Background: Atrial fibrillation (AF) after bioprosthetic valve (BPV) replacement is common in older patients with multiple comorbidities and is associated with a heightened risk of thromboembolism. Anticoagulation therapy is often indicated, but renal impairment and other comorbidities elevate bleeding risk, making clinical decisions complex. This study compared clinical outcomes between warfarin and direct oral anticoagulants (DOACs) in this high-risk population.

Methods and Results: This subgroup analysis of the BPV-AF Registry included 612 patients treated with oral anticoagulants after BPV replacement, stratified by renal function: normal or mild impairment (creatinine clearance [CCr] ≥50 mL/min), mild-to-moderate impairment (30 mL/min ≤ CCr < 50 mL/min), and moderate-to-severe impairment (15 mL/min ≤ CCr < 30 mL/min). Baseline characteristics and outcomes were analyzed within each stratum. The composite outcome of stroke, systemic embolism, and cardiovascular events was numerically less frequent in the DOAC than warfarin group across all strata, although the differences were not statistically significant. Major bleeding also tended to be lower in the DOAC group.

Conclusions: In this study from a Japanese nationwide registry comparing outcomes of AF patients after BPV replacement with severe renal impairment between those treated with DOACs and those treated with warfarin, comparative conclusions between DOACs and warfarin cannot be drawn because of the small sample size. Nonetheless, both anticoagulants may be acceptable in clinical practice, highlighting the need for individualized decision-making based on patient risk.

Background: Heart failure (HF) is an increasing public health concern in Japan, largely related to the aging population. This protocol describes the rationale, objectives, and methods of the Hokuriku-plus Heart Failure Registry (HpHFR), designed to establish a comprehensive clinical and digital database to assess novel prognostic indicators in patients with HF.

Methods and Results: HpHFR is a prospective, multicenter observational cohort study that has enrolled patients with acute or chronic HF from 5 Japanese centers. Eligible patients provided informed consent and underwent baseline clinical, laboratory, and biometric assessment, including digital phonocardiography and wearable device data. Follow-up assessment will be conducted at 4, 12, 26, and 52 weeks. Primary outcomes include all-cause death, HF-related hospitalization, and worsening HF. Secondary outcomes are the changes in clinical parameters over time. A digital substudy will investigate continuous biometric monitoring, and a genomic substudy explores the loss of chromosome Y as a prognostic biomarker.

Conclusions: In conclusion, this study protocol summarizes the development of a valuable prospective cohort resource. This registry will provide a unique dataset enabling multifaceted investigations to improve HF prediction and management by systematically integrating comprehensive clinical and laboratory data with biometric indicators derived from digital devices and genomic markers.

Despite advances in the treatment of cardiogenic shock (CS), it remains associated with high mortality rates. To improve patient outcomes, management in a dedicated care center has been proposed. However, the definition of a dedicated CS center has not been systematically examined, and no consensus exists across major societies or guidelines. The aim of this scoping review was to identify key elements defining CS centers linked to better patient outcomes and guide future research. This review was conducted in accordance with the PRISMA extension for scoping reviews. The PubMed, Cochrane, and Web of Science electronic databases were systematically searched to identify studies published from inception to July 19, 2023. Twenty observational studies examining hospital characteristics and patient outcomes with CS were included. Higher volumes of CS patients, more board-certified cardiologists, percutaneous coronary intervention (PCI) availability 24/7, and the presence of cardiovascular intensive care units, left ventricular assist device (LVAD) centers, and hub-and-spoke systems were associated with better outcomes. Inconsistent associations were observed for the number of PCIs, extracorporeal membrane oxygenation, and percutaneous microaxial ventricular assist device procedures, and LVAD case volume and the availability of cardiac surgical support were not associated with improved outcomes. This scoping review identified candidate elements of CS centers linked to better outcomes, providing a foundation for developing an optimal CS care system.

Background: Hospitalization-associated disability (HAD) is linked to poor post-discharge outcomes in older individuals with heart failure (HF). We investigated whether HAD could be predicted by physical activity measured using a wearable device.

Methods and Results: We retrospectively analyzed data from 104 older individuals with HF whose physical activity was recorded for 3 consecutive days after initiating cardiac rehabilitation. Physical activity was categorized as sedentary behavior (≤1.5 metabolic equivalents [METs]), light-intensity physical activity (LPA; 1.6–2.9 METs), and moderate-to-vigorous physical activity (≥3.0 METs). HAD was observed in 31 (29.8%) individuals. LPA duration was significantly shorter in the HAD than non-HAD group (mean [±SD] 45.7±24.9 vs. 121.2±67.4 min/day; P<0.0001). In receiver operating characteristic curve analysis, the optimal LPA cut-off was 68 min/day, with 87.1% sensitivity and 80.8% specificity (area under the curve=0.888; P<0.0001).

Conclusions: Physical activity measured using a wearable device may be useful in predicting HAD in older individuals with HF.

Background: Recently, shock teams have been introduced to optimize cardiogenic shock (CS) care; however, their clinical benefits remain unclear. We conducted a systematic review and meta-analysis to assess whether management by a shock team improves outcomes in patients with CS.

Methods and Results: This meta-analysis was conducted according to the PRISMA guidelines. Studies comparing adults with CS managed with or without a shock team were identified from the PubMed, Web of Science, and Cochrane Library databases. The primary outcome was short-term mortality (cardiac intensive care unit, in-hospital, or 30-day mortality); the secondary outcome was bleeding. Of the 7 retrospective cohort studies that met the inclusion criteria, 3 without a critical risk of bias were included in the analysis. Shock team management was significantly associated with lower short-term mortality (odds ratio [OR] 0.52; 95% confidence interval [CI] 0.32–0.85; P=0.010) and bleeding complications (OR 0.62; 95% CI 0.43–0.91; P=0.010). Sensitivity analysis using crude data also supported the mortality benefit (OR 0.68; 95% CI 0.54–0.85; P<0.010). However, no randomized trials were included, and the certainty of evidence was rated very low owing to the risk of bias and inconsistency.

Conclusions: Shock team management may improve short-term outcomes in patients with CS; however, the level of evidence is very low. Further prospective studies are needed to evaluate optimal shock team composition and roles.

Background: Comprehensive monitoring of cardiovascular disease (CVD) is essential in rapidly aging societies such as Japan. The Japanese Circulation Society (JCS) launched the Japanese Registry Of All cardiac and vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) registry, linking annual JROAD questionnaires with nationwide DPC administrative claims to enable patient-level analyses of hospitalized CVD care. This Protocol Paper presents a comprehensive overview of the registry.

Methods and Results: Using anonymized data (April 2012–March 2023), we described temporal trends in patient demographics, principal CVD diagnoses, major interventions, disease-specific severity, and hospital characteristics. From FY2012–FY2022, participating facilities increased from 610 to 860, with registered patients more than doubling. Median age rose from 73.0 to 75.0 years; patients aged ≥90 years nearly quadrupled. The proportion of angina pectoris admissions declined (26.8% to 11.7%), while absolute numbers remained stable. Atrial fibrillation/flutter admissions rose in both proportion (4.1% to 5.9%) and absolute number. Heart failure admissions increased steadily, with its proportion showing a U-shaped trend. Catheter ablations for atrial fibrillation/flutter increased over fivefold, exceeding 64,000, while percutaneous coronary interventions for acute myocardial infarction surpassed 46,000.

Conclusions: JROAD-DPC now captures over 1.5 million annual CVD hospitalizations, providing a nationwide, large-scale longitudinal view of cardiovascular care in Japan. Its scale and validated coding enable robust analyses of trends and outcomes, supporting national CVD policy evaluation and improvement.

Background: Studies of off-loading devices for chronic limb-threatening ischemia (CLTI) are scarce. We investigated (1) the effect of the application of early therapy sandals on changes in the Clinical Frailty Scale (CFS) scores of patients with CLTI before and after hospitalization, and (2) adverse events such as wound deterioration and reamputation.

Methods and Results: We retrospectively analyzed the cases of 51 patients (51 limbs) with toe amputation after revascularization and compared 2 groups: patients who did not apply any load during the off-loading duration and focused on resistance training (the ‘usual rehabilitation’ group), and those who used therapeutic sandals and performed walking and aerobic exercises with partial off-loading from an early stage (the ‘orthotic’ rehabilitation group). The before-to-after hospitalization change in the CFS score was 0 (−1, 0) in the usual rehabilitation group, and 0 (0, 1) in the orthotic rehabilitation group (P=0.002), a significant difference. There were no significant between-group differences in wound healing duration (usual rehabilitation group, 48 [19,76.5] days; orthotic rehabilitation group, 41 [27.5,78.8] days) or reamputation rate (usual rehabilitation group, 5 [22%]; orthotic rehabilitation group, 3 [11%]).

Conclusions: The early postoperative use of therapeutic sandals tended to shorten the duration of complete off-loading after toe amputation due to CLTI and to help maintain CFS scores throughout the hospitalization duration. It was also shown to have a minimal impact on treatment delay and reamputation.

Background: B-type natriuretic peptide (BNP) is a key biomarker for heart failure (HF) and widely used for risk stratification. Elevated BNP levels in acute stroke are linked to poor outcomes, but its prognostic value in the post-acute phase remains unclear.

Methods and Results: This retrospective study included 876 patients admitted to a rehabilitation hospital after acute cerebral infarction or hemorrhage between February 2019 and December 2022. Patients were classified into 4 groups based on BNP or N-terminal prohormone of BNP. The primary outcome was all-cause unfavorable events, including in-hospital death or transfer due to worsening condition. The severely elevated BNP group had a significantly higher risk of all-cause unfavorable events (hazard ratio: 2.34; 95% confidence interval: 1.26–4.32) than the normal group. No significant difference was observed in the mildly or moderately elevated BNP groups. BNP showed superior predictive value over HF diagnosis in terms of area under the receiver operating characteristic curve (0.712 vs. 0.691), net reclassification improvement (0.304, P=0.002), and integrated discrimination improvement (0.025, P=0.015). Higher BNP was associated with lower body mass index, reduced estimated glomerular filtration rate, longer time from stroke onset, atrial fibrillation, and cardioembolic stroke.

Conclusions: BNP levels in the post-acute stroke phase were significantly associated with unfavorable outcomes and may serve as a useful prognostic marker.

Background: Catheter ablation (CA) is a well-established therapy for arrhythmia, but the impact of CA strategies has not been thoroughly investigated. Nagano Prefecture comprises a large geographical area and some hospitals do not have cardiac surgeons, thus limiting the application of CA strategies. The aim of this study was to investigate the detailed strategies for CA in Nagano Prefecture and to clarify their efficacy and safety.

Methods and Results: The Shinshu Catheter Ablation (Shinshu-AB) Registry is a multicenter prospective observational registry. Patients treated with CA for any type of arrhythmia are included. Data on the target arrhythmia(s), CA strategy, outcomes, and complications were collected and analyzed at Shinshu University Hospital. The study was approved by the institutional review boards of all investigational sites and registered in the UMIN Clinical Trials Registry (UMIN-55562). Primary endpoints were the composite incidence of arrhythmia recurrence, procedure-related adverse events, and cardiovascular events. The secondary endpoints were acute success, chronic success for >12 months, and all-cause death.

Conclusions: The Shinshu-AB Registry provides real-world data from the Nagano Prefecture on the outcomes and complications of CA for various types of arrhythmias.

Background: The advent of transcatheter aortic valve implantation (TAVI) has increased the rate of aortic valve treatment in frail older adults. Factors contributing to frailty include sarcopenia (characterized by reduced muscle mass), osteopenia (characterized by decreased bone mineral density), and the newly termed osteosarcopenia, which is characterized by a simultaneous decline in muscle mass and bone mineral density. In this study, we aimed to investigate the impacts of sarcopenia, osteopenia, and osteosarcopenia on the clinical outcomes of TAVI.

Methods and Results: We retrospectively analyzed 490 patients who underwent TAVI for aortic stenosis at Yamaguchi University Hospital between April 2014 and March 2025. Osteopenia, sarcopenia, and osteosarcopenia were diagnosed by preprocedural computed tomography. Patients were classified into normal (N), sarcopenia alone (S), osteopenia alone (O), and osteosarcopenia (OS) groups. Early clinical outcomes and 1-year survival rates exhibited no significant differences among the groups. However, the 5-year survival rates were 94.1%, 77.6%, 60.4%, and 46.5% in the N, S, O, and OS groups, respectively (P<0.05). The Cox proportional hazards model revealed osteosarcopenia as a significant risk factor for late death (hazard ratio, 2.09; P=0.0002).

Conclusions: Preoperative evaluation of muscle mass and bone density aids in stratifying TAVI risk.

Background: Although metabolic dysfunction-associated fatty liver disease is typically diagnosed using ultrasonography, the fatty liver index (FLI) offers a simple alternative. Brachial-ankle pulse wave velocity (baPWV) is an established marker of arterial stiffness and a predictor of cardiovascular events. This study investigated the association between FLI and baPWV in a general Japanese population.

Methods and Results: This cross-sectional study included participants aged ≥18 years, excluding those with atrial fibrillation, lower extremity artery disease, severe aortic stenosis, or missing data. The primary outcome was an elevated baPWV (≥1,800 cm/s). Multivariable logistic regression analysis was performed to assess the association between FLI and elevated baPWV, considering FLI both as a categorical variable (low risk: FLI <30; moderate risk: FLI ≥30 and <60; high risk: FLI ≥60) and as a continuous variable (per 10-unit increase). The analysis included 10,122 individuals (mean age 54.3 years; 55% male). In multivariable-adjusted models, the odds of elevated baPWV were significantly higher in the moderate-risk (odds ratio [OR] 1.47; 95% confidence interval [CI] 1.20–1.79) and high-risk (OR 1.78; 95% CI 1.33–2.38) groups, using the low-risk group as the reference category. Each 10-unit increase in FLI was associated with significantly higher odds of the outcome (OR 1.16; 95% CI 1.10–1.22).

Conclusions: FLI showed a significant association with arterial stiffness in the general Japanese population.

Background: Because the optimal choice of vasopressor for the initial treatment of cardiogenic shock (CS) remains controversial, we conducted a systematic review and meta-analysis to evaluate whether noradrenaline improves clinical outcomes compared with other vasopressors (adrenaline, dopamine, and vasopressin) in patients with CS.

Methods and Results: PubMed, CENTRAL, and Web of Science databases were searched for randomized controlled trials (RCTs) and observational studies comparing noradrenaline with other vasopressors in adults with CS. A meta-analysis was conducted using fixed-effect models where appropriate. Two RCTs were included (n=337). One trial enrolled 57 patients and compared the effects of noradrenaline and adrenaline. Another study included 280 patients with CS as a subgroup and compared noradrenaline with dopamine. Pooled analysis showed that noradrenaline likely reduced the 28-day mortality rate compared with other vasopressors (very-low certainty). This corresponded to approximately 110 fewer deaths per 1000 patients (95% confidence interval: 217 fewer to 5 fewer). Secondary outcomes from the Levy study indicated fewer adverse events in the noradrenaline group.

Conclusions: Noradrenaline likely reduces the 28-day mortality rate compared with other vasopressors (very-low certainty) in CS. Given the small number of studies and the potential bias, further large-scale trials are warranted.

Background: Frailty is a crucial factor in the prognoses of patients who undergo transcatheter aortic valve implantation (TAVI); however, comprehensive assessments of this parameter are not frequently performed in this regard. This study evaluated the prognostic value of the Kihon Checklist (KCL), which covers physical, cognitive, and social domains, for patients receiving TAVI.

Methods and Results: We retrospectively analyzed data from 986 patients who underwent elective TAVI between May 2017 and September 2022. Frailty was classified according to the KCL as non-frail (for scores of 0–3), pre-frail (4–7), or frail (≥8). The primary outcome measure was all-cause mortality following discharge. Kaplan-Meier, Cox regression, and classification and regression tree (CART) analyses were used. Of the overall patient cohort, 47.4% were classified as frail. Over a mean follow-up period of 968±578 days, 18.1% died. Frailty was significantly associated with higher mortality (adjusted hazard ratio 1.771; 95% confidence interval 1.096–2.862; P<0.02). Impaired socialization and physical function were also found to represent independent predictors of mortality. CART identified socialization as the primary node in the risk stratification.

Conclusions: Preoperative frailty, as defined by the KCL, was found to be independently associated with mortality after TAVI. Social and physical domains were also found to have strong prognostic relevance in this context.

Background: Enteral nutrition (EN) is often delayed in critically ill cardiovascular patients due to concerns about bowel ischemia, especially when under vasopressor or mechanical support. We evaluated the impact of a structured EN protocol designed to promote timely and safe nutrition delivery in the Cardiac Care Unit (CCU).

Methods and Results: This single-center retrospective study compared mechanically ventilated CCU patients before (April 2019–March 2020) and after (April 2022–March 2023) protocol implementation. The protocol specified hemodynamic safety thresholds and used a peptide-based formula. Outcomes included EN-related complications, time to EN initiation, and nutritional adequacy within the first week. A total of 116 patients (58 per group) were analyzed. No significant differences were observed in vomiting (P=0.717), diarrhea (P=0.219), or bowel ischemia (P=0.364). The post-protocol group showed a significantly shorter time to EN initiation (median 39.5 vs. 76.0 h; P<0.001). By Day 5, enteral energy adequacy improved (40.8% vs. 12.3%; P<0.001), and protein adequacy increased (62.2% vs. 31.0%; P<0.001). Exploratory analyses showed no significant differences in CCU stay, ventilator-free days, or in-hospital deaths.

Conclusions: The EN protocol enabled earlier initiation and improved EN delivery in high-risk CCU patients without increasing complications, offering a safe and practical approach to narrowing the gap between guidelines and practice.

Background: Managing heart failure complicated by severe right heart failure with implantable mechanical circulatory support remains a significant challenge. One therapeutic strategy is biventricular assist device (BiVAD) support, typically involving the off-label use of 2 implantable left ventricular assist devices (LVADs). Because the available data of implantable BiVAD support remain limited, we reviewed the data for 6 patients on implantable BiVAD support.

Methods and Results: Between January 2010 and March 2019, 6 patients underwent BiVAD implantation at Osaka University Hospital. Their mean age was 31±11 years, and 2 (33%) were male. The right ventricular assist devices (RVADs) utilized were Jarvik2000 (Jarvik Heart, NY, USA) in 4 patients (67%), and HVAD (HeartWare, Framingham, MA, USA) in 2 patients (33%). The survival rates at 1 and 3 years after BiVAD implantation were 83% and 67%, respectively. Of the 6 patients, 4 underwent heart transplantation at 553, 709, 791, and 1,245 days, respectively, following RVAD implantation; 2 patients died during follow-up at 280 and 511 days, respectively, after RVAD implantation. Stroke occurred in 3 patients. Hemolysis or pump thrombosis occurred in 3 patients. Heart failure occurred in 3 patients. Device-related infection occurred in 1 patient.

Conclusions: Although implantable BiVAD support provided a feasible bridge to transplantation with favorable survival, the high incidence of complications indicates that significant challenges remain in optimizing patient outcomes and emphasizes the necessity for RV-specific device development.

Background: This study aimed to evaluate the effects of protein and amino acid supplementation on physical performance in patients with chronic heart failure (CHF).

Methods and Results: Studies from PubMed, the Cochrane Library, CINAHL, Web of Science, and PEDro published up to August 2024 were identified using a comprehensive strategy with no limitations on publication date or language. The primary outcome was physical performance, assessed using the 6-min walk distance (6MWD) test. This study included 15 randomized controlled trials involving a total of 744 patients. Control groups received either a placebo or usual care, including standard heart failure treatment. The meta-analysis demonstrated a significant improvement in 6MWD in the supplementation group compared with controls (mean difference 35.25 m; 95% confidence interval 15.93–54.58; I²=38%). Subgroup analysis showed no significant difference between supplementation alone and supplementation combined with exercise, suggesting independent effects. Patients aged ≥65 years showed similar benefits.

Conclusions: Our meta-analysis indicated that physical performance in patients with CHF was improved by using protein and amino acid supplementation, particularly in older adults or those unable to engage in adequate exercise therapy. However, the overall quality of the evidence was very low.

Background: Malnutrition worsens outcomes in heart failure (HF). Although nutritional therapy is important, evidence for enhanced nutritional care (ENC) combined with exercise therapy (ET) is limited.

Methods and Results: This systematic review and meta-analysis evaluated ENC, alone or with ET, in HF. Randomized controlled trials (RCTs) published to March 31, 2023, were identified through comprehensive searches. Meta-analyses used a random-effects model with risk ratios (RRs) or mean differences (MDs) and 95% confidence intervals (CIs). Twenty-five RCTs were included: 20 assessed ENC alone and 5 assessed ENC+ET. ENC alone did not reduce all-cause mortality but was associated with fewer post hoc-defined cardiovascular events (RR 0.64; 95% CI 0.48–0.85), driven largely by 1 study and considered exploratory. ENC+ET improved 6-min walk distance (MD 39.85 m; 95% CI 13.05–66.65) and handgrip strength.

Conclusions: ENC may reduce cardiovascular events and improve physical function in HF, particularly with ET, but evidence is preliminary and large-scale trials are warranted.

Background: Although pulse rate variability (PRV) is considered a potential surrogate marker for heart rate variability in the assessment of autonomic function, it is not clear whether PRV-derived parameters predict mortality risk in the general population.

Methods and Results: Between 2009 and 2018, a total of 5,943 Japanese individuals, aged 30–79 years, were recruited for a prospective study and followed until the end of 2022. The pulse wave was examined over a 5-min period using a fingertip photoplethysmography sensor to determine the resting heart rate (RHR) and the time and frequency domains of PRV. A Cox proportional hazard model was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of PRV-derived parameters for all-cause mortality using the penalized cubic splines method. During 12.4 years of follow up, 437 deaths were recorded. The HR for mortality, adjusted for sex, age, and community, for the lowest quartiles of the standard deviation of the normal-to-normal intervals (SDNN) increased 1.51 times (95% CI 1.15–1.98) vs. the third quartile. Although mortality risk was attenuated after adjustment for several confounders and RHR, PRV-derived parameters of autonomic function showed significant non-linearity of association with mortality risk in the spline analysis.

Conclusions: Low values of PRV-derived autonomic parameters were associated with an increased risk of all-cause mortality in the general Japanese population.

Background: Atrial functional mitral regurgitation (FMR) results from left atrial enlargement and dysfunction, typically observed in patients with atrial fibrillation (AF). Predictors of sinus rhythm maintenance after catheter ablation in atrial FMR patients are not well understood.

Methods and Results: We retrospectively reviewed 1,410 consecutive patients who underwent initial catheter ablation for AF at Kobe University Hospital between January 2014 and December 2022. Of these patients, 56 (4%; mean [±SD] age 68±8 years; 68% male) had significant (moderate, n=48; severe, n=8) atrial FMR based on pre-ablation transesophageal echocardiography. At follow-up echocardiography, a reduction in the left atrial diameter (LAd) was observed in 30 patients, whereas improvement in mitral regurgitation (MR) was noted in 26. During a mean follow-up period of 835 days, AF recurred in 23 (41%) patients. Kaplan-Meier curves for AF recurrence did not differ based on LAd reductions or MR improvements alone. However, recurrence rates were significantly lower in patients who achieved both LAd reduction and MR improvement than in those who did not achieve both changes (P=0.0259). Multivariate analysis revealed that the combination of LAd reduction and MR improvement was the only significant predictor of a decrease in AF recurrence (hazard ratio 0.275; 95% confidence interval 0.091–0.826; P=0.021).

Conclusions: In AF patients with significant atrial FMR, achieving both LAd reduction and MR improvement after ablation is important to reduce the risk of AF recurrence.

Background: Cardiac rupture (CR), encompassing both free wall and ventricular septal ruptures, is a serious complication of ST-segment elevation myocardial infarction (STEMI). In this study, we aimed to investigate the incidence, characteristics, and clinical outcomes of CR in patients with STEMI.

Methods and Results: The Japan Acute Myocardial Infarction Registry (JAMIR) is a multicenter prospective study. Of the 3,411 patients hospitalized with acute MI between 2015 and 2017, data from 2,626 patients with STEMI (612 women [23.3%]; median age, 68 years) were analyzed. CR occurred in 34 patients (1.3%), comprising free wall rupture in 25 cases (73.5%), ventricular septal rupture in 8 cases (23.5%), and both in 1 case (2.9%). Compared to those without CR, the cumulative incidence of the primary endpoints (cardiovascular death, non-fatal MI, or non-fatal stroke) at 1 year was significantly higher in the CR group (64.7% vs. 7.9%, log-rank P<0.001). Factors independently associated with CR included older age, anterior wall infarction, and prolonged onset-to-admission time. Notably, the incidence of CR increased with longer onset-to-admission times (0–3 h, 0.6%; 3–6 h, 1.7%; 6–12 h, 1.7%; ≥12 h, 3.6%; P for trend <0.001), but was not associated with door-to-device times (≤90 min, 0.7% vs. >90 min, 1.4%; P=0.156).

Conclusions: CR following STEMI is associated with delayed onset-to-admission time and poor clinical outcomes.

Background: The clinical implementation of secondary prevention implantable cardioverter-defibrillator (ICD) implantation in hemodialysis (HD) patients in Japan remains poorly characterized. We sought to characterize practice patterns and factors associated with secondary prevention ICD implantation in HD patients surviving cardiac arrest due to ventricular arrhythmias.

Methods and Results: Using the nationwide JROAD-DPC database (2012–2020), we analyzed cardiac arrest survivors with ventricular arrhythmias and no prior ICD. We assessed patient factors associated with ICD implantation and analyzed temporal trends in device selection, institutional and geographical variations in utilization patterns among HD patients. Among 17,653 cardiac arrest survivors, 530 of 1,931 HD patients (27%) received ICDs, significantly lower than 6,870 of 15,722 non-HD patients (44%; P<0.001). Multivariable analysis revealed that HD treatment was an independent negative predictor of ICD implantation (odds ratio 0.42, 95% confidence interval [CI] 0.37-0.47). Subcutaneous-ICD use among HD patients increased significantly from 13% to 32% during 2016–2019 (P<0.001 for trend). Among HD patients, ICD implantation rates were consistent across institutional characteristics and geographical regions.

Conclusions: This nationwide analysis revealed significantly lower secondary prevention ICD use in HD patients compared to non-HD patients, with consistent implementation patterns across Japan’s healthcare system. These findings provide important baseline evidence for developing consensus regarding ICD therapy and underscore the need for future prospective studies to guide optimal ICD selection in this population.

Background: Reliable assessment of pitting edema remains a challenge, especially in remote care, because it is inherently subjective. We developed a video-based deep learning (DL) model to objectively classify the severity of pitting edema.

Methods and Results: A total of 247 videos from 34 consecutive hemodialysis patients were analyzed. A convolutional neural-network (EfficientNetB0) was trained using pre and postpressing pretibial images graded on a 0–4 scale. The model achieved 81.5% accuracy, 81.2% sensitivity, and 81.9% specificity in distinguishing grades 3–4 edema from grades 0–1. For extreme cases (grade 0 vs. 4), accuracy improved to 85.8%.

Conclusions: This pilot study demonstrated feasibility of video-based DL for edema detection. Larger, more diverse datasets and clinical validation are needed for generalization.

Background: Left ventricular (LV) dysfunction after mitral valve (MV) repair for degenerative mitral regurgitation (DMR) is a poor prognostic factor. Preoperative LV end-systolic diameter (LVESD) and LV ejection fraction (LVEF) are used in guidelines as indices for LV dysfunction, with cut-off values of 60% for LVEF and 40 mm for LVESD. However, these factors have received little validation in Japanese patients.

Methods and Results: We evaluated preoperative echocardiographic data in 322 Japanese patients who underwent MV repair for DMR to identify factors associated with postoperative LV dysfunction. Postoperative LV dysfunction was observed in 31 (10%) patients, who had greater LVESD (39±6 mm vs. 33±5 mm; P<0.001) and lower LVEF (62±5% vs. 67±5%; P<0.001) preoperatively, compared with the non-LV dysfunction group. The optimal threshold of preoperative LVESD and LVEF for predicting postoperative LV dysfunction in receiver operating characteristic curve analysis was 36 mm (AUC=0.819; P<0.001) and 61% (AUC=0.706; P<0.001), respectively. Kaplan–Meier analysis showed a significantly lower rate of avoided adverse cardiac events in the LV dysfunction group (P<0.001).

Conclusions: The criteria for LVESD in MV repair in patients with DMR should be lower than the values indicated by the guidelines. Adoption of these revised criteria may improve prognosis after surgery in Japanese patients.

Background: Transient high-glucose exposure induces Erk2 phosphorylation and cell proliferation in human coronary artery endothelial cells (HCAEC), but the upstream mechanisms remain unclear.

Methods and Results: HCAEC were exposed to 183 mg/dL L-glucose or D-glucose for 1 h followed by 23 h in a glucose-free medium. Transient high D-glucose decreased miR-138 levels, increased Giα2 protein levels, inactivated Rap1, and activated Ras, leading to Erk2 activation.

Conclusions: Transient high D-glucose exposure activates Erk2 via the miRNA-138/Giα2/Rap1/Ras signaling axis, suggesting a potential therapeutic target for atherosclerosis.

Background: Although mitral valve repair typically leads to left atrial reverse remodeling, persistent left atrial enlargement is associated with poor prognosis. Factors contributing to postoperative left atrial enlargement remain poorly understood. Left atrial strain analysis may offer supplementary evaluation of left atrial function, complementing conventional volume-based assessments.

Methods and Results: Echocardiographic data of 76 patients who underwent mitral valve repair for primary mitral regurgitation due to leaflet prolapse were retrospectively analyzed. Left atrial volume index and strain parameters were evaluated preoperatively and 1 year postoperatively. Predictors of postoperative left atrial enlargement (left atrial volume index ≥34 mL/m²) were assessed by logistic regression and receiver operating characteristic analyses. Postoperatively, left atrial volume index decreased significantly (from 64.4±23.1 to 36.6±10.5 mL/m²; P<0.01) and there was a significant decline in left atrial strain parameters. Preoperative left atrial early longitudinal strain rate was an independent predictor of postoperative left atrial enlargement (odds ratio 0.076; 95% confidence interval 0.07–0.80; P=0.032), with a receiver operating characteristic curve-derived cut-off of 0.815%/s (area under the curve 70.2%, sensitivity 81.1%, specificity 59.0%).

Conclusions: Left atrial early longitudinal strain rate is an independent predictor of postoperative left atrial enlargement following mitral valve repair, providing valuable prognostic information.

Background: Spontaneous coronary artery dissection (SCAD) causes acute myocardial infarction (AMI). Clinical characteristics of SCAD patients remain insufficiently understood.

Methods and Results: We analyzed AMI patients aged ≤60 years using the nationwide Japanese Registry of All Cardiac and Vascular Diseases–Diagnosis Procedure Combination database (2012.04.01–2022.03.31). SCAD was defined by International Classification of Diseases, 10th revision code I24.8 and the presence of keyword ‘coronary artery dissection’. The primary outcome was in-hospital all-cause mortality. Among 96,304 eligible patients, 330 (0.34%) had SCAD. SCAD patients were younger (P<0.001), more often female (P<0.001), and had fewer atherogenic risk factors. They less frequently received aspirin (P<0.001), angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (P<0.001), statins (P<0.001), and percutaneous coronary intervention (PCI; P<0.001). After propensity score matching, in-hospital all-cause mortality did not differ between SCAD and non-SCAD patients (1.0% vs. 2.9%; P=0.142). The subgroup analysis revealed that the use of aspirin was associated with a lower adjusted in-hospital all-cause mortality (P=0.002), whereas primary PCI (P=0.223), β-blocker (P=0.646), and statin (P=0.608) were not. Of note, older SCAD patients were more likely to exhibit inferior MI (P=0.036 for trend) with shorter duration of hospitalization (P=0.025 for trend).

Conclusions: Short-term outcomes in SCAD patients are comparable with those of atherosclerotic AMI. While aspirin lowered in-hospital mortality, PCI, β-blocker, and statin did not. Our findings suggest the need for physicians to select appropriate therapeutic management in SCAD patients to achieve better outcomes.

Background: Acute kidney injury (AKI) is a common and serious post-transcatheter aortic valve replacement (TAVR) complication that affects patient outcomes. Low-flow, low-gradient (LFLG) aortic stenosis (AS) and chronic kidney disease (CKD) represent a high-risk subset of patients undergoing TAVR. The objective of this study was to evaluate the prognostic impact of LFLG-AS and AKI in CKD patients undergoing TAVR.

Methods and Results: A retrospective analysis was conducted on 324 patients with CKD stage G3a-5 who underwent TAVR for severe AS between August 2015 and December 2022. Patients were stratified into 4 groups according to the presence of LFLG- AS and AKI. The primary endpoint was defined as all-cause mortality or heart failure during the 2-year follow-up period. During a median period of 13 months, 46 (14%) patients reached the primary endpoint. The difference between the baseline values for renal function of the patients with AKI or without AKI was not significant. The patients without either condition who had the most favorable outcomes were those without LFLG-AS or AKI. Patients with LFLG-AS only or AKI only had intermediate outcomes. The patients with LFLG-AS and AKI showed significantly higher mortality and adverse outcomes than the other groups (log-rank P<0.001).

Conclusions: This study highlighted the severe prognostic implications of AKI for patients with LFLG-AS who undergo TAVR.

Background: The incidence of atrial fibrillation (AF) is high in lung cancer patients, but the clinical and prognostic significance of AF during the non-perioperative period is unknown.

Methods and Results: We performed a retrospective single-center cohort study of consecutive patients diagnosed with primary lung cancer. Of the 383 patients included in this study, 27 (7.04%) developed AF during the non-perioperative period (median follow-up 1.68 years). At the baseline, the AF group had a significantly higher prevalence of age ≥70 years or older, diabetes, heart diseases, chronic kidney disease, and high C-reactive protein (CRP) (>0.6 mg/dL). Multivariate analysis using propensity scores showed that high CRP was an independent risk factor for developing AF (odds ratio 3.08; 95% confidence interval 1.17–8.06; P=0.022). Although most (81.5%) of the AF group had no or mild symptoms, the overall survival rate was significantly lower in the AF than non-AF group. Body mass index ≤25.4 kg/m²was associated with lower survival rate in the AF group, but not in the non-AF group.

Conclusions: In lung cancer patients, the incidence of AF was high during the non-perioperative period, and high CRP was an independent risk factor for developing non-perioperative AF. Although the symptoms were milder, non-perioperative AF was associated with a higher risk of all-cause mortality, and BMI had significant predictive value for mortality.

Background: Although implantable cardioverter-defibrillators (ICD) offer prognostic benefit for patients with reduced left ventricular ejection fraction (LVEF), they remain underused in Japan.

Methods and Results: We analyzed 25 patients who underwent primary prevention ICD implantation. During a median follow-up of 52.6 months, no appropriate shocks occurred, but non-sustained ventricular tachycardia (NSVT) was frequently observed. Two patients underwent antitachycardia pacing. LVEF improved to >35% in nearly half of the patients.

Conclusions: Cardiac resynchronization therapy and pharmacotherapy possibly improved cardiac function. Unnecessary shock delivery programming may have also contributed to the favorable outcomes.

Extracorporeal membrane oxygenation (ECMO) delivers powerful mechanical circulatory support while simultaneously offering respiratory support; however, it can increase afterload and is associated with potential device-related vascular complications. To date, several randomized controlled trials have failed to demonstrate a prognostic benefit of routine use of ECMO in patients with cardiogenic shock secondary to acute myocardial infarction or in those with out-of-hospital cardiac arrest. Therefore, the routine use of ECMO is not a guideline-recommended therapeutic strategy. However, in real-world clinical practice, a considerable proportion of patients with cardiogenic shock and cardiac arrest have no other therapeutic options besides ECMO to save their life. Additionally, a combination of ECMO with other mechanical circulatory support devices, such as an intra-aortic balloon pump and percutaneous ventricular assist device, may help reduce the limitations of ECMO and improve patient outcomes. The results of ongoing randomized trials will shape our understanding of the role of ECMO itself and the combination strategies in patients with cardiogenic shock and out-of-hospital cardiac arrest.

Background: Chronic heart failure (CHF) affects millions worldwide, posing a significant burden on healthcare resources. For patients with HF with reduced ejection fraction (HFrEF) following a worsening event, vericiguat is a promising new treatment. In this study we evaluated the budgetary impact on Japan’s health system with the introduction of vericiguat as an add-on to standard of care (SoC) for chronic HFrEF after a worsening event.

Methods and Results: An economic model was developed comparing SoC to a scenario in which vericiguat is introduced as an add-on therapy over a 5-year time horizon. A literature review, medical claims data and clinical trial data were used to derive inputs. Total healthcare costs after introducing vericiguat were estimated to increase <1% over 5 years compared to the SoC scenario showing a cumulated budget impact of US$41,027,304. Increases were driven by drug and medical costs, but were partially offset by decreasing costs for hospitalizations, terminal care, and urgent HF visits. In the sensitivity analyses, the hospitalization rate had the largest effect on the overall budget impact.

Conclusions: This analysis highlighted the minimal budgetary impact of vericiguat and its potential to reduce hospitalizations in Japan. Although drug and monitoring costs increased, reductions in acute care expenses helped offset these costs. Further research is needed on long-term cost-effectiveness and real-world outcomes.

Background: Sex differences exist in atherosclerotic cardiovascular disease, partly due to the anti-atherosclerotic properties of estrogens in women. While polyvascular disease (PolyVD) exhibits worse outcomes, it is unknown whether women have an impact on cardiovascular outcomes of PolyVD.

Methods and Results: We analyzed 678 coronary artery disease patients receiving PCI. PolyVD was defined as the concomitance of ischemic stroke and/or lower extremity arterial disease (LEAD). The occurrence of 3-year major adverse cardiovascular events (MACE; i.e., all-cause death + non-fatal myocardial infarction + ischemic stroke + ischemic-driven non-culprit lesion revascularization + LEAD) was compared between men and women with and without PolyVD, respectively. Women accounted for 17.8% and 21.1% of patients with and without PolyVD, respectively (P=0.34). In patients without PolyVD, women presented marginally higher on-treatment low-density lipoprotein cholesterol (LDL-C) levels (101.5 vs. 93.0 mg/dL; P=0.05). However, women exhibited a lower 3-year MACE risk (adjusted hazard ratio [HR] 0.31; 95% confidence interval [CI] 0.11–0.88; P=0.02). In patients with PolyVD, women exhibited higher LDL-C levels (103.0 vs. 82.0 mg/dL; P=0.04). Furthermore, even after adjusting clinical demographics and risk factor control, the 3-year MACE risk did not differ between males and females (adjusted HR 0.67; 95% CI 0.29–1.57; P=0.36).

Conclusions: Women without PolyVD were less likely to experience 3-year MACE, whereas cardiovascular outcomes in women with PolyVD were similar to men with PolyVD. These findings suggest a need to intensify anti-atherosclerotic management in both men and women with PolyVD.

Background: Inflammation in epicardial adipose tissue (EAT) has been hypothesized to influence heart structure and function, thereby contributing to aortic valve (AV) disease. However, it remains unclear how the biological state of EAT is related to AV hemodynamics.

Methods and Results: We studied 50 patients with AV calcification who underwent elective cardiac surgery (cardiac valve surgery and/or coronary artery bypass graft). Echocardiographic data (AV area index [AVAI] and peak transvalvular AV velocity [PAVV]), were acquired before surgery. During cardiac surgery, 2 EAT samples were obtained for immunohistochemistry and the number of CD68- and CD11c-positive macrophages and osteocalcin-positive cells was counted in 6 random high-power fields (×400 magnification). PAVV, but not AVAI, was positively correlated with the number of CD11c-positive macrophages and osteocalcin-positive cells in EAT in patients with clinical AV stenosis (AS), defined as PAVV ≥2.5 m/s. On multivariate analysis adjusted for left ventricular function, the number of osteocalcin-positive cells in EAT was independently correlated with increased PAVV (β=0.42; P=0.013) and the presence of clinical AS (odds ratio per 1-unit increase 1.14; P=0.011), whereas there was no correlation between increased PAVV or the presence of clinical AS and the number of CD68- and CD11c-positive macrophages in EAT.

Conclusions: The biological activities of EAT, which are characterized mainly by osteogenic activity, are associated with AV hemodynamics and may contribute to AS progression.

Background: The optimal period for discontinuing tafamidis in wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) patients based on cost-effectiveness is unknown.

Methods and Results: A retrospective analysis of 80 tafamidis-treated ATTRwt-CM patients was conducted. The median follow up was 26.4 months; 17 patients permanently discontinued tafamidis, and 12 patients died after a median of 1.0 month following tafamidis discontinuation. Discontinuation was mainly due to non-cardiovascular hospitalization; deaths were mostly non-cardiovascular and occurred early after discontinuation.

Conclusions: The period from tafamidis discontinuation to death was shorter in ATTRwt-CM patients hospitalized for non-cardiovascular diseases. Discussions of the right period for discontinuation are needed.

Background: Electrode catheter placement into the coronary sinus (CS) is critical for electrophysiologic studies. Although central venous approaches (e.g., internal jugular or subclavian) are well documented, peripheral venous approaches like the cubital vein are not. This study evaluated the feasibility and safety of CS catheter placement via the right cubital vein during atrial fibrillation (AF) ablation.

Methods and Results: Of 1,363 consecutive patients who underwent first-time AF ablation at Sakurabashi Watanabe Advanced Healthcare Hospital between January 2019 and December 2021, 1,274 underwent at least 1 right cubital vein puncture attempt. The success rate, causes of failure, and complications were analyzed. CS catheters were successfully placed via the right cubital vein in 1,214 (95.3%) patients, whereas placements were unsuccessful in 60 (4.7%) patients. Although older patients were more likely to experience unsuccessful placements, there were no significant differences in other baseline characteristics between the 2 groups. Unsuccessful placements were attributed to failure in venipuncture or sheath insertion (n=49) and failure to advance the CS catheter through the vein (n=11). No major complications were reported.

Conclusions: CS catheter placement via the right cubital vein demonstrated high feasibility and safety, with a 95% success rate and minimal complications. This approach offers a practical and technically straightforward alternative for placing CS catheters, particularly in patients with adequate vein development.

Background: Electrical storm (ES) is defined as a condition in which ventricular tachycardia (VT) or ventricular fibrillation (VF) episodes requiring electrical shock or implantable cardioverter-defibrillator (ICD) shocks occur ≥3 times within 24 h. It is a life-threatening condition, and treatment options include antiarrhythmic drugs, sedation, circulatory support, and catheter ablation. Sedation is conventionally performed for repeated electrical shocks; however, evidence for its effectiveness in ES suppression remains limited. This scoping review aimed to assess whether the use of sedatives is beneficial for ES suppression.

Methods and Results: This scoping review followed the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Three online databases were searched to identify studies published from the inception of each database until September 18, 2024. To date, no randomized or quasi-randomized controlled trials or observational analytical studies have met the inclusion criteria for the use of sedation in patients with ES.

Conclusions: This scoping review underscores the need for high-quality studies to enhance the level of evidence and bridge knowledge gaps, ultimately aiming to shift the care paradigm for patients with ES.

Background: This study retrospectively evaluated the safety of resuscitation training during the Coronavirus Disease 2019 (COVID-19) pandemic under Japan Resuscitation Council (JRC) guidance.

Methods and Results: From 2018 to 2024, all participating staff were monitored by the Infection Prevention and Control Center. Although learner numbers declined in 2020, training sessions increased, and numbers returned to prepandemic levels. The Resuscitation Quality Improvement program enabled flexible, contactless training, further boosting participation. Notably, no COVID-19 cases were linked to training sessions.

Conclusions: These findings demonstrate that resuscitation training can be conducted safely by adhering to JRC guidance, even during a public health crisis.

Background: There is a substantial risk of slow flow during percutaneous coronary intervention (PCI) for the culprit lesion in acute myocardial infarction (AMI), which can lead to adverse outcomes. We hypothesized that single-step long balloon inflation during stent deployment was associated with a more favorable final Thrombolysis in Myocardial Infarction (TIMI) flow grade. This retrospective study aimed to compare both the final TIMI flow grade and the delta TIMI flow grade in intravascular ultrasound (IVUS)-guided PCI for AMI between patients with long balloon inflation and those with conventional inflation.

Methods and Results: Long inflation was defined as single-step inflation ≥60 s at stent deployment. The primary endpoints were achievement of the final TIMI flow grade 3 and the delta TIMI flow grade, defined as the difference between the initial and final grades. We analyzed 336 AMI patients with attenuation plaque on IVUS, dividing them into a long inflation group (n=50) and a conventional inflation group (n=286). Despite a significantly higher TIMI thrombus grade in the long inflation group (P<0.001), the rate of the final TIMI 3 flow was similar (90% vs. 88.5%; P=1.00). However, the delta TIMI flow grade was significantly greater in the long inflation group (P=0.028).

Conclusions: Single-step long balloon inflation may be a simple and feasible method to achieve optimal final TIMI flow in IVUS-guided PCI for AMI.

Background: Malnutrition is a significant prognostic factor in chronic heart failure (CHF), particularly among older adults. The geriatric nutritional risk index (GNRI) is a screening tool for assessing malnutrition in this population. Although low GNRI is associated with increased deaths of patients with HF, the prognostic impact of longitudinal GNRI changes in malnourished patients remains unclear.

Methods and Results: This post-hoc analysis of the KUNIUMI registry chronic cohort, a prospective observational study of patients with pre-HF/HF, assessed GNRI at baseline and 1-year follow-up. The annual GNRI change (∆GNRI) was calculated, and its association with all-cause death in malnourished patients was analyzed. The primary outcome was all-cause death, with a 2-year follow-up after the initial 1-year assessment. Among 1,242 patients (mean age: 74.4±10.9 years), 19.8% had low GNRI (<92). All-cause death was significantly higher in patients with low GNRI than in those with high GNRI (30.1% vs. 7.1%; P<0.001). In patients with low GNRI, multivariable Cox regression showed a significant association between ∆GNRI and death (hazard ratio: 0.94; 95% confidence interval: 0.91–0.96; P<0.001). Multiple linear regression indicated that nutritional counseling positively influenced ∆GNRI, but HF severity was not significantly associated.

Conclusions: ∆GNRI is a significant prognostic indicator in malnourished patients with pre-HF/HF. Serial GNRI assessments may improve risk stratification and guide nutritional interventions.

Background: The Navitor valve shows excellent valve function and high deliverability. However, valve pop-up during valve implantation remains a concern.

Methods and Results: We defined pop-up as an upward valve dislocation ≥3 mm after implantation. Pop-up occurred in 13 (19%) of 67 patients, with 2 (3.0%) patients requiring a second valve. The depth ratio between non- and left-coronary cusp side at the 80% release and aortic valve calcification score were identified as predictors of valve pop-up.

Conclusions: Pop-up of the Navitor valve occurred in 19% of patients. Inconsistent valve depth and severe leaflet calcification were predictors of valve pop-up.