Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Advance online publication
Displaying 1-50 of 103 articles from this issue
  • Koji Matsuo, Kei Yoneki, Kikka Kobayashi, Daiki Onoda, Kazuhiro Mibu, ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0925
    Published: March 19, 2024
    Advance online publication: March 19, 2024
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    Background: Low muscle mass in patients with acute heart failure (AHF) is associated with poor prognosis; however, this is based on a single baseline measurement, with little information on changes in muscle mass during hospitalization and their clinical implications. This study investigated the relationship between changes in rectus femoris cross-sectional area (RFCSA) on ultrasound and the prognosis of patients with AHF.

    Methods and Results: This is a retrospective evaluation of 284 AHF patients (mean [±SD] age 79.1±11.9 years; 116 female). RFCSA assessments at admission (pre-RFCSA), ∆RFCSA (i.e., the percentage change in RFCSA from admission to 2 weeks), and composite prognosis (all-cause death and heart failure-related readmission) within 1 year were determined. Patients were divided into 4 groups according to their median pre-RFCSA and ∆RFCSA after sex stratification: Group A, higher pre-RFCSA/better ∆RFCSA; Group B, higher pre-RFCSA/worse ∆RFCSA; Group C, lower pre-RFCSA/better ∆RFCSA; Group D, lower pre-RFCSA/worse ∆RFCSA. In the Cox regression analysis, with Group A as the reference, the cumulative event rate of Group C (hazard ratio [HR] 3.39; 95% confidence interval [CI] 0.71–16.09; P=0.124) did not differ significantly; however, the cumulative event rates of Group B (HR 7.93; 95% CI 1.99–31.60; P=0.003) and Group D (HR 9.24; 95% CI 2.57–33.26; P<0.001) were significantly higher.

    Conclusions: ∆RFCSA during hospitalization is useful for risk assessment of prognosis in patients with AHF.

  • Kensuke Yokoi, Tomonori Katsuki, Takanori Yamaguchi, Toyokazu Otsubo, ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0892
    Published: March 16, 2024
    Advance online publication: March 16, 2024
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    Supplementary material

    Background: Pulmonary vein (PV) stenosis (PVS) is a serious complication of atrial fibrillation (AF) ablation. The objective of this study was to describe interventional treatments for PVS after AF ablation and long-term outcomes in Japanese patients.

    Methods and Results: This multicenter retrospective observational study enrolled 30 patients (26 [87%] male; median age 55 years) with 56 severe PVS lesions from 43 PV interventional procedures. Twenty-seven (90%) patients had symptomatic PVS and 19 (63%) had a history of a single AF ablation. Of the 56 lesions, 41 (73%) were de novo lesions and 15 (27%) were retreated. Thirty-three (59%) lesions were treated with bare metal stents, 14 (25%) were treated with plain balloons, and 9 (16%) were treated with drug-coated balloons. All lesions were successfully treated without any systemic embolic event. Over a median follow-up of 584 days (interquartile range 265–1,165 days), restenosis rates at 1 and 2 years were 35% and 47%, respectively. Multivariate Cox regression analysis revealed devices <7 mm in diameter (hazard ratio [HR] 2.52; 95% confidence interval [CI] 1.04–6.0; P=0.040) and totally occluded lesions (HR 3.33; 95% CI 1.21–9.15; P=0.020) were independent risk factors for restenosis.

    Conclusions: All PVS lesions were successfully enlarged by the PV intervention; however, restenosis developed in approximately half the lesions within 2 years.

  • Ichiro Mizushima, Noriyasu Morikage, Eisaku Ito, Fuminori Kasashima, Y ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0026
    Published: March 16, 2024
    Advance online publication: March 16, 2024
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    Background: In 2018, diagnostic criteria were introduced for IgG4-related periaortitis/periarteritis and retroperitoneal fibrosis (PA/RPF). This study assessed the existing criteria and formulated an improved version.

    Methods and Results: Between August 2022 and January 2023, we retrospectively analyzed 110 Japanese patients diagnosed with IgG4-related disease (IgG4-RD) involving cardiovascular and/or retroperitoneal manifestations, along with 73 non-IgG4-RD patients (“mimickers”) identified by experts. Patients were stratified into derivation (n=88) and validation (n=95) groups. Classification as IgG4-RD or non-IgG4-RD was based on the 2018 diagnostic criteria and various revised versions. Sensitivity and specificity were calculated using experts’ diagnosis as the gold standard for the diagnosis of true IgG4-RD and mimickers. In the derivation group, the 2018 criteria showed 58.5% sensitivity and 100% specificity. The revised version, incorporating “radiologic findings of pericarditis”, “eosinophilic infiltration or lymphoid follicles”, and “probable diagnosis of extra-PA/-RPF lesions”, improved sensitivity to 69.8% while maintaining 100% specificity. In the validation group, the original and revised criteria had sensitivities of 68.4% and 77.2%, respectively, and specificities of 97.4% and 94.7%, respectively.

    Conclusions: Proposed 2023 revised IgG4-related cardiovascular/retroperitoneal disease criteria show significantly enhanced sensitivity while preserving high specificity, achieved through the inclusion of new items in radiologic, pathological, and extra-cardiovascular/retroperitoneal organ categories.

  • Wataru Fujimoto, Susumu Odajima, Hiroshi Okamoto, Masamichi Iwasaki, M ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0930
    Published: February 17, 2024
    Advance online publication: February 17, 2024
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    Supplementary material

    Background: Early detection and intervention for preclinical heart failure (HF) are crucial for restraining the potential increase in patients with HF. Thus, we designed and conducted a single-center retrospective cohort study to confirm the efficacy of B-type natriuretic peptide (BNP) for the early detection of preclinical HF in a primary care setting.

    Methods and Results: We investigated 477 patients with no prior diagnosis of HF who were under the care of general practitioners. These patients were categorized into 4 groups based on BNP concentrations: Category 1, 0 pg/mL≤BNP≤35 pg/mL; Category 2, 35 pg/mL<BNP≤100 pg/mL; Category 3, 100 pg/mL<BNP≤200 pg/mL; and Category 4, BNP >200 pg/mL. There was a marked and statistically significant increase in the prevalence of preclinical HF with increasing BNP categories: 19.9%, 57.9%, 87.5%, and 96.0% in Categories 1, 2, 3, and 4, respectively. Compared with Category 1, the odds ratio of preclinical HF in Categories 2, 3, and 4 was determined to be 5.56 (95% confidence interval [CI] 3.57–8.67), 23.70 (95% CI 8.91–63.11), and 171.77 (95% CI 10.31–2,861.93), respectively.

    Conclusions: Measuring BNP is a valuable tool for the early detection of preclinical HF in primary care settings. Proactive testing in patients at high risk of HF could play a crucial role in addressing the impending HF pandemic.

  • Zhanqi Feng, Lingjie Zhang, Meiying Cheng, Zitao Zhu, Honglei Shang, L ...
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-23-0684
    Published: March 14, 2024
    Advance online publication: March 14, 2024
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    Supplementary material
  • Akira Fujiyoshi, Shun Kohsaka, Jun Hata, Mitsuhiko Hara, Hisashi Kai, ...
    Article type: JCS GUIDELINES
    Article ID: CJ-23-0285
    Published: March 13, 2024
    Advance online publication: March 13, 2024
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  • Masato Nakamura, Nobuaki Suzuki, Kenshi Fujii, Jungo Furuya, Tomohiro ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0877
    Published: March 13, 2024
    Advance online publication: March 13, 2024
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    Supplementary material

    Background: The 1-year clinical outcomes of the Absorb GT1 Japan post-market surveillance (PMS) suggested that an appropriate intracoronary imaging-guided bioresorbable vascular scaffold (BVS) implantation technique may reduce the risk of target lesion failure (TLF) and scaffold thrombosis (ST) associated with the Absorb GT1 BVS. The long-term outcomes through 5 years are now available.

    Methods and Results: This study enrolled 135 consecutive patients (n=139 lesions) with ischemic heart disease in whom percutaneous coronary intervention (PCI) with the Absorb GT1 BVS was attempted. Adequate lesion preparation, imaging-guided appropriate sizing, and high-pressure post-dilatation using a non-compliant balloon were strongly encouraged. All patients had at least 1 Absorb GT1 successfully implanted at the index procedure. Intracoronary imaging was performed in all patients (optical coherence tomography: 127/139 [91.4%] lesions) and adherence to the implantation technique recommendations was excellent: predilatation, 100% (139/139) lesions; post-dilatation, 98.6% (137/139) lesions; mean (±SD) post-dilatation pressure, 18.8±3.5 atm. At 5 years, the follow-up rate was 87.4% (118/135). No definite/probable ST was reported through 5 years. The cumulative TLF rate was 5.1% (6/118), including 2 cardiac deaths, 1 target vessel-attributable myocardial infarction, and 3 ischemia-driven target lesion revascularizations.

    Conclusions: Appropriate intracoronary imaging-guided BVS implantation, including the proactive use of pre- and post-balloon dilatation during implantation may be beneficial, reducing the risk of TLF and ST through 5 years.

  • Kyu-Yong Ko, Iksung Cho, Dae-Young Kim, Hee Jeong Lee, Kyungeun Ha, Se ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0552
    Published: March 12, 2024
    Advance online publication: March 12, 2024
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    Supplementary material

    Background: Percutaneous mitral valvuloplasty (PMV) is a standard treatment for severe rheumatic mitral stenosis (RMS). However, the prognostic significance of the change in mitral valve area (∆MVA) during PMV is not fully understood.

    Methods and Results: This study analyzed data from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, which included 3,140 patients with severe RMS. We focused on patients with severe RMS undergoing their first PMV. Changes in echocardiographic parameters, including MVA quantified before and after PMV, and composite outcomes, including mitral valve reintervention, heart failure admission, stroke, and all-cause death, were evaluated. An optimal result was defined as a postprocedural MVA ≥1.5 cm2without mitral regurgitation greater than Grade II. Of the 308 patients included in the study, those with optimal results and ∆MVA >0.5 cm² had a better prognosis (log-rank P<0.001). Patients who achieved optimal results but with ∆MVA ≤0.5 cm² had a greater risk of composite outcomes than those with optimal outcomes and ∆MVA >0.5 cm² (nested Cox regression analysis, hazard ratio 2.27; 95% confidence interval 1.09–4.73; P=0.028).

    Conclusions: Achieving an increase in ∆MVA of >0.5 cm2was found to be correlated with improved outcomes. This suggests that, in addition to achieving traditional optimal results, targeting an increase in ∆MVA of >0.5 cm2could be a beneficial objective in PMV treatment for RMS.

  • Ryuki Chatani, Yugo Yamashita, Takeshi Morimoto, Nao Muraoka, Wataru S ...
    Article type: LATE BREAKING CLINICAL TRIAL (JCS 2024)
    Article ID: CJ-24-0004
    Published: March 08, 2024
    Advance online publication: March 08, 2024
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    Supplementary material

    Background: Patients with appropriately selected low-risk pulmonary embolism (PE) can be treated at home, although it has been controversial whether applies to patients with cancer, who are considered not to be at low risk.

    Methods and Results: The current predetermined companion report from the ONCO PE trial evaluated the 3-month clinical outcomes of patients with home treatment and those with in-hospital treatment. The ONCO PE trial was a multicenter, randomized clinical trial among 32 institutions in Japan investigating the optimal duration of rivaroxaban treatment in cancer-associated PE patients with a score of 1 using the simplified version of the Pulmonary Embolism Severity Index (sPESI). Among 178 study patients, there were 66 (37%) in the home treatment group and 112 (63%) in the in-hospital treatment group. The primary endpoint of a composite of PE-related death, recurrent venous thromboembolism (VTE) and major bleeding occurred in 3 patients (4.6% [0.0–9.6%]) in the home treatment group and in 2 patients (1.8% [0.0–4.3%]) in the in-hospital treatment group. In the home treatment group, there were no cases of PE-related death or recurrent VTE, but major bleeding occurred in 3 patients (4.6% [0.0–9.6%]), and 2 patients (3.0% [0.0–7.2%]) required hospitalization due to bleeding events.

    Conclusions: Active cancer patients with PE of sPESI score=1 could be potential candidates for home treatment.

  • Keiko Inoue, Tomoko Machino-Ohtsuka, Yoko Nakazawa, Noriko Iida, Rumi ...
    Article type: LATE BREAKING CLINICAL TRIAL (JCS 2024)
    Article ID: CJ-24-0065
    Published: March 08, 2024
    Advance online publication: March 08, 2024
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    Supplementary material

    Background: In the present study, we aimed to investigate whether early cardiac biomarker alterations and echocardiographic parameters, including left atrial (LA) strain, can predict anthracycline-induced cardiotoxicity (AIC) and thus develop a predictive risk score.

    Methods and Results: The AIC registry is a prospective, observational cohort study designed to gather serial echocardiographic and biomarker data before and after anthracycline chemotherapy. Cardiotoxicity was defined as a reduction in left ventricular ejection fraction (LVEF) ≥10 percentage points from baseline and <55%. In total, 383 patients (93% women; median age, 57 [46–66] years) completed the 2-year follow-up; 42 (11.0%) patients developed cardiotoxicity (median time to onset, 292 [175–440] days). Increases in cardiac troponin T (TnT) and B-type natriuretic peptide (BNP) and relative reductions in the left ventricular global longitudinal strain (LV GLS) and LA reservoir strain [LASr] at 3 months after anthracycline administration were independently associated with subsequent cardiotoxicity. A risk score containing 2 clinical variables (smoking and prior cardiovascular disease), 2 cardiac biomarkers at 3 months (TnT ≥0.019 ng/mL and BNP ≥31.1 pg/mL), 2 echocardiographic variables at 3 months (relative declines in LV GLS [≥6.5%], and LASr [≥7.5%]) was generated.

    Conclusions: Early decline in LASr was independently associated with subsequent cardiotoxicity. The AIC risk score may provide useful prognostication in patients receiving anthracyclines.

  • Toshihisa Anzai
    Article type: MESSAGE FROM THE EDITOR-IN-CHIEF
    Article ID: CJ-66-0223
    Published: March 08, 2024
    Advance online publication: March 08, 2024
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  • Tetsuya Matoba, Yasuhiro Nakano, Shunsuke Katsuki, Tomomi Ide, Shouji ...
    Article type: 2023 JCS REPORT
    Article ID: CJ-24-0127
    Published: March 07, 2024
    Advance online publication: March 07, 2024
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    The 87thAnnual Meeting of the Japanese Circulation Society (JCS2023) was held in March 2023 in Fukuoka, Japan, marking the first in-person gathering after the COVID-19 pandemic. With the theme of “New Challenge With Next Generation” the conference emphasized the development of future cardiovascular leaders and technologies such as artificial intelligence (AI). Notable sessions included the Mikamo Lecture on heart failure and the Mashimo Lecture on AI in medicine. Various hands-on sessions and participatory events were well received, promoting learning and networking. Post-event surveys showed high satisfaction among participants, with positive feedback on face-to-face interactions and the overall experience. JCS2023, attended by 17,852 participants, concluded successfully, marking a significant milestone in post-pandemic meetings, and advancing cardiovascular medicine.

  • Teruhiko Imamura, Michikazu Nakai, Yoshitaka Iwanaga, Yoko Sumita, Mis ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0924
    Published: March 06, 2024
    Advance online publication: March 06, 2024
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    Supplementary material

    Background: The introduction of transcatheter edge-to-edge repair for moderate-to-severe or severe mitral regurgitation (MR) utilizing the MitraClip system became reimbursed and clinically accessible in Japan in April 2018. This study presents the 2-year clinical outcomes of all consecutively treated patients who underwent MitraClip implantation in Japan and were prospectively enrolled in the Japanese Circulation Society-oriented J-MITRA registry.

    Methods and Results: Analysis encompassed 2,739 consecutive patients enrolled in the J-MITRA registry with informed consent (mean age: 78.3±9.6 years, 1,550 males, STS risk score 11.7±8.9), comprising 1,999 cases of functional MR, 644 of degenerative MR and 96 in a mixed group (DMR and FMR). The acute procedure success rate was 88.9%. After MitraClip implantation, >80% exhibited an MR grade ≤2+ and the trend was sustained over the 2 years. Within this observation period, the mortality rate was 19.3% and the rate of heart failure readmissions was 20.6%. The primary composite endpoint, inclusive of cardiovascular death and heart failure readmission, was significantly higher in patients with functional MR than in with degenerative MR (32.0% vs. 17.5%, P<0.001).

    Conclusions: The 2-year clinical outcomes after MitraClip implantation were deduced from comprehensive data within an all-Japan registry.

  • Seitaro Oda
    Article type: EDITORIAL
    Article ID: CJ-24-0150
    Published: March 02, 2024
    Advance online publication: March 02, 2024
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  • Feng Sheng, Alex Y. Wang, Kazumasa Miyawaki, Takahiro Tsuchiya, Nobuhi ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0814
    Published: March 01, 2024
    Advance online publication: March 01, 2024
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    Supplementary material

    Background: Real-world utilization data for evolocumab, the first proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor to be introduced in Japan in 2016, to date are limited. This study aimed to clarify the current real-world patient user profiles of evolocumab based on large-scale health claims data.

    Methods and Results: This retrospective database study examined patients from a health administrative database (MDV database) who initiated evolocumab between April 2016 (baseline) and November 2021. Characteristics and clinical profiles of this patient population are described. In all, 4,022 patients were included in the final analysis. Most evolocumab prescriptions occurred in the outpatient setting (3,170; 78.82%), and 940 patients (23.37%) had a recent diagnosis of familial hypercholesterolemia. Common recent atherosclerotic cardiovascular disease events at baseline included myocardial infarction (1,633; 40.60%), unstable angina (561; 13.95%), and ischemic stroke (408; 10.14%). Comorbidity diseases included hypertension (2,504; 62.26%), heart failure (1,750; 43.51%), diabetes (1,199; 29.81%), and chronic kidney disease (297; 7.38%). Among the lipid-lowering regimens concomitant with evolocumab, ezetimibe+statin was used most frequently (1,281; 31.85%), followed by no concomitant lipid-lowering regimen (1,190; 29.59%), statin (950; 23.62%), and ezetimibe (601; 14.94%). The median evolocumab treatment duration for all patients was 260 days (interquartile range 57–575 days).

    Conclusions: This study provides real-world insights into evolocumab utilization in Japan for optimizing patient care and adherence to guideline-based therapies to better address hypercholesterolemia in Japan.

  • Hiroaki Kawano, Satoshi Ikeda, Koshiro Kanaoka, Shuntaro Sato, Ryo Eto ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0914
    Published: March 01, 2024
    Advance online publication: March 01, 2024
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    Supplementary material

    Background: Multisystem inflammatory syndrome (MIS) is a hyperinflammatory shock associated with cardiac dysfunction and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, there are no reports on using MIS criteria, such as multisystemic inflammation (MSI) in fulminant myocarditis, without SARS-CoV-2 infection. This study investigated the differences in clinical characteristics and course between patients with fulminant lymphocytic myocarditis (FLM) plus MSI and those without MSI.

    Methods and Results: This multicenter retrospective cohort study included 273 patients with FLM registered in the JROAD-DPC database between April 2014 and March 2017. We evaluated the presence of MSI using criteria modified from previously reported MIS criteria and compared the characteristics and risk of mortality or heart transplantation between FLM patients with MSI and without MSI. Of the 273 patients with FLM, 107 (39%) were diagnosed with MSI. The MSI group was younger (44 vs. 57 years; P<0.0001) and had more females (50% vs. 36%; P=0.0236), a higher incidence of pericardial effusion (58% vs. 40%; P=0.0073), and a lower 90-day mortality rate (19% vs. 33%; P=0.0185) than the non-MSI group. The risk of mortality at 90 days was lower in FLM patients aged <50 years with MSI aged <50 years than in those without MSI (P=0.0463).

    Conclusions: These results suggest that MSI may influence the prognosis of FLM, especially in patients aged <50 years.

  • Koichi Akutsu, Hideaki Yoshino, Tomoki Shimokawa, Hitoshi Ogino, Takas ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0636
    Published: February 28, 2024
    Advance online publication: February 28, 2024
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    Background: Epidemiological data on ruptured aortic aneurysms from large-scale studies are scarce. The aims of this study were to: clarify the clinical course of ruptured aortic aneurysms; identify aneurysm site-specific therapies and outcomes; and determine the clinical course of patients receiving conservative therapy.

    Methods and Results: Using the Tokyo Acute Aortic Super Network database, we retrospectively analyzed 544 patients (mean [±SD] age 78±10 years; 70% male) with ruptured non-dissecting aortic aneurysms (AAs) after excluding those with impending rupture. Patient characteristics, status on admission, therapeutic strategy, and outcomes were evaluated. Shock or pulselessness on admission were observed in 45% of all patients. Conservative therapy, endovascular therapy (EVT), and open surgery (OS) accounted for 32%, 23%, and 42% of cases, respectively, with corresponding mortality rates of 93%, 30%, and 29%. The overall in-hospital mortality rate was 50%. The prevalence of pulselessness was highest (48%) in the ruptured ascending AA group, and in-hospital mortality was the highest (70%) in the ruptured thoracoabdominal AA group. Multivariable logistic regression analysis indicated in-hospital mortality was positively associated with pulselessness (odds ratio [OR] 10.12; 95% confidence interval [CI] 4.09–25.07), and negatively associated with invasive therapy (EVT and OS; OR 0.11; 95% CI 0.06–0.20).

    Conclusions: The outcomes of ruptured AAs remain poor; emergency invasive therapy is essential to save lives, although it remains challenging to reduce the risk of death.

  • Satoshi Ishii, Masaru Hatano, Shun Minatsuki, Kazutoshi Hirose, Akihit ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0790
    Published: February 23, 2024
    Advance online publication: February 23, 2024
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    Background: Whether comprehensive risk assessment predicts post-referral outcome in patients with pulmonary arterial hypertension (PAH) referred for lung transplantation (LT) in Japan is unknown.

    Methods and Results: We retrospectively analyzed 52 PAH patients referred for LT. Risk status at referral was assessed using 3- and 4-strata models from the 2022 European Society of Cardiology and European Respiratory Society guidelines. The 3-strata model intermediate-risk group was further divided into 2 groups based on the median proportion of low-risk variables (modified risk assessment [MRA]). The primary outcome was post-referral mortality. During follow-up, 9 patients died and 13 patients underwent LT. There was no survival difference among 3-strata model groups. The 4-strata model classified 33, 16, and 3 patients as low intermediate, high intermediate, and high risk, respectively. The 4-strata model identified high-risk patients with a 1-year survival rate of 33%, but did not discriminate survival between the intermediate-risk groups. The MRA classified 15, 28, 8, and 1 patients as low, low intermediate, high intermediate, and high risk, respectively. High intermediate- or high-risk patients had worse survival (P<0.001), with 1- and 3-year survival rates of 64% and 34%, respectively. MRA high intermediate- or high-risk classification was associated with mortality (hazard ratio 12.780; 95% confidence interval 2.583–63.221; P=0.002).

    Conclusions: Patients classified as high intermediate or high risk by the MRA after treatment should be referred for LT.

  • Masatsugu Miyagawa, Yuki Nakajima, Nobuhiro Murata, Yasuo Okumura
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-23-0855
    Published: February 21, 2024
    Advance online publication: February 21, 2024
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  • Megumi Kawashima, Takashi Hisamatsu, Akiko Harada, Aya Kadota, Keiko K ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0725
    Published: February 20, 2024
    Advance online publication: February 20, 2024
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    Supplementary material

    Background: Deviations of hemoglobin from normal levels may be a factor in cardiovascular disease (CVD) risk; however, conclusive evidence is lacking. In addition, preclinical conditions may influence hemoglobin concentrations, but studies focusing on reverse causation are limited. Thus, we examined the relationship between hemoglobin concentrations and CVD mortality risk, considering reverse causation.

    Methods and Results: In a prospective cohort representative of the general Japanese population (1990–2015), we studied 7,217 individuals (mean age 52.3 years; 4,219 women) without clinical CVD at baseline. Participants were categorized into sex-specific hemoglobin quintiles (Q1–Q5) and data were analyzed using the Cox proportional hazards model adjusted for possible confounders. During a 25-year follow-up, 272 men and 334 women died from CVD. Adjusted hazard ratios for CVD mortality across sex-specific quintiles, using Q3 as the reference, were significantly higher for Q1 (1.40; 95% confidence interval [CI] 1.08–1.82) and Q5 (1.49; 95% CI 1.14–1.96), and remained significant after excluding deaths within the first 5 years of follow-up to consider reverse causation (1.35 [95% CI 1.02–1.79] and 1.45 [95% CI 1.09–1.94], respectively). A similar U-shaped association was seen between transferrin saturation levels and CVD mortality, but after excluding deaths within the first 5 years the association was significant only for Q1.

    Conclusions: Low and high hemoglobin concentrations were associated with an increased risk of CVD mortality.

  • Masaomi Kimura
    Article type: EDITORIAL
    Article ID: CJ-24-0041
    Published: February 16, 2024
    Advance online publication: February 16, 2024
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  • Hiroshi Tsunamoto, Hiroyuki Yamamoto, Akiko Masumoto, Yasuyo Taniguchi ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0777
    Published: February 08, 2024
    Advance online publication: February 08, 2024
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    Background: We investigated the efficacy of left ventricular (LV) myocardial damage by native T1mapping obtained with cardiac magnetic resonance (CMR) for patients undergoing transcatheter edge-to-edge repair (TEER).

    Methods and Results: We studied 40 symptomatic non-ischemic heart failure (HF) patients and ventricular functional mitral regurgitation (VFMR) undergoing TEER. LV myocardial damage was defined as the native T1Z-score, which was converted from native T1values obtained with CMR. The primary endpoint was defined as HF rehospitalization or cardiovascular death over 12 months after TEER. Multivariable Cox proportional hazards analysis showed that the native T1Z-score was the only independent parameter associated with cardiovascular events (hazard ratio 3.40; 95% confidential interval 1.51–7.67), and that patients with native T1Z-scores <2.41 experienced significantly fewer cardiovascular events than those with native T1Z-scores ≥2.41 (P=0.001). Moreover, the combination of a native T1Z-score <2.41 and more severe VFMR (effective regurgitant orifice area [EROA] ≥0.30 cm2) was associated with fewer cardiovascular events than a native T1Z-score ≥2.41 and less severe VFMR (EROA <0.30 cm2; P=0.002).

    Conclusions: Assessment of baseline LV myocardial damage based on native T1Z-scores obtained with CMR without gadolinium-based contrast media is a valuable additional parameter for better management of HF patients and VFMR following TEER.

  • Shigetoyo Kogaki
    Article type: EDITORIAL
    Article ID: CJ-24-0043
    Published: February 15, 2024
    Advance online publication: February 15, 2024
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  • Ling Kuo, Guan-Jie Wang, Shih-Ling Chang, Yenn-Jiang Lin, Fa-Po Chung, ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0808
    Published: February 14, 2024
    Advance online publication: February 14, 2024
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    Supplementary material

    Background: The aim of this study was to build an auto-segmented artificial intelligence model of the atria and epicardial adipose tissue (EAT) on computed tomography (CT) images, and examine the prognostic significance of auto-quantified left atrium (LA) and EAT volumes for AF.

    Methods and Results: This retrospective study included 334 patients with AF who were referred for catheter ablation (CA) between 2015 and 2017. Atria and EAT volumes were auto-quantified using a pre-trained 3-dimensional (3D) U-Net model from pre-ablation CT images. After adjusting for factors associated with AF, Cox regression analysis was used to examine predictors of AF recurrence. The mean (±SD) age of patients was 56±11 years; 251 (75%) were men, and 79 (24%) had non-paroxysmal AF. Over 2 years of follow-up, 139 (42%) patients experienced recurrence. Diabetes, non-paroxysmal AF, non-pulmonary vein triggers, mitral line ablation, and larger LA, right atrium, and EAT volume indices were linked to increased hazards of AF recurrence. After multivariate adjustment, non-paroxysmal AF (hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4–0.8; P=0.003) and larger LA-EAT volume index (HR 1.1; 95% CI 1.0–1.2; P=0.009) remained independent predictors of AF recurrence.

    Conclusions: LA-EAT volume measured using the auto-quantified 3D U-Net model is feasible for predicting AF recurrence after CA, regardless of AF type.

  • Chia-Yi Chin, Chun-An Chen, Chun-Min Fu, Jui-Yu Hsu, Hsin-Chia Lin, Sh ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0891
    Published: February 08, 2024
    Advance online publication: February 08, 2024
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    Background: Complications arising from transcatheter closure of perimembranous ventricular septal defects (pmVSD) in children, such as residual shunts and aortic regurgitation (AR), have been observed. However, the associated risk factors remain unclear. This study identified risk factors linked with residual shunts and AR following transcatheter closure of pmVSD in children aged 2–12 years.

    Methods and Results: The medical records of 63 children with pmVSD and a pulmonary-to-systemic blood flow ratio <2.0 who underwent transcatheter closure between 2011 and 2018 were analyzed with a minimum 3-year follow-up. The success rate of transcatheter closure was 98.4%, with no emergency surgery, permanent high-degree atrioventricular block, or mortality. Defects ≥4.5 mm had significantly higher odds of persistent residual shunt (odds ratio [OR] 6.85; P=0.03). The use of an oversize device (≥1.5 mm) showed a trend towards reducing residual shunts (OR 0.23; P=0.06). Age <4 years (OR 27.38; 95% confidence interval [CI] 2.33–321.68) and perimembranous outlet-type VSD (OR 11.94, 95% CI 1.10–129.81) were independent risk factors for AR progression after closure.

    Conclusions: Careful attention is crucial for pmVSDs ≥4.5 mm to prevent persistent residual shunts in transcatheter closure. Assessing AR risk, particularly in children aged <4 years, is essential while considering the benefits of pmVSD closure.

  • Hye Won Kwon, Mi Kyoung Song, Sang Yun Lee, Gi Beom Kim, Jae Gun Kwak, ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0752
    Published: February 06, 2024
    Advance online publication: February 06, 2024
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    Background: Coronary artery complications (CACs) in patients who undergoing prosthetic pulmonary valve implantation for congenital heart disease can lead to fetal outcomes. However, the incidence of and risk factors for CACs in these patients remain unknown.

    Methods and Results: A retrospective cohort study was conducted on patients who underwent cardiac computed tomography or invasive coronary angiography after prosthetic pulmonary valve implantation at Seoul National University Hospital from June 1986 to May 2021. Among 341 patients, 25 (7.3%) were identified with CACs, and 2 of them died. Among the patients with CACs, congenital coronary anomalies and an interarterial course of the coronary artery were identified in 11 (44%) and 18 (72%) patients, respectively. Interarterial and intramural courses of the coronary artery were associated with a 4.4- and 10.6-fold increased risk of CACs, respectively. Among patients with tetralogy of Fallot and pulmonary atresia, the aortic root was rotated further clockwise in patients with coronary artery compression compared to those without it (mean [±SD] 128.0±19.9° vs. 113.5±23.7°; P=0.024). The cut-off rotation angle of the aorta for predicting the occurrence of coronary artery compression was 133°.

    Conclusions: Perioperative coronary artery evaluation and prevention of CACs are required in patients undergoing prosthetic pulmonary valve implantation, particularly in those with coronary artery anomalies or severe clockwise rotation of the aortic root.

  • Akira Kasagawa, Ikutaro Nakajima, Yui Nakayama, Daisuke Togashi, Kenic ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0229
    Published: February 02, 2024
    Advance online publication: February 02, 2024
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    Background: High shock impedance is associated with conversion failure among patients with subcutaneous implantable cardioverter defibrillators (S-ICD). Currently, there is no preoperative assessment method for predicting high shock impedance. This study examined the efficacy of chest computed tomography (CT) as a preoperative evaluation tool to assess the shock impedance of S-ICDs.

    Methods and Results: The amount of adipose tissue adjacent to the device and anteroposterior diameter at the basal heart region were measured preoperatively using chest CT. We examined the correlation between these measurements and shock impedance at the conversion test. We enrolled 43 patients with S-ICDs (mean [±SD] age 54±15 years; body mass index 23±4 kg/m2; PRAETORIAN score 30–270 points; amount of adipose tissue 1,250±716 cm3), who underwent intraoperative conversion tests by inducing ventricular fibrillation, which was terminated with a 65-J shock. A sufficient concordance correlation coefficient was observed between the shock impedance and the amount of adipose tissue (r=0.616, P<0.01) and anteroposterior diameter (r=0.645, P<0.01). In multiple regression analysis, the amount of adipose tissue (β=0.439, P=0.009) and anteroposterior diameter (β=0.344, P=0.038) were identified as independent predictive factors of shock impedance.

    Conclusions: The preoperative CT-measured amount of adipose tissue and basal heart anteroposterior diameter are independent predictors of shock impedance. These parameters may be more accurate in identifying higher shock impedance in patients with S-ICDs.

  • Diandong Jiang, Yuxin Zhang, Yingchun Yi, Lijian Zhao, Jianli Lv, Jing ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0583
    Published: January 31, 2024
    Advance online publication: January 31, 2024
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    Background: Potential differences in complications and/or long-term outcomes of perimembranous ventricular septal defect (pmVSD) closures with 3-mm waist vs. 4-mm waist double-disk symmetrical occluders are not known.

    Methods and Results: A total of 395 consecutive pediatric patients with pmVSD recruited between January 2017 and March 2021 underwent successful transcatheter closure using symmetrical pmVSD devices. The final analysis involved 208×3-mm and 172×4-mm cases. The median follow-up was 42 months (range: 12–62 months). A total of 175 post-procedure adverse events (AEs) were observed. Most of these AEs were temporary, and there were only 8 major AEs. Compared to the 3-mm waist group, the incidence of residual shunts was significantly higher in the 4-mm waist group (13.4% vs. 6.7%; P=0.030), whereas other AEs showed similar incidences between the 2 groups. Multivariate Cox regression analysis revealed that larger defect, higher ratio between device size and body surface area, and longer procedure time can cause an increased likelihood of AEs, and smaller defect or left disk placement within aneurysmal tissue may reduce it.

    Conclusions: Transcatheter closure of pmVSD using a symmetrical double-disk occluder is safe and effective. Compared with a 3-mm waist symmetrical occluder, transcatheter closure with a 4-mm waist symmetrical occluder correlated with higher incidences of residual shunts.

  • Shigehiro Miyazaki, Haruhiko Higashi, Yasushi Takasaki, Toru Miyoshi, ...
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-23-0885
    Published: January 31, 2024
    Advance online publication: January 31, 2024
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    Supplementary material
  • Jining He, Xiaohui Bian, Rui Zhang, Sheng Yuan, Changdong Guan, Tongqi ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-22-0743
    Published: December 23, 2023
    Advance online publication: December 23, 2023
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    Background: The clinical impact of relative improvements in coronary physiology in patients receiving percutaneous coronary intervention (PCI) for coronary artery disease (CAD) remains undetermined.

    Methods and Results: The quantitative flow ratio (QFR) recovery ratio (QRR) was calculated in 1,424 vessels in the PANDA III trial as (post-PCI QFR−pre-PCI QFR)/(1−pre-PCI QFR). The primary endpoint was the 2-year vessel-oriented composite endpoint (VOCE; a composite of vessel-related cardiac death, vessel-related non-procedural myocardial infarction, and ischemia-driven target vessel revascularization). Study vessels were dichotomously stratified according to the optimal QRR cut-off value. During the 2-year follow-up, 41 (2.9%) VOCEs occurred. Low (<0.86) QRR was associated with significantly higher rates of 2-year VOCEs than high (≥0.86) QRR (6.6% vs. 1.4%; adjusted hazard ratio [aHR] 5.05; 95% confidence interval [CI] 2.53–10.08; P<0.001). Notably, among vessels with satisfactory post-procedural physiological results (post-PCI QFR >0.89), low QRR also conferred an increased risk of 2-year VOCEs (3.7% vs. 1.4%; aHR 3.01; 95% CI 1.30–6.94; P=0.010). Significantly better discriminant and reclassification performance was observed after integrating risk stratification by QRR and post-PCI QFR to clinical risk factors (area under the curve 0.80 vs. 0.71 [P=0.010]; integrated discrimination improvement 0.05 [P<0.001]; net reclassification index 0.64 [P<0.001]).

    Conclusions: Relative improvement of coronary physiology assessed by QRR showed applicability in prognostication. Categorical classification of coronary physiology could provide information for risk stratification of CAD patients.

  • Hsiu-An Lee, Feng-Cheng Chang, Jih-Kai Yeh, Ying-Chang Tung, Victor Ch ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0640
    Published: January 27, 2024
    Advance online publication: January 27, 2024
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    Supplementary material

    Background: When mitral valve (MV) surgery is indicated, repair is preferred over replacement; however, this preference is not supported by evidence from clinical trials. Furthermore, the benefits of MV repair may not be universal for all etiologies of MV disease.

    Methods and Results: This study identified a total of 18,428 patients who underwent MV repair (n=4,817) or MV replacement (n=13,611) during 2001–2018 from Taiwan’s National Health Insurance Research Database. These patients were classified into 4 etiologies: infective endocarditis (IE, n=2,678), rheumatic heart disease (RHD, n=4,524), ischemic mitral regurgitation (IMR, n=3,893), and degenerative mitral regurgitation (DMR, n=7,333). After propensity matching, all-cause mortality during follow-up was lower among patients receiving MV repair than among patients receiving MV replacement in the IE, IMR, and DMR groups (hazard ratio [HR]=0.72, 95% confidence interval [CI]: 0.55–0.93; HR=0.82, 95% CI: 0.73–0.92; and HR 0.73, 95% CI: 0.64–0.84, respectively). However, in the RHD group, the MV reoperation rate was higher after MV repair than after MV replacement (subdistribution HR=1.91, 95% CI: 1.02–3.55).

    Conclusions: In comparison with MV replacement, MV repair was associated with a lower late mortality in patients with IE, IMR, and DMR, and a higher risk of reoperation in patients with RHD.

  • Hibiki Iwakoshi, Yusuke C Asada, Mitsuko Nakata, Masahiro Makino, Jun ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0682
    Published: January 27, 2024
    Advance online publication: January 27, 2024
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    Supplementary material

    Background: The impact of sleep apnea (SA) on heart rate variability (HRV) in atrial fibrillation (AF) patients has not been investigated.

    Methods and Results: Of 94 patients who underwent AF ablation between January 2021 and September 2022, 76 patients who had a nocturnal Holter electrocardiography and polysomnography conducted simultaneously were included in the analysis. A 15-min duration of HRV, as determined by an electrocardiogram during apnea and non-apnea time, were compared between patients with and without AF recurrence at 12 months’ postoperatively. Patients had a mean age of 63.4±11.6 years, 14 were female, and 20 had AF recurrence at 12 months’ follow-up. The root mean square of the difference between consecutive normal-to-normal intervals (RMSSD, ms) an indicator of a parasympathetic nervous system, was more highly increased in patients with AF recurrence than those without, during both apnea and non-apnea time (apnea time: 16.7±4.5 vs. 13.5±3.3, P=0.03; non-apnea time: 20.9±9.5 vs. 15.5±5.9, P<0.01). However, RMSSD during an apneic state was decreased more than that in a non-apneic state in both groups of patients with and without AF recurrence (AF recurrence group: 16.7±4.5 vs. 20.9±9.5, P<0.01; non-AF recurrence group; 13.5±3.3 vs. 15.5±5.9, P=0.03). Consequently, the effect of AF recurrence on parasympathetic activity was offset by SA. Similar trends were observed for other parasympathetic activity indices; high frequency (HF), logarithm of HF (lnHF) and the percentage of normal-to-normal intervals >50 ms (pNN50).

    Conclusions: Without considering the influence of SA, the results of nocturnal HRV analysis might be misinterpreted. Caution should be taken when using nocturnal HRV as a predictor of AF recurrence.

  • Feng-Cheng Chang, Chun-Yu Chen, Yi-Hsin Chan, Yu-Ting Cheng, Chia-Pin ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0687
    Published: January 24, 2024
    Advance online publication: January 24, 2024
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    Supplementary material

    Background: Mitral valve (MV) disease is the most common form of valvular heart disease. Findings that indicate women have a higher risk for unfavorable outcomes than men remain controversial. This study aimed to determine the sex-based differences in epidemiological distributions and outcomes of surgery for MV disease.

    Methods and Results: Overall, 18,572 patients (45.3% women) who underwent MV surgery between 2001 and 2018 were included. Outcomes included in-hospital death and all-cause mortality during follow up. Subgroup analysis was conducted across different etiologies, including infective endocarditis (IE), degenerative, ischemic, and rheumatic mitral pathology. The overall MV repair rate was lower in women than in men (20.5% vs. 30.6%). After matching, 6,362 pairs (woman : man=1 : 1) of patients were analyzed. Women had a slightly higher risk for in-hospital death than men (10.8% vs. 9.8%; odds ratio [OR]: 1.11, 95% confidence interval [CI]: 0.99–1.24; P=0.075). Women tended to have a higher incidence of de novo dialysis (9.8% vs. 8.6%; P=0.022) and longer intensive care unit stay (8 days vs. 7.1 days; P<0.001). Women with IE had poorer in-hospital outcomes than men; however, there were no sex differences in terms of all-cause mortality.

    Conclusions: Sex-based differences of MV intervention still persist. Although long-term outcomes were comparable between sexes, women, especially those with IE, had worse perioperative outcomes than men.

  • Naoki Nishiura, Shunsuke Kubo, Chihiro Fujii, Yuki Shima, Akihiro Ikut ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0929
    Published: January 24, 2024
    Advance online publication: January 24, 2024
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    Supplementary material

    Background: Clinical outcomes after percutaneous coronary intervention have improved with the use of drug-eluting stents, but data beyond 10 years are limited. The purpose of this study was to evaluate the clinical outcomes of patients undergoing sirolimus-eluting stent implantation with follow-up beyond 10 years and to determine the impact of clinical and angiographic characteristics on long-term prognosis.

    Methods and Results: The clinical outcomes of 885 patients who had undergone sirolimus-eluting stent implantation at a single institution were retrospectively reviewed. Primary endpoints included in the analysis were clinically driven target lesion revascularization (cTLR) and target lesion revascularization (TLR). Univariate and multivariate nominal logistic regression was used for data analysis. The incidence rates of cTLR and TLR beyond 10 years after sirolimus-eluting stent implantation were 16.4% and 36.8%, respectively, with cTLR tending to decrease beyond 10 years. Acute coronary syndrome was a predominant trigger for cTLR. Age, statin use, and stent restenosis emerged as predictors of cTLR within 10 years, but no significant predictors other than age were identified beyond 10 years.

    Conclusions: Events continue to occur beyond 10 years after sirolimus-eluting stent implantation, with a trend toward an increase in acute coronary syndromes. It is important to be vigilant about the occurrence of acute coronary syndromes during long-term follow-up.

  • Aya Miyazaki
    Article type: EDITORIAL
    Article ID: CJ-23-0963
    Published: January 24, 2024
    Advance online publication: January 24, 2024
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  • Hyewon Shin, Jae Suk Baek, Mi Jin Kim, Seulgi Cha, Jeong Jin Yu
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0491
    Published: January 23, 2024
    Advance online publication: January 23, 2024
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    Supplementary material

    Background: Permanent pacemaker (PPM) implantation has been identified as a risk factor for morbidity and mortality after Fontan operation. This study investigated the factors associated with outcomes in patients with Fontan physiology who underwent PPM implantation.

    Methods and Results: We retrospectively reviewed 508 patients who underwent Fontan surgery at Asan Medical Center between September 1992 and August 2022. Of these patients, 37 (7.3%) received PPM implantation. Five patients were excluded, leaving 32 patients, of whom 11 were categorized into the poor outcome group. Poor outcomes comprised death, heart transplantation, and “Fontan failure”. Clinical, Fontan procedure-related, and PPM-related factors were compared between the poor and good outcome groups. Ventricular morphology, Fontan procedure-associated factors, pacing mode, high ventricular pacing rate, and time from first arrhythmia to PPM implantation did not differ significantly between the 2 groups. However, the poor outcome group exhibited a significantly longer mean paced QRS duration (P=0.044). Receiver operating characteristic curve analysis revealed a paced QRS duration cut-off value of 153 ms with an area under the curve of 0.73 (P=0.035).

    Conclusions: A longer paced QRS duration was associated with poor outcomes, indicating its potential to predict adverse outcomes among Fontan patients.

  • Ryo Abe, Toshiyuki Ko, Shunsuke Inoue, Seitaro Nomura, Takahiro Jimba, ...
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-23-0938
    Published: January 20, 2024
    Advance online publication: January 20, 2024
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  • Susumu Odajima, Makoto Nishimori, Hiroshi Okamoto, Ken-ichi Hirata, Hi ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0798
    Published: January 19, 2024
    Advance online publication: January 19, 2024
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    Supplementary material

    Background: Detection of left ventricular (LV) abnormalities is essential for patients with preclinical heart failure (HF) to delay progression to clinical HF. Global longitudinal strain (GLS) is a sensitive marker for the early occurrence of subtle abnormalities in LV function, but not all echocardiographic instruments can measure GLS.

    Methods and Results: We studied 853 preclinical HF patients to devise a scoring system for predicting low GLS (<16%). The associations of medical history and echocardiographic parameters with low GLS were evaluated using Cox proportional hazards analysis. Model 1 of the system consisted of medical history; for Model 2, conventional echocardiographic parameters were added to Model 1. For Model 1, a score ≥5 points meant prediction of low GLS with 90.2% sensitivity and 62.9% specificity (male=1 point, hypertension=4 points, dyslipidemia=1 point, atrial fibrillation=2 points, history of cardiac surgery=2 points). For Model 2, a score ≥4 points denotes prediction of low GLS with 80.3% sensitivity and 76.5% specificity (male=1 point, hypertension=2 points, atrial fibrillation=2 points, LV mass index >116 g/m2[male] or >96 g/m2[female]=1 point, LV ejection fraction <59%=2 points, E/e′ >14=1 point).

    Conclusions: Our scoring system provides an easy-to-use evaluation of LV longitudinal myocardial dysfunction, and may prove useful for risk stratification of patients with preclinical HF.

  • Kensaku Nishihira, Michikazu Nakai, Nehiro Kuriyama, Kosuke Kadooka, Y ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0837
    Published: January 18, 2024
    Advance online publication: January 18, 2024
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    Supplementary material

    Background: The efficacy of guideline-directed medical therapy (GDMT) in the elderly remains unclear. This study evaluated the impact of GDMT (aspirin or a P2Y12inhibitor, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, β-blocker, and statin) at discharge on long-term mortality in elderly patients with acute myocardial infarction (AMI) who had undergone percutaneous coronary intervention (PCI).

    Methods and Results: Of 2,547 consecutive patients with AMI undergoing PCI in 2009–2020, we retrospectively analyzed 573 patients aged ≥80 years. The median follow-up period was 1,140 days. GDMT was prescribed to 192 (33.5%) patients at discharge. Compared with patients without GDMT, those with GDMT were younger and had higher rates of ST-segment elevation myocardial infarction and left anterior descending artery culprit lesion, higher peak creatine phosphokinase concentration, and lower left ventricular ejection fraction (LVEF). After adjusting for confounders, GDMT was independently associated with a lower cardiovascular death rate (hazard ratio [HR] 0.35; 95% confidence interval [CI] 0.16–0.81), but not with all-cause mortality (HR 0.77; 95% CI 0.50–1.18). In the subgroup analysis, the favorable impact of GDMT on cardiovascular death was significant in patients aged 80–89 years, with LVEF <50%, or with an estimated glomerular filtration rate ≥30 mL/min/1.73 m2.

    Conclusions: GDMT in patients with AMI aged ≥80 years undergoing PCI was associated with a lower cardiovascular death rate but not all-cause mortality.

  • Tetsuya Takahashi, Kentaro Iwata, Tomoyuki Morisawa, Michitaka Kato, Y ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0722
    Published: January 13, 2024
    Advance online publication: January 13, 2024
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    Background: This study determined the incidence of hospitalization-associated disability (HAD) and its characteristics in older patients with heart failure in Japan.

    Methods and Results: Ninety-six institutions participated in this nationwide multicenter registry study (J-Proof HF). From December 2020 to March 2022, consecutive heart failure patients aged ≥65 years who were prescribed physical rehabilitation during hospitalization were enrolled. Of the 9,403 patients enrolled (median age 83.0 years, 50.9% male), 3,488 (37.1%) had HAD. Compared with the non-HAD group, the HAD group was older and had higher rates of hypertension, chronic kidney disease, and cerebrovascular disease comorbidity. The HAD group also had a significantly lower Barthel Index score and a significantly higher Kihon checklist score before admission. Of the 9,403 patients, 2,158 (23.0%) had a preadmission Barthel Index score of <85 points. Binomial logistic analysis revealed that age and preadmission Kihon checklist score were associated with HAD in patients with a preadmission Barthel Index score of ≥85, compared with New York Heart Association functional classification and preadmission cognitive decline in those with a Barthel Index score <85.

    Conclusions: This nationwide registry survey found that 37.1% of older patients with HF had HAD and that these patients are indicated for convalescent rehabilitation. Further widespread implementation of rehabilitation for older patients with heart failure is expected in Japan.

  • Manabu Nitta, Shintaro Nakano, Makoto Kaneko, Kiyohide Fushimi, Kiyosh ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0758
    Published: January 12, 2024
    Advance online publication: January 12, 2024
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    Background: Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking.

    Methods and Results: Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018–March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0–20.8] vs. 9.0 [4.0–16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0–59.0] vs. 23.0 [6.3–43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20–12.20] vs. 5.23 [3.41–7.00] million Japanese yen; P<0.001).

    Conclusions: Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.

  • Shuhei Yamamoto, Masatsugu Okamura, Yoshihiro J. Akashi, Shinya Tanaka ...
    Article type: REVIEW
    Article ID: CJ-23-0820
    Published: January 12, 2024
    Advance online publication: January 12, 2024
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    Background: This study aimed to clarify the effects of exercise-based cardiac rehabilitation (CR) on patients with heart failure.

    Methods and Results: Patients were divided into groups according to intervention duration (<6 and ≥6 months). We searched for studies published up to July 2023 in Embase, MEDLINE, PubMed, and the Cochrane Library, without limitations on data, language, or publication status. We included randomized controlled trials comparing the efficacy of CR and usual care on mortality, prehospitalization, peak oxygen uptake (V̇O2), and quality of life. Seventy-two studies involving 8,495 patients were included in this review. It was found that CR reduced the risk of rehospitalization for any cause (risk ratio [RR] 0.80; 95% confidence interval [CI] 0.70–0.92) and for heart failure (RR 0.88; 95% CI 0.78–1.00). Furthermore, CR was found to improve exercise tolerance (measured by peak V̇O2and the 6-min walk test) and quality of life. A subanalysis performed based on intervention duration (<6 and ≥6 months) revealed a similar trend.

    Conclusions: Our meta-analysis showed that although CR does not reduce mortality, it is effective in reducing rehospitalization rates and improving exercise tolerance and quality of life, regardless of the intervention duration.

  • Naoaki Onishi, Kazuaki Kaitani, Yoshihisa Nakagawa, Atsushi Kobori, Ko ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0671
    Published: January 11, 2024
    Advance online publication: January 11, 2024
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    Supplementary material

    Background: Catheter ablation (CA) for atrial fibrillation (AF) in patients on hemodialysis (HD) is reported to have a high risk of late recurrence (LR). However, the relationship between early recurrence (ER) within a 90-day blanking period after CA in AF patients and LR in HD patients remains unclear.

    Methods and Results: Of the 5,010 patients in the Kansai Plus Atrial Fibrillation Registry, 5,009 were included in the present study. Of these patients, 4,942 were not on HD (non-HD group) and 67 were on HD (HD group). HD was an independent risk factor for LR after the initial CA (adjusted hazard ratio 1.6; 95% confidence interval 1.1–2.2; P=0.01). In patients with ER, the rate of sinus rhythm maintenance at 3 years after the initial CA was significantly lower in the HD than non-HD group (11.4% vs. 35.4%, respectively; log-rank P=0.004). However, in patients without ER, there was no significant difference in the rate of sinus rhythm maintenance at 3 years between the HD and non-HD groups (67.7% vs. 74.5%, respectively; log-rank P=0.62).

    Conclusions: ER in HD patients was a strong risk factor for LR. However, even HD patients could expect a good outcome without ER after the initial CA.

  • Keiko Shimamoto, Takeshi Aiba
    Article type: EDITORIAL
    Article ID: CJ-23-0884
    Published: December 29, 2023
    Advance online publication: December 29, 2023
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  • Yasuyuki Shiraishi, Yuka Kurita, Hiromasa Mori, Kazuyuki Oishi, Miyuki ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0440
    Published: December 22, 2023
    Advance online publication: December 22, 2023
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    Supplementary material

    Background: This retrospective observational study investigated the incidence of worsening renal function (WRF) in patients hospitalized for heart failure (HF) and treated with intravenous diuretics in Japan.

    Methods and Results: Associations between WRF at any point and HF treatments, and the effects of WRF on outcomes were evaluated (Diagnosis Procedure Combination database). Of 1,788 patients analyzed (mean [±SD] age 80.5±10.2 years; 54.4% male), 641 (35.9%) had WRF during a course of hospitalization for worsening HF: 208 (32.4%) presented with WRF before admission (BA-WRF; estimated glomerular filtration rate decreased by ≥25% from baseline at least once between 30 days prior to admission and admission); 44 (6.9%) had WRF that persisted before and after admission (P-WRF); and 389 (60.7%) had WRF develop after admission (AA-WRF). Delayed initial diuretic administration, higher maximum doses of intravenous diuretics during hospitalization, and diuretic readministration during hospitalization were associated with a significantly higher incidence of AA-WRF. Patients with WRF at any time point were at higher risk of death during hospitalization compared with patients without WRF, with adjusted hazard ratios of 3.56 (95% confidence interval [CI] 2.23–5.69) for BA-WRF, 3.23 (95% CI 2.21–4.71) for AA-WRF, and 13.16 (95% CI 8.19–21.15) for P-WRF (all P<0.0001).

    Conclusions: Forty percent of WRF occurred before admission for acute HF; there was no difference in mortality between patients with BA-WRF and AA-WRF.

  • Yoh Arita, Tomohiko Ishibashi, Yoshikazu Nakaoka
    Article type: REVIEW
    Article ID: CJ-23-0780
    Published: December 19, 2023
    Advance online publication: December 19, 2023
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    Takayasu arteritis (TAK) is a rare disease characterized by inflammation of large blood vessels, which results in vascular stenosis, occlusion, and aneurysm formation. The principal treatment has been glucocorticoids, but the recent emergence of biological disease-modifying anti-rheumatic drugs (bDMARDs), represented by tocilizumab (TCZ), has significantly changed the treatment landscape. Both cardiologists and cardiovascular surgeons will encounter patients receiving these drugs who require catheterization, other invasive procedures, or surgery. Several bDMARDs have shown promise against TAK in clinical studies and their use is expected to increase in the future. Janus kinase inhibitors may also be effective. Here, we review the evidence supporting the use of TCZ and other immunosuppressants in TAK and provides an update on their status as well as the relevant guidelines.

  • Aya Hirata, Takumi Hirata
    Article type: EDITORIAL
    Article ID: CJ-23-0815
    Published: December 16, 2023
    Advance online publication: December 16, 2023
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  • Takeo Horikoshi, Takamitsu Nakamura, Toru Yoshizaki, Jun Nakamura, Man ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0733
    Published: December 15, 2023
    Advance online publication: December 15, 2023
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    Supplementary material

    Background: Non-ST-elevation myocardial infarction (NSTEMI) carries a poor prognosis, and accurately prognostication has significant clinical importance. In this study, we analyzed the predictive value of the CHADS2, CHA2DS2-VASc, and R2-CHADS2scores for major adverse cardiac events (MACE) following percutaneous coronary intervention (PCI) in patients with NSTEMI using data from a prospective multicenter registry.

    Methods and Results: The registry included 440 consecutive patients with NSTEMI and coronary artery disease who underwent successful PCI. Patients were clinically followed for up to 3 years or until the occurrence of MACE. MACE was defined as a composite of all-cause death and nonfatal MI. During the follow-up period, 55 patients (12.5%) experienced MACE. Risk analysis of MACE occurrence, adjusted for the multivariable model, demonstrated a significant increase in risk with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores. Kaplan-Meier analysis showed a higher incidence of MACE in patients with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores, both in the short- and long-term periods.

    Conclusions: Patients with NSTEMI and higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores displayed a greater incidence of MACE.

  • Ichitaro Abe, Naohiko Takahashi
    Article type: EDITORIAL
    Article ID: CJ-23-0825
    Published: December 13, 2023
    Advance online publication: December 13, 2023
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  • Hiroki Ikenaga, Shinya Takahashi, Yukiko Nakano
    Article type: EDITORIAL
    Article ID: CJ-23-0866
    Published: December 13, 2023
    Advance online publication: December 13, 2023
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