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Limited data exists on ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) managed by a well-organized cardiac care network in a metropolitan area. We analyzed the Tokyo CCU network database in 2009–2010. Of 4329 acute myocardial infarction (AMI) patients including STEMI (n = 3202) and NSTEMI (n = 1127), percutaneous coronary intervention (PCI) was performed in 88.8 % of STEMI and 70.4 % of NSTEMI patients. Mean onset-to-door and door-to-balloon times in STEMI patients were shorter than those in NSTEMI patients (167 vs 233 and 60 vs 145 min, respectively, p

Compared with short-acting diuretics (SD), furosemide, long-acting diuretics (LD) have been shown to be associated with a lower risk of heart failure (HF) readmission in small-scale studies. The type of diuretics (i.e., SD or LD) can affect long-term outcomes through mediating neurohormonal

The therapeutic role of transcatheter aortic valve implantation (TAVI) in high surgical risk or inoperable cases has been established. Most of the candidates for TAVI are elderly and have multiple comorbidities including chronic kidney disease. However, contrast-enhanced computed tomography and coronary angiography, both of which require iodine contrast media, are essential for pre-procedural planning. In addition, TAVI could have adverse effects on kidney function including contrast media-induced nephrotoxicity. Acute kidney injury following TAVI has been reported to be related to poor prognosis. In a case with advanced renal dysfunction, we successfully avoided post-procedural acute kidney injury by performing pre-procedural evaluation using minimal contrast and TAVI without contrast media. If anatomical conditions and experiences of the heart team are adequate, renoprotective TAVI should be a favorable therapy for patients with aortic stenosis complicated by renal dysfunction.

As the definition of type 2 acute myocardial infarction (AMI) is obscure, the characteristics of this disease vary among studies. The clinical significance of type 2 AMI is unclear. We surveyed the Tokyo Cardiovascular Care Unit (CCU) Network registry between 2010 and 2014. The difference in clinical characteristics and the impact of revascularization in patients with type 1 and type 2 AMI were evaluated. The cohort study included 12514 patients admitted to CCU (type 1 AMI, 12023; type 2 AMI, 491; mean age, 68 ± 15 years; 75% male). Coronary angiography was performed in 11402 patients (95%) with type 1 AMI and 427 (87%) with type 2 AMI (p

Background Transcatheter aortic valve replacement (TAVR) for patients with rheumatic heart disease (RHD) has not been well-known. This study aimed to assess characteristics and computed tomography (CT) findings of the aortic valve in old patients with RHD and to investigate the safety and efficacy in the patients who underwent TAVR. Methods and results Of 352 consecutive patients with severe aortic stenosis (AS) who underwent TAVR at the Sakakibara Heart Institute between 2013 and 2016, 10 patients (2.8%) were considered to have degenerative calcified rheumatic AS by transthoracic echocardiography. Young patients with rheumatic AS without any calcification were not indicated for TAVR in this study. They were likely to have previous pacemaker implantation, atrial fibrillation, anticoagulants, diuretics, reduced ejection fraction, mitral valve involvement, and high pulmonary artery pressure. CT was able to clearly visualize irregular valve thickening, commissure fusion, and a relatively small amount of calcification from the tip of the leaflet to the base of the aortic valve. Mortality at 30 days after TAVR was 0%, with a mean Society of Thoracic Surgeons Score of 7 ± 4%. Device success was 90%, and no patients met the safety endpoint at 30 days. Conclusions CT was able to visualize the calcified aortic valve in old patients with RHD, and we demonstrate the safety and efficacy of TAVR in this specific population. Care should be taken for procedural success in particular characteristics with marginal calcified aortic valve, anticoagulant use with low body mass index, or concomitant mitral valve disease.

BACKGROUND Various frailty markers have been developed to guide better patient selection for transcatheter aortic valve implantation (TAVI). This study aimed to investigate the frequency and specific causes of unplanned hospital readmission after TAVI, and to investigate which frailty markers better predicted outcomes.Methods and Results:We retrospectively reviewed 155 patients for whom we calculated their Short Physical-Performance Battery (SPPB), Placement of AoRTic TraNscathetER Valve (PARTNER) frailty scale, frailty index, clinical frailty scale, modified Fried scale, and gait speed. The primary endpoint was unplanned readmission following TAVI. The clinical model was established using variables that were identified as independent predictors in multivariate analysis. Incremental values were assessed after adding each frailty marker to the clinical model, and were compared between frailty markers. Although unplanned readmission

Multidectector computed tomography (MDCT) has revealed leaflet thrombosis in approximately one-tenth of transcatheter aortic valves. 1,2 Most leaflet thromboses are silent, whereas some thrombi res...

Atrioventricular block that requires permanent pacemaker implantation is a transcatheter aortic valve implantation (TAVI)-related complication. The Micra Transcatheter Pacing System (Medtronic, Min...

Objectives We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings. Background Transesophageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, CA). However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complex because of shadowing from the surgical ring. In these patients, TEE may be suboptimal for guiding the procedure, even using three-dimensional imaging. Methods This retrospective analysis included data from 121 consecutive patients with mitral regurgitation who underwent MitraClip procedures at the University of Virginia. ICE was used adjunctively when there was difficulty with TEE, particularly for assessing the insertion of the posterior leaflet into the MitraClip's arms. The ICE catheter was introduced transarterially into the left ventricle and flexed to obtain the short-axis view. Results Six patients had prior surgical rings, and in five, we used adjunctive ICE. The etiology of the mitral regurgitation was prolapse of the posterior leaflet in one patient and restriction of the posterior leaflet due to ischemic tethering in the remainder. All images were obtained from the left ventricle, and were adequate for assessing posterior leaflet insertion and the perpendicularity of the MitraClip arms. The procedural success rate was 80%. There was no adverse event related to the ICE procedure. Conclusions Mitral valve repair with the MitraClip system assisted by ICE is feasible in patients with prior surgical rings, achieving an excellent risk profile and satisfactory procedural success. © 2015 Wiley Periodicals, Inc.

Objectives To report the efficacy and safety of the use adjunctive intracardiac echocardiography (ICE) during percutaneous transluminal mitral commissurotomy (PTMC) in patients without transesophageal echocardiography (TEE). Background Patients with mitral stenosis are at a high risk of developing a left atrial (LA) thrombus. Traditionally, TEE has been used prior to PTMC to identify the presence of LA thrombi. There have been no reports of the use of ICE to assess the LA for thrombi prior to PTMC. Methods We retrospectively reviewed 20 patients who underwent ICE prior to PTMC. All PTMC procedures were performed via the antegrade transvenous approach using an Inoue balloon. Initially, ICE was used from the right atrium to confirm the absence of a thrombus on the left side of the septum and was subsequently used to guide the transseptal puncture. Following these procedures, the ICE was advanced into the LA through a transseptal sheath to visualize the LAA. Results Visualization of the thrombus/spontaneous echo contrast was considered to be diagnostic in all cases. Seventy percent of the patients were discharged on day after the procedure. No patients required intubation during the procedure, and there were no complications that could be attributed to the use of ICE. At six months after the PTMC, the incidence of stroke was zero. Conclusions ICE-guided PTMC offers excellent visualization of the LA and the LAA with satisfactory clinical outcomes and low risk. As a part of the PTMC procedure, ICE safely provides a valid alternative to a separate TEE procedure. © 2015 Wiley Periodicals, Inc.

Purpose: Postoperative intensive care unit (ICU) stay after cardiac surgeries has been extensively studied, but little attention has been given to ICU stay following transcatheter aortic valve replacement (TAVR). This study examined ICU stay after TAVR. Methods: Two hundred and forty-five patients who underwent TAVR between April 2010 and October 2016 were studied retrospectively. We investigated the status of ICU stay, the predictors of prolonged ICU stay (PICUS), and its impact on short- and long-term outcomes. Prolonged ICU stay was defined as post-TAVR ICU stay longer than 2 days (day of TAVR + 1 day). Results: Length of ICU stay was 2.6 ± 4.9 days, and PICUS was identified in 14.7% of the patients. The predominant reason for PICUS was congestive heart failure or circulatory failure (41.7%). Pulmonary dysfunction and nontransfemoral approach were independent predictors of PICUS (pulmonary dysfunction: odds ratio = 2.64, 95% confidence interval [CI]: 1.05-7.35; nontransfemoral approach: odds ratio = 2.81, 95% CI: 1.15-6.89). Prolonged ICU stay was associated with higher rate of 30-day combined end point (PICUS vs non-PICUS: 44.4% vs 3.3%, P < .0001), longer postoperative hospital stay (49.9 ± 141.9 days vs 12.0 ± 6.0 days, P < .0001), and lower rate of discharge home (77.8% vs 95.2%, P = .0002). Patients with PICUS had worse long-term survival ( P < .0001), and PICUS was a predictor of mortality (hazard ratio: 4.21, 95% CI: 2.09-8.22). Conclusion: Prolonged ICU stay following TAVR was found in 14.7%, and pulmonary dysfunction and nontransfemoral approach were associated with PICUS. Short- and long-term prognoses were worse in patients with PICUS than those without.

Frailty has become a major theme in cardiovascular diseases due to the aging population. Recently, variable frailty markers have been developed to guide better patient selection in transcatheter aortic valve implantation (TAVI). This study aimed to investigate the timing, and specific causes of

A 65-year-old woman with hypertrophic obstructive cardiomyopathy presented with dyspnea. Transthoracic echocardiography showed severe mitral regurgitation (MR) due to systolic anterior motion and a peak gradient of 102 mmHg across the LV outflow. Cardiac magnetic resonance imaging (CMR) showed patchy late gadolinium enhancement in the hypertrophied septum. Because of non-responsiveness to medical treatment, percutaneous alcohol septal ablation (ASA) was conducted. The septal perforator that supplied the hypertrophic myocardium originated from the intermediate artery. A 2.0-mm over-the-wire balloon was used to occlude the intermediate artery and 1.1 ml of ethanol was injected slowly into the target septal perforator branch. The gradient decreased markedly to 5 mmHg immediately after ASA, and electrocardiogram showed right bundle branch block. Echocardiographic findings at 1 week were satisfactory. However, CMR showed delayed enhancement in both the hypertrophic basal septum and the lateral wall. The clinical course was uneventful, and she has maintained NHYA functional class 1 so far. In this case, proximal migration of the balloon or an undersized occluding balloon may have caused lateral infarction through leakage of ethanol into another branch. CMR is a useful modality to verify whether the ASA procedure has induced the appropriate controlled infarction.

Following the first successful transcatheter aortic valve replacement (TAVR) in 2002, TAVR has globally evolved to become a standard procedure in high-risk patients. Surgical aortic valve replacement in non-high-risk patients remains the gold standard for treatment of severe aortic stenosis. However, a paradigm shift appears to be occurring in the direction of treating lower-risk patients, and several studies have suggested its impact on clinical outcomes. In this review, we highlight the current status of TAVR in intermediate-risk patients and review major trials including Placement of AoRTic TraNscathetER (PARTNER) 2A randomized intermediate-risk trial using SAPIEN XT (Edwards Lifesciences Corp, Irvine, CA) recently presented with excellent outcomes and the lowest major complications rate at the American College of Cardiology’s 65th Annual Scientific Session in Chicago. Clinical trials in low-risk patients using SAPIEN 3 and CoreValve Evolut R have just been launched, and they are going to be important milestones in the TAVR field.

Frailty has become high-priority theme in cardiovascular diseases because of aging and increasingly complex nature of patients. Low muscle mass is characteristic of frailty, in which invasive interventions are avoided if possible because of decreased physiological reserve. This study aimed to determine if the psoas muscle area (PMA) could predict mortality and to investigate its utility in patients who underwent transcatheter aortic valve replacement (TAVR). We retrospectively reviewed 232 consecutive patients who underwent TAVR. Cross-sectional areas of the psoas muscles at the level of fourth lumbar vertebra were measured by computed tomography and normalized to body surface area. Patients were divided into tertiles according to the normalized PMA for each gender (men: tertile 1, 1,708 to 1,178 mm 2 /m 2 ; tertile 2, 1,176 to 1,011 mm 2 /m 2 ; and tertile 3, 1,009 to 587 mm 2 /m 2 ; women: tertile 1, 1,436 to 962 mm 2 /m 2 ; tertile 2, 952 to 807 mm 2 /m 2 ; and tertile 3, 806 to 527 mm 2 /m 2 ). Smaller normalized PMA was independently correlated with women and higher New York Heart Association classification. After adjustment for multiple confounding factors, the normalized PMA tertile was independently associated with mortality at 6 months (adjusted hazard ratio 1.53, 95% confidence interval 1.06 to 2.21). Kaplan–Meier analysis showed that tertile 3 had higher mortality rates than tertile 1 at 6 months (14% and 31%, respectively, p = 0.029). Receiver-operating characteristic analysis showed that normalized PMA provided the increase of C -statistics for predicting mortality for a clinical model and gait speed. In conclusion, PMA is an independent predictor of mortality after TAVR and can complement a clinical model and gait speed.

Many patients affected with mitral valve regurgitation suffer from multiple comorbidities. The MitraClip device provides a safe means of transcatheter valve repair in patients with suitable mitral valve anatomy who are at prohibitive risk for surgery. We describe our early procedural outcomes and present a summary of the current state of MitraClip technology in the United States.We performed a retrospective chart review of initial high-risk or inoperable patients who underwent MitraClip placement at our institution after completion of the EVEREST II study. We examined the primary outcome of 30-day mortality, and secondary outcomes included extent of reduction of mitral regurgitation (MR), New York Heart Association (NYHA) functional class improvement, length of stay, and major complications.A total of 115 high-risk patients (mean Society of Thoracic Surgeons predicted risk of mortality 9.4%±6.1%) underwent the MitraClip procedure at our institution between March 2009 and April 2014. Co-morbidities including coronary artery disease (67.8%), pulmonary disease (39.1%) and previous cardiac surgery (44.3%) were common. The device was placed successfully in all patients with a 30-day mortality of 2.6%. All patients demonstrated 3+ or 4+ MR on preoperative imaging, and 80.7% of patients had trace or 1+ MR at hospital discharge. NYHA class improved substantially, with 79% of patients exhibiting class III or IV symptoms pre-procedure and 81% reporting class I or II symptoms at one month follow-up.The MitraClip procedure provides a safe alternative to surgical or medical management for high-risk patients with MR and suitable valve anatomy. A comprehensive heart team approach is essential, with surgeons providing critical assessment of patient suitability for surgery versus percutaneous therapy as well as performance of the valve procedure.

Background: Pulmonary hypertension (PH) is common among patients requiring mitral valve treatment, and even mild PH adversely affect outcome. The aim of the study was to investigate the response of pulmonary artery pressure (PAP) in patients undergoing MitraClip and determine the prognostic effect of residual PH. Methods: From 2007 to 2013, 121 consecutive patients undergoing the MitraClip were retrospectively reviewed. Patients were categorized into two groups according to residual PH defined by post-procedural PAP obtained by transthoracic echocardiography. The primary endpoint was combined endpoints of all-cause mortality, left ventricular assist device implantation, shock, mitral valve surgery, New York Heart Association III-IV, re-hospitalization due to heart failure, new onset atrial fibrillation requiring hospitalization, ventricular arrhythmia, mechanical ventilation more than 48 hours, admission longer than two weeks. Patients with existing pulmonary disease or systemic disease affecting PAP were excluded. Results: Forty seven of 86 had residual PH. Patients with residual PH had higher pre-procedural PAP, and higher six months PAP than those without residual PH (pre-procedural, 50.3±13.4 vs 42.2±9.8 mmHg, p=0.003; at six months, 45.4±14.0 vs 34.7±9.9 mmHg, p Conclusion: Patients with residual PH have higher rate of adverse events associated with heart failure even with successful MR reduction, and additional medical intervention, such as pulmonary vasodilator, should be considered.

We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings.Transesophageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, CA). However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complex because of shadowing from the surgical ring. In these patients, TEE may be suboptimal for guiding the procedure, even using three-dimensional imaging.This retrospective analysis included data from 121 consecutive patients with mitral regurgitation who underwent MitraClip procedures at the University of Virginia. ICE was used adjunctively when there was difficulty with TEE, particularly for assessing the insertion of the posterior leaflet into the MitraClip's arms. The ICE catheter was introduced transarterially into the left ventricle and flexed to obtain the short-axis view.Six patients had prior surgical rings, and in five, we used adjunctive ICE. The etiology of the mitral regurgitation was prolapse of the posterior leaflet in one patient and restriction of the posterior leaflet due to ischemic tethering in the remainder. All images were obtained from the left ventricle, and were adequate for assessing posterior leaflet insertion and the perpendicularity of the MitraClip arms. The procedural success rate was 80%. There was no adverse event related to the ICE procedure.Mitral valve repair with the MitraClip system assisted by ICE is feasible in patients with prior surgical rings, achieving an excellent risk profile and satisfactory procedural success.

The simple, functional 6-min walk test (6MWT) can predict exercise capacity and is widely used to assess treatment outcomes [(1)][1]. Transcatheter mitral valve repair (TMVR) (MitraClip, Abbott Vascular, Menlo Park, California) has become widely adopted for clinical use in high-risk or prohibitive

Frailty is known to correlate with mortality in cardiovascular diseases. Gait speed, a commonly accepted frailty metric, has not been well validated in patients undergoing transcatheter aortic valve replacement (TAVR). Recently, psoas muscle area (PMA), measured by computed tomography, has been

Pulmonary hypertension (PH) is common in MR. A previous trial demonstrated significant hemodynamic improvement after MitraClip therapy, but it was less effective than surgery and is a potential cause of iatrogenic mitral stenosis. Clinical characteristics associated with delta sPAP after MitraClip

This study aimed to determine if age-adjusted Charlson comorbidity index could predict mortality in patients undergoing transcatheter mitral valve repair (TMVR), and to assess its discriminatory performance in long-term outcomes. Comorbidity increases markedly with aging, and they often negatively

A 78-year-old woman complained of experiencing dyspnea (New York Heart Association II) and faintness. Echocardiography revealed she had asymmetric left ventricular hypertrophy, and a dynamic left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion of the mitral valve. It also revealed calcification of the noncoronary cusp and a high-flow velocity in the LVOT (6.3m/s). The planimetry measurement with transesophageal echocardiography was 0.89cm 2 (aortic valve area/body surface area: 0.69cm 2 /m 2 ). Later, she was diagnosed with hypertrophic obstructive cardiomyopathy (HOCM) and aortic stenosis (AS). However, during the catheterization, the transvalvular pressure gradient (PG) was only 25mmHg. In order to solve this, we performed a percutaneous transluminal septal myocardial ablation. As a result, the PG of the LVOT decreased from 152mmHg to 25mmHg. We first thought that the LVOT obstruction had reduced the flow passing through the aortic valve, and restricted the motion of the aortic valve leaflets. We also considered the possibility that the aortic valve area had been underestimated. The hemodynamic study played an important role in the decision for the treatment plan. The present case was a combination of HOCM and "mild" AS. Learning objective : We know that we can distinguish between a left ventricular outflow tract obstruction and aortic stenosis using continuous-wave Doppler according to the phase of the peak gradient. However, if both are present, it is uncertain whether we can distinguish between them. It is necessary to measure the subaortic pressure and flow passing through the aortic valve accurately by catheterization in order to know which is the chief pathology.>

An 89-year-old woman with severe aortic stenosis underwent transfemoral aortic valve replacement. The postoperative course was uneventful except transient bradycardia immediately after the procedure. Echocardiographic finding showed excellent valvular function. After discharge, the patient died suddenly. Autopsy findings showed compression of the atrioventricular conduction system region at the septum by the stent strut. Microscopic examination showed atrophy of the conduction fibers with eosinophilic degeneration of the cytoplasm or coagulation necrosis with pyknosis in the bundle of His and the left bundle branch. Compression by the stent strut triggering dysfunction of the conduction system could have caused fatal arrhythmic event.

Clinical feature of refractory hypertrophic obstructive cardiomyopathy (HOCM) with pulmonary hypertension (PH) remains unclear. From December 2007 to May 2011, total of 92 consecutive patients (57 female, 35 male; mean age 61±16years) with refractory symptomatic HOCM who underwent percutaneous

A 71-year-old man with symptomatic severe aortic stenosis was referred for transcatheter aortic valve replacement (TAVR). His medical history included paroxysmal atrial fibrillation, mild mitral regurgitation, and moderate mitral stenosis with a 10-mm Hg mean transmitral gradient determined using