Both diversity of symptoms and variability of the severity of symptoms, especially walk-in mode of admission lead ER physicians to miss AAD in about 1 in 6 cases of AAD. It is therefore important to keep AAD as a differential diagnosis in mind, even when patients present with mild enough symptoms that allow them to walk into the ER.

Introduction The optimal ablation strategy is unknown regarding a superior vena cava isolation (SVCI). This study aimed to examine the feasibility and safety and to analyze the lesion characteristics of the SVCI using high‐power, short‐duration (HPSD) ablation. Methods and Results A total of 100 patients underwent an index SVCI using HPSD (n = 50, HPSD group) or conventional lower‐power and longer‐duration (n = 50, LPLD group) ablation, using the Thermocool Smarttouch SF. In the HPSD group, ablation was performed with a power of 50 W for 7 s, and was limited to 4 s at the lateral segment close to the right phrenic nerve. The ablation setting used in the LPLD group was 20–25 W for 20–30 s and was limited to 10–20 W for 15–30 s at the lateral segment when diaphragmatic capture was seen. An electrical SVCI was achieved in all patients. The HPSD group required a significantly shorter procedure time (10.8 ± 3.2 vs. 14.8 ± 6.4 min; p < .01), shorter radiofrequency duration (49 ± 16 vs. 282 ± 124 s; p < .01), fewer lesions (8.3 ± 2.5 vs. 10.4 ± 4.4; p < .01), and lower ablation index (316 ± 38 vs. 356 ± 62; p < .001) than the LPLD group. The incidence of a postprocedural asymptomatic mild diaphragmatic elevation was comparable (2% in the HPSD group vs. 6% in the LPLD group; p = .61). Conclusion The 50‐W HPSD ablation strategy allowed for a successful, fast, and safe SVCI with the fewer ablation lesions and the lower ablation index.

Background: Malnutrition is associated with a poor prognosis in heart failure, angina pectoris, and peripheral artery disease. However, the clinical importance of the preprocedural nutrition status of patients requiring pacemaker implantation (PMI) for bradycardia is unclear. Methods: We retrospectively enrolled 521 patients (median 79 years) who underwent their first PMI between January 1, 2012 and June 30, 2017. The nutrition status before implantation was assessed by the geriatric nutritional risk index (GNRI). The association between the preprocedural GNRI-based nutritional status and all-cause mortality was investigated. Results: GNRI-based high (GNRI <82) and moderate (GNRI 82 to <92) malnutrition status were found in 9.2% and 34.0%, respectively. During a median follow-up of 1178 days, 71 patients died. The mortality rate, which was analyzed using survival curves, was significantly stratified by the GNRI-based malnutrition status [high: 52.0% (25/48), moderate: 16.9% (30/177), low: 5.4% (16/296), p < 0.001). On a multivariate Cox-proportional hazard analysis, GNRI-based high malnutrition status independently predicted allcause death (hazard ratio: 4.49, 95% confidence interval: 2.59-7.80, p < 0.001). A sensitivity analysis based on the controlling nutritional status score showed consistent results. On a receiver operating characteristic curve analysis, GNRI had a high predictive value for all-cause mortality (area under the curve, 0.78, 95% confidence interval: 0.72-0.84, p < 0.001). Conclusions: Preprocedural malnutrition was significantly associated with poor outcomes of patients who underwent PMI. Assessing the nutritional status in advance is important for risk stratification, and improving the nutritional status may be an option for managing these patients.

BackgroundThe clinical impact of a decrease in impedance during radiofrequency catheter ablation (RFCA) has not been fully clarified. The aim of the study was to analyze the impact of impedance decrease and to determine its optimal cutoff value during RFCA.MethodsWe evaluated 34 consecutive patients (total 3264 lesions, mean age 66 ± 8.7 years, 10 females) who underwent their first ablation for atrial fibrillation (AF). The impedance decrease, average contact force (CF), application time, force‐time integral (FTI), product of impedance decrease and application time (PIT), and the product of impedance decrease and FTI (PIFT) were measured for all lesions. Levels of cardiac troponin I (TrpI) were measured for assessment of myocardial injury. The incidence of intraprocedural pulmonary vein‐left atrium reconnection or dormant conduction (reconnection) was determined. The relationships between the ablation parameters and the increase in TrpI (ΔTrpI) were evaluated. The predictive value of the parameters for reconnection was assessed using receiver operating characteristic (ROC) curve analysis.ResultsReconnection was detected in 18 patients. Average FTI and PIT were significantly correlated with ΔTrpI (FTI: r 2 = .19, P = .0090, PIT: r 2 = .21, P = .0058). PIFT was correlated with ΔTrpI and was the best of the three indexes (PIFT: r 2 = .29, P = .0010). In ROC curve analysis, the area under the curve for predicting reconnection was 0.71 and the optimal cutoff value was 5200 for PIFT (sensitivity 78%, specificity 63%).ConclusionThe combination of CF and a decrease in impedance could be important in the evaluation of myocardial lesions and reconnection during RFCA.

Objective: Although deep vein thrombosis (DVT) followed by pulmonary thromboembolism (PE) is a critical complication during pregnancy, there have been few reports about its intrapartum management. We evaluated intrapartum management by using a temporary inferior vena cava filter (IVCF) in pregnant women with PE/DVT.Materials and Methods: Eleven women with PE/DVT during pregnancy between January 2004 and December 2016 were included. The patients were hospitalized for intravenous unfractionated heparin infusion after acute PE/DVT onset. Seven patients were discharged and continued treatment with subcutaneous injection of heparin at the outpatient unit. IVCF was implanted 1–3 days before delivery in 10 patients. Anticoagulant therapy was discontinued 6–12 h before delivery. We retrospectively analyzed rates of maternal or perinatal death, and recurrence of symptomatic PE/DVT.Results: One patient was diagnosed as having PE/DVT and 10 had DVT alone. One patient suffered hemorrhagic shock during delivery; however, maternal or perinatal death and recurrence of symptomatic PE/DVT did not occur in any patient.Conclusion: Maternal or perinatal death and recurrence of symptomatic PE/DVT was not seen in women diagnosed as having PE/DVT during pregnancy and treated with anticoagulant therapy and IVCF.