Background There are some controversial reports related to the pro‐arrhythmic or anti‐arrhythmic potential of cardiac resynchronization therapy (CRT) and little is known about the relationship between ventricular arrhythmia (VA) and left ventricular (LV)‐lead threshold. Hypothesis Upgrade CRT is anti‐arrhythmic effect of VA with implantable cardioverter‐defibrillator (ICD) patients and has a relationship with the incident of VA and LV‐lead threshold. Methods Among 384 patients with the implantation of CRT‐defibrillator (CRT‐D), 102 patients underwent an upgrade from ICD to CRT‐D. We divided patients into three groups; anti‐arrhythmic effect after upgrade (n = 22), pro‐arrhythmic effect (n = 14), and unchanging‐VA events (n = 66). The VA event was determined by device reports. We described the electrocardiography parameters, LV‐lead characteristics, and clinical outcomes. Results Before upgrade, the numbers of VA were 305 episodes and the numbers of ICD therapy were 157 episodes. While after upgrade, the numbers of VA were 193 episodes and the number of ICD therapy were 74 episodes. Ventricular tachycardia cycle length (VT‐CL) after upgrade was significantly slower as compared to those with before upgrade. Pro‐arrhythmic group was significantly higher with delta LV‐lead threshold (after 1 month—baseline) as compared to those with anti‐arrhythmic group (0.74 vs −0.21 V). Furthermore, pro‐arrhythmic group was significantly bigger with delta VT‐CL (after 3 months—before 3 months) as compared to those with anti‐arrhythmic group ( P = .03). Conclusions We described upgrade‐CRT was associated with reduction of VA, ICD therapies and VT‐CL. While 14 patients had a pro‐arrhythmic effect and LV lead threshold might be associated with VA‐incidents.

Background: Atrial fibrillation (AF) is a leading preventable cause of heart failure (HF) for which early detection and treatment is critical. Subclinical-AF is likely to go untreated in the routine care of patients with cardiac resynchronization therapy defibrillator (CRT-D). Hypothesis: The hypothesis of our study is that subclinical-AF is associated with HF hospitalization and increasing an inappropriate therapy. Methods: We investigated 153 patients with an ejection fraction less than 35%. We divided into three groups, subclinical-AF (n = 30), clinical-AF (n = 45) and no-AF (n = 78). We compared the baseline characteristics, HF hospitalization, and device therapy among three groups. The follow-up period was 50 months after classification of the groups. Results: The average age was 66 ± 15 years and the average ejection fraction was 26 ± 8%. Inappropriate therapy and biventricular pacing were significantly different between subclinical-AF and other groups (inappropriate therapy: subclinical-AF 13% vs clinical-AF 8.9% vs no-AF 7.7%: P = .04, biventricular pacing: subclinical-AF 81% vs clinical-AF 85% vs no-AF 94%, P = .001). Using Kaplan-Meier method, subclinical-AF group had a significantly higher HF hospitalization rate as compared with other groups. (subclinical-AF 70% vs clinical-AF 49% vs no-AF 38%, log-rank: P = .03). In multivariable analysis, subclinical-AF was a predictor of HF hospitalization. Conclusions: Subclinical-AF after CRT-D implantation was associated with a significantly increased risk of HF hospitalization. The loss of the biventricular pacing and increasing an inappropriate therapy might affect the risk of HF hospitalization.

: The risk of cardiogenic cerebral infarction is quanti ed by the CHA 2 DS 2 -VASc score in patients with atrial brillation, with female gender shown to be one of the risk factors. However, the relationships between gender and blood coagulation markers have not been investigated. Thus, the aim of the present study was to investigate relationships between gender and the coagulation and fibrinolysis systems. In the present study, 1025 patients 517 females F group , 508 males M group who visited the outpatient clinic and had markers of the brinolytic and coagulation systems measured at the Division of Cardiology of Showa University Hospital from June 2011 to June 2014 were evaluated retrospectively. Thrombomodulin TM , prothrombin fragment 1 2 PTF 1 2 , thrombin-antithrombin complex TAT , plasmin-2 -plasmin inhibitor complex PIC , and D-dimer levels were analyzed. Furthermore, patients without diabetes mellitus and vascular disease were divided into two groups according to age : a younger Y group 75 years and an elderly E group ≥ 75 years . In the Y group, TM levels were signi cantly lower in the F than M group P 0.0001 , but in the E group there was no signi cant difference in TM levels between these two groups. PTF 1 2 levels were signi cantly higher in the F group for each age group Y group, P 0.0426 ; E group, P 0.0214 . In the Y group, PIC levels were signi cantly higher in the F than M group P 0.0015 , but there was no difference in PIC levels between the F and M groups in the E group. Thus, in the F group, vascular endothelial dysfunction progressed in the E group. These observations suggest that the coagulation system is relatively accelerated, without any acceleration in the brinolytic system, in the F group with aging. The present study has shown that, in outpatients of a cardiovascular department, gender is a signi cant factor affecting blood coagulation systems.

Patient: Female, 68 Final Diagnosis: Hepatocellular carcinoma Symptoms: Shortness of breath Medication: — Clinical Procedure: Cardiac resynchronization therapy Specialty: Cardiology Objective: Diagnostic/therapeutic accidents Background: Intracardiac thrombosis has been known to be associated with not only hepatocellular carcinoma but also with amyloidosis and use of a cardiac implantable electronic device. We report a case of a continuous tumor thrombus with hepatocellular carcinoma from the portal vein and hepatic vein to the right atrium via the inferior vena cava in a patient with a cardiac amyloidosis and an implanted cardiac resynchronization therapy (CRT) device. Case Report: A 68-year-old female first admitted to our hospital because of heart failure with an AL type primary cardiac amyloidosis. After 3 years, she underwent an implantation of a CRT device for biventricular pacing following repeated episodes of heart failure and low left ventricular ejection fraction of 34% with NYHA class III. Again, she presented with symptoms of heart failure and cardiomegaly on chest x-ray at 7 years after the CRT device implantation. The echocardiography showed a huge echogenic mass occupying the right atrium, and 64 multi-detector computed tomography showed a lobulated heterogeneously enhancing mass of hepatocellular carcinoma in the right upper lobe of her liver and a continuous tumor thrombus from the portal vein and hepatic vein to the right atrium via the inferior vena cava. Conclusions: Intracardiac thrombosis and heart failure occurred in a patient with hepatocellular carcinoma and cardiac amyloidosis, who had an implanted CRT device, which resulted not only in hypercoagulability by the hepatocellular carcinoma itself and the accumulation of various risk factors, but also the progression of myocardial damage with the development of amyloidosis.

Introduction Left bundle branch block (LBBB) with superior axis is common in patients with idiopathic‐ventricular arrhythmia (VA) originating from the tricuspid annulus (TA) and rarely from the cardiac basal crux and mitral annulus (MA). We described the electrocardiography and electrophysiological findings of idiopathic‐VA presenting with LBBB and superior axis. Methods and Results We described 42 idiopathic‐VA patients who had an LBBB and superior axis; 15 basal crux‐VA, 17 TA‐VA, and 10 MA‐VA. No patient had a structural heart disease. Among patients with idiopathic‐VA referred for ablation, we investigated the electrocardiogram and clinical characteristics of basal crux‐VA as compared with other LBBB and superior axis‐VA. The left ventricular ejection fraction with MA‐VA was significantly lower in comparison with basal crux‐VA (P = .01). All patients had a positive R wave in lead I and aVL. The maximum deflection index with basal crux‐VA was significantly higher in comparison with TA‐VA or MA‐VA (P = .01). Patients with basal crux‐VA presented with QS wave in lead II more frequently as compared with TA‐VA or MA‐VA (P = .001). All MA‐VA patients had Rs wave in V6, and basal crux‐VA, and TA‐VA patients had a monophasic R wave or Rs wave in V6. Basal crux‐VA patients underwent ablation in the middle cardiac vein (MCV) or coronary sinus (success rate: 94%, recurrence rate: 6%). Conclusions We could distinguish basal crux‐VA, TA‐VA, and MA‐VA, using a combination of clinical and electrocardiographic findings. These findings might be useful for counseling patients about an ablation strategy. Ablation via the MCV is effective for eliminating basal crux‐VA.