Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
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Showing 1-50 articles out of 73 articles from Advance online publication
  • Kuo-Liong Chien, Hung-Ju Lin, Ta-Chen Su, Yun-Yu Chen, Pei-Chun Chen
    Type: ORIGINAL ARTICLE
    Subject Area: Epidemiology
    Article ID: CJ-17-0910
    [Advance publication] Released: April 27, 2018
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    Background:Predicting future coronary artery disease (CAD) risk by model-based approaches can facilitate identification of high-risk individuals for prevention and management. Therefore, we compared the consistency and performance of various CAD models for primary prevention using 1 external validation dataset from a national representative cohort in Taiwan.

    Methods and Results:The 10 CAD prediction models were assessed in a validation cohort of 3559 participants (≥35 years old, 53.5% women) from a Taiwanese national representative cohort that was followed up for a median 9.70 (interquartile range, 9.63–9.74) years; 63 cases were documented as developing CAD events. The overall κ value was 0.51 for all 10 models, with a higher value for women than for men (0.53 for women, 0.40 for men). In addition, the areas under the receiver operating characteristics curves ranged from 0.804 (95% confidence interval, 0.758–0.851) to 0.847 (95% confidence interval, 0.805–0.889). All non-significant chi-square values indicated good calibration ability.

    Conclusions:Our study demonstrated these 10 CAD prediction models for primary prevention were feasible and validated for use in Taiwanese subjects. Further studies of screening and management are warranted.

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  • Jinhee Ahn, Hyun Jung Kim, Jeong Cheon Choe, Jin Sup Park, Hye Won Lee ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1423
    [Advance publication] Released: April 27, 2018
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    Background:Atrial fibrillation (AF) frequently coexists with heart failure (HF) with reduced ejection fraction (EF). This meta-analysis compared AF control strategies, that is, rhythm vs. rate, and catheter ablation (CA) vs. anti-arrhythmic drugs (AAD) in patients with AF combined with HF.

    Methods and Results:The MEDLINE, EMBASE, and CENTRAL databases were searched, and 13 articles from 11 randomized controlled trials with 5,256 patients were included in this meta-analysis. The outcomes were echocardiographic parameters (left ventricular EF, LVEF), left atrial (LA) size, and left ventricular end-systolic volume, LVESV), clinical outcomes (mortality, hospitalization, and thromboembolism), exercise capacity, and quality of life (QOL). In a random effects model, rhythm control was associated with higher LVEF, better exercise capacity, and better QOL than the rate control. When the 2 different rhythm control strategies were compared (CA vs. AAD), the CA group had significantly decreased LA size and LVESV, and improved LVEF and 6-min walk distance, but mortality, hospitalization, and thromboembolism rates were not different between the rhythm and rate control groups.

    Conclusions:In AF combined with HF, even though mortality, hospitalization and thromboembolism rates were similar, a rhythm control strategy was superior to rate control in terms of improvement in LVEF, exercise capacity, and QOL. In particular, the CA group was superior to the AAD group for reversal of cardiac remodeling.

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  • Takumi Hirata, Tomonori Okamura
    Type: EDITORIAL
    Article ID: CJ-18-0422
    [Advance publication] Released: April 27, 2018
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  • Hsin-Hua Chou, Hsuan-Li Huang, Chien-An Hsieh, Shih-Jung Jang, I-Shian ...
    Type: ORIGINAL ARTICLE
    Subject Area: Peripheral Vascular Disease
    Article ID: CJ-18-0077
    [Advance publication] Released: April 26, 2018
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    Background:Recent randomized trials have shown the treatment benefits of use of a drug-coated balloon (DCB) over conventional percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal disease. However, the effectiveness and safety of DCB for dialysis patients remain unclear.

    Methods and Results:Consecutive dialysis patients, who underwent PTA or DCB for femoropopliteal disease, were assessed retrospectively via 2:1 propensity score matching. Effectiveness and safety endpoints, including binary restenosis, clinically driven target lesion revascularization (CD-TLR), amputations, major adverse cardiac events (MACE), and deaths, were compared between groups. A total of 278 dialysis patients with 339 limbs were eligible for matching: 84 limbs from 77 patients treated with PTA and 46 limbs from 37 patients treated with DCB were compared after matching. Baseline patient and lesion characteristics were not different between groups. Patients treated with DCB had significantly higher rates of freedom from binary restenosis (52.4% vs. 18.6%, P<0.001) and CD-TLR (56.4% vs. 25.9%, P=0.001) at 2 years compared with patients treated with PTA. Both groups had similar outcomes for amputation, MACE, and death. Cox proportional analysis showed that treatment with DCB was independently associated with a reduction of binary restenosis (hazard ratio [HR] 0.368, P=0.001) and CD-TLR (HR 0.390, P=0.004).

    Conclusions:This study suggested superior 2-year outcomes using DCB compared with PTA and similar safety profiles in dialysis patients with femoropopliteal disease.

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  • Masanobu Ohya, Takenobu Shimada, Kohei Osakada, Akimune Kuwayama, Kats ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-18-0114
    [Advance publication] Released: April 26, 2018
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    Background:Data on bleeding events in Japanese patients with acute coronary syndrome (ACS) are insufficient. In addition, the efficacy and safety of a maintenance dose of prasugrel 2.5 mg/day in high bleeding risk patients are unknown.

    Methods and Results:We prospectively enrolled 1,167 consecutive patients with suspected ACS and undergoing percutaneous coronary intervention. The maintenance dose of prasugrel 2.5 mg/day was prescribed for patients with a low body weight (≤50 kg), elderly (≥75 years), or renal insufficiency (eGFR ≤30 mL/min/1.73 m2). In-hospital events were assessed in 992 ACS patients treated with drug-eluting stents. Excluding 29 in-hospital deaths, out-of-hospital events were assessed in 963 ACS patients. The primary safety outcome measure was major bleeding (Bleeding Academic Research Consortium types 3 and 5). The incidence of in-hospital major bleeding was 3.4%. Multivariate analysis showed that being elderly, low body weight, renal insufficiency, stroke history, femoral approach, and mechanical support usage were independent predictors of in-hospital major bleeding. The cumulative 1-year incidence of out-of-hospital major bleeding was not significantly different between the prasugrel 2.5 mg/day (n=284) and 3.75 mg/day (n=487) groups (1.6% vs. 0.7%, log-rank P=0.24). That of out-of-hospital definite or probable stent thrombosis was 0% in both groups.

    Conclusions:The maintenance dose of adjusted prasugrel 2.5 mg/day seems to be one option in ACS patients at high bleeding risk.

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  • Michael CH Seng, Xiayan Shen, Kangjie Wang, Daniel TT Chong, Jiang Min ...
    Type: ORIGINAL ARTICLE
    Subject Area: Imaging
    Article ID: CJ-18-0134
    [Advance publication] Released: April 25, 2018
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    Background:Cardiac size measurements require indexing to body size. Allometric indexing has been investigated in Caucasian populations but a range of different values for the so-called allometric power exponent (b) have been proposed, with uncertainty as to whether allometry offers clinical utility above body surface area (BSA)-based indexing. We derived optimal values forbin normal echocardiograms and validated them externally in cardiac patients.

    Methods and Results:Values forbwere derived in healthy adult Chinese males (n=1,541), with optimalbfor left ventricular mass (LVM) of 1.66 (95% confidence interval 1.41–1.92). LV hypertrophy (LVH) defined as indexed LVM >75 g/m1.66was associated with adverse outcomes in an external validation cohort (n=738) of patients with acute coronary syndrome (odds ratio for reinfarction: 2.4 (1.1–5.4)). In contrast, LVH defined by BSA-based indexing or allometry using exponent 2.7 exhibited no significant association with outcomes (P=NS for both). Cardiac longitudinal function also varied with body size: septal and RV free wall s’, TAPSE and lateral e’ all scaled allometrically (b=0.3–0.9).

    Conclusions:An optimalbof 1.66 for LVM in healthy Chinese was found to validate well, with superior clinical utility both to that of BSA-based indexing and tob=2.7. The effect of allometric indexing of cardiac function requires further study.

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  • Yoshihiro Seo, Masayoshi Yamamoto, Tomoko Machino-Ohtsuka, Tomoko Ishi ...
    Type: RAPID COMMUNICATION
    Article ID: CJ-18-0171
    [Advance publication] Released: April 24, 2018
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    Background:This study aimed to investigate the effect and safety of sodium glucose cotransporter 2 inhibitors (SGLT2-Is) in patients with drug-refractory heart failure (HF).

    Methods and Results:In 12 diabetic patients with advanced HF, SGLT2-Is were added to the treatment regimen. At 6 months after administration, improvements in New York Heart Association class and reduction in B-type natriuretic peptide levels were observed, in particular in patients with high right atrial pressure. During follow-up, they had neither cardiac events nor adverse side effects.

    Conclusions:SGLT2-Is may be useful and safe in diabetic patients with drug-refractory HF, in particular accompanied by right-sided HF.

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  • Tomoya Yamashita, Tomohiro Hayashi, Naofumi Yoshida, Ken-ichi Hirata
    Type: EDITORIAL
    Article ID: CJ-18-0335
    [Advance publication] Released: April 24, 2018
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  • Joji Ishikawa, Hideo Hirose, Joseph E Schwartz, Shizukiyo Ishikawa
    Type: ORIGINAL ARTICLE
    Subject Area: Epidemiology
    Article ID: CJ-17-1084
    [Advance publication] Released: April 20, 2018
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    Background:Minor ST-T changes are frequently observed on the electrocardiogram (ECG), but the risk of stroke associated with such changes is unclear.

    Methods and Results:In 10,642 subjects from the Japanese general population, we evaluated minor and major ST-T changes (major ST depression ≥0.1 mV) on ECGs obtained at annual health examinations. At baseline, minor ST-T changes were found in 10.7% of the subjects and 0.5% had major ST-T changes. Minor ST-T changes were associated with older age, female gender, higher systolic blood pressure, presence of hyperlipidemia, and use of antihypertensive medication. There were 375 stroke events during the follow-up period (128.7±28.1 months). In all subjects, minor ST-T changes (HR, 2.10; 95% CI: 1.57–2.81) and major ST-T changes (HR, 8.64; 95% CI: 4.44–16.82) were associated with an increased risk of stroke, but the stroke risk associated with minor ST-T changes had borderline significance after adjustment for conventional risk factors (P=0.055). In subgroup analysis, the risk of stroke was significantly associated with minor ST-T changes in subjects who had hyperlipidemia (HR, 1.75; 95% CI: 1.15–2.67) compared to those without hyperlipidemia (HR, 1.01; 95% CI: 0.64–1.59; P for interaction=0.016), even after adjustment for ECG-diagnosed left ventricular hypertrophy.

    Conclusions:Minor ST-T changes were particularly associated with a higher risk of stroke in subjects with hyperlipidemia and this association was independent of electrocardiographic left ventricular hypertrophy.

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  • Hye Bin Gwag, Ga Yeon Lee, Jin-Oh Choi, Hae-Young Lee, Jae-Joong Kim, ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-17-1389
    [Advance publication] Released: April 20, 2018
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    Background:The outcomes of heart failure (HF) with mid-range ejection fraction (HFmrEF) have been rarely studied, and follow-up data on left ventricular ejection fraction (LVEF) are scarse.

    Methods and Results:Patients were selected from a prospective multicenter registry of patients hospitalized for acute HF and then classified in the improved group if they exhibited %LVEF change ≥5 with follow-up LVEF ≥50%. Follow-up LVEF reported at least 90 days after discharge was used for classification. Of the 3,085 patients with acute HF, 454 were classified in the HFmrEF, and 276 had follow-up data. Of these 276 patients, 34.1% were classified in the improved group. Multivariate analysis revealed that hypertension, higher heart rate, lower serum sodium level, and maintenance therapy with β-blocker were associated with improved LVEF. The survival rate was significantly higher in the improved group than in the other groups. Young age and maintenance therapy with renin-angiotensin system blockers or aldosterone antagonists were significantly associated with better survival in HFmrEF.

    Conclusions:One-third of HFmrEF patients showed improved LVEF; moreover, the survival rate in the improved group was higher than the other groups. Renin-angiotensin system blockers and aldosterone antagonists could improve the survival of HFmrEF patients.

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  • Kyu Kim, Young-Guk Ko, Chul-Min Ahn, Pil-Ki Min, Jae-Hwan Lee, Chang-H ...
    Type: ORIGINAL ARTICLE
    Subject Area: Peripheral Vascular Disease
    Article ID: CJ-17-1464
    [Advance publication] Released: April 20, 2018
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    Background:There are limited data comparing the outcomes of subintimal vs. intraluminal approach in the treatment of long femoropopliteal artery occlusions. The objective of this study was to investigate the efficacy and safety of the subintimal approach for long femoropopliteal artery occlusions.

    Methods and Results:From a multicenter retrospective registry cohort, we included a total of 461 patients with 487 femoropopliteal artery occlusions classified as Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II C/D for this analysis. We compared the immediate and mid-term outcomes of subintimal vs. intraluminal approaches. There were 228 patients with 243 limbs in the subintimal group, and 233 patients with 244 limbs in the intraluminal group. Baseline clinical and lesion characteristics were comparable between the 2 groups. The technical success rate was significantly higher in the subintimal group than in the intraluminal group (95.1% vs. 89.8%, P=0.041). The clinical primary patency (67.5% vs. 73.4% at 12 months, 54.0% vs. 61.3% at 24 months; P=0.086) and target lesion revascularization (TLR)-free survival (89.5% vs. 86.3% at 12 months, 77.6% vs. 76.0% at 24 months; P=0.710) did not differ significantly between the subintimal and the intraluminal groups.

    Conclusions:In long femoropopliteal occlusions, the subintimal approach achieved a higher technical success rate and similar mid-term primary patency and TLR-free survival compared with intraluminal approach.

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  • Toshiaki Ebina
    Type: EDITORIAL
    Article ID: CJ-18-0399
    [Advance publication] Released: April 20, 2018
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  • Kentaro Ejiri, Toru Miyoshi, Kunihisa Kohno, Makoto Nakahama, Masayuki ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiovascular Intervention
    Article ID: CJ-17-1000
    [Advance publication] Released: April 18, 2018
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    Background:The effect of remote ischemic preconditioning (RIPC) on periprocedural myocardial damage (pMD) in patients undergoing percutaneous coronary intervention (PCI) is controversial. The aim of this study was to investigate the effect of RIPC or intravenous nicorandil on pMD following elective PCI in a subgroup of patients with complex coronary lesions from a multicenter randomized controlled trial.

    Methods and Results:Patients with stable angina who underwent elective PCI were assigned to 3 groups: control, upper-limb RIPC or intravenous nicorandil. The major outcome was pMD incidence following PCI, with pMD defined as an elevated level of high-sensitivity cardiac troponin T or creatine kinase myocardial band at 12 or 24 h after PCI. A total of 171 patients with complex coronary lesions (ACC-AHA coronary classification type B2 or C) were analyzed. The incidence of pMD following PCI was significantly lower in the RIPC group than in the control group (44.4% vs. 66.1%; P=0.023). The adjusted odds ratio (95% confidence interval) for pMD in the RIPC vs. the controls was 0.41 (0.18−0.94). The incidence of pMD in the nicorandil group was not significantly reduced compared with the control groups.

    Conclusions:This substudy suggested that RIPC prior to PCI prevented pMD in patients with complex coronary lesions. Further investigation in a multicenter prospective study is needed to confirm these results.

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  • Takashi Yamauchi, Takano Hiroshi, Koichi Toda, Yoshiki Sawa, Osaka Car ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiovascular Surgery
    Article ID: CJ-17-1340
    [Advance publication] Released: April 17, 2018
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    Background:The hospital mortality rate in >80-year-old patients undergoing surgical aortic valve replacement (SAVR) is reportedly satisfactory, but how such patients’ functional status both at discharge and during the postoperative hospitalization period might affect their quality of life and medical costs remains unclear.

    Methods and Results:The adverse events of 161 patients aged >80 years who underwent SAVR with or without coronary artery bypass grafting were retrospectively investigated. Adverse events were defined as hospital death, a long hospital stay (>60 days) attributable to major complications or requirement for rehabilitation, or a depressed status at discharge (modified Rankin scale score >4). A total of 18.6% of patients developed adverse events, and their hospital mortality rate was 4.3%. Logistic regression analysis revealed that a perfusion time >3 h (P=0.0331; odds ratio, 2.685) and EuroSCORE II >10% (P<0.0001; odds ratio, 8.232) were significant risk factors for adverse events. The average medical cost was approximately 1.5-fold higher in patients with adverse events (¥8,360,880 vs. ¥5,234,660, P=0.0016).

    Conclusions:Clinical findings focusing on status at discharge and during postoperative hospitalization of SAVR in patients aged >80 years was relatively high compared with hospital mortality, especially in patients with a longer perfusion time and high EuroSCORE. Further studies are necessary to define the indications for SAVR in patients aged >80 years in the era of transcatheter AVR.

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  • Yuki Saito, Mahoto Kato, Koichi Nagashima, Koyuru Monno, Yoshihiro Aiz ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-17-1344
    [Advance publication] Released: April 17, 2018
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    Background:Acute decompensated heart failure (ADHF) is often accompanied by liver congestion through increased right atrial pressure (RAP). Liver stiffness (LS) assessed non-invasively using transient elastography is related to increased RAP and liver congestion in patients with general HF. We investigated the relationship of LS with clinical and echocardiographic variables and outcomes in patients with ADHF.

    Methods and Results:The subjects were 105 patients with ADHF admitted to hospital between October 2016 and June 2017. Patients were divided into 2 groups based on median LS at admission (low LS <8.8 kPa [n=52] vs. high LS ≥8.8 kPa [n=53]). Death from cardiovascular disease and readmission for HF were primary endpoints. Total bilirubin and γ-glutamyl transpeptidase levels, MELD-XI score, diameters of the inferior vena cava and right ventricle, and severity of tricuspid regurgitation were greater in the high LS group (all P<0.05). During a median (interquartile range) follow-up period of 153 (83–231) days, cardiac events occurred in 29 patients (54%) in the high LS group and in 13 (25%) in the low LS group (P=0.001). After adjusting for variables that influence organ congestion, a high LS ≥8.8 kPa was still significantly associated with cardiac events (all P<0.05).

    Conclusions:Increased LS measured by transient elastography reflects RAP elevation, hepatic congestion, and hepatic dysfunction. LS upon admission may be a useful prognostic marker in patients with ADHF.

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  • Hideto Ozawa, Takayoshi Ueno, Masaki Taira, Koichi Toda, Toru Kuratani ...
    Type: LATE BREAKING CLINICAL TRIAL (JCS 2018)
    Article ID: CJ-18-0150
    [Advance publication] Released: April 14, 2018
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    Background:Tissue engineering has advanced the technique of decellularization of the heart valve. The valve is reseeded with the patient’s own cells after implantation with suppression of immunologic reactions. The same advantage has been reported for fresh decellularized heart valves, and more than 10 years of excellent outcomes have been achieved. We began performing such heart valve implantations in 2013 as part of a clinical study at Osaka University. We report our evaluation of the safety and efficacy of heart valve implantation.

    Methods and Results:Human pulmonary valves from the German Society for Tissue Transplantation (n=2) or from Japanese heart transplant recipient heart (n=4) were used to make decellularized heart valves; the decellularization process was the same as that used in Europe. Valves were implanted in 5 adults with pulmonary valve insufficiency after tetralogy of Fallot repair and in 1 infant with a double-outlet right ventricle with pulmonary stenosis. Postoperative echocardiography and cardiac magnetic resonance imaging revealed that the valve and ventricular function were significantly improved and maintained postoperatively.

    Conclusions:Decellularized heart valves could be the new material used as artificial heart valves. Pulmonary allografts derived from the hearts of heart transplant recipients are considered to be useful material for decellularized heart valves. The application of this valve to Japanese clinical circumstances and using the hearts of heart transplant recipients is considered to be very significant.

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  • Toshiya Kojima, Katsuhito Fujiu, Nobuaki Fukuma, Hiroshi Matsunaga, Ts ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1114
    [Advance publication] Released: April 13, 2018
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    Background:Periprocedural anticoagulation is important in catheter ablation (CA) of atrial fibrillation (AF) and there is increasing evidence that uninterrupted vitamin K antagonist (VKA) therapy is superior to interrupted anticoagulation strategies. Since the emergence of direct oral anticoagulants (DOACs), numerous studies have shown promising results for their use in uninterrupted strategies. However, further studies are needed to further define the efficacy and safety of performing AF ablation with uninterrupted factor XA inhibitors or direct thrombin inhibitors.

    Methods and Results:We have performed CA of AF without discontinuation of either VKA or DOAC therapy since April 2014. A total of 376 patients with AF underwent CA including pulmonary vein isolation. All of the patients were divided into 2 groups (uninterrupted VKA or uninterrupted DOACs). Anticoagulation with DOACs was associated with fewer complications than uninterrupted VKA therapy (P=0.04). There were significant differences between groups in the rates of congestive heart failure, left ventricular ejection fraction, body weight, and estimated glomerular filtration rate and of the CHADS2, CHA2DS2-VASc and HAS-BLED scores. Therefore, we also analyzed the results using the propensity score-matching method. We found no significant difference in periprocedural complications between uninterrupted VKA or DOACs therapy (P=0.65).

    Conclusions:CA of AF without discontinuation of DOACs is not inferior to CA without discontinuation of a VKA, with regard to ischemic or hemorrhagic complications.

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  • Taichi Sakaguchi, Toshinori Totsugawa, Masahiko Kuinose, Kentaro Tamur ...
    Type: ORIGINAL ARTICLE
    Subject Area: Valvular Heart Disease
    Article ID: CJ-17-1319
    [Advance publication] Released: April 13, 2018
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    Background:Although minimally invasive mitral valve repair (MIMVR) is increasingly being performed, only a few clinical studies from Japanese institutions have been reported.

    Methods and Results:From 2006 to 2017, 387 consecutive patients (135 females, mean age 56±13 years) underwent an initial isolated MIMVR through a right minithoracotomy. The mitral etiology was degenerative in 348, functional in 22, and endocarditis in 13 cases. Repair techniques included leaflet resection/plication in 280, chordal reconstruction in 109, and annuloplasty alone in 24 patients, and concomitant procedures included tricuspid valve repair and atrial fibrillation ablation in 70 (18.1%) and 78 (20.2%), respectively. Hospital mortality rate was 0.26%; 2 patients (0.5%) required intraoperative conversion to a median sternotomy. Perioperative morbidity included stroke (1.3%), reoperation for bleeding (0.8%), prolonged ventilation (0.5%), and permanent pacemaker implantation (2.1%). The transfusion rate was 14.7% and median ventilation time was 4 hours. Overall 5-year survival was 96.9%. For patients with degenerative mitral regurgitation (MR), the 5-year freedom from reoperation or severe recurrent MR, and freedom from ≥moderate MR were 94.7% and 82.2%, respectively. Repair for anterior mitral leaflet prolapse and the initial 30 cases were associated with higher occurrence of recurrent MR.

    Conclusions:MIMVR can be performed safely with low levels of mortality and morbidity, and provides sufficient repair durability. A learning curve exists in terms of repair durability, especially for anterior mitral leaflet repair.

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  • Kengo Tanabe
    Type: EDITORIAL
    Article ID: CJ-18-0331
    [Advance publication] Released: April 13, 2018
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  • Rikuta Hamaya, Akinori Sugano, Yoshihisa Kanaji, Tadashi Fukuda, Yoshi ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-17-1449
    [Advance publication] Released: April 12, 2018
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    Background:Few studies have documented changes in myocardial blood flow (MBF) after percutaneous coronary intervention (PCI). Phase-contrast cine cardiovascular MRI (PC-CCMR) of the coronary sinus (CS) is a promising approach to quantify MBF. The aim of this study was to quantify CS flow (CSF) on PC-CCMR as a measure of volumetric MBF before and after elective PCI.

    Methods and Results:We prospectively studied 34 patients with stable angina undergoing elective PCI for a single de novo lesion. Breath-hold PC-CCMR of CS was acquired to assess CSF and coronary flow reserve (CFR) at rest and during maximum hyperemia both before and after PCI (median, 3 days before PCI and 10 days after PCI, respectively). In total, hyperemic CSF increased significantly after PCI (before PCI, median, 2.3 mL/min/g [IQR, 1.5–3.2 mL/min/g] after PCI, 3.0 [1.8–3.7] mL/min/g), although 13 patients (38.2%) had a decrease despite successful PCI and fractional flow reserve (FFR) improvement. Global CFR also significantly increased from a median of 2.5 (IQR, 1.5–3.5) to 3.4 (IQR, 2.1–4.2), whereas 12 patients had decreased CFR after PCI. Pre-PCI hyperemic CSF was the only independent factor of change in CSF following PCI.

    Conclusions:Serial PC-CCMR of CS as a measure of change in absolute MBF is feasible. Uncomplicated PCI does not necessarily increase hyperemic global MBF, despite regional FFR improvement.

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  • Min Chul Kim, Myung Ho Jeong, Doo Sun Sim, Young Joon Hong, Ju Han Kim ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-18-0112
    [Advance publication] Released: April 12, 2018
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    Background:There is little information regarding comparison of ticagrelor and prasugrel in patients with ST-segment elevation myocardial infarction (STEMI). We sought to compare clinical outcomes between ticagrelor and prasugrel in STEMI.

    Methods and Results:A total of 1,440 patients with STEMI who underwent successful primary percutaneous coronary intervention were analyzed; the data were obtained from the Korea Acute Myocardial Infarction Registry-National Institutes of Health. Of the patients, 963 received ticagrelor, and 477 received prasugrel. The primary study endpoint was 12-month major adverse cardiac events (MACE), including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). MACE occurred in 91 patients (6.3%) over the 1-year follow-up, and there were no differences in the incidence of MACE (hazard ratio [HR] 1.20, 95% confidence interval [CI] 0.76–1.91, P=0.438) between the 2 groups. Analysis by propensity score matching (429 pairs) did not significantly affect the results. The incidence of in-hospital major bleeding events was still comparable between the 2 groups (2.4% vs. 2.5%, odds ratio 0.75, 95% CI 0.30–1.86, P=0.532), and there was no significant difference in the incidence of MACE (5.4% vs. 5.8%, HR 0.98, 95% CI 0.56–1.74, P=0.951) after matching.

    Conclusions:Ticagrelor and prasugrel showed similar efficacy and safety profiles for treating STEMI in this Korean multicenter registry.

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  • Shingo Sasaki, Hirofumi Tomita, Takuo Tsurugi, Yuji Ishida, Yoshihiro ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1001
    [Advance publication] Released: April 11, 2018
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    Background:The entirely subcutaneous implantable cardioverter defibrillator (S-ICD) was introduced as a new alternative to conventional transvenous ICD (TV-ICD) in Japan in February 2016, but its safety and efficacy are unclear.

    Methods and Results:A total of 60 patients (48 men, median age, 60 years; IQR, 44–67 years; primary prevention, n=24) underwent S-ICD implantation between February 2016 and August 2017. The device pocket was formed in the intermuscular space between the serratus anterior muscle and the latissimus dorsi muscle, and the parasternal S-ICD lead was placed according to pre-implant screening. Defibrillation test was performed in 56 patients (93%). Ventricular fibrillation (VF) was induced in 55 patients and terminated by a single 65-J shock in all patients. The median time to shock therapy was 13.4 s (IQR, 12.1–14.9 s) and the median post-shock impedance of the S-ICD lead was 64 Ω (IQR, 58–77 Ω). There were no operation-related complications or subsequent infectious complications. During follow-up (median, 275 days; IQR, 107–421 days), 1 patient (1.7%) had appropriate shock for VF with successful termination, whereas 5 patients (8.3%) had inappropriate shock due to oversensing of myopotential (n=3) or T-wave (n=1), and detection of supraventricular tachycardia (n=1).

    Conclusions:S-ICD is a safe and effective alternative to conventional TV-ICD. The long-term safety and efficacy of the S-ICD need further investigation.

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  • Masato Furuhashi, Megumi Matsumoto, Marenao Tanaka, Norihito Moniwa, T ...
    Type: ORIGINAL ARTICLE
    Subject Area: Metabolic Disorder
    Article ID: CJ-18-0082
    [Advance publication] Released: April 10, 2018
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    Background:Xanthine oxidoreductase (XOR) is an enzyme that catalyzes the formation of uric acid from hypoxanthine and xanthine, leading to an increase in superoxide and reactive oxygen species. Activation of XOR promotes oxidative stress-related tissue injury. We investigated the associations between metabolic parameters and plasma XOR activity measured by a sensitive and accurate assay using a combination of liquid chromatography and triple quadrupole mass spectrometry to detect [13C2,15N2]-uric acid using [13C2,15N2]-xanthine as a substrate.

    Methods and Results:A total of 627 Japanese subjects (M/F, 292/335) from the Tanno-Sobetsu Study, a population-based cohort, were recruited. Plasma XOR activity was significantly higher in males than in females, and habitual smoking was associated with elevation of activity. Plasma XOR activity was positively correlated with body mass index (BMI; r=0.323, P<0.001), waist circumference, blood pressure, and levels of liver enzymes including alanine transaminase (r=0.694, P<0.001), uric acid (r=0.249, P<0.001), triglycerides (r=0.312, P<0.001), hemoglobin A1c, fasting glucose, insulin and HOMA-R (r=0.238, P<0.001) as a marker of insulin resistance and was negatively correlated with high-density lipoprotein cholesterol level. On stepwise and multivariate regression analyses, BMI, smoking and levels of alanine transaminase, uric acid, triglycerides and HOMA-R were independent predictors of plasma XOR activity after adjustment for age and gender.

    Conclusions:Plasma XOR activity is a novel biomarker of metabolic disorders in a general population.

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  • Tatsuya Umeda, Ai Hayashi, Akiko Harada, Kotoba Okuyama, Carl A. Baxte ...
    Type: ORIGINAL ARTICLE
    Subject Area: Epidemiology
    Article ID: CJ-17-0971
    [Advance publication] Released: April 07, 2018
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    Background:To understand the recent management status in Japan, we determined the low-density lipoprotein cholesterol (LDL-C) goal attainment (GA) rate of patients initiating statin monotherapy for dyslipidemia.

    Methods and Results:Dyslipidemic patients undergoing either primary prevention with high cardiovascular risk or secondary prevention (defined by 2012 Japan Atherosclerosis Society Guidelines) were retrospectively analyzed from a hospital-based claims database. In both groups, the LDL-C levels and GA rates of patients treated with intensive or standard statin monotherapy for ≥4 weeks (January 2012–August 2016) were evaluated. Among 1,501,013 dyslipidemic patients, 11,695 and 9,642 were included in the primary and secondary prevention groups, respectively. A total of 94% of patients underwent statin monotherapy as the initial lipid-lowering therapy, of which most (≥80%) took intensive statins. The proportions of patients in the primary prevention group who achieved an LDL-C goal <120 mg/dL by intensive and standard statins were 81.1% and 61.2%, respectively, and the proportions of those who achieved a goal <100 mg/dL in the secondary prevention group were 73.3% and 48.1%, respectively. The GA rates were similar regardless of disease complications.

    Conclusions:Most patients (>70%) in both groups achieved LDL-C management goals using intensive statin monotherapy. Further treatment approaches are required for high-risk patients not achieving LDL-C goals by initial statin monotherapy. Continuous efforts are crucial for adherence and persistence of lipid-lowering therapies.

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  • Satoshi Katano, Akiyoshi Hashimoto, Katsuhiko Ohori, Ayako Watanabe, R ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiac Rehabilitation
    Article ID: CJ-17-1202
    [Advance publication] Released: April 07, 2018
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    Background:Whether the short-term effect of cardiac rehabilitation (CR) in elderly patients with heart failure (HF) is influenced by nutritional status is uncertain, so the present study investigated the effect of nutritional status on functional recovery after CR in elderly HF inpatients.

    Methods and Results:We enrolled 145 patients admitted for treatment of HF who were aged ≥65 years and had a low functional status defined as a Barthel index (BI) score ≤85 points at the commencement of CR. Nutritional status was assessed by the Mini Nutritional Assessment Short Form (MNA-SF) and total energy intake per day. The primary endpoint was functional status determined by the BI score at discharge. The median CR period was 20 days (interquartile range: 14–34 days), and 87 patients (60%) were functionally dependent (BI score ≤85) at discharge. Multivariate logistic regression analysis showed that MNA-SF score (odds ratio [OR]: 0.76, P=0.02) and total energy intake at the commencement of CR (OR: 0.91, P=0.02) were independent predictors of functional dependence after CR. MNA-SF score ≤7 and total energy intake ≤24.5 kcal/kg/day predicted functional dependence at discharge with moderate sensitivity and specificity.

    Conclusions:MNA-SF score and total energy intake at the commencement of CR are novel predictors of the extent of functional recovery of elderly HF inpatients after in-hospital CR.

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  • Takafumi Oka, Koichi Inoue, Koji Tanaka, Yuko Hirao, Takaaki Isshiki, ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-17-1383
    [Advance publication] Released: April 07, 2018
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    Background:QRS duration (QRSd) and morphology are established response predictors of cardiac resynchronization therapy (CRT). However, evidence in Japanese populations is lacking.

    Methods and Results:We retrospectively analyzed the Japanese multicenter CRT database. We divided patients according to their intrinsic QRSd and morphology, and assessed echocardiographic responses and clinical outcomes. The primary endpoint was a composite of all-cause death or hospitalization because of heart failure. A total of 510 patients were enrolled: 200 (39%) had left bundle branch block (LBBB) and QRSd ≥150 ms; 80 (16%) had LBBB (QRSd: 120–149 ms); 61 (12%) had non-LBBB (NLBBB) (QRSd: ≥150 ms); 54 (11%) had NLBBB (QRSd: 120–149 ms); 115 (23%), narrow (<120 ms). The proportion of echocardiographic responders was higher in LBBB (QRSd ≥150 ms) [74% vs. 51% vs. 38% vs. 52% vs. 50%, LBBB (QRSd ≥150 ms) vs. LBBB (QRSd 120–149 ms) vs. NLBBB (QRSd ≥150 ms) vs. NLBBB (QRSd 120–149 ms) vs. narrow, respectively, P<0.001]. During follow-up (3.2±1.5 years), the incidence of the primary endpoint was lowest in the LBBB group (QRSd ≥150) (28.6% vs. 42.3% vs. 45.9% vs. 55.6% vs. 55.3%, respectively, P<0.001). This difference was still significant after adjusting for other baseline characteristics.

    Conclusions:In this Japanese patient population, LBBB intrinsic QRS morphology and prolonged QRSd (≥150 ms) exhibited the best response to CRT.

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  • Lisheng Lin, Takashi Murakami, Junko Shiono, Hitoshi Horigome
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0075
    [Advance publication] Released: April 06, 2018
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  • Nobuhiko Haruki, Takeshi Onohara, Daiki Tsujimoto, Kazuhiko Iitsuka, Y ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0081
    [Advance publication] Released: April 06, 2018
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  • Takahiko Nagase, Stefano Bordignon, Laura Perrotta, Fabrizio Bologna, ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1324
    [Advance publication] Released: April 05, 2018
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    Background:The incidence of pulmonary vein stenosis (PVS) after AF ablation following contemporary procedures remains unclear. We compared the incidence of PVS/narrowing (PVS/N) after PV isolation (PVI) for (1) 3-D mapping-guided wide-area encircling irrigated radiofrequency current (RFC) ablation; (2) first–third-generation big cryoballoon (CB1–3) ablation; and (3) laser balloon (LB) ablation.

    Methods and Results:All patients undergoing a second procedure between January 2012 and November 2016 were subgrouped according to index ablation (PVI): RFC; CB; or LB. PVS/N was classified using PV diameter ratio (second/index procedure) on selective PV angiogram performed before ablation: mild, 25–49%; moderate, 50–74%; or severe, ≥75%. A total of 344 patients (1,362 PV) were analyzed (RFC, n=211; 840 PV; CB1, n=21; 82 PV; CB2,3, n=64; 250 PV; LB, n=48; 190 PV). In the LB group, 45 patients (94%) were treated with dose ≥8.5 W. Second procedures were performed on average 14.9±14.1 months after the index procedure. Mild PVS/N was observed in 18.4%, 9.5% and 3.6% of PV in the LB, RFC and CB groups, respectively (P<0.01). Moderate PVS was recognized in 2 PV (0.1%; RFC, LB). Severe PVS was never observed, and no PV intervention/surgery was required.

    Conclusions:The risk for significant PVS is low after RFC/CB. The incidence of mild PVS/N was highest after standard-dose LB ablation and lowest after high-dose CB ablation.

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  • Seiichi Hiramori, Yoshimitsu Soga, Norihiko Kamioka, Takashi Miura, Ta ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-17-0663
    [Advance publication] Released: April 04, 2018
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    Background:Several studies have reported a relationship between clinical outcomes and the ankle-brachial index (ABI) in different populations. However, the relationship in Japanese patients or in patients undergoing percutaneous coronary intervention (PCI) has not been examined well.

    Methods and Results:The subjects were 1,857 patients who underwent PCI from July 2007 to May 2010 and in whom the carotid and renal arteries and abdominal aorta were examined simultaneously by ultrasonography and ABI. We investigated the relationship between ABI and major adverse cardiovascular events (MACE: all-cause death, myocardial infarction, and stroke). The median follow-up was 1,322 days (interquartile range: 1,092–1,566 days). Patients with low (<0.9), borderline (0.9–1.0) and high ABI (>1.4) had significantly higher incidence of MACE at 4 years (31%, 15%, 10%, and 29% for the low, borderline, normal, and high groups, respectively; log-rank P<0.0001) and all-cause mortality at 4 years (22%, 12%, 6.9%, and 29%, respectively; P<0.0001) compared with the normal ABI group (1.0≤ABI≤1.4). The adjusted hazard ratios for MACE were 2.35 (1.72–3.20), 1.27 (0.89–1.80) and 1.87 (0.81–3.79) for low, borderline and high ABI, respectively.

    Conclusions:This study suggested that ABI provides additional information for cardiovascular disease risk stratification in Japanese patients undergoing PCI, even it is borderline ABI.

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  • Hashrul N. Rashid, Adam J. Brown, Liam M. McCormick, Ameera S. Amirudd ...
    Type: REVIEW
    Article ID: CJ-17-1363
    [Advance publication] Released: April 04, 2018
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    Subclinical leaflet thrombosis (SLT) following transcatheter aortic valve replacement (TAVR) has been increasingly recognized. SLT has the hallmark features of hypo-attenuated leaflet thickening (HALT) on multidetector computed tomography (MDCT), which may result in hypoattenuation affecting motion (HAM). The actual prevalence of this condition is uncertain, with limited observational registries. SLT has caught the attention of the cardiovascular community because of concerns regarding its clinical sequelae, specifically the potential increased incidence of cerebrovascular events. There are available, albeit sparse, data to suggest that when left untreated, SLT may lead to valve deterioration with potential hemodynamic compromise and potentially clinically overt prostheses thrombosis. Some clinicians have opted to treat patients with SLT with anticoagulation. Although anticoagulation may be a rational treatment option, little data exist on the safety and efficacy of this treatment. This is particularly important considering TAVR patients also have higher bleeding risk than the standard population. In this review, we aim to summarize the current evidence on SLT, explore its pathophysiological mechanism, discuss the current treatment options and future trials that may clarify the optimal antithrombotic strategies of SLT.

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  • Hyun Ju Yoon, Kye Hun Kim, Hyukjin Park, Jae Yeong Cho, Young Joon Hon ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-17-1197
    [Advance publication] Released: March 31, 2018
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    Background:Diastolic function is an independent predictor of death in heart failure (HF), but the effect of a change in diastolic function during hospitalization on clinical outcomes in patients with hypertensive HF (HHF) has been poorly studied. Therefore, the aim of this study was to investigate the effect of predischarge diastolic functional recovery (DFR) on future clinical outcomes in hospitalized patients with a first diagnosis of HHF.

    Methods and Results:A total of 175 hospitalized patients with HHF were divided into 2 groups according to the change in diastolic function on predischarge echocardiography in comparison with baseline echocardiography: DFR group (n=74, 54.2±17.1 years, 55 males) vs. no DFR group (n=101, 59.1±16.8 years, 72 males). During 66.5±37 months of clinical follow-up, major adverse cardiac events (MACE) occurred in 89 patients: 85 HF rehospitalizations, 4 deaths, no MI. The number of MACE were significantly higher in the no DFR group than in the DFR group (61.6% vs. 32.4%, P<0.001). Predischarge systolic functional recovery was not a predictor of MACE, but impaired DFR was an independent predictor of MACE (RR=2.952, P=0.010, confidence interval, 1.878–6.955).

    Conclusions:Impaired predischarge DFR, regardless of the type of HF or predischarge systolic functional recovery, is an independent predictor of future MACE in HHF. Changes in diastolic function should be carefully monitored and would be useful in risk stratification of HHF.

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  • Shuhei Tanaka, Tadakazu Hirai, Kyoko Inao, Nobuyuki Fukuda, Keiko Naka ...
    Type: ORIGINAL ARTICLE
    Subject Area: Stroke
    Article ID: CJ-17-1238
    [Advance publication] Released: March 31, 2018
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    Background:Abnormalities in the left atrium (LA) detected on transesophageal echocardiography (TEE) are reliable predictors of thromboembolism in patients with atrial fibrillation (AF). Cardiac troponin I, a marker of subclinical myocardial damage, may also be a predictor of thromboembolic events in patients with AF. The relationship between cardiac troponin I and thromboembolic risk on TEE, however, remains unclear.

    Methods and Results:TEE and laboratory data, including high sensitivity cardiac troponin I (hs-cTnI) and CHA2DS2-VASc score, were analyzed in 199 patients with non-valvular AF (NVAF). Patients were stratified into those with or without LA abnormality, defined as LA appendage flow velocity <20 cm/s or dense spontaneous echo contrast. On multiple logistic analysis of the clinical variables, hs-cTnI was associated with LA abnormality (95% CI: 1.0003–1.020, P=0.034). The area under the curve for LA abnormality increased on addition of hs-cTnI to CHA2DS2-VASc score. The incidence rate of ischemic stroke was higher in the high hs-cTnI group than in the low-hs-cTnI group (log-rank test, P<0.05).

    Conclusions:Elevated hs-cTnI was independently associated with LA abnormality in NVAF patients. hs-cTnI level may be a useful biomarker for risk stratification of thromboembolism in NVAF patients.

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  • Themistoklis Katsimichas, Tomohito Ohtani, Daisuke Motooka, Yasumasa T ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-17-1285
    [Advance publication] Released: March 30, 2018
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    Background:Research suggests that heart failure with reduced ejection fraction (HFrEF) is a state of systemic inflammation that may be triggered by microbial products passing into the bloodstream through a compromised intestinal barrier. However, whether the intestinal microbiota exhibits dysbiosis in HFrEF patients is largely unknown.

    Methods and Results:Twenty eight non-ischemic HFrEF patients and 19 healthy controls were assessed by 16S rRNA analysis of bacterial DNA extracted from stool samples. After processing of sequencing data, bacteria were taxonomically classified, diversity indices were used to examine microbial ecology, and relative abundances of common core genera were compared between groups. Furthermore, we predicted gene carriage for bacterial metabolic pathways and inferred microbial interaction networks on multiple taxonomic levels.Bacterial communities of both groups were dominated by the Firmicutes and Bacteroidetes phyla. The most abundant genus in both groups wasBacteroides. Although α diversity did not differ between groups, ordination by β diversity metrics revealed a separation of the groups across components of variation.StreptococcusandVeillonellawere enriched in the common core microbiota of patients, whileSMB53was depleted. Gene families in amino acid, carbohydrate, vitamin, and xenobiotic metabolism showed significant differences between groups. Interaction networks revealed a higher degree of correlations between bacteria in patients.

    Conclusions:Non-ischemic HFrEF patients exhibited multidimensional differences in intestinal microbial communities compared with healthy subjects.

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  • Toru Miyoshi, Hiroshi Matsuoka, Hideo Kawakami, Kazuoki Dai, Tetsuya S ...
    Type: ORIGINAL ARTICLE
    Subject Area: Imaging
    Article ID: CJ-17-1396
    [Advance publication] Released: March 30, 2018
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    Background:The vascular response, in terms of quality and quantity, of the second- and third-generation drug-eluting stents (2G- and 3G-DES, respectively) was assessed prospectively on coronary angioscopy (CAS).

    Methods and Results:The Multicenter study on Intra-Coronary AngioScopy After Stent (MICASA) is a multicenter CAS registry. A total of 107 DES (71 2G- and 36 3G-DES) were prospectively observed on CAS 8.7±2.7 months after percutaneous coronary intervention. Neointimal coverage (NC) grade was evaluated using a 4-point grading scale, from 0 (no coverage) to 3 (complete coverage). Plaque yellow color (YC) was also assessed using a 4-point grading system, from 0 (white) to 3 (bright yellow). Max-NC (2G-DES vs. 3G-DES: 2.14±0.68 vs. 2.44±0.73, P=0.023); min-NC (1.07±0.48 vs. 1.39±0.60, P=0.002), and dominant-NC (1.57±0.69 vs. 2.08±0.84, P=0.002) were significantly higher and the YC grade (1.23±0.82 vs. 0.86±0.76, P=0.031) significantly lower in the 3G-DES group than in the 2G-DES group. There was no significant difference in the presence of thrombus (28.2% vs. 22.2%, P=0.51) between the 2G- and 3G-DES groups.

    Conclusions:The higher NC grade and lower YC grade in 3G-DES than in 2G-DES might be associated with better long-term clinical outcome, which remains to be determined in future studies.

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  • Yukiko Matsumura-Nakano, Hiroki Shiomi, Takeshi Morimoto, Satoshi Shiz ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1278
    [Advance publication] Released: March 29, 2018
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    Background:Patients with concomitant atrial fibrillation (AF) and coronary stenting are at high risk for both cardiovascular and bleeding events. We aimed to evaluate the influence of sex on long-term clinical outcomes in this patient subset.

    Methods and Results:We identified 1,450 patients with AF and coronary stenting in a patient-level pooled database from 3 Japanese studies, and compared 3-year clinical outcomes between men and women (n=1,075, and n=375, respectively). The cumulative 3-year incidence of all-cause death was significantly higher in women than in men (26.5% vs. 17.2%, log-rank P<0.001), although after adjusting for confounders, the excess mortality risk of women relative to men was no longer significant (hazard ratio (HR): 1.12, 95% confidence interval (CI): 0.85–1.46, P=0.42). There were no significant differences in the adjusted 3-year risks for myocardial infarction or stroke between men and women (HR: 1.25, 95% CI: 0.62–2.40, P=0.52, and HR: 1.15, 95% CI: 0.75–1.74, P=0.52, respectively). However, both the cumulative 3-year incidence of and adjusted risk for major bleeding were significantly higher in women than in men (17.0% vs. 11.3%, log-rank P=0.002, and HR: 1.47, 95% CI: 1.03–2.07, P=0.03).

    Conclusions:Among patients with concomitant AF and coronary stenting, there were no significant differences in the adjusted 3-year risks for all-cause death, myocardial infarction, and stroke between men and women. However, women as compared with men were associated with excess adjusted risk for major bleeding.

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  • Albert Youngwoo Jang, Connor O’Brien, Wook-Jin Chung, Pyung Chun Oh, J ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-17-1113
    [Advance publication] Released: March 28, 2018
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    Background:Indwelling urethral catheters (IUC) are routinely inserted for the purpose of monitoring urine output in patients with acute heart failure (AHF). The benefit of IUC in patients capable of complying with urine collection protocols is unclear, and IUC carry multiple risks. This study describes the impact of IUC on AHF treatment.

    Methods and Results:A total of 540 records were retrospectively analyzed. After exclusion criteria were applied, 316 patients were propensity matched to establish groups of 100 AHF patients who either did (IUC(+)) or did not receive an IUC (IUC(−)) upon admission. Hospital length of stay (9 vs. 7 days), in-hospital urinary complications (24 vs. 5%), and 1-year urinary tract infection rate (17 vs. 6%; HR, 3.145; 95% CI: 1.240–7.978) were significantly higher in the IUC(+) group (P<0.05 for all). There were no differences in 30-day rehospitalization (6 vs. 6%; HR, 0.981; 95% CI: 0.318–3.058; P=0.986) or major adverse cardiac/cerebrovascular events at 1 year (37 vs. 32%, HR, 1.070; 95% CI: 0.636–1.799; P=0.798).

    Conclusions:Based on this retrospective analysis, the routine use of IUC may increase length of stay and UTI complications in AHF patients without reducing the risk for major cardiovascular and cerebrovascular events or 30-day rehospitalization rate.

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  • Jun Masuda, Mikio Kishi, Naoto Kumagai, Toru Yamazaki, Kenji Sakata, T ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-17-1275
    [Advance publication] Released: March 27, 2018
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    Background:There are few reports examining regional differences between rural prefectures and metropolitan areas in the management of acute myocardial infarction (AMI) in Japan.

    Methods and Results:In the Rural AMI registry, a prospective, multi-prefectural registry of AMI in 4 rural prefectures (Ishikawa, Aomori, Ehime and Mie), a total of 1,695 consecutive AMI patients were registered in 2013. Among them, 1,313 patients who underwent primary percutaneous coronary intervention (PPCI) within 24 h of onset were enrolled in this study (Rural group), and compared with the cohort data from the Tokyo CCU Network registry for AMI in the same period (Metropolitan group, 2,075 patients). The prevalence of direct ambulance transport to PCI-capable facilities in the Rural group was significantly lower than that in the Metropolitan group (43.8% vs. 60.3%, P<0.01), which resulted in a longer onset-to-balloon time (OTB: 225 vs. 210 min, P=0.02) and lower prevalence of PPCI in a timely fashion (OTB ≤2 h: 11.5% vs. 20.7%, P<0.01) in the Rural group. Multivariate analysis revealed that direct ambulance transport was the strongest predictor for PPCI in a timely fashion (odds ratio=4.13, P<0.001).

    Conclusions:AMI patients in rural areas were less likely to be transported directly to PCI-capable facilities, resulting in time delay to PPCI compared with those in metropolitan areas.

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  • Yingguang Li, Zehang Li, Emil N. Holck, Bo Xu, Antonios Karanasos, Zhe ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiovascular Intervention
    Article ID: CJ-17-1332
    [Advance publication] Released: March 24, 2018
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    Background:Development of methods for accurate reconstruction of bioresorbable scaffolds (BRS) and assessing local hemodynamics is crucial for investigation of vascular healing after BRS implantation.

    Methods and Results:Patients with BRS that crossed over in a coronary bifurcation were included for analysis. Reconstructions of the coronary lumen and BRS were performed by fusion of optical coherence tomography and coronary angiography generating a tree model (TM) and a hybrid model with BRS (TM-BRS). A virtual BRS model with thinner struts was created and all 3 models were analyzed using computational fluid dynamics to derive: (1) time-average shear stress (TASS), (2) TASS gradient (TASSG), which represents SS heterogeneity, and (3) fractional flow reserve (FFR). Reconstruction of the BRS was successful in all 10 patients. TASS and TASSG were both higher by TM-BRS than by TM in main vessels (difference 0.27±4.30 Pa and 10.18±27.28 Pa/mm, P<0.001), with a remarkable difference at side branch ostia (difference 13.51±17.40 Pa and 81.65±105.19 Pa/mm, P<0.001). With thinner struts, TASS was lower on the strut surface but higher at the inter-strut zones, whereas TASSG was lower in both regions (P<0.001 for all). Computational FFR was lower by TM-BRS than by TM for both main vessels and side branches (P<0.001).

    Conclusions:Neglecting BRS reconstruction leads to significantly lower SS and SS heterogeneity, which is most pronounced at side branch ostia. Thinner struts can marginally reduce SS heterogeneity.

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  • Francesco Liotta, Francesco Annunziato, Sergio Castellani, Maria Boddi ...
    Type: ORIGINAL ARTICLE
    Subject Area: Regenerative Medicine
    Article ID: CJ-17-0720
    [Advance publication] Released: March 23, 2018
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    Background:The therapeutic efficacy of bone marrow mononuclear cells (BM-MNC) autotransplantation in critical limb ischemia (CLI) has been reported. Variable proportions of circulating monocytes express low levels of CD34 (CD14+CD34lowcells) and behave in vitro as endothelial progenitor cells (EPCs). The aim of the present randomized clinical trial was to compare the safety and therapeutic effects of enriched circulating EPCs (ECEPCs) with BM-MNC administration.

    Methods and Results:ECEPCs (obtained from non-mobilized peripheral blood by immunomagnetic selection of CD14+and CD34+cells) or BM-MNC were injected into the gastrocnemius of the affected limb in 23 and 17 patients, respectively. After a mean of 25.2±18.6-month follow-up, both groups showed significant and progressive improvement in muscle perfusion (primary endpoint), rest pain, consumption of analgesics, pain-free walking distance, wound healing, quality of life, ankle-brachial index, toe-brachial index, and transcutaneous PO2. In ECEPC-treated patients, there was a positive correlation between injected CD14+CD34lowcell counts and the increase in muscle perfusion. The safety profile was comparable between the ECEPC and BM-MNC treatment arms. In both groups, the number of deaths and major amputations was lower compared with eligible untreated patients and historical reference patients.

    Conclusions:This study supports previous trials showing the efficacy of BM-MNC autotransplantation in CLI patients and demonstrates comparable therapeutic efficacy between BM-MNC and EPEPCs.

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  • Toshiyuki Nagai, Tsutomu Yoshikawa, Yoshihiko Saito, Yasuchika Takeish ...
    Type: LATE BREAKING COHORT STUDY (JCS 2018)
    Article ID: CJ-18-0073
    [Advance publication] Released: March 23, 2018
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    Background:Despite the specific characteristics of heart failure with preserved ejection fraction (HFpEF) having been demonstrated predominantly from registries in Western countries, important international differences exist in terms of patient characteristics, management and medical infrastructure between Western and Asian countries.

    Methods and Results:We performed nationwide registration of consecutive Japanese hospitalized HFpEF patients with left ventricular EF ≥50% from 15 sites between November 2012 and March 2015. Follow-up data were obtained up to 2 years post-discharge. A total of 535 patients were registered. The median age was 80 years and 50% were female. The most common comorbid conditions were hypertension (77%) and atrial fibrillation (AF: 62%), but body mass index was relatively low. In-hospital mortality rate was 1.3% and the median length of hospitalization was 16 days. By 2 years post-discharge, 40.8% of patients had all-cause death or HF hospitalization. Approximately one-half of deaths had a cardiac cause. Lower serum albumin on admission was one of the strongest independent determinants of worse clinical outcome.

    Conclusions:Japanese HFpEF patients were less obese, but had a substantially higher prevalence of AF and lower incidence of subsequent events compared with previous reports. Our findings indicated that specific preventative and therapeutic strategies focusing on AF and nutritional status might need to be considered for Japanese hospitalized patients with HFpEF.

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  • Akihide Konishi, Mami Ho, Yuko Shirai, Haruki Shirato
    Type: REVIEW
    Article ID: CJ-17-1425
    [Advance publication] Released: March 21, 2018
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    A prospective randomized clinical trial showed that the BioFreedom stent (Biosensors International), which is a polymer-free and carrier-free drug-coated stent, was significantly superior to a bare-metal stent (BMS) in patients at high bleeding risk who were receiving a 1-month course of dual antiplatelet therapy (DAPT). However, the stent thrombosis rate (2.01% for BioFreedom vs. 2.20% for BMS) was 4–6-fold higher than that of approved drug-eluting stents based on real-world data in Japan. Furthermore, the frequency of stent thrombosis at more than 1 month with the BioFreedom stent was slightly higher than that at less than 1 month. This result suggested that it would not be acceptable to stop DAPT universally at 1 month. Thus, the target patients for the BioFreedom stent are unspecified patients at high bleeding risk needing to continue DAPT for as long as necessary in Japan. Therefore, based on the pre- and post-marketing balance of medical devices regulations, regulatory approval was given for unspecified patients conditionally upon real-world data collection of 2,000 patients with a Use-Results Survey, instead of conducting additional pre-marketing clinical trial(s). The Use-Results Survey System is part of a strategy to expedite patients’ access to innovative medical devices and to accelerate the development of medical devices.

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  • Naoki Masaki, Yuriko Saiki, Masato Endo, Kay Maeda, Osamu Adachi, Masa ...
    Type: ORIGINAL ARTICLE
    Subject Area: Pediatric Cardiology and Adult Congenital Heart Disease
    Article ID: CJ-17-0754
    [Advance publication] Released: March 16, 2018
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    Background:Pulmonary hypertension (PH) is more progressive in trisomy 21 patients. However, pulmonary arteriopathic lesions in these patients have not been fully characterized histopathologically.

    Methods and Results:A retrospective review of a lung biopsy registry identified 282 patients: 188 patients with trisomy 21 (Group D) and 94 without (Group N). The mean age at lung biopsy was 3 and 7 months (P<0.0001). Pulmonary arterial pressure (PAP) and pulmonary vascular resistance were similar between the 2 groups. There were no significant differences in the proportion of patients with irreversible intimal lesions or the index of pulmonary vascular disease (IPVD; a measure of the degree of pulmonary arteriopathy progression) between the 2 groups. In addition, after propensity score matching for patient background (n=43 in each group), there were no significant differences in IPVD (P=0.29) or the ratio of irreversible intimal changes between the D and N groups (P=0.39). Multivariate analysis identified age (P<0.0001) and PAP (P=0.03) as the only risk factors for progression of pulmonary arteriopathy.

    Conclusions:Histopathologically, early progression of pulmonary arteriopathy in patients with trisomy 21 was not proved compared with patients without trisomy 21. Although we cannot exclude the possibility of bias in the Group D and N patients who were slated for lung biopsy, factors other than pulmonary arteriopathy may affect the marked progression of clinical PH in trisomy 21 patients.

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  • Taku Omori, Ryuji Okamoto, Hajime Fujimoto, Jun Masuda, Tetsu Kobayash ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0154
    [Advance publication] Released: March 13, 2018
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  • Atsushi Sugiura, Hideki Kitahara, Kenichi Fujii, Yoshihide Fujimoto, Y ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0013
    [Advance publication] Released: March 09, 2018
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  • Yukihito Sato, Yoshio Kita, Masatoshi Shimada, Kiyomi Matsushita, Hisa ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-17-0861
    [Advance publication] Released: March 02, 2018
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    Background:The Hyogo Prefectural Government has been enforcing a smoking ban ordinance since April 2013. The present survey was conducted to determine the extent to which the smoking ban has been successfully implemented in eating establishments in Kobe City and Amagasaki City.

    Methods and Results:The Health and Welfare Department of the Hyogo Prefectural Government provided a list of eating establishments in Kobe and Amagasaki City. From these, we chose 1,300 from each city using random number generation. Responses were obtained from 310 establishments in Kobe City (response rate: 23.8%) and 297 in Amagasaki City (22.8%). Overall, 58.1% of the establishments surveyed in Kobe City were aware of the ordinance, a recognition rate significantly higher than that of Amagasaki City, where only 45.5% of eateries were aware of the ordinance (P=0.003). Of the Kobe City eateries, 31.7% had succeeded in implementing a complete ban on smoking. In Amagasaki City, the rate was significantly lower, at just 13.4% (P<0.001). A logistic regression analysis showed that coffee shops, Japanese-style taverns, bars, and eating establishments that served alcohol were the independent significant predictors of low compliance. Kobe City restaurants, women, and families were the independent significant predictors of high compliance with the complete smoking ban.

    Conclusions:The rates of recognition and implementation of the complete smoking ban were significantly lower in Amagasaki City than in Kobe City. There needs to be a strong and continuous socialization campaign to promote the ordinance.

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  • Ming-Shyan Lin, Chang-Min Chung, Ming-Ling Chang, Mei-Yen Chen, Shih-T ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-17-1118
    [Advance publication] Released: March 02, 2018
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    Background:Although hepatitis C virus (HCV) is a known risk factor for cardiovascular disease, whether antiviral therapy (AVT) can reduce heart failure (HF) hospitalizations is unknown.

    Methods and Results:In this population-based cohort study, we used data from the Taiwan National Health Insurance Research Database to evaluate the effect of interferon-based therapy (IBT) on cardiovascular events in patients with chronic HCV infection. Clinical outcomes evaluated included HF hospitalizations; a composite of acute myocardial infarction, ischemic stroke, and peripheral artery disease; all-cause death; and cardiovascular death. Of 83,229 eligible patients with chronic HCV infection, we compared 16,284 patients who received IBT with untreated subjects after propensity score matching. Patients who received IBT were less likely to be hospitalized for HF compared with untreated subjects (incidence density.ID, 0.9 vs. 1.5 events per 103person-years; hazard ratio.HR, 0.58; 95% confidence interval.CI, 0.42–0.79; P=0.001). Compared with untreated subjects, the treated group had significantly lower risk of composite vascular events (ID, 3.7 vs. 5.0 events per 103person-years; P<0.001), all-cause death (ID, 5.6 vs. 17.2 events per 103person-years; P<0.001), and cardiovascular death (ID, 0.2 vs. 0.6 events per 103person-years; P=0.001).

    Conclusions:AVT for chronic HCV infection might offer protection against HF hospitalizations, critical vascular events, and cardiovascular death beyond known beneficial effects.

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  • Byung Jin Kim, Dae Chul Seo, Bum Soo Kim, Jin Ho Kang
    Type: ORIGINAL ARTICLE
    Subject Area: Hypertension and Circulatory Control
    Article ID: CJ-17-1188
    [Advance publication] Released: February 28, 2018
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    Background:The relationship between chronic smoking and hypertension (HTN) is inconclusive in previous studies, which were mainly based on self-reported smoking status. The aim of this study was to evaluate the association of cotinine-verified smoking status with incident HTN.

    Methods and Results:A total of 74,743 participants (43,104 men; age 38±5.4 years) were included in the study, with a mean follow-up period of 29 months. Individuals were divided into 4 groups on the basis of their cotinine-verified smoking status at baseline and at follow-up (never-smoking, new-smoking, former-smoking, and sustained-smoking). The incidence rate of HTN in the never-smoking, new-smoking, former-smoking, and sustained-smoking groups was 8.2%, 7.6%, 10.1%, and 8.7% for men and 1.8%, 2.5%, 1.5%, and 2.2% for women, respectively. In a multivariate Cox-hazard regression analysis adjusted for the variables with a univariate relationship, new-smoking and sustained-smoking had decreased relative risks (RRs) for incident HTN compared with never-smoking (RR [95% CI], 0.75 [0.58, 0.96] for new-smoking and 0.82 [0.74, 0.90] for sustained-smoking). Cotinine-verified current smoking at baseline was also inversely associated with incident HTN compared with cotinine-verified never-smoking at baseline (0.91 [0.84, 0.98]). These results remained significant only in men, although there was no sex interaction.

    Conclusions:This longitudinal study showed that cotinine-verified new-smoking and sustained-smoking decreased the risk for incident HTN, especially in men, compared with never-smoking.

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  • Toshiki Sawai, Munenari Ikezawa, Atsuya Hirota, Shigetada Yamamoto, Hi ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-17-1039
    [Advance publication] Released: February 23, 2018
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  • Loukman Omarjee, Vincent Jaquinandi, Audrey Camarzana, Frederic Roulea ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-17-1131
    [Advance publication] Released: February 22, 2018
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