Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Advance online publication
Displaying 1-50 of 72 articles from this issue
  • Kozo Okada
    Article type: EDITORIAL
    Article ID: CJ-24-0289
    Published: May 22, 2024
    Advance online publication: May 22, 2024
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  • Shumpei Kosugi, Isamu Mizote, Daisuke Nakamura, Shigeru Miyagawa, Yasu ...
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-24-0305
    Published: May 21, 2024
    Advance online publication: May 21, 2024
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  • Tatsuya Sakamoto, Eisuke Usui, Masahiro Hoshino, Masahiro Hada, Tatsuh ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0934
    Published: May 18, 2024
    Advance online publication: May 18, 2024
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    Supplementary material

    Background: Myocardial bridge (MB) is a common coronary anomaly characterized by a tunneled course through the myocardium. Coronary computed tomography angiography (CCTA) can identify MB. The impact of MB detected by CCTA on coronary physiological parameters before and after percutaneous coronary intervention (PCI) is unknown.

    Methods and Results: We investigated 141 consecutive patients who underwent pre-PCI CCTA and fractional flow reserve (FFR)-guided elective PCI for de novo single proximal lesions in the left anterior descending artery (LAD). We compared clinical demographics and physiological parameters between patients with and without CCTA-defined MB. MB was identified in 46 (32.6%) patients using pre-PCI CCTA. The prevalence of diabetes was higher among patients with MB. Median post-PCI FFR values were significantly lower among patients with than without MB (0.82 [interquartile range 0.79–0.85] vs. 0.85 [interquartile range 0.82–0.89]; P=0.003), whereas pre-PCI FFR values were similar between the 2 groups. Multivariable linear regression analysis revealed that the presence of MB and greater left ventricular mass volume in the LAD territory were independently associated with lower post-PCI FFR values. Multivariable logistic regression analysis also revealed that the presence of MB and lower pre-PCI FFR values were independent predictors of post-PCI FFR values ≤0.80.

    Conclusions: CCTA-defined MB independently predicted both lower post-PCI FFR as a continuous variable and ischemic FFR as a categorical variable in patients undergoing elective PCI for LAD.

  • Toshiro Kitagawa, Kazuhiro Sentani, Yuki Ikegami, Taiichi Takasaki, Sh ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0226
    Published: May 18, 2024
    Advance online publication: May 18, 2024
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    Supplementary material

    Background: The relationships of the clinical and biological attributes of epicardial adipose tissue (EAT) with aortic valve calcification (AVC) have not been characterized. We evaluated the relationships of the clinical and histological features of EAT with AVC assessed using computed tomography (CT).

    Methods and Results: We enrolled 43 patients undergoing cardiac CT examination prior to elective cardiac surgery in whom AVC was identified on CT. EAT volume and density, coronary calcium score (CCS), AVC score (AVCS), and coronary atherosclerosis on CT angiography were evaluated in each patient. During cardiac surgery, 2 EAT samples were obtained for immunohistochemistry. The number of CD68- and CD11c-positive macrophages and osteocalcin-positive cells was counted in 6 random high-power fields of EAT sections. EAT density, but not EAT volume normalized to body surface area, was positively correlated with the number of macrophages and osteocalcin-positive cells in EAT. There was a positive correlation between ln(AVCS), but not ln(CCS+1), and the number of macrophages and osteocalcin-positive cells in EAT. Multivariate analysis revealed significant positive correlations for ln(AVCS) with EAT density (β=0.42; P=0.0072) and the number of CD68-positive macrophages (β=0.57; P=0.0022), CD11c-positive macrophages (β=0.62; P=0.0003), and osteocalcin-positive cells (β=0.52; P=0.0021) in EAT.

    Conclusions: Inflammation and osteogenesis in EAT, reflected by high CT density, are associated with the severity of AVC representing aortic valve degeneration.

  • Masaki Nakashima, Masanori Yamamoto, Mitsuru Sago, Shuhei Tanaka, Ryuk ...
    Article type: LATE BREAKING COHORT STUDY (JCS 2024)
    Article ID: CJ-24-0062
    Published: May 17, 2024
    Advance online publication: May 17, 2024
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    Supplementary material

    Background: Limited data are available regarding clinical outcomes after percutaneous left atrial appendage closure using WATCHMAN FLX (WM-FLX) and WATCHMAN-2.5 (WM2.5) devices in Asian patients.

    Methods and Results: Data of 1,464 consecutive patients (WM-FLX, n=909; WM2.5, n=555) were extracted from a Japanese multicenter registry, and clinical data were compared between the 2 groups. No in-hospital deaths, periprocedural stroke, or device embolization occurred. Procedural success was significantly higher in the WM-FLX than WM2.5 group (95.8% vs. 91.9%; P=0.002) owing to the lower incidence of periprocedural pericardial effusion (0.55% vs. 1.8%; P=0.021). No significant differences in all-cause death, postprocedural stroke, and device-related thrombus were observed between the 2 groups. However, the cumulative bleeding rate at 1 year was substantially lower in the WM-FLX group (7.8% vs. 16.4%; P<0.001). Landmark analysis of bleeding events highlighted lower bleeding rates in the WM-FLX than WM2.5 group within the first 6 months (6.4% vs. 14.8%; P<0.001), with comparable bleeding rates over the 6- to 12-month period (1.5% vs. 3.2%, respectively; P=0.065).

    Conclusions: This study demonstrated higher early safety and lower 1-year bleeding rates in the WM-FLX than WM2.5 group. The lower bleeding events with WM-FLX are likely due to multiple factors other than purely difference in devices, such as postprocedural drug regimen.

  • Ritsuko Kohno, Katsuhide Hayashi, Yasushi Oginosawa, Haruhiko Abe
    Article type: EDITORIAL
    Article ID: CJ-24-0310
    Published: May 17, 2024
    Advance online publication: May 17, 2024
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  • Ryo Horita, Makoto Hashimoto, Yuhei Kasai, Ryo Otake, Hidemasa Shitan, ...
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-24-0006
    Published: May 14, 2024
    Advance online publication: May 14, 2024
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    Supplementary material
  • Isamu Mizote, Daisuke Nakamura, Koichi Maeda, Tomoharu Dohi, Kazuo Shi ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0050
    Published: May 11, 2024
    Advance online publication: May 11, 2024
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    Background: Based on the results of a clinical trial in Japan, transcatheter aortic valve replacement (TAVR) for hemodialysis (HD) patients gained approval; however, mid-term TAVR outcomes and transcatheter aortic valve (TAV) durability in HD patients remain unexplored.

    Methods and Results: We analyzed background, procedural, in-hospital outcome, and follow-up data for 101 HD patients and 494 non-HD patients who underwent TAVR using balloon-expandable valves (SAPIEN XT or SAPIEN 3) retrieved from Osaka University Hospital TAVR database. Periprocedural mortality and TAVR-related complications were comparable between HD and non-HD patients. However, Kaplan-Meier analysis revealed that HD patients had significantly lower survival rates (log-rank test, P<0.001). In addition, HD patients had significantly higher rates of severe structural valve deterioration (SVD) than non-HD patients (Gray test, P=0.038).

    Conclusions: TAVR in HD patients had comparable periprocedural mortality but inferior mid-term survival and TAV durability than in non-HD patients. Indications for TAVR in younger HD patients should be carefully determined, considering the possibility of a TAV-in-TAV procedure when early SVD occurs.

  • Teiji Akagi, Hidehiko Hara, Hideaki Kanazawa, Shigefumi Fukui, Yoichir ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0080
    Published: May 11, 2024
    Advance online publication: May 11, 2024
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    Supplementary material

    Background: The AmplatzerTM PFO Occluder was approved for marketing in Japan in May 2019, and the Amplatzer PFO Occluder Japan Post-marketing Surveillance (PFO Japan PMS) study was initiated in December 2019. This analysis presents 30-day clinical outcomes for PFO Japan PMS study patients.

    Methods and Results: PFO Japan PMS is a prospective single-arm non-randomized multicenter clinical study. Eligible patients were indicated for patent foramen ovale (PFO) closure and underwent an implant attempt with the AmplatzerTM PFO Occluder. Technical success was defined as successful delivery and release of the occluder; procedural success was defined as technical success with no serious adverse events (SAEs) within 1 day of the procedure. The primary safety endpoint includes predefined device- and/or procedure-related SAEs through 30 days after the procedure. From December 2019 to July 2021, 500 patients were enrolled across 53 Japanese sites. The mean (±SD) patient age was 52.7±15.4 years, and 29.8% of patients were aged >60 years. Technical and procedural success rates were both high (99.8% and 98.8%, respectively). Further, there was only one primary safety endpoint event (0.2%): an episode of asymptomatic paroxysmal atrial fibrillation that occurred 26 days after the procedure.

    Conclusions: In this real-world Japanese study with almost one-third of patients aged >60 years, PFO closure with the AmplatzerTM PFO Occluder was performed successfully and safely, with a low incidence of procedure-related atrial arrhythmias.

  • Shiro Nakamori, Kaoru Dohi
    Article type: EDITORIAL
    Article ID: CJ-24-0266
    Published: May 11, 2024
    Advance online publication: May 11, 2024
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  • Takanari Fujii
    Article type: EDITORIAL
    Article ID: CJ-24-0272
    Published: May 11, 2024
    Advance online publication: May 11, 2024
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  • Peijian Wei, Fang Fang, Fengwen Zhang, Yihang Li, Pengxu Kong, Shuyi F ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0800
    Published: May 09, 2024
    Advance online publication: May 09, 2024
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    Supplementary material

    Background: Congenital left circumflex coronary artery fistula (LCX-CAF) is a relatively rare type of coronary artery fistula (CAF); little is known about the outcomes of transcatheter closure (TCC) of LCX-CAF.

    Methods and Results: All consecutive patients admitted to Fuwai Hospital and scheduled for TCC of LCX-CAF between January 2012 and December 2022 were reviewed retrospectively. Of the 25 consecutive patients (mean [±SD] age 34±20 years; 48% male) admitted and scheduled for TCC of congenital LCX-CAF, the procedure was feasible in 22 (77.3%). The mean (±SD) diameter of the fistulas was 6.99±2.04 mm; 21 (84%) patients had a large fistula (i.e., diameter >2-fold greater than non-feeding coronary artery). Occluders were deployed via a transarterial approach and arteriovenous loop in 6 (27.3%) and 16 (72.7%) patients, respectively. No procedural complications were recorded. Although the procedural success rates are similar for single LCX-CAF and left anterior descending CAF (81.25% vs. 92.86%; P=0.602), the mean time from initial angiography to first occluder deployment is significantly longer for LCX-CAF (83.06±36.07 vs. 36.00±9.49 min; P<0.001). The mean (±SD) follow-up time was 62.2±45.5 months. The incidence of myocardial infarction and recanalization of the fistula was 4.5% (1/22) and 9.1% (2/22), respectively.

    Conclusions: TCC of LCX-CAF is a feasible and effective alternative to surgical repair, with comparable outcomes in selected patients. Optimal medical therapy to prevent post-closure myocardial infarction requires further investigation.

  • Yuki Obayashi, Yasuaki Takeji, Tomohiko Taniguchi, Takeshi Morimoto, S ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0103
    Published: May 09, 2024
    Advance online publication: May 09, 2024
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    Supplementary material

    Background: Data on concomitant mitral regurgitation (MR) in patients with severe aortic stenosis (AS) are scarce.

    Methods and Results: We investigated the risk of concomitant MR in patients with severe AS in the CURRENT AS Registry-2 according to initial treatment strategy (transcatheter aortic valve implantation [TAVI], surgical aortic valve replacement [SAVR], or conservative). Among 3,365 patients with severe AS, 384 (11.4%) had moderate/severe MR (TAVI: n=126/1,148; SAVR: n=68/591; conservative: n=190/1,626). The cumulative 3-year incidence for death or heart failure (HF) hospitalization was significantly higher in the moderate/severe than no/mild MR group in the entire population (54.6% vs. 34.3%, respectively; P<0.001) and for each treatment strategy (TAVI: 45.0% vs. 31.8% [P=0.006]; SAVR: 31.9% vs. 18.7% [P<0.001]; conservative: 67.8% vs. 41.6% [P<0.001]). The higher adjusted risk of moderate/severe MR relative to no/mild MR for death or HF hospitalization was not significant in the entire population (hazard ratio [HR] 1.15; 95% confidence interval [CI] 0.95–1.39; P=0.15); however, the risk was significant in the SAVR (HR 1.92; 95% CI 1.04–3.56; P=0.04) and conservative (HR 1.30; 95% CI 1.02–1.67; P=0.04) groups, but not in the TAVI group (HR 1.03; 95% CI 0.70–1.52; P=0.86), despite no significant interaction (Pinteraction=0.37).

    Conclusions: Moderate/severe MR was associated with a higher risk for death or HF hospitalization in the initial SAVR and conservative strategies, while the association was less pronounced in the initial TAVI strategy.

  • Mina Tsukuda, Hiroki Matsuzoe, Shunsuke Sato, Mayumi Inaba, Hiroshi Ta ...
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-24-0250
    Published: May 01, 2024
    Advance online publication: May 01, 2024
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  • Tomoya Hoshi, Mitsuaki Sawano, Shun Kohsaka, Hideki Ishii, Tetsuya Ama ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0966
    Published: April 27, 2024
    Advance online publication: April 27, 2024
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    Supplementary material

    Background: Women with acute myocardial infarction (AMI) often present a worse risk profile and experience a higher rate of in-hospital mortality than men. However, sex differences in post-discharge prognoses remain inadequately investigated. We examined the impact of sex on 1-year post-discharge outcomes in patients with AMI undergoing percutaneous coronary intervention.

    Methods and Results: We extracted patient-level data for the period January 2017–December 2018 from the J-PCI OUTCOME Registry, endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics. One-year all-cause and cardiovascular mortality and major adverse cardiovascular events were compared between men and women. In all, 29,856 AMI patients were studied, with 6,996 (23.4%) being women. Women were significantly older and had a higher prevalence of comorbidities than men. Crude all-cause mortality was significantly higher among women than men (7.5% vs. 5.4% [P<0.001] for ST-elevation myocardial infarction [STEMI]; 7.0% vs. 5.2% [P=0.006] for non-STEMI). These sex-related differences in post-discharge outcomes were attenuated after stratification by age. Multivariate analysis demonstrated an increase in all-cause mortality in both sexes with increasing age and advanced-stage chronic kidney disease (CKD).

    Conclusions: Within this nationwide cohort, women had worse clinical outcomes following AMI than men. However, these sex-related differences in outcomes diminished after adjusting for age. In addition, CKD was significantly associated with all-cause mortality in both sexes.

  • Yusei Nishikawa, Hiroyuki Takaoka, Ken Kato, Joji Ota, Yoshitada Noguc ...
    Article type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-24-0139
    Published: April 27, 2024
    Advance online publication: April 27, 2024
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  • Haruyo Yasui, Yasushi Sakata, Ryo Kawasaki, Ken-Ichi Hirata
    Article type: REVIEW
    Article ID: CJ-24-0211
    Published: April 27, 2024
    Advance online publication: April 27, 2024
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    Supplementary material

    In Japan, cerebrovascular diseases and cardiovascular diseases (CVDs) are major causes of death and long-term care. Against this, the Cerebrovascular and Cardiovascular Disease Control Act was passed by a legislative body and promulgated in December 2018, and enacted on December 1, 2019. Based on the Japanese National Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular Disease (Japanese National Plan), prefectural plans have been formulated and published from March 2021 to January 2023. Although the majority of individual measures were comprehensively articulated in accordance with the Japanese National Plan, some prefectures did not describe individual measures such as research, collection of medical information, consultation support for patients with CVD, palliative care, assistance for patients with sequelae, support for maintaining a balance between treatment and work, and measures from childhood and adolescence. Furthermore, a few specific indicators were set for these measures and those related to chronic care. This review identifies the current status of prefectural plans and discusses future challenges and directions.

  • Kensaku Matsuda, Hiroshi Mitsuo, Takuya Nishijima, Hikaru Uchiyama, To ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0864
    Published: April 24, 2024
    Advance online publication: April 24, 2024
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    Background:  Several studies have shown that sodium-glucose cotransporter-2 inhibitors have a renoprotective effect on acute kidney injury (AKI), but their effect on cardiac surgery-associated AKI is unknown.

    Methods and Results:  AKI was induced in 25 rabbits without diabetes mellitus by cardiopulmonary bypass (CPB) for 2 h and they were divided into 5 groups: sham; dapagliflozin-treated sham; CPB; dapagliflozin-treated CPB; and furosemide-treated CPB (n=5 in each group). Dapagliflozin was administered via the femoral vein before initiating CPB. Kidney tissue and urine and blood samples were collected after the surgical procedure. There were no differences in the hemodynamic variables of each group. Dapagliflozin reduced serum creatinine and blood urea nitrogen concentrations, and increased overall urine output (all P<0.05). Hematoxylin and eosin staining showed that the tubular injury score was improved after dapagliflozin administration (P<0.01). Dapagliflozin administration mitigated reactive oxygen species and kidney injury molecule-1 as assessed by immunohistochemistry (both P<0.0001). Protein expression analysis showed improvement of inflammatory cytokines and apoptosis, and antioxidant enzyme expression was elevated (all P<0.05) through activation of the nuclear factor erythroid 2-related factor 2 pathway (P<0.01) by dapagliflozin.

    Conclusions:  Acute intravenous administration of dapagliflozin protects against CPB-induced AKI. Dapagliflozin may have direct renoprotective effects in renal tubular cells.

  • Joji Hoshino, Shunsuke Saito, Ikuko Shibasaki, Toshimi Sairenchi, Shoh ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0879
    Published: April 24, 2024
    Advance online publication: April 24, 2024
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    Background: Sacubitril/valsartan, being both a neprilysin inhibitor and angiotensin receptor blocker, exhibits a renin-angiotensin-aldosterone system (RAAS) inhibitory effect. However, no study has investigated the administration of sacubitril/valsartan in patients early after surgery using cardiopulmonary bypass.

    Methods and Results: This was a prospective observational study of 63 patients who underwent open heart surgery and were treated with sacubitril/valsartan. No serious adverse events occurred. Among the 63 patients, sacubitril/valsartan was discontinued in 13 due to hypotension (n=10), renal dysfunction (n=2), and dizziness (n=1). Atrial natriuretic peptide concentrations increased significantly from Day 3 of treatment (P=0.0142 vs. Postoperative Day 1) and remained high thereafter. In contrast, plasma renin activity was significantly suppressed from Day 3 onwards (P=0.00206 vs. Postoperative Day 1). A decrease in creatinine concentrations and an increase in the estimated glomerular filtration rate were observed on Day 3; this improvement in renal function was not observed in the historical control group, in which patients did not receive sacubitril/valsartan. New postoperative atrial fibrillation was less frequent in the study group compared with the historical control (12.7% vs. 38.0%; P=0.0034).

    Conclusions: Sacubitril/valsartan administration was safe immediately after open heart surgery in patients without postoperative hypotension. It enhanced serum atrial natriuretic peptide concentrations and suppressed RAAS activation.

  • Kyoko Soejima, Kathryn Hilpisch, Megan L. Samec, Rebecca L. Temple, Ma ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0083
    Published: April 24, 2024
    Advance online publication: April 24, 2024
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    Background: The Micra leadless pacemaker was developed to fit inside the right ventricle, thereby reducing overall complications by 48% compared with a historical control group. The current labeling restricts implants to the femoral approach. In this article we used 3-dimensional computer models of human hearts to demonstrate why implants can be difficult in small patients and how using the jugular approach reduces these difficulties.

    Methods and Results: Cardiac computed tomography scans were made of 45 pacemaker patients, 26 in the US and 19 from a single center in Japan. Dimensional measurements were taken in all 45 hearts, and these dimensions were compared between patient cohorts and between the Micra delivery tool dimension and patient heart dimensions. Hearts were smaller among patients in the Japanese than US cohort. In addition, the tool dimension exceeded heart dimensions in a larger percentage of hearts from Japanese patients. Three dimensions were identified that most likely limit navigating across the tricuspid valve to the right ventricle in smaller hearts and for which the jugular approach improved navigation.

    Conclusions: Although the femoral procedure today maintains an excellent safety profile and procedure experience for most global implants, this study provides the rationale as to why the jugular approach may improve the ease of the Micra implant in small hearts, namely by reducing the tortuosity of the navigation across the tricuspid valve.

  • Chengchen Hu, Jamie Francisco, Dominic P. Del Re, Junichi Sadoshima
    Article type: REVIEW
    Article ID: CJ-24-0171
    Published: April 19, 2024
    Advance online publication: April 19, 2024
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    The evolutionarily conserved Hippo pathway plays a pivotal role in governing a variety of biological processes. Heart failure (HF) is a major global health problem with a significant risk of mortality. This review provides a contemporary understanding of the Hippo pathway in regulating different cell types during HF. Through a systematic analysis of each component’s regulatory mechanisms within the Hippo pathway, we elucidate their specific effects on cardiomyocytes, fibroblasts, endothelial cells, and macrophages in response to various cardiac injuries. Insights gleaned from both in vitro and in vivo studies highlight the therapeutic promise of targeting the Hippo pathway to address cardiovascular diseases, particularly HF.

  • Haifen Huang, Bin Peng, Qingyong Chen, Yi Wang, Ren Li
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0769
    Published: April 16, 2024
    Advance online publication: April 16, 2024
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    Supplementary material

    Background: Foam cell formation is an important step for atherosclerosis (AS) progression. We investigated the mechanism by which the long non-coding RNA (lncRNA) nuclear-enriched abundant transcript 1 (NEAT1) regulates foam cell formation during AS progression.

    Methods and Results: An in vivo AS model was created by feeding ApoE−/−mice a high-fat diet. Oxidized low-density lipoprotein (ox-LDL)-stimulated macrophages were used as a cellular AS model. Interactions between NEAT1, miR-17-5p, itchy E3 ubiquitin protein ligase (ITCH) and liver kinase B1 (LKB1) were analyzed. NEAT1 and ITCH were highly expressed in clinical samples collected from 10 AS patients and in ox-LDL-treated macrophages, whereas expression of both miR-17-5p and LKB1 was low. ITCH knockdown inhibited ox-LDL-induced lipid accumulation and LDL uptake in macrophages. Mechanistically speakingly, ITCH promoted LDL uptake and lipid accumulation in macrophages by mediating LKB1 ubiquitination degradation. NEAT1 knockdown reduced LDL uptake and lipid accumulation in macrophages and AS progression in vivo. NEAT1 promoted ITCH expression in macrophages by acting as a sponge for miR-17-5p. Inhibition of miR-17-5p facilitated ox-LDL-induced increase in LDL uptake and lipid accumulation in macrophages, which was reversed by NEAT1/ITCH knockdown.

    Conclusions:NEAT1 accelerated foam cell formation during AS progression through the miR-17-5p/ITCH/LKB1 axis.

  • Kohei Hachiro, Noriyuki Takashima, Tomoaki Suzuki
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0081
    Published: April 13, 2024
    Advance online publication: April 13, 2024
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    Supplementary material

    Background: We determined the left ventricular end-systolic diameter (LVDs) cut-off value for risk of major adverse cardiac and cerebrovascular events (MACCE) in Japanese asymptomatic or mildly symptomatic patients undergoing aortic valve replacement (AVR) for aortic valve regurgitation (AR), and investigated the effect of left ventricular dilation on long-term postoperative outcomes.

    Methods and Results: The 168 patients who underwent surgical AVR for AR at Shiga University of Medical Science between January 2002 and December 2022 were included in this study. Receiver operating characteristic curve analysis showed that the cut-off value of preoperative LVDs for the incidence of MACCE was 42.8 mm (area under the curve 0.616). Postoperative outcomes were compared between patients with preoperative LVDs >42.8 mm (n=77) and those with preoperative LVDs ≤42.8 mm (n=91) using propensity score matching. The 10-year estimated rates of freedom from MACCE in those with LVDs >42.8 and ≤42.8 mm were 59.9% and 85.7%, respectively; the curves differed significantly (P=0.004). In multivariable Cox proportional hazard regression analyses, preoperative LVDs >42.8 mm was an independent predictor of MACCE (hazard ratio 2.485; 95% confidence interval 1.239–4.984; P=0.010).

    Conclusions: Preoperative LVDs >42.8 mm is associated with an increased risk of MACCE in Japanese patients undergoing AVR for AR.

  • Yoshinari Enomoto, Takanori Ikeda, Keijiro Nakamura, Mahito Noro, Kaor ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0801
    Published: April 12, 2024
    Advance online publication: April 12, 2024
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    Background: Despite an increased incidence of chronic heart failure (HF) and sudden cardiac death (SCD), the use of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) is much lower in Japan than in Western countries. The HF Indication and SCD Prevention Trial Japan (HINODE) prospectively assessed the mortality rate, appropriately treated ventricular arrhythmias (VA), and HF in Japanese patients with a higher risk of HF.

    Methods and Results: HINODE consisted of ICD, CRT-defibrillator (CRT-D), pacing, and non-device treatment cohorts. This subanalysis evaluated the impact of the implantation of high-voltage devices (HVD; ICD and CRT-D) in 171 Japanese patients. We compared all-cause mortality, VA, and HF events between elderly (age >70 years at study enrollment) and non-elderly HVD recipients. The estimated survival rate through 24 months in the HVD cohort was 85.8% (97.5% lower control limit 77.6%). The risk of all-cause mortality was increased for the elderly vs. non-elderly (hazard ratio [HR] 2.82; 95% confidence interval [CI] 1.01–7.91; P=0.039), but did not differ after excluding ICD patients with CRT-D indication (HR 2.32; 95% CI 0.79–6.78; P=0.11). There were no differences in VA and HF event-free rates between elderly and non-elderly HVD recipients (P=0.73 and P=0.55, respectively).

    Conclusions: Although elderly patients may have a higher risk of mortality in general, the benefit of HVD therapy in this group is comparable to that in non-elderly patients.

  • Naoki Fujimura, Hideaki Obara, Kentaro Matsubara, Naoki Toya, Naoko Is ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0135
    Published: April 12, 2024
    Advance online publication: April 12, 2024
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    Background: Despite the widespread use of PROPATEN®, a bioactive heparin-bonded expanded polytetrafluoroethylene graft, in bypass surgery, there are only a few reports of long-term results. We evaluated the long-term results of PROPATEN®use for above-knee femoropopliteal bypass (AKFPB).

    Methods and Results: After PROPATEN®-based AKFPB, patients were prospectively registered at 20 Japanese institutions between July 2014 and October 2017 to evaluate long-term results. During the median follow-up of 76 months (interquartile range 36–88 months) for 120 limbs (in 113 patients; mean [±SD] age 72.7±8.1 years; 66.7% male; ankle-brachial index [ABI] 0.45±0.27; lesion length 26.2±5.7 cm; chronic limb-threatening ischemia in 45 limbs), there were 8 major amputations; however, clinical improvement was sustained (mean [±SD] ABI 0.87±0.23) and the Rutherford classification grade improved in 105 (87.5%) limbs at the latest follow-up. At 8 years, the primary patency, freedom from target-lesion revascularization, secondary patency, survival, and amputation-free survival, as estimated by the Kaplan-Meier method, were 66.3±4.8%, 71.5±4.4%, 86.5±3.4%, 53.1±5.0%, and 47.4±5.3%, respectively.

    Conclusions: This multicenter prospective registry-based analysis showed sustained excellent clinical improvement and secondary patency for up to 8 years following PROPATEN®-based AKFPB. PROPATEN®constitutes a durable and good revascularization option for complex superficial femoral artery lesions, especially when endovascular treatment is inappropriate or an adequate venous conduit is unavailable.

  • Chang Hoon Kim, Seung Hun Lee, Hyun Kuk Kim, Min Chul Kim, Ju Han Kim, ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0129
    Published: April 11, 2024
    Advance online publication: April 11, 2024
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    Supplementary material

    Background: Limited data exist regarding the prognostic implications of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with non-ST-elevation myocardial infarction (NSTEMI) who undergo percutaneous coronary intervention (PCI).

    Methods and Results: Of 13,104 patients in the nationwide Korea Acute Myocardial Infarction Registry-National Institutes of Health, 3,083 patients with NSTEMI who underwent PCI were included in the present study. The primary endpoint was major adverse cardiovascular events (MACE) at 3 years, a composite of all-cause death, recurrent myocardial infarction, unplanned repeat revascularization, and admission for heart failure. NT-proBNP was measured at the time of initial presentation for the management of NSTEMI, and patients were divided into a low (<700 pg/mL; n=1,813) and high (≥700 pg/mL; n=1,270) NT-proBNP group. The high NT-proBNP group had a significantly higher risk of MACE, driven primarily by a higher risk of cardiac death or admission for heart failure. These results were consistent after confounder adjustment by propensity score matching and inverse probability weighting analysis.

    Conclusions: In patients with NSTEMI who underwent PCI, an initial elevated NT-proBNP concentration was associated with higher risk of MACE at 3 years, driven primarily by higher risks of cardiac death or admission for heart failure. These results suggest that the initial NT-proBNP concentration may have a clinically significant prognostic value in NSTEMI patients undergoing PCI.

  • Toshiaki Isogai, Nobuaki Michihata, Akira Okada, Kojiro Morita, Hiroki ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0770
    Published: April 05, 2024
    Advance online publication: April 05, 2024
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    Supplementary material

    Background: Kampo, a Japanese herbal medicine, is approved for the treatment of various symptoms/conditions under national medical insurance coverage in Japan. However, the contemporary nationwide status of Kampo use among patients with acute cardiovascular diseases remains unknown.

    Methods and Results: Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified 2,547,559 patients hospitalized for acute cardiovascular disease (acute myocardial infarction, heart failure, pulmonary embolism, or aortic dissection) at 1,798 hospitals during the fiscal years 2010–2021. Kampo medicines were used in 227,008 (8.9%) patients, with a 3-fold increase from 2010 (4.3%) to 2021 (12.4%), regardless of age, sex, disease severity, and primary diagnosis. The top 5 medicines used were Daikenchuto (29.4%), Yokukansan (26.1%), Shakuyakukanzoto (15.8%), Rikkunshito (7.3%), and Goreisan (5.5%). From 2010 to 2021, Kampo medicines were initiated earlier during hospitalization (from a median of Day 7 to Day 3), and were used on a greater proportion of hospital days (median 16.7% vs. 21.4%). However, the percentage of patients continuing Kampo medicines after discharge declined from 57.9% in 2010 to 39.4% in 2021, indicating their temporary use. The frequency of Kampo use varied across hospitals, with the median percentage of patients prescribed Kampo medications increasing from 7.7% in 2010 to 11.5% in 2021.

    Conclusions: This nationwide study demonstrates increasing Kampo use in the management of acute cardiovascular diseases, warranting further pharmacoepidemiological studies on its effectiveness.

  • Yuta Suzuki, Hidehiro Kaneko, Akira Okada, Jin Komuro, Atsushi Mizuno, ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-24-0039
    Published: April 04, 2024
    Advance online publication: April 04, 2024
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    Background: Hypertension is a major cause of cardiovascular disease (CVD). In patients with hypertension, unawareness of the disease often results in poor blood pressure control and increases the risk of CVD. However, data in nationwide surveys regarding the proportion of unaware individuals and the implications of such on their clinical outcomes are lacking. We aimed to clarify the association between unawareness of being prescribed antihypertensive medications among individuals taking antihypertensive medications and the subsequent risk of developing CVD.

    Methods and Results: This retrospective cohort study analyzed data from the JMDC Claims Database, including 313,715 individuals with hypertension treated with antihypertensive medications (median age 56 years). The primary endpoint was a composite of myocardial infarction, angina pectoris, stroke, heart failure, and atrial fibrillation. Overall, 19,607 (6.2%) individuals were unaware of being prescribed antihypertensive medications. During the follow-up period, 33,976 composite CVD endpoints were documented. Despite their youth, minimal comorbidities, and the achievement of better BP control with a reduced number of antihypertensive prescriptions, unawareness of being prescribed antihypertensive medications was associated with a greater risk of developing composite CVD. Hazard ratios of unawareness of being prescribed antihypertensive medications were 1.16 for myocardial infarction, 1.25 for angina pectoris, 1.15 for stroke, 1.36 for heart failure, and 1.28 for atrial fibrillation. The results were similar in several sensitivity analyses, including the analysis after excluding individuals with dementia.

    Conclusions: Among individuals taking antihypertensive medications, assessing the awareness of being prescribed antihypertensive medications may help identify those at high risk for CVD-related events.

  • Satoshi Akagi
    Article type: EDITORIAL
    Article ID: CJ-24-0195
    Published: March 30, 2024
    Advance online publication: March 30, 2024
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  • Shingo Kato, Takeshi Kitai, Daisuke Utsunomiya, Mai Azuma, Kazuki Fuku ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0729
    Published: March 29, 2024
    Advance online publication: March 29, 2024
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    Background: This prospective multicenter study assessed the prevalence of myocardial injury in patients with COVID-19 using cardiac magnetic resonance imaging (CMR).

    Methods and Results: We prospectively screened 505 patients with moderate to severe COVID-19 disease from 7 hospitals in Japan. Of these patients, 31 (mean [±SD] age 63.5±10.4 years, 23 [74%] male) suspected of myocardial injury, based on elevated serum troponin or B-type natriuretic peptide concentrations either upon admission or 3 months after discharge, underwent CMR 3 months after discharge. The primary endpoint was the presence of myocardial injury, defined by any of the following: (1) contrast enhancement in the left or right ventricle myocardium on late gadolinium enhancement CMR; (2) left or right ventricular dysfunction (defined as <50% and <45%, respectively); and (3) pericardial thickening on contrast enhancement. The mean (±SD) duration between diagnosis and CMR was 117±16 days. The primary endpoint was observed in 13 of 31 individuals (42%), with 8 (26%) satisfying the modified Lake Louise Criteria for the diagnosis of acute myocarditis.

    Conclusions: This study revealed a high incidence of myocardial injury identified by CMR in patients with moderate to severe COVID-19 and abnormal findings for cardiac biomarkers.

  • Masatsune Ogura
    Article type: EDITORIAL
    Article ID: CJ-24-0186
    Published: March 29, 2024
    Advance online publication: March 29, 2024
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  • Hirochika Yamasaki, Hidekazu Kondo, Tomoaki Shiroo, Naohiro Iwata, Ter ...
    Article type: ORIGINAL ARTICLE
    Article ID: CJ-23-0948
    Published: March 22, 2024
    Advance online publication: March 22, 2024
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    Background: The prevalence of transthyretin amyloid cardiomyopathy (ATTR-CM) in atrial fibrillation (AF) patients remains unclear. We explored the efficacy of computed tomography-based myocardial extracellular volume (CT-ECV) combined with red flags for the early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.

    Methods and Results: Patients referred for AF ablation at Oita University Hospital were prescreened using the red-flag signs defined by echocardiographic or electrocardiographic findings, medical history, symptoms, and blood biochemical findings. Myocardial CT-ECV was quantified in red flag-positive patients using routine pre-AF ablation planning cardiac CT with the addition of delayed-phase cardiac CT scans. Patients with high (>35%) ECV were evaluated using technetium pyrophosphate (99 mTc-PYP) scintigraphy. A cardiac biopsy was performed during the planned AF ablation procedure if 99 mTc-PYP scintigraphy was positive. Between June 2022 and June 2023, 342 patients were referred for AF ablation. Sixty-seven (19.6%) patients had at least one of the red-flag signs. Myocardial CT-ECV was evaluated in 57 patients because of contraindications to contrast media, revealing that 16 patients had high CT-ECV. Of these, 6 patients showed a positive 99 mTc-PYP study, and 6 patients were subsequently diagnosed with wild-type ATTR-CM via cardiac biopsy and genetic testing.

    Conclusions: CT-ECV combined with red flags could contribute to the systematic early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.

  • 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.

  • 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.

  • 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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    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.

  • 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.

  • Masaomi Kimura
    Article type: EDITORIAL
    Article ID: CJ-24-0041
    Published: February 16, 2024
    Advance online publication: February 16, 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.

  • 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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    Supplementary material

    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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    Supplementary material

    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.

  • 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.

  • 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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    Supplementary material

    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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  • 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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