Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
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Showing 1-50 articles out of 91 articles from Advance online publication
  • Tetsu Tanaka, Kazuyuki Yahagi, Taishi Okuno, Kei Sato, Akira Osanai, M ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0115
    [Advance publication] Released: June 22, 2018
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  • Junichi Ozawa, Seiko Ohno, Yusuke Fujii, Takeru Makiyama, Hiroshi Suzu ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1032
    [Advance publication] Released: June 21, 2018
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    Background:Catecholaminergic polymorphic ventricular tachycardia (CPVT) has been often misdiagnosed as long QT syndrome (LQTS) type 1 (LQT1), which phenotypically mimics CPVT but has a relatively better prognosis.

    Methods and Results:The derivation and validation cohorts consisted of 146 and 21 patients, respectively, all of whom had exercise- or emotional stress-induced cardiac events. In the derivation cohort, 42 and 104 patients were first clinically diagnosed with CPVT and LQTS, respectively. Nine of 104 patient who had initial diagnosis of LQTS were found to carryRYR2mutations. They were misdiagnosed due to 4 different reasons: (1) transient QT prolongation after cardiopulmonary arrest; (2) QT prolongation after epinephrine test; (3) absence of ventricular arrhythmia after the exercise stress test (EST); and (4) assumption of LQTS without evidence. Based on genetic results, we constructed a composite scoring system by modifying the Schwartz score: replacing the corrected QT interval (QTc) at 4 min recovery time after EST >480 ms with that at 2 min, or with ∆QTc (QTc at 2 min of recovery−QTc before exercise) >40 ms and assigning a score of −1 for ∆QTc <10 ms or documented polymorphic ventricular arrhythmias. This composite scoring yielded 100% sensitivity and specificity for the clinical differential diagnosis between LQT1 and CPVT when applied to the validation cohort.

    Conclusions:The modified Schwartz score facilitated the differential diagnosis between LQT1 and CPVT.

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  • Yonghuai Wang, Guangyuan Li, Chunyan Ma, Zhengyu Guan, Xuanyi Jin, Yan ...
    Type: ORIGINAL ARTICLE
    Subject Area: Imaging
    Article ID: CJ-17-1422
    [Advance publication] Released: June 21, 2018
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    Background:Septal leftward motion followed by a counter motion during early systole is known as septal flash (SF) in patients with isolated complete left bundle-branch block (cLBBB). This study aimed to determine the predictive value of SF for reduction of left ventricular (LV) global systolic function using 2D speckle-tracking echocardiography (2D STE) in cLBBB patients.

    Methods and Results:The study group of 41 patients with isolated cLBBB and preserved LV ejection fraction and 41 age- and sex-matched control subjects were studied. The presence of SF and LV global longitudinal strain (GLS) were defined and measured using 2D STE. Multivariate logistic regression analysis identified the presence of SF as an independent factor predicting LV GLS >−20% in isolated cLBBB patients (odds ratio, 1.38; 95% confidence interval, 1.10–1.72; P=0.005). LV GLS in cLBBB patients with SF further decreased over time, whereas LV GLS did not decrease in patients without SF. The presence of SF was shown to be an independent factor predicting the reduction of LV global systolic function (relative reduction in LV GLS >15% from baseline to 2-year follow-up) (odds ratio, 1.27; 95% confidence interval, 1.06–1.50; P=0.008).

    Conclusions:Assessment of SF by 2D STE may be an easy and effective method of predicting the reduction in LV global systolic function in isolated cLBBB patients.

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  • Mizuri Taki, Yusuke Ishiyama, Hiroyuki Mizuno, Takahiro Komori, Ken Ko ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-18-0375
    [Advance publication] Released: June 21, 2018
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    Background:Brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) are prognostic biomarkers. Although these 2 peptides differ with regard to biological characteristics, there are few reports on the differences between BNP and NT-proBNP with regard to cardiovascular events or according to sex.

    Methods and Results:Between 2005 and 2012, this study analyzed 3,610 of 4,310 Japanese outpatients (mean age, 65 years; men, n=1,664; women, n=1,947) with a history of at least one cardiovascular event who were recruited to the Japan Morning Surge-Home Blood Pressure Study. During an average 4-year follow-up, there were 129 cardiovascular events. Both median BNP (21.1 pg/mL; IQR, 10.9–40.6 pg/mL vs. 16.2 pg/mL, IQR, 7.2–36.2 pg/mL, P<0.001) and median NT-proBNP (54.7 pg/mL; IQR, 30.2–102.6 pg/mL vs. 44.9 pg/mL, IQR, 20.7–92.6 pg/mL, P<0.001) were significantly higher in women than in men. A 1-SD increment in log-transformed BNP (hazard ratio [HR], 2.18; 95% CI: 1.53–3.10) and NT-proBNP (HR, 2.39; 95% CI: 1.73–3.31) was associated with a significant increase in cardiovascular events in women; in men, only NT-proBNP showed this association. There was an interaction between log-transformed BNP (P=0.007) or NT-proBNP (P=0.001) and cardiovascular events according to sex.

    Conclusions:Both BNP and NT-proBNP predicted cardiovascular outcomes in a large Japanese clinical population. BNP and NT-proBNP were significantly stronger predictors in women than in men.

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  • Shigeki Kimura, Tomoyo Sugiyama, Keiichi Hishikari, Shun Nakagama, Shu ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiovascular Intervention
    Article ID: CJ-18-0186
    [Advance publication] Released: June 15, 2018
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    Background:The in vivo lesion morphologies and plaque components of coronary chronic total occlusion (CTO) lesions remain unclear.

    Methods and Results:We investigated 57 consecutive CTO lesions in 57 patients with stable angina pectoris undergoing elective percutaneous coronary intervention with intravascular ultrasound (IVUS) and coronary angioscopy (CAS) examination. All CTO lesions were classified according to the proximal angiographic lumen pattern; tapered-type (T-CTO) and abrupt-type (A-CTO). The differences in the intracoronary images of these lesion types were evaluated according to the location within the CTO segment. A total of 35 lesions (61.4%) were T-CTO. T-CTO lesions had higher frequencies of red thrombi (proximal 71.4%; middle 74.3%; distal 31.4%; P<0.001) and bright-yellow plaques (yellow-grade 2–3) (48.6%; 74.3%; 2.9%; P<0.001) at the proximal or middle than at the distal subsegment; A-CTO lesions showed no significant differences among the 3 sub-segments. At the middle subsegment, T-CTO lesions showed higher frequencies of positive remodeling (51.4% vs. 18.2%, P=0.01) and bright-yellow plaques (74.3% vs. 13.6%, P<0.001) compared with A-CTO lesions. Multivariate analysis identified bright-yellow plaque as an independent predictor (odds ratio, 7.25; 95% confidence interval, 1.25–42.04; P=0.03) of the occurrence of periprocedural myocardial necrosis.

    Conclusions:The combination of IVUS and CAS analysis may be useful for identifying lesion morphology and plaque components, which may help clarify the pathogenetic mechanism of CTO lesions.

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  • Yuichiro Maekawa, Keitaro Akita, Shuichiro Takanashi
    Type: REVIEW
    Article ID: CJ-18-0575
    [Advance publication] Released: June 15, 2018
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    Hypertrophic cardiomyopathy (HCM) is a complex and relatively common genetic cardiac disease that has been the subject of intense investigation for over 50 years. Most patients with HCM are asymptomatic, but some develop symptoms, often many years after the appearance of electrocardiographic or echocardiographic evidence of left ventricular hypertrophy. Symptoms due to the left ventricular outflow tract obstruction frequently worsen over time, requiring septal reduction therapy (SRT) despite optimal medical therapy. Percutaneous transluminal septal myocardial ablation (PTSMA) and surgical myectomy are collectively known as SRT. In this review, we will focus on the emerging concept and practical implication of SRT and the available evidence on either PTSMA or surgical myectomy in the literature.

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  • Chung Hun Kim, Jeong Hoon Yang, Taek Kyu Park, Young Bin Song, Joo-Yon ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-17-1272
    [Advance publication] Released: June 14, 2018
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    Background:We investigated whether the outcome of revascularization differed from the outcome of medical therapy in chronic kidney disease (CKD) and non-CKD patients with chronic total occlusion (CTO).

    Methods and Results:A total of 2,010 patients with CTO who underwent revascularization (n=1,355), including percutaneous coronary intervention (n=878) and coronary artery bypass grafting (n=477), or had medical therapy alone (n=655) were examined. The primary outcome was all-cause death during follow-up. Among the non-CKD patients (n=1,679), revascularization had a lower incidence of all-cause death (adjusted hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.41–0.72, P<0.001) compared with medical therapy. Among the CKD patients (n=331), the difference in the incidence of all-cause death was not as marked between the 2 treatments (adjusted HR 0.71, 95% CI 0.48–1.06, P=0.09). There was a significant interaction between kidney function and treatment strategy (revascularization vs. medical therapy) on all-cause death (P for interaction=0.014).

    Conclusions:Based on the clinical outcomes, in CTO patients with preexisting CKD, revascularization via PCI or bypass surgery might not be as effective as in non-CKD patients.

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  • Mikiko Ohashi, Takashi Kohno, Shun Kohsaka, Ryoma Fukuoka, Kentaro Hay ...
    Type: ORIGINAL ARTICLE
    Subject Area: Preventive Medicine
    Article ID: CJ-17-1395
    [Advance publication] Released: June 13, 2018
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    Background:Excessive daytime sleepiness (EDS) is a significant public health concern, with sleep-disordered breathing (SDB) being a common cause. However, their precise relationship in patients with cardiovascular disease (CVD) is unclear. Furthermore, whether comorbid psychological disorders could contribute to EDS remains unknown. We aimed to assess the prevalence of EDS and its related factors, including SDB and depression, in patients with CVD.

    Methods and Results:We analyzed data from 1,571 patients admitted for various CVDs in a single university hospital (median age, 67 [56–76] years; 29.6% women). We assessed EDS using the Japanese version of the Epworth Sleepiness Scale (ESS; median 6.0 [4.0–9.0]). The presence of EDS (ESS >10, n=297 [18.9%]) did not differ between patients with and without SDB, which was screened with nocturnal pulse oximetry. In contrast, the patients with EDS had higher depression scores (Hospital Anxiety and Depression Scale subscore for depression [HADS-D] and Patient Healthcare Questionnaire [PHQ]-9). The depression scores, measured by HADS-D (odds ratio [OR] 1.14; 95% confidence interval [CI], 1.07–1.22) and PHQ-9 (OR, 1.14; 95% CI, 1.07–1.20) were independent determinants of EDS. These relationships among EDS, SDB, and depression were consistent among the subgroups with cardiovascular comorbidities.

    Conclusions:The presence of EDS is associated with depressive symptoms, but not with SDB, in patients with CVD, suggesting that these patients should be thoroughly assessed for psychological disturbances.

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  • Kenji Sakamoto, Suguru Nagamatsu, Eiichiro Yamamoto, Koichi Kaikita, K ...
    Type: REVIEW
    Article ID: CJ-18-0516
    [Advance publication] Released: June 13, 2018
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    In the past decades, coronary imaging has evolved as a valuable adjunct to angiography, providing scientific insights into vascular biology and practical guidance by direct visualization of atherosclerosis and other pathologic conditions within the vessel walls. Especially with intravascular ultrasound (IVUS), the signal is able to penetrate below the luminal surface, so the entire cross-section of an artery, including the complete thickness of the plaque, can be imaged in real-time. On the other hand, optical coherence tomography (OCT) has been offering higher image resolution of both the plaque and the luminal surface. These technologies offer the opportunity to gather diagnostic information about the process of atherosclerosis and to directly observe the effects of various interventions on the plaque and arterial walls. IVUS has proven itself to be a practical and useful tool in the evaluation and optimal guidance of interventional vascular medicine. In this review, we detail the current modalities of coronary imaging and their usefulness in the diagnosis and management of patients with high-risk coronary plaques.

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  • Raisuke Iijima, Norihiro Kougame, Hidehiko Hara, Masao Moroi, Masato N ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiovascular Intervention
    Article ID: CJ-18-0121
    [Advance publication] Released: June 12, 2018
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    Background:The aim of this study was to investigate whether drug-coated balloon (DCB) treatment is effective for de novo coronary lesions that are unsuitable for drug-eluting stent (DES) implantation.

    Methods and Results:This retrospective study included 118 de novo lesions that were not suitable for DES implantation. Of the lesions, 40% was treated because of very small vessel disease. Patients with planned non-cardiac surgery and at high bleeding risk were 3% and 19%, respectively, and lesions that easily develop stent fracture comprised 26%. Clinically driven target lesion revascularization (TLR) was the primary endpoint. The rate of suboptimal lesion preparation before DCB treatment was set as the secondary endpoint. Optimal lesion preparation was defined as acquisition of Thrombolysis in Myocardial Infarction flow grade 3, minor coronary dissection, and residual stenosis ≤30%. The rate of suboptimal lesion preparation was 2.5% and 3 patients needed bail-out stenting. Accordingly, 115 patients were treated with a DCB. Clinically driven TLR had occurred in 8 patients (7.0%) at the 8-month follow-up. The presence of chronic total occlusion was identified as an independent predictor for TLR (odds 11.57; 95% confidence interval, 1.38–135.54; P=0.02).

    Conclusions:For lesions that are unsuitable for stent implantation, stent-less intervention using a DCB should be considered initially. The present study also highlighted that lesion preparation is key to a successful DCB strategy.

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  • Toshiki Kuno, Akimichi Shibata, Masaki Kodaira, Yohei Numasawa
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0143
    [Advance publication] Released: June 12, 2018
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  • Michihiro Satoh, Takahisa Murakami, Kei Asayama, Takuo Hirose, Masahir ...
    Type: ORIGINAL ARTICLE
    Subject Area: Epidemiology
    Article ID: CJ-17-1227
    [Advance publication] Released: June 09, 2018
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    Background:N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been used for risk stratification in heart failure or acute coronary syndrome, but the beyond 5-year predictive value of NT-proBNP for stroke remains an unsettled issue in Asian patients. The aim of the present study was to clarify this point.

    Methods and Results:We followed 1,198 participants (33.4% men; mean age, 60.5±11.1 years old) in the Japanese general population for a median of 13.0 years. A first stroke occurred in 93 participants. Referencing previous reports, we stratified participants according to NT-proBNP 30.0, 55.0, and 125.0 pg/mL. Using the NT-proBNP <30.0 pg/mL group as a reference, adjusted HR for stroke (95% CI) in the NT-proBNP 30.0–54.9-pg/mL, 55.0–124.9-pg/mL, and ≥125.0-pg/mL groups were 1.92 (0.94–3.94), 1.77 (0.85–3.66), and 1.99 (0.86–4.61), respectively. With the maximum follow-up period set at 5 years, the hazard ratio of the NT-proBNP≥125.0-pg/mL group compared with the <30.0-pg/mL group increased significantly (HR, 4.51; 95% CI: 1.03–19.85). On extension of the maximum follow-up period, however, the association between NT-proBNP and stroke risk weakened.

    Conclusions:NT-proBNP was significantly associated with an elevated stroke risk. Given, however, that the predictive power decreased with the number of years after NT-proBNP measurement, NT-proBNP should be re-evaluated periodically in Asian patients.

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  • Rui Fu, Chenxi Song, Jingang Yang, Yan Wang, Bao Li, Haiyan Xu, Xiaoji ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-17-1078
    [Advance publication] Released: June 08, 2018
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    Background:Accurate risk stratification of non-ST segment elevation myocardial infarction (NSTEMI) patients is important due to great variability in mortality risk, but, to date, no prediction model has been available. The aim of this study was therefore to establish a risk score to predict in-hospital mortality risk in NSTEMI patients.

    Methods and Results:We enrolled 5,775 patients diagnosed with NSTEMI from the China Acute Myocardial Infarction (CAMI) registry and extracted relevant data. Patients were divided into a derivation cohort (n=4,332) to develop a multivariable logistic regression risk prediction model, and a validation cohort (n=1,443) to test the model. Eleven variables independently predicted in-hospital mortality and were included in the model: age, body mass index, systolic blood pressure, Killip classification, cardiac arrest, electrocardiogram ST-segment depression, serum creatinine, white blood cells, smoking status, previous angina, and previous percutaneous coronary intervention. In the derivation cohort, the area under curve (AUC) for the CAMI-NSTEMI risk model and score was 0.81 and 0.79, respectively. In the validation cohort, the score also showed good discrimination (AUC, 0.86). Diagnostic performance of CAMI-NSTEMI risk score was superior to that of the GRACE risk score (AUC, 0.81 vs. 0.72; P<0.01).

    Conclusions:The CAMI-NSTEMI score is able to accurately predict the risk of in-hospital mortality in NSTEMI patients.

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  • Hee Tae Yu, Pil-Sung Yang, Tae-Hoon Kim, Jae-Sun Uhm, Jong-Youn Kim, B ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1358
    [Advance publication] Released: June 08, 2018
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    Background:Catheter ablation is a good treatment option for atrial fibrillation (AF) in young symptomatic patients. However, there is little information on the efficacy of catheter ablation of early-onset AF between sexes.

    Methods and Results:This study included 1,060 patients under the age 60 years old (837 men, 49.8±7.7 years old, 70.8% paroxysmal AF) who underwent catheter ablation for AF. Sex differences in clinical presentation and ablation outcomes were compared with and without propensity score-matching. During 24.5±18.9 months of follow-up, women showed significantly higher clinical recurrence of AF than men (log-rank, P=0.002). Female sex was independently associated with post-ablation clinical recurrence of AF (adjusted hazard ratio (HR) 2.58 [1.06–6.30], P=0.037). Women had a higher proportion of left ventricular diastolic dysfunction (E/Em, P<0.001), higher prevalence of heart failure (P=0.017), greater left atrial (LA) volume index (P=0.001), lower LA endocardial voltage (P<0.001), and higher parasympathetic nervous activity (root-mean square of differences, P<0.001; high-frequency (HF), P=0.010) than men. After a second ablation procedure (n=111), women still showed a higher clinical recurrence rate than men (log-rank, P=0.003) during 22.9±15.0 months of follow-up.

    Conclusions:Among patients with early-onset AF who underwent catheter ablation, women showed poorer clinical outcomes than men after de novo and second procedures. Left ventricular dysfunction, LA remodeling, and autonomic nervous function may be potential mechanisms underlying sex differences in catheter ablation outcomes of early-onset AF.

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  • Takashi Horie, Seiji Yamazaki, Sayaka Hanada, Shuzo Kobayashi, Tatsuo ...
    Type: ORIGINAL ARTICLE
    Subject Area: Peripheral Vascular Disease
    Article ID: CJ-17-1220
    [Advance publication] Released: June 07, 2018
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    Background:The clinical usefulness of peripheral blood (PB) mononuclear cell (MNC) transplantation in patients with peripheral arterial disease (PAD), especially in those with mild-to-moderate severity, has not been fully clarified.

    Methods and Results:A randomized clinical trial was conducted to evaluate the efficacy and safety of granulocyte colony-stimulating factor (G-CSF)-mobilized PBMNC transplantation in patients with PAD (Fontaine stage II–IV and Rutherford category 1–5) caused by arteriosclerosis obliterans or Buerger’s disease. The primary endpoint was progression-free survival (PFS). In total, 107 subjects were enrolled. At baseline, Fontaine stage was II/III in 82 patients and IV in 21, and 54 patients were on hemodialysis. A total of 50 patients had intramuscular transplantation of PBMNC combined with standard of care (SOC) (cell therapy group), and 53 received SOC only (control group). PFS tended to be improved in the cell therapy group than in the control group (P=0.07). PFS in Fontaine stage II/III subgroup was significantly better in the cell therapy group than in the control group. Cell therapy-related adverse events were transient and not serious.

    Conclusions:In this first randomized, large-scale clinical trial of G-CSF-mobilized PBMNC transplantation, the cell therapy was tolerated by a variety of PAD patients. The PBMNC therapy was significantly effective for inhibiting disease progression in mild-to-moderate PAD.

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  • Yasuaki Tanaka, Atsushi Takahashi, Takamitsu Takagi, Jun Nakajima, Kat ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1352
    [Advance publication] Released: June 07, 2018
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    Background:The aim of this study was to categorize the conduction patterns between the right atrium (RA) and the superior vena cava (SVC), and to determine the ideal procedure for SVC isolation using a novel high-resolution mapping system.

    Methods and Results:RA-SVC conduction was evaluated using the RHYTHMIA system in 113 patients (age 62.8±11.5 years, paroxysmal: 67) with atrial fibrillation (AF) after pulmonary vein (PV) isolation. In 56 patients, a line of conduction block was found to run obliquely just above the sinus node (Block group). The remaining 57 patients did not have block (Non-block group). Non-PV foci were spontaneous or provoked with isoproterenol after electrical cardioversion of pacing-induced AF. In 43 patients with SVC foci (Block group: 22, Non-Block group: 21), SVC was isolated by radiofrequency applications delivered along the line connecting the open ends of the block line (Block group) or by conventional methods (Non-block group). The Block group required fewer radiofrequency deliveries for SVC isolation than the Non-Block group (4.2±0.9 vs. 10.2±2.8 times; P<0.0001). The isolated SVC area was larger in the Block group (15.7±3.7 vs. 10.5±3.1 cm2; P<0.0001).

    Conclusions:We found that approximately half of patients with AF had a diagonal line of block at the RA-SVC junction that could be utilized to isolate the SVC with fewer radiofrequency deliveries.

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  • Yoshiharu Soga, Hiromasa Kira, Makoto Wakamiya, Naomi Manabe, Takamits ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-17-1094
    [Advance publication] Released: June 06, 2018
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  • Miwa Ishida, Yoko Yamada, Tomohiro Mizutani, Atsuko Hara, Yoshiki Seki ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0070
    [Advance publication] Released: June 06, 2018
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  • Yoshinari Enomoto, Hikari Hashimoto, Rina Ishii, Shunsuke Torii, Keiji ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0263
    [Advance publication] Released: June 06, 2018
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  • Takahiro Okumura, Toyoaki Murohara
    Type: EDITORIAL
    Article ID: CJ-18-0584
    [Advance publication] Released: June 06, 2018
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  • Ruka Yoshida, Itsuro Morishima, Kensuke Takagi, Yasuhiro Morita, Hidey ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiovascular Intervention
    Article ID: CJ-17-1171
    [Advance publication] Released: June 01, 2018
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    Background:Whether direct oral anticoagulants (DOACs) are safer and more effective than vitamin K antagonist (VKA) for preventing thrombotic events in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remains unknown.

    Methods and Results:Between April 2011 and March 2014, data from 2,045 consecutive patients who underwent PCI were retrospectively examined. Of them, 129 patients treated with oral anticoagulants (OACs) and antiplatelet agents because of AF were enrolled. Primary bleeding outcome was a composite of major and minor bleeding, as per the Thrombolysis in Myocardial Infarction criteria. Secondary efficacy outcome was a composite outcome of death, myocardial infarction (MI), stroke, and target-lesion revascularization (TLR). Of the 129 patients, VKA was used in 84 and DOACs in 45. The mean time in the therapeutic range for the VKA group was 52.6%. The ratio of CHA2D2-VASC and HAS-BLED scores ≥3 was similar between the groups (VKA, 90.5%; DOAC, 84.4%; P=0.31 and VKA, 79.8%; DOAC, 68.9%; P=0.17, respectively). During follow-up (median, 1,080 days), the primary bleeding outcome tended to occur less (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.24–1.11, P=0.10) and the composite secondary efficacy outcome significantly less frequently (HR, 0.40; 95% CI, 0.14–0.91; P=0.03) in the DOAC group.

    Conclusions:Compared with DOACs, VKA with poorly controlled INR and antiplatelet agents correlated with adverse outcomes of death, MI, stroke, and TLR in patients undergoing PCI.

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  • Sohei Yoshimura, Masatoshi Koga, Shoichiro Sato, Kenichi Todo, Hiroshi ...
    Type: ORIGINAL ARTICLE
    Subject Area: Stroke
    Article ID: CJ-18-0067
    [Advance publication] Released: June 01, 2018
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    Background:We determined the 2-year long-term risk-benefit profile in patients with stroke or transient ischemic attack (TIA) receiving warfarin or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF) using a prospective, multicenter, observational registry in Japan.

    Methods and Results:NVAF patients within 7 days after onset of ischemic stroke/TIA were enrolled in 18 stroke centers. Outcome measures included ischemic and bleeding events and death in the 2-year follow-up period. We enrolled 1,116 patients taking either warfarin (650 patients) or DOACs (466 patients) at acute hospital discharge. DOAC users were younger and had lower National Institutes of Health Stroke Scale, CHADS2and discharge modified Rankin Scale scores than warfarin users (P<0.0001 each). Incidences of stroke/systemic embolism (adjusted hazard ratio, 1.07; 95% CI, 0.66–1.72), all ischemic events (1.13; 0.72–1.75), and ischemic stroke/TIA (1.58; 0.95–2.62) were similar between groups. Risks of intracranial hemorrhage (0.32; 0.09–0.97) and death (0.41; 0.26–0.63) were significantly lower for DOAC users. Infection was the leading cause of death, accounting for 40% of deaths among warfarin users.

    Conclusions:Stroke/TIA patients receiving DOACs for secondary prevention were younger and had lower stroke severity and risk indices than those receiving warfarin. Estimated cumulative incidences of stroke and systemic embolism within 2 years were similar between warfarin and DOACs users, but those of death and intracranial hemorrhage were significantly lower among DOAC users.

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  • Akinori Sawamura, Takahiro Okumura, Masaaki Ito, Yukio Ozaki, Nobuyuki ...
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-18-0136
    [Advance publication] Released: June 01, 2018
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    Background:Fulminant myocarditis (FM) presents various abnormal findings on ECG, the prognostic impact of which has not been not fully elucidated. The aim of this study was therefore to clarify the prognostic value of ECG data in FM patients supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO).

    Methods and Results:In this multicenter chart review, we investigated 99 patients with FM supported by VA-ECMO. The final cohort consisted of 87 patients (mean age, 52±16 years; female, 42%) after 12 patients who required conversion to other forms of mechanical circulatory support were excluded. The median LVEF was 14.5%. At the time of VA-ECMO initiation, 38 patients (44%) had arrhythmias including atrial fibrillation (6%), complete atrioventricular block (CAVB; 17%), and ventricular tachycardia or fibrillation (VT/VF; 15%). Of the 49 patients with sinus rhythm (SR), 26 had QRS duration ≥120 ms (wide QRS). On logistic regression analysis, wide QRS predicted in-hospital death in patients with SR (OR, 3.6; 95% CI: 1.07–13.61, P=0.04). Compared with SR with narrow QRS (QRS duration <120 ms), CAVB and VT/VF had a higher risk of in-hospital death (CAVB: OR, 7.20; 95% CI: 1.78–34.15, P=0.005; VT/VF: OR, 8.10; 95% CI: 1.86–42.31, P=0.005).

    Conclusions:In patients with FM, CAVB and VT/VF carried a higher risk of in-hospital death. Wide QRS also predicted a higher risk of in-hospital death in patients with SR.

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  • Won-Jong Park, Jang-Won Son, Chan-Hee Lee, Jung-Hee Lee, Ung Kim, Jong ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-17-1361
    [Advance publication] Released: May 31, 2018
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  • Takeshi Soeki, Tomomi Matsuura, Takeshi Tobiume, Sachiko Bando, Kazuhi ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-0758
    [Advance publication] Released: May 30, 2018
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    Background:The ability to identify risk markers for new-onset atrial fibrillation (AF) is critical to the development of preventive strategies, but it remains unknown whether a combination of clinical, electrocardiographic, and echocardiographic parameters predicts the onset of AF. In the present study, we evaluated the predictive value of a combined score that includes these parameters.

    Methods and Results:We retrospectively studied 1,040 patients without AF who underwent both echocardiography and 24-h Holter electrocardiography between May 2005 and December 2010. During a median follow-up period of 68.4 months (IQR, 49.9–93.3 months), we investigated the incidence of new-onset AF. Of the 1,040 patients, 103 (9.9%) developed AF. Patients who developed AF were older than patients who did not. Total heart beats, premature atrial contraction (PAC) count, maximum RR interval, and frequency of sinus pause quantified on 24-h electrocardiography were associated with new-onset AF. LA diameter (LAD) on echocardiography was also associated with the development of AF. On multivariate Cox analysis, age ≥58 years, PAC count ≥80 beats/day, maximum RR interval ≥1.64 s, and LAD ≥4.5 cm were independently associated with the development of AF. The incidence rate of new-onset AF significantly increased as the combined score (i.e., the sum of the risk score determined using hazard ratios) increased.

    Conclusions:A combined score that includes age, PAC count, maximum RR interval, and LAD could help characterize the risk of new-onset AF.

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  • Shiro Baba, Daisuke Yoshinaga, Kentaro Akagi, Koichi Matsuda, Atsushi ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0449
    [Advance publication] Released: May 30, 2018
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  • Po-Lin Chen, Ting-Chao Lin, I-Ming Chen
    Type: ORIGINAL ARTICLE
    Subject Area: Peripheral Vascular Disease
    Article ID: CJ-18-0163
    [Advance publication] Released: May 29, 2018
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    Background:Endovascular therapy has become the first-line treatment for most peripheral artery diseases, but re-entry into the true lumen is not always possible, particularly in some cases of chronic total occlusion (CTO). We previously reported a novel hybrid Viabahn-assisted bypass (VAB) technique to facilitate revascularization of the femoro-popliteal CTO. This study assessed the midterm results of VAB technique.

    Methods and Results:Between January 2013 and April 2017, 440 patients received femoro-popliteal intervention and 17 of them (mean age, 76.2 years; 11 male patients) were treated using the VAB technique. The technical success was 100%. The mean follow-up period was 27.4±14.4 months (range, 6–50 months). Two patients underwent major amputation at 6 and 11 months postoperatively, but they died of acute myocardial infarction and of sepsis, respectively. Another 3 patients received re-intervention because of edge stenosis of the Viabahn stent graft. Another patient had acute Viabahn thrombosis and was treated using open thrombectomy. The primary and secondary patency rates at 12 months were both 88.2%, and at 24 months they were 69.2% and 84.6%, respectively.

    Conclusions:The VAB technique could be a safe and feasible alternative treatment for long femoro-popliteal CTO when conventional treatments fail. The technical success is high, and the midterm patency rates are acceptable.

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  • Suguru Miyazaki, Kenji Kuwaki, Kan Kajimoto, Satoshi Matsushita, Shizu ...
    Type: ORIGINAL ARTICLE
    Subject Area: Valvular Heart Disease
    Article ID: CJ-17-0900
    [Advance publication] Released: May 25, 2018
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    Background:Low flow (LF; i.e., reduced left ventricular stroke volume index <35 mL/m2) can occur with severe aortic stenosis (AS). However, few studies have investigated the effects of LF on early and late outcomes after aortic valve replacement (AVR) for severe AS.

    Methods and Results:In all, 285 severe AS patients undergoing isolated AVR at Juntendo University Hospital between August 2002 and August 2015 were enrolled in the study. In this cohort, 52 patients (18%) had LF. Compared with patients with normal flow (NF) severe AS, early postoperative mortality (9.6% vs. 1.2%; P=0.006), gastrointestinal complications (5.7% vs. 0.8%; P=0.04), and the duration of the intensive care unit (ICU) stay (81.7 vs. 35.3 h; P=0.02) were increased in LF patients with severe AS. LF was an independent predictor of early mortality (Model A, odds ratio [OR] 6.81, P=0.01; Model B, OR 6.69, P=0.01) and composite complications (Model A, OR 2.44, P=0.02). In propensity score-matched comparisons, early mortality (12.8% vs. 0%; P=0.02), composite complications (28.2% vs. 10.2%; P=0.04), and duration of ICU stay (97.4 vs. 22.1 h; P=0.006) were significantly increased in LF than NF patients.

    Conclusions:LF, as an important independent risk factor for postoperative mortality and morbidity, should be included in risk stratification and assessment in severe AS patients.

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  • Kageyuki Oba, Minetaka Maeda, Gulinu Maimaituxun, Satoshi Yamaguchi, O ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-18-0021
    [Advance publication] Released: May 25, 2018
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    Background:Although increasing evidence suggests that epicardial adipose tissue volume (EATV) is associated with atrial fibrillation (AF), it is controversial whether there is a dose-response relationship of increasing EATV along the continuum of AF. We evaluated the effect of the EATV on the prevalence of paroxysmal AF (PAF) and persistent AF (PeAF) and the relationships with cardiac structure and functional remodeling.

    Methods and Results:Subjects who underwent multidetector computed tomography (MDCT) coronary angiography because of symptoms suggestive of coronary artery disease were divided into sinus rhythm (SR) (n=112), PAF (n=133), and PeAF (n=71) groups. The EATV index (EATV/body surface area, mL/m2) was strongly associated with the prevalence of PAF and PeAF on the model adjusted for known AF risk factors. The effect of the EATV index on the prevalence of PeAF, but not on that of PAF, was modified by the left atrial (LA) dimension, suggesting that extension of the LA dimension is related to EATV expansion in PeAF. The cutoff value of the EATV index for the prevalence was higher in PeAF than in PAF (64 vs. 55 mL/m2, P<0.01).

    Conclusions:The EATV index is associated with the prevalence of PAF and PeAF, and its cutoff values are predictive for PAF and PeAF development independently of other AF risk factors.

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  • Hiromi Kayamori, Takeshi Kashimura, Yosuke Horii, Tsutomu Kanazawa, To ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0332
    [Advance publication] Released: May 25, 2018
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  • Daehoon Kim, Pil-Sung Yang, Tae-Hoon Kim, Jae-Sun Uhm, Junbeom Park, H ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-17-1179
    [Advance publication] Released: May 24, 2018
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    Background:Both atrial fibrillation (AF) and osteoporosis are common in older adults. The purpose of this study was to investigate whether comorbid AF in patients with osteoporosis is associated with fracture incidence, or death after fracture.

    Methods and Results:From the National Health Insurance Service database of Korea, we selected 31,778 patients with osteoporosis. During a median follow-up of 48 months, the incidence of bone fractures was higher in AF patients than in non-AF patients (3.20 vs. 2.18 per 100 person-years), respectively. In the multivariate Cox regression analysis, AF was associated with fracture independently of other risk factors with an adjusted hazard ratio (HR) of 1.21 (95% confidence interval [CI], 1.02–1.41; P=0.031). The mortality rate after fracture was significantly higher in AF patients than it was in non-AF patients (adjusted HR, 1.92; 95% CI, 1.35–3.27; P=0.016). After propensity score-matching, AF was consistently associated with a higher risk of osteoporotic fracture and subsequent death after fracture. In AF patients, older age, female sex, being underweight (body mass index <18.5 kg/m2), decreased physical activity (exercise <3 times/week), history of stroke or transient ischemic attack, thiazide use, sedative use, and higher CHADS2(≥2 points) or CHA2DS2-VASc (≥2 points) scores were associated with the incidence of fractures.

    Conclusions:Comorbid AF in patients with osteoporosis was associated with an increased risk of bone fracture and death after fracture.

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  • Shao-Wei Chen, Victor Chien-Chia Wu, Yu-Sheng Lin, Ching-Chang Chen, D ...
    Type: ORIGINAL ARTICLE
    Subject Area: Cardiovascular Surgery
    Article ID: CJ-18-0003
    [Advance publication] Released: May 24, 2018
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    Background:This study compared the long-term outcomes of prosthetic heart valve replacement with mechanical or bioprosthetic valves in patients with prior stroke.

    Methods and Results:In total, 1,984 patients with previous stroke who had received valve replacement between 2000 and 2011 were identified using the Taiwan National Health Insurance Research Database. Propensity score matching analysis was used. Ultimately, 547 patients were extracted from each group and were eligible for analysis. On survival analysis, the risks of all-cause mortality and recurrence of stroke were similar. The incidence of major bleeding was greater in the mechanical valve group than in the bioprosthetic valve group (P=0.040), whereas no difference was observed in re-do valve surgery. On subgroup analysis, the bioprosthetic valve was favored for older age (≥60 years) and previous gastrointestinal (GI) bleeding patients. The mechanical valve, however, was favored for younger patients (<60 years).

    Conclusions:In patients with previous stroke, bioprosthetic valves had a lower incidence of complications connected to major bleeding than did the mechanical valves. Survival and stroke recurrence rates, however, did not differ between the 2 groups. We recommend bioprosthetic valves for patients >60 years or who have a history of GI bleeding.

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  • Yuichi Kawase, Reo Hata, Takeshi Tada, Harumi Katoh, Kazushige Kadota
    Type: ORIGINAL ARTICLE
    Subject Area: Heart Failure
    Article ID: CJ-18-0057
    [Advance publication] Released: May 24, 2018
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    Background:Carperitide is used to treat acute heart failure (AHF) in Japan. Whether the degree of pulmonary congestion is associated with the effects of carperitide on AHF is unclear.

    Methods and Results:We retrospectively investigated the in-hospital outcomes and prognoses of 742 patients hospitalized for AHF between February 2015 and January 2017 and classified them into carperitide and non-carperitide groups, stratified according to the degree of pulmonary congestion. The median follow-up duration after admission was 231 days. In patients with moderate–severe pulmonary congestion, the rate of remaining congestion on chest X-ray at discharge was lower in the carperitide group than in the non-carperitide group (1.5% vs. 9.0%, P=0.004). Also, the carperitide group had significant reduction in a composite of all-cause death or rehospitalization for HF (adjusted hazard ratio, 0.62; 95% CI: 0.41–0.93; P=0.02). In patients with no–mild pulmonary congestion, carperitide was not associated with better clinical outcome.

    Conclusions:In the treatment of AHF with moderate–severe pulmonary congestion, carperitide is associated with more effective decongestion in the short term and better prognosis in the long term.

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  • Nobuo Sasaki, Hideya Yamamoto, Ryoji Ozono, Saeko Fujiwara, Yasuki Kih ...
    Type: ORIGINAL ARTICLE
    Subject Area: Epidemiology
    Article ID: CJ-18-0031
    [Advance publication] Released: May 23, 2018
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    Background:N-Terminal pro B-type natriuretic peptide (NT-proBNP) is widely used as a marker of ventricular dysfunction. However, data regarding the association of NT-proBNP with blood pressure (BP) and pulse pressure (PP) in the elderly population are limited.

    Methods and Results:The present cross-sectional study involved 6,529 participants, aged ≥70 years, without cardiovascular disease (CVD), who underwent general health examinations. Serum NT-proBNP concentrations were determined, with high NT-proBNP concentrations defined as those ≥125 pg/mL. Subjects were divided into five groups based on PP (<50, ≥50 to <60, ≥60 to <70, ≥70 to <80, and ≥80 mmHg). NT-proBNP was positively associated with systolic BP, whereas a U-shaped association was found between diastolic BP and NT-proBNP. The odds ratios for high NT-proBNP concentrations in the PP ≥80 and ≥70 to <80 mmHg groups (OR 1.83 [P<0.001] and 1.40 [P<0.005], respectively) were significantly higher than in the PP <50 mmHg group. All data were adjusted for age, sex, body mass index, hemoglobin concentration, serum creatinine, pulse rate, smoking, alcohol intake, and antihypertensive medication intake, and the presence of diabetes and dyslipidemia.

    Conclusions:The results suggest that NT-proBNP concentrations may be a marker of not only ventricular dysfunction, but also arterial stiffness in the elderly population without CVD.

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  • Shu Yoshihara, Masaki Matsunaga, Fumihiko Tanioka, Masaaki Naito
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0202
    [Advance publication] Released: May 22, 2018
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  • Nobuhiro Handa, Hiraku Kumamaru, Kei Torikai, Shun Kohsaka, Morimasa T ...
    Type: ORIGINAL ARTICLE
    Subject Area: Valvular Heart Disease
    Article ID: CJ-18-0211
    [Advance publication] Released: May 22, 2018
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    Background:The introduction of transcatheter aortic valve implantation (TAVI) into Japan was strictly controlled to optimize patient outcomes. The goal of this study was to assess if increasing experience during the introduction of this procedure was associated with outcomes.

    Methods and Results:The initial 1,752 patients registered in the Japanese national TAVI registry were included in the study. The association between operator procedure number and incidence of the early safety endpoint at 30 days (ESE30) as defined in the Valve Academic Research Consortium-2 consensus document was evaluated. Patients were divided into 4 groups by quartiles of procedure count (Groups I–IV in order of increasing number of procedures). Median patient age was 85 years, and 30.5% were male. The 30-day mortality rate was 1.4% (n=24), and 78 patients (7.9%) experienced 95 ESE30. Among the variables included in the model, ESE30 was associated with non-transfemoral approach (P=0.004), renal dysfunction (Cr >2.0 mg/dL) (P=0.01) and NYHA class III/IV (P=0.04). ESE30 incidence was not significantly different between Groups I–III and Group IV. Spline plots demonstrated that experience of 15–20 cases in total was needed to achieve a consistent low risk of ESE30.

    Conclusions:Increasing experience was associated with better outcomes, but to a lesser degree than in previous reports. Our findings suggested that the risks associated with the learning curve process were appropriately mitigated.

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  • Akihito Saito, Katsura Soma, Toshiya Kojima, Toshiro Inaba, Atsushi Ya ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0219
    [Advance publication] Released: May 22, 2018
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  • Umiko Ishizaki, Michinobu Nagao, Yumi Shiina, Kenji Fukushima, Tatsuno ...
    Type: ORIGINAL ARTICLE
    Subject Area: Pediatric Cardiology and Adult Congenital Heart Disease
    Article ID: CJ-17-1260
    [Advance publication] Released: May 18, 2018
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    Background:Long-term hepatic dysfunction is an increasingly recognized complication of the Fontan operation for univentricular hearts. The purpose of this study was to determine whether Fontan-associated liver disease (FALD) could be predicted by flow dynamics in the right atrium (RA) of Fontan circulation.

    Methods and Results:Cardiac MRI and the serum levels of total bilirubin (TBil) and hyaluronic acid (HA) were analyzed in 36 patients who underwent an atriopulmonary connection type of Fontan operation. The mean follow-up period was 53 months. Three views (axial, coronal, and sagittal) of the cine images were scanned for the maximum cross-section of the RA obtained with1.5-Tesla scanner. We developed a “vortex flow map” to demonstrate the ratio of the circumferential voxel movement in each phase to the total movement throughout a cardiac cycle towards the center of the RA. The maximum ratio was used as the magnitude of vortex flow (MVF%) in the 3 views of the RA cine imaging. Patients with coronal MVF ≥13.6% had significantly lower free rates of TBil ≥1.8 mg/dL than those with coronal MVF <13.6% (log-rank value=4.50; P<0.05; hazard ratio=4.54). Patients with sagittal MVF ≥14.0% had significantly lower free rates of HA ≥50 ng/mL than those with coronal MVF <14.0% (log-rank value=4.40; P<0.05; hazard ratio=4.12).

    Conclusions:A reduced vortex flow in the RA during the late phase of the Fontan operation was associated with the development of FALD. MVF can be used as an imaging biomarker to predict FALD.

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  • Shohei Yoshida, Koichi Toda, Shigeru Miyagawa, Yasushi Yoshikawa, Hiro ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0207
    [Advance publication] Released: May 18, 2018
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  • Yoichiro Otaki, Tetsu Watanabe, Hiroki Takahashi, Takayuki Sugai, Miyu ...
    Type: ORIGINAL ARTICLE
    Subject Area: Peripheral Vascular Disease
    Article ID: CJ-17-1446
    [Advance publication] Released: May 17, 2018
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    Background:Peripheral artery disease (PAD) is a risk factor for the development of cardiovascular disease and death. Surfactant protein-D (SP-D) is a 43-kDa protein secreted from type II pneumocytes in the lungs. Recent studies have demonstrated that circulating SP-D plays a key role in the development of atherosclerosis and is related to clinical outcomes in patients with ischemic heart disease. However, it remains unclear whether circulating SP-D is associated with clinical outcomes in patients with PAD.

    Methods and Results:We enrolled 364 patients with PAD who underwent endovascular therapy. We measured serum levels of SP-D and Krebs von den Lungen-6 (KL-6). During a median follow-up period of 974 days, there were 69 major adverse cardiovascular and leg events (MACLE), including 48 major adverse cardiovascular events (MACE). Kaplan-Meier analysis demonstrated that patients with high SP-D (≥110 ng/mL) had higher rates of MACE and MACLE than those with low SP-D. Multivariate Cox proportional hazard regression analysis demonstrated that SP-D, but not KL-6, was an independent predictor of MACE and MACLE. The addition of SP-D to known risk factors significantly improved the C index and net reclassification index. The circulating SP-D level was affected by sex, diabetes mellitus, and cilostazol prescription.

    Conclusions:Circulating SP-D was associated with clinical outcomes in patients with PAD, suggesting that it may be a new therapeutic target in these patients.

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  • Hiroshi Yamato, Ying Jiang
    Type: EDITORIAL
    Article ID: CJ-18-0488
    [Advance publication] Released: May 17, 2018
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  • Shin Ito, Masafumi Kitakaze
    Type: EDITORIAL
    Article ID: CJ-18-0499
    [Advance publication] Released: May 17, 2018
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  • Masaki Kodaira, Hiroyuki Yamazaki, Ryota Tabei, Toshiki Kuno, Kazuhiko ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0094
    [Advance publication] Released: May 16, 2018
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  • Hiroki Tateishi, Yosuke Miyazaki, Takayuki Okamura, Rodrigo Modolo, Mo ...
    Type: ORIGINAL ARTICLE
    Subject Area: Valvular Heart Disease
    Article ID: CJ-17-1375
    [Advance publication] Released: May 15, 2018
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    Background:The clinical robustness of contrast-videodensitometric (VD) assessment of aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) has been demonstrated. Correct acquisition of aortic root angiography for VD assessment, however, is hampered by the opacified descending aorta and by individual anatomic peculiarities. The aim of this study was to use preprocedural multi-slice computed tomography (MSCT) to optimize the angiographic projection in order to improve the feasibility of VD assessment.

    Methods and Results:In 92 consecutive patients, post-TAVI AR (i.e., left ventricular outflow tract [LVOT] AR) was assessed on aortic root angiograms using VD software. The patients were divided into 2 groups: The first group of 54 patients was investigated prior to the introduction of the standardized acquisition protocol; the second group of 38 consecutive patients after implementation of the standardized acquisition protocol, involving MSCT planning of the optimal angiographic projection. Optimal projection planning has dramatically improved the feasibility of VD assessment from 57.4% prior to the standardized acquisition protocol, to 100% after the protocol was implemented. In 69 analyzable aortograms (69/92; 75%), LVOT-AR ranged from 3% to 28% with a median of 12%. Inter-observer agreement was high (mean difference±SD, 1±2%), and the 2 observers’ measurements were highly correlated (r=0.94, P<0.0001).

    Conclusions:Introduction of computed tomography-guided angiographic image acquisition has significantly improved the analyzability of the angiographic VD assessment of post-TAVI AR.

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  • Keishi Moriwaki, Tetsushiro Takeuchi, Naoki Fujimoto, Toshiki Sawai, Y ...
    Type: ORIGINAL ARTICLE
    Subject Area: Ischemic Heart Disease
    Article ID: CJ-18-0083
    [Advance publication] Released: May 12, 2018
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    Background:The present study was conducted to assess the cardiovascular effects of dipeptidyl peptidase-4 inhibitors (DPP4i) on coronary flow reserve (CFR), left ventricular (LV) function and endothelial function of the peripheral artery by comparison with those of α-glucosidase inhibitors (αGI) in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD).

    Methods and Results:We randomly assigned 30 patients with T2DM and CAD to receive either sitagliptin or voglibose, and 28 patients (age 69±9 years, 75% male, hemoglobin A1c [HbA1c] 6.62±0.48%) completed the study (14 in each group). CFR and LV function, assessed by cardiac magnetic resonance imaging, and endothelial function, assessed by reactive hyperemia peripheral arterial tonometry (RH-PAT), were measured at baseline and 24 weeks after treatment. Clinical and laboratory parameters, including HbA1c level, plasma active glucagon-like peptide-1 concentrations, and biomarkers of inflammation, were unchanged in both groups after 24 weeks of treatment. CFR were unchanged in both the αGI group (3.01±0.98 at baseline and 3.06±0.8 after treatment, P=NS) and the DPP4i group (4.29±2.04 at baseline and 3.63±1.31 after treatment, P=NS), with no interaction effect. LV functional parameters and the reactive hyperemia index also remained unchanged after the 24-week treatment.

    Conclusions:DPP4i did not improve CFR, LV function or endothelial function of the peripheral artery in patients with relatively well-controlled T2DM and CAD.

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  • Michiaki Higashitani, Yukari Uemura, Atsushi Mizuno, Makoto Utsunomiya ...
    Type: ORIGINAL ARTICLE
    Subject Area: Peripheral Vascular Disease
    Article ID: CJ-18-0105
    [Advance publication] Released: May 11, 2018
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    Background:The present study was performed to clarify whether the preoperative clinical symptoms for endovascular therapy (EVT) can predict post-EVT death and cardiovascular prognosis in Japanese patients with peripheral artery disease (PAD), including acute disease.

    Methods and Results:The TOkyo taMA peripheral vascular intervention research COmraDE (Toma-Code) Registry is a Japanese prospective cohort of 2,321 consecutive patients with PAD treated with EVT, in 34 hospitals in the Kanto and Kōshin’etsu regions, from August 2014 to August 2016. In total, 2,173 symptomatic patients were followed up for a median of 10.4 months, including 1,370 with claudication, 719 with critical limb ischemia (CLI), and 84 with acute limb ischemia (ALI) for EVT. The all-cause death rates per 100 person-years for claudication, CLI and ALI were 3.5, 26.2, and 24.5, respectively. Similarly, major adverse cardiac and cerebrovascular events (MACCE) rates per 100 person-years for claudication, CLI, ALI, and others were 5.2, 31.2, and 29.7, respectively. After adjusting for the predictors of all-cause death and MACCE, namely, age, body mass index <18, diabetes mellitus, dialysis, cerebrovascular disease, and low left ventricular ejection fraction, it was determined that the preoperative indication for EVT was strongly associated with all-cause death and MACCE.

    Conclusions:The preoperative clinical symptoms for EVT can predict the prognosis in patients with PAD undergoing EVT.

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  • Yuhei Nojima, Shinsuke Nanto, Hidenori Adachi, Madoka Ihara, Tetsuya K ...
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0160
    [Advance publication] Released: May 11, 2018
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  • Kuniyasu Harimoto, Tatsuya Kawasaki, Tadaaki Kamitani
    Type: IMAGES IN CARDIOVASCULAR MEDICINE
    Article ID: CJ-18-0311
    [Advance publication] Released: May 11, 2018
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  • Yong-Giun Kim, Kee-Joon Choi, Seungbong Han, Ki Won Hwang, Chang Hee K ...
    Type: ORIGINAL ARTICLE
    Subject Area: Arrhythmia/Electrophysiology
    Article ID: CJ-18-0113
    [Advance publication] Released: May 10, 2018
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    Background:Although the prevalence of both atrial fibrillation (AF) and metabolic syndrome (MetS) has been increasing in East Asia, the association between them is uncertain.

    Methods and Results:A total of 24,741 middle-aged Korean men without baseline AF were enrolled in a health screening program from January 2003 to December 2008. Among them, 21,981 subjects were evaluated to determine the risk of AF based on baseline MetS status through December 2016. At every visit, the subjects were evaluated for AF using ECG. MetS was defined using the criteria of the International Diabetes Federation and was present in 2,529 subjects (11.5%). Mean (±standard deviation) age was 45.9±5.3 years. During a mean follow-up of 8.7 years, 168 subjects (0.8%) were diagnosed with AF. The age-adjusted and multivariate-adjusted hazard ratios (HR) for MetS with AF were 1.62 (P=0.02) and 1.57 (P=0.03), respectively. Among the components of MetS, central obesity (age-adjusted HR 1.62, P<0.01) and raised blood pressure (age-adjusted HR 1.43, P=0.02) were associated with an increased risk of AF.

    Conclusions:MetS is associated with an increased risk of AF in middle-aged East Asian men. Of the components of MetS, central obesity is the most potent risk factor for the development of AF in this population.

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  • Sadako Motoyama, Hajime Ito, Masayoshi Sarai, Yasuomi Nagahara, Keiich ...
    Type: ORIGINAL ARTICLE
    Subject Area: Imaging
    Article ID: CJ-17-1281
    [Advance publication] Released: May 09, 2018
    JOURNALS FREE ACCESS FULL-TEXT HTML ADVANCE PUBLICATION

    Background:Limitations of coronary computed tomography (CTA) include false-positive stenosis at calcified lesions and assessment of in-stent patency. A prototype of ultra-high resolution computed tomography (U-HRCT: 1,792 channels and 0.25-mm slice thickness×128 rows) with improved spatial resolution was developed. We assessed the diagnostic accuracy of coronary artery stenosis using U-HRCT.

    Methods and Results:Seventy-nine consecutive patients who underwent CTA using U-HRCT were prospectively included. Coronary artery stenosis was graded from 0 (no plaque) to 5 (occlusion). Stenosis grading at 102 calcified lesions was compared between U-HRCT and conventional-resolution CT (CRCT: 896 channels and 0.5-mm slice thickness×320 rows). Median stenosis grading at calcified plaque was significantly improved on U-HRCT compared with CRCT (1; IQR, 1–2 vs. 2; IQR, 1–3, P<0.0001). Assessability of in-stent lumen was evaluated on U-HRCT in 79 stents. Stent strut thickness and luminal diameter were quantitatively compared between U-HRCT and CRCT. Of 79 stents, 83.5% were assessable on U-HRCT; 80% of stents with diameter 2.5 mm were regarded as assessable. On U-HRCT, stent struts were significantly thinner (median, 0.78 mm; IQR, 0.7–0.83 mm vs. 0.83 mm; IQR, 0.75–0.92 mm, P=0.0036), and in-stent lumens were significantly larger (median, 2.08 mm; IQR, 1.55–2.51 mm vs. 1.74 mm; IQR, 1.31–2.06 mm, P<0.0001) than on CRCT.

    Conclusions:U-HRCT with improved spatial resolution visualized calcified lesions with fewer artifacts. The in-stent lumen of stents with diameter ≥2.5 mm was assessable on U-HRCT.

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