wave front propagation, especially in low voltage zones. By performing HDM mapping inside the PVAI lines after conventional encirclement lesions, we hoped to identify any RPs associated with ECs inside our PVAI lines. Thus, the purpose of this study was to determine the prevalence and number of ECs inside the PVAI lines after a conventional PVAI, and the effect of an EC ablation on the outcomes in patients with non-valvular paroxysmal (pAF), persistent (persAF), and long-lasting AF (LLAF). Methods Baseline Clinical Characteristics of the Patient GroupsThe present study was approved by the institutional review committee and ethics review board of our hospital, the Ethical Review Board of Steel Memorial Yawata Hospital. The procedures were followed in accordance with the Declaration of Helsinki and the ethical standards of the responsible committee on human experimentation. Moreover, we enrolled this study in an international registry of P ulmonary vein (PV) antrum isolation (PVAI) with radiofrequency catheter ablation (RFCA) has proven to be a useful strategy for atrial fibrillation patients (AF) worldwide. 1 To prevent initiating and maintaining AF, a complete PVAI should be a target of the AF treatment. 1 However, in spite of establishing complete PVAI lines, we rarely experience and encounter remaining potentials (RPs) inside our PVAI lines detected by high-density mapping (HDM). Then, when we perform pacing from the ablation catheter on the RPs inside our PVAI lines, we confirm that the pacing can capture RPs and conduct to the atrium. This finding indicates the existence of epicardial connection(s) (ECs) from inside the PVAI lines to the atrium after establishing complete conventional PVAI lines. The recent Intellamap Orion 2 (Boston Scientific Corporation, Marlborough, MA, USA) and Advisor TM HD Grid 3 (Abbott, Plymouth, MN, USA) advanced catheter technologies, which are directional HDM catheters, can not only identify low voltages and small local electrical signals, but also more importantly can capture the direction of the

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Background and Objective: Hypertension (HT) is one of the most important risk factors for cardiovascular disease; however, about 30% of hypertensive subjects in Japan are estimated to be left unaware-untreated. The authors studied clinical characteristics of unaware-untreated HT (UAUT-HT) subjects using data of a large health checkup and public medical insurance. Methods:In a Japanese city, 54,287 persons underwent a public health checkup for 40-74 years old in 2017. The information on their medical diagnosis were obtained from the national medical insurance system. Among all examinees, 28,167 (51.9%) were hypertensive (systolic blood pressure (SBP) > = 140 mmHg, diastolic BP (DBP) > = 90 mmHg, took antihypertensive agents, or had diagnosis of hypertension on the national medical insurance system). If subjects took antihypertensive agents or had HT diagnosis, they were considered as aware HT. If not, the subjects were considered as UAUT-HT. Demographic factors were compared between UAUT-HT and aware HT.Results: Of all HT subjects, 13,426 (47.7%) were SBP < 140 and DBP < 90 mmHg (well controlled) under treatment, 6,727 (23.9%) were BP > = 140 /90 mmHg (poorly controlled) under treatment, 3,147 (11.2%) were aware of HT but untreated, and 4,867 (17.3%) were UAUT-HT. Compared with aware HT, the UAUT-HT group was younger (age < 65y; UAUT-HT, 25%; aware HT, 16%), leaner (BMI> = 25; 27%, 36%), had more female (57%, 52%), more subjects without proteinuria (82%, 75%), higher SBP and DBP (SBP, 148 ± 11, 136 ± 16; DBP, 85 ± 10, 78 ± 11), lower fasting blood glucose (99 ± 34, 103 ± 23, mg/ dl), lower HbA1c (5.8 ± 0.7, 5.9 ± 0.8, %), higher LDL-cholesterol (133 ± 33, 120 ± 30, mg/dl), lower serum uric acid (5.2 ± 1.3, 5.4 ± 1.3, mg/dl), and higher eGFR (71 ± 13, 67 ± 14, ml/min/1.73^2). These were all significant differences (p < 0.01). Conclusion:These results suggest that the UAUT-HT subjects are young and have favorable health condition except for high BP and LDL-cholesterol level compared with aware HT. In such relatively healthy subjects, blood pressure may not be paid enough attention to consult and treat. Social enlightenment on HT for broader population may be needed.

Background Atrial fibrillation (AF) and heart failure (HF) frequently coexist and AF is associated with an exacerbation of HF. Catheter ablation (CA) of AF has proven to be an established treatment for patients with HF associated with AF. Ordinarily, CA of AF is an elective procedure. Case summary We present a 68-year-old male case with chief complaint of palpitation and general malaise, and appetite loss, associated with acute decompensated HF resulting from drug-refractory AF and left ventricular (LV) diastolic dysfunction. He underwent an urgent CA therapy for AF under mechanical support via intra-aortic balloon pumping (IABP), which dramatically improved the hemodynamic status and clinical outcomes. Discussion Despite their shared common risk factors, AF, HF, and LV diastolic dysfunction subtypes exacerbate each other and create a vicious triad of AF, HF, and LV diastolic dysfunction, developing into acute decompensated HF. Thus, it is important to overcome this vicious cycle using noninvasive and/or invasive strategies. Performing an urgent CA of AF for acute decompensated HF may be a challenging strategy and have not been well established. However, urgent CA using mechanical hemodynamic support, including IABP, might be an effective and feasible strategy in patients with medically intractable, severe ADHF associated with LVDD and drug-refractory AF as in this present case. Hemodynamically unstable patients, as in the present case, require prompt and careful monitoring of their clinical condition. Thus, it may also be important to consider the appropriate timing for optimal treatment in these patients.

Background Premature ventricular complexes (PVCs) are the most common arrhythmia observed in patients without structural heart disease (SHD). Frequent PVCs cause left ventricular (LV) dilation and dysfunction without SHD, so-called PVC-induced cardiomyopathy (PIC). Obstructive sleep apnea (OSA) is a highly prevalent disease worldwide and is strongly associated with arrhythmias including PVCs. PVCs have been reported in up to two-thirds of patients with OSA. Continuous positive airway pressure (CPAP) is a well-established primary treatment modality in patients with moderate to severe OSA. Case summary We present a 69-year-old male case with severe OSA and an improvement in his PIC following CPAP therapy. He has remained well without any symptoms or arrhythmias for 2 years after the introduction of the CPAP therapy for his OSA. Discussion Using CPAP therapy for the treatment of his OSA, we could improve his PIC in accordance with a reduction in frequent PVCs without ablation of the PVCs. Ablation only without CPAP therapy may not be able to completely treat PIC associated with OSA as in this present case. Thus, physicians should be aware of the possibility of PVCs associated with OSA when examining patients with PVCs. To the best of our knowledge, this is the first report of a case of an improvement in the PIC following CPAP therapy in a patient with severe OSA. Future investigations should focus on whether CPAP therapy can improve PIC associated with OSA and prevent a progression to heart failure and result in an improvement in the prognosis.