Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 86, Issue 1
Displaying 1-35 of 35 articles from this issue
Message From the Editor-in-Chief
Focus on issue: Heart Failure and Cardiomyopathy
Reviews
  • Byung Joo Sun, Jae-Hyeong Park
    Article type: REVIEW
    2022 Volume 86 Issue 1 Pages 6-13
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: June 05, 2021
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    Unlike the left ventricle (LV), the left atrium (LA) has a thin-walled structure and has been regarded as a simple conduit chamber. However, the unique function of the LA to modulate LV filling has recently drawn much attention. Because LA structure and function are directly influenced by the LV filling pressure, LA assessment is an essential step in the diagnosis of diastolic dysfunction that can help predict new-onset atrial fibrillation, assess the risk of further embolic events, and identify high-risk patients for adverse cardiovascular events. Even in the recent era of multimodality imaging, 2-dimensional (2D) echocardiography is the most common imaging method and the central modality for evaluation of LA function. LA strain derived from 2D echocardiography can help assess LA function objectively and demonstrates the 3 distinct phasic motions of the LA cycle. Further, LA strain provides invaluable pathophysiologic information and helps to predict clinical prognosis in various cardiovascular diseases. In this review article, we focus on LA strain: basic concepts, advantages over conventional parameters, and some unresolved issues. Additionally, we present a brief history of the clinical evidence for LA strain. Through this review, we suggest echocardiography for LA strain assessment in clinical practice.

  • Samira R. Aili, Phillip Lo, Jeanette E. Villanueva, Yashutosh Joshi, S ...
    Article type: REVIEW
    2022 Volume 86 Issue 1 Pages 14-22
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: October 27, 2021
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    Supplementary material

    Background:Frailty is prevalent in patients with heart failure (HF) and associated with increased morbidity and mortality. Hence, there has been increased interest in the reversibility of frailty following treatment with medication or surgery. This systematic review aimed to assess the reversibility of frailty in patients with HF before and after surgical interventions aimed at treating the underlying cause of HF. It also aimed to assess the efficacy of cardiac rehabilitation and prehabilitation in reversing or preventing frailty in patients with HF.

    Methods and Results:Searches of PubMed, MEDLINE and Academic Search Ultimate identified studies with HF patients undergoing interventions to reverse frailty. Titles, abstracts and full texts were screened for eligibility based on the PRISMA guidelines and using predefined inclusion/exclusion criteria in relation to participants, intervention, control, outcome and study design. In total, 14 studies were included: 3 assessed the effect of surgery, 7 assessed the effect of rehabilitation programs, 2 assessed the effect of a prehabilitation program and 2 assessed the effect of program interruptions on HF patients.

    Conclusions:Overall, it was found that frailty is at least partially reversible and potentially preventable in patients with HF. Interruption of rehabilitation programs resulted in deterioration of the frailty status. Future research should focus on the role of prehabilitation in mitigating frailty prior to surgical intervention.

Original Articles
HFpEF
  • Bolrathanak Oeun, Shungo Hikoso, Daisaku Nakatani, Hiroya Mizuno, Shin ...
    Article type: ORIGINAL ARTICLE
    Subject area: HFpEF
    2022 Volume 86 Issue 1 Pages 23-33
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: August 27, 2021
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    Supplementary material

    Background:Although diastolic dysfunction is important pathophysiology in heart failure with preserved ejection fraction (HFpEF), its prognostic impact in HFpEF patients, including those with atrial fibrillation (AF), remains to be elucidated.

    Methods and Results:We included the data for 863 patients (321 patients with AF) registered in a prospective multicenter observational study of patients with HFpEF. Patients were divided into 3 groups according to the 2016 ASE/EACVI recommendations. The primary endpoint was a composite of all-cause death or HF rehospitalization. Median age was 83 years, and 55.5% were female. 196 (22.7%) were classified with normal diastolic function (ND), 253 (29.3%) with indeterminate (ID) and 414 (48.0%) with diastolic dysfunction (DD). The primary endpoint occurred more frequently in patients with DD than in those with ND or ID (log-rank P<0.001 for DD vs. ND, and log-rank P=0.007 for DD vs. ID, respectively). Taking ND as the reference, multivariable Cox regression analysis revealed that DD (hazard ratio (HR): 1.57, 95% confidence interval (CI):1.06–2.32, P=0.024) was independently associated with the composite endpoint, whereas ID (HR: 1.28, 95% CI: 0.84–1.95, P=0.255) was not. DD was associated with the composite endpoint in both patients with and without AF.

    Conclusions:HFpEF patients classified with DD using the 2016 ASE/EACVI recommendations had worse clinical outcomes than those with ND or ID. DD may be considered a prognostic marker in patients with HFpEF regardless of AF.

  • Chisato Izumi
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 34-36
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 07, 2021
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  • Daisuke Harada, Hidetsugu Asanoi, Takahisa Noto, Junya Takagawa
    Article type: ORIGINAL ARTICLE
    Subject area: HFpEF
    2021 Volume 86 Issue 1 Pages 37-46
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: July 30, 2021
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    Supplementary material

    Background:The heterogeneity of B-type natriuretic peptide (BNP) levels among individuals with heart failure and preserved ejection fraction (HFpEF) makes predicting the development of cardiac events difficult. This study aimed at creating high-performance Naive Bayes (NB) classifiers, beyond BNP, to predict the development of cardiac events over a 3-year period in individual outpatients with HFpEF.

    Methods and Results:We retrospectively enrolled 234 outpatients with HFpEF who were followed up for 3 years. Parameters with a coefficient of association ≥0.1 for cardiac events were applied as features of classifiers. We used the step forward method to find a high-performance model with the maximum area under the receiver operating characteristics curve (AUC). A 10-fold cross-validation method was used to validate the generalization performance of the classifiers. The mean kappa statistics, AUC, sensitivity, specificity, and accuracy were evaluated and compared between classifiers learning multiple factors and only the BNP. Kappa statistics, AUC, and sensitivity were significantly higher for NB classifiers learning 13 features than for those learning only BNP (0.69±0.14 vs. 0.54±0.12 P=0.024, 0.94±0.03 vs. 0.84±0.05 P<0.001, 85±8% vs. 64±20% P=0.006, respectively). The specificity and accuracy were similar.

    Conclusions:We created high-performance NB classifiers for predicting the development of cardiac events in individual outpatients with HFpEF. Our NB classifiers may be useful for providing precision medicine for these patients.

  • Takuya Kishi
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 47-48
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 14, 2021
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Cardiac Rehabilitation
  • Kayo Misumi, Michio Nakanishi, Hiroyuki Miura, Ayumi Date, Tatsuo Toke ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiac Rehabilitation
    2022 Volume 86 Issue 1 Pages 49-57
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: June 30, 2021
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    Background:In patients with chronic heart failure with reduced ejection fraction (HFrEF), cardiac resynchronization therapy (CRT) improves left ventricular ejection fraction (LVEF) and exercise-based cardiac rehabilitation (ECR) enhances exercise capacity. This study examined the relationship between the 2 responses.

    Methods and Results:Sixty-four consecutive HFrEF patients who participated in a 3-month ECR program after CRT were investigated. Patients were categorized according to a median improvement in peak oxygen uptake (PV̇O2) after ECR of 7% as either good (n=32; mean percentage change in PV̇O2[%∆PV̇O2]=23.2%) or poor (n=32; mean %∆PV̇O2=2.5%) responders. There was no significant difference in baseline characteristics between the good and poor responders, except for PV̇O2(51% vs. 59%, respectively; P=0.01). The proportion of good CRT responders was similar between the good and poor responders (%∆LVEF ≥10%; 53% vs. 47%, respectively; P=NS). Overall, there was no significant correlation between %∆LVEF after CRT and %∆PV̇O2after ECR. Notably, among poor CRT responders (n=32), the prevalence of atrial fibrillation (0% vs. 29%; P<0.03) and baseline PV̇O2(48% vs. 57%; P<0.05) were significantly lower among those with a good (n=15) than poor (n=17) response to ECR.

    Conclusions:In patients with HFrEF, good ECR and CRT responses are unrelated. A good PV̇O2response to ECR can be achieved even in poor CRT responders, particularly in those with a sinus rhythm or low baseline PV̇O2.

  • Takanori Yasu
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 58-59
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: August 28, 2021
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  • Hidenori Kato, Hiroki Watanabe, Akira Koike, Longmei Wu, Kosuke Hayash ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiac Rehabilitation
    2022 Volume 86 Issue 1 Pages 60-67
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 11, 2021
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    Supplementary material

    Background:Aiming to establish an effective tool in new cardiac rehabilitation programs, we investigated the use of a lumbar-type hybrid assistive limb (HAL) in patients with heart failure (HF) who had difficulty in walking at the usual speed of healthy subjects (≈80 m/min).

    Methods and Results:We randomly assigned 28 HF patients (age, 73.1±13.8 years) to perform a sit-to-stand exercise with or without HAL. The sit-to-stand exercise was repeated as many times as possible as cardiac rehabilitation therapy over a period of 6–10 days. We measured 5 parameters before and after the completion of cardiac rehabilitation: B-type natriuretic peptide, Short Physical Performance Battery (SPPB), 6-min walking distance (6MWD), 30-s chair-stand test (CS-30), and isometric knee extensor muscle strength. The SPPB and 6MWD were significantly improved, and the CS-30 score was somewhat improved, after the exercise therapy in both the HAL and non-HAL groups. The knee extensor muscle strength improved significantly in the HAL group (0.29±0.11 to 0.35±0.11 kgf/kg, P<0.01), but showed no change in the non-HAL group (0.35±0.11 to 0.35±0.13 kgf/kg, P=0.40).

    Conclusions:The improved knee extensor muscle strength in the HAL group suggests that the lumbar-type HAL may be an effective tool for cardiac rehabilitation in HF patients with frailty, which is a predictor of poor prognosis in HF.

  • Hiroyuki Miura, Chiaki Yokota
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 68-69
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: October 08, 2021
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  • Satoshi Katano, Toshiyuki Yano, Katsuhiko Ohori, Hidemichi Kouzu, Ryoh ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiac Rehabilitation
    2022 Volume 86 Issue 1 Pages 70-78
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 17, 2021
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    Supplementary material

    Background:A strategy to predict mortality in elderly heart failure (HF) patients has not been established.

    Methods and Results:We retrospectively enrolled 413 HF patients aged ≥65 years (mean age 78 years) who had received comprehensive cardiac rehabilitation (CR) during hospitalization. Basic activities of daily life were assessed before discharge using the Barthel index (BI). Of 413 HF patients, 116 (28%) died during a median follow-up period of 1.90 years (interquartile range 1.20–3.23 years). An adjusted dose-dependent association analysis showed that the hazard ratio (HR) of mortality increased in an almost linear manner as the BI score decreased, and that a BI score of 85 corresponded to an HR of 1.0. Kaplan-Meier survival curves showed that the survival rate was lower for patients with a low BI (<85) than for those with a high BI (≥85; 65% vs. 74%, respectively; P=0.007). In multivariate Cox regression analyses, low BI was independently associated with higher mortality after adjusting for predictors, including B-type natriuretic peptide. Inclusion of the BI into the adjusted model improved the accuracy of the prediction of mortality.

    Conclusions:A BI score <85 at the time of discharge is associated with increased mortality independent of known prognostic markers, and achieving functional status with a BI score ≥85 by comprehensive CR during hospitalization may contribute to favorable outcomes in elderly HF patients.

  • Makoto Murata, Yasuyuki Kobayashi, Hitoshi Adachi
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiac Rehabilitation
    2022 Volume 86 Issue 1 Pages 79-86
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: October 28, 2021
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    Supplementary material

    Background:Minute ventilation/carbon dioxide production (V̇E/V̇CO2) is a variable of cardiopulmonary exercise testing (CPET), which is evaluated by arterial CO2pressure and ventilation-perfusion mismatch via invasive methods. This study evaluated substitute non-invasively obtained variables for minimum V̇E/V̇CO2(Min) and V̇E vs. V̇CO2slope (Slope) and the relationship between Min and Slope.

    Methods and Results:This study enrolled 1,052 patients with heart disease who underwent CPET and impedance cardiography simultaneously. At first, the correlations between the end-tidal CO2pressure (PETCO2), tidal volume/respiratory rate (TV/RR) ratio, V̇E and V̇CO2Y-intercept (Y-int), and cardiac index (CI) and the Min and Slope were investigated. Second, the correlation between Min and Slope was investigated. PETCO2showed the largest correlation value among the 4 variables. These 4 variables could reveal 84.2% and 81.9% of Min and Slope, respectively. Although Slope correlated with Min (R=0.868) and predicted 78.9% of Min, considering these 4 variables, Slope+Y-int was more strongly correlated with Min (R=0.940); the Slope+Y-int revealed 90.6% of the Min relationship in the multiple regression analysis.

    Conclusions:Over 80% of the Min and Slope values were revealed with the above-mentioned 4 variables collected non-invasively. The formula, Min∝Slope+Y-int, can reveal >90% of the Min/Slope relationships, and the Y-int may be a crucial factor to clarify the relationship between Min and Slope.

Cardiomyopathy
  • Susumu Katsushika, Satoshi Kodera, Mitsuhiko Nakamoto, Kota Ninomiya, ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiomyopathy
    2022 Volume 86 Issue 1 Pages 87-95
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: June 26, 2021
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    Supplementary material

    Background:Because the early diagnosis of subclinical cardiac sarcoidosis (CS) remains difficult, we developed a deep learning algorithm to distinguish CS patients from healthy subjects using echocardiographic movies.

    Methods and Results:Among the patients who underwent echocardiography from January 2015 to December 2019, we chose 151 echocardiographic movies from 50 CS patients and 151 from 149 healthy subjects. We trained two 3D convolutional neural networks (3D-CNN) to identify CS patients using a dataset of 212 echocardiographic movies with and without a transfer learning method (Pretrained algorithm and Non-pretrained algorithm). On an independent set of 41 echocardiographic movies, the area under the receiver-operating characteristic curve (AUC) of the Pretrained algorithm was greater than that of Non-pretrained algorithm (0.842, 95% confidence interval (CI): 0.722–0.962 vs. 0.724, 95% CI: 0.566–0.882, P=0.253). The AUC from the interpretation of the same set of 41 echocardiographic movies by 5 cardiologists was not significantly different from that of the Pretrained algorithm (0.855, 95% CI: 0.735–0.975 vs. 0.842, 95% CI: 0.722–0.962, P=0.885). A sensitivity map demonstrated that the Pretrained algorithm focused on the area of the mitral valve.

    Conclusions:A 3D-CNN with a transfer learning method may be a promising tool for detecting CS using an echocardiographic movie.

  • Tomoko Ishizu
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 96-97
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 02, 2021
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  • Sayaka W Ozawa, Shinya Takarada, Mako Okabe, Nariaki Miyao, Hideyuki N ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiomyopathy
    2022 Volume 86 Issue 1 Pages 98-105
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: August 03, 2021
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    Supplementary material

    Background:Left ventricular noncompaction (LVNC) is morphologically characterized by numerous prominent trabeculations and a severely thickened, two-layered myocardium. The fetal onset of LVNC has rarely been described.

    Methods and Results:We conducted nationwide retrospective surveys on fetal cardiomyopathy (CM) in Japan from 2010 to 2016, from which 38 fetal patients with CM were enrolled, including 16 patients with LVNC. The rate of diagnostic concordance was 56.3% between fetal and postnatal visits in LVNC patients. The increase in the ratio of noncompacted to compacted (N/C) myocardium was time-dependent throughout the fetal period till birth (LV lateral: 1.6±0.1 to 2.8±0.2; LV apex: 2.0±0.1 to 3.2±0.2). Of all fetuses, 16 (42.1%) died or underwent heart transplantation (HT), with 3 intrauterine deaths. Lower fetal cardiovascular profile score (odds ratio, 26.9; P=0.0266) was a risk factor for death or HT. N/C ratio ≥1.6 at the apex at the first visit was a significant predictor of LVNC (odds ratio, 47.8; P=0.0113).

    Conclusions:This is the first study to reveal the etiology of fetal CM based on results from a nationwide survey in Japan, highlighting the difficulty of diagnosing LVNC in fetal patients. To better understand and manage fetal CM, novel diagnostic criteria of LVNC in fetus should be established.

  • Shigetoyo Kogaki
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 106-108
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 25, 2021
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  • Hiroki Mori, Tadahiro Yoshikawa, Hitomi Kimura, Hiroshi Ono, Hitoshi K ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiomyopathy
    2022 Volume 86 Issue 1 Pages 109-115
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 28, 2021
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    Background:There has been no nationwide survey on the prognosis of pediatric dilated cardiomyopathy (DCM) in Japan. Therefore, we designed this retrospective multicenter study to investigate the long-term survival rate in pediatric patients with DCM in Japan.

    Methods and Results:In this multicenter retrospective observational study, data were reviewed for 106 patients aged <18 years who had been diagnosed with DCM at any 1 of 18 Japanese institutions between 1990 and 2014. The median age at diagnosis was 2.0 years and the median duration of observation was 3.3 years. Most DCM patients were diagnosed because of symptoms of heart failure. On echocardiography, the median left ventricular end-diastolic dimension z score was 5.4 and fractional shortening was 0.10. Freedom from death or transplantation rates at 1, 3, 5, 10, and 20 years after diagnosis were 76%, 66%, 64%, 58%, and 43%, respectively. Freedom from death rates at 1, 5, 10, and 20 years after diagnosis were 81%, 75%, 72%, and 53%, respectively. The incidence of heart transplantation at 1, 5, 10, and 20 years after diagnosis was 6%, 15%, 20%, and 20%, respectively, suggesting that only 15% of patients in Japan underwent heart transplantation within 5 years of diagnosis.

    Conclusions:In Japan, the prognosis of pediatric DCM is poor and the rate of heart transplantation is low.

  • Yu Nakagama, Masamichi Ito
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 116-117
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: October 28, 2021
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  • Masao Yoshinaga, Hitoshi Horigome, Mamoru Ayusawa, Kazushi Yasuda, Shi ...
    Article type: ORIGINAL ARTICLE
    Subject area: Cardiomyopathy
    2022 Volume 86 Issue 1 Pages 118-127
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: October 06, 2021
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    Supplementary material

    Background:The usefulness of electrocardiographic (ECG) voltage criteria for diagnosing hypertrophic cardiomyopathy (HCM) in pediatric patients is poorly defined.

    Methods and Results:ECGs at the 1st grade (mean [±SD] age 6.6±0.3 years) were available for 11 patients diagnosed with HCM at around the 7th grade (13.2±0.3 years). ECGs were available for another 64 patients diagnosed with HCM in the 1st (n=15), 7th (n=32), and 10th (n=17) grades. Fifty-one voltage criteria were developed by grade and sex using 62,841 ECGs from the general population. Voltage criteria were set at the 99.95th percentile (1/2,000) point based on the estimated prevalence of childhood HCM (2.9 per 100,000 [1/34,483]) to decrease false negatives. Conventional criteria were from guidelines for school-aged children in Japan. Of 11 patients before diagnosis, 2 satisfied conventional criteria in 1st grade; 5 (56%) of the remaining 9 patients fulfilled 2 voltage criteria (R wave in limb-lead I [RI]+S wave in lead V3 [SV3] and R wave in lead V3 [RV3]+SV3). Robustness analysis for sensitivity showed RV3+SV3 was superior to RI+SV3. For all patients after diagnosis, RI+SV4 was the main candidate. However, conventional criteria were more useful than voltage criteria.

    Conclusions:Early HCM prediction was possible using RV3+SV3 in >50% of patients in 1st grade. Voltage criteria may help diagnose prediagnostic or early HCM, and prevent tragic accidents, although further prospective studies are required.

ACHD
  • Naofumi F. Sumitomo, Kazuki Kodo, Jun Maeda, Masaru Miura, Hiroyuki Ya ...
    Article type: ORIGINAL ARTICLE
    Subject area: ACHD
    2021 Volume 86 Issue 1 Pages 128-135
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: October 15, 2021
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    Background:The correlation between the Z-score of the left ventricular (LV) diameter and the LV volume-overload due to pulmonary over-circulation in children with ventricular septal defect (VSD) or patent ductus arteriosus (PDA) remains unclear.

    Methods and Results:The present, retrospective study enrolled 70 children (aged 0.3–16.8 years; 33 males, 37 females) with a diagnosis of isolated VSD and/or PDA who underwent cardiac catheterization (CC) between 2015 and 2019. Patients with chromosomal/genetic anomalies, growth disorder, right-ventricular enlargement or other conditions causing LV enlargement were excluded. Echocardiographic parameters were retrospectively evaluated from the medical records, converted to a Z-score, then compared with CC data. The pulmonary-systemic flow ratio on CC (cQp/Qs) correlated significantly with the Z-score of both the LV end-diastolic diameter (Zd) (r=0.698, P<0.0001) and LV end-systolic diameter (r=0.593, P<0.0001). Regression analysis and curve-fitting were used to predict the cQp/Qs based on the Zd, and a significant regression equation was found on cubic regression (R2of 0.524, P<0.0001) showing a strong correlation with the cQp/Qs (r=0.724, P<0.0001).

    Conclusions:The Z-score of the LV diameter can be a useful, non-invasive marker for evaluating LV volume overload and determining the surgical indications in children with VSD or PDA because of its strong correlation with the cQp/Qs.

  • Satoshi Masutani
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 136-137
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: November 23, 2021
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  • Tae Yokouchi-Konishi, Keiko Ohta-Ogo, Chizuko A. Kamiya, Tadasu Shiono ...
    Article type: ORIGINAL ARTICLE
    Subject area: ACHD
    2022 Volume 86 Issue 1 Pages 138-146
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: September 08, 2021
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    Background:Pregnant women with a Fontan circulation have a high risk of obstetric complications, such as preterm delivery and small for gestational age (SGA), which may be affected by low blood flow to the placenta and hypoxia. This study investigated placental pathology in a Fontan circulation.

    Methods and Results:Eighteen pregnancies in 11 women with a Fontan circulation were reviewed. Pregnancy outcomes showed 9 miscarriages and 9 live births, with 4 preterm deliveries. Five neonates were SGA (<5th percentile). Eight placentas from live births in 7 women were available for the study. Five placentas had low weight placenta for gestational age, and 7 grossly showed a chronic subchorionic hematoma. Histological examination revealed all placentas had some form of histological hypoxic lesions: maternal vascular malperfusion in 7, fetal vascular malperfusion in 1, and other hypoxia-related lesions in 8. Quantitative analyses, including immunohistochemistry (CD31, CD68, and hypoxia inducible factor-1α antibodies) and Masson’s trichrome staining, were also performed and compared with 5 control placentas. Capillary density and the area of fibrosis were significantly greater in placentas from women with a Fontan circulation than in control placentas.

    Conclusions:Placentas in a Fontan circulation were characterized by a high frequency of low placental weight, chronic subchorionic hematoma, and constant histological hypoxic changes, which could reflect altered maternal cardiac conditions and lead to poor pregnancy outcomes.

Population Science
  • Yu Sato, Akiomi Yoshihisa, Ryohei Takeishi, Himika Ohara, Yukiko Sugaw ...
    Article type: ORIGINAL ARTICLE
    Subject area: Population Science
    2022 Volume 86 Issue 1 Pages 147-155
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: October 26, 2021
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    Supplementary material

    Background:It has recently been reported that the simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition, which excludes 6 rare criteria, is comparable to the original ARC-HBR definition in predicting major bleeding in patients with coronary artery disease (CAD) who undergo percutaneous coronary intervention. In this study, we investigated whether the simplified ARC-HBR definition could be applied to patients with heart failure (HF) to identify those at high bleeding risk (HBR).

    Methods and Results:In all, 2,437 patients hospitalized for HF were enrolled in this study. Patients were divided into 2 groups based on the simplified ARC-HBR definition: those at HBR (n=2,026; 83.1%) and those not (non-HBR group; n=411; 16.9%). The HBR group was older (72.0 vs. 61.0 years; P<0.001) and had a lower prevalence of CAD (31.1% vs. 36.5%; P=0.034) than the non-HBR group. Kaplan-Meier analysis showed that post-discharge bleeding events defined as hemorrhagic stroke or gastrointestinal bleeding were more frequent in the HBR than non-HBR group (log-rank P<0.001). The simplified ARC-HBR definition accurately predicted bleeding events (Fine-Gray model; hazard ratio 2.777, 95% confidence interval 1.464–5.270, P=0.001).

    Conclusions:The simplified ARC-HBR definition predicts a high risk of bleeding events in patients with HF.

  • Kotaro Nochioka
    Article type: EDITORIAL
    2022 Volume 86 Issue 1 Pages 156-157
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: November 26, 2021
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  • Shinya Fujiki, Takeshi Kashimura, Yuji Okura, Kunio Kodera, Hiroshi Wa ...
    Article type: ORIGINAL ARTICLE
    Subject area: Population Science
    2022 Volume 86 Issue 1 Pages 158-165
    Published: December 24, 2021
    Released on J-STAGE: December 24, 2021
    Advance online publication: November 16, 2021
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    Background:Heart failure in elderly people causes physical and cognitive dysfunction and often requires long-term care insurance (LTCI); however, among patients with left ventricular (LV) systolic dysfunction, the incidence and risk factors of future LTCI requirements need to be elucidated.

    Methods and Results:The study included 1,852 patients aged ≥65 years with an echocardiographic LV ejection fraction (LVEF) ≤50%; we referred to their LTCI data and those of 113,038 community-dwelling elderly people. During a mean 1.7-year period, 332 patients newly required LTCI (incidence 10.7 per 100 person-years); the incidence was significantly higher than that for the community-dwelling people (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.32–1.64). On multivariate analysis, the risk factors at the time of echocardiography leading to future LTCI requirement were atrial fibrillation (HR, 1.588; 95% CI, 1.279–1.971), history of stroke (HR, 2.02; 95% CI, 1.583–2.576), osteoporosis (HR, 1.738; 95% CI, 1.253–2.41), dementia (HR, 2.804; 95% CI, 2.075–3.789), hypnotics (HR, 1.461; 95% CI, 1.148–1.859), and diuretics (HR, 1.417; 95% CI, 1.132–1.773); however, the LVEF was not a risk factor (HR, 0.997; 95% CI, 0.983–1.011).

    Conclusions:In elderly patients with LV systolic dysfunction, the incidence of LTCI requirement was more common than that for community-dwelling people; its risk factors did not include LVEF, but included many other non-cardiac comorbidities and therapies, suggesting the need for interdisciplinary cooperation to prevent disabilities.

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