Search

Whether free fatty acids (FFAs), which are generators of reactive oxygen species and substrates of cytotoxic lipid peroxidation products in proximal tubules of the kidney, can be a predictor of worsening renal function (WRF) is not fully elucidated. A total of 110 patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention within 24 h after symptom onset were included. The exclusion criteria were out-of-hospital cardiac arrest, vasospastic angina, hemodialysis, and/or lack of data. FFAs and serum cystatin C were measured on admission, and urinary liver-type fatty acid-binding protein (L-FABP) was measured 3 h after admission. WRF, defined as an increase in serum creatinine by ≥ 0.3 mg/dL for 2-year follow-up, was observed in 16 patients (15%). A multivariate logistic regression analysis (a stepwise algorithm) revealed that the FFA level was an independent predictor of WRF (P = 0.024). The FFA level was associated with WRF adjusted after serum cystatin C (odds ratio [OR]: 1.378 per 1 mEq/L, P = 0.017), L-FABP (OR: 1.370 per 1 mEq/L, P = 0.016), or the Mehran contrast-induced nephropathy (CIN) risk score (OR: 1.362 per 1 mEq/L, P = 0.021). The FFA level was inversely associated with the change in estimated glomerular filtration rate level for 2 years (R2 = 0.051, P = 0.018). The FFA level on admission was associated with the mid-term WRF in patients with STEMI.

The vascular involvement in patients with Behcet's disease is defined as vascular Behcet's disease, which can greatly influence the prognosis. However, there are few reports on endovascular treatment (EVT) for subclavian pseudoaneurysms with long-term prognosis over 10 years. We present the case of a 42-year-old man with left subclavian artery pseudoaneurysm due to vascular Behcet's disease who was treated with EVT along with immunosuppressive therapies. Subsequently, 8 years after, the aneurysm recurred in the stent with stent fracture. Therefore, additional EVT was performed. We present the details of the patient's clinical course over 10 years after the EVT.

This study aimed to evaluate the characteristics and prognosis of patients with vasospastic angina (VSA) diagnosed by a provocation test with a secondary prevention implantable cardioverter defibrillator (ICD), compared with patients with organic coronary stenosis. We retrospectively evaluated 309 consecutive patients who received an ICD implantation between January 2010 and March 2018 in our institutions. Of these patients, 206 were implanted with an ICD for secondary prevention. In these 206 patients, 40 with VSA and 72 with organic coronary stenosis were evaluated. Patients with VSA were characterized by younger age (56.1 ± 13.1 versus 69.2 ± 9.5 years, respectively), and a lower prevalence of diabetes (15.0% versus 40.3%, respectively) and heart failure (2.5% versus 26.4%, respectively) than patients with organic coronary stenosis (P < 0.001). Using the Kaplan-Meier analysis, with the VSA group as the reference, the incidence of appropriate ICD shock was similar between the two groups (hazard ratio, 0.85; 95% confidence interval, 0.341-2.109; P = 0.722). The incidence of ventricular fibrillation was significantly higher in the VSA group (hazard ratio, 0.22; 95% confidence interval, 0.057-0.814; P = 0.024), whereas the incidence of major adverse cardiac events, including cardiac death, nonfatal myocardial infarction, hospitalization for unstable angina pectoris, and heart failure, was significantly higher in the organic coronary stenosis group (hazard ratio, 13.1; 95% confidence interval, 1.756-98.17; P = 0.012). In conclusion, patients with VSA with an ICD implanted for secondary prevention have a higher risk of ventricular fibrillation and lower risk of major adverse cardiac events than patients with organic coronary stenosis.

BACKGROUND In the treatment of adult congenital heart disease (ACHD), the transfer of patients from pediatric cardiologists to ACHD cardiologists is of relevance. However, little is known about the clinical courses of ACHD patients that have been referred by non-CHD-specialized doctors (n-CSDs). METHODS This retrospective cohort study included 230 patients (average age: 37 ± 15.2 years, male: 97) who were referred to a single specialized ACHD center between April 2016 and July 2019. We compared the characteristics and clinical courses between patients referred by n-CSDs and those referred by CHD-specialized-doctors (CSDs). RESULTS Overall, 121 (53%) patients were referred by n-CSDs. Among them, 91 (75%) patients were referred by adult cardiologists. Univariate analysis showed that the patients referred by n-CSDs were older than those referred by CSDs (41.6 ± 16.3 vs. 32.0 ± 12.0 years, p

A 54-year-old male with a history of unrepaired ventricular septal defect (VSD) suffered from easy fatigability on exertion. A Levine grade V/VI continuous murmur was auscultated. Transthoracic echocardiogram showed a ruptured sinus of Valsalva aneurysm (SVA) and a significant left-to-right shunting from the ascending aorta to the right ventricle (RV). In addition, a 36 mmHg of pressure gradient was observed between the inflow and outflow tract in the RV, suggesting double-chambered RV (DCRV). Cardiac catheterization also revealed 33 mmHg of the pressure gradient in the mid-potion of the RV, which was coincident with DCRV. A calculated pulmonary-to-systemic flow ratio was 3.0. Therefore, the patient was offered surgical repair of the ruptured SVA and VSD, which was successfully performed. During the surgery, an anomalous muscle band, which is usually the cause of DCRV, was not found, instead, a thickened RV free-wall due to the exposure of the left-to-right shunt flow, so-named jet lesion, was found. Therefore, surgical resection of the anomalous muscle band was not required. The protruded SVA toward the RV, the jet lesion, and the increased RV stroke volume, which could induce relative stenosis, were the causes of the unusual DCRV.

A 20-year-old male without any symptoms was referred for heart murmur on a medical examination. A thrill was palpable at the upper left sternal border. His cardiac murmur showed respiratory variation. The systolic murmur was louder (Levine grade IV/VI) during expiration and diminished during inspiration (Levine grade I/VI). He was thin and had a narrow thoracic cage in the anteroposterior direction due to straight back syndrome (SBS). An echocardiogram and a right ventriculogram showed changes in the diameter of the right ventricular outflow tract (RVOT) on respiration. During expiration, the RVOT was compressed and narrow, while it was expanded during inspiration. Cardiac catheterization demonstrated a 10-mmHg of pressure gradient across the RVOT during expiration but no pressure gradient during inspiration. Thus, respiratory compression to the RVOT by a narrow thoracic cage due to SBS was the cause of the cardiac murmur with respiratory alterations. Our case highlights the importance of physical examination, including an inspection of the patient’s physique.

The incidence of ventricular arrhythmia in patients with an implanted pacemaker is not yet known. The aim of this study was to analyze non-sustained ventricular tachycardia (NSVT) episodes based on stored electrograms (EGM) and determine the occurrence rate and risk factors for NSVT in a pacemaker population.This study included 302 consecutive patients with a dual-chamber pacemaker. A total of 1024 EGMs stored in pacemakers as ventricular high-rate episodes were analyzed. The definition of NSVT was ≥ 5 consecutive ventricular beats at ≥ 150 bpm lasting < 30 seconds.In baseline, most patients (94.8%) had ≥ 60% left ventricular ejection fraction. Of 1024 EGMs, 420 (41.0%) showed appropriate NSVT episodes, as well as premature atrial contractions, atrial tachyarrhythmia, or atrial fibrillation with a rapid ventricular response, whereas other EGMs did not show an actual ventricular arrhythmia. On EGM analysis, during a mean follow-up period of 46.1 months, NSVT occurred one or more times in 82 patients (33.1%). On multivariate analysis, ≥ 50% right ventricular pacing was an independent risk factor for NSVT (odds ratios, 4.519; P < 0.001), but NSVT was not associated with increased all-cause mortality.Moreover, in the pacemaker population, ≥ 50% right ventricular pacing is an independent risk factor for NSVT; however, NSVT was not associated with increased all-cause mortality because of the preserved left ventricular function.

Background The efficacy and bleeding complications of direct oral anticoagulant (DOAC) therapy for cancer-associated venous thromboembolism (VTE) in routine clinical practice remain unclear. Moreover, data on long-term outcomes in patients with cancer-associated VTE who received DOAC therapy are limited.Methods and Results:This retrospective study enrolled 1,096 consecutive patients with acute VTE who received warfarin or DOAC therapy between April 2014 and May 2017. The mean follow-up period was 665±490 days. The number of cancer-associated VTE patients who received DOAC therapy was 334. Patients who could not be followed up and those prescribed off-label under-dose DOAC were excluded. Finally, 303 patients with cancer-associated VTE were evaluated. The number of cases of major bleeding and VTE recurrence was 54 (17.8%) and 26 (8.6%), respectively. In the multivariate analysis, the factors correlated with major bleeding were high cancer stage, high performance status, liver dysfunction, diabetes mellitus, and stomach cancer; those correlated with recurrent VTE were initial diagnosis of pulmonary embolism, uterine cancer, and previous cerebral infarction. Major bleeding was an independent risk factor of all-cause death. In the Kaplan-Meier analysis, those who received prolonged DOAC therapy had lower composite major bleeding and recurrent VTE risks than those who did not. Conclusions In DOAC therapy for cancer-associated VTE, major bleeding prevention is important because it is an independent risk factor of death.

The aim of the present study was to determine whether urinary 8-hydroxydeoxyguanosine (8-OHdG), which is a marker of oxidative stress, can predict future cardiovascular death in patients with acute coronary syndrome (ACS). A total of 551 consecutive patients with ACS who underwent admission urinary 8-OHdG measurements were enrolled in this study. The patients were divided into 2 groups according to the optimal cutoff value of admission urinary 8-OHdG determined by a receiver-operating characteristics curve for the prediction of cardiovascular death: a high admission urinary 8-OHdG group, 169 patients with admission urinary 8-OHdG ≥ 17.92 ng/mg creatinine; and a low admission urinary 8-OHdG group, 382 patients with admission urinary 8-OHdG

Background The importance of advance care planning (ACP) has been recognized in the palliative care of patients with heart failure. It is necessary for dissemination of ACP to characterize the perceptions of physicians and nurses towards ACP and to promote mutual understanding. The aim of this study is to investigate the perceptions of physicians and nurses concerning ACP for patients with heart failure. Methods We conducted a self-administered questionnaire survey with physicians and nurses who belonged to the 427 certified institutions for implantable cardioverter defibrillator (ICD) and/or cardiac resynchronization therapy (CRT) in Japan. The self-administered questionnaire was originally designed based on the guidelines on palliative care or ACP and previous studies on the barriers of ACP. We asked the participants the recognition about condition/timing to implement ACP, Content of care to be implemented in ACP, and barriers against implementing ACP. A Mann-Whitney U test was performed and r value was calculated an effect size (ES) in order to evaluate the characteristic perceptions among physicians and nurses. Results Valid responses were obtained from 163 physicians (38.2%) and 208 nurses (48.7%). Regarding the condition/timing, nurses tended to recognize that ACP should be implemented from earlier clinical stages than physicians. Regarding the contents of ACP, both physicians and nurses placed emphasis in assessing the patient's perception of disease progression. The biggest difference was found in the item "Ask patient about what has been important in life so far"; 78.6% of physicians but 94.2% of nurses chose "it must/should be implemented" (Cohen's r=0.31). Regarding the barriers, both physicians and nurses recognized the difficulty in prognosis prediction. The biggest differences were found in the items "Medical staff does not know how to implement ACP for patients and their families" (45.6% of physicians and 70.4% of nurses chose "strongly agree/agree", r=0.27), and "There is disagreement regarding care goals among team members of different professions" (18.5% in physicians and 43.3% in nurses, r=0.27). Conclusions It is suggested that discussions and further studies are necessary concerning the condition/ timing of implementing ACP from early stages, specific manuals/protocols and recommendation on rolesharing within a multidisciplinary team.

Adiponectin (APN) has cardioprotective properties and bisoprolol has been reported to increase myocardial APN expression and reduce myocardial damage. Administration of landiolol, which has a higher cardio-selectivity and shorter half-life than bisoprolol, during the percutaneous coronary intervention (PCI) may increase serum APN and high-molecular weight (HMW)-APN, an active form of APN, in patients with stable angina pectoris (SAP). We recruited 70 patients with SAP and randomized them to intravenous landiolol during PCI (N = 35) or control group (N = 35). The primary endpoint was serum APN and HMW-APN level 3 days after PCI. There was no difference in the primary endpoint between the landiolol and control groups (8.93 ± 5.24 vs. 10.18 ± 5.81 μg/mL, p = 0.35 and 3.36 ± 2.75 vs. 4.28 ± 3.13 μg/mL, p = 0.20) for APN and HMW-APN levels, respectively. APN and HMW-APN level were significantly decreased 1 day after PCI [−0.55 ± 0.92 μg/mL (9.87–9.32 μg/mL), p

The patient was a 19-year-old woman who had experienced headache for 1 year. Soon after birth, ventricular septal defects were diagnosed, the size of which were small, therefore not requiring surgical repair. She also noticed hypertension, with up to 184/110 mmHg of blood pressure. Her physical examination revealed a difference in blood pressure between her upper and lower limbs (160/108 and 92/65 mmHg, respectively). A cardiac computed tomography image clearly demonstrated the narrowing of the aortic isthmus. Coarctation of the aorta (CoA) was definitively diagnosed and was the cause of the upper limb hypertension and headache. Cardiac catheterization revealed 3.8 mm of the aortic isthmus and 65 mmHg of the peak-to-peak pressure gradient across the CoA. The patient was offered endovascular therapy of the CoA. A non-covered stent implantation was successfully performed and the pressure gradient across the aortic isthmus disappeared. Her upper limb hypertension also improved. Aortic angioscopy revealed a yellow plaque on the aortic intima, located proximal to the coarctation site, which was exposed owing to high blood pressure. Our case highlights that an atherosclerotic change can develop even in young patients with hypertension.

A 76-year-old male was admitted to our hospital for progressive bilateral pleural effusion. Because of typical echocardiographic findings such as left ventricular (LV) hypertrophy, thickness of the mitral valve, and a granular sparkling appearance of the LV wall, amyloid cardiomyopathy was suspected. Regardless of up-titration of several diuretic agents, the bilateral pleural effusion did not improve. Because the histological findings of the right ventricular septum (direct-fast-scarlet staining) obtained by biopsy that demonstrated amyloid deposits in perivascular and pericellular lesions, amyloid cardiomyopathy was diagnosed. However, cardiac catheterization revealed normal right and left atrial pressure and normal right and left ventricular end-diastolic pressure. Therefore, hemodynamic deterioration was less likely to be the cause of persistent pleural effusion. Amyloid deposits were also detected in the pleural biopsy specimen, so pleural amyloidosis was diagnosed and may have played an important role in the refractoriness of the pleural effusion.

The Diamondback 360® coronary orbital atherectomy system (OAS) can safely debulk calcified lesions by pullback of the crown, if the crown is advanced to the distal of the lesion. The aim of this study was to compare crossability with two types of crown in OAS. Thirty-six consecutive severely calcified lesions in 33 patients who underwent percutaneous coronary intervention with the coronary OAS were included. The micro crown was used in 18 consecutive lesions from April 2018 to February 2019, and the classic crown with the glide assist was used in 18 consecutive lesions from March 2019 to August 2019. Good crossability was defined as the ability to cross the lesion before orbital atherectomy or to cross the lesion with a first session of orbital atherectomy. We also tried to elucidate whether the crown could cross the lesion without using the glide assist in 13 consecutive lesions at the end of the classic crown cases. Good crossability was more often observed in cases with the classic crown (17 of 18 lesions, 94%) than the micro crown (6 of 18 lesions, 33%) (P

Background: The efficacy and bleeding complications of direct oral anticoagulant (DOAC) therapy for isolated distal deep vein thrombosis (IDDVT) associated with cancer in routine clinical practice remain unclear. Moreover, prior studies on prolonged therapy for IDDVT are limited. Methods: This retrospective study enrolled 1641 consecutive patients with acute venous thromboembolism (VTE) who had received oral anticoagulant therapy, including warfarin or DOAC, between April 2014 and September 2018 in our institutions. In these patients, 200 patients with cancer-associated IDDVT were evaluated. Results: Mean follow-up period was 780 ± 593 days. Major bleeding and VTE recurrence were observed in 22 (11.0%) and 11 (5.5%) patients, respectively. In multivariate analysis, statistically significant factors correlated with major bleeding were advanced cancer stage, high performance status, stomach cancer, and gallbladder cancer; those correlated with all-cause death were advanced cancer stage, high performance status, liver dysfunction, pancreatic cancer, and major bleeding. Cumulative events of major bleeding and recurrence between patients with prolonged DOAC therapy (≥90 days) and those with nonprolonged therapy were not significantly different. Conclusions: Preventing major bleeding is important because it is a significant risk factor for all-cause death. Major bleeding and recurrent events were comparable between prolonged and nonprolonged therapy.

A 56-year-old man was admitted with a diagnosis of non-ST-segment elevation myocardial infarction, after surgery for total arch replacement, aortic root replacement with a mechanical aortic valve, and coronary artery reconstruction by the Piehler method for acute aortic dissection. Coronary angiography (CAG) revealed a 99% stenosis of the anastomosis site between the J Graft (Japan Lifeline, Tokyo, Japan) and the saphenous vein graft (SVG), which was distally sutured to his right coronary artery (posterior descending artery). After percutaneous coronary intervention (PCI) with a drug-eluting stent to the anastomosis site, repeated in-stent restenosis unfortunately occurred. Despite repeated PCIs, he was again admitted due to exertional angina pectoris, with proven inferior myocardial ischemia by stress myocardial perfusion imaging. We therefore decided to use a coronary covered stent for the anastomosis site to seal neointimal proliferation. GRAFTMASTER 2.8/19 mm (Abbott, CA, USA) was implanted in the anastomosis site, and a follow-up CAG one-year later revealed that the covered stent was clearly opened. To the best of our knowledge, this is the first paper to demonstrate the usefulness of a covered stent for repeated restenosis of the anastomosis site between SVG and graft prostheses.

A 75-year-old male suffered from dyspnea on exertion. In a referring hospital, cardiac catheterization demonstrated a 25% increase in oxygen saturation between the high superior vena cava (SVC) and the right atrium, suggesting a pre-tricuspid left-to-right shunt. However, neither an intracardiac shunt nor a partial anomalous pulmonary venous connection was detected. Therefore, he was referred to our hospital for further evaluation. A transesophageal echocardiogram revealed a retrograde-dominant bidirectional flow in the right upper pulmonary vein (RUPV). A contrast agent injected via the left upper limb appeared in the SVC and thereafter some contrast entered into the RUPV. A three-dimensional reconstructed computed tomography showed a side-to-side communication between the RUPV and the SVC. A cavopulmonary window was definitively diagnosed, in which the RUPV not only drained into the left atrium but also connected to the SVC side-to-side.

Recent pacemakers with transthoracic impedance sensors have a specific algorithm identifying sleep apnea (SA). Our aim was to evaluate the algorithm in Japanese patients.Consecutive patients implanted with a pacemaker with sleep apnea monitoring algorithm at our hospital were enrolled prospectively. After implantation, patients underwent polysomnography (PSG). The respiratory disturbance index measured by pacemaker (RDI-PM) was extracted in the morning after PSG.Forty-five patients were recruited; 78% of patients underwent overnight PSG completely, and among them RDI-PM was invalid for one patient. Then the analysis was performed in 34 patients. Moderate/severe SA (apnea hypopnea index, AHI≥15events/h) and severe SA (AHI≥30events/h) by PSG were diagnosed in 65% and 41% of patients. The mean AHI-PSG and RDI-PM were 30.4±22.6 and 21.7±14.2events/h, respectively. There was a significant positive correlation between AHI-PSG and RDI-PM (r=0.543; p=0.001). The correlation was stronger in the severe SA group (r=0.664; p=0.010), in a group whose apnea index was higher than hypopnea index (r=0.822; p=0.002), and in a group whose central sleep apnea (CSA) index was higher than obstructive sleep apnea index (r=0.977; p0.001). RDI-PM cut-off value for identifying severe SA was 22 (area under the curve, 0.682; sensitivity, 64%; specificity, 75%).The pacemaker-based algorithm is a useful screening tool for SA in Japanese individuals, especially in the severe SA group, apnea-dominant group, and CSA-dominant group.

1 Current status of non‐pharmacotherapies in Japan Pacemaker treatment for bradyarrhythmia was first approved for national health insurance coverage in Japan in 1974, and its use rapidly became widespread thereafter. Approximately 40 years later, in 2017, the number of patients treated with this technology has increased to 60 137 (41 895 new cases and approximately 18 242 replacements). 5 Capsule‐shaped leadless pacemaker also became available in 2016, and this technology is being established as a new option. Non‐pharmacological treatment of tachy‐arrhythmia began in 1969 from when Will C. Sealy performed surgery in patients with Wolff‐Parkinson‐White (WPW) syndrome (Figure 1). Since then, the application of surgical treatment has expanded to conditions such as ventricular tachycardia (VT) and atrial fibrillation (AF), and surgery has been the pioneer of radical therapy for tachyarrhythmias. At the present time, many surgical methods have been replaced by catheter ablation; however, surgical treatment still remains an indispensable option for patients with a tachycardia resistant to other medical treatments. Open in a separate window FIGURE 1 History of non‐pharmacotherapy of cardiac arrhythmia

Background Transseptal puncture and pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) are generally performed via the inferior vena cava (IVC). However, in cases where the IVC is inaccessible, a specific strategy may be needed. Case summary An 86-year-old woman with paroxysmal AF and an IVC filter in situ was referred to our hospital for ablation therapy. An IVC filter for pulmonary embolism and deep venous thrombosis had been implanted 15 years prior, therefore we selected a transoesophageal echocardiography (TOE)-guided transseptal puncture using a superior vena cava (SVC) approach. After the single transseptal puncture, we performed fast anatomical mapping, voltage mapping by multipolar mapping catheter, and then PVI by contact force-guided radiofrequency catheter using a steerable sheath. Following the ablation, bidirectional conduction block between the four pulmonary veins and the left atrium was confirmed by both radiofrequency and mapping catheter. No complications occurred and no recurrence of AF was documented in the 12 months after the procedure. Discussion When performing a transseptal puncture during AF ablation, an SVC approach, via access through the right internal jugular vein, enables the sheath to directly approach the left atrium without angulation and improves operability of the ablation catheter. Combining the use of general anaesthesia, TOE, a steerable sheath, and contact force-guided ablation may contribute to achieving minimally invasive PVI with a single transseptal puncture via an SVC approach.

Introduction Radiofrequency (RF) ablation for ventricular arrhythmia in patients with reduced left ventricular ejection fraction (LVEF) is recognized to be one of the important strategies for suppressing the fatal arrhythmia events. Although, RF ablation for those patients has been performed for decades, the optimal endpoint remains unclear. Hypothesis We assessed the hypothesis that non-inducibility of any ventricular tachycardia (VT) or ventricular fibrillation (VF) immediately after VT ablation predicts long-term recurrence free rate of ventricular arrhythmia in patients who were diagnosed sustained VT with reduced LVEF. Methods From January 2014 to August 2019, we conducted a single center retrospective analysis for 127 consecutive patients with right or left ventricular arrhythmia who performed the first time RF ablation. Exclusion criteria were LVEF >50% and RF ablations for premature ventricular contraction or for non-sustained VT. Then 26 patients (age 69 ± 7, male 92%) were enrolled. All of the ablation procedures were performed using irrigated RF catheters and 3D mapping systems. We defined non-inducible group as the patients without monomorphic VT (clinical monomorphic VT or non-clinical monomorphic VT with any cycle length), polymorphic VT and VF by electrophysiological study (EPS) immediately after the ablation. The primary endpoint of this study was a recurrence of any sustained VT and VF during the follow up period. Results All of 26 patients were followed for a mean of 30.9 ± 22.3months.Of those patients, 7 patients were non-inducible group and 19 patients were inducible group. Age, sex, body mass index, coronary risk factors, LVEF (non-inducible:42 ± 5% vs inducible:35 ± 10%, p = 0.12), renal function and the etiology of LV dysfunction did not differ between patients with non-inducible group and inducible group (all non-significant). Catheter ablation procedural characteristics including activation mapping (non-inducible:29% vs inducible:36%, p = 1.00), entrainment mapping (14% vs 42%, p = 0.19), substrate mapping (86% vs 95%, p = 0.47), pace-mapping (86% vs 68%, p = 0.63), RF time (21 ± 13vs 18 ± 21min, p = 0.70), number of RF applications (27 ± 13vs 27 ± 32, p = 0.89), fluoroscopy time (77 ± 50vs 87 ± 42min, p = 0.59) and procedure time (309 ± 87vs 282 ± 61min, p = 0.37) did not differ between two groups. Medications before and after the VT ablation did not differ between two groups. The recurrence of any sustained VT and VF significantly lower in patients with non-inducible group than those with inducible group (Figure). Conclusion This study demonstrated that, in patients with reduced LVEF presenting sustained VT who performed RF ablation, non-inducibility of any VT and VF immediately after RF ablation predicts long-term decreased risk of recurrence of any sustained VT and VF. Not only clinical but also non-clinical VT and VF may be targeted as well at the first time VT ablation for those patients. Abstract Figure

Background Pulmonary vein isolation (PVI) with radiofrequency ablation (RFA) is one of the important procedures for atrial fibrillation (AF). Attaining the stability of RFA, respiratory management and pain control during the procedure are required. Purpose We compared the characteristic parameters and procedural outcomes between general anesthesia and moderate (conscious) sedation in patients with AF performed RFA. Methods We performed a retrospective, 2-center observational study to compare the general anesthesia with moderate sedation during RFA on AF from January 2018 until December 2018. In general anesthesia group, we administrated propofol and muscle relaxants under mechanical ventilation. In moderate sedation group, we administrated dexmedetomidine and/or propofol with analgesic drug. Procedural time of AF ablation, first-pass PVI (pulmonary vein isolation after completing the right or left circle) were assessed. Results A total of 98 patients with mean age 66 ± 11 years were enrolled (80 males, 81%). Of these, 19 patients were performed RFA under general anesthesia and 79 patients were performed under moderate sedation. Age, gender, BMI, medications before admission and CHADs2 score (general anesthesia:1.9 ± 1.2 vs moderate sedation:1.5 ± 1.1, p = 0.14), left atrium diameter (40.2 ± 6.2 vs 40.6 ± 6.8 mm, p = 0.81) and proportion of paroxysmal AF (47.4 vs 54.4%, p = 0.61) were similar between two groups. Our study found catheter RFA with general anesthesia to be associated with reduced procedural time (161 ± 29 vs 241 ± 58 minutes, p Conclusions RFA under general anesthesia improved first-pass PVI (quality of PVI) and shortened procedural time. General anesthesia may attribute to attaining the catheter and patient stability during RFA for PVI.

Endothelial dysfunction and increased arterial stiffness gradually develop before the manifestation of catastrophic cardiovascular events. Therefore, detection and assessment of vascular function are required to address pre-existing pathological conditions. However, the currently available diagnostic devices and methods are insufficient due to variability among investigators and the time-consuming nature of manual procedures.Recently, novel devices were developed for the detection of both arterial stiffness and endothelial dysfunction in a single blood pressure measurement using a cuff-oscillometric technique (AVE-1500, Shisei Datum, Japan). API (arterial pressure volume index) is defined as the reciprocal of the slope of the tangent of the brachial artery pressure-volume curve, and AVI (arterial velocity pulse index) is defined as the ratio of the difference between the ejection and reflection waves. In the present study, we performed retrospective, cross-sectional analyses of subjects (n = 102; mean age = 70.5 ± 10.4 years) with detailed coronary angiographic examinations and clinical background parameters.After adjusting for various variables using multiple linear regression analyses, we found that API, but not AVI, was significantly correlated with coronary artery severity and complexity scores.We propose that API may be a new vascular index useful for monitoring and assessing the severity and complexity of atherosclerosis in subjects with coronary artery disease and for evaluating atherosclerotic diseases.

Background Sleep-disordered breathing (SDB) is associated with cardiovascular complications. However, the effect of SDB on renal function in patients with acute coronary syndrome (ACS) treated by percutaneous coronary intervention (PCI) remains unclear. Methods We enrolled 154 consecutive ACS patients without heart failure. A sleep study was performed immediately after PCI. Results The mean apnea-hypopnea index (AHI) was 16.4 ± 13.1, and 33 patients (21%) had severe SDB, defined as AHI ≥ 25. Estimated glomerular filtration rate (eGFR) values on admission (60 ± 12 mL/min/1.73 m2 vs. 67 ± 17 mL/min/1.73 m2, p = 0.046) and at discharge (54 ± 15 mL/min/1.73 m2 vs. 63 ± 15 mL/min/1.73 m2, p = 0.002) were lower in patients with severe SDB than in those patients without severe SDB. Multiple linear regression analysis showed that AHIs were significantly correlated with absolute changes in eGFR values from admission to discharge (β = 0.201, p = 0.004). Median 24-h urinary noradrenaline excretion measured on the same day of the sleep study was higher [297 (interquartile range {IQR}: 232–472) vs. 174 (IQR: 107–318) μg/day, p = 0.021] in patients with severe SDB. On multivariate logistic regression analysis, the presence of severe SDB was a significant predictor (adjusted odds ratio 3.76, 95% confidence interval 1.06–13.9, p = 0.047) for eGFR of less than 45 mL/min/1.73 m2 at discharge. This association was independent of age, eGFR on admission, and a presentation of ST-segment elevation myocardial infarction. Conclusion In patients with ACS who undergo PCI, severe SDB is associated with impaired renal function on admission and its deterioration during hospitalization. Further studies will be needed to conclude that SDB would be a therapeutic target in ACS.

Background A global study designed to demonstrate the safety and efficacy of a transcatheter pacing system included 38 Japanese patients enrolled at 4 sites. Subgroup analysis to evaluate the performance of the leadless intracardiac transcatheter pacing system in Japanese patients was performed.Methods and Results:Safety and efficacy outcomes, patient and implant procedure characteristics, and patient and physician acceptability from the Japanese population were compared with those from outside Japan. Differences in patient characteristics, implant procedure characteristics and patient acceptability were observed. There were no major complications in Japanese patients and pacing thresholds remained low and stable throughout follow-up. There were no observable differences between Japanese patients and patients from outside Japan in the freedom from major complication rate at 12-months post-implant (100.0% vs. 95.7%, P=0.211) or physician acceptability. Conclusions Although some differences in specific baseline characteristics, such as body size and pacing indication, and in implant procedure characteristics, including anticoagulation strategy and hospitalization period, were observed in the Japanese patients, transcatheter pacemaker performance was similar to that in the global trial. (Clinical Trial Registration: ClinicalTrials.gov ID NCT02004873.).

A 17-year-old woman was resuscitated from cardiac arrest due to ventricular fibrillation and was diagnosed with concealed long QT syndrome. She underwent subcutaneous implantable cardiac defibrillator (S-ICD) implantation at our hospital. The device electrogram immediately after implantation was normal. Four days after implantation, she received an inappropriate shock. The device interrogation revealed a continuous baseline shift and frequent oversensing for low amplitude signals, followed by a shock. A chest radiograph in the orthogonal view showed entrapped subcutaneous air surrounding the distal electrode. Entrapped subcutaneous air can cause inappropriate shocks in the early period after S-ICD implantation.

Background An early IV beta blocker during primary percutaneous coronary intervention (PCI) has been shown to reduce infarct size in ST-segment elevation acute myocardial infarction (STEMI), although the underlying mechanism is unknown. The aim of this study was to investigate the efficacy of early infusion of landiolol, the short-acting beta-1 adrenergic receptor blocker, on the reperfusion status in a STEMI. Methods We conducted a prospective, single-group trial of landiolol during the primary PCI for a STEMI. Landiolol was started intravenously just before reperfusion. The reperfusion status and outcomes in 55 treated patients were compared with those in 60 historical controls treated without landiolol. The optimal reperfusion was assessed by an ST-segment resolution (STR), coronary flow, and myocardial brush grade (MBG) after reperfusion. Results Patients in the landiolol group achieved a higher rate of an STR (64% vs. 42%, p =0.023) and MBG 2/3 (64% vs. 45%, p =0.045), whereas coronary flow was comparable between the two groups. A multivariate analysis showed that landiolol use was an independent predictor of an STR (odds ratio 2.99, 95% confidence interval 1.25–7.16, p =0.014). The incidence of non-sustained ventricular tachycardia (27% vs. 50%, p =0.014), hypotension (15% vs. 32%, p =0.046), and progression to Killip class grade III or IV (0% vs. 10%, p =0.028) were lower in the landiolol group. Conclusion Early infusion of landiolol during the primary PCI was associated with optimal reperfusion and a lower incidence of adverse events in comparison with the control group.

Some experimental studies have shown that direct oral anticoagulants (DOACs) have anti-inflammatory effects. However, the interval changes in inflammatory markers in patients with non-valvular atrial fibrillation (AF) who receive DOACs remain unknown. Between July 2013 and April 2014, a total of 187 AF patients randomly assigned to receive rivaroxaban (n = 91) or dabigatran (n = 96) were assessed for eligibility. The levels of the following inflammatory markers were serially evaluated: high-sensitivity C-reactive protein, pentraxin-3, interleukin (IL)-1β, IL-6, IL-18, tumor necrosis factor-α, monocyte chemotactic protein-1, growth and differentiation factor-15, and soluble thrombomodulin (sTM). The aim in this study was to evaluate the anti-inflammatory effects of rivaroxaban and dabigatran in patients with AF, in addition to the impact of markers on bleeding events. Finally, 117 patients (rivaroxaban: n = 55, dabigatran: n = 62) were included in the analysis at 12 months. Although the interval changes in sTM levels tended to be greater in the dabigatran group [0.3 (0–0.7) vs. 0.5 (0–1.0) FU/ml, p = 0.061], there were no significant differences in the interval changes in any inflammatory marker between 2 groups. There were no significant differences in bleeding events between 2 groups. The interval changes in sTM levels were significantly greater in patients with bleeding compared with those without [0.8 (0.5–1.3) vs. 0.4 (− 0.1–0.8) FU/ml, p = 0.017]. There were no significant differences in the interval changes in any inflammatory marker between rivaroxaban and dabigatran treatments in patients with AF. The increased levels of sTM after DOACs treatment might be related to bleeding events.

Background The incidence of atrioventricular block (AVB) in pacemaker patients with sick sinus syndrome (SSS) is not yet known. The aim of this study was to analyze AVB episodes in SafeR mode based on stored electrograms (EGM), and determine the occurrence rate and risk factors for advanced AVB in a pacemaker population with SSS. Methods and results The study included 50 consecutive patients with SSS without a history of advanced AVB who had a dual-chamber pacemaker programmed in SafeR mode. A total of 377 EGM stored in the pacemakers as AVB episodes fulfilling the second- or third-degree criterion were analyzed. Of 377 EGM, 73 EGM (19.4%) were appropriate episodes, whereas the other EGM did not show actual AVB, and showed atrial tachyarrhythmia, ventricular event in the blanking period, or premature atrial contractions with block. On EGM analysis, advanced AVB occurred in 9 patients (18%), and the occurrence rate was 11.7% per year. Moreover, on multivariate analysis β-blocker use was an independent risk factor for advanced AVB (OR, 9.10; P=0.004). Conclusions The occurrence rate of advanced AVB in patients with SSS is much higher than previously reported, and β-blocker use is an independent risk factor for advanced AVB. SafeR is useful to detect latent AVB. Stored EGM, however, sometimes include inaccurately classified events.

BACKGROUND The characteristics and prognosis of implanted pacemaker-identified new-onset atrial fibrillation (AF) in Japanese people has not been well evaluated.Methods and Results:A total of 395 consecutive patients with newly implanted pacemakers were retrospectively analyzed between January 2010 and December 2015 at Yokohama City University Hospital. Patients with a prior history of AF, VVI mode pacemaker, congenital heart disease, severe valvular heart disease, and cardiovascular surgery before pacemaker implantation were excluded. Among the remaining patients, 44 (21.3%) developed new AF during follow-up (mean follow-up, 1,115±651 days; range, 9-2,176 days). Patients with new-onset AF had a significantly higher CHADS2score (2.09±1.27 vs. 1.31±1.08, P

Patients with corrected transposition of great arteries (c-TGA) are generally known to develop atrioventricular block, systemic right ventricular dysfunction, and tricuspid regurgitation over time, which are associated with tachyarrhythmia and progressive heart failure. A 76-year-old man had been diagnosed with c-TGA. He developed a cardiopulmonary arrest while playing tennis, and an automated external defibrillator detected ventricular fibrillation (VF). Immediate cardiopulmonary resuscitation and intensive treatment were performed. He fully recovered without neurological sequelae. QRS duration was 172ms. Echocardiography showed marked dysfunction and dyssynchrony of the systemic right ventricle (systemic right ventricular end-diastolic diameter/end-systolic diameter=73/60mm, systemic right ventricular ejection fraction=34%). For secondary prevention and treatment of progressive heart failure, cardiac resynchronization therapy with defibrillator (CRT-D) implantation was recommended. Venography via the left cubital superficial vein revealed a persistent left superior vena cava (PLSVC) and giant coronary sinus that did not connect with the right superior vena cava (SVC). Because of the acute angle between the PLSVC and great cardiac vein, we selected a right-sided approach via the right SVC. We were finally able to deliver a coronary sinus lead to the lateral vein. CRT-D implantation can be achieved even in patients with c-TGA and PLSVC. Learning objective: CRT-D implantation can be achieved even in a patient with c-TGA and PLSVC.>

Background Research on the correlation of serum bilirubin level with cardiac function as well as outcomes in heart failure patients with cardiac resynchronization therapy (CRT) has not yet been reported. The aim of this study was to analyze the relationship between change in serum bilirubin level and left ventricular reverse remodeling, and also to clarify the impact of bilirubin change on clinical outcomes in CRT patients. Methods We evaluated 105 consecutive patients who underwent CRT. Patients who had no serum total-bilirubin data at both baseline and 3–9 months’ follow-up or had died less than 3 months after CRT implantation were excluded. Accordingly, a total of 69 patients were included in the present analysis. The patients were divided into two groups: decreased bilirubin group (serum total-bilirubin level at follow-up ≤ that at baseline; n = 48) and increased bilirubin group (serum total-bilirubin level at follow-up > that at baseline; n = 21). Results Mean follow-up period was 39.3 months. In the decreased bilirubin group, mean left ventricular end-systolic diameter decreased from 54.5 mm to 50.2 mm (p = 0.001) and mean left ventricular ejection fraction increased significantly from 29.8% to 37.0% (p = 0.001). In the increased bilirubin group, there was no significant change in echocardiographic parameters from baseline to follow-up. In Kaplan–Meyer analysis, cardiac mortality combined with heart failure hospitalization in the increased bilirubin group was significantly higher than that in the decreased bilirubin group (log-rank p = 0.018). Multivariate Cox regression analysis revealed that increased bilirubin was an independent predictor of cardiac mortality combined with heart failure hospitalization (OR = 2.66, p = 0.023). Conclusions The change in serum bilirubin is useful for assessment of left ventricular reverse remodeling and prediction of outcomes in heart failure patients with CRT.

BACKGROUND Obstruction of the access vein is a well-known complication after cardiovascular implantable electronic device (CIED) implantation. In that case, well-developed collateral superficial veins are frequently observed on the skin surface around the CIED. The aim of this study was to clarify the relationship between venous obstruction and development of a superficial vein across the clavicle. METHODS AND RESULTS A total of 107 patients scheduled for generator replacement, device upgrade, or lead extraction were enrolled. The skin surface around the device was photographed. A 20-ml bolus of contrast medium was injected into a peripheral arm vein on the side of CIED implantation, and contrast venography was performed. Venous obstruction was defined as luminal diameter narrowing >75%. Venography showed venous obstruction in 27 patients (25.2%). There were no statistically significant differences in patient characteristics between the venous obstruction and no venous obstruction group. Of 107 patients, 44 (41.1%) had a superficial vein across the clavicle on the side of CIED implantation. The sensitivity of the presence of a superficial vein across the clavicle in the diagnosis of venous obstruction was 96.3% and specificity was 77.5% (P

BackgroundRenal insufficiency is recognized as a predictor of mortality and adverse outcome in heart failure (HF) patients. However, the long-term clinical outcome of cardiac resynchronization therapy (CRT) in Japanese HF patients with renal insufficiency remains uncertain.MethodsWe evaluated 67 consecutive patients who underwent CRT at our hospital. The patients were divided into two groups according to a baseline estimated glomerular filtration rate (e-GFR) cut-off value of 50ml/min, which is defined as the time at which patients should be referred to a nephrologist, by the Japanese Society of Nephrology. Follow-up echocardiographic findings and renal function were examined at 3–6 months after CRT. Then, we compared long-term clinical outcomes between the two groups, and analyzed the effect of CRT on renal function, echocardiographic parameters and cardiac survival.ResultsDuring a mean follow-up period of 30.3 months, patients with advanced renal insufficiency (e-GFR

Contraction delay of the lateral left ventricular free wall can be improved by biventricular pacing. Cardiac resynchronization therapy (CRT) is based on the principle of resynchronizing un-uniformed contraction of the ventricle. Prolongation of the QRS duration on an electrocardiogram served as an indirect marker to identify mechanical dyssynchrony. One of the greatest problems is approximately 30% of the patients who met the criteria do not respond for CRT. One possible explanation for the lack of response for CRT could be the absence of sufficient dyssynchrony to allow the therapy to have any impact. Direct assessments of mechanical dyssynchrony might better select responder patients for CRT. However, RethinQ study demonstrated that patients with heart failure and narrow QRS intervals might not benefit from CRT, even with dyssynchrony. Moreover, the results of the PROSPECT study suggest given the modest sensitivity and specificity in the multicenter setting, despite training and central analysis, no single echocardiographic measurement of dyssynchrony could be recommended to improve patient selection for CRT beyond current guidelines. At present, assessment of mechanical dyssynchrony is not necessary in determining CRT indication. Current indication including QRS width is recommended as selection criteria to identify patients suitable for CRT.

A 60-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) was implanted dual-chamber ICD for the purpose of both the left ventricular outflow tract (LVOT) gradient reduction by ventricular pacing and the primary prevention of ventricular tachyarrhythmia. Because the LVOT gradient reduction and improvement of symptoms by pacing were insufficient, however, a new pacing lead was inserted in the right ventricular apex at a different position 1.5 cm away from the site of the defibrillation lead, and the LVOT gradient greatly declined from 108 to 30 mmHg. This DDD pacing was continued over seven years. On this occasion, he was referred to our hospital because of battery depletion, and a cardiac catheterization study was performed after ICD replacement. The LVOT gradient was 10 mmHg in sinus rhythm. After administration of isoproterenol (0.02γ), the gradient was increased to 92 mmHg in sinus rhythm. DDD pacing using a newly placed ventricular pacing lead significantly decreased the gradient to 36 mmHg. This case study indicated that DDD pacing from a suitable location in the right ventricular apex caused a marked early reduction in the LVOT gradient, and at long-term follow up a further significant effect was obtained, also in sinus rhythm.

複数のCFRP板を鋼板に接着する際，CFRP板に段差を設けると，接着剤に生じるせん断応力を低減でき，CFRP板が鋼板からはく離するときの荷重，すなわち，はく離荷重が上昇することが知られている．これまでに，一つの段差を有するCFRP板接着鋼板に対して，鋼板の応力を所定の値まで低減させ，はく離荷重を最大にする各CFRP板の必要接着長さと最適剛性を理論的に明らかにした．本研究では，1枚のCFRP板が鋼板の上下面に対称に接着されたCFRP板接着鋼板において，CFRP板の接着長さが長くなると，鋼板中央に生じる応力と，CFRP板の付着端の接着剤に生じる高いせん断応力がそれぞれ一定値に収束する性質を各段に適用することにより，複数の段差を有するCFRP板接着鋼板のはく離荷重を最大にする各CFRP板の必要接着長さと最適剛性を与える．

Blood pressure (BP) variability is calculated as the standard deviation of ambulatory BP. Blood pressure variability is associated with the cardiovascular morbidity; however whether it is related to target organ damage is controversial. In this study we examined a possible relationship between the BP variability and left ventricular hypertrophy (LVH), and between BP variability and brachial-ankle pulse wave velocity (baPWV). The present study was conducted on 111 consecutive Japanese hypertensive patients who were hospitalized for the educational program in our hospital under stable sodium chloride intake (6 g/day). Blood pressure measurements were at 30-minute intervals all day. In a multivariable analysis adjusted with confounding factor, LVH was associated with 24-hour systolic BP (SBP), 24 hour diastolic BP (DBP), daytime SBP, daytime DBP, nighttime SBP, and nighttime DBP. Additionally, nighttime DBP variability was related to LVH. By the same method, baPWV as a dependent variable was related to 24-hour SBP and nighttime SBP. Furthermore, nighttime SBP variability was concerned with baPWV. The LVH was associated with not only BP level but also with nighttime DBP variability. The baPWV was also related not only to BP level but also to nighttime SBP variability.

Purpose: To predict the optimal atrioventricular (AV) delay using the phonocardiogram (PCG). Methods: We studied 12 recipients of cardiac resynchronization therapy (CRT) system and eight recipients of dual-chamber pacemakers implanted for AV block with normal left ventricular (LV) function. The amplitude of the first heart sound (S1) was recorded by PCG and the LV outflow tract (OT) time-velocity integral (TVI) was measured by pulsed Doppler echocardiography. The AV delay was prolonged in 20-ms increments, from 60 ms to 240 ms. Ishikawa's method was used for the echocardiographic optimization of the AV delay. The relation between S1 amplitude and the AV delay was analyzed. Results: The correlation between the amplitude of S1 and the length of AV delay showed an S-shaped curve. The AV delay at the inflection point of each patient's S-shaped curve (161.2 ± 19.5 ms) was positively correlated with the optimal AV delay determined by echocardiography (148.3 ± 16.9 ms, r = 0.83, P < 0.001). In addition, there was a positive correlation between the AV delay at the maximal TVI of LVOT (150.8 ± 22.7 ms) and the AV delay at the inflection point of the S-shaped curve (159.5 ± 24.9 ms, r = 0.87, P < 0.001). In two CRT system recipients, an optimal AV delay could not be found by echocardiography; however, an optimal AV delay could be determined by PCG. Conclusions: A high correlation was observed between the optimal AV delay determined by phonocardiography versus echocardiography.

We examined risk factors for coronary heart disease (CHD) by ambulatory blood pressure (BP) monitoring in 72 diabetic hypertensives who were hospitalized for the educational program. The patients were divided into two groups (CHD group, 19 subjects; and non-CHD group, 53 subjects) along with or without co-existing CHD. On ambulatory BP monitoring, no significant differences were found between the groups regarding BP values through the day. However, the CHD group had a significantly greater BP variability than non-CHD group. The result of logistic regression analysis demonstrated that nighttime systolic BP variability was an independent risk factor for CHD.