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Background: Fulminant myocarditis presentation (FMP) is a rare and severe presentation of myocarditis. The natural history of FMP and its clinical features associated with poor outcomes are incompletely understood because there is a lack of generalizable evidence. Methods: This multicenter retrospective cohort study included patients hospitalized with histologically proven myocarditis who underwent catecholamine or mechanical support from 235 cardiovascular training hospitals across Japan between April 2012 and March 2017. Clinical features and the prognostic predictors of death or heart transplantation within 90 days on the basis of clinical and pathologic findings were determined using the Kaplan-Meier method, log-rank test, and Cox regression analysis. Results: This study included 344 patients with histologically proven FMP (median age, 54 years; 40% female). The median follow-up was 600 days (interquartile range, 36 to 1599 days) and the cumulative risk of death or heart transplantation at 90 days was 29% (n=98). Results from multivariable Cox regression analysis showed that older age, nonsinus rhythm, low left ventricular wall motion ( Conclusions: The results from analyses of data from this multicenter registry demonstrated that patients with FMP are at a higher risk of death or heart transplantation in real-world settings. These observations inform which clinical and pathologic findings may be useful for prognostication in FMP. Registration: URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000039763.

Introduction: In patients with initial shockable rhythms had favor outcomes than those with non-shockable rhythms, and those of asystole had worst outcomes. Purpose: The purpose of the study is to investigate the predictors of favorable outcomes in specific in the asystole rhythms. Method: Patients who were resuscitated after out-of-hospital cardiac arrest and were underwent targeted temperature management were enrolled in this study. Patients were divided into 3 groups according to initial recorded rhythms after indexed cardiac arrest. Favorable outcomes were defined as cerebral performance category of 1 or 2 after 90 days of indexed cardiac arrest. The logistic regression analysis was performed to assesses independent predictor of favorable outcomes. Results: Among the 305 study patients, 57 (19%) patients had initially recorded asystole rhythms, 149 (49%) patients had shockable rhythms, and 99 (32%) patients had pulseless electrical activity (PEA). The patients of PEA were elder (median 62 y [interquartile range 49 y - 72 y], 65 [57 - 75], and 62 [49 - 74], P = 0.03 in the patients of shockable, PEA, and asystole), the rate of male was higher in the shockable (86%, 58%, and 72%, P < 0.001), the time interval from collapse to return of spontaneous circulation (ROSC) were longer in the asystole (28 min [17 - 48], 37 [24 - 53], and 46 [39 - 61], P < 0.001), and the lactate of hospital arrival were higher in the asystole (10.1 mmol/l [6.1 mmol/l - 13.6 mmol/l], 12.0 [8.6 - 15.4], and 13.3 [9.6 - 18.3], P = 0.002). The rate of acute coronary syndrome as the cause of arrest were similar between the groups (45%, 34%, and 28%, P = 0.06). The rate of favorable outcome was 53%, 21%, and 12% (P < 0.001), respectively. The time interval from collapse to ROSC were independently associated with favorable outcomes in the patients of all initial recorded rhythms. Conclusions: The cardiac arrest patients who were witnessed arrest or shorter interval from collapse to ROSC with initial recorded asystole rhythms had favor outcomes than those not. We could not find specific predictors in the patients with asystole.

Introduction: Malnutrition, cognitive decline and heart failure (HF) frequently coexist in the elderly. A recent systematic review revealed that malnutrition was a possible contributing factor of cognitive impairment. Although several studies reported the association of malnutrition with poor HF prognosis, the underlying pathophysiology has been unclear. Hypothesis: We assessed the hypothesis that malnutritional status might be associated with cognitive dysfunction in the elderly with HF. In addition, we investigated whether left ventricular ejection fraction (LVEF) moderates that relationship or not. Methods: Nutritional status and cognitive function were evaluated using the geriatric nutritional risk index (GNRI), controlling nutritional status (CONUT) score and mini-mental state examination (MMSE) in 245 elderly inpatients in stable phase of HF (82.9±6.0 years old, male 49.4%). Echocardiography was performed at admission. HF with preserved EF (HFpEF) was defined according to LVEF more than 50% (n=129). Results: According to the quartile of MMSE score (< 19, ≥19 to 27≤, >27), significant associations of MMSE score were observed with GNRI (89.1 vs 95.4 vs 95.5, p=0.004) and CONUT score (3.50 vs 2.71 vs 2.61, p=0.039) among three groups. In the logistic regression analysis adjusted for the confounders including age, gender, LVEF, brain natriuretic peptide level, systolic blood pressure at admission, diuretics and antihypertensive medication use, GNRI (β=0.96, 95%CI:0.93 to 0.99, p=0.008) and CONUT score (β=1.18, 95%CI:1.01 to 1.37, p=0.03) each was significantly associated with cognitive dysfunction (defined as MMSE score Conclusions: In conclusion , lower GNRI and higher CONUT score were shown to be significant indicators of cognitive dysfunction in the elderly HF patients. These results highlight the importance of stratifying by nutritional status for a clinical intervention of cognitive dysfunction in the elderly patients without HFpEF.

Introduction: Idiopathic ventricular fibrillation (IVF) including Brugada syndrome (BS) is one of causes of cardiac arrest without prior overt cardiac dysfunction. Hypothesis: We assessed the hypothesis that patents of IVF had favor outcomes than those of non-IVF after cardiac arrest treated with targeted temperature management (TTM). Methods: Patients who were treated with TTM after cardiac arrest between 2000 and 2019 were enrolled in the study. Patients were divided into 2 groups according to whether the patients were diagnosed as IVF or not. The patients treated with TTM were routinely performed coronary angiography. Results: Among the study patients (N = 306), 35 (11%) patients were IVF and 7 were BS. The patients of the IVF group were significantly younger (median 53 y vs. 64 y) than those of the non-IVF group. The prevalence of initial rhythm was shockable (69% vs. 47%, P = 0.02) was significantly higher in the patients of the IVF group than those of the non-IVF group. Among the patients in the non-IVF group, 114 patients (42%) were diagnosed as acute coronary syndrome and 93 patients (35%) were treated with coronary revascularization. The prevalence of male sex (77% vs 74%, P = 0.70) and witnessed to arrest (80% vs. 81%, P = 0.87), and low-flow time (29 min vs. 38 min [20 - 43 min vs. 21 - 52 min, P = 0.15]) were similar between the 2 groups. The prevalence of performing extracorporeal resuscitation (9% s 43%, P < 0.001) were lower in the patients of the IVF group. The 8-y survival rate were shown in the figure. All of the BS patients were witnessed arrest and were discharged without severe neurological deficit. The IVF as the cause of arrest was independently associated with 8-y survival. Conclusions: The patients of IVF had favor outcomes than those of non-VF. One of causes may be the lower prevalence of requiring extracorporeal circulatory support due to less cardiac dysfunction. The patients of BS had the tendency toward higher survival rate than those of non-BS IVF patients.

Introduction: Mortality in patients with acute coronary syndrome (ACS) due to unprotected left main coronary artery (LMA) occlusion is high. Extracorporeal membrane oxygenation (ECMO) could rapidly provide circulatory support. Hypothesis: This study aimed to verify the hypotheses that the patient who required circulatory support with ECMO in acute phase of LMA-ACS had greater cardiac function deterioration and had higher mortality in the chronic phase than those who did not require ECMO. Methods: Patients with LMA-ACS who underwent percutaneous coronary revascularization between 2000 and 2020 were enrolled in this study. The patients were divided into two groups based on whether or not they received ECMO. Thirty-day (acute phase) and 30-day to 6-year (chronic phase) survival curves were constructed by Kaplan-Meier method. The cause of death in acute and chronic phase were examined. Results: Among the 85 study patients, 23 (27%) were in the ECMO-group. Median age was younger in the ECMO-group (65 y [57 - 72] vs. 73 y [69 - 83], p < 0.01), and male sex (67% vs. 63%) were similar in ECMO group and non-ECMO groups respectively. The prevalence of ST elevation myocardial infarction (STEMI), non-STEMI, unstable angina were 52%, 48%, and 0% vs. 15%, 42%, and 44% in the ECMO group and non-ECMO group, respectively. The 30-day mortality was significantly higher in ECMO group (61% vs. 15%, p < 0.01); however, the 30-day to 6-year mortality was similar between the two groups (41% vs. 33%, p = 0.59) (Figure). The cause of death in the acute phase were cardiac failure (79% and 67%) and those in chronic phase were cardiac failure (50% and 25%), malignancy (0% and 13%), and infection (50% and 36%). Conclusions: The mortality in chronic phase in LMA-ACS patients who survived up to 30 days were similar in ECMO group and non-ECMO group. Moreover the patients whose cardiac function deteriorated severely and required ECMO in acute phase had similar prognosis to those that did not require ECMO.

Introduction: While clinical predictors of plaque erosion (PE) in patients with acute coronary syndromes (ACS) were reported, PE was more frequently observed in the population with normal kidney function. On the other hand, earlier studies indicated that spotty calcification related to plaque rupture on the culprit site in ACS. However, the morphological features of coronary calcification on culprit site have not been investigated in relation to PE. Hypothesis: We assessed the hypothesis that the morphology of calcification on culprit site was associated with PE in ACS patients without chronic kidney disease (CKD). Methods: In the 166 ACS patients (66.9±10.7 years old, male 83 %), based on Optical Coherence Tomography/ Optical Frequency Domain Imaging, existence of PE on culprit site was investigated. In the morphological features of coronary calcification, the maximum thickness, maximum area, maximum angle, minimum depth from the lumen in axial sections, and the length in longitudinal image were determined. Results: There were the 73 patients with PE, 58 patients with calcification and 38 patients with CKD. A marginal significant difference in thickness (300 vs 190μm, p=0.07) and significant difference in angle (60 vs 23degree, p=0.001), area (0.89 vs 0.43mm 2 , p=0.001) and length (2.34 vs 1.12 mm, p=0.03) were observed between the patients with PE and the patients without PE. In the multiple regression analysis adjustment for age, gender, region location, maximum creatine phosphokinase, STEMI or not, diabetes mellitus, angiotensin receptor blockers use, statin use and systolic blood pressure on admission, angle (OR: 1.01, 95%CI: 1.002 to 1.013, p=0.005) and area (OR: 1.46, 95%CI: 1.02 to 2.1, p=0.04) each had significant associations with PE. Specifically, only in the patients without CKD, thickness (p=0.025), angle (p=0.003) and area (p=0.013) were significant indicators of PE. Conclusions: In conclusion, morphology of calcification on culprit site was a significant indicator of PE in the patients with ACS. Specifically, larger calcification might serve as a pathophysiology underlying in the phenotype of plaque vulnerability in ACS patients with normal kidney function.

Introduction: It is well known that blood transfusion can worsen outcomes in patients with acute coronary syndrome without cardiac arrest. However, little is known regarding patients receiving blood transfusion after cardiac arrest in the current era of targeted temperature management (TTM) and coronary reperfusion. Hypothesis: We assessed the hypothesis that blood transfusion worsen the prognosis of patients after cardiac arrest. Methods: Adult comatose survivors of cardiac arrest treated with TTM were enrolled in this study. We assessed the association between blood transfusion and 90-day survival. We constructed 90-day survival curves using the Kaplan-Meier method to assess the impact of blood transfusion after cardiac arrest. Cox proportional hazards regression was utilized to adjust for the association of blood transfusion and 90-day survival. A P < 0.05 was defined as statistically significant. Results: Among all study patients (N = 253), the median age was 62 years (interquartile range, 52 - 72 years), 75% were men, 51% had shockable initial rhythms, and the time interval from collapse to return of spontaneous circulation was 37 min (21 - 57 min). After hospital arrival, 60% of the study patients underwent immediate coronary angiography, 31% underwent subsequent coronary revascularization, and 99 patients (39%) received blood transfusions. The prevalence of blood transfusion were significantly higher in the patients underwent coronary revascularization (57% vs. 31%, P < 0.001). The 90-day survival curves are shown in the figure. Blood transfusion was independently associated with reduced 90-day survival (hazard ratio 0.68 [95% confidence interval, 0.47 - 0.98], P = 0.04). Conclusions: Blood transfusion may worsen survival in patients not treated with coronary revascularization, but not in patients treated with coronary revascularization after cardiac arrest in the current TTM era.

Background: Previous studies have reported plaque rupture and erosion were the most common causes of acute coronary syndrome (ACS) and spotty calcifications was identified as a marker of plaque rupture. Optical coherence tomography (OCT) offers a high-resolution imaging to assess the plaque morphology and coronary calcification. Purpose: The aim of this study was to evaluate the relationship between the distribution of coronary calcification and the culprit lesion morphology in patients with ACS. Methods: We enrolled consecutive 183 patients with ACS (mean age: 68 ± 11 years, 148 males). Culprit lesion was assessed by OCT and patients were divided into the rupture and non-rupture group according to the OCT findings. Maximum radial thickness, cross-sectional area of calcification and radial depth from the lumen and longitudinal length of calcification were compared between 2 groups. Results: Plaque rupture was detected at culprit site in 105 patients and coronary calcification was identified in 58 patients. There were no significant differences in age and gender between 2 groups. Maximum thickness, area and longitudinal length of calcification were smaller in rupture group (457.4 ± 284.9 μm vs. 722.1 ± 384.1 μm, p < 0.01, 0.7 ± 0.4 mm 2 vs. 1.8 ± 1.4 mm 2 , p < 0.01, 2.2 ± 1.1 mm vs. 5.6 ± 5.3 mm, p[[Unsupported Character - Codename ­]] < 0.01, respectively). Radial depth of calcification from the lumen was significantly geater in rupture group (150.0 ± 65.3 μm vs. 83.1 ± 63.3 μm, p Conclusions: Distribution of coronary calcification could be associated with morphological etiology of ACS.

We read with great interest the article by Lopez-de-Sa et al1 on the 2 hypothermia levels post cardiac arrest trial. The article provides insights into the management of comatose survivors of cardiac arrest and the future prospective for randomized trials concerning optimal target temperatures for therapeutic hypothermia. The authors worked with the assumption that the relative risk of 6-month survival free of dependence would be 1.86 with a cooling level of 32°C compared with …

Background— Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. Methods and Results— This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P =0.01), the intra-arrest PCI was higher (88% versus 70%; P =0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25–51] versus 54 minutes [34–74 minutes]; P =0.002). Conclusions— Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed.