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Infective endocarditis is one of the complications following the percutaneous occlusion of an atrial septal defect (ASD) with a closure device. To the best of our knowledge, no case reports have been published of infective endocarditis associated with the Figulla Flex Ⅱ ASD occluder (FSO; Occlutech GmbH, Jena, Germany). We present the case of a 50-year-old woman who underwent a transcatheter closure of an ASD with FSO almost 2 years prior to presentation to our institution. Echocardiography showed a mobile vegetation (20 × 10 mm), and her blood culture grew β-hemolytic streptococci. Magnetic resonance imaging revealed acute cerebral infarction. Those findings were diagnosed as late infective endocarditis associated with the ASD closure device. The patient was treated with antibiotics and underwent surgical removal of the FSO, which showed incomplete endothelialization, and surgical repair of ASD. After surgery, the patient made a complete recovery without complications or residual shunts. This case highlights the risk of late infective endocarditis in patients after closure of ASD with an FSO with incomplete endothelialization.

Background: Short-term mortality of lethal cardiogenic shock (CS) patients due to acute coronary syndrome (ACS) remains to be improved. The veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been applied as the effective lifesaving modality for CS patients. While VA-ECMO maintains end-organ perfusion, it increases the damaged left ventricular (LV) afterload. Combined treatment of VA-ECMO and a micro-axial Impella pump, ECPELLA, simultaneously provides the systemic circulatory support and LV unloading. However, it remains unknown whether LV unloading effect by ECPELLA can reduce the myocardial damage and the mortality. Purpose: This study was to assess whether ECPELLA reduces myocardial damage and improves the mortality of CS patients due to ACS. Methods: From January 2012 to May 2021, 66 consecutive patients with lethal CS (SCAI stage-E) due to ACS were enrolled. All patients received VA-ECMO support prior to or after the percutaneous coronary intervention. Among them, 34 patients received ECPELLA and 32 patients received VA-ECMO + IABP. We assessed serum CK-MB levels and the cumulative 30-day mortality. Results: There were no significant difference in age, rate of male sex, coronary risk factors, ST elevated ACS, left main trunk (LMT) lesion, and the time from onset to reperfusion between two treatment groups. The ECPELLA group had significantly lower peak CK-MB and lower 30-day all-cause mortality compared to the VA-ECMO + IABP group [Peak CPK level: median (IQR); 295 (92-507) vs.580 (219-1090): p=0.002, the 30-day mortality rate: 50% vs. 76%: p=0.02, respectively]. Multivariate Cox proportional hazard analysis including age, the time form onset to reperfusion, LMT lesion, E-CPR, and ECPELLA revealed that the ECPELLA (HR: 0.30 95% confidence interval:0.13-0.64; p=0.002) was independently associated with the 30-day all-cause mortality. Conclusion: Results suggest that the ECPELLA reduces the myocardial damage shown by peak CK-MB and improves the 30-day mortality.

Background: Extracorporeal cardiopulmonary resuscitation (E-CPR) using venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a novel lifesaving method for refractory cardiac arrest (CA). However, VA-ECMO increases damaged left ventricular (LV) afterload. The percutaneous microaxial pump Impella can reduce LV preload with simultaneous circulatory support, which may have a significant effect on clinical outcome by concomitant use of VA-ECMO and IMPELLA (ECPELLA). In the current retrospective cohort study, we assessed factors affecting the outcome of CA patients who underwent E-CPR.Method: We retrospectively reviewed 149 consecutive CA patients with E-CPR from January 2012 through December 2020 in our institute. Patients were divided into three groups: ECEPLLA (n=29), IABP + VA-ECMO (n=78), and single VA-ECMO (n=42). We assessed 30-day survival and neurological outcome using cerebral performance categories (CPCs).Results: There were no significant differences in age, sex, out-of-hospital CA, or acute coronary syndrome among the groups. ECPELLA showed the highest cumulative 30-day survival (ECPELLA: 55%, IABP + VA-ECMO: 23%, VA-ECMO: 9.5; p=0.001) and the rates of CPC score 1 or 2 (ECPELLA: 31%, IABP + VA-ECMO: 13%, VA-ECMO: 7%; p=0.02). Multivariate analysis revealed that age (hazard ratio [HR], 1.30, 95% confidence interval [CI], 1.13-1.52, P=0.005) and time from CA to ECMO support (HR, 1.22, 95% CI, 1.13-1.31, PConclusion: Earlier initiation of E-CPR is critical to improve patient survival and neurological outcome. Additional Impella support, ECPELLA, appears to significantly improve the clinical outcome.

Background: Extracorporeal cardiopulmonary resuscitation (E-CPR) using venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a novel lifesaving method for refractory cardiac arrest (CA). However, VA-ECMO increases damaged left ventricular (LV) afterload. The percutaneous microaxial pump, Impella, can reduce LV preload with simultaneous circulatory support, which may have significant effect on clinical outcome by concomitant use of VA-ECMO and IMPELLA (ECPELLA). In the current retrospective cohort study, we assessed factors affecting outcome of CA patients who underwent E-CPR.Method: We retrospectively reviewed 149 consecutive CA patients with E-CPR from January 2012 through December 2020 in our institute. Patients were divided into three groups, ECEPLLA (n=29), IABP + VA-ECMO (n=78), and single VA-ECMO (n=42). We assessed 30-day survival and neurological outcome using the Cerebral Performance Categories (CPC). Results: There were no significant differences in age, gender, out of hospital CA, acute coronary syndrome among groups. The ECPELLA showed the highest cumulative 30-day survival (ECPELLA: 55%, IABP + VA-ECMO: 23%, VA-ECMO: 9.5; p=0.001) and the rates of CPC score 1 or 2 (ECPELLA: 31%, IABP + VA-ECMO: 13%, VA-ECMO: 7%; p=0.02). Multivariate analysis revealed that age (hazard ratio [HR], 1.30, 95% confidence interval [CI], 1.13-1.52, P=0.005) and Time from CA to ECMO support (HR, 1.22, 95%CI, 1.13-1.31, PConclusion: Earlier initiation of E-CPR is critical to improve patient survival and neurological outcome. Additional Impella support, ECPELLA, appears to significantly improve the clinical outcome.

Background: Guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. Objective: To evaluate the impact of the prehospital mobile cloud ECG transmission system (C-ECG) on DTBT and mortality in patients with STEMI. Methods: On June 2018, eight mobile C-ECG systems (SCUNA®, MEHERGEN GROUP) were implemented into the Uki and Kamimashiki fire departments in Kumamoto, Japan. Within two years, 428 ECGs of patients complaining of chest pain, difficulty in breathing and any other symptom that the emergency staff deemed necessary were transmitted to our hospital. 119 patients were diagnosed with ACS, 93 received emergency CAG and 69 were diagnosed with STEMI. After excluding eight patients with onset to arrival over 24 hours, a total of 137 consecutive STEMI patients received emergency PCI during the study period. Among them, 68 received PCI during the pre-C-ECG period (Pre: from June 2016 to May 2018), whereas 69 were received during the post-C-ECG period (Post: June 2018 to May 2020). We compared the DTBT, Onset to Recanalization time (OTRT), and in-hospital mortality between the two periods. Results: There was no significant difference in age, gender, Killip classification, and number of diseased coronary lesion between the two periods. The door to Cath-Lab time (DTCT) and DTBT were significantly shorter in the post-C-ECG period compared to the pre-C-ECG period (Pre: 34 min [IQR; 23-44] vs. Post: 24 min [IQR; 18-38]; P=0.01, Pre: 66 min [IQR; 48-80] vs. Post: 49 min [IQR; 42-71]; P=0.02, respectively). Furthermore, OTRT was also significantly shorter in the post-C-ECG period compared to the pre-C-ECG period (Pre: 190 min [IQR; 137-343] vs. Post: 153 min [IQR; 110-247]; P=0.02). However, peak-CPK and in-hospital mortality were not significantly different between the two periods (Pre: 2254 IU/L [IQR; 1153-4257] vs. Post: 1985 IU/L [IQR; 740-4021]; P=0.2, Pre: 5.9% vs. Post: 4.4%; P=0.7, respectively). Conclusion: Prehospital mobile cloud ECG transmission system reduced not only the DTBT but also OTRT.

Background: Various predictors in patients with acute pulmonary embolism (PE) have been reported for in-hospital mortality and chronic thromboembolic pulmonary hypertension (CTEPH), but none have been established conclusively. Methods and Results: We retrospectively analyzed data that might be associated with in-hospital mortality and CTEPH from patients with acute PE who were admitted to our hospital. Among 163 patients (aged 69.3± 14.6 years) with acute PE, 11 patients (6.7%) died in the hospital. We examined the following acute and chronic-phase data: vital signs, echocardiography values, medications, laboratory test results, blood gas data and heparin infusion time. Multivariate logistic regression analysis showed that the acute-phase levels of plasma B-type natriuretic peptide (BNP) (odds ratio (OR), 1.003; 95% confidence interval (CI), 1.0004-1.0053; P = 0.034,) and arterial blood gas lactate (OR, 1.306; 95% CI, 1.056-1.615; P = 0.014) were significant independent predictors of in-hospital mortality. The area under the receiver operating characteristic (AUROC) curves of BNP and arterial blood lactate levels for in-hospital mortality were 0.846 and 0.921, respectively. (BNP, 400.65 pg/mL [sensitivity 77.8%, specificity 84.6%]; lactate 7.9 mmol/L [sensitivity 81.8%, specificity 89.5%]). In univariate logistic regression analysis, the plasma BNP level > 400.65 pg/mL and lactate level > 7.9 mmol/L on admission were significant predictors for in-hospital mortality (OR 62.5, 95% CI 10.0-390.3; P = 0.0001). Among 152 patients (aged 68.9±14.6 years) with acute PE who did not die in-hospital, 15 (9.8%) patients progressed to CTEPH. Multivariate logistic regression analysis showed that right ventricular systolic pressure (RVSP) at admission was an independent and significant predictor for CTEPH (OR, 1.183; 95% CI, 1.090-1.285; P = 0.0001). The AUROC curve of RVSP for developing CTEPH was 0.944. (RVSP, 51.4 mm Hg [sensitivity 86.7%, specificity 83.8%]). Conclusions: In patients with acute PE, the acute-phase BNP and arterial blood lactate levels are effective predictors of in-hospital mortality. And RVSP during the acute phase, but not during the chronic phase is an effective predictor of progression to CTEPH.

Background: Extracorporeal CPR (E-CPR) using a veno-arterial ECMO (VA-ECMO) is effective for patients with refractory cardiac arrest. Intra-aortic balloon pumping (IABP) is often combined with VA-ECMO to increase coronary perfusion. However, this combination significantly increases left ventricular afterload. Recent studies showed VA-ECMO combined with IMPELLA pump (ECPELLA) had beneficial effect on refractory cardiogenic shock. Objective: Evaluate outcome of ECPELLA patients who underwent E-CPR as compared to ECMO with IABP. Method: We retrospectively reviewed 140 consecutive patients who underwent E-CPR from January 2012 through May 2020 in our institute. Thirty-eight patients who received ECMO alone were excluded, and 102 patients were recruited. Twenty-four patients underwent ECPELLA (ECPELLA group) and 78 patients underwent ECMO with IABP (IABP group). The 30-day survival rate and the rate of grades 1 and 2 Cerebral Performance Categories (CPC) as the neurological prognosis were assessed. Result: ECPELLA group showed significantly shorter time from cardiac arrest to ECMO placement compared to IABP group (24 min [IQR; 13-41] vs. 49 min [IQR; 28-75]; P=0.0003). The rate of favorable neurological prognosis were significantly higher in the ECPELLA group (38% vs. 13% ; P=0.01). The 30-day all-cause mortality of ECPELLA was significantly lower than IABP (P=0.005 by log-rank test). Multivariate cox proportional hazard analysis including the age, Out of hospital cardiac arrest, shockable rhythm, Acute coronary syndrome, Collaapse-to-ECMO under 60min, and ECPELLA revealed that the age (hazard ratio [HR], 1.34 (10 years increase), 95%CI, 1.11-1.63, P=0.002), Collapse-to-ECMO under 60 min (HR, 0.45, 95%CI, 0.23-0.87, P=0.02) and ECPELLA (HR, 0.48, 95%CI, 0.22-0.95, P=0.035) were significantly associated with 30-day mortality. Conclusion: ECPELLA improves mortality and favorable neurological outcome in patients who underwent E-CPR.

Background: Extracorporeal CPR (E-CPR) is a lifesaving method for refractory cardiac arrest (CA), and IABP has been often used as the additional circulatory support. However, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) increase damaged left ventricular (LV) afterload. The percutaneous microaxial pump, IMPELLA, can reduce damaged LV preload and afterload with circulatory support. Concomitant use of VA-ECMO and IMPELLA (ECPELLA) may have significant effect on clinical outcome. Objective: This study is to evaluate the effects of ECPELLA on clinical outcome of patients with out of hospital cardiac arrest (OHCA) or CA at the emergency room (ERCA) who underwent E-CPR. Method: We retrospectively reviewed 140 consecutive patients who underwent E-CPR from January 2012 through May 2020 in our institute. Seventy-four in-hospital CA patients were excluded, and 66 patients with OHCA or ERCA were recruited. Patients were divided into three groups ECEPLLA (n=13), ECMO with IABP (n=40), and ECMO alone (n=13). The primary endpoint was 30-day mortality. Secondary endpoint was good neurological outcome at hospital discharge defined as cerebral performance categories (CPC) of 1 or 2. Result: There were no significant differences in age, sex, OHCA, acute coronary syndrome in all three groups. The rate of shockable rhythm was higher in the ECPELLA and ECMO with IABP groups than ECMO alone. ECPELLA had the shortest time from CA to ECMO support compared with other groups. The 30-day survival and favorable neurological prognosis rates were significantly higher in the ECPELLA group, compared with other groups (ECPELLA: 61% vs. IABP: 18% vs. ECMO alone: 15%; P=0.008, ECPELLA: 38% vs. IABP: 8% vs. ECMO alone: 8%; P=0.03). Multivariate cox regression analysis including age, sex, time from CA to ECMO support and ECPELLA revealed that age (hazard ratio [HR], 1.36 (10 years increase), 95% confidence interval [CI], 1.11-1.67, P=0.04), male (HR, 2.42, 95%CI, 1.04-5.66, P=0.04), time from CA to ECMO support (HR, 1.01, 95%CI, 1.01-1.03, P=0.04), and ECPELLA (HR, 0.35, 95%CI, 0.13-0.91, P=0.03) were significantly associated with 30-day mortality. Conclusion: ECPELLA could improve 30-day mortality and neurological outcome in OHCA or ERCA patients who underwent E-CPR.

The aim of this study was to evaluate the association of functional mitral regurgitation (FMR), preserved or reduced ejection fraction (EF), and ischemic or nonischemic origin with outcomes in patients discharged alive after hospitalization for acute decompensated heart failure (HF). Of the 4,842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 3,357 patients were evaluated to assess the association of FMR, preserved or reduced EF, and ischemic or nonischemic origin with the primary end point (all-cause death and readmission for HF after discharge). At the time of discharge, FMR was assessed semiquantitatively (classified as none, mild, or moderate to severe) by color Doppler analysis of the regurgitant jet area. According to multivariable analysis, in the ischemic group, either mild or moderate to severe FMR in patients with a preserved EF had a significantly higher risk of the primary end point than patients without FMR (hazard ratio [HR] 1.60; 95% confidence interval [CI] 1.12 to 2.29; p = 0.010 and HR 1.98; 95% CI 1.30 to 3.01; p = 0.001, respectively). In patients with reduced EF with an ischemic origin, only moderate to severe FMR was associated with a significantly higher risk of the primary end point (HR 1.67; 95% CI 1.11 to 2.50; p = 0.014). In the nonischemic group, there was no significant association between FMR and the primary end point in patients with either a preserved or reduced EF. In conclusion, among patients with acute decompensated HF with a preserved or reduced EF, the association of FMR with adverse outcomes may differ between patients who had an ischemic or nonischemic origin of HF.

Background: Encouraging results of extracorporeal cardiopulmonary resuscitation (E-CPR) for patients with refractory cardiac arrest have been shown. However, an optimal timing to switch from conventional CPR to E-CPR are not well established. To determine the optimal timing when E-CPR should be performed, we investigated the relationship between the time from collapse to the initiation of extracorporeal membrane oxygenation (Collapse-to-ECMO time ) and neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) treated with E-CPR. Methods: A total of 80 consecutive patients (age 64±16 years, male ratio 76%, shockable rhythm 48%, and OHCA 51%) received E-CPR between January 2012 and May 2019. The primary endpoint was survival with good neurological outcomes at hospital discharge (a cerebral performance category of 1 or 2). Results: Of the 80 patients included, 8 had good neurological outcomes. The rate of male was significantly higher in the good outcome group compared with the non-good outcome group. There was no significant difference in the age and the rates of initial shockable rhythm and acute coronary syndrome between the two groups. IHCA had the better outcomes compared with OHCA, but the difference does not reach significance [15.4% (6 of 39) vs. 4.9% (2 of 41); P=0.1]. The median Collapse-to-ECMO time was significantly shorter in the good outcome group compared with the non-good outcome group (38.5 min, interquartile range [IQR], 19.3-54.5 vs. 58.5 min, IQR, 35.3-76.0: p = 0.04). The area under the receiver operating curve of the Collapse-to-ECMO time for predicting a good neurological outcome was 0.72, and the optimal cutoff time was 60 min. Stepwise multivariate logistic regression analysis including data on age, sex, shockable rhythm, OHCA, and the Collapse-to-ECMO time under 60 min revealed that a male sex (P=0.03), shockable rhythm (P=0.03) and the Collapse-to-ECMO time under 60 min (P Conclusions: The Collapse-to-ECMO time was independently associated with good neurological outcomes. In patients with refractory cardiac arrest, it may be considered to initiate E-CPR within 60 min from collapse regardless of OHCA or IHCA.

Background: Prolonged conventional cardiopulmonary resuscitation (C-CPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to C-CPR. However, the indication and optimal duration to switch from C-CPR to E-CPR are not well established. In addition, the opportunities to develop teamwork skills and expertise to mitigate risks are few. We thus developed the implementation protocol for the E-CPR simulation program, and investigated whether the faster deployment of extracorporeal membrane oxygenation (ECMO) improves the neurological outcome in patients with refractory OHCA. Methods: A total of 42 consecutive patients (age 58±16 years, male ratio 90%, and initial shockable rhythm 64%) received E-CPR (3% of OHCA) during the study period. Among them, 32 (76%) were deployed ECMO during the pre-intervention time period (Pre: from January 2012 to September 2017), whereas 10 (24%) were deployed during the post-intervention time period (Post: October 2017 to May 2019). We compared the door to E-CPR time, collapse to E-CPR time, 30-day mortality, and favorable neurological outcome (Cerebral Performance Categories 1, 2) between the two periods. Results: There was no significant difference in age, the rates of male sex and shockable rhythm, and the time form collapse to emergency room admission between the two periods. The door to E-CPR time and the collapse to E-CPR time were significantly shorter in the post-intervention period compared to the pre-intervention period (Pre: 39 min [IQR; 30-50] vs. Post: 29 min [IQR; 22-31]; P=0.007, Pre: 76 min [IQR; 58-87] vs. Post: 59 min [IQR; 44-68]; P=0.02, respectively). The 30-day mortality was similar between the two periods (Pre: 88% vs. Post: 80%; P=0.6). In contrast, the rate of favorable neurological outcome at the time of discharge was significantly higher in post-intervention period (Pre: 0% vs. Post: 20%; P=0.01) compared to the pre-intervention period. Conclusion: A comprehensive simulation-based training for E-CPR seems to improve the neurological outcome in patients with refractory OHCA patients.

SummaryAn 87-year-old woman who had metastatic lung cancer presented with intermittent chest discomfort. The emergent coronary angiogram showed a giant saddle thrombus at the left main coronary artery bifurcation without flow limitation. We performed thrombolysis with unfractionated heparin and warfarin under careful observation of the thrombus with a 320-row area detector computed tomography (ADCT). Ten days later, the second examination with ADCT revealed complete resolution of the saddle thrombus. During the follow-up, neither chest pain nor enzymatic cardiac damage was reported. In this carefully observed case, a less invasive strategy instead of catheter intervention or strong thrombolysis might have led to a favorable clinical outcome.

The saphenous vein is a widely used blood vessel for arterial bypass procedures. Failures of saphenous vein aortocoronary bypass grafts are predominantly the result of subsequent vein graft atherosclerotic disease. Rarely saphenous vein grafts undergo aneurysmal degeneration. This report describes a case of a ruptured aneurysm in a saphenous vein graft that occurred in an 82-year-old female who underwent a coronary artery bypass operation 18 years previously. We could not resuscitate her, but describe the autopsy findings in detail.

Background— Although type B aortic dissection has been treated with β blockers to lower the arterial blood pressure (BP), there has been little evidences about reduction in heart rate (HR). We assessed whether tight HR control improved the outcome of medical treatment in patients with aortic dissection. Methods and Results— From 1997 to 2005, 171 patients with acute aortic dissection medically treated and controlled to lower BP under 120 mm Hg were enrolled. Based on the average HR at 3, 5, and 7 days after the onset, patients were divided into tight HR (5 mm, and surgical requirement between two groups. During a median follow-up of 27.0 months, late organ or limb ischemia, aortic rupture, recurrent dissection, pathological aortic expansion, and aortic surgery occurred in 0, 8, 14, 39, and 26 patients, respectively. Reduction in aortic events was observed in tight HR control group (12.5%) compared to conventional HR control group (36.0%), (Odds ratio: 0.25, C.I.: 0.08 to 0.77, P Conclusions— The present study demonstrated that tight heart rate control improved the outcome of medical treatment in patients with aortic dissection.

Background : Although type B aortic dissection (AD) has been treated with beta-blocker to lower the arterial blood pressure (BP), there has been little evidences about reduction in heart rate (HR). We assessed whether tight HR control improved the outcome of medical treatment in patients with AD. Methods and Results : From 1997 to 2005, consecutive 223 patients with AD medically treated and controlled to lower BP under 120 mmHg were enrolled. Based on the average HR at 3, 5, and 7 days after the onset, patients were divided to tight HR ( . Conclusions : The present study demonstrated that tight heart rate control improved the outcome of medical treatment in patients with AD.