Heart failure is an ambiguous term as a technical terminology, which means sometimes an existence of ventricular dysfunction, and sometimes a decompensated heart failure with symptoms and signs due to clinical congestion. Diagnostic procedure for congestive heart failure, so called Framingham Criteria, has been no changed for approximately half a century, however, the therapeutic strategy has been improved considerably, resulting in the congestion could be managed and heart failure patients released from symptoms and signs by congestion. Ironically, that makes the word heart failure more complex and obscure. Chronic heart failure is a new concept that is constructed by NYHA functional class as a degree of symptoms and by stage of heart failure as a degree of remodeling of myocardium due to neurohumoral activation, renin-angiotensin-aldosterone system and sympathetic nerve system, and would be able to cover all conditions of heart failure and also to provide the managements for patients in each stage. More understanding for the concept of chronic heart failure is beneficial regarding clinical managements of heart failure for not only cardiologists, but also all attending physicians.

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Background: The mechanisms underlying self-perpetuation of persistent atrial fibrillation (AF) are not well understood. To gain insight into these mechanisms, we compared biatrial electroanatomic maps, obtained during sinus rhythm, in patients with paroxysmal AF, patients with persistent AF, and patients without AF (control patients). Methods: The study involved 12 patients with paroxysmal AF (9 men, 3 women; 62 ± 11 years of age), 6 patients (5 men, 1 woman; 62 ± 6 years of age) with persistent AF treated unsuccessfully by direct-current cardioversion, and 6 patients (1 man, 5 women; 53 ± 16 years of age) with a left-sided accessory pathway but no AF (control patients). Biatrial voltage mapping was performed during sinus rhythm using the CARTO system. The clinical and electroanatomic characteristics of the 3 groups of patients were evaluated and analyzed statistically. Results: The proportions of normal and low voltage areas in the right and left atria were not different between the control and paroxysmal AF groups. The proportion of the right atrial (RA) low voltage (< 0.5 mV) area did not differ between the 3 groups; however, the RA and left atrial (LA) normal voltage (≥ 1.5 mV) areas were significantly smaller in the persistent AF group. The LA low voltage area was significantly larger in patients with persistent AF. Conclusion: The relatively large RA normal voltage and LA low voltage areas that we observed in patients with persistent AF may play a crucial role in the self-perpetuation of AF.

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Background: The optimal technique for recording of the electrogram to detect complete cavo-tricuspid isthmus (CTI) block during radiofrequency ablation (RFA) of the typical atrial flutter (AFL) using non-contact mapping system remains unclear. The aim of this study was to investigate the characteristics of the local virtual unipolar electrogram recorded at the ablation line during coronary sinus pacing after RFA of the CTI. Methods: Non-contact mapping was performed in 8 patients with AFL. Non-contact virtual unipolar electrograms were obtained before and after CTI linear ablation. All unipolar electrograms were acquired with both wide-band (0.5-300 Hz and 0.5-IC 150 Hz) and narrow-band filtering (32-300 Hz). The unipolar electrogram measurements included both the peak-to-peak voltage and peak-negative voltage for both filter settings, and the morphological characteristics of the second component of double potentials. Results: Comparison of the electrogram voltage along the ablation line before and after ablation demonstrated: 1) peak-negative voltage reduction at the mid-portion of the ablation line by 0.5-IC 150 Hz filtering, and 2) the second component of unipolar electrogram morphologies of R, Rs or rSR were the most sensitive and speci-c recording technique to predict conduction block. Conclusions: Non-contact unipolar electrograms using the peak-negative voltage with 0.5-IC 150 Hz and a predominant R-wave pattern in the second component at the ablation line indicate complete CTI block, even in the presence of transcristal conduction.

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要旨　症例は66 歳，男性．慢性B 型肝炎のフォロー中に20 mm 大のHCC を指摘された．ICGR15 15%．肝障害度A，Child-Pugh score Grade A，T1N0M0 ステージI と診断した．腫瘍は肝深部に認め，占居部位は術前シミュレーションにて肝S7 と判断した．術中超音波検査は腫瘍の認識は困難であったが，Counterstaining 法で領域を同定し，肝深部は術前シミュレーションを参考に，肝S7 切除を施行した．術後合併症なく第9 病日に退院した．肝機能と腫瘍局在に応じた至適術式の決定に術前3D-CT シミュレーションは有用であった．

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リンパ節転移を伴った甲状腺微小癌を経験した．症例は68 歳，女性．甲状腺腫瘍を指摘され来院した．超音波検査で甲状腺に多発する腫瘍を認めた．穿刺吸引細胞診を施行したところ左葉の直径5 mm の腫瘤のみがClass IV の診断であった．甲状腺亜全摘術＋リンパ節郭清術を施行した．病理組織診断は多発する腺腫様甲状腺腫と直径5 mm のpapillary carcinoma であり，左気管傍リンパ節に転移を認めた．微小癌の予後は良好とされるが，今後の慎重な経過観察が必要であると考えられた．

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Isolated left ventricular noncompaction (IVNC) is a cardiac abnormality of unknown etiology characterized by prominent left ventricular trabeculations and deep intertrabecular recesses. IVNC sometimes develops as life threatening cardiac arrhythmias, i.e., ventricular tachycardia and ventricular fibrillation. Herein, we present a rare case of supraventricular tachycardia in a patient with IVNC.

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症例は55 歳女性，7 日前より全身倦怠感を認め，かかりつけ医（心療内科）を受診した．その後，症状の増悪を認め，前医に搬送された．心筋逸脱酵素の上昇を認め，緊急心臓カテーテル検査を施行したが，冠動脈の狭窄病変は認めなかった．血行動態が保てず，大動脈バルーンパンピング，経皮的心肺補助装置を挿入し当院へ搬送となった．劇症型心筋炎の診断で，左心補助人工心臓による循環補助を行ったが，右心不全の悪化を認め6 日後に，右心補助人工心臓による補助も施行し，加療を行うも奏功せず入院11 日目，死亡退院となった．劇症型心筋炎は稀な疾患であり，両心室補助人工心臓を施行した1 例を経験したので報告する．

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