Background:The impact of high-power radiofrequency (RF) application in ablation index (AI)-guided atrial fibrillation (AF) ablation has not been elucidated.

Methods and Results:We investigated 1,333 patients undergoing first AF ablation (median age 68 years; interquartile range [IQR] 61–73 years). The first 301 patients underwent AI-guided conventional power RF application (CP group), whereas the following 1,032 patients underwent high-power RF application (HP group). The minimum AI target values were 400, 360, and 260 at the left atrial anterior wall, posterior wall, and esophagus, respectively. RF power in the CP group was 30–40, 20–25, and 20 W at the anterior wall, posterior wall, and esophagus, respectively, compared with 50, 40, and 25, respectively, in the HP group. Procedure time was shorter in the HP than CP group (median 153 [IQR 129–190] vs. 180 (IQR 152–229) min; P<0.0001). The percentage of first-pass pulmonary vein isolation (69% vs. 73%; P=0.07) and all procedure-related complications (2.0% vs. 3.4%; P=0.19) was similar. Kaplan-Meier analysis showed similar recurrence-free survival (RFS) for all AF types. Respective 1-year RFS in the CP and HP groups was 82% and 87% in paroxysmal AF, 78% and 82% in persistent AF, and 59% and 58% in long-standing persistent AF.

Conclusions:In AI-guided AF ablation, high-power RF application shortens the procedure time without increasing complications and with similar outcomes.

Background:Despite the prognostic effectiveness of cardiac rehabilitation (CR) in patients with cardiovascular disease (CVD), it has been underutilized. Understanding the trend of dissemination of CR over the years would help provide a perspective of CR in Japan.

Methods and Results:A retrospective epidemiological survey between fiscal years 2010 and 2017 was conducted using the diagnosis procedure combination database (a Japanese administrative database). Data on 2,046,302 patients with CVD from 1,632 hospitals were extracted. The proportion of CR-certified hospitals among hospitals treating patients with CVD increased from 31.6% in 2010 to 56.6% in 2017. Over the same period, the participation rate in inpatient CR (ICR) increased from 18.3% to 39.0%, but the participation rate in outpatient CR (OCR) remained low (from 1.4% to 2.5%). The CR participation rates varied widely according to the main disease group. Approximately 95% of ICR participants did not continue CR after discharge.

Conclusions:The number of CR-certified hospitals increased from 2010 to 2017, leading to increased ICR participation across patients with CVD; however, OCR has remained extremely underutilized. Immediate action is urgently required to increase the use of OCR.

Background:Low-triiodothyronine (T₃) syndrome is a known complication in intensive care unit (ICU) patients, but the underlying mechanisms and prognostic impact are unclear.

Methods and Results:This study retrospectively enrolled 2,976 patients who required care in the ICU. Of these patients, 2,425 were euthyroid and were divided into normal (n=1,666; free T₃[FT₃] ≥1.88 µIU/L) and low-FT₃(n=759; FT₃<1.88 µIU/L) groups. Multivariate logistic regression analysis revealed that prognostic nutritional index >46.03 (odds ratio [OR] 2.392; 95% confidence interval [CI] 1.904–3.005), age (per 1-year increase; OR 1.022; 95% CI 1.013–1.031), creatinine (per 0.1-mg/dL increase; OR 1.019; 95% CI 1.014–1.024), and C-reactive protein (per 1-mg/dL increase; OR 1.123; 95% CI 1.095–1.151) were independently associated with low FT₃. Survival rates (within 365 days) were significantly lower in the low-FT₃group. A multivariate Cox regression model showed that low FT₃was an independent predictor of 365-day mortality (hazard ratio 1.785; 95% CI 1.387–2.297). Low-T₃syndrome was significantly more frequent in patients with non-cardiovascular than cardiovascular diseases (73.5% vs. 25.8%). Prognosis was significantly poorer in the low-FT₃than normal group for patients with cardiovascular disease, particularly those with acute coronary syndrome and acute heart failure.

Conclusions:Low-T₃syndrome was associated with aging, inflammatory reaction, malnutrition, and renal insufficiency and could lead to adverse outcomes in patients admitted to a non-surgical ICU.

Background:Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, has demonstrated survival benefit and reduces heart failure hospitalization compared with enalapril in patients with heart failure and reduced ejection fraction. However, its efficacy in real-world practice in Japan remains unknown.

Methods and Results:We initiated sacubitril/valsartan treatment for 37 patients (median age 68 years; median left ventricular ejection fraction 37%) between August and November 2020. Within 3 months, sacubitril/valsartan was discontinued in 3 patients due to symptomatic hypotension or worsening heart failure. Two patients were hospitalized due to worsening heart failure, with one of these patients undergoing percutaneous mitral valve repair. Three patients received scheduled non-pharmacological treatment: 1 received cardiac resynchronization therapy (CRT), 1 received CRT and underwent transcatheter aortic valve implantation, and 1 underwent left ventricular assist device implantation. Of the 30 patients who continued sacubitril/valsartan for 3–6 months without additional non-pharmacological therapy, there was a tendency for a decrease in N-terminal pro B-type natriuretic peptide concentrations (baseline vs. after 3–6 months ARNI treatment; median 733 vs. 596 pg/mL; P=0.097) and an increase in left ventricular ejection fraction (median 37% vs. 39%; P=0097).

Conclusions:Sacubitril/valsartan therapy with a lower initial dose was safe and may be effective in Japanese heart failure patients in a real-world setting. Further evaluation of optimal patient selection and clinical management using sacubitril/valsartan is warranted.

Background:Female sex is reported to be associated with poor prognosis in hypertrophic cardiomyopathy (HCM). The plasma B-type natriuretic peptide (BNP) concentration is a prognostic predictor in HCM. However, the effect of sex on BNP concentrations remains unclear among HCM patients.

Methods and Results:Patient records in the Clinical Personal Records of HCM national database of the Japanese Ministry of Health, Labour and Welfare from 2009 to 2014 were analyzed. Of 3,570 HCM patients, 611 in whom BNP concentrations were assessed at both baseline and the 2-year follow-up were included in this analysis. The mean age was 60.4 years and 254 (41.6%) patients were female. Median (interquartile range) BNP concentrations were higher in females than males at both baseline (320.3 [159.0–583.1] vs. 182.8 [86.1–363.9] pg/mL; P<0.001) and the 2-year follow-up (299.2 [147.0–535.3] vs. 161.0 [76.2–310.0] pg/mL; P<0.001). Female sex was associated with higher natural log-transformed BNP at the 2-year follow-up regardless of clinical characteristics, including echocardiographic findings and BNP concentrations at baseline (coefficient 0.31; 95% confidence interval 0.13–0.48; P<0.001). Cubic spline analysis showed that, among patients with high BNP concentrations at baseline, females had higher BNP concentrations at the 2-year follow-up than males.

Conclusions:In HCM, female sex was associated with higher BNP concentrations than male sex, independent of clinical characteristics, including BNP concentrations at baseline.

Background:Disease understanding in patients with congenital heart disease is important in transitional and lifelong care. This study aimed to develop the Japanese version of the Leuven Knowledge Questionnaire for Congenital Heart Disease (LKQCHD) and identify factors associated with disease-related knowledge.

Methods and Results:After confirming the content and face validity of the scale, a questionnaire including the LKQCHD was distributed to 59 eligible patients aged >16 years attending a university hospital. For the 58 participants who responded (30 males, 28 females; median age 22 years), the mean (±SD) LKQCHD total score was 53.7±15.4, with mean (±SD) scores for each domain as follows: Disease and Treatment, 68.3±19.7; Preventing Complications, 45.8±19.0; Physical Activity, 74.1±34.1; Sex and Heredity, 37.9±35.4; and Contraception and Pregnancy, 40.2±29.1. Regarding known-groups validity, we found a positive correlation between the LKQCHD score and age (ρ=0.268, P=0.042), and a significantly low LKQCHD score in the moderate/severe disease group (η²=0.131, P=0.021). Regarding convergent validity, the LKQCHD score was positively correlated with the total and subscale scores of the Resilience Assessment Tool (r=0.213 [P=0.109] andr=0.405 [P=0.002], respectively).

Conclusions:We confirmed the validity of the Japanese version of the LKQCHD, concluding that patient education regarding long-term complications, prevention methods, heredity, pregnancy, and childbirth is needed.

Background:Although many risk factors have been reported to be associated with poor clinical outcomes following transcatheter aortic valve replacement (TAVR), the implications of inadequate cardiac unloading following TAVR remain unknown. We investigated the prognostic impact of inadequate cardiac unloading following TAVR.

Methods and Results:We retrospectively analyzed a cohort of patients with severe aortic stenosis who underwent invasive hemodynamic assessment following TAVR. The impact of inadequate cardiac unloading, defined as an elevated pulmonary capillary wedge pressure (PCWP), on the composite primary endpoint of cardiovascular mortality or heart failure readmission was investigated. Eighty-two patients (median age 86 years; 57 women) were included. Median PCWP following TAVR was 9 mmHg (interquartile range 7–13 mmHg). A higher PCWP tended to be associated with an increased risk of adverse cardiovascular events (adjusted hazard ratio 1.18; 95% confidence interval 0.99–1.41). A cut-off value of PCWP >12 mmHg, calculated by time-dependent receiver operating characteristics analysis, stratified the cumulative incidence of the primary endpoint (2-year incidence of 36% vs. 8%). Uptitration of the diuretic dose was associated with event freedom among those with PCWP >12 mmHg.

Conclusions:Inadequate cardiac unloading following TAVR was associated with an increased risk of adverse clinical events. Uptitration of medical therapies to improve cardiac hemodynamics after TAVR may reduce this risk.

Background:In Japan, district differences in the prevalence of cardiovascular disease (CVD) are well-known. This study examined district differences in Japan in measured values of arterial stiffness, an independent risk factor for CVD.

Methods and Results:Local residents participating in health checkups conducted in the Wakayama (n=461) and Nagano (n=186) prefectures in 2018 were recruited to the study. Brachial-ankle pulse wave velocity (baPWV) was evaluated as an index of arterial stiffness. After multivariate adjustment, baPWV was significantly higher in the Wakayama than Nagano district in subjects aged ≥70 years (mean [±SE] 1,912±25 vs. 1,763±30 cm/s; P<0.01), but not in subjects aged <70 years. Multivariate linear regression analysis demonstrated that the Wakayama/Nagano district difference was significantly (P<0.01) associated with baPWV.

Conclusions:District differences were observed in the measured values of arterial stiffness in Wakayama and Nagano. The Wakayama and Nagano prefectures are representative areas with a relatively high and relatively low prevalence of CVD, respectively, in Japan. Therefore, based on the results of the present study, we propose to conduct a study to examine whether district differences in arterial stiffness underlie district differences in the prevalence of CVD.