The natural history and optimal interventional timing in patients with isolated severe tricuspid regurgitation (TR) have not been well studied. This study aimed to investigate long‐term clinical outcomes and risk factors associated with poor prognosis in patients with isolated severe TR. Methods and Results Consecutive transthoracic echocardiographic examinations in 2877 patients with isolated severe TR were retrospectively reviewed. Patients with significant left‐sided valve disease or repeated examinations were excluded. Primary outcome was defined as a composite of all‐cause death and hospitalization for heart failure. Among the 613 enrolled patients (mean age, 74±13 years; men, 38%), 141 died, and 62 were hospitalized for heart failure during the median follow‐up period of 26.5 (interquartile range, 6.0–57.9) months. The 5‐year event‐free rate was 60.1%. TR pressure gradient (adjusted hazard ratio [HR], 1.03 [95% CI, 1.01–1.04]), blood urea nitrogen (adjusted HR, 1.02 [95% CI, 1.01–1.04]), left atrial volume index (adjusted HR, 1.01 [95% CI, 1.002–1.02]), and serum albumin (adjusted HR, 0.56 [95% CI, 0.36–0.95]) were identified as independent predictors of adverse events. A risk model based on the 4 clinical factors that included pulmonary hypertension (TR pressure gradient >40 mm Hg), elevated blood urea nitrogen levels (>25 mg/dL), decreased albumin levels (<3.7 g/dL), and left atrial enlargement (left atrial volume index <34 mL/m 2 ) revealed a graded increase in the risk of adverse events ( P <0.001). Conclusions The prognosis of isolated severe TR is not always favorable. Careful attention should be paid to patients with concomitant risk factors, such as pulmonary hypertension, elevated blood urea nitrogen levels, decreased albumin levels, and left atrial enlargement.

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