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BACKGROUND: High bleeding risk (HBR) and complex percutaneous coronary intervention (PCI) are major determinants for dual antiplatelet therapy (DAPT) duration. OBJECTIVES: The aim of this study was to evaluate the effects of HBR and complex PCI on short vs standard DAPT. METHODS: Subgroup analyses were conducted on the basis of Academic Research Consortium-defined HBR and complex PCI in the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Verulam's-Eluting Cobalt-Chromium Stent-2) Total Cohort, which randomly compared clopidogrel monotherapy after 1-month DAPT with 12-month DAPT with aspirin and clopidogrel after PCI. The primary endpoint was the composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) or bleeding (Thrombolysis In Myocardial Infarction [TIMI] major or minor) endpoints at 1 year. RESULTS: Regardless of HBR (n=1, 893 [31.6%]) and complex PCI (n=999 [16.7%]), the risk of 1-month DAPT relative to 12-month DAPT was not significant for the primary endpoint (HBR, 5.01% vs 5.14%; non-HBR, 1.90% vs 2.02%; P interaction=0.95) (complex PCI, 3.15% vs 4.07%; noncomplex PCI, 2.78% vs 2.82%; P interaction=0.48) and for the cardiovascular endpoint (HBR, 4.35% vs 3.52%; and non-HBR, 1.56% vs 1.22%; P interaction=0.90) (complex PCI, 2.53% vs 2.52%; noncomplex PCI, 2.38% vs 1.86%; P interaction=0.53), while it was lower for the bleeding endpoint (HBR, 0.66% vs 2.27%; non-HBR, 0.43% vs 0.85%; P interaction=0.36) (complex PCI, 0.63% vs 1.75%; noncomplex PCI, 0.48% vs 1.22%; P interaction=0.90). The absolute difference in the bleeding between 1- and 12-month DAPT was numerically greater in patients with HBR than in those without HBR (-1.61% vs-0.42%). CONCLUSIONS: The effects of 1-month DAPT relative to 12-month DAPT were consistent regardless of HBR and complex PCI. The absolute benefit of 1-month DAPT over 12-month DAPT in reducing major bleeding was numerically greater in patients with HBR than in those without HBR. Complex PCI might not be an appropriate determinant for DAPT durations after PCI. (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 [STOPDAPT-2], NCT02619760; Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS [STOPDAPT-2 ACS], NCT03462498).

Recent retrospective investigations have suggested that optical coherence tomography (OCT) enables the diagnosis of underlying acute coronary syndrome (ACS) causes such as plaque rupture, plaque erosion, and calcified nodule. The relationships of these etiologies with clinical outcomes, and the clinical utility of OCT-guided primary percutaneous coronary intervention (PCI) are not systematically studied in real-world ACS treatment settings.The TACTICS registry is an investigator-initiated, prospective, multicenter, observational study to be conducted at 21 hospitals in Japan. A total of 700 patients with ACS (symptom onset within 24 h) undergoing OCT-guided primary PCI will be enrolled. The primary endpoint of the study is to identify the underlying causes of ACS using OCT-defined morphological assessment of the culprit lesion. The key secondary clinical endpoints are hazard ratios of the composite of cardiovascular death, non-fatal myocardial infarction, heart failure, or ischemia-driven revascularization in patients with underlying etiologies at the 12- and 24-month follow-ups. The feasibility of OCT-guided primary PCI for ACS will be assessed by the achievement rates of optimal post-procedural results and safety endpoints.The TACTICS registry will provide an overview of the underlying causes of ACS using OCT, and will reveal any difference in clinical outcomes depending on the underlying causes. The registry will also inform on the feasibility of OCT-guided primary PCI for patients with ACS.

The long-term safety and utility of intravascular ultrasound (IVUS)-guided zero-contrast percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) are unknown.Methods and Results: A total of 698 consecutive patients treated with PCI (1,061 procedures) in our center were studied. Patients with acute coronary syndrome, who are on maintenance hemodialysis, and who had a planned rotational atherectomy were excluded. Finally, they were divided into 2 groups: zero-contrast PCI (n=55, 78 procedures) and conventional PCI (n=462, 670 procedures). After propensity score matching, 50 patients were matched for each group to evaluate long-term outcomes. Primary endpoints were major adverse cardiovascular events (MACE), including all-cause death, non-fatal myocardial infarction (MI), and clinically driven target lesion revascularization. All patients in the zero-contrast PCI group had stage 3-5 CKD with an estimated glomerular filtration rate of 38.3±14.8 mL/min/1.73 mIVUS-guided zero-contrast PCI might be safe and feasible in patients with CKD with satisfactory acute and long-term renal and cardiovascular outcomes.

We evaluated the basic characteristics and efficacy of our newly developed patient fixation system for head and neck radiotherapy that uses a dedicated mouthpiece and dental impression materials. The present investigation demonstrated that with this system, the changes in the absorbed dose to water depending on the material of the mouthpiece were small, with a maximum of 0.32% for a 10-MV photon beam. For the dental impression material, we selected a silicone material with the lowest Hounsfield unit (HU) value that had little effect on the generation of artifacts and the quality of the X-ray beam. Multiphase magnetic resonance imaging (MRI) revealed that the head-up and -down motions in the thermoplastic shell without the mouthpiece were 5.76 ± 1.54 mm, whereas the motion with the mouthpiece decreased significantly to 1.72 ± 0.92 mm (P = 0.006). Similarly, the head-left and -right motion displacement decreased from 6.32 ± 1.86 mm without the mouthpiece to 1.80 ± 0.42 mm with the mouthpiece (P = 0.003). Regarding the tongue depressor function of the mouthpiece, the median distance from the hard palate to the surface of the tongue was 28.42 mm. The present results indicate that the new immobilization device developed herein that uses a mouthpiece and a thermoplastic shell is useful for suppressing patients’ head motions and tongue positions.

Background We investigated the efficacy of superselective intra-arterial infusion of high-dose cisplatin (CDDP) with concomitant radiotherapy (RADPLAT) using three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT), and we analyzed the relationship between the total radiation dose and the treatment outcome in localized maxillary sinus cancer. Methods We examined the cases of 58 patients with localized maxillary sinus cancer who were treated with RADPLAT at our institution from March 2004 to November 2020. These 58 patients include 34 who received 3DCRT and 24 who have received IMRT. Results The median follow-up period was 38.4 months. The median prescribed dose to the local lesion was 66 Gy in the 3DCRT group and 70 Gy in the IMRT group. CDDP (100–120 mg/m2) were administered with a median of 6 cycles once a week. The 5-year local control rate and overall survival rate were 69.9% and 72.2%, respectively. The patients who were treated with 70 Gy had significantly higher local control rate (87.7%) than the patients treated with 60 Gy or lower (41.0%) (p = 0.011). Conclusions The patients who had received 70 Gy using IMRT had significantly higher local control rate. The total dose may have an impact on the local control rate in RADPLAT.

To establish a predictive model for pain response following radiotherapy using a combination of radiomic and clinical features of spinal metastasis. This retrospective study enrolled patients with painful spine metastases who received palliative radiation therapy from 2018 to 2019. Pain response was defined using the International Consensus Criteria. The clinical and radiomic features were extracted from medical records and pre-treatment CT images. Feature selection was performed and a random forests ensemble learning method was used to build a predictive model. Area under the curve (AUC) was used as a predictive performance metric. 69 patients were enrolled with 48 patients showing a response. Random forest models built on the radiomic, clinical, and ‘combined’ features achieved an AUC of 0.824, 0.702, 0.848, respectively. The sensitivity and specificity of the combined features model were 85.4% and 76.2%, at the best diagnostic decision point. We built a pain response model in patients with spinal metastases using a combination of clinical and radiomic features. To the best of our knowledge, we are the first to examine pain response using pre-treatment CT radiomic features. Our model showed the potential to predict patients who respond to radiation therapy.

A recent thinner strut drug-eluting stent might facilitate early strut coverage after its placement. We aimed to investigate early vascular healing responses after the placement of an ultrathin-strut bioresorbable-polymer sirolimus-eluting stent (BP-SES) compared to those with a durable-polymer everolimus-eluting stent (DP-EES) using optical coherence tomography (OCT) imaging.This study included 40 patients with chronic coronary syndrome (CCS) who underwent OCT-guided percutaneous coronary intervention (PCI). Twenty patients each received either BP-SES or DP-EES implantation. OCT was performed immediately after stent placement (baseline) and at 1-month follow-up.At one month, the percentage of uncovered struts reduced significantly in both the BP-SES (80.9 ± 10.3% to 2.9 ± 1.7%; P < 0.001) and DP-EES (81.9 ± 13.0% to 5.7 ± 1.8%; P < 0.001) groups, and the percentage was lower in the BP-SES group than in the DP-EES group (P < 0.001). In the BP-SES group, the percentage of malapposed struts also decreased significantly at 1 month (4.9 ± 3.7% to 2.6 ± 3.0%; P = 0.025), which was comparable to that of the DP-EES group (2.5 ± 2.2%; P = 0.860). The optimal cut-off value of the distance between the strut and vessel surface immediately after the placement to predict resolved malapposed struts was ≤ 160 μm for BP-SES and ≤ 190 μm for DP-EES.Compared to DP-EES, ultrathin-strut BP-SES demonstrated favorable vascular responses at one month, with a lower rate of uncovered struts and a comparable rate of malapposed struts.

Recent clinical studies suggest that newer-generation drug-eluting stents that combine ultrathin struts and nanocoating (biodegradable polymer sirolimus-eluting stents, BP-SES) could improve long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). However, the early vascular response to BP-SES in these patients has not been investigated so far.We examined this response in 20 patients with STEMI caused by plaque rupture using frequency-domain optical coherence tomography (OCT) to understand the underlying mechanisms. Plaque rupture was diagnosed by OCT before PCI with BP-SES implantation was performed. OCT was again performed before the final angiography (post-PCI) and after 2 weeks (2W-OCT).BP-SES placement caused protrusion of atherothrombotic material into the stent lumen and incomplete stent apposition in all patients. After 2 weeks, incomplete stent apposition was significantly reduced (% malapposed struts: post-PCI 4.7 ± 3.3%; 2W-OCT 0.9 ± 1.2%; P < 0.0001), and the percentage of uncovered struts also significantly decreased (% uncovered struts: post-PCI; 69.8 ± 18.3%: 2W-OCT; 29.6 ± 11.0%, P < 0.0001). The maximum protrusion area of the atherothrombotic burden was significantly reduced (post-PCI 1.36 ± 0.70 mm2; 2W-OCT 0.98 ± 0.55 mm2; P = 0.004).This study on the early vascular responses following BP-SES implantation showed rapid resolution of atherothrombotic material and progression of strut apposition and coverage. (UMIN000041324).

The purpose of this study was to educate operators regarding cardiac catheterization using radiation protection slides prepared for this study and to consider whether or not this radiation protection education contributes to reducing the exposure of the operator's ocular lens. Thermoluminescent dosimeter (TLD) was installed at the outside left, inside left, outside right, and inside right of the X-ray protective eyewear of the operators performing the cardiac catheterization. The exposure dose rate before and after radiation protection education for 3 operators performing cardiac catheterization was compared. The exposure dose ratio was defined by dividing the TLD measurement value, which is the air kerma calculated by the X-ray diagnosis apparatus for the angiography. In other words, this can calculate the ratio of how much the operators are exposed to radiation from the dose of the patient per examination. When comparing the radiation dose ratio obtained from the dosimeter installed on the right outer side before and after education, p-value was

This study used cine-magnetic resonance imaging (cine-MRI) to evaluate the safety and efficacy of a novel airbag system combined with a shell-type body fixation system in reducing respiratory motion in normal volunteers. The airbag system consists of a six-sided polygon inflatable airbag, a same shape plate, a stiff air supply tube, an air-supply pump and a digital pressure load cell monitor. Piezoelectric sensors were installed in the plate to detect compression pressure load changes; pressure load data were transferred to the digital pressure load cell monitor through Bluetooth. Five volunteers underwent cine-MRI with and without airbag compression to detect differences in the respiratory motion of the organs. The volunteers’ physiologic signs were stable during the experiment. The maximum inspiration pressure load was 4.48 ± 0.86 kgf (range, 4.00–6.00 kgf), while the minimum expiration pressure load was 3.69 ± 0.95 kgf (range, 2.8–5.3 kgf). Under airbag compression, the right diaphragm movement was reduced from 19.50 ± 6.43 mm to 9.60 ± 3.61 mm (P

The mortality rate of acute myocardial infarction (AMI) has improved dramatically because of reperfusion therapy during the last 40 years; however, recent temporal trends for AMI have not been fully clarified in Japan.The purpose of this study was to elucidate the temporary trend in in-hospital mortality and treatment of AMI for the last decade in the Tokyo Metropolitan area.We enrolled 30,553 patients from the Tokyo Cardiovascular Care Unit Network Registry, diagnosed with AMI from 2007 to 2016, as part of an ongoing, multicenter, cohort study. We analyzed the temporal trends in basic characteristics, treatment, and in-hospital mortality of AMI.The overall emergency percutaneous coronary intervention (PCI) rate significantly increased (This large cohort study from Tokyo revealed that in-hospital mortality of AMI significantly decreased with the increase in emergency percutaneous coronary intervention rate over the decade, particularly for high-risk patients such as older patients and those with cardiogenic shock.

Introduction Radiation therapy is widely used for prostate cancer, but radiation-induced sarcomas have been rarely reported. Case presentation A 77-year-old Japanese male was diagnosed with prostate cancer and received a combined androgen blockade and radiation therapy (total dose of 76 Gy). Five years after the radiation therapy, testicular pain and dysuria appeared. Computed tomography showed a soft tissue dense mass with invasion to the right subpubic ramus and prostate, mainly to the perineum. A needle biopsy revealed the pathological features of high-grade sarcoma. The patient was diagnosed with radiation-induced sarcoma based on the cancer's occurrence in the vicinity of the radiation field. Conclusion Although irradiation is one of the important treatments for prostate cancer, the risk of radiation-induced malignancy should be considered.

Highlights • Even small declines in renal function are associated with worse short-term outcomes after AMI. • The clinical impact of the timing of acute kidney injury (AKI) onset after AMI is unknown. • Early-phase AKI is associated with poor long-term mortality. • Late-phase AKI is not associated with poor long-term mortality. • Careful clinical attention and intensive care should be used in patients with early-phase AKI after AMI., Background The mechanisms and clinical impact of acute kidney injury (AKI) after acute myocardial infarction (AMI) may differ depending on whether AKI develops during the early or late phase after AMI. The present study assessed the timing of AKI onset and the prognostic impact on long-term outcomes in patients hospitalized with AMI. Methods The present study enrolled consecutive AMI survivors who had undergone successful percutaneous coronary interventions at admission. AKI was defined as an increase in the serum creatinine level of ≥0.3 mg/dL above the admission value within 7 days of hospitalization. AKI patients were further divided into two subgroups (early-phase AKI: within 3 days vs. late-phase AKI: 4 to 7 days after AMI onset). The primary endpoint was all-cause death. Results In total, 506 patients were included in this study, with 385 men and a mean age of 69.5 ± 13.5 years old. The mean follow-up duration was 1289.5 ± 902.8 days. AKI developed in 127 patients (25.1%). Long-term mortality was significantly higher in the AKI group than in the non-AKI group (log-rank p

Deep-inspiration breath-hold radiotherapy (DIBH-RT) to reduce the cardiac dose irradiation is widely used but some patients experience little or no reduction. We constructed and compared two prediction models to evaluate the usefulness of our new synthetic DIBH-CT (sCT) model. Ninety-four left-sided breast cancer patients (training cohort: n = 64, test cohort: n = 30) underwent both free-breathing and DIBH planning. The U-Net-based sCT generation model was developed to create the sCT treatment plan. A linear prediction model was constructed for comparison by selecting anatomical predictors of past literature. The primary prediction outcome is the mean heart dose (MHD) reduction, and the coefficient of determination (R2), root mean square error (RMSE) and mean absolute error (MAE) were calculated. Moreover, we evaluated the heart and lungs contours’ similarity and Hounsfield unit (HU) difference between both images. The median MHD reduction was 1.14 Gy in DIBH plans and 1.09 Gy in sCT plans (P = 0.96). The sCT model achieved better performance than the linear model (R2: 0.972 vs 0.450, RMSE: 0.120 vs 0.551, MAE: 0.087 vs 0.412). The organ contours were similar between DIBH-CT and sCT: the median Dice (DSC) and Jaccard similarity coefficients (JSC) were 0.912 and 0.838 for the heart and 0.910 and 0.834 for the lungs. The HU difference in the soft-tissue region was smaller than in the air or bone. In conclusion, our new model can generate the affected CT by breath-holding, resulting in high performance and well-visualized prediction, which may have many potential uses in radiation oncology.

A pivotal trial indicated that an initial invasive strategy did not improve the clinical outcomes in patients with moderate or severe ischemic heart disease and advanced chronic kidney disease (CKD) as compared with an initial conservative strategy. It is well known that contrast-induced nephropathy (CIN) is associated with worse prognosis after percutaneous coronary intervention (PCI). Minimum contrast PCI may lower the risk of CIN and improve the clinical outcomes of ischemic heart disease and advanced CKD. Here we report a case involving a 46-year-old woman with ischemic cardiomyopathy who was scheduled to start hemodialysis for end-stage diabetic nephropathy but exhibited improved renal function in accordance with the left ventricular function after PCI with an extremely low contrast dose. Accordingly, dialysis was not performed, and the patient did not require it for >2 years after coronary revascularization. The present case supports aggressive examination and revascularization for severe heart failure with an extremely low amount of contrast, even if the patient has complex coronary lesions and end-stage CKD.

Introduction: Atrial functional mitral regurgitation (AFMR) is one of the significant factors to worsen the outcomes in heart failure. The optimal therapy for AFMR is still controversial. Previous studies reported AFMR patients underwent mitral valve repair alone frequently had heart failure re-hospitalization or stroke after surgery. New guidelines recommend adding surgical ablation as a concomitant procedure for class I indications. However, many surgeons avoid concomitant procedure especially in patients with extremely enlarged left atrium (LA) and long atrial fibrillation (AF) duration. Hypothesis: Routine strategy of adding surgical ablation and appendectomy and aggressive LA plication to mitral valve repair might improve the outcomes with keeping sinus rhythm and without stroke events in AFMR patients. Methods and Results: We investigated 35 consecutive patients with severe AFMR who underwent surgery in our institute between 2014 and 2018. Our strategy was Cox-maze IV and appendectomy for all patients and if LA volume was more than 200 ml by echocardiography, we added LA plication. In addition to clinical data and conventional echocardiographic assessment (Table), left ventricular (LV) function was evaluated using 2D speckle tracking echocardiography. MR grade improved in all patients. Despite enlarged LA, 76% of patients regained sinus rhythm and atrial kick was detected by pulse doppler method (mean value: 55 ± 19 cm/s). After 2-year follow-up, LV global longitudinal strain and LA peak strain were significantly improved (Table). During 4.1 ± 1.3 years observation, no patient experienced heart failure re-hospitalization and stroke. Conclusions: Majority of AFMR patients had long duration of AF and severely enlarged LA. The routine Cox-maze IV, appendectomy and aggressive LA plication in enlarged LA patients improved LV and LA function. This strategy may contribute to the better long-term outcomes of AFMR compared to mitral valve repair alone.

Background It is known that the early coronary revascularization in patients with non-ST-elevation myocardial infarction (NSTEMI) was associated with favorable clinical outcomes. However, it is still unclear whether this efficacy is equivalent over all the ages of the patients. Methods Patients with NSTEMI were screened from the database of the Tokyo CCU network registry. Of those, the patients treated without revascularization (medical treatment) were matched with the patients receiving revascularization by propensity score matching. The probabilities of in-hospital death were calculated in the logistic regression model. In two subgroups stratified according to median of the age (elderly and non-elderly subgroups), the odds ratios of revascularization for in-hospital death were calculated. Results In the patients registered between 2013 and 2017, 4,851 patients with NSTEMI were identified. After the screening, 370 patients with medical treatment were matched with 370 patients treated with revascularization. The incidence of in-hospital death was significantly higher in the patients with medical treatment (20.3% vs 13.0%, P=0.01). The two probability curves of in-hospital death in patients with and without revascularization converged as age increased. In the elderly subgroup, the revascularization was not significantly associated with favorable outcome of mortality, whereas it had a significant impact on mortality in the non-elderly subgroup (odds ratio: 0.47 [95% CI 0.23–0.95]). Conclusion The impact of revascularization on short-term mortality in patients with NSTEMI tended to be reduced as age increased. Funding Acknowledgement Type of funding source: None

Background It is known that low diastolic blood pressure (DBP) is associated with long-term cardiovascular events after acute myocardial infarction (AMI). However, the impact of low diastolic blood pressure on short-term outcome has not yet been well investigated. Methods and results We included 15,208 patients who were hospitalized for AMI and registered in the Tokyo CCU network registry between 2013 and 2016. Thirty-day in-hospital mortality rate was 4.8% (728/15,208). To assess the relationship between DBP at the time of admission and 30-day mortality non-linearly, spline regression model was applied with the stratification of the cohort according to tercile of systolic blood pressure (SBP, low:≤122 mmHg, intermediate:123–148 mmHg, high:≥149 mmHg) and J-curve phenomenon was observed in the low and high SBP groups. In multivariate logistic regression analysis, adjusted odds ratio of the lowest quintile of DBP (≤64 mmHg) was 1.65 (95% CI:1.02–2.66) in low SBP group and 4.55 (95% CI:1.72–12.00) in high SBP group. Conclusion Low DBP was associated with increased 30-day in-hospital mortality rate after AMI even in patients with high SBP. Funding Acknowledgement Type of funding source: None

Background Fractional flow reserve (FFR) is one of most reliable index for the determining the functional severity coronary artery stenosis. Adenosine is the most commonly used agent for maximal hyperaemia. However, adenosine can cause chest discomfort, bronchial hyper-reactivity, and atrioventricular block. The aim of this study is to evaluate the safety and efficacy of intracoronary nicorandil as an alternative hyperaemic agent for FFR. Methods and results We enrolled consecutive 82 patients (87 lesions) who underwent FFR measurement in our center from Nov. 2018. We compared three groups; intravenous infusion of adenosine (150 μg/kg/min); and adenosine added intracoronary nicorandil 2mg; and intracoronary nicorandil 4mg. Mean FFR value was 0.83±0.09, 0.82±0.09, 0.82±0.08, There was a strong correlation among three groups (R2>0.9). Mean cyclic change in FFR was 0.026±0.023, 0.019±0.010, 0.016±0.014, respectively, cyclic change was smallest in intracoronary nicorandil 4mg group (vs ATP; p Conclusions Intracoronary nicorandil 4mg is a simple, safe, and effective way to induce steady-state hyperaemia for FFR. Figure 1 Funding Acknowledgement Type of funding source: None

Background: Deep inspiration breath-hold (DIBH) radiotherapy is effective but requires specific devices for tracking the respiratory cycle or surface motion. There are some reports of DIBH without such devices. However, to the best of our knowledge, no study has evaluated all three components which are: setup accuracy, dose assessment, and treatment time. We evaluated the accuracy, effect of dose reduction on organs at risk (OARs), and the treatment time of our DIBH technique, which avoids the use of such devices.Methods: We analyzed 64 left-sided early breast cancer patients. Three-dimensional conformal radiotherapy treatment plans of 42.56 Gy in 16 fractions were created in free-breathing (FB) and DIBH settings. Thirty patients were evaluated for inter- and intra-fractional displacement. The treatment room entry-to-exit times were measured and retrospectively compared with those of 44 right breast cancer patients who received FB radiotherapy (Right-FB) in the same period. The volumes and dose metrics of the clinical target volume (CTV) and contoured OARs (HEART, left anterior descending artery [LAD], and LUNG) were compared between FB and DIBH.Results: The average inter-fractional, intra-fractional, and overall setup displacement were 2.32 ± 1.30, 0.55 ± 0.43, and 2.46 ± 1.24 mm, respectively. Compared to Right-FB, the medians of entry-to-exit times slightly increased in DIBH (9 vs 7 minutes, P = 3.95e-23). The LUNG volume in DIBH was 1.58 times larger than that in FB, but other volumes were not statistically different. Compared to FB, the median HEART, LAD, and mean LUNG doses decreased significantly in DIBH: 1.67 vs 0.71 (P = 9.72e-15), 13.0 vs 2.3 (P = 6.65e-15), and 2.42 vs 2.03 (P = 6.80e-8) Gy, respectively. CTV doses were not statistically different.Conclusions: With only minor setup errors, this simple and cost-effective DIBH technique is a feasible method. It can be easily tested for new facilities and is expected to accelerate the further clinical implementation.Trial registration

BACKGROUND Characteristics and treatment outcomes of acute myocardial infarction (AMI) patients have been studied; however, those of recent myocardial infarction (RMI) patients remain unclear. This study aimed to clarify characteristics, treatment strategy, and in-hospital outcomes of RMI patients in the Tokyo CCU network database.Methods and Results:In total, 1,853 RMI and 12,494 AMI patients from the Tokyo CCU network database during 2013-2016 were compared. Both RMI and AMI were redefined by onset times of 2-28 days and ≤24 h, respectively. The RMI group had a higher average age (70.4±12.9 vs. 68.0±13.4 years, P

Background Little information is available on non-cardiovascular (CV) death in acute heart failure (AHF) patients. The present study determined the incidence, time course, and factors associated with long-term non-CV death in AHF patients in a real-world setting. Methods The ATTEND registry, a nationwide, prospective observational multicenter cohort study, included 4842 consecutive patients hospitalized for AHF. The primary endpoint of the present study was non-CV death. Results Median follow-up duration from admission was 513 (range, 385–778) days. Over the study period, 1183 patients died; 356 deaths (30.1%) were non-CV related. The proportion of non-CV deaths increased in the later follow-up phase (0–180days, 26.7%; 181–360days, 38.4%; >360days, 36.6%, p p p =0.003), history of stroke (HR 1.44, p =0.011), renal insufficiency (HR 1.07, per 10ml/min/1.73m 2 decrease in estimated glomerular filtration, p =0.015), and hemoglobin (HR 1.15 per 1.0g/dl decrease, p p =0.023), prior hospitalization for heart failure (HR 1.34, p =0.017), C-reactive protein (HR 1.04, p p =0.016). Conclusions The incidence of non-CV death was high in patients with AHF, accounting for 30% of long-term mortality. Furthermore, the proportion of non-CV death increased in the later follow-up phase. Better understanding of non-CV death and more comprehensive treatment of non-CV comorbidities are vital to further improving prognosis in AHF patients.

Introduction Coronary artery disease (CAD) is a major cause of the morbidity and mortality in diabetic patients, however aggressive screening for CAD in asymptomatic patients is not recommended in guidelines. Chronic kidney disease (CKD) is one of serious co-morbidity and such patients especially tends to be observed without angiography to avoid contrast induced nephropathy. It is well known that systemic atherosclerosis worsens renal function. Thus, chronic kidney disease (CKD) may be associated with potential myocardial ischemia and worse clinical outcomes in asymptomatic DM patients. Purpose To determine the impact of CKD on the incidence of silent myocardial ischemia (SMI) and the long-term outcomes in asymptomatic patients with DM. Methods A total of 461 consecutive patients with DM were prospectively studied from July 2011 to August 2017. All patients were asymptomatic and self-sufficient in daily life. They underwent the ergometer exercise test. Coronary angiography was performed when the stress test was positive, or the patients did not achieve 90% of target heart rate. Primary end point was major adverse cardiac and cerebrovascular events (MACCE) including death, non-fatal myocardial infarction and stroke. Results SMI was diagnosed in 81 patients. The incidence of SMI increased with higher stage of CKD as shown in Figure. The median follow-up duration from diagnosis was 35 (15–57) months in the overall cohort of 461 diabetic patients. SMI patients had worse clinical outcomes (Figure). Among 81 patients with SMI, severe CKD group (≥ stage 3a) had worse long-term outcomes. After adjustment of age, gender and coronary risk factors, eGFR was independently associated with MACCE in diabetic patients with SMI [HR0.96, 95% CI (0.923–0.996), p=0.028]. Incidence of SMI and Kaplan-Meier curves Conclusions The incidence of potential CAD was high in CKD and the long-term outcomes of those patients were poor in asymptomatic DM. CKD patients should be aggressively screened for CAD and more intensively treated in our daily practice of DM.

Aortoiliac bypass surgery is the gold standard strategy for removing persistent ischaemia resulting from bilateral aortoiliac occlusive disease, a condition known as Leriche syndrome. However, the impact of aortoiliac bypass surgery on the blood flow of the renal artery is not fully understood. Here, we report a case of worsening renal failure caused by renal steal immediately after aortoiliac bypass for Leriche syndrome. The revascularisation of bilateral renal arteries dramatically improved the patient’s renal function and allowed us to discontinue both haemodialysis and diuretics. This case demonstrates that in rare instances, haemodynamic change induced by aortoiliac bypass surgery affects the arteries feeding other organs. Careful preoperative evaluation for the corresponding branches of the aorta is indispensable. Optimal revascularisation should be performed to avoid serious complications after aortoiliac bypass if the patient is at risk of developing critical ischaemia.

A polytetrafluoroethylene (PTFE)-covered stent was deployed for enlarging coronary aneurysms in a 73-year-old man. Optical coherence tomography (OCT) and coronary angioscopy performed 3 months later revealed naked stent struts and thin patches of red thrombi covering the PTFE membrane even under dual antiplatelet therapy (DAPT). After 5-month warfarin administration under DAPT, OCT and angioscopy showed a clear extinction of the thin patches of red thrombi on the PTFE membrane and stent struts, although most of the struts were still naked. The addition of anticoagulation therapy to DAPT may reduce thrombosis events in patients treated with PTFE-covered stents.

Primary percutaneous coronary intervention (PCI) is the standard treatment in patients with ST-elevation myocardial infarction (STEMI). However, some patients still develop ST re-elevation during PCI, resulting in further myocardial damage and a poor outcome. An undersized-stenting approach may prevent ST re-elevation. We aimed to determine the association between final stent area and ST re-elevation during primary PCI for STEMI.Overall, 102 consecutive STEMI patients who underwent primary PCI under integrated backscatter intravascular ultrasound guidance were enrolled. The stent-reference (SR) ratio was defined as the stent cross-sectional area (CSA) divided by the average CSA of the 5-mm proximal and distal reference lumens. The patients were divided into two groups according to the SR ratio: undersize group (SR1.0, n=62) and oversize group (SR≥1.0, n=40). The incidences of ST re-elevation and total ST resolution (STR) were compared.The oversize group showed a higher incidence of ST re-elevation (32.5 vs. 9.7%, p=0.004) and a lower total STR (22.4±62.7 vs. 43.4±38.6%, p=0.04). After adjustment, the oversized-stenting approach was independently associated with ST re-elevation [odds ratio: 3.74, 95% confidence interval (CI) 1.27-12.1, p=0.02]. The peak creatine kinase-MB level was higher in the oversize group (341±259 vs. 242±208IU/l, p=0.04). The incidences of stent thrombosis and restenosis were similar between the two groups.An oversized-stenting approach in patients with STEMI was associated with a higher incidence of ST re-elevation and a lower total STR, resulting in increased myocardial damage.

Aim: The vascular endothelium plays a key role in the pathophysiology of atherosclerosis. Flow-mediated dilation (FMD) is a novel way of assessing endothelial function. Cilostazol is a unique antiplatelet drug that also has the potential to improve endothelial function. The objective of this present study was to investigate the effects of cilosatzol on endothelial function as assessed by FMD. Methods: Fifty-one patients with coronary artery disease (CAD) were assigned to one of two groups: the Cilostazol(+) group (with cilostazol) and Cilostazol(−) group (without cilostazol). In addition to conventional dual antiplatelet therapy with aspirin and clopidogrel/ticlopidine, the Cilostazol(+) group (n = 27) was also given cilostazol (100 mg/day). The Cilostazol(−) group (n = 24) did not receive cilostazol. FMD was assessed at enrollment and after 6–9 months. Results: The FMD of both the Cilostazol(+) and Cilostazol(−) groups remained similar at 5.2 (interquartile range: 3.8–8.5) to 5.4 (interquartile range: 4.2–6.7) (P = 0.29) and 5.0 (interquartile range: 3.6–6.4) to 4.9 (interquartile range: 4.0–7.0) (P = 0.38), respectively. However, the diameters of the baseline and maximal brachial arteries tended to increase in the Cilostazol(−) group (baseline: 4.2 ± 0.7 to 4.4 ± 0.7, P = 0.18; maximal: 4.5 ± 0.7 to 4.6 ± 0.7 P = 0.22), whereas that of the Cilostazol(−) group tended to decrease (baseline: 4.1 ± 0.6 to 3.9 ± 0.5, P = 0.10; maximal: 4.3 ± 0.7 to 4.1 ± 0.5, P = 0.05). The rates of change in the baseline diameter (Cilostazol(+): 3.7 ± 9.8% vs. Cilostazol(−): −3.8 ± 12.2%, P = 0.03) and maximal diameter (Cilostazol(+): +3.1 ± 8.9% vs. Cilostazol(−): −4.4 ± 12.0%, P = 0.02) were significantly different. Conclusion: Although cilostazol didn't affect the FMD, there was a significant difference in the rates of change in baseline and maximal brachial artery diameter. This may have a beneficial effect in patients with cardiovascular disease.

Many areas on earth have hot climates because of the high temperatures during summer and strong solar radiation. Water mist cooling is useful as an environmentally friendly urban system that can provide relief in these high-temperature conditions. To improve the utilization of the water mist cooling system, radiative transfer analysis was conducted to develop a mist cooling device that can block the uncomfortable solar radiation without causing discomfort because of the use of nano- and microsized droplets and bubbles. Herein, the radiative properties of single-water droplets and bubbles are calculated from a broad range of particle sizes and wavelengths. The extinction and scattering efficiencies of microscale droplets and bubbles are high in the solar spectral region, and they have the potential to reflect near infrared light. To model the radiative transfer in a water mist layer, a radiation analysis was conducted in a parallel plane model in one-dimension. The effects of particle size on spectral reflectance and total solar reflectance were discussed. The total solar reflectance is shown to increase with increasing particle sizes until it reaches its maximum value. It is demonstrated that undesirable thermal radiation can be reflected with the use of optimized water particles.

Background: Diabetic patients often have coronary artery disease (CAD) without symptoms. It is known that females tend to have silent or less chest pain and worse prognoses when they develop acute coronary syndrome. Thus, sex differences may impact long-term outcomes in diabetes mellitus (DM) patients with silent myocardial ischemia (SMI). The present study aimed to assess the influence of sex on long-term outcomes in DM patients with SMI. Methods: A total of 461 consecutive asymptomatic and self-sufficient DM patients seen at our hospital from 2011 to 2017 were prospectively reviewed. Patients underwent an ergometer exercise test. When the exercise test was positive or the patient could not achieve 90% of their target heart rate, coronary angiography was performed. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs), including death, non-fatal myocardial infarction, and stroke. Results: SMI was diagnosed in 81 patients. The median follow-up duration from diagnosis was 35 (15–57) months. The incidence of SMI was similar in females and males [34/170 (20%) vs. 47/291 (16.2%), p = 0.36]. Enrolled patients were divided into four groups according to sex and the presence/absence of SMI. Female patients with SMI showed worse clinical outcomes. After adjustment for age and coronary risk factors, female SMI was independently associated with MACCEs [hazard ratio 2.59, 95% confidence interval 1.07–5.68, p = 0.024], while male SMI was not. Conclusions: Female SMI was associated with worse long-term outcomes in DM patients. Early diagnosis of potential SMI and appropriate care are required in female DM patients. (UMIN000038340). Keywords: Gender, Diabetes mellitus, Silent myocardial ischemia

The mechanisms responsible for persistent and lethal coronary spasm remain incompletely understood. Our group treated a patient with non-ST-elevation myocardial infarction (MI) caused by a spontaneously persistent spasm associated with high-grade macrophage accumulation. A 48-year-old man was transferred to an emergency room because of persisted chest tightness. The patient’s chest pain subsided without ST elevation when he arrived at the hospital, but he tested positive for fatty acid-binding protein. Emergent coronary angiography revealed a subtotal occlusion in the middle of the right coronary artery. The occluded lesion was released immediately after an injection of isosorbide dinitrate. No disruption, ulceration or erosion was observed at the culprit lesion segment on optical coherence tomography. The only finding was high-grade macrophage accumulation in the segment of the persistent focal coronary spasm. The present case suggests that the early stage of atherosclerosis with high-grade macrophage accumulation was associated with persistent coronary spasm resulting in acute MI.

Multiple coronary fistulae that drain into the left ventricle are rarely associated with apical hypertrophic cardiomyopathy.1 On the other hand, associations of left ventricular noncompaction (LVNC) and multiple coronary fistulae or hypertrophic cardiomyopathy have previously been reported in several cases.2,3 We report here a unique case of apical hypertrophy of the left ventricle, multiple coronary–left ventricular fistulae, and a morphological structure of the left ventricular myocardium mimicking LVNC. A 59-year-old man was admitted to our hospital for fever and rapidly progressing dyspnea that had persisted for 10 days. He had been diagnosed with apical hypertrophic cardiomyopathy in his 30s, although he had no regular medical checkups and was asymptomatic. On admission, the patient had mild wheezes audible in the midportion of the right lung and a diastolic murmur heard at the Erb and the cardiac apical area. Chest x-ray and computed tomography revealed cardiac enlargement with increased pulmonary vasculature, granular shadows in the lower areas of both lungs, and increased density of the right middle lung area. These findings suggested failure of the left side of the heart with pneumonia. A 12-lead electrocardiogram (ECG) …