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  • In addition our present findings demonstrated that

    2019-05-28

    In addition, our present findings demonstrated that NOACs may offer advantages over warfarin therapy besides efficiency and safety. The time to ECV in the present OAC-naïve patients was significantly shorter in the NOAC group compared to the VKA group. This may be explained by the delayed achievement of adequate anticoagulation prior to ECV in the VKA group. In a prospective study, Cappato et al. showed that rivaroxaban is safe and effective for ECV and may shorten the levomefolate calcium of premedication to ECV compared to warfarin [18], similar to what we observed in the present study. The current guideline from the Japanese Circulation Society recommends a reduced INR target level of 1.6–2.6 in AF patients aged ≥70 years [11]. The reasons for this include the relatively high incidence of intracranial hemorrhage among Asians on OAC treatment compared with Caucasians, especially among the elderly [21]. Therefore, theoretically, the results from the studies comparing NOACs and VKAs with a target INR of 2.0–3.0 [8–10,18–20] may not be reproducible in Japanese patients. In this regard, the present study provides information of clinical significance. Of our 406 patients, there were only four cases of systemic thromboembolism (all stroke) (0.99%); three in the VKA group and one patient who was treated with the NOAC dabigatran. The patients with stroke were relatively old, at >70 years. The prevalence of thromboembolic events was so low that we could not determine the significance between the VKA and NOACs groups. All three patients in the VKA group appeared to have high CHAD2 and CAH2DS-VASc scores. By contrast, in the NOACs group, there was only one patient complicated by stroke. The patient was treated initially with 300mg/day dabigatran, but after successful ECV and a day after dose replacement with 220mg/day, a stroke occurred despite the patient׳s CAHDS2 score of 0. Apparently, the clinical benefit of NOACs over warfarin is to allow fixed-dose regimens without laboratory monitoring. However, in this particular patient, the APTT decreased from 40.2s to 29.3s by reducing the dose from 300mg daily to 220mg daily, suggesting that the reversal of the anticoagulation status may have been involved levomefolate calcium in the occurrence of the patient׳s ischemic stroke. This case, which shows a pitfall of NOAC usage, should be kept in mind. Since atrial stunning that promotes thromboembolic stroke is observed in patients after ECV [22], anticoagulation therapy should be strictly maintained until the recovery of atrial function.
    Conclusions
    Conflict of interest
    Introduction In recent years, the number of patients with cardiac implantable devices (CID) has increased, including those with pacemakers and implantable cardioverter defibrillators (ICD). CID and pacing leads have been developed as advancements in medical technology. The current generation of CID has already achieved favorable longevity, greater variety, and smaller size compared with previously available devices. Although CIDs still need to be changed every 5–10 years due to battery drain, exchanging pacing leads easily is impossible. Therefore, long-term reliability is essential for pacing leads. It is well known that the longevity of pacing leads is associated with venous approach, insulation materials, and lead structures [1,2]. FINELINE II Sterox EZ Leads (Boston Scientific, Minneapolis, MN, USA), which are sweet-tip type screw-in active-fixation leads, have been used worldwide since 2001. More than one million of these pacing leads have been implanted, and the number is expected to increase because these leads are compatible with magnetic resonance imaging (MRI). The purpose of this study was to investigate the long-term reliability and stability of electrical characteristics in sweet-tip type active fixation leads.
    Materials and methods
    Results The mean follow-up period was 51.3±29.2 months (median, 48 months). Seven hundred fifty patients (464 men and 286 women) were included in this study. The mean age of the patients was 68.8±13.0 years (range, 11–94 years). The indications for pacemaker or ICD implantation are provided in Table 1, which included sick sinus syndrome, atrioventricular (AV) block, ventricular tachycardia, atrial fibrillation (AF) with bradycardia, and other conditions (neurally mediated syncope, hypertrophic obstructive cardiomyopathy, or congestive heart failure) in 279 (37%), 253 (34%), 167 (22%), 47 (6%), and 4 patients (1%), respectively. A total of 1092 leads could be traced for investigation in this study. The details of the implanted lead models are shown in Table 2. Among these, 682 and 410 leads were implanted in the atrium and ventricle, respectively. Regarding venous access, the cephalic vein cut down (CVC) and SVP methods were used for 914 (84%) and 178 leads (16%), respectively. The overall lead survival rate was 99.6% at both 5 and 10 years (median, 4 years) (Fig. 1). The details of the issues with implanted leads during the follow-up period are summarized in Table 3.