Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 84, Issue 3
Displaying 1-33 of 33 articles from this issue
Message From the Editor-in-Chief
Reviews
  • Hidehiro Kaneko, Hiroyuki Morita, Issei Komuro
    Article type: REVIEW
    2020 Volume 84 Issue 3 Pages 371-373
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 15, 2020
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    The new Imperial era, Reiwa, started in May, 2019. After World War II, Reiwa is the third Imperial era following Showa and Heisei. In each era, we had specific healthcare problems in cardiovascular medicine and implemented preventive strategies against them. Furthermore, nationwide healthcare policies such as a universal healthcare insurance system (kaihoken) and health check-up system largely contribute to overcoming these problems. Here, we summarize the specific issues in cardiovascular medicine and nationwide strategies policies against them in each era. We also describe what we should do in the new Imperial era from the cardiovascular viewpoint.

Editorials
Original Articles
Arrhythmia/Electrophysiology
  • Ken-ichi Hiasa, Hidetaka Kaku, Hiroshi Inoue, Takeshi Yamashita, Masah ...
    Article type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2020 Volume 84 Issue 3 Pages 388-396
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: January 23, 2020
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    Background:Atrial fibrillation (AF) is increasing as the global population ages. Elderly AF patients (≥75 years) have a worse prognosis than younger patients, and effective management is often difficult due to multiple comorbidities. This analysis examined the age-related differences in clinical characteristics and treatment in real-world elderly Japanese AF patients.

    Methods and Results:The ANAFIE Registry is a multicenter, prospective, observational registry of 32,726 non-valvular AF patients aged ≥75 years. The present study assessed the age-related differences in baseline clinical status and anticoagulant therapy between age groups 75–<80, 80–<85, 85–<90, and ≥90 years. The prevalence of persistent or permanent AF increased, and that of paroxysmal AF decreased, with increasing age (trend P<0.0001). The risk of stroke, based on CHADS2and CHA2DS2-VASc scores, and bleeding, based on HAS-BLED score, increased with age. Both warfarin and apixaban were used more often as age increased (trend P<0.0001, for each), while other anticoagulants were used less. Anticoagulant doses were significantly lower in older patients.

    Conclusions:Permanent/persistent AF, comorbidities, and cardiovascular and bleeding risk all increased significantly with age. Furthermore, use of warfarin and apixaban increased with age, accompanied by a decrease in other oral anticoagulant usage.

  • Taro Temma, Toshiyuki Nagai, Masaya Watanabe, Rui Kamada, Yumi Takahas ...
    Article type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2020 Volume 84 Issue 3 Pages 397-403
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 01, 2020
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    Supplementary material

    Background:Atrial fibrillation (AF) is an important prognostic determinant in heart failure (HF) with preserved ejection fraction (HFpEF). However, it is unclear which HFpEF phenotypes are affected by AF in terms of long-term clinical outcomes because HFpEF is a heterogeneous syndrome with comorbidities such as coronary artery disease (CAD). In this study we determined the differential prognostic significance of AF in HFpEF patients according to CAD status.

    Methods and Results:Data for 408 hospitalized HFpEF patients enrolled in the Japanese Heart Failure Syndrome with Preserved Ejection Fraction Nationwide Multicenter Registry were analyzed. Patients were divided into 4 groups according to the presence of AF and CAD. The primary outcome was the composite of all-cause death and HF rehospitalization. The incidence of adverse events was higher in the AF–non-CAD than non-AF–non-CAD group (P=0.004). On multivariable Cox regression analysis with prespecified confounders, AF–non-CAD was significantly associated with an increased risk of adverse events than non-AF–non-CAD (adjusted HR, 1.91; 95% CI: 1.02–3.92) regardless of the type of AF. In contrast, risk was comparable between the AF–CAD and non-AF–CAD groups (adjusted HR, 1.24; 95% CI: 0.64–2.47).

    Conclusions:In HFpEF patients without CAD, AF was independently related to adverse events, indicating that intensive management of AF would have more beneficial effects particularly in HFpEF patients without CAD.

  • Ekrem Üçer, Sabine Fredersdorf, Joachim Seegers, Florian Poschenrieder ...
    Article type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2020 Volume 84 Issue 3 Pages 404-410
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 05, 2020
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    Background:We recently demonstrated that the acute reconnection rate detected with adenosine provocation test (APT) was significantly lower after pulmonary vein isolation (PVI) with visually guided laser balloon ablation (VGLB) than with RF ablation (RF). We evaluated the recurrence rate of atrial arrhythmias at 12 months after VGLB vs. RF and the significance of APT results for the outcome.

    Methods and Results:Fifty patients with paroxysmal AF were randomized to either RF or VGLB ablation in a 1 : 1 fashion. After PVI each PV underwent an APT. All patients underwent a 3-day Holter and clinical follow-up every 3 months. Significantly less PVs reconnected during APT in the VGLB-arm (10 PV (10.8%) vs. 29 PV (30.9%); P=0.001). Significantly less patients had a recurrence of atrial arrhythmia in the VGLB-arm (3 vs. 9; P=0.047). In the VGLB-arm no recurrence was seen in those patients with a negative APT (negative predictive value (NPV)=100%). Only 3 of the 8 patients with a positive APT in the VGLB-arm had a recurrence (positive PV (PPV)=37%). Recurrences in the RF-arm were seen in 3 patients with positive APT as well as in 6 patients with negative APT (PPV=18% and NPV=33%).

    Conclusions:There was significantly less recurrence of atrial arrhythmias at 12 months after PVI with VGLB. A negative APT after PVI with VGBL predicted freedom from AF with a very high NPV meaning that the high acute efficiency of the VGLB persisted long term.

  • Yuma Hamanaka, Yohei Sotomi, Akio Hirata, Tomoaki Kobayashi, Yasuhiro ...
    Article type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2020 Volume 84 Issue 3 Pages 411-418
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 11, 2020
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    Supplementary material

    Background:This study investigated the impact of systemic inflammation on bleeding risk in non-valvular atrial fibrillation (NVAF) patients treated with direct oral anticoagulants (DOAC).

    Methods and Results:We conducted a single-center prospective registry of 2,216 NVAF patients treated with DOAC: the DIRECT registry (UMIN000033283). High-sensitivity C-reactive protein (hsCRP) was measured ≤3 months before (pre-DOAC hsCRP) and 6±3 months after initiation of DOAC (post-DOAC hsCRP). Multivariate logistic regression model was used to assess the influence of systemic inflammation and conventional bleeding risk factors on major bleeding according to International Society on Thrombosis and Haemostasis criteria. Based on the findings, we created a new bleeding risk assessment score: the ORBIT-i score, which included post-DOAC hsCRP >0.100 mg/dL and all components of the ORBIT score. A total of 1,848 patients had both pre- and post-DOAC hsCRP data (follow-up duration, 460±388 days). Post-DOAC hsCRP was associated with major bleeding (OR, 2.770; 95% CI: 1.687–4.548, P<0.001). Patients with post-DOAC hsCRP >0.100 mg/dL more frequently had major bleeding than those without (log-rank test, P<0.001). ORBIT-i score had the highest C-index of 0.711 (95% CI, 0.654–0.769) compared with the ORBIT and HAS-BLED scores.

    Conclusions:Persistent systemic inflammation was associated with major bleeding risk. ORBIT-i score had a higher discriminative performance compared with the conventional bleeding risk scores.

  • Koichiro Kumagai, Hideko Toyama, Takashi Ashihara
    Article type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2020 Volume 84 Issue 3 Pages 419-426
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 13, 2020
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    Background:Additional benefits of posterior left atrial (LA) box isolation (BOXI) over pulmonary vein isolation (PVI) in persistent atrial fibrillation (perAF) have been reported, but the mechanism is still unclear. We evaluated the effects of BOXI on rotors and multiple wavelets in the whole LA.

    Methods and Results:Twenty patients with perAF (including 12 cases of longstanding perAF) underwent PVI. Real-time phase mapping (ExTRa Mapping) was performed in the whole LA during AF. Subsequently, BOXI was added and re-ExTRa Mapping was performed again at the same site. The nonpassively activated ratio (%NP), the ratio of the form of rotors and multiple wavelets to the recording time, was compared before and after BOXI. After BOXI, the %NP significantly decreased in the anterior wall (from 53±22% to 39±23%, P=0.010), inferior wall (from 51±16% to 34±19%, P=0.001), and LA appendage (from 23±27% to 16±19%, P=0.049). However, there were no significant differences in the septum (49±19% vs. 49±18%, P=0.562) or lateral wall (41±19% vs. 38±15%, P=0.526).

    Conclusions:BOXI not only reduced the critical mass for maintenance of AF, but also decreased the rotors and multiple wavelets in the anterior wall, inferior wall and LA appendage during perAF.

Cardiac Rehabilitation
  • Hideki Origuchi, Haruki Itoh, Shin-ichi Momomura, Ryuji Nohara, Hiroyu ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiac Rehabilitation
    2020 Volume 84 Issue 3 Pages 427-435
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 08, 2020
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    Supplementary material

    Background:There is little evidence regarding the effect of outpatient cardiac rehabilitation (CR) on exercise capacity or the long-term prognosis in patients after coronary artery bypass graft surgery (CABG). This study aimed to determine whether participation in outpatient CR improves exercise capacity and long-term prognosis in post-CABG Japanese patients in a multicenter cohort.

    Methods and Results:We enrolled 346 post-CABG patients who underwent cardiopulmonary exercise testing during early (2–3 weeks) and late (3–6 months) time points after surgery. They formed the Active (n=240) and Non-Active (n=106) CR participation groups and were followed for 3.5 years. Primary endpoint was a major adverse cardiac event (MACE): all-cause death or rehospitalization for acute myocardial infarction/unstable angina/worsening heart failure. Peak oxygen uptake at 3–5 months from baseline was significantly more increased in Active than in Non-Active patients (+26±24% vs. +19±20%, respectively; P<0.05), and the MACE rate was significantly lower in Active than Non-Active patients (3.4% vs. 10.5%, respectively; P=0.02). Multivariate Cox proportional hazard analysis showed that participation in outpatient CR was a significant prognostic determinant of MACE (P=0.03).

    Conclusions:This unique study showed that a multicenter cohort of patients who underwent CABG and actively participated in outpatient CR exhibited greater improvement in exercise capacity and better survival without cardiovascular events than their counterparts who did not participate.

Cardiovascular Surgery
  • Chuan Wang, Ping Li, Fan Zhang, Qingyu Kong, Jingxing Li
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiovascular Surgery
    2020 Volume 84 Issue 3 Pages 436-444
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: January 30, 2020
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    Supplementary material

    Background:This analysis compared short-term mortality, sternal wound infection (SWI), and long-term survival outcomes in diabetic patients who underwent coronary artery bypass grafting (CABG) with bilateral (BIMA) vs. single (SIMA) internal mammary artery, as well as in diabetic vs. non-diabetic patients undergoing BIMA grafting.

    Methods and Results:Nineteen studies were included in the study, covering 21,143 different patients. Of these patients, 6,464 underwent CABG with BIMA, 10,264 underwent CAGB with SIMA, 11,584 had diabetes, and 6,717 did not. Compared with SIMA, BIMA had a significantly lower risk of in-hospital mortality (odds ratio [OR] 0.73, P=0.02), but a significantly higher risk of SWI (OR 1.30, P=0.04). However, compared with non-diabetic patients who underwent CABG with BIMA, diabetic patients with BIMA grafting did not have significantly higher risks of either mortality (OR 1.22, P=0.53) or SWI (OR 1.10, P=0.72). No significant differences were detected with different harvesting techniques. Longer term, BIMA was associated with a significantly higher rate of survival than SIMA (hazard ratio [HR] 0.76, P<0.001).

    Conclusions:Results from the 2 types of comparisons indicate that BIMA is a preferable option for diabetic patients, even though it has a higher risk of infection. CABG with BIMA is also associated with a long-term survival benefit.

Critical Care
  • Nobunaga Okada, Tasuku Matsuyama, Sachiko Morita, Naoki Ehara, Nobuhir ...
    Article type: ORIGINAL ARTICLE
    Subject area: Critical Care
    2020 Volume 84 Issue 3 Pages 445-455
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: January 30, 2020
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    Background: The Osborn wave (OW) is often observed in hypothermic patients; however, whether OW in hypothermic patients is related to the development of fatal ventricular arrhythmia, including ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), remains undetermined. This study aimed to estimate the association between OW and the incidence of fatal ventricular arrhythmias.

    Methods and Results: This retrospective study used the Japanese Accidental Hypothermia Network registry database and included 572 hypothermic patients. Patients were divided into the OW group (those with OW) and non-OW group (those without OW). The relationship between the development of fatal arrhythmias and presence of OW was assessed using the chi-squared test. All patients who developed VF/VT (n=10) had OW on electrocardiogram upon hospital arrival. The presence of OW had a sensitivity of 100%, specificity of 47.8%, positive predictive value of 4.0%, and negative predictive value of 100% for VF/VT development. The in-hospital mortality rate was 22.3% in the OW group and 21.2% in the non-OW group (P=0.781).

    Conclusions: OW was observed in all hypothermic patients with VF/VT. The occurrence of ventricular arrhythmias is highly unlikely in the absence of OW on the electrocardiogram. Although the presence of OW might be used to predict these fatal arrhythmias in hypothermic patients, there was no association between the presence of OW and in-hospital mortality.

Heart Failure
  • Akihito Miyoshi, Nobuhiro Nishii, Yoji Okamoto, Shinpei Fujita, Kenji ...
    Article type: ORIGINAL ARTICLE
    Subject area: Heart Failure
    2020 Volume 84 Issue 3 Pages 456-462
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 08, 2020
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    Background:In heart failure (HF) patients implanted with high-energy devices, worsening of HF can be diagnosed from intrathoracic impedance (ITI) before symptoms appear. Early therapeutic intervention can prevent HF worsening, but the optimal intervention remains unknown. This study aimed to examine which lifestyle modifications or medications can improve HF indicators in asymptomatic HF patients diagnosed from ITI.

    Methods and Results:This multicenter, prospective, randomized study included patients with high-energy devices, left ventricular ejection fraction <40%, or with a history of HF hospitalization. After the OptiVol alert was evoked by decreased ITI, patients underwent examinations. If they were diagnosed with HF, they were randomly assigned to 3 groups: lifestyle modification, diuretic, or nitrate. After 1 week, they underwent the same examinations. The primary endpoint was change in ITI and serum B-type natriuretic peptide (BNP). Totally, 57 patients were randomized. In all 3 groups, ITI was significantly increased post-intervention compared with pre-intervention. In the diuretic and nitrate groups, logBNP post-intervention was significantly lower than pre-intervention, but not in the lifestyle modification group.

    Conclusions:Compared with lifestyle modifications, diuretic and nitrate therapy for 1 week may be more effective management of HF detected by decreased ITI. However, lifestyle modification may have the additional benefits of reducing the workload or cost.

Ischemic Heart Disease
  • Toshimitsu Sato, Yoshiyasu Minami, Kiyoshi Asakura, Masahiro Katamine, ...
    Article type: ORIGINAL ARTICLE
    Subject area: Ischemic Heart Disease
    2020 Volume 84 Issue 3 Pages 463-470
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: January 25, 2020
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    Supplementary material

    Background:The pathophysiology and chronological course of atherosclerosis seems to be different between men and women due to biological differences, and age and gender differences in plaque composition of coronary lesions remain to be elucidated.

    Methods and Results:A total of 860 consecutive patients with a median age of 69 years (IQR, 60–78 years) who underwent optical coherence tomography (OCT) of culprit lesions was included. The composition of culprit plaque on OCT was compared between female (n=171) and male (n=689) subjects in younger (<70 years old) and elderly (≥70 years old) patients. In elderly patients, the prevalence of thin-cap fibroatheroma (TCFA) was significantly higher in women than in men (30.6 vs. 15.2%, P<0.001). In younger patients, the prevalence of large calcification was significantly higher in women than in men (60.0 vs. 32.8%, P<0.001). The prevalence of other vulnerable plaque characteristics (i.e., macrophages, microchannels, and spotty calcification), was similar between women and men. Elderly women had a significantly higher prevalence of TCFA (OR, 2.13; 95% CI: 1.33–3.44, P=0.002) than other patients.

    Conclusions:Women had a higher prevalence of TCFA and of large calcification than men in patients ≥70 and <70 years old, respectively. This may facilitate the understanding of gender differences in the pathogenesis of coronary atherosclerosis, and the tailoring of therapy and of prevention according to age and gender.

  • Yasuaki Takeji, Hiroki Shiomi, Takeshi Morimoto, Yutaka Furukawa, Nats ...
    Article type: ORIGINAL ARTICLE
    Subject area: Ischemic Heart Disease
    2020 Volume 84 Issue 3 Pages 471-478
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: January 29, 2020
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    Supplementary material

    Background:The effect of diabetes mellitus (DM) status on the long-term risk for heart failure (HF) in patients undergoing coronary revascularization has not been adequately evaluated.

    Methods and Results:In this study, 15,231 patients who underwent coronary revascularization in the CREDO-Kyoto Registry Cohort-2 were divided into 2 groups according to DM status (DM group: n=5,999; Non-DM group: n=9,232). The DM group was further divided into 2 groups according to insulin treatment (insulin-treated DM [ITDM]: n=1,353; non-insulin-treated DM [NITDM]: n=4,646). The primary outcome measure was HF hospitalization. The cumulative 5-year incidence of HF hospitalization was significantly higher in the DM than non-DM group (11.0% vs. 6.6%, respectively; log-rank P<0.0001), and in the ITDM than NITDM group (14.6% vs. 10.0%, respectively; log-rank P<0.0001). After adjusting for confounders, the increased risk of HF hospitalization with DM relative to non-DM remained significant (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.30–1.67, P<0.0001), whereas the risk associated with ITDM relative to NITDM was not significant (HR 1.17, 95% CI 0.96–1.43, P=0.12).

    Conclusions:The adjusted long-term risk for HF hospitalization after coronary revascularization was significantly higher in DM than non-DM patients, regardless of revascularization strategy, but did not differ between ITDM and NITDM patients.

  • Yuji Mizuno, Eisaku Harada, Fumihito Kugimiya, Makoto Shono, Izumi Kus ...
    Article type: ORIGINAL ARTICLE
    Subject area: Ischemic Heart Disease
    2020 Volume 84 Issue 3 Pages 479-486
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: January 31, 2020
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    Background:Aldehyde dehydrogenase 2 (ALDH2) plays a central role in the biotransformation of glyceryl trinitrate (GTN) or nitroglycerin, which is widely used for the treatment of coronary artery disease (CAD). The deficient variant ALDH2 genotype (ALDH2*2) is prevalent among East Asians. This study examined whether there are differences in nitroglycerine-mediated dilation (NMD) and flow-mediated dilation (FMD) response between wildALDH2*1/*1and variantALDH2*2patients with CAD.

    Methods and Results:The study subjects comprised 55 coronary spastic angina (CSA) patients, confirmed by coronary angiography and intracoronary injection of acetylcholine (42 men and 13 women, mean age 68.0±9.0 years). They underwent NMD and FMD tests in the morning before and after continuous transdermal GTN administration for 48 h. NMD was lower at baseline inALDH2*2than in theALDH2*1/*1group (P=0.0499) and decreased significantly in both groups (P<0.0001 and P<0.0001, respectively) after GTN, with significantly lower levels in theALDH2*2group (P=0.0002). FMD decreased significantly in bothALDH2*1/*1andALDH2*2groups (P<0.0001and P=0.0002, respectively) after continuous GTN administration, with no significant differences between the 2 groups both before and after GTN.

    Conclusions:Continuous administration of GTN produced endothelial dysfunction as well as nitrate tolerance in bothALDH2*1/1andALDH2*2patients with CSA.ALDH2*2attenuated GTN response and exacerbated GTN tolerance, but not endothelial dysfunction, as compared toALDH2*1/*1in patients with CSA.

Myocardial Disease
  • Soichiro Ogura, Kazufumi Nakamura, Hiroshi Morita, Norihisa Toh, Koji ...
    Article type: ORIGINAL ARTICLE
    Subject area: Myocardial Disease
    2020 Volume 84 Issue 3 Pages 487-494
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 08, 2020
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    Supplementary material

    Background:Multiple spikes in the QRS complex (fragmented QRS [fQRS]) on 12-lead electrocardiography have been associated with ventricular arrhythmic events (VAEs) in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to assess the association between new appearances of fQRS and cardiac events in patients with HCM.

    Methods and Results:The association between baseline fQRS and cardiac events, namely VAEs, heart failure-related hospitalization, and all-cause death, was evaluated retrospectively in 146 HCM patients (46 patients with fQRS, 100 without fQRS). The median follow-up was 5.3 years. Cardiac events occurred in 29 patients with baseline fQRS and 32 patients without baseline fQRS (63% vs. 32%; P<0.001). VAEs occurred in a significantly larger percentage of patients with than without baseline fQRS (54% vs. 23%, respectively; P<0.001). Of the 100 patients without baseline fQRS, 33 had a new appearance of fQRS during the 4.6-year follow-up, whereas 67 did not. VAEs occurred more frequently in the 33 patients with the appearance of fQRS than in those without (42% vs. 13%, respectively; P=0.001). Multivariable analysis showed that the new appearance of fQRS documented before VAEs was associated with VAEs (hazard ratio 4.29, 95% confidence interval 1.81–10.2; P=0.001).

    Conclusions:The new appearance of fQRS was associated with an increased risk of VAEs in HCM patients.

Pediatric Cardiology and Adult Congenital Heart Disease
  • Masatoshi Shimada, Takaya Hoashi, Jun Iida, Hajime Ichikawa
    Article type: ORIGINAL ARTICLE
    Subject area: Pediatric Cardiology and Adult Congenital Heart Disease
    2020 Volume 84 Issue 3 Pages 495-500
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 05, 2020
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    Background:The aim of this study was to assess the impact of surgeon years of experience on clinical outcomes of tetralogy of Fallot (TOF) repair using technical performance score (TPS), and to investigate the possibility of safe operations by surgical trainees.

    Methods and Results:We assessed the cases of 159 consecutive patients who underwent TOF repair between 2001 and 2015. Thirteen different primary surgeons performed operations with 41 different first assistants. The primary surgeon and first assistant mean postgraduate years were 19.1±5.1 years (range, 5.7–31.6 years) and 11.2±6.3 years (range, 3.2–36.3 years), respectively. TPS was assigned using pre-discharge echocardiography based on original criteria. Logistic regression analysis was used to examine the factors associated with TPS. TPS could be scored for all patients, 16 of whom were graded as having optimal (10%), 119 as adequate (75%), and 24 as having inadequate (15%) TPS. None of the preoperative and perioperative variables affected TPS. Although neither the primary surgeon nor the first assistant postgraduate years was associated with TPS independently, total primary surgeon and first assistant postgraduate years correlated with TPS (OR, 1.07; 95% CI: 1.01–1.13, P=0.031).

    Conclusions:Primary surgeon postgraduate years was not associated with TPS for TOF repair. TOF repair can be performed adequately and safely by surgical trainees under the support of highly experienced supervisors.

Peripheral Vascular Disease
  • Shintaro Shibutani, Hideaki Obara, Kentaro Matsubara, Naoki Toya, Naok ...
    Article type: ORIGINAL ARTICLE
    Subject area: Peripheral Vascular Disease
    2020 Volume 84 Issue 3 Pages 501-508
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 14, 2020
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    Background:This study prospectively analyzed the midterm results of above-the-knee femoropopliteal bypass (AKb) using bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with femoropopliteal occlusive disease.

    Methods and Results:This prospective, multicenter, non-randomized study reviewed limbs undergoing AKb with HB-ePTFE graft for femoropopliteal lesion in 20 Japanese institutions between July 2014 and October 2017. Primary efficacy endpoints were primary, primary assisted, and secondary graft patency. Safety endpoints included any major adverse limb event and perioperative mortality. During the study period, 120 limbs of 113 patients (mean age, 72.7 years) underwent AKb with HB-ePTFE grafts. A total of 45 patients (37.5%) had critical limb ischemia and 17 (15.0%) were on hemodialysis (HD). Median duration of follow-up was 16 months (range, 1–36 months). Estimated 1- and 2-year primary, primary assisted, and secondary graft patency rates were 89.4% and 82.7%, 89.4% and 87.2%, and 94.7% and 92.5%, respectively. On univariate analysis of 2-year primary graft patency, having 3 run-off vessels, cuffed distal anastomoses, no coronary artery disease, and no chronic kidney disease requiring HD were significantly associated with favorable patency.

    Conclusions:AKb using HB-ePTFE grafts achieved favorable 2-year graft patency. AKb using HB-ePTFE grafts may therefore be an acceptable, highly effective treatment option for femoropopliteal artery lesions.

Preventive Medicine
  • Hayato Tada, Akihiro Nomura, Kenichi Yoshimura, Hiroshi Itoh, Issei Ko ...
    Article type: ORIGINAL ARTICLE
    Subject area: Preventive Medicine
    2020 Volume 84 Issue 3 Pages 509-515
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 06, 2020
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    Supplementary material

    Background:Few data specifically investigate associations between fasting/non-fasting triglycerides (TG) and cardiovascular (CV) events under statin therapy among Japanese diabetic patients.

    Methods and Results:We recruited 4,988 participants with diabetes from the EMPATHY study. Median follow-up was 3 years. We evaluated associations between serum fasting/non-fasting TG and first CV events in Cox-regression hazard models adjusted by classical risk factors. CV events were defined as (1) major adverse cardiac events (MACE) including myocardial infarction, stroke, or cardiac death; and (2) CV diseases (CVD) including myocardial infarction, unstable angina, ischemic stroke, or large artery disease or peripheral arterial disease. Fasting as well as non-fasting TG were associated with MACE (adjusted hazard ratio [HR]: 1.017 per 10 mg/dL; 95% confidence interval [CI]: 1.000–1.037; P=0.046, adjusted HR: 1.028 per 10 mg/dL; 95% CI: 1.006–1.050; P=0.0091) and CVD (adjusted HR: 1.024 per 10 mg/dL; 95% CI: 1.011–1.038; P=4.4×10−3, adjusted HR: 1.028 per 10 mg/dL; 95% CI: 1.010–1.046; P=4.9×10−3). Comparing the top quartile with the bottom quartile of non-fasting TG, adjusted HR significantly increased 5.18 (95% CI: 1.38–18.3, P=0.014) for MACE, and 2.40 (95% CI: 1.11–4.75, P=0.021) for CVD, while adjusted HR did not change when divided into quartile of fasting TG.

    Conclusions:Non-fasting TG could be considered as a substitute for fasting TG as a risk stratification for future CV events among Japanese diabetic patients.

Stroke
  • Kodai Kanemaru, Takeshi Yoshimoto, Hiroshi Inoue, Takeshi Yamashita, M ...
    Article type: ORIGINAL ARTICLE
    Subject area: Stroke
    2020 Volume 84 Issue 3 Pages 516-523
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: January 25, 2020
    JOURNAL FREE ACCESS FULL-TEXT HTML

    Background:Despite the well-established benefits in patients with non-valvular atrial fibrillation (NVAF), oral anticoagulants (OAC) have been underused in elderly patients. We investigated the characteristics and status of anti-thrombotic therapy in elderly NVAF patients in Japan according to a history of stroke or of transient ischemic attack (TIA).

    Methods and Results:In a multicenter, prospective, observational study, 32,726 Japanese patients aged ≥75 years with NVAF were enrolled, and divided into 3 groups for the present analysis: 6,543 patients with previous ischemic stroke (IS) or TIA (2,410 women), 275 with previous hemorrhagic stroke (HS; 113 women), and the other 25,908 without previous stroke or TIA (11,470 women). Median CHADS2score was 5 in patients with IS/TIA, 2 in those with HS and 2 in those without stroke/TIA (P<0.05). Anti-thrombotic agents were used in 97.1% of patients with IS/TIA (OAC alone in 73.0%; antiplatelets alone in 3.7%; and both in 23.4%), 90.2% of those with HS (84.7%, 3.2%, and 12.1%, respectively), and 94.1% of those without stroke/TIA (83.4%, 2.7%, and 13.9%, respectively; P<0.05 for any anti-thrombotic choice). Of patients taking OAC, 72.2% received direct OAC (DOAC).

    Conclusions:In this unique nationwide NVAF registry of >30,000 elderly patients, >90% of patients, even those with HS, received anti-thrombotic therapy, nearly always with OAC. DOAC were the major choice of OAC.

Rapid Communications
  • Daisuke Sueta, Eiichiro Yamamoto, Miyuki Sato, Takahiko Sato, Koichiro ...
    Article type: RAPID COMMUNICATION
    2020 Volume 84 Issue 3 Pages 524-528
    Published: February 25, 2020
    Released on J-STAGE: February 25, 2020
    Advance online publication: February 04, 2020
    JOURNAL FREE ACCESS FULL-TEXT HTML
    Supplementary material

    Background:Although it has been discussed which measures against atherosclerotic diseases should be started in childhood, the current situation in Japan is unclear.

    Methods and Results:We conducted a health management survey of all 12-year-old children in a local town for 20 years. The body mass index tended to decrease over time. Although the serum low-density lipoprotein cholesterol level did not change, the levels of serum high-density lipoprotein cholesterol and serum triglycerides significantly increased over time.

    Conclusions:The serum triglyceride levels in school children increased significantly, probably through lifestyle changes, and the health management system should be reviewed.

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