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The coronavirus disease 2019 (COVID-19) pandemic has changed the lives of healthcare professionals, especially vulnerable physicians such as young or female cardiologists. In Japan, they are facing the fear of not only infection but also weak and unstable employment, difficulties in medical practice and training anxiety, implications for research and studying abroad, as well as worsened mental health issues due to social isolation. Conversely, some positive aspects are seen through the holding of remote meetings and conferences. Here, we suggest a new working style for cardiologists, as well as offer solutions to the medical employment problems that have been taken place in Japan.

Background Conventional group-based outpatient cardiac rehabilitation through monitoring and center-based approaches for patients in the recovery phase has shown strong evidence for the prevention of cardiovascular diseases. However, there are some cases in which maintaining attendance of center-based cardiac rehabilitation is difficult. Objective This study aims to ascertain the safety and efficacy of remote cardiac rehabilitation (RCR) in the recovery phase in patients with cardiovascular disease. Methods Patients satisfying the study criteria will be recruited from multiple institutions (approximately 30) across Japan. In total, 75 patients (approximately 2 or 3 patients from each institution) are proposed to be recruited. Patients enrolled in the RCR group will be lent devices necessary for RCR (including calibrated ergometers and tablets). Patients will perform anaerobic exercise at home using ergometer for 30-40 minutes at least 3 times weekly. During exercise, an instructor will monitor the patient in real time (using interactive video tools and monitoring tools for various vital data). Moreover, educational instructions will be given 3 times weekly using e-learning methods. Results The primary endpoint is the peak oxygen uptake 2-3 months from the start of exercise or 6-min walk test. The extracted data will be compared between RCR patients and controls without RCR. Conclusions The establishment of the system of RCR proposed in this study will lead to the development of more extensive applications, which have been insufficient through conventional interventions. Trial Registration University Hospital Medical Information Network—Clinical Trials Registry UMIN–CTR UMIN000042942; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048983 International Registered Report Identifier (IRRID) DERR1-10.2196/30725

BACKGROUND Conventional group-based outpatient cardiac rehabilitation through monitoring and center-based approaches for patients in the recovery phase has shown strong evidence for the prevention of cardiovascular diseases. However, there are some cases in which maintaining attendance of center-based cardiac rehabilitation is difficult. OBJECTIVE This study aims to ascertain the safety and efficacy of remote cardiac rehabilitation (RCR) in the recovery phase in patients with cardiovascular disease. METHODS Patients satisfying the study criteria will be recruited from multiple institutions (approximately 30) across Japan. In total, 75 patients (approximately 2 or 3 patients from each institution) are proposed to be recruited. Patients enrolled in the RCR group will be lent devices necessary for RCR (including calibrated ergometers and tablets). Patients will perform anaerobic exercise at home using ergometer for 30-40 minutes at least 3 times weekly. During exercise, an instructor will monitor the patient in real time (using interactive video tools and monitoring tools for various vital data). Moreover, educational instructions will be given 3 times weekly using e-learning methods. RESULTS The primary endpoint is the peak oxygen uptake 2-3 months from the start of exercise or 6-min walk test. The extracted data will be compared between RCR patients and controls without RCR. CONCLUSIONS The establishment of the system of RCR proposed in this study will lead to the development of more extensive applications, which have been insufficient through conventional interventions. CLINICALTRIAL University Hospital Medical Information Network—Clinical Trials Registry UMIN–CTR UMIN000042942; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048983 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/30725

Few reports have discussed appropriate strategies for patient referrals to advanced heart failure (HF) centers with available left ventricular assist devices (LVADs). We examined the association between the characteristics and prognoses of referred patients with advanced HF and the bed volume of the referring hospitals. This retrospective analysis evaluated 186 patients with advanced HF referred to our center for consultation about the indication of LVAD between January 1, 2015, and August 31, 2018. We divided the patients into two groups according to the bed volume of their referring hospital (high bed volume hospitals (HBHs): ≥ 500 beds in the hospital; low bed volume hospitals (LBHs): P = 0.021). Kaplan–Meier analysis indicates that the occurrence of the primary outcome was significantly higher in the HBH patients than in the LBH patients (log-rank P = 0.0022). Multivariate Cox proportional hazards analysis revealed that catecholamine support on transfer and long disease duration were statistically significant predictors of the primary outcome. Patients from HBHs had a greater risk of the primary outcome. However, the multivariate analysis did not indicate an association between referral from an HBH and the primary outcome. In contrast, catecholamine support on transfer, long duration of disease, and low blood pressure were independent predictors of the primary outcome. Therefore, these should be considered when determining the timing of a referral to an advanced HF center, irrespective of the bed volume of the referring hospital.

Background:Connective tissue disease (CTD) associated pulmonary arterial hypertension (PAH) is considered to be an indication for immunosuppressive therapy (IT) except scleroderma associated PAH. However, the response rate defined by improvement of WHO functional class and hemodynamic parameters is reported to be around 50% [1]. Since CTDs are systemic diseases, it may be difficult to evaluate the efficacy of IT by subjective symptoms. Although there are previous studies reporting that the combined use of IT and pulmonary vasodilators significantly improved hemodynamics [2], response to IT without titration of pulmonary vasodilators remains to be elucidated.Objectives:To examine whether IT is effective for CTD-PAH.Methods:We retrospectively examined the medical records of consecutive 13 patients with CTD-PAH (female 13, mean age 47 ± 15 years) treated with methylprednisolone (1 mg/kg/day, oral) and intravenous bolus cyclophosphamide (IVCY) (500 mg/m2) every four weeks for six times. Patient characteristics are described in Table 1. Right heart catheterization (RHC) was done at prior to IT, before adding PAH specific agents, and at the fifth or sixth course of IVCY. In treated cases, the previous vasodilators remained unchanged during the first term of IT.Results:At the first follow up RHC, decrease of mean pulmonary arterial pressure over 5 mmHg was observed in all patients, and decrease of pulmonary vascular resistance (PVR) was observed in twelve out of 13 patients (Figure 1). Over 20% of PVR reduction was observed more in the patients of pulmonary vasodilator naïve and started IT within one year from symptoms than others (6/7 vs 1/6, p=0.03). Although six-minutes walk distance (6MWD) tended to be prolonged between first and second RHC (298 ± 70 m vs 382 ± 81 m; p=0.054; n = 9), 6MWD was shortened in some cases with good hemodynamic improvement (2/5). All patients were prescribed oral PAH specific agents finally, but no one needed parenteral prostanoids. Two patients (15%) died during maintenance therapy for causes other than PAH. Three-year and five-year survival rates were 91.7% and 81.5%, respectively.Conclusion:IT without titration of pulmonary vasodilators significantly improved hemodynamic parameters despite of less improvement in 6MWD in CTD-PAH patients. Considering that CTDs itself might affect the exercise tolerance regardless of PAH, these hemodynamic changes may contribute to better prognosis and IT might be considered especially for patients early in clinical courses and treatment naïve.References:[1]Jais X, Launay D, Yaici A, et al. Immunosupressive therapy in lupus-and mixed connective tissue disease-associated pulmonary arterial hypertension. ARTHRITIS RHEUM. 2008; 58(2): 521-531.[2]Yamamoto M S, Fukumoto Y, Sugimura K, et al. Intensive immunosuppressive therapy improves pulmonary hemodynamics and long-term prognosis in patients with pulmonary arterial hypertension associated with connective tissue diseasae. Circ J. 2011; 75: 2668-2674.Table 1.Characteristics of patientsPatientAge,yrConnective Tissue DiseaseYears from symptom to immunosuppressive therapyPrevious vasodilatorsvasodilators at final visit147SS1.5PGI2ERA262SS, RA2nonePDE5332SS1noneERA457SS, SSc0.5nonePDE5526SS,MCTD, SLE,SSc0.5nonePDE5670SSc, SS s/o13sGC, ERAsGC, ERA732SS s/o, SLE0.1nonePDE5831MCTD3ERA,PDE5, PGI2ERA,PDE5, PGI2943SSc, SLE0.6ERA, PDE5ERA,PDE5, PGI21067MCTD,PM0nonesGC1141SS0.1noneERA, PDE51269SS0.3nonePDE51344SS, MCTD s/o, SLE s/o0.1noneERA, sGCN.A, not acquired; s/o, suspect of; SS, Sjögren’s syndrome; RA, rheumatoid arthritis; SSc systemic sclerosis; SLE, systemic lupus erythematosus; MCTD, mixed connective tissue disease; PM, Polymyositis; PGI2, prostacyclin derivative; sGC, soluble guanylate cyclase stimulator; ERA, endothelin receptor antagonist; PDE5, phosphodiesterase type 5 inhibitor.Figure 1.Hemodynamic changes during immunosuppressive therapyDisclosure of Interests:Risa Kishikawa: None declared, Masaru Hatano Speakers bureau: Janssen Pharmaceutical K.K, Bayer Yakuhin, Ltd., Grant/research support from: Janssen Pharmaceutical K.K, Nippon Shinyaku Co., Ltd., MOCHIDA PHARMACEUTICAL CO., LTD., Satoshi Ishii: None declared, Mai Shimbo: None declared, Akihito Saito: None declared, Shun Minatsuki: None declared, Yukiko Iwasaki: None declared, Keishi Fujio Speakers bureau: Tanabe Mitsubishi, Bristol Myers, Eli Lilly, Chugai, Jansen, Pfizer, Ono, AbbVie, Ayumi, Astellas, Sanofi, Novartis, Daiichi Sankyo, Eisai, Asahi Kasei, Japan Blood Products Organization, and Kowa, Grant/research support from: Tanabe Mitsubishi, Bristol Myers, Eli Lilly, Chugai, AbbVie, Ayumi, Astellas, Sanofi, Eisai, Tsumura & Co., and Asahi Kasei., Issei Komuro Speakers bureau: AstraZeneka, Daiichi Sankyo Company, Limited, Takeda Pharmaceutical Company Limited, Bayer Yakuhin, Ltd, Pfizer Japan Inc., and Ono Pharmaceutical Co., Ltd., Grant/research support from: Daiichi Sankyo Company, Ltd, Sumitomo Dainippon Pharma Co., Ltd., Takeda Pharmaceutical Company Ltd, Mitsubishi Tanabe Pharma Corporation, Teijin Pharma Limited, Idorsia Pharmaceuticals Ltd, Otsuka Pharmaceutical Co., Ltd., Bayer Yakuhin, Ltd. Ono Pharmaceutical Co., Ltd. Toa Eiyo Ltd

Infective endocarditis (IE) associated with atrial septal defect (ASD) is extremely rare. However, tricuspid regurgitation (TR) secondary to right ventricular overload is a potential cause of IE, and once it occurs, the development of a paradoxical embolism may lead to fatal complications. We herein report the case of a 50-year-old woman who was admitted due to a persistent fever resistant to antibiotics. Echocardiography showed secundum ASD, moderate TR and a mobile vegetation measuring 15×10 mm attached to the tricuspid valve. Given the risk of developing a paradoxical embolism, urgent surgery was successfully performed.

A 60-year-old man presented with chest pain after an accidental fall. Chest x-ray showed massive opacification of the left lung, implying haemothorax ( Panel A ). Echocardiography revealed not only a tiny pericardial effusion but also a subtle flow signal with a 0.38 m/s peak systolic velocity from the right ventricle (RV) into the pericardial …

Although several cases of thrombus-in-transit associated with pro-thrombotic conditions have been reported (1-3), a transit thrombus located in the right ventricular (RV) cavity is extremely rare (4,5). Here, we report a case of nephrotic syndrome (NS) with a RV thrombus-in-transit that threatened to cause a fatal pulmonary embolism (PE). A 32-year-old male who had complained of right leg edema 1 month earlier, was referred to our hospital with chest pain. A chest X-ray revealed a right pulmonary infiltrative shadow. Contrast-enhanced chest computed tomography (CT) revealed filling defects in not only the right pulmonary inferior lobe artery, suggestive of a PE, but also in the RV cavity (Figure 1A). Transthoracic echocardiography (TTE) detected a large lobulated mass (23 mm × 30 mm) in the RV cavity with preserved contractile function of the right and left ventricles (Figure 1B). Interestingly, close observation by TTE revealed that the lobulated mass was not attached to the RV wall, and that the two lobules of the mass rubbed against one another, implying that the longitudinal mass was folded, and straddled the chordae tendineae of the tricuspid valve (TV) (Figure 2). The laboratory data were as follows: d-dimer, 8.28 μg/mL; serum albumin, 0.4 g/dL; total cholesterol, 363 mg/dL; and urinary protein excretion, 17.9 g/gCr, indicating NS. Based on these findings, we strongly suspected that the mass in the RV was an embolus derived from a deep vein thrombosis caused by NS, which subsequently caused a small PE. A thrombus formed inside the vein in the right leg might retain the shape of the vessel in which it originates. Initially, this patient was treated with 18,000 U/day heparin for 4 days, but the RV thrombus-in-transit was not reduced in size. The regimen was then modified to a continuous infusion of urokinase (240,000 U/day), and 4 days later, transesophageal echocardiography revealed an isolated thrombus that had become slightly smaller but still clung tightly to the chordae tendineae of the TV (Figures 3,​,4).4). As a result of thrombolytic therapy for 10 days, TTE and enhanced CT demonstrated the disappearance of the RV thrombus (Figure 5), and that the pulmonary artery thrombus was reduced in size. Subsequently, intravenous infusion of heparin was resumed and continued until renal biopsy was performed. The patient did not have any hemorrhagic complications. A percutaneous renal biopsy demonstrated that a minimal change disease was the cause of the NS. The anticoagulation therapy regimen was changed to warfarin, and steroid therapy for the treatment of minimal change disease was started. Normalization of d-dimer levels was achieved 4 weeks later. The patient’s recovery was uneventful. Anticoagulation therapy was continued, as a residual small thrombus behind venous valve pockets in the right leg was observed by vascular ultrasound. Figure 1 On enhanced computed tomography (CT), filling defects in the right ventricular (RV) cavity (A, arrow) were found. Transthoracic echocardiography (TTE) showing a large lobulated mass in the RV cavity (B). Figure 2 Transthoracic echocardiography (TTE) showing a large lobulated mass in the right ventricle (RV) cavity. The mass was not attached to the RV wall. Note that the two lobules of the mass rubbed against one another (6). Available online: http://www.asvide.com/articles/921 ... Figure 3 A transesophageal echocardiographic image. Note the thrombus clinging tightly to the chordae tendineae of the tricuspid valve (TV). Figure 4 A transesophageal echocardiographic image produced 4 days after initiating thrombolytic therapy. Note the isolated thrombus, which had become slightly smaller but still clung tightly to the chordae tendineae of the tricuspid valve (TV) (7). Available ... Figure 5 Transthoracic echocardiography (TTE) and transesophageal echocardiography showing the disappearance of the right ventricle (RV) thrombus (8). Available online: http://www.asvide.com/articles/923 In this case, TTE revealed a large lobulated mass in the RV cavity. The differential diagnosis of the RV mass included primary or metastatic cardiac neoplasms (9) and large vegetation. In addition to a history of leg edema and a typical NS profile on laboratory analysis, the lack of adhesion of the mass to the RV wall and the lack of association with valve leaflets helped to distinguish the thrombus. Unlike other modalities of cardiac imaging, the contribution of echocardiography to tissue characterization is limited; however, echocardiography can evaluate rapid motion with ease. Notably, the finding of the rubbing motion of the two lobules of the mass, constituting a unique echocardiographic appearance, has not been reported previously and represents valuable information for the diagnosis of a thrombus-in-transit which straddled the chordae tendineae of the TV. Although a right cardiac thrombus-in-transit under pro-thrombotic conditions has rarely been reported, it occurs predominantly in the right atrium (10). In addition to the low pressure in the chamber, structural features of the RV such as multiple chordal attachments to the ventricular septum, a triangular-shaped ventricular cavity, the presence of the moderator band, coarse apical trabeculation, and a trileaflet atrioventricular valve may predispose the RV to a thrombus-in-transit compared to the left ventricle. Nevertheless, a transit RV thrombus entangled in the chordae tendineae of the TV is extremely rare. Because the chordae tendineae must work together with TV leaflets and papillary muscles to ensure proper coaptation, its main role is recognized to be in transmitting tension to the TV, causing them to open and close. Interestingly, the chordae tendineae in this case also acted as a protective filter and prevented a massive fatal PE. In this case, the therapeutic options included medication and surgery. Myers et al. have shown that thrombolysis is less desirable than surgical thromboembolectomy for the treatment of a biatrial thromboembolus caught in transit across a patent foramen ovale (11). Given the negligible risk for systemic embolism due to the lack of a patent foramen ovale and the high risk of cardiac surgery due to the patient’s poor general condition, we decided to give thrombolytic therapy. Although the selected treatment in this case was met with good clinical outcome, the treatment selection for other thrombus-in-transit cases warrants further investigation.

Calcified amorphous tumor (CAT) is a rare, non-neoplastic tumor involving calcium deposition in amorphous materials. Although its etiology is unknown, cases have frequently been reported in patients with hemodialysis for chronic kidney disease. We herein describe a case of cardiac CAT in a 64-year-old woman who had been on hemodialysis for diabetic nephropathy for 20 years, and the findings of the present patient, in association with the findings of previous case reports, suggest that end-stage renal disease seems to play an important role in the onset of CAT, especially in CAT formation at the mitral annulus, which appears to differ from CAT occurring at other sites.

The morphological determinants of left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM) are not completely understood. We aimed to identify the anatomical risks of the obstruction using echocardiography.Fifty patients with untreated HCM were classified into two groups: those with LVOT pressure gradient (LVOTPG) ≥ 30 mmHg (obstructive HCM [HOCM] group) and those with LVOTPG < 30 mmHg (HNCM group). The echocardiographic morphological variables were analyzed to determine whether they were predictive of LVOT obstruction. Systolic anterior motions of the mitral valve were observed in 100% of patients in the HOCM group but only in 58% in the HNCM group. There were no significant differences in wall thickness, end-systolic LV dimension (LVDs), or LVOT diameter between the two groups. However, HOCM subjects had a shorter distance from papillary muscles to the inter-ventricular septum (5.97 ± 2.3 versus 9.20 ± 1.9 mm, respectively, P < 0.0001) and a longer anterior mitral leaflet (AML) length (24.7 ± 5.8 versus 20.1 ± 5.4 mm, respectively, P < 0.01) compared to the HNCM group. The AML length/LVDs ratio was significantly higher in the HOCM group compared to the HNCM group (1.02 ± 0.34 versus 0.78 ± 0.26, P < 0.01), and an LVOT obstruction was predicted with an area under the curve of 0.71 (P < 0.05). Multiple linear regression revealed that only the AML length/LVDs ratio was independently associated with LVOTPG (P < 0.01).The AML length/LVDs ratio has a significant predictive value for LVOT obstruction and a strong relationship with LVOTPGs. The AML length/LVDs ratio determines the anatomical risk of LVOT obstruction in HCM.

Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) can provide unique visualization and better understanding of the relationship among cardiac structures. Here, we report the case of an 85-year-old woman with an obstructed mitral prosthetic valve diagnosed promptly by RT3D-TEE, which clearly showed a leaflet stuck in the closed position. The opening and closing angles of the valve leaflets measured by RT3D-TEE were compatible with those measured by fluoroscopy. Moreover, RT3D-TEE revealed, in the ring of the prosthetic valve, thrombi that were not visible on fluoroscopy. RT3D-TEE might be a valuable diagnostic technique for prosthetic mitral valve thrombosis.

A 55-year-old man with hereditary haemorrhagic telangiectasia manifesting with giant pulmonary arteriovenous malformations (PAVMs; Panel A ) was admitted for a brain abscess and subsequent antibiotic-resistant fever. An echocardiogram revealed a mobile 9 × 7 mm mass attached to the posterior papillary muscle (PPM), with no valvular involvement, masquerading as an intracardiac tumour or …

Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) can provide unique visualization and better understanding of the relationship among cardiac structures. Here, we report the case of an 85-year-old woman with an obstructed mitral prosthetic valve diagnosed promptly by RT3D-TEE, which clearly showed a leaflet stuck in the closed position. The opening and closing angles of the valve leaflets measured by RT3D-TEE were compatible with those measured by fluoroscopy. Moreover, RT3D-TEE revealed, in the ring of the prosthetic valve, thrombi that were not visible on fluoroscopy. RT3D-TEE might be a valuable diagnostic technique for prosthetic mitral valve thrombosis.