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We report a case of ventricular septal defect (VSD) in which we attempted to treat pulmonary arterial hypertension (PAH) with the goal of VSD closure in an adult with suspected Eisenmenger syndrome in childhood. Four years previously (age 41 years), she was referred to our department due to repeated hemoptysis requiring further treatment of PAH. We started combination therapy with several pulmonary vasodilators. Two years later, her pulmonary vascular resistance (PVR) was improved but still not at the level where VSD closure was possible. To control the increased PA flow resulting from intensive PAH treatment and to reduce the risk of hemoptysis, we performed pulmonary artery banding (PAB). As the risk of hemoptysis decreased, a prostacyclin analog was introduced, and the dose was increased. More than 1 year after PAB, active vasoactivity testing became positive, suggesting that the pulmonary vascular lesion was now “reversible”. We performed VSD closure and atrial septal defect creation even though her PVR was still high. After the operation, her exercise capacity was remarkably improved. We suggest that stepwise surgical repair with pulmonary vasodilators is an important treatment option for select patients with VSD with severe PAH.

BackgroundTreatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) remain limited. Selexipag, an oral selective IP prostacyclin receptor agonist approved for pulmonary arterial hypertension, is a potential treatment option for CTEPH.MethodsIn this multicentre, randomised, double-blind, placebo-controlled study, 78 Japanese patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and/or balloon pulmonary angioplasty were randomly assigned to receive placebo or selexipag. The primary end-point was the change in pulmonary vascular resistance (PVR) from baseline to week 20. Secondary end-points were changes in other haemodynamic parameters: 6-min walk distance (6MWD), Borg dyspnoea scale score, World Health Organization (WHO) functional class, EuroQol five-dimension five-level tool and N-terminal pro-brain natriuretic peptide.ResultsThe change in PVR was −98.2±111.3 dyn·s·cm−5 and −4.6±163.6 dyn·s·cm−5 in the selexipag and placebo groups, respectively (mean difference −93.5 dyn·s·cm−5; 95% CI −156.8 to −30.3; p=0.006). The changes in cardiac index (pConclusionSelexipag significantly improved PVR and other haemodynamic variables in patients with CTEPH, although exercise capacity remained unchanged. Further large-scale investigation is necessary to prove the role of selexipag in CTEPH.

Objective Whether or not adaptive servo-ventilation (ASV) is effective in preventing arrhythmias in patients with heart failure (HF) due to ischemic heart disease (IHD) is unclear. This study estimated the effects of ASV therapy on arrhythmias in patients with HF due to IHD. Methods One hundred and forty-one consecutive hospitalized patients with HF due to IHD (mean age: 74.9±11.9 years old) were retrospectively assessed in this study. Of the 141 patients, 75 were treated with ASV (ASV group), and 66 were treated without ASV (Non-ASV group). We estimated the incidence of arrhythmias, including paroxysmal atrial fibrillation (PAF) and ventricular tachycardia (VT), during one-year follow-up in both groups using multivariable logistic regression models. Results Men accounted for 55.3% of the study population. There were no significant differences in the baseline clinical characteristic data between the ASV and Non-ASV groups with respect to age, sex, heart rate, risk factors, oral medication, or laboratory data, including the estimated glomerular filtration rate (eGFR), brain natriuretic peptide, and left ventricular ejection fraction. ASV therapy was associated with a reduced incidence of arrhythmia after adjusting for demographic and cardiovascular disease risk factors (odds ratio, 0.27; 95% confidence interval, 0.11 to 0.63; p

Background: Sleep-disordered breathing (SDB) is a cause of heart failure. Adaptive servo-ventilation (ASV) is one of the treatments for SDB. Recently, ASV has been applied to the treatment of patients with heart failure and SDB. The aim of this study was to estimate whether ASV therapy is effective and safe for patients with heart failure with reduced ejection fraction (HFrEF) compared with standard medical therapy in the real world, using three-year follow-up data.Methods: The patients with HFrEF (n=186) were treated with standard medical therapy plus ASV therapy (ASV group; n=57) or standard medical therapy alone (control group; n=129). We followed up the patients for 3 years.Results: The ASV group had significantly lower baseline left ventricular ejection fraction than the control group (27.9 ± 8.6% vs. 34.1 ± 8.8%; P

Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, improves cardiac sympathetic nerve activity (CSNA) in ischemic heart disease or chronic heart failure. However, its effects on CSNA and myocyte dysfunction in acute heart failure (AHF) remain unclear. We investigated the effects of adding intravenous nicorandil to standard therapy on CSNA and myocyte dysfunction in AHF.We selected 70 patients with mild to moderate nonischemic AHF who were treated with standard conventional therapy soon after admission. Thirty-five patients were assigned to additionally receive intravenous nicorandil (4-12 mg/h; group A), whereas the remaining patients continued their current drug regimen (group B). Delayed total defect score (TDS), delayed heart to mediastinum count (H/M) ratio, and washout rate (WR) were determined by (123)I-metaiodobenzylguanidine (MIBG) scintigraphy within 3 days of admission and 4 weeks later. High sensitivity troponin T (hs-TnT) level was also measured at the same time points.After treatment, MIBG scintigraphic parameters significantly improved in both groups. However, the extent of the changes in these parameters in group A significantly exceeded the extent of the changes in group B [TDS -11.3 ± 4.3 in group A vs -4.0 ± 6.0 in group B (p 0.01); H/M ratio 0.31 ± 0.16 vs 0.14 ± 0.16 (p 0.01); WR -13.8 ± 7.8 % vs -6.1 ± 8.9 % (p 0.01)]. The hs-TnT level decreased significantly from 0.052 ± 0.043 to 0.041 ± 0.033 ng/ml (p 0.05) in group A, but showed no significant change in group B. Moreover, in both groups, no relationships between the extent of changes in MIBG parameters and hs-TnT level were observed.Adding intravenous nicorandil to standard therapy provides additional benefits for CSNA and myocyte dysfunction over conventional therapy alone in AHF patients. Furthermore, the mechanisms of improvement in CSNA and myocyte dysfunction after nicorandil treatment in AHF patients were distinct.

Background and purposeIt is unclear whether adaptive servo-ventilation (ASV) is safe and effective in patients with severe systolic heart failure (HF). Our aim in this study was to estimate the safety and efficacy of ASV therapy for patients with severe systolic HF.Methods and subjectsSeventy-six HF patients (age: 69±12 years; 53 men), categorized as New York Heart Association (NYHA) Class II–IV, with left ventricular ejection fraction (LVEF) of

Background: Although adaptive servo-ventilation (ASV) therapy is considered clinically beneficial to patients with heart failure (HF), a large proportion of patients fail to show improvement in HF. We aimed to identify reliable markers indicative of a favorable response to ASV. Methods: We evaluated 103 consecutive patients with New York Heart Association (NYHA) class II–IV HF who were scheduled for ASV therapy for 3 months. Patients were classified as responders if their brain natriuretic peptide levels were decreased after 3 months. Results: Twenty-one patients (20.3%) failed to respond to ASV. No significant differences were observed between responders and nonresponders with regard to NYHA classification, age, gender, body mass index, drug therapy, and cardiovascular risk factors. Polysomnography showed no significant baseline differences between the 2 groups in the apnea–hypopnea index (AHI) and percent sleep time of oxygen saturation level below 90% (responders, 4.7% ± 9.2%; nonresponders, 3.7% ± 6.0%; P=0.68). The percent sleep time of oxygen saturation level below 90% is similar parameter as cumulative percentage of time at a pulse-oximetry oxygen saturation below 90% (CT90%) which is measured by in-home screening. We named it “Modified CT90%”. After ASV therapy for 3 months, NYHA classification remarkably improved in responder group. Logistic regression analysis revealed that improvement of modified CT90%

Background:Acute myocardial infarction (AMI) induces marked activation of the sympathetic nervous system. Fatty acid binding protein 4 (FABP4) is not only an intracellular protein, but also a secreted adipokine that contributes to obesity-related metabolic complications. Here, we examined the role of serum FABP4 as a pathophysiological marker in patients with AMI.Methods and results:We studied 106 patients presenting to the emergency unit with a final diagnosis of AMI, including 12 patients resuscitated from out-of-hospital cardiac arrest (OHCA) caused by ventricular fibrillation. FABP4 levels peaked on admission or just after percutaneous coronary intervention and declined thereafter. Regression analysis revealed no significant correlation between peak FABP4 and peak cardiac troponin T determined by Roche high-sensitive assays (hs-TnT). Notably, FABP4 levels were particularly elevated in AMI patients who were resuscitated from OHCA (median 130.2 ng/mL, interquartile range (IQR) 51.8–243.9 ng/mL) compared with those without OHCA (median 26.1 ng/ml, IQR 17.1–43.4 ng/mL), while hs-TnT levels on admission were not associated with OHCA. Immunohistochemistry of the human heart revealed that FABP4 is abundantly present in adipocytes within myocardial tissue and epicardial adipose tissue. An in vitro study using cultured adipocytes showed that FABP4 is released through a β3-adrenergic receptor (AR)-mediated mechanism.Conclusions:FABP4 levels were significantly elevated during the early hours after the onset of AMI and were robustly increased in OHCA survivors. Together with the finding that FABP4 is released from adipocytes via β3-AR-mediated lipolysis, our data provide a novel hypothesis that serum FABP4 may represent the adrenergic overdrive that accompanies acute cardiovascular disease, including AMI.

Background: Adaptive servo-ventilation (ASV) is used to treat sleep apnea in heart failure (HF). However, it is unclear whether ASV improves the long-term prognosis for all patients with HF, regardless of the severity of sleep-disordered breathing (SDB). We therefore aimed to estimate the long-term prognosis associated with ASV therapy for patients with HF by the severity of SDB.Methods: Sixty-one consecutive patients with HF (mean age ± standard deviation: 70 ± 10 years) were initiated on ASV therapy for HF treatment after polysomnography. Patients were then classified into the following three groups based on their apnea–hypopnea index (AHI): a severe group with an AHI of ≥40/h (n = 28); a moderate group with an AHI of ≥20/h but Results: No significant differences were observed between the three study groups in the risk of fatal cardiovascular events (p = 0.207).Conclusions: Our results suggest that ASV therapy is associated with a good prognosis and that ASV therapy is effective, regardless of the severity of SDB.

Background: It is unclear whether adaptive servo-ventilation (ASV) is effective for all patients with heart failure (HF). The aim of the present study was therefore to investigate the effectiveness of ASV for all patients with HF. Methods and Results: Sixty-one patients with HF were recommended for ASV treatment, regardless of sleep-disordered breathing (SDB) severity and type. On the basis of the apnea-hypopnea index (AHI) results, patients were classified into 3 groups: 28 patients with AHI ≥40/h were designated as group A; 20 patients with AHI ≥20/h and

Our aim in this study was to estimate the effectiveness of the integrated area of desaturation (IAD) index as a measure of sleep-disordered breathing (SDB) severity. The study comprised 98 patients with 36 old myocardial infarction (OMI), 40 with acute myocardial infarction (AMI), and 22 without myocardial infarction as control normal subjects. The ejection fraction was significantly lower (OMI: 48.3±14.6% vs. AMI: 56.0±10.5% vs. Control: 67.1±9.3%, p p p

We report a novel apolipoprotein A-I (apoA-I) mutation identified in a 64-year-old patient with marked plasma high density lipoprotein (HDL) cholesterol (4 mg/dl) and apoA-I (5 mg/dl) deficiency, prior myocardial infarction, and moderate corneal opacities. Coronary angiography revealed extensive atherosclerosis in all three major vessels. Genomic DNA sequencing of the proband revealed a homozygous novel deletion of two successive adenine residues in codon 138 in the apoA-I gene, resulting in a frameshift mutation at amino acid residues 138–178, which we have designated as apoA-I Tomioka. His elder brother was also homozygous for apoA-I Tomioka with marked HDL cholesterol and apoA-I deficiency, but had no clinical evidence of coronary heart disease. Other family members including three siblings and two sons were heterozygous for the mutation, and had approximately 50% of normal plasma HDL cholesterol, and apoA-I. Analysis of apoA-I-containing HDL particles by two-dimensional gel electrophoresis revealed undetectable apoA-I HDL particles in the homozygotes, while in heterozygotes, the mean concentrations of apoA-I in large α-1 and very small preβ-1 HDL subpopulations were significantly decreased at about 35% of normal. Thus, apoA-I Tomioka, a novel deletion mutation in codon 138 of the apoA-I gene, is the causative defect in this case of HDL deficiency.

This report describes a 77-year-old woman with a single coronary artery who suffered an acute anterior wall myocardial infarction. The single coronary artery arose from the right coronary artery through the transverse trunk, and there were no other cardiovascular anomalies. Coronary angiography did not reveal significant coronary artery stenosis in the left anterior descending artery. The patient was treated medically in the acute phase. She developed typical angina and evidence of myocardial ischemia, and underwent successful coronary artery bypass grafting in the chronic phase with anterior chest pain.

Fatty acid binding protein 4 (FABP4, also designated as adipocyte-FABP or aP2) has been described to be most exclusively expressed in adipocytes and macrophages. Circulating FABP4 levels have been linked to metabolic alternations that are associated adiposity. We have recently reported that FABP4 is

Adaptive servo-ventilation (ASV) is used as the device to treat not only sleep disordered breathing but also heart failure (HF) in Japan. Though arrhythmias often occur in HF patients, it is unclear that ASV is effective in preventing arrhythmias for patients with ischemic cardiomyopathy (ICM). Our

Objective Short-acting loop diuretics are known to enhance cardiac sympathetic nerve activity (CSNA) in patients with chronic heart failure (CHF). The effects of two loop diuretics—long-acting azosemide and short-acting furosemide—on CSNA were evaluated using 123I-metaiodobenzylguanidine (MIBG) scintigraphy in patients with CHF. Methods The present study was a subanalysis of our previously published study, which had reported that serial 123I-MIBG studies were the most useful prognostic indicator in patients with CHF. Patients with CHF (n=208, left ventricular ejection fraction

Background: Adaptive servo-ventilation (ASV) has been used as therapy for heart failure (HF). The objective of the present study was to estimate the effect of ASV on 1-year prognosis in HF patients. Methods and Results: After optimizing medical therapy, a 1-year follow-up study was conducted of 85 HF patients (mean age, 72±10 years; 46 men), categorized as New York Heart Association class II-IV. The patients were classified into 2 groups based on adherence to ASV therapy. Use of ASV for ≥4h/night was designated as good adherence, and use of ASV for

Objective Metabolic syndrome (MetS) is one of the coronary risk factors for cardiovascular disease and is closely related with sleep-disordered breathing (SDB). Our aim in this study was to estimate the relationship between sleep-related breathing events and coronary risk factors, including MetS. Methods We determined the prevalence of MetS in 195 patients with cardiovascular disease. Based on Japanese MetS criteria, 56 patients had MetS (Group A), whereas 139 patients did not (Group B). We assessed SDB and sleep-related breathing events, including nocturnal desaturation, in both groups using a type 3 apparatus (Morpheus®; Teijin Pharma Limited, Tokyo, Japan). Results Seventy-seven percent of the patients with MetS (43/56) met the criteria for SDB based on apnea hypopnea index (AHI). The AHI value was significantly greater in Group A than in Group B (30.1±19.0/hr vs. 17.7±14.7/hr; p

Sleep-disordered breathing (SDB) and cardiovascular disease (CVD) are closely related; however, the effect of SDB on the long-term prognosis of patients with CVD is unknown. Our aim in this study was to assess the association between SDB and fatal cardiovascular events in patients with CVD. We performed a long-term follow-up study of 135 patients with CVD. The average observation period was 610 +/- 268 days. The patients were classified into 2 groups based on their apnea index: patients with apnea indexor=5/h (Group H) were diagnosed with SDB (n = 43), and those with apnea index5/h (Group L) were diagnosed without SDB (n = 92). In Group H, obstructive sleep apnea (OSA) was diagnosed if obstructive apnea index wasor=5/h, and central sleep apnea was diagnosed if central apnea index wasor=5/h. Group H had a significantly lower survival rate than Group L (p0.005), particularly those with OSA in Group H (p0.0005). In a Cox proportional hazards model with presence of OSA, age, brain natriuretic peptide, left ventricular ejection fraction, and cardiovascular risk factors, the odds ratio of fatal cardiovascular events was 2.45 (95% confidence interval 1.26 to 5.08) for OSA (p0.01), which was associated with an increased risk of mortality. In conclusion, our results suggest that SDB is associated with a poorer long-term prognosis and that the presence of OSA is a strong predictor of fatal cardiovascular events in patients with CVD.

ASV (Adaptive-Servo Ventilator) is recognized as one of the effective option for treatment of heart failure, such as repeat readmission in treatment-resistant. In heart failure patients it is said that the Frank-Starling curve is improved by the adequate PEEP by ASV. However excessive PEEP leads to decrease in stroke volume (SV). It has been difficult to determine the value of the adequate PEEP in the clinical up to the present. To patient who introduced the ASV in our hospital, PEEP is raised adequate from 2cmH2O to 15cmH2O to assess the SV using AESCULON mini is a non-invasive cardiac output monitor. We will report on two cases which introduced ASV in heart failure due to ischemic heart disease. First case showed SV 48ml/CI 1.9L/min/m without using ASV, SV 53ml/CI 2.0 L/min/m in PEEP 5cmH2O, SV 63ml/CI 2.3 L/min/m in PEEP13cmH2O. It obtained the elevation of SV in PEEP 13cmH2O. Second case showed SV 60ml/CI 2.6 L/min/m 2 without using ASV, SV 55ml/CI 2.5 L/min/m in PEEP5cmH2O, SV 51ml/CI 2.3 L/min/m 2 in PEEP15cmH2O. Excessive PEEP leads to decrease in SV. PEEP is being fixed to 5cmH2O in the initial state of ASV. In many cases, it has been used without changing the settings. It may be important to adjust the PEEP setting for each case and condition.

Statin therapy reduces enhanced cardiac sympathetic nerve activity (CSNA) in patients with heart disease, and prevents left ventricular (LV) remodeling in chronic heart failure (CHF) patients. We sought to evaluate the effects of statin therapy on CSNA, as evaluated by 123I-metaiodobenzylgua

Adaptive servo ventilation (ASV) has been successfully used for treating heart failure (HF) in patients with central sleep apnea. However, it remains what factors are the most important predictors of fatal cardiovascular events after ASV therapy. The Integrated Area of Desaturation (IAD) index is

Summary Background and purpose In Japan, there are two sleep-disordered breathing (SDB)-related problems, which include diagnosing SDB using a portable device (PD) and treating mild-to-moderate SDB (mm-SDB) using continuous positive airway pressure (CPAP) for severe SDB (s-SDB) in obstructive sleep apnea (OSA) patients. Our aims were to evaluate the effectiveness of a PD in diagnosing SDB in patients with cardiovascular disease (CVD), and to assess the difference between mm-SDB [apnea-hypopnea index (AHI): 20–40 h−1] and s-SDB (AHI: >40 h−1) using brain natriuretic peptide (BNP) in OSA patients. Methods and subjects After their underlying CVD was treated, full-night sleep studies using polysomnography (PSG) and PD were performed on the same day. Results Eighty-three patients underwent full-night PSG simultaneously with PD. The average duration of the sleep study was 8.6 ± 6.2 days. There was a tendency for a higher AHI value obtained with PSG (PSG, 28.9 ± 24.3 h−1; PD, 22.3 ± 16.7 h−1; p = 0.05). However, the specificity and sensitivity of diagnosing SDB using PD were 86% and 81%, respectively. Using PD, twenty-nine OSA patients had mm-SDB and eleven patients had s-SDB. The BNP value was higher in the mm-SDB patients (318 ± 550 pg/ml) than in the s-SDB patients (202 ± 160 pg/ml). Conclusions The PD was effective in diagnosing SDB in patients with CVD. The BNP value was higher in the mm-SDB patients. Therefore, they need to be treated with CPAP to treat underlying CVD.