Background: This study evaluated the prognostic impact of left ventricular (LV) apical aneurysm identified by transthoracic echocardiography (TTE) in a Japanese cohort with hypertrophic cardiomyopathy (HCM).

Methods and Results: We retrospectively enrolled 369 consecutive HCM patients from 2 centers (2016–2023). LV apical aneurysm was defined on TTE as a discrete, thin-walled dyskinetic/akinetic apical outpouching with a wide neck. Primary outcomes were all-cause death and cardiovascular (CV) death. Secondary outcomes were hospitalization for worsening heart failure, systemic embolism, sustained ventricular tachycardia (VT), and sudden cardiac death (SCD)-equivalent events (resuscitated cardiac arrest or appropriate implantable cardioverter defibrillator therapy). LV apical aneurysm was present in 47 of 369 patients (12.7%). There were no significant between-group differences in all-cause death (log-rank P=0.162) or CV death (P=0.103). Patients with LV apical aneurysm more frequently had baseline sustained VT and SCD-equivalent events; however, Kaplan–Meier analyses indicated no significant differences between groups in incident sustained VT and SCD-equivalent events after enrollment. In multivariable Cox models, age, B-type natriuretic peptide (BNP), and SCD-equivalent events were independently associated with all-cause death; BNP and SCD-equivalent events were independently associated with CV death.

Conclusions: In this cohort, echocardiography-identified LV apical aneurysm was associated with a greater burden of baseline arrhythmic events, but not higher mortality. TTE provides a practical means of identifying this phenotype. BNP and SCD-equivalent events were more closely associated with mortality.

Background: Postoperative pericardial effusion (PPE) is a known complication associated with the use of leadless pacemakers (LPMs). The risk score (RS) is a useful tool for risk stratification. This study evaluated the utility of risk stratification using the RS in Japanese patients who received the Micra LPM.

Methods and Results: We retrospectively enrolled 443 patients who received Micra LPMs that were implanted at 4 institutions between August 2017 and August 2024. Patients were risk stratified using the RS into 3 groups: low risk (score ≤0), intermediate risk (score 1), and high risk (score ≥2). PPEs were observed in 9.0% (20/221), 11.7% (9/77) and 17.9% (26/145) of patients in the low-, intermediate-, and high-risk groups, respectively (P=0.041). In multivariable analysis, chronic obstructive pulmonary disease was a significant risk factor (P=0.014) for PPE, whereas prior cardiac surgery significantly reduced the risk of PPE (P=0.023). Older age, being female, and hemodialysis were not identified as risk factors. Subsequently, we modified the RS (mRS). Using the mRS, PPEs were observed in 8.8% (27/306), 16.5% (14/85), and 26.9% (14/52) of patients in the low-, intermediate-, and high-risk groups, respectively (P<0.001).

Conclusions: The original RS is useful for PPE risk stratification after Micra LPM implantation. However, the mRS provides better risk discrimination and may therefore be a more suitable tool for use in the Japanese population.

Background: The real-world impact of in-hospital intensification of guideline-directed medical therapy (GDMT) on clinical outcomes in patients with heart failure (HF) remains uncertain. We evaluated the association between in-hospital GDMT intensification and long-term outcomes using data from the multicenter QHEART-R cohort.

Methods and Results: We analyzed 3,190 patients hospitalized for worsening HF. In-hospital GDMT intensification was quantified by the change in the simple GDMT score from admission to discharge (∆S-GDMT). The primary outcome was a composite of all-cause death or hospitalization for HF (HHF). The mean (±SD) age of the cohort was 77.7±14.0 years, 53% were male, and the mean hospital stay was 20±16 days. The cohort included 1,477 (46%) patients with HF with reduced ejection fraction (HFrEF), 435 (14%) with HF with mildly reduced ejection fraction (HFmrEF), and 1,276 (40%) with HF with preserved ejection fraction. Four-year event-free survival was 32.4% for the primary outcome, 82.5% for cardiovascular (CV) death, and 50.4% for HHF. In patients with HFrEF/HFmrEF, a greater ∆S-GDMT was independently associated with a lower risk of the primary outcome (adjusted hazard ratio 0.90; 95% confidence interval 0.86–0.93; P<0.001), regardless of the number of prior HHF or the simple GDMT score at discharge.

Conclusions: In-hospital GDMT intensification was associated with improved long-term outcomes in patients with HFrEF/HFmrEF. Hospitalization represents a critical opportunity to optimize GDMT and improve prognosis.

Background: Pulmonary hypertension (PH), a progressive multisystemic disorder characterized by right ventricular failure and hepatic congestion, significantly alters platelet dynamics and liver function. This study evaluated the ability of the platelet–albumin–bilirubin index (PALBI), a marker of the hepatic–cardiac axis, to discriminate between PH patients and healthy individuals and to predict 360-day all-cause mortality and heart failure-related hospitalizations (HFH).

Methods and Results: This retrospective study included 3,432 individuals (1,520 PH patients, identified based on high-risk echocardiographic parameters to reflect real-world clinical practice). PH patients had higher PALBI scores than healthy controls (−2.08 vs. −2.50; P=0.001). For disease discrimination, PALBI had an area under the curve (AUC) of 0.748 (cut-off −2.27; sensitivity 77%, specificity 80%), outperforming the neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein. In the PH cohort (21.5% mortality; 36.4% HFH), PALBI was an independent predictor of 360-day mortality and HFH (odds ratios 1.24 [P=0.003] and 1.18 [P=0.006], respectively). PALBI (cut-off −1.98) outperformed estimated glomerular filtration rate, age, and NLR in predicting mortality; when combined with N-terminal pro B-type natriuretic peptide, mortality prediction accuracy rose by 15.6%. Kaplan–Meier analysis confirmed a significant stepwise decline in survival across PALBI tertiles (P<0.001). In Group I PH, the AUC for the combination of PALBI+REVEAL risk score was 0.064 higher than that for the REVEAL risk score alone (P<0.05).

Conclusions: PALBI is a robust, cost-effective prognostic tool for PH. It independently predicts short-term mortality and HFH, offering enhanced risk stratification for high-risk patients in clinical settings.

Background: Tafamidis improves survival in patients with transthyretin amyloid cardiomyopathy (ATTR-CM); however, its cost raises concerns regarding healthcare sustainability. We evaluated the stage-specific cost-effectiveness of tafamidis in Japan.

Methods and Results: Individual patient-level data were reconstructed from published Kaplan–Meier curves from the ATTR-ACT long-term extension study. Time-dependent survival benefit between early (continuous tafamidis) and delayed (placebo-to-tafamidis) tafamidis initiation was quantified using restricted mean survival time (RMST). Stage-specific incremental cost-effectiveness ratios (ICERs) were estimated according to National Amyloidosis Centre (NAC) stage. Drug costs reflected the official Japanese reimbursement price, and quality-adjusted life years (QALYs) were derived from RMST gains. The primary endpoint was cardiovascular mortality. At maximum follow-up, RMST gains were 15.7, 13.1, and 1.2 months in NAC stage I, II, and III, respectively ICERs declined over time but remained above commonly accepted Japanese willingness-to-pay thresholds (5,000,000–15,000,000 yen/QALY). The lowest ICER was 47,000,000 yen/QALY in NAC stage I at 90 months. Sensitivity analyses showed that results were robust across utility assumptions, whereas drug cost was the principal determinant of cost-effectiveness.

Conclusions: The survival benefit and economic value of tafamidis varied by disease stage. Earlier-stage patients derived the greatest benefit and economic value; however, ICERs remained above Japanese willingness-to-pay thresholds across all NAC stages. Earlier diagnosis may maximize clinical benefit, but substantial price reduction is likely required for sustainable healthcare in ATTR-CM.

Background: As Japan faces a heart failure (HF) pandemic, geriatric health service facilities (GHSFs) are vital for transitional HF care from hospital to home. This study investigated HF care practices, challenges, and support needs in Japanese GHSFs.

Methods and Results: We conducted a cross-sectional web-based survey of 171 GHSFs. We analyzed current management practices, perceived difficulties, and support needs regarding HF care in GHSFs. Concerns over high medication costs for HF were the primary reason for admission refusal (49.7%). Although daily symptom assessments, including dyspnea and edema were common, weight monitoring was conducted only monthly in 50.3% of facilities. HF care infrastructure was inadequate: 99.4% of GHSFs had no specialized staff (e.g., certified HF educators), only 38.0% had access to expert consultation, and only 56.7% provided HF-specific rehabilitation. Consequently, 44.4% of representatives reported significant perceived difficulty in HF care, primarily in judging consultation timing (75.0%). Facilities reporting low/neutral satisfaction with information desired advance care planning (ACP) and consultation criteria. HF patients had significantly lower home discharge rates than the overall facility residents (median [interquartile range] 20.0% [4.1–34.6%] vs. 34.0% [19.0–49.0%]; P<0.01).

Conclusions: Concerns over financial barriers, along with structural and communication barriers in GHSFs, drive admission refusals and complicate HF management, potentially limiting home discharge. Improving transitional HF care requires addressing these financial concerns, providing standardized staff education and specialized support, and bridging information gaps, specifically regarding ACP and consultation criteria, between hospitals and facilities.

Background: Right ventricular involvement (RVI) in acute myocardial infarction (AMI) patients is recognized as a high-risk subset. However, its impact on bleeding and mortality is not well defined in patients with right coronary artery (RCA)-related ST-segment elevation acute myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).

Methods and Results: Using data from the multicenter, prospective Japan AMI Registry including 3,411 patients, we analyzed 993 patients with RCA-related STEMI who underwent PCI. The incidence of all-cause mortality and major bleeding, defined as Bleeding Academic Research Consortium Type 3 or 5, was compared between patients with and without RVI. RVI was present in 9% (n=92) of patients. During a 12-month follow-up, RVI was independently associated with an increased risk of all-cause mortality (adjusted hazard ratio [HR] 2.05; 95% confidence interval [CI] 1.11–3.79) and major bleeding (adjusted HR 2.28; 95% CI 1.13–4.57) in Cox analysis, although this bleeding association was attenuated in adjusted competing-risk analysis (adjusted subdistribution HR 1.87; 95% CI 0.90–3.89). Among patients with RVI, those who experienced major bleeding had a significantly higher risk of death (HR 4.88, 95% CI 1.63–14.58).

Conclusions: In patients with RCA-related STEMI treated with PCI, RVI was associated with increased mortality and appeared to be associated with a higher risk of bleeding.

Background: Disproportionate (d-) functional mitral regurgitation (FMR) is characterized by greater mitral regurgitation (MR) severity than expected from left ventricular (LV) dilatation. Morphological determinants of this imbalance remain unclear.

Methods and Results: Consecutive patients who underwent transcatheter edge-to-edge repair (TEER) for symptomatic FMR were divided into 2 groups: d-FMR and proportionate (p-) FMR (effective regurgitant orifice area [EROA]/LV end-diastolic volume [LVEDV] >0.20 or ≤0.20 mm²/mL, respectively). Of the 114 FMR patients included, those with d-FMR (n=66) were more likely to be female and had a significantly larger EROA than patients with p-FMR (n=48), despite a smaller LVEDV index and lower tenting height. Metrics of LV dyssynchrony and etiologies were similar between the 2 groups, but the d-FMR group had a higher proportion of pseudo-prolapse (28.8% vs. 8.3%; P=0.007), extreme mitral annular dilatation (>700 mm²/m²; 53.0% vs. 29.2%; P=0.011), and deep indentation (24.2% vs. 4.2%; P=0.004). Although these factors were prevalent in the population, no patient with MR due purely to any of these factors underwent TEER. After adjustment by age, sex, and LVEDV index, the number of factors present was associated with d-FMR (odds ratio 4.15; P<0.001). Similar results were obtained when using an EROA/LVEDV cut-off of 0.14 mm²/mL.

Conclusions: Additional morphological factors were associated with greater MR severity beyond LV size and with residual MR after TEER, supporting a phenotype-based interpretation of FMR disproportionality.

Background: Radial wall strain (RWS) is a potential marker of plaque vulnerability; however, its association with plaque morphology in future acute coronary syndrome (ACS) remains unclear.

Methods and Results: We retrospectively enrolled 98 patients with ACS who underwent optical coherence tomography-guided percutaneous coronary intervention and had a prior coronary angiography (CAG) 1 month to 5 years before ACS. RWS was calculated as the maximum percentage change in lumen diameter within a cardiac cycle (RWS_max). Mild-to-intermediate stenotic lesions on the index CAG were classified as culprit lesions (CLs) and non-CLs (NCLs) of ACS. CLs were further categorized as plaque rupture (PR) or erosion (PE). We identified 74 CLs (50 PRs, 24 PEs) and 96 NCLs. Angiographic and physiological parameters were comparable across the groups; however, RWS_maxwas significantly higher in both PRs and PEs than in NCLs (15.8% vs. 12.6%, P<0.001; 14.1% vs. 12.6%, P=0.012, respectively). In Cox regression analysis, RWS_maxwas associated with subsequent PRs (hazard ratio [HR] 1.56; 95% confidence interval [CI] 1.34–1.82; P<0.001) and PEs (HR 1.33; 95% CI 1.05–1.67; P=0.017). Multinomial logistic regression showed that higher RWS_maxfavored PR, lower RWS_maxfavored NCL, and the estimated probability of PE remained low across the RWS_maxspectrum.

Conclusions: RWS_maxwas independently associated with subsequent PR and PE, with a higher estimated probability of PR than of PE.

Background: Endomyocardial biopsy (EMB) remains the gold standard for diagnosing acute myocarditis (AM); however, its prognostic value has not been fully established. We investigated the prognostic impact of EMB, with a focus on fulminant myocarditis (FM).

Methods and Results: We included 841 AM patients across 7 hospitals who were categorized having undergone EMB (n=268) or not (n=573). The primary outcome was in-hospital death; the secondary outcome was a composite of all-cause death, cardiac transplantation, or left ventricular assist device implantation. In-hospital mortality was lower in the EMB group (6.3% vs. 11.5%; P=0.019), with a similar reduction in the EMB group among patients with FM (11.3% vs. 23.7%; P=0.002), despite a higher rate of extracorporeal membrane oxygenation. During a median follow-up of 447 days, the composite outcome was also lower in the EMB group among patients with FM (P=0.031). In multivariable analyses, EMB was independently associated with lower in-hospital mortality in both the overall cohort and the FM subgroup. Outcomes did not differ substantially across histopathologic subtypes, although patients with giant cell myocarditis had a worse prognosis.

Conclusions: In patients with AM, EMB was associated with lower in-hospital mortality and improved long-term outcomes, particularly among those with FM. Further well-designed prospective studies are warranted to evaluate the clinical impact of EMB and its potential role in improving outcomes.

Background: Syncope is common in patients with congenital long QT syndrome (LQTS). However, not all episodes of syncope or loss of consciousness are caused by torsades de pointes (TdP); some are attributable to bradycardia or non-cardiac causes. This study investigated the clinical utility of implantable loop recorders (ILRs) in patients with LQTS presenting with unexplained syncope.

Methods and Results: We retrospectively studied 18 patients with LQTS (7 with LQTS type (LQT) 1, 3 with LQT2, 1 with LQT3, and 7 genotype-negative LQTS) who underwent ILR implantation for recurrent syncope. Multiple causes of syncope were suspected in each patient; there were 14 cases of arrhythmia, 4 of epilepsy, 8 of neurally mediated syncope (NMS), and 9 of unknown cause. During a mean (±SD) follow-up of 37±22 months after ILR implantation, 8 (44%) patients experienced recurrent syncope. Four episodes were caused by TdP and the remaining 4 episodes were attributed to epilepsy or NMS (cardioinhibitory type). No significant difference was observed in baseline clinical characteristics between patients with and without TdP following ILR implantation, but female sex (P=0.051) and a higher Schwartz score (P=0.08) tended to be associated with TdP.

Conclusions: Syncope in patients with LQTS is not always attributable to TdP, and non-arrhythmic causes should be considered. Although ILRs may aid in diagnostic evaluation, careful risk stratification remains essential in patients with suspected arrhythmic syncope.

Background: Reliable preoperative risk assessment is essential in cardiac surgery. In Japan, coronary artery bypass grafting (CABG) risk models have been developed from the Japan Cardiovascular Surgery Database – Adult section (JCVSD-A), with JapanSCORE I and II released previously. To reflect contemporary practice, we developed and validated JapanSCORE III, an updated risk model for isolated CABG, using JCVSD-A.

Methods and Results: We identified patients undergoing isolated CABG between 2018 and 2023 in the JCVSD-A. The dataset was temporally split into development (2018–2022) and validation (2023) cohorts. A least absolute shrinkage and selection operator model was developed to predict operative mortality, incorporating imaging-based predictors and clinically relevant factors. Secondary outcome models were constructed for stroke, reoperation, prolonged ventilation, renal failure, deep sternal wound infection (DSWI), gastrointestinal complications, and intensive care unit stay >7 days. Model performance was assessed by areas under the curve (AUC) and calibration plots. Among 70,180 patients (mean age 69.3 years; 20% women), operative mortality was 2.7%. The incidence of stroke, reoperation, prolonged ventilation, renal failure, DSWI, gastrointestinal complications, and prolonged ICU stay was 1.8%, 1.5%, 3.7%, 2.0%, 1.1%, 1.3%, and 13.2%, respectively. Operative mortality and renal failure models demonstrated good discrimination (AUC >0.8) and calibration in validation.

Conclusions: Operative outcomes remained stable despite increasing predicted risk. The JapanSCORE III models showed good predictive performance, providing valid tools for preoperative risk stratification.

Background: The Asian Working Group for Sarcopenia (AWGS) updated its diagnostic criteria in 2025 by incorporating body mass index (BMI)-adjusted skeletal muscle mass. This revision may influence the prevalence and clinical interpretation of sarcopenic obesity in heart failure (HF).

Methods and Results: We conducted a single-center retrospective cohort study of 589 patients aged ≥65 years who were hospitalized for HF. Application of the AWGS 2025 criteria significantly altered classification, increasing the prevalence of sarcopenic obesity from 7.8% to 13.6%. Among the 4 groups defined by sarcopenia (AWGS 2025) and obesity, patients with sarcopenia without obesity had the worst prognosis, whereas those with sarcopenic obesity had preserved survival (log-rank P=0.038). Following the transition from the AWGS 2019 to AWGS 2025 criteria, newly classified patients with sarcopenic obesity were more frequently female and had a higher BMI with preserved height-adjusted muscle mass compared with patients with persistent sarcopenic obesity. Mortality and gait speed were comparable between the persistent and newly classified sarcopenic obesity groups (both P>0.05). The AWGS 2025 sarcopenia–obesity phenotype classification showed no improvement in discrimination or the Akaike information criterion for prognosis compared with the AWGS 2019 classification (both P>0.05).

Conclusions: The AWGS 2025 criteria increase the prevalence of sarcopenic obesity by identifying a distinct phenotype in patients with HF. However, this expanded classification does not improve risk stratification.

Background: Remote monitoring (RM) enables early detection of abnormalities in cardiac implantable electronic devices (CIED), but implementation remains suboptimal.

Methods and Results: We analyzed 396,296 patients hospitalized for CIED implantation and evaluated changes after RM reimbursement revision using an interrupted time-series analysis. The proportion increased by 4.89% (95% confidence interval [CI]: 3.71 to 6.06%) in the pacemaker implantation cohort, but no significant increase was observed in the implantable cardioverter defibrillator and cardiac resynchronization therapy cohort (0.79%; 95% CI: –1.12 to 2.71%).

Conclusions: The effect of reimbursement policy changes on RM adoption may differ according to the type of CIED.

Background: Sex differences in outcomes after transcatheter aortic valve implantation (TAVI) for aortic stenosis in Japan have not been fully investigated.

Methods and Results: Using a nationwide registry, we evaluated sex differences in post-TAVI outcomes. In all, 36,353 patients (23,978 women, 12,375 men) were included. Women were older (84.9 vs. 83.5 years; P<0.001), had a smaller body surface area (BSA; 1.38 vs. 1.60 m²; P<0.001), and a lower prevalence of comorbidities than men. In-hospital mortality was comparable between women and men (1.2% vs. 1.3%, respectively; P=0.367). Women had higher rates of major red cell concentrate (RCC) transfusion (10.1% vs. 8.7%; P<0.001) and permanent pacemaker implantation (PPI; 7.1% vs. 5.9%; P<0.001). In multivariable analysis, BSA was inversely associated with in-hospital mortality (adjusted odds ratio [aOR] 0.84 per 0.1-m²increase; 95% confidence interval [CI] 0.77–0.91; P<0.001). Female sex was independently associated with lower risks of in-hospital mortality (aOR 0.60; 95% CI 0.45–0.81) and major RCC transfusion (aOR 0.79; 95% CI 0.71–0.89), but a higher risk of PPI (aOR 1.15; 95% CI 1.02–1.30).

Conclusions: In a Japanese TAVI registry, crude mortality was comparable between the sexes, but women had higher major RCC transfusion and PPI rates. After adjusting for BSA and available measured covariates, female sex was associated with lower in-hospital mortality. Combined sex and BSA assessment appears important for predicting post-TAVI outcomes.

Takayasu arteritis (TAK) is a chronic, refractory large-vessel vasculitis designated as a Designated Intractable Disease in Japan. The Japanese diagnostic criteria for TAK, last revised in 2017, have been updated to the 2026 version as part of the Japanese Circulation Society 2026 guidelines on the management of large vessel vasculitis, and are presented here in English for the first time. The revision was conducted through a 3-round modified Delphi process involving a panel of 21 experts, supplemented by email discussion and an in-person meeting. The updated criteria incorporate 3 major changes: new symptoms were added and a qualifying statement introduced in Section A; pulmonary artery involvement was elevated to a main criterion in Section B; and IgG₄-related periaortitis, Cogan syndrome, and drug-induced aortitis were added in Section C. These updates reflect advances in imaging technology and international classification frameworks, with an emphasis on improving diagnostic sensitivity to reduce missed diagnoses.

Background: Diastolic dysfunction is a recognized chronic allograft complication, and a restrictive left ventricular filling pattern is associated with adverse outcomes. However, the underlying pathophysiological mechanisms remain unclear.

Methods and Results: This study included 32 heart transplant recipients with a normal filling pattern at 1-year after transplantation. Five-year echocardiography classified patients into restrictive (n=12) and non-restrictive (n=20) groups. All patients underwent right heart catheterization and right ventricular endomyocardial biopsy at 1 and 5 years. Bulk RNA sequencing was performed on paired biopsy samples from 10 patients with available tissue. From 1 to 5 years, the restrictive group demonstrated significantly greater increases in pulmonary artery wedge pressure and the E/A and E/e′ ratios, with no histopathological evidence of rejection and similar myocardial interstitial fibrosis in the 2 groups (P=0.81). Transcriptome analysis demonstrated that there was significant enrichment of immune and inflammatory pathways, including gene sets annotated as allograft rejection and T cell receptor signaling (P_adjusted<0.05), in the restrictive group at 5 years. Temporal analysis revealed that these pathways were downregulated from 1 to 5 years in the non-restrictive group but remained persistently activated in the restrictive group.

Conclusions: The development of a restrictive filling pattern is associated with elevated intracardiac pressures and a persistent immune-related transcriptome signature, despite no histological evidence of rejection.

Background: Data on asymptomatic deep vein thrombosis (DVT) remain limited. This prospective study investigated the incidence of cancer-associated venous thromboembolism (CA-VTE) in patients receiving cancer treatment with scheduled DVT monitoring.

Methods and Results: Patients with newly diagnosed locally advanced, recurrent, or metastatic solid cancers without prior VTE were enrolled. Mandatory baseline venous ultrasonography excluded pre-existing DVT. VTE was assessed at Weeks 12, 24, 36, 48, 72, and 96 by lower-extremity ultrasonography, supplemented by contrast-enhanced computed tomography. The primary endpoint was the incidence of CA-VTE within 24 weeks, and a key secondary endpoint was the incidence within 96 weeks. Cox proportional hazards regression was used to explore factors predictive of newly developed VTE. Among 178 patients (median age 68 years; 32% female), the most common primary site of cancer was the gastrointestinal tract (38%). Adenocarcinoma and squamous cell carcinoma each accounted for 43% of enrolled cases. VTE occurred in 23 (12.9%) and 36 (20.2%) patients within 24 and 96 weeks, with most being asymptomatic (91.3% and 69.4%, respectively). CA-VTE incidence did not differ by tumor site or histology, and no predictive factors were identified. Eleven patients required anticoagulation at VTE diagnosis, and 3 further patients required anticoagulation after progression of initially asymptomatic distal DVT.

Conclusions: CA-VTE incidence was alarmingly high, regardless of tumor site or histology. Because anticoagulation was required in a considerable proportion of patients who developed VTE, scheduled DVT monitoring may be warranted.

Background: The true incidence of pulmonary vein (PV) stenosis after radiofrequency (RF) ablation for atrial fibrillation remains uncertain because routine imaging surveillance is not universally performed and many cases of PV stenosis are asymptomatic.

Methods and Results: This single-center retrospective study included atrial fibrillation ablation procedures with both pre- and postprocedural (based on clinical indication) cardiac computed tomography (CT) imaging ≥30 days after ablation. PV stenosis was defined as ≥50% luminal reduction and classified as moderate (50–89%), severe (90–98%), or complete (≥99%) occlusion. Among 303 RF procedures in 242 patients, PV stenosis occurred in 49 (16%) procedures, and severe stenosis or occlusion in 28 (9.2%), mostly asymptomatic. Although the overall incidence did not differ between high-power strategies, severe stenosis was more frequently observed with temperature-controlled RF catheters under very high-power, short-duration settings. No PV stenosis was observed after pulsed field ablation.

Conclusions: In this CT-enriched cohort, the incidence of PV stenosis after RF ablation was higher than previously reported symptomatic rates, largely reflecting improved detection of subclinical PV injury. Specific catheter–energy combinations may be associated with severe PV stenosis. These findings suggest that not all high-power strategies are equivalent and that the interaction between the energy delivery profile and catheter technology may influence the risk of clinically significant PV injury. Procedural optimization and risk-adapted imaging follow-up may help mitigate PV-related complications.

Background: Occlusion of the culprit artery (OCA) is observed in a substantial proportion of non-ST-segment elevation myocardial infarction (NSTEMI) patients, showing a poor clinical prognosis. NSTEMI management remains challenging, potentially due to pathophysiological mechanisms across different clinical phenotypes. This study investigated the morphological features of culprit plaque in NSTEMI with vs. without OCA.

Methods and Results: In all, 324 NSTEMI patients who underwent optical coherence tomography (OCT) imaging were enrolled in this study. Patients were divided into an OCA group (n=105; 32.4%) and a non-OCA group (n=219; 67.6%). Compared with the non-OCA group, the OCA group had significantly higher rates of plaque rupture (67.6% vs. 42.5%; P<0.001), lipid-rich plaque (81.0% vs. 67.1%; P=0.01), thin-cap fibroatheroma (48.6% vs. 25.1%; P<0.001), thrombus (88.6% vs. 66.7%; P<0.001), macrophage accumulation (92.4% vs. 76.7%; P<0.001), and cholesterol crystals (48.6% vs. 27.4%; P<0.001) on OCT. Symptom-to-catheter time was found to be an independent predictor of 2-year major adverse cardiovascular events for OCA patients.

Conclusions: The underlying plaque morphologies were different between OCA and non-OCA patients. The OCA had a higher rate of plaque rupture, with more features (e.g., lipid-rich plaque, thin-cap fibroatheroma, thrombus, macrophage accumulation, cholesterol crystals) resembling ST-elevation myocardial infarction-like plaques. Symptom-to-catheter time was an independent predictor of major adverse cardiovascular events in the OCA group.

Background: Although intensive care is considered important for cardiovascular emergencies, large-scale evidence comparing outcomes by initial admission ward remains limited in Japan.

Methods and Results: Using the JROAD database, we identified patients hospitalized for cardiovascular emergencies after ambulance transport between April 2016 and March 2024 and classified patients by initial ward (intensive care unit [ICU], high care unit [HCU], or general ward [GW]). Deaths within 24 h were excluded. Multivariable logistic regression analysis was performed with adjustment for demographics, comorbidities, acute therapies, and hospital cardiologist staffing. Among 1,211,636 admissions, there were 323,220 (26.7%) deaths within 24 h; thus, 888,416 admissions (ICU, 212,059; HCU, 124,468; GW, 551,889) were analyzed. In-hospital mortality was 10.8%, 9.7%, and 12.2% for patients admitted to the ICU, HCU, and GW, respectively. Compared with the GW, the adjusted odds of death were lower for the ICU (odds ratio [OR] 0.718; 95% confidence interval [CI] 0.703–0.734) and HCU (OR 0.928; 95% CI 0.906–0.950). A higher number of board-certified cardiologists was independently associated with lower in-hospital mortality (OR 0.977 per additional board-certified cardiologist; 95% CI 0.976–0.978). Findings were consistent for acute myocardial infarction, acute heart failure, aortic dissection, and pulmonary embolism.

Conclusions: Higher-acuity admission and a higher number of cardiologists were independently associated with lower in-hospital mortality, supporting optimization of critical care access for high-risk cardiovascular emergencies in Japan.

Background: Frailty is common in patients with heart failure and is associated with adverse outcomes. Although metabolic dysregulation has been implicated in frailty, the relationship between plasma amino acid profiles and frailty remains incompletely defined.

Methods and Results: We conducted a single-center ambispective cross-sectional study of 413 patients hospitalized for heart failure (median age 78 years). Plasma concentrations of 31 amino acids were measured. Frailty status was assessed using the Japanese version of the Cardiovascular Health Study criteria. An unbiased analytical framework integrating multivariate analyses and multivariable logistic regression was applied with adjustment for heart failure severity, renal function, nutritional status, and body composition. Associations with all-cause mortality were evaluated using Cox models. Frailty was present in 228 (55%) patients. Unbiased analyses identified urea cycle-related metabolites as key features associated with frailty. In fully adjusted models, higher plasma citrulline and ornithine concentrations were independently associated with frailty, whereas arginine concentrations were not. These associations were independent of nutritional indices, skeletal muscle mass, and established prognostic factors. Neither citrulline nor ornithine was independently associated with mortality. Pathway analysis demonstrated enrichment of arginine biosynthesis and arginine–proline metabolism.

Conclusions: Elevated citrulline and ornithine were independently associated with frailty in patients with heart failure, suggesting that dysregulated arginine-related metabolism may represent a metabolic signature of the frailty phenotype distinct from mortality risk.

Background: This study investigated the ability of coronary computed tomography angiography (CCTA)-derived computational fluid dynamics (CFD) parameters to identify lesions associated with subsequent acute coronary syndrome (ACS).

Methods and Results: The study included 37 patients with well-documented ACS and available CCTA performed at least 1 week before the event. Lesions identified on CCTA were classified as culprit (n=37) or non-culprit (n=42). Information on clinical characteristics and anatomical features was collected. CFD analysis was performed to compute wall shear stress (WSS) and axial plaque stress (APS) at both the segment (seg) and arc levels, with minimum (min) and maximum (max) values recorded. Univariate and multivariate logistic regression analyses were used to identify predictors of ACS. Significant stenosis was more frequent in culprit than non-culprit lesions (P=0.033). Compared with non-culprit lesions, culprit lesions had lower min(APS_seg) values but higher max(|APS|_seg) and max(WSS_seg), although the differences were not statistically significant. In multivariate analysis, vessel location, min(APS_seg) (odds ratio [OR] 3.17, P=0.047), and max(WSS_seg) (OR 6.99, P=0.020) were independently associated with the occurrence of ACS events. Incorporating CFD parameters max(|APS|_seg), min(APS_seg) and max(WSS_seg) into a model containing clinical and anatomical variables significantly improved ACS prediction (area under the curve 0.862 vs. 0.781; P=0.044).

Conclusions: CCTA-derived CFD parameters are independently associated with the development of ACS. Integrating multiple CFD metrics enhances the predictive performance beyond traditional clinical and anatomical characteristics, supporting their potential role in risk stratification.

Background: Using the Japan Organ Transplant Network national waitlist, this study investigated confounding factors for waitlist mortality and transplant probability among adult heart transplant candidates, focusing on heart disease and change in status (from registration to observation on June 30, 2024), to provide insights into the use of underlying heart disease or severity in the current revision of the heart transplant allocation criteria.

Methods and Results: All-cause waitlist mortality and heart transplantation probability were assessed using Gray’s test, as well as univariate and multivariate Fine–Gray subdistribution hazard regression models. After excluding heart–lung transplantation candidates, patients with missing data, patients who were never on the waitlist after revision of the Organ Transplant Act, and patients aged <18 and ≥60 years at the time of registration, 1,522 patients were included in the final cohort. Heart transplant candidates with congenital heart disease had a higher risk of mortality, whereas patients waiting for retransplantation had no chance of transplantation and all died. The mortality rate was significantly higher for patients listed as Status 2 (unchanged) at observation than those listed as Status 1 (unchanged).

Conclusions: Prioritization of candidates with congenital heart disease should be considered to reduce the risk of mortality while patients are on the transplant waitlist.

Background: The clinical consequences of discontinuing proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have not been elucidated.

Methods and Results: We analyzed 208 patients with coronary artery disease treated with PCSK9 inhibitors. During a median follow-up of 1,096 days, 94 patients discontinued treatment and they had a higher incidence of major adverse cardiovascular events (MACE) than those who continued. Event curves diverged approximately 3 years after discontinuation. Multivariable Cox analysis showed that discontinuation was associated with a higher incidence of MACE.

Conclusions: Discontinuation of PCSK9 inhibitors was associated with worse cardiovascular outcomes.

Background: Cardiac allografts show poorer long-term survival and decreased tolerance compared to renal allografts, but the underlying mechanisms remain unclear.

Methods and Results: We established heterotopic heart and kidney allotransplantation models in Bama miniature pigs. Single-cell RNA sequencing (scRNA-seq) was performed to analyze normal heart/kidney tissues and allografts. Transcription factor analysis focused on T-cell subsets, with key findings validated using clinical human heart tissues (normal vs. acute rejection) and a mouse heart transplantation model (to test MYC inhibition). T/NK (TNK) subsets in cardiac allografts exhibited higher expression of genes linked to immune system activation, mature B-cell differentiation, and immune memory. The TNFRSF4+ CD4+ T-cell subset was selectively expanded in cardiac allografts (but reduced in renal allografts) during acute rejection, with transcriptional analysis identifying MYC as a master regulator of glycolysis-related genes in this subset. In the mouse heart transplant model, inhibition of MYC (via 10058-F4) reduced the proportion of TNFRSF4+ CD4+ T cells and significantly prolonged cardiac allograft survival.

Conclusions: Our study identified a MYC-driven, glycolysis-dependent expansion of TNFRSF4+ CD4+ T cells as a key mechanism contributing to the heightened rejection susceptibility of cardiac allografts (vs. renal allografts). These findings provide a rationale for developing cardiac-targeted immunosuppressive strategies.

Background: Early detection of subclinical worsening heart failure (HF) is essential to enable timely, proactive treatment that may alter the clinical course and prevent hospitalization. This study demonstrates how early non-invasive telemonitoring of respiratory stability time (RST) can detect subclinical worsening HF.

Methods and Results: Daily RST was calculated automatically from all-night respiratory signals in 66 patients. Subclinical worsening was detected by declines in RST preceding overt worsening HF in the control group (blinded to RST; n=35) and in the RST group (RST monitored daily by clinicians; n=31). The RST recovery zone sufficient to avert hospitalization was determined by RST responses to treatment escalation for overt worsening HF. Two clinically relevant RST thresholds were identified: RST <20 s, indicating a high-risk zone for subclinical worsening preceding hospitalization; and RST ≥30 s, defining a recovery target zone associated with hospitalization avoidance. The duration of subclinical worsening HF from the onset of RST decline <20 s to overt worsening was 40.0 days in the control group. In contrast, the interval from the onset of overt worsening HF to hospitalization was markedly shorter (control group, 7.5 days; RST group, 8.0 days).

Conclusions: Noninvasive RST telemonitoring enables early detection of the prolonged subclinical worsening phase of HF and provides a clinically actionable biological target for proactive intervention aimed at preventing HF-related hospitalization.

Background: Heart failure (HF) is a progressive disease characterized by an increasing incidence of hospitalization over time. HeartLogic^TM(HL) is a multiparametric remote monitoring system designed to detect early signs of HF decompensation. Using a multicenter database, this real-world study evaluated whether responses to HL alerts could reduce HF-related hospitalization.

Methods and Results: We retrospectively analyzed 246 patients implanted with an HL-enabled implantable cardioverter-defibrillator or cardiac resynchronization therapy defibrillator across 8 Japanese centers. Patients were categorized as alert-responsive (AR; n=167) or non-responsive (NR; n=79). Alert responses included multidisciplinary review and telephone triage to determine the need for clinical visits. HF hospitalization rates during the alert-off (before activation) and the alert-on (after alert activation) periods were compared. During the alert-off period, 50 hospitalizations occurred over 648 person-years (77.1 per 1,000 person-years); during the alert-on, 91 hospitalizations occurred over 498 person-years (182.6 per 1,000 person-years). From the alert-off to the alert-on period, HF hospitalization increased 3.24-fold (95% confidence interval [CI] 1.63–6.41) in the NR group, but only 1.28-fold (95% CI 0.81–2.03) in the AR group. The relative increase in HF hospitalization was significantly attenuated in the AR group (adjusted relative ratio 0.40; 95% CI 0.18–0.89; P=0.025).

Conclusions: Although HF-related hospitalizations progressively increase as the disease advances, real-world alert responses may reduce hospitalizations and healthcare costs in clinical practice.

Background: ¹⁸F-FDG PET/CT patterns in cardiac sarcoidosis (CS) across diagnostic subgroups are incompletely characterized.

Methods and Results: We analyzed 221 patients with definite CS (DCS), probable CS with active extracardiac sarcoidosis (PCS-A), or probable CS without extracardiac involvement (PCS-N). DCS exhibited more severe perfusion defects than PCS-A and PCS-N. FDG uptake was similar in DCS and PCS-A, but lower in PCS-N. Abnormalities predominated in the basal/mid-septum and apical cap.

Conclusions: Distinct PET patterns characterize CS diagnostic categories and support current diagnostic criteria.

Background: Patients with heart failure with preserved ejection fraction (HFpEF) and right ventricular (RV)–pulmonary arterial (PA) uncoupling, as assessed by a decrease ratio of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP) on echocardiography, have poorer outcomes than patients without RV-PA uncoupling.

Methods and Results: The MONACO trial was an adaptive, randomized, double-blind, placebo-controlled study that enrolled hospitalized patients with HFpEF admitted to 12 centers in Japan. Patients who had left ventricular ejection fraction ≥50% and TAPSE/PASP <0.57 mm/mmHg at discharge were randomized 1 : 1 to receive pimobendan 1.25 mg b.i.d. or placebo. The primary objective was to evaluate changes from baseline (day 0) to day 30 in exercise capacity measured by the 6-minute walking test. Enrollment was terminated due to the invalid result of the planned interim analysis. The median age of participants was 82 years and 46% were women. Pimobendan (n=24) or placebo (n=26) was administrated orally. At day 30, mean changes in 6-minute walking distance in patients who received pimobendan (+26.9 m [95% confidence interval; −2.0, +55.8]) or placebo (+21.4 m [95% confidence interval; −14.3, +57.2]) were not significantly different (P=0.402).

Conclusions: Among patients with HFpEF and RV-PA uncoupling, administration of pimobendan for 30 days did not result in significant improvement in exercise capacity compared with placebo.

Background: Nationwide data on in-hospital deaths and complications between leadless pacemakers (LPMs) and transvenous pacemakers (TVPMs) in Japan remain limited.

Methods and Results: Using a nationwide database, we identified adults who underwent TVPM or LPM implantation between 2017 and 2023. LPM implantation increased from 0.5% to 25% (P for trend <0.001). LPMs were selected more often as patient age increased and those undergoing dialysis or with dementia and atrial fibrillation (P<0.001). After propensity score matching (12,599 per group), composite outcomes (in-hospital deaths and all complications) were comparable between the LPM and TVPM groups (5.41% vs. 5.59%, respectively; P=0.44; odds ratio [OR] 0.95; 95% confidence interval [CI] 0.84–1.07). All-cause in-hospital death did not differ between groups (LPM, 1.09%; TVPM, 1.05%; P=0.55; OR 1.07; 95% CI 0.83–1.38), whereas all-cause death within 7 days after implantation was higher in the LPM group (0.58% vs. 0.33%; P=0.003; OR 1.80; 95% CI 1.21–2.67). All complications was comparable between the LPM and TVPM groups (LPM, 4.78%; TVPM, 4.82%; P=0.59; OR 0.96; 95% CI 0.85–1.09), but cardiac tamponade was more frequent in the LPM group (0.29% vs. 0.06%; P<0.001; OR 5.42; 95% CI 2.38–12.32).

Conclusions: Composite outcomes were comparable between the LPM and TVPM groups, but the rates of cardiac tamponade and all-cause death within 7 days after implantation were higher in the LPM group.

Background: Clinical outcome determinants in cardiac stereotactic body radiotherapy (cardiac-SBRT)/stereotactic arrhythmia radioablation (STAR), a minimally invasive therapy for refractory ventricular tachycardia (VT), remain unclear. We report the final analysis of Japan’s first prospective study following a previously published interim report.

Methods and Results: Between 2019 and 2024, 8 patients with recurrent VT refractory to medical therapy and unsuitable for or refractory to catheter ablation were enrolled. Primary endpoints were safety and VT suppression. Exploratory analyses examined irradiation distribution and autonomic function. Median age was 69 years (75% male), ejection fraction 25%, and median follow-up 2.2 years. Targets were defined using multimodal assessment, with a median planning target volume of 88.9 cc. Treatment-related adverse events included only grade 1 nausea (n=1). Implantable cardioverter-defibrillator shock suppression was 73.6% at 6 months and 76.8% at 1 year. Antitachycardia pacing suppression reached 97.9%, with near-complete suppression in 5 survivors. Analyses remained descriptive and hypothesis-generating. Heart rate variability suggested increased parasympathetic activity, and ¹²³I-metaiodobenzylguanidine imaging indicated reduced washout rate. Three patients died within 2 years but had advanced preexisting heart failure; irradiation more often involved inferior segments. Survival differences were not explained by cohort-level B-type natriuretic peptide levels or systolic function changes.

Conclusions: Cardiac-SBRT/STAR achieved sustained arrhythmia suppression. Heart failure severity, irradiation location, and autonomic function, with their interaction, may be associated with clinical outcomes.

Background: Heart failure (HF) is characterized by recurrent clinical deterioration, and multidimensional frailty (i.e., functional status, nutritional status, sarcopenia-related phenotypes, and cognitive impairment) is a key determinant of prognosis. We explored longitudinal changes in these multidimensional domains across recurrent hospitalizations for HF.

Methods and Results: This single-center retrospective cohort study analyzed 337 patients initially hospitalized for HF between 2016 and 2024 who subsequently experienced ≥1 rehospitalization (total 780 admissions). Longitudinal changes across repeated hospitalizations were evaluated using age- and sex-adjusted linear mixed-effects models. The median age was 83 years, and 47.2% were women. Across repeated hospitalizations, frailty and functional status worsened (Clinical Frailty Scale, β=0.40, P<0.001; Barthel Index, β=−4.21, P<0.001; Short Physical Performance Battery score, β=−0.56, P=0.043). Gait speed also declined, although this trend did not reach statistical significance (β=−0.03, P=0.089). Nutritional status deteriorated (Controlling Nutritional Status score, β=0.56, P<0.001; Geriatric Nutritional Risk Index, β=−2.37, P<0.001). Sarcopenia-related indices deteriorated (appendicular skeletal muscle index, β=−2.79, P=0.006; grip strength, β=−4.64%, P<0.001). Cognitive function assessed by the Mini-Mental State Examination showed no significant longitudinal change (β=0.11, P=0.501).

Conclusions: Many domains of frailty deteriorated across recurrent hospitalizations for HF, suggesting cumulative frailty progression.

Background: Heart failure (HF) is associated with poor clinical outcomes and is classified into Stages A–D. Estimated plasma volume (ePV) is a marker of plasma volume expansion. Prognostic markers applicable across all HF stages may enable the early identification of patients at high risk of adverse clinical outcomes. This study evaluated the impact of ePV on clinical outcomes in patients with Stage A–D HF.

Methods and Results: ePV was measured using the PRIME Plus analyzer in 494 patients with HF (Stage A, n=78; Stage B, n=274; Stage C/D, n=142) admitted to our hospital in 2022. Over a median follow-up of 3 years, 95 HF-related events, defined as HF rehospitalization and deaths, and 43 all-cause deaths occurred. Kaplan–Meier analysis demonstrated that patients in the highest ePV tertile had the greatest risk of HF-related events and all-cause deaths. Multivariable Cox proportional hazards regression analysis identified ePV as an independent predictor of HF-related events (hazard ratio [HR] 1.48; 95% confidence interval [CI] 1.26–1.73; P<0.0001) and all-cause deaths (HR 1.35; 95% CI 1.06–1.73; P=0.0158). The addition of ePV to established cardiovascular risk factors significantly improved the C-statistic (0.7009 vs. 0.7415; P=0.0260), net reclassification index, and integrated discrimination index.

Conclusions: This study demonstrates that ePV is a feasible prognostic marker for HF-related events and all-cause deaths in patients with Stage A–D HF.

Background: The use of information and communication technology (ICT) as a strategy to improve the quality of emergency medical care is gaining attention. A survey was conducted to investigate the extent to which ICT is being used in cardiovascular emergencies.

Methods and Results: A web-based questionnaire survey targeting cardiovascular surgery, cardiology, and emergency medicine departments at 320 facilities was conducted. The survey questions focused primarily on the presence and effectiveness of image sharing between hospitals and information sharing with emergency technicians using ICT, challenges in the use of ICT, and barriers hindering ICT adoption. The adoption rates of ICT for image sharing in cardiovascular surgery and electrocardiogram transmission in cardiology were 24% and 28%, respectively. ICT implementation was evaluated as being highly useful not only for reducing time to treatment but also for improving collaboration between medical professionals both within and outside the hospital. In emergency medicine, ICT collaboration with emergency technicians was implemented at 38% of hospitals, with image sharing at the emergency scene being prevalent. In cardiovascular surgery, 29% of facilities reported that the number of non-urgent transfers decreased or decreased significantly due to ICT implementation.

Conclusions: Although ICT utilization remains at 20–25%, expectations for its widespread adoption are extremely high. Conversely, concerns about the costs and differences in ICT platforms are common, and there is a desire to adopt compatible systems.

Background: Despite intensive control of established coronary risk factors, such as dyslipidemia, hypertension, and diabetes, cardiovascular events continue to occur in high-risk patients. Residual risk attributable to chronic low-grade inflammation has therefore emerged as a major clinical concern.

Methods and Results: This narrative review summarizes current evidence regarding the role of low-intensity chronic inflammation in cardiovascular disease risk, based on literature searches of PubMed. Randomized controlled trials targeting inflammation, including Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS), Colchicine Cardiovascular Outcomes Trial (COLCOT), and Low-Dose Colchicine 2 Trial (LoDoCo2), demonstrated that suppression of chronic inflammation reduces cardiovascular disease events independently of low-density lipoprotein cholesterol levels. In addition, evidence from randomized trials, observational studies, and systematic reviews supports the clinical value of high-sensitivity C-reactive protein for identifying residual inflammatory risk, including in Japanese patients at high cardiovascular risk.

Conclusions: High-sensitivity C-reactive protein is a practical and reliable biomarker for assessing low-grade chronic inflammation. Therapeutic strategies targeting inflammation are as important as lipid-lowering interventions and represent a promising approach for reducing residual cardiovascular risk.