A 37-year-old female who delivered her second child via a cesarean section 4 months previously presented to our hospital with gradual worsening of dyspnea on effort. Chest radiographic appearance showed cardiomegaly (cardiothoracic ratio 61%) and slight bilateral pulmonary congestion. Echocardiogram revealed diffuse hypokinesis of both left and right ventricles (left ventricular ejection fraction 29%) and large biventricular thrombus [left ventricular apex (28 mm × 21 mm, 22 mm × 14 mm) and right ventricular apex (16 mm × 11 mm)]. She was diagnosed as having peripartum cardiomyopathy (PPCM) and anticoagulation therapy was started. Surgical thrombectomy was not selected because of risk of complications. Massive cerebral infarction occurred 10 days after diagnosis. She was discharged with aphasia and right incomplete hemiplegia 65 days after admission.Biventricular thrombus is a rare complication of PPCM. If high risk of massive embolism is considered, surgical thrombectomy may be warranted even in cases with low cardiac function.

Aims Although the delivery catheter system for pacemaker-lead implantation is a new alternative to the stylet system, no randomized controlled trial has addressed the difference in right ventricular (RV) lead placement accuracy to the septum between the stylet and the delivery catheter systems. This multicentre prospective randomized controlled trial aimed to prove the efficacy of the delivery catheter system for accurate delivery of RV lead to the septum. Methods and results In this trial, 70 patients (mean age 78 ± 11 years; 30 men) with pacemaker indications of atrioventricular block were randomized to the delivery catheter or the stylet groups. Right ventricular lead tip positions were assessed using cardiac computed tomography within 4 weeks of pacemaker implantation. Lead tip positions were classified into RV septum, anterior/posterior edge of the RV septal wall, and RV free wall. The primary endpoint was the success rate of RV lead tip placement to the RV septum. Results Right ventricular leads were implanted as per allocation in all patients. The delivery catheter group had higher success rate of RV lead deployment to the septum (78 vs. 50%; P = 0.024) and narrower paced QRS width (130 ± 19 vs. 142 ± 15 ms P = 0.004) than those in the stylet group. However, there was no significant difference in procedure time [91 (IQR 68–119) vs. 85 (59–118) min; P = 0.488] or the incidence of RV lead dislodgment (0 vs. 3%; P = 0.486). Conclusion The delivery catheter system can achieve a higher success rate of RV lead placement to the RV septum and narrower paced QRS width than the stylet system. Trial registration number jRCTs042200014 (https://jrct.niph.go.jp/en-latest-detail/jRCTs042200014)

Although a robust relationship between aberrant serum polyunsaturated fatty acids (PUFAs) profile and coronary artery disease (CAD) has been reported, the details concerning the association between aberrant PUFAs profile and clinical feature of CAD are not fully discovered. Therefore, we investigated the relationship between serum PUFAs and clinical profiles in CAD patients. We classified 595 consecutive CAD patients, who underwent coronary angiography into 3 groups according to the clinical profiles of CAD (group A: early phase ACS, n = 96; group B: stable CAD with previous history of ACS, n = 259; group C: stable CAD without previous history of ACS, n = 240) and measured serum n-3 [eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA)] and n-6 [arachidonic acid (AA)] PUFAs. Serum EPA, DHA, and EPA/AA ratio were significantly low in the order of group A < B < C [EPA; 48.1 (34.1-60.3) μg/ml, 61.7 (41.2-94.5) μg/ml, and 74.4 (52.7-104.9) μg/ml, DHA; 113.1 (92.8-135.1) μg/ml, 125.8 (100.4-167.2) μg/ml, and 140.1 (114.7-177.0) μg/ml, EPA/AA ratio; 0.31 (0.22-0.45), 0.39 (0.26-0.62), and 0.44 (0.31-0.69), medians with interquartile range, p < 0.01]. Multiple regression analysis revealed that EPA (p = 0.009) and EPA/AA ratio (p = 0.023), but not DHA and DHA/AA ratio, were negatively associated with clinical profiles of ACS in CAD patients. Significant correlation was not observed between PUFAs profile and severity of coronary stenosis. Low serum EPA and EPA/AA ratio correlates with clinical profiles of ACS in patients with CAD, regardless of the extent and severity of coronary artery stenosis.

Case series Patients: Male, 15-year-old • Female, 19-year-old Final Diagnosis: Wolff-Parkinson-White (WPW) syndrome Symptoms: Palpitation Medication: — Clinical Procedure: — Specialty: Anatomy • Cardiology Objective: Unknown etiology Background: Radiofrequency ablation in cases of Wolff-Parkinson-White (WPW) syndrome is a relatively safe procedure that yields good results. However, the electrical characteristics of WPW syndrome have not yet been fully elucidated. Herein, we report 2 cases of WPW syndrome, wherein antegrade conduction was abolished first, followed by retrograde conduction. Case Reports: Case 1: A 15-year-old boy who recently reported experiencing frequent palpitations was diagnosed with type A WPW syndrome by electrocardiography (ECG). Radiofrequency energy was delivered to the earliest activation site using an ablation catheter. This procedure abolished antegrade accessory pathway conduction in 6 seconds, and then the ablation was continued for 60 seconds; however, retrograde accessory pathway conduction remained intact. Hence, radiofrequency ablation was performed to further deliver radiofrequency energy to abolish the retrograde accessory pathway conduction. Case 2: A 19-year-old woman with palpitations since elementary school was diagnosed with type A WPW syndrome by ECG. Radiofrequency energy was delivered to the earliest activation site through an ablation catheter to abolish antegrade accessory pathway conduction in approximately 1 second, and then the ablation was continued for 60 seconds. Retrograde accessory pathway conduction was preserved, and further radiofrequency ablation performed multiple times in the same vicinity abolished retrograde accessory pathway conduction. Conclusions: We managed 2 cases of WPW syndrome wherein antegrade and retrograde accessory pathway conduction were individually abolished. This phenomenon may have been caused by an incomplete lesion that resulted in a functional block.

a b s t r a c tAn 82-year-old female with a history of hypertrophic cardiomyopathy (HCM), sick sinus syndrome (SSS), and an implanted DDD pacemaker was admitted to our hospital for congestive heart failure caused by rapid atrial fibrillation. After administration of amiodarone, atrial fibrillation (AF) became atrial flutter (AFL). Electrophysiological investigation revealed counterclockwise AFL. Catheter ablation of the cavotricuspid isthmus was performed. Burst pacing from the coronary sinus ostium to confirm the block line of the isthmus induced rapid, regular, ventricular pacing at a rate of 110 bpm. The differential diagnosis of this tachycardia included ectopic atrial tachycardia and pacemaker-mediated, endless loop tachycardia (ELT). We diagnosed this arrhythmia as ELT, because temporary reprogramming of the pacemaker mode from DDD to VVI terminated the tachycardia. In this patient, pacing parameters favored ELT (long atrioventricular delay [AVD] and short postventricular atrial refractory period [PVARP]), and atrioventricular and ventriculoatrial conduction time was prolonged as a result of amiodarone administration.The ELT continued because the rate was lower than the programmed upper tracking rate. Reprogramming the parameter (decreasing AVD and increasing PVARP) resulted in termination of ELT.